Based on interview and record review, conducted during a site visit on 08/14/24 through 08/16/24, it was confirmed the facility failed to ensure the completeness of resident records for 1 of 1 sampled resident (#7). Findings include, but are not limited to:  

A review of Resident 7's records, including progress notes, dated 10/28/23 through 01/23/24, indicated the following:

* S/He was admitted on 10/27/23.

* The facility's initial screening "Offline Evaluation Form" was undated and unsigned.

* Resident 7's move-in 'Temporary Plan of Care', dated 10/27/23, contained areas that were blank, which included: hearing, grooming, behaviors, safety, pain issues, and devices; and lacked clear direction; and lacked who and how services are to be provided.

In an interview on 08/16/24, Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) stated the "Temporary Plan of Care" is initial service plan they implement upon move in and after 30 days generate a full service plan.  

On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 3, Staff 4, and Staff 22 (Regional Director of Operations).

Verbal Plan of Correction: The Administrator in collaboration with Health Services Director and Resident Care Coordinator will ensure a newly admitted resident's service plan will be completed.  

A.

Based on interview and record review, conducted during a site visit on 08/14/24 through 08/16/24, it was confirmed the facility failed to complete a service plan before resident move-in; and the facility failed to include written description of who shall provide the services, and what, when, how, and how often the service shall be provided for 1 of 1 sampled resident (#7). Findings include, but are not limited to:

A review of Resident 7's records, including progress notes, dated 10/28/23 through 01/23/24, indicated s/he was admitted on 10/27/23. The facility's initial screening "Offline Evaluation Form", (undated),  indicated Resident 7 required the following:

* In area of mobility, s/he requires escorts for meals and activities;

* Cues and reminders for dressing/grooming;

* Partial assistance with bathing.

* One person assist with toileting and cleaning;

* S/He "needs reminders/cues during meal times; assist with directions".

* S/He was able to recognize family by face and name, but otherwise had "no recall ability".

* S/He uses glasses.

* Resident 7's move-in 'Temporary Plan of Care', dated 10/27/23, contained areas that were blank, which included: hearing, grooming, behaviors, safety, pain issues, and devices; and lacked clear direction; and lacked who and how services are to be provided.

In an interview on 08/16/24, Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) stated initial screenings of perspective residents occur before move-in and are completed by them. Staff 3 conducts the nursing assessments and Resident Care Coordinators develop the service plan.

On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 3, Staff 4, and Staff 22 (Regional Director of Operations).

Verbal Plan of Correction: Health Services Coordinator will ensure residents' service plan provide clear directions to staff.

B.

Based on observation, interview, and record review, conducted during a site visit on 08/14/24 through 08/16/24, the facility's failure to have a service plan that is reflective of the resident's needs for 1 of 1 sampled resident (#2) was substantiated; and failed to include a written description of who shall provide the services and what, when, how, and how often services shall be provided. Findings include, but are not limited to:

In an interview on 08/15/24, at 2:27 pm, Resident 2 stated the following:

·S/He gets showers two to three times per week unless s/he doesn't feel like it and described his/her other care needs.

·Described the quality of care provided by direct care staff as "good".

·When asked if Resident 2 had seen his/her service plan, s/he stated:  "No. I've refused to sign."  

·Is able to transfer independently.

On 08/15/24, at approximately 2:27pm, Resident 2 was observed to use a urinal and bed pan.

In an interview on 08/16/24 at approximately 8:52am, Staff 20 (CG) stated Resident 2's care needs included emptying urinals and bed pans, and transfers with one staff person assistance.  

A review of Resident 2's records including his/her service plan dated 05/22/24, temporary service plans, dated 03/11/24 through 07/29/24, and Behavior Support Plan, dated 04/16/24, indicated the following:

·His/Her service plan was signed by the resident on 05/22/24.

·Transfers are to be completed with two-person assistance.

·Toileting required staff assistance and used a commode and is incontinent of bladder and bowels.

·S/He has experienced behaviors which include making rude or inappropriate comments toward staff members; reporting to staff and Department personnel that property has been stolen and investigations have been completed and does not confirm the allegation; and refusing to attend meals or refusing meal trays, and then reporting to Department personnel staff have refused to provide meals. Staff are to document all refusals of food.

Resident 2's service plan lacked the frequency of toileting needs and omitted any references to his/her Behavior Support Plan and the interventions used to address the identified behaviors.

It was determined the facility failed to have a service plan that is reflective of the resident's needs and failed to provide a frequency for services to be provided.

On 08/16/24, these findings were reviewed with Staff 1 (Executive Director), Staff 3 (RN), Staff 4 (RCC), and Staff 22 (Regional Director of Operations).

Plan of Correction:

Within five days, Staff 3 and Staff 4 will review Resident 2's current needs and conduct a quarterly evaluation.

Based on interview, observation, and record review, conducted during a site visit on 8/14/24 through 08/16/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Finding include, but are not limited to:

In an interview on 08/16/24 at 2:17 pm, Staff 1 (Executive Director) stated the following:

* The facility uses proprietary software for their ABST.

* Software is tied into resident service plans.

* Facility takes the total care times (6791) divided by 60 (minutes in an hour), and divided by 7.5 hour shifts resulting in the total number of staff (15.09) per day

* Two residents are expected to move out by end of day.

* The facility's census was 58.

In an interview on 08/16/24 at 2:50 pm, Staff  4 (RCC) stated s/he does the staff schedule and schedules staff to the maximum number of staff that was set approximately three years ago and the facility's ABST is not referenced.

A review of the facility's ABST and resident rosters (undated) indicated the following:

* There were 57 residents were entered. One of the resident's entered had their move-in date postponed.

* All residents entered had their profiles updated within the last quarter.

* Two residents- Resident 10 and Resident 11 - were not listed on the ABST list.

The facility's posted staffing plan showed a total of 14 direct care staff are needed and this did not match or exceed the ABST.

c.

In separate interviews, direct care staff stated on day shift the facility is regularly staffed with two-to-three caregivers per floor and one medication technician per floor, and one bath aide per floor for a total of approximately 10 direct care staff on day shift, and approximately 6-8 direct care staff on swing shift.

A review of the facility's staff schedule, dated 08/01/24 through 0/31/24,  indicated the facility was staffed consistently above their ABST.

d.

In an interview on 08/15/24, at 1:25 pm, Resident 1 stated what his/her care needs were, call light response times were within 15 minutes, and had no complaints about his/her care needs. On 08/15/24,  at  2:01 pm, staff was observed responding to Resident 1's activated call light and provided toileting assistance.

In an interview on 08/15/24, at 2:27 pm, Resident 2 stated s/he gets showers two to three times per week unless s/he doesn't feel like it, and described the quality of care provided by direct care staff as "good".

In an interview on 08/15/24 at 3:07 pm, Resident 3 stated what his/her care needs were, described the quality of care provided by direct care staff as "good" and their response times to call lights as "fast".

The facility failed to fully implement and update an Acuity Based Staffing Tool after Resident 10 and Resident 11 were not listed in the facility's ABST.

On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Administrator).