Based on observation, interview, and record review, during a site visit conducted on 05/29/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 3 of 3 sampled residents (#1, #2, and #3). Findings include, but are not limited to:

On 05/29/24, CS observed the following:

"Three CG's, two working the floor while one provided the one-on-one assistance and one MT working.

"Resident 1, Resident 2, and an unsampled resident had hair that was greasy, nails unclipped and dirty with particles under the nails.

In separate interviews on 05/29/24, staff stated the following:

"There have been no showers completed yet today.    

"There are no activities personnel, Caregiver's have been expected to absorb those job duties.

"A resident who as of last week, required 24-hour one on one assistance.

"There are two residents that require two-person transfer.

On 05/29/24, Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) stated the facility had been short staffed on multiple occasions resulting in resident needs having been missed, such as showers. Staff 1 stated the system for documenting and auditing showers has not been working effectively. Staff 1 could not ensure showers were being completed. Staff 1 stated there had been multiple occasions when there was only one CG and one MT working during day shift.

On 05/29/24, Resident 1 stated s/he has not been getting the services required. Resident 1 had no knowledge of his/her last shower and indicated the facility often said s/he refused the shower when that was not the case.

A review of the facility's posted staffing plan indicated the following:

"The facility used two 12-hour shifts;

"Day shift required two CGs and one MT; and

"Night shift required one CG and one MT.

A review of the staff schedule, dated 02/01/24 through 05/29/24, indicated the facility was consistently short staffed, often scheduling one CG one MT for day shift.  

A review of timecards from 05/01/24 through 05/29/24, indicated the facility had been short staffed on multiple days.

A review of service plans indicated Resident 1 dated 04/18/24 required one CG assist every Tuesday and Saturday. Resident 2 dated 05/01/24 required full assistance with showering. Resident 3 dated 05/13/24 required one CG assist with showers every Monday and Saturday day shift.

A review of the facility's "shower sheets" from 04/01/24 through 05/29/24 revealed no documented evidence showers had been completed according to the shower schedule.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 05/29/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.

Verbal POC: ED will bring back the shower sheets to document showers have been completed. ED has been working on hiring more staff members, recently able to use agency staff for supports, and intends to move from two twelve-hour shifts to three eight-hour shifts.

Based on interview and record review, during a site visit conducted on 05/29/24, it was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire. Findings include but are not limited to:

During an interview on 03/19/24, Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) acknowledged staff training records were incomplete or non-existent.  

A review of current facility staffs 30-day competency training checklist indicated the following;

·Staff that had no training records were as follows:

oStaff 9 (CG) Date of Hire: 02/09/24.

oStaff 10 (CG) Date of Hire: 02/15/24.

oStaff 13 (CG) Date of Hire: 02/15/24.

·Staff to have incomplete training records were as follows:

oStaff 4: (Housekeeper/CG) Date of Hire: 03/03/22.

oStaff 8: (CG) Date of Hire: 05/16/22.

oStaff 11: (CG) Date of Hire: 05/03/24.

oStaff 12: (CG) Date of Hire: 03/05/24.

It was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire.

On 05/29/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.

Verbal POC: Staff 3 (MT), Staff 5 (CG) working during site visit had complete training records. Staff 4 was scheduled as housekeeper during the site visit not providing care and Staff 12 (CG) training was completed and needed his/her signature on the training records to show completion. The Executive Director will get the additional staff training records completed on his/her next time of work. ED stated all staff had been fully trained in his/her job duties, however staff did not have complete training records.