Based on interview and document review, it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of records. Findings include, but not limited to:

A review of medication incident report dated 12/26/23 for Resident 1 indicated the following:

·Corrective actions taken following med error reported  " Counseling performed, Physician Contacted, Review of the 8 rights of medication assistance with return demonstration. "

During interviews on 04/03/24, Staff 3 (MT/RCC) stated the previous RCC did mark on the incident report that staff was counseled which is incorrect. Staff 5 (MT/RA) stated  "I made a med error and the documents said I was counseled and talked to, but I never was" . S/he stated that staff member who documented that was no longer working at the facility.

The findings were reviewed with and acknowledged by Staff 3 on 04/03/24 and with Staff 1 (ED) on 04/04/24.

It was confirmed the facility failed to develop and implement a written policy that prohibits the falsification of records.

Plan of correction: Previous RCC no longer is working at the facility. ED will ensure that the new RCC is trained on accurate documentation and will be documenting any follow up conversations or trainings given to staff. ED will follow up with all parties involved before signing off on incident reports.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to ensure service plans were updated quarterly for 2 of 3 sampled residents (#2, 4, and 5), whose service plans were reviewed. Findings include, but are not limited to:

A review of Resident 2's service plan dated 12/17/23 and Resident 5's service plan dated 12/21/23 indicated the facility had not updated the residents service plan quarterly.

During an interview, Staff 1 (ED) confirmed the facility had been behind on resident service plans and stated s/he had been working on getting them updated.

The findings were reviewed with and acknowledged by Staff 1 on 04/04/24.

It was confirmed the facility failed to ensure service plans were updated quarterly.

Verbal plan of correction: ED and RCC have already been working on getting all of the service plans updated that are out of date.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#3). Findings include, but not limited to:

Compliance Specialist (CS) reviewed Resident 3's March 2024 MAR and physician orders which indicated the following:

·Order dated 03/21/23 for Hydroxyzine Pamoate 25 MG Capsule to be given one capsule by mouth twice daily for itching

·MAR shows resident did not receive his/her Hydroxyzine scheduled for 8 pm on 03/24/24

·Order dated 03/31/23 for Melatonin Soft Gel 10 MG Capsule to be given 1 capsule by mouth every day at bedtime for insomnia

·MAR shows between 03/02/24-03/20/24 resident did not receive his/her Melatonin on twelve different dates due to  "awaiting med from pharmacy"

During an interview, Staff 1 (MT/RCC) stated the power did go out for a few days, however, they had printed MARs and the correct orders were added or updated on the paper MAR. Staff 5 (MT/RA) stated medications are not always re-ordered timely.

The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.

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

Verbal plan of correction: ED has been working with each MT doing 1:1 training, re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:

Compliance Specialist (CS) reviewed Resident 1's December 2023 MAR, progress notes, and physician orders which indicated the following:

·Order dated 03/30/23 for Clonazepan 1 MG Tablet to be given one tablet by mouth twice daily for anxiety

·Progress note and incident report dated 12/26/23 stated resident was given his/her PRN Lorazepam on 12/24/23 and 12/25/23 instead of scheduled Clonazepan

During an interview, Staff 3 (MT/RCC) stated the incident did occur and the MT should have matched the bubble pack to the MAR.

The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.

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

Verbal plan of correction: ED has been working with each MT doing 1:1 training, Re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 2 sampled residents (#1's and 4). Findings include, but are not limited to:

Compliance Specialist (CS) reviewed Resident 1's January 2024 MAR, progress notes, and physician orders which indicated the following:

·Order dated 03/30/23 for Clonazepam 1 MG Tablet to be given one tablet by mouth twice daily for anxiety

·Progress notes and incident report dated 01/22/24 reported resident missed his/her 7:30am Clonazepam

Compliance Specialist (CS) reviewed Resident 4's January 2024 MAR, progress notes, and physician orders which indicated the following:

·Order dated 08/17/23 for Lorazepam 1 MG Tablet to be given one tablet by mouth three times daily for anxiety

·Progress notes and incident report dated 01/08/24 reported resident missed his/her 2pm Lorazepam

·MAR indicated from 01/19/24-01/22/24 resident did not receive his/her Lorazepam due to  "awaiting med from pharmacy"

During an interview, Staff 3 (MT/RCC) stated the incident did occur.

The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.

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

Verbal plan of correction: ED has been working with each MT doing 1:1 training, Re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In review of the facility's ABST and resident roster on 04/03/24, it was determined all 17 residents were entered into the ABST. The tool contained all 22 required ADLs and generated a 24-hour staffing plan. There were 7 residents on the ABST that had not been updated at least quarterly with the oldest date being 11/14/23.

In an interview on 04/05/24, Staff 1 (ED) stated the previous RCC had not been keeping the ABST updated.

On 04/05/24, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.

Based on interview and record review, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 3 of 3 sampled staff (#'s 3, 4, and 5). Findings include, but are not limited to:

Compliance Specialist (CS) reviewed completed MT training and Medication Aide Training procedures for Staff 3 (MT), Staff 4 (MT), and Staff 5 (MT) which indicated the following:

·Staff 3's completed MT Skills checklist was dated 03/01/24, however, was working as the MT on the February 2024 staff schedule.

·Staff 4 did not have a completed MT Skills checklist and was working as MT.

·Staff 5's completed MT Skills checklist was dated 03/26/24, however, was scheduled as the MT alone in March 2024 prior to completing the training.

During an interview on 04/05/24, Staff 1 (ED) stated s/he could not find completed training documents for some staff. S/he also stated they had found some that hadn't been completed by the previous RCC.

The findings were reviewed with and acknowledged by Staff 1 on 04/05/24.

It was determined the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing.

Plan of correction: ED is working to make sure that all staff have completed their required trainings and document them. They will make sure that MTs have the trainings completed before their next shifts.