Based on observation and interview, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to have a posted staffing plan. Findings include, but are not limited to:
A posted staffing plan could not be located or observed during the site visit.
During an interview on 03/12/24, Staff 4 (Regional Director of Operations) confirmed a staffing plan was not posted in the facility.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4, and Staff 9 (Corporate LPN) on 03/12/24.
The facility failed to have a posted staffing plan.
Verbal Plan of Correction: The staffing plan was posted by end of day 03/12/24.
Based on observation and interview, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to have medical and other records kept confidential. Findings include, but are not limited to:
On 03/10/24 at 12:23 pm, a laptop was observed, open, displaying residents names and medication orders on top of a medication cart. A narcotics log book was open, displaying resident information. The cart and laptop were not not being monitored by staff. The records were open and viewable at 12:56 pm.
On 03/12/24 at 6:31 am a narcotics log was open and resident information was viewable. The log was not being monitored by staff.
During an interview on 03/12/24, Staff 4 (Regional Director of Operations) stated staff were to lock the laptop and cover resident information when not in use.
The facility failed to have medical and other records kept confidential.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 (Corporate LPN) on 03/12/24.
Verbal Plan of Correction: Re-training of staff on confidentiality and privacy was to begin on 3/12/24. Spot check each day of week each shift for one week and then audit 2x/ week.
Based on observation, interview and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to prepare menus at least one week in advance, be made available to all residents, ensure any meal substitutions must be of similar nutritional value if a resident refuses a food that is served, inform residents in advance of menu changes and failed to ensure food was prepared and served in accordance with food sanitation rules. Findings include, but are not limited to:
On 03/10/24, a daily menu visible to residents was observed and reviewed. The daily meals were listed as follows:
Breakfast:
Hot Cereal
Yogurt
Toast
Sliced Peaches
Lunch:
Seasoned Pot Roast
Cauliflower
Homestyle Potatoes
Choc\Cherry Cake
The following observations and interviews were made and conducted during the noon meal:
*At 1:15 pm - A family member of a resident was observed preparing food in the community's kitchen. S/he did not wash his/her hands. S/he was observed taking blueberries from the fridge, rinsing them in his/her hands in the sink, and serving a large bowl of yogurt and blueberries to a resident. S/he returned to the kitchen and got utensils out of a drawer to set the table for the residents. Staff 2 (Universal worker) was preparing turkey from the crockpot on the counter, cutting and serving it on plates. The family member got ice from counter top ice maker and added it to a resident cup. The family member stated loudly that s/he was not sure what Staff 2 was making for lunch that day. Staff 2 replied they were having turkey breast and scalloped potatoes.
*At 1:30 pm - The noon meal was served to residents. Roasted turkey breast and scalloped potatoes were served. No vegetable was served with lunch.
*At 1:48 pm - a resident family member served cookies to residents. S/he did not wash his/her hands and picked up cookies with bare hands, put them in a napkin and served to residents.
*At 2:02 pm - Staff 1 stated s/he did not take the temperature of the turkey and did not know to what temperature it was cooked. The compliance Specialist (CS) temped the turkey that was still in the crockpot on " warm " setting and it was about 122 degrees, in the danger zone. Staff 1 said she did take the temperature of the potatoes which were about 120 degrees. Staff 1 was asked if s/he knew what temperature the potatoes should be cooked to, and s/he did not know. Then, s/he opened a cupboard which had a sheet posted of proper cooking temperatures, but still could not answer the question. CS asked if the temperatures of meals were recorded anywhere. S/he showed the CS their temperature logs which were blank for both breakfast and lunch that day. Staff 1 stated the breakfast menu was also wrong, that they didn't have pancakes, but had biscuits and gravy. Staff 2 entered the kitchen. The CS asked Staff 2 about the temperatures and s/he said the potatoes were about 180 degrees and turkey was over 160 degrees. Staff 2 was asked if there was a vegetable or fruit served with lunch and s/he said s/he had broccoli, but did't have time to make it.
*At 2:17 pm Staff 1 was observed filling in the temperature logs.
In review of the temperature logs, it was noted the meals for Sunday 03/10/24 were to be:
Breakfast:
Fluffy Pancakes
Scrambled Eggs
Fresh Fruit
100% Juice
Beverage Choice
Lunch:
Seasoned Pot Roast
Au Gratin Potatoes
Parsley Carrots
Baked Roll
Pumpkin Pie
During an observation and interview on 03/10/24, Resident 3 was observed to not eat the noon meal. S/he stated that s/he didn't want it.
A review of Resident 3's service plan dated 02/07/24 indicated s/he was diabetic and insulin dependent.
During an interview on 03/10/24, Staff 1 and Staff 2 stated Resident 3 was not offered a replacement meal, but was given a banana.
Upon return to the facility on 03/12/24, the posted menu, visible to residents was the same as it was on 03/10/24.
The facility failed to prepare menus at least one week in advance, be made available to all residents, ensure any meal substitutions must be of similar nutritional value if a resident refuses a food that is served, inform residents in advance of menu changes and failed to ensure food was prepared and served in accordance with food sanitation rules.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 (Corporate LPN) on 03/12/24.
Plan of Correction: Regional Director of Operations to follow-up and train staff who worked on 03/10/24 by end of week. Facility leadership will conduct spot audits of food temperatures for next week during all three meals, ensure menus are being followed and posted for residents, and that staff offer replacement meals for residents. Regional Director of Operations will follow up with family members to ensure they have a food handlers card.
Based on observation, interview, and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to implement a service plan reflective of resident needs, update resident service plans quarterly, and include a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:
1. Resident 1's service plan dated 02/07/24 was reviewed and was not reflective or did not provide clear direction to staff in the following areas:
*Repositioning/bed mobility;
*Dressing/undressing;
*Toileting/incontinence care/catheter care;
*Assistive devices, including hospital bed;
*Evacuation assistance;
*Mobility and transfers;
*Meal assistance; and
*Hospice and Outside Providers.
During an interview on 03/10/24, Witness 1 (Family Member) stated on Super Bowl Sunday Resident 1 was only repositioned twice during a 48 hour period. S/he stated they usually have two people help Resident 1 when s/he needs his/her brief changed and sometimes there is only one person working on night shift.
2. A review of Resident 2's service plan dated 10/26/23 was reviewed and indicated the following:
*Resident 2 required assistance with toileting every two hours;
*Resident 2 liked to nap between meals;
*Resident 2 needed cueing for fluids throughout the day; and
*Resident 2 received assistance with showering on Wednesdays and Saturdays on day shift.
Resident 2 was observed from approximately 12:25 pm to 4:25 pm on 03/10/24. Resident 2 was not provided toileting assistance until 4:25 pm. Resident 2 was not offered to be taken to his/her room for a nap during this time. Resident 2 was observed sitting at the dining table, drinking from an empty mug at 2:40 pm. Resident 2 was not offered more fluids until 3:03 pm when Staff 1 (Universal Worker) offered him/her more coffee.
A review of the facility's shower schedule indicated Resident 2 was to receive a shower on Sunday and Wednesday.
Resident 2's shower documentation from 02/07/24 through 03/09/24 was reviewed which indicated Resident 2 received only two showers during this time.
3. Resident 3's service plan dated 02/07/24 was reviewed and not reflective of needs or did not provide clear direction to staff in the following areas:
*Bathing/showers; and
*Behaviors
Resident 3's shower documentation for 02/01/24 through 03/11/24 was reviewed which indicated Resident 3 only received a shower one time during the time period.
During an interview on 03/12/24, Staff 9 (Corporate LPN) acknowledged that showers were not provided as scheduled.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 on 03/12/24.
The facility failed to implement a service plan reflective of resident needs, update resident service plan 30 days after move-in and quarterly, and include a written description of who shall provide the services and what, when, how, and how often the services shall be provided
Verbal plan of Correction: Staff identified an issue 03/11/24 with PCC (Electronic Medical Record) not tracking service plan updates. Evaluation was completed and family to be contacted today for a care conference to review new service plan for Resident 2, whose service plan was out of date. Facility to increase staffing to remedy the implementation portion of this concern. Facility to audit service plans for accuracy within 30 days.
Based on interview and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to have delegation and teaching provided and documented by a RN. Findings include, but are not limited to:
Resident 3's Medicaction Administration Report for 03/01/24 through 03/10/24 was reviewed which revealed Staff 1 (Universal Worker) gave Resident 3 insulin and other injectectable medications on 03/01/24, 03/08/24 and 03/10/24.
On 03/10/24 the following occured:
At approximately 3:30 pm documentation of RN delegations was requested from Staff 5 (Administrator of Pacific Living Madras).
At approximately 3:40 pm Staff 1 stated s/he had given Resident 3's insulin and other injections on 03/10/24 and thought s/he had been delegated to do so, but could not remember when.
At approximately 4:00 pm a green binder containing delegation information from June 2023 and 2022 was received and reviewed.
At approximately 4:45 pm Compliance Specialist (CS) placed a phone call to Staff 6 (Facility RN). During interview, Staff 6 stated s/he was on a plane about to take off and that "delegations are fine" and then hung up.
Immediately following the phone call, additional delegation records were located by Staff 5, but were incomplete. There was no evidence that Staff 1 or Staff 2 (Universal Worker) were delegated for any tasks.
At 4:48 pm the request for an immediate, written plan of correction was submitted.
At 5:45 pm a written plan of correction was accepted.
The facility failed to have delegation and teaching provided and documented by a RN.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 (Corporate LPN) on 03/12/24.
Based on observation, interview, and record review, conducted during a site visit on 03/10/24 and 03/12/24, 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 (#s 1, 2, and 3). Findings include, but are not limited to:
1. During the site visit on 03/10/24, two universal workers were observed working in the facility. No posted staffing plan was observed on 03/10/24 or 03/12/24. During the site visit, universal workers were observed preparing meals, housekeeping services and doing laundry.
During an interview on 03/10/24, Staff 1 (Universal Worker) stated the facility was staffed as follows:
Weekend staffing:
Weekend Days: 2 Universal Workers;
Weekend Evenings: 2 Universal Workers; and
Weekend Nights: 1 Universal Worker.
Monday - Friday Staffing Plan:
Day: 3 Universal Workers;
Evenings: 3 Universal Workers; and
Nights: 2 Universal Workers.
The facility's ABST was reviewed on 03/10/24 and revealed the need for the following staff hours:
Day: 20.18 hours (3 universal workers);
Evenings: 17.29 (3 universal workers); and
Night: 4.64 hours (1 universal worker).
Time cards for 02/23/24-02/25/24, 03/01/24-03/03/24 and 03/08/24-03/10/24 were reviewed which revealed the facility was consistently staffed significantly below what was required by their ABST on the weekends.
2. Resident 1's service plan dated 02/07/24 was reviewed and indicated Resident 1 was totally dependent for cares, but did not specify how many staff were required for each care.
During an interview on 03/10/24, Witness 1 (Family Member) stated there was not enough staff on the weekend and the weekend staff were not skilled. S/he further stated on Super Bowl Sunday Resident 1 was only repositioned twice during a 48 hour period. S/he stated they usually have two people help Resident 1 when s/he needs his/her brief changed. Sometimes there is only one person working on night shift.
3. A review of Resident 2's service plan dated 10/26/23 indicated the following:
*Resident 2 required assistance with toileting every two hours;
*Resident 2 liked to nap between meals;
*Resident 2 needed cueing for fluids throughout the day; and
*Resident 2 received assistance with showering on Wednesdays and Saturdays on day shift.
Resident 2 was observed from approximately 12:25 PM to 4:25 PM on 03/10/24. Resident 2 was not provided toileting assistance until 4:25 PM. Resident 2 was not offered to be taken to his/her room for a nap during this time. Resident 2 was observed sitting at the dining table, drinking from an empty mug at 2:40 PM. Resident 2 was not offered more fluids until 3:03 PM when Staff 1 offered her more coffee.
A review of the facility's shower schedule indicated Resident 2 was to receive a shower on Sunday and Wednesday.
Resident 2's shower documentation from 02/07/24 through 03/09/24 was reviewed which indicated Resident 2 received only two showers during this time.
4. Resident 3's service plan dated 02/07/24 was reviewed and indicated:
*Resident 3 required assistance with showers on Tuesdays and Saturdays on day shift.
The facility's shower schedule confirmed Resident 3 received showers on Tuesdays and Saturdays.
Resident 3's shower documentation for 02/01/24 through 03/11/24 was reviewed which indicated Resident 3 only received a shower one time during the time period.
5. During an interview on 03/10/24, Staff 2 (Universal worker) stated s/he was unable to prepare a vegetable for the noon meal because s/he did not have enough time.
No vegetable was served with the noon meal on 03/10/24.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 (Corporate LPN) on 03/12/24.
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.
Verbal Plan of Correction: Facility will staff 3 Universal Workers on day and evening shifts and 2 Universal Workers on night including the weekend. Agency is being utilized to fill in when facility staff are not available.
Based on observation, interview, and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:
1. During the site visit on 03/10/24, two universal workers were observed working in the facility. No posted staffing plan was observed. Universal workers were observed preparing meals, housekeeping services and doing laundry. No staff-led activities were observed.
During an interview on 03/10/24, Staff 1 (Universal Worker) stated the facility was staffed as follows:
Weekend staffing:
Weekend Days: 2 Universal Workers;
Weekend Evenings: 2 Universal Workers; and
Weekend Nights: 1 Universal Worker.
Monday - Friday Staffing Plan:
Day: 3 Universal Workers;
Evenings: 2 Universal Workers; and
Nights: 2 Universal Workers.
The facility's ABST was reviewed on 03/10/24 and revealed the need for the following staff hours:
Day: 20.18 hours (3 universal workers);
Evenings: 17.29 (3 universal workers); and
Night: 4.64 hours (1 universal worker).
Time cards for 02/23/24-02/25/24, 03/01/24-03/03/24 and 03/08/24-03/10/24 were reviewed which revealed the facility was consistently staffed significantly below what was required by their ABST on the weekends.
2. Resident 1's ABST Profile was not updated in the previous quarter as required by rule.
Resident 1's service plan dated 02/07/24 was reviewed and indicated Resident 1 was totally dependent for cares, but did not specify how many staff were required for each care.
During an interview on 03/10/24, Witness 1 (Family Member) stated there was not enough staff on the weekend and the weekend staff were not skilled. S/he further stated on Super Bowl Sunday Resident 1 was only repositioned twice during a 48 hour period. S/he stated they usually have two people help Resident 1 when s/he needs his/her brief changed. Sometimes there is only one person working on night shift.
3. Resident 2's ABST Profile was not updated in the previous quarter as required by rule.
A review of Resident 2's service plan dated 10/26/23 indicated the following:
*Resident 2 required assistance with toileting every two hours;
*Resident 2 liked to nap between meals;
*Resident 2 needed cueing for fluids throughout the day; and
*Resident 2 received assistance with showering on Wednesdays and Saturdays on day shift.
Resident 2 was observed from approximately 12:25 PM to 4:25 PM on 03/10/24. Resident 2 was not provided toileting assistance until 4:25 PM. Resident 2 was not offered to be taken to his/her room for a nap during this time. Resident 2 was observed sitting at the dining table, drinking from an empty mug at 2:40 PM. Resident 2 was not offered more fluids until 3:03 PM when Staff 1 offered him/her more coffee. No other fluids were offered during this time.
A review of the facility's shower schedule indicated Resident 2 was to receive a shower on Sunday and Wednesday.
Resident 2's shower documentation from 02/07/24 through 03/09/24 was reviewed which indicated Resident 2 received only two showers during this time.
4. Resident 3's ABST Profile was not updated in the previous quarter as required by rule.
Resident 3's service plan dated 02/07/24 was reviewed and indicated:
*Resident 3 required assistance with showers on Tuesdays and Saturdays on day shift.
The facility's shower schedule confirmed Resident 3 received showers on Tuesdays and Saturdays.
Resident 3's shower documentation for 02/01/24 through 03/11/24 was reviewed which indicated Resident 3 only received one shower during the time period.
5. During an interview on 03/10/24, Staff 2 (Universal worker) stated s/he was unable to prepare a vegetable for the noon meal because s/he did not have enough time.
No vegetable was served with the noon meal on 03/10/24.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 (Regional Director of Operations) and Staff 9 (Corporate LPN) on 03/12/24.
It was confirmed the facility failed to fully implement an ABST.
Verbal Plan of Correction: Facility will staff 3 Universal Workers on day and evening shifts and 2 Universal Workers on night including the weekend. Agency is being utilized to fill in when facility staff are not available.
Based on observation, interview and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confined 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 2 of 2 sampled staff (#s 1 and 2). Findings include, but are not limited to:
Training records for Staff 1 (Universal Worker) were reviewed on 03/10/24 and revealed Staff 1's 30 day orientation training checklist was completed on 09/12/23. Staff 1's training records also included medication pass competency on 09/11/23, which was not signed by Staff 1, but was signed by Staff 6 (Facility RN). Staff 1's training documents also contained another 30 day orientation training checklist which was completed on 11/12/23. Staff 1's trainer for the 11/12/23 checklist was Staff 2 (Universal Worker).
Training records for Staff 2 were reviewed on 03/10/24 and revealed Staff 2's 30 day orientation training checklist was completed on 08/10/23. Staff 2's trainer was Staff 1. Staff 2's 30 day orientation training checklist was not reviewed by a manager. There was no documented evidence that Staff 2 had any training on medication pass competencies.
Resident 1's MAR for 02/01/24 through 02/29/24 revealed Staff 2 had administered medications.
During an interview on 03/10/24, Witness 1 (family member) described an event in which Staff 2 had given Resident 1 10 x the amount of their prescribed methadone (a narcotic pain medication) which resulted in an overdose and Staff 2 being removed from the medication cart for training. This event was reported to Adult Protective Services for investigation.
During an interview on 03/12/24, Staff 4 (Regional Director of Operations) stated initially Staff 1 trained Staff 2 when Staff 1 was the administrator for a short time. S/he further explained that Staff 1 was demoted back to a universal worker and was re-trained by Staff 2.
The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 and Staff 9 (Corporate LPN) on 03/12/24.
Plan of correction: All staff members will be completing a comprehensive re-training of skills within 30 days, but beginning 03/12/24 with anyone who administers medications.
Based on observation, interview and record review, conducted during a site visit on 03/10/24 and 03/12/24, it was confirmed the facility failed to have a meaningful activities program that promote or help sustain the physical and emotional well-being of residents. Findings include, but are not limited to:
An activities calendar was observed in the dining room and reviewed, and was not for the current month.
There were no activities observed to occur in the facility during the site visit.
During an interview on 03/12/24, Staff 4 (Regional Director of Operations) stated that staff were to lead activities and staff was responsible for ensuring activities were offered.
The findings were reviewed with and acknowledged by Staff 3 (Administrator), Staff 4 and Staff 9 (Corporate LPN) on 03/12/24.
The facility failed to have a meaningful activities program that promote or help sustain the physical and emotional well-being of residents.
Verbal Plan of correction: Faciltiy to Increase staffing. Updated activities calendar has been posted and residents will receive new calendars. Administrator to do audits/spot checks for charting and activities.