Based on interview and record review, conducted during a site visit on 04/22/24 the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4) was substantiated. Findings include, but are not limited to:

Interviews with Staff 1 (Administrator) and Staff 2 (RCC) were conducted:

"Staff 1 stated the incident occurred and a facility self-report was made.

"Staff 2 stated s/he administered the incorrect medication dose and completed the associated incident report.

Review of Resident 4's MAR, dated 11/01/23 through 11/30/23, and signed prescriber order, dated 12/09/23 indicated s/he was ordered "clonazepam 1 MG TAB - 0.5 tablet (0.5mg) by mouth every day at noon".

Review of the incident report, dated 11/05/23, indicated during the 12p, med pass on 11/01/23 and 11/02/23 Staff 2 administered 1mg of clonazepam instead of .5 mg of clonazepam.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Findings were reviewed and acknowledged by Staff 1.

VPC:

Staff 1 and 2 will hold MT meetings to review proper  MAR reading and procedures and reinforce the importance of matching medications accurately to the MAR.

Based on interview and record review conducted during a site visit on 04/22/2024, it was determined that the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 1 of 3 sampled residents (#1, # 2 and #3). Findings include, but are not limited to:

Interview with Staff 1 (Administrator) was conducted indicating:

·The facility reported use of the State Acuity-Based Staffing Tool (ABST) to generate its staffing plan.

·Current census: 36 residents

·Reported staffing levels:

oDay shift:  4 caregivers (CG) / 1 medication technician (MT)

oSwing shift:  4 (CG) / 1 (MT)

oNight (Noc) shift:  2 (CG) / 1(MT)

The following records were reviewed and indicated:

·Staff Roster

·Resident Roster

oAssisted Living: 23 residents

oMemory Care: 13 residents

·Facility Posted Staffing

oDay Shift: 2 CG and 1 MT (MT covers both ALF and MC)

oSwing Shift: 2 CG and 1 MT (MT covers both ALF and MC)

oNight (Noc) Shift: 1 CG and 1 MT (MT covers both ALF and MC)

oPosted staffing does not align with the facility ' s reported schedule.

·Facility ABST Tool

oAssisted Living: 24 Residents

oMemory Care: 13 Residents

oFacility ABST does not match Resident Roster. (Staff 1 noted one resident had been removed, as they no longer reside at the facility.)

oFacility ABST tool does not reflect current ADL needs for Residents 1, 2 and 3.  

oFacility is not staffing to the levels indicated by the ABST tool. (Swing shift is short by one caregiver.)

It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.

Findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Staff 1 will audit the ABST tool to ensure that all residents are accurately entered, acuity levels are properly updated, and an accurate staffing plan is generated based on resident needs.