Based on interview and record review, conducted during a site visit on

06/12/24, it was confirmed the facility failed to implement a service plan that

reflects the resident's needs for 3 of 3 sampled residents (#s1, 2, and 3).

Findings include, but are not limited to:

During an interview on 06/12/24, Staff 1 (ED) indicated the facility was cited

during their survey conducted on 05/21/24 for service plans not being person

centered. Staff 1 indicated s/he and Staff 2 (RCC) had been working on

changing and updating all resident service plans.

A review of service plans indicated the following;

·  Resident 1 service plan dated 05/17/24, indicated resident was

independent with showers. Staff are to provide stand by assistance with

showers to help reduce falls.

·  Resident 2 service plan dated 04/22/24, indicated resident was a one person full assist twice per week.

·  Resident 3 service plan dated 04/30/24, indicated resident was a two person full assist twice per week.

A review of the shower schedule indicated the following;

·  Resident 1 scheduled for showers on swing shift for Monday and

Wednesdays.

·  Resident 2 scheduled for showers on swing shift for Sunday and

Thursdays.

·  Resident 3 scheduled for showers on day shift for Wednesday and

Saturdays.

A review of shower sheets from 04/01/24 through 06/05/24 provided from the

facility indicated the following;

·  Resident 1 had not been provided eighteen of twenty showers during the

timeframe.

·  Resident 2 had not been provided fifteen of eighteen showers during the

timeframe. A shower sheet on 04/20/24, noted residents '  hair was

matted and scalp was irritated and scabby.

·  Resident 3 had not been provided five of nineteen showers during the

timeframe.

It was confirmed the facility failed to implement a service plan that reflects the

resident's needs.

On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal POC: ED and RCC have been going through all resident's service

plans to make them more person centered. ED will bring back shower sheet

and ensure staff have completed them and will audit to ensure showers are

being provided.

Based on interview and record review, conducted during a site visit on

06/12/24, it was confirmed the facility failed to ensure the staff person who

administers the medication must visually observe the resident take the

medication for 1 of 3 sampled residents (#1). Findings include, but are not

limited to:

During an interview on 06/12/24, Staff 1 (ED) indicated there had been issues

with staff not observing residents take his/her medications. Staff 1 stated s/he

had planned to request an order from Resident 1's physician to allow

medications to be left at bedside, as this was Resident 1's preference. S/he

acknowledged there was no current order.

During an interview on 06/12/24, Resident 1 stated, "There have been times

staff has left my medication on the counter since it takes me awhile to take my

medication in the morning."

A review of the service plan for Resident 1 dated 05/17/24, indicated the

resident required assistance with medication two times a day.

It was confirmed the facility failed to ensure the staff person who administers

the medication must visually observe the resident take the medication.

On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal POC: The facility will follow the doctor's orders as prescribed effective

immediately. The ED will reach out to doctor for approval to get a bedside

medication order.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

During an interview on 06/12/24, Resident 1 indicated call light response times take longer than 20 minutes to get staff to respond and assist. Resident 1 indicated s/he had not received showers due to lack of staff.

During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility scheduled two 12-hour shifts and does not follow the three 8-hour shifts.

A review of the posted staffing plan indicated the following:

·Day shift: Two caregivers and two med techs.

·Swing shift: Two caregivers and two med techs.

·Night shift: Two caregivers and one med tech.

A review of the facility's staff schedule and timecards for 04/01/24 through 04/03/24 and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan.

A review of the facility-wide call light history report dated 04/25/24 through 05/01/24 indicated 32 call light response times that had exceeded 15 minutes. Twenty of those response times had exceeded 20 minutes with the longest wait time of 30 minutes.

A review of service plans indicated the following:

·Resident 1's service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls.

·Resident 2's service plan dated 04/22/24, indicated resident was a one-person full assist twice per week.

·Resident 3's service plan dated 04/30/24, indicated resident was a two-person full assist twice per week.

A review of the shower schedule indicated the following:

·Resident 1 scheduled for showers on swing shift for Monday and Wednesdays.

·Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.

·Resident 3 scheduled for showers on day shift for Wednesday and Saturdays.

A review of shower sheets, dated 04/01/24 through 06/05/24, provided from the facility indicated the following:

·Resident 1 had not been provided eighteen of twenty showers during the timeframe.

·Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents' hair was matted and scalp was irritated and scabby.

·Resident 3 had not been provided five of nineteen showers during the timeframe.

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

On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will continue to audit call lights and will ensure showers are completed.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility had been scheduling for two 12-hour shifts and was not appropriately staff to accommodate three 8-hour shifts. The facility had one resident who required two-person transfer and the current census was 49 residents.

A review of the posted staffing plan and the facility ABST indicated the following;

·Day shift from 6:00 AM to 2:00 PM staffed with two med techs and two caregivers.

·Swing shift from 2:00 PM to 10:00 PM staffed with two med techs and two caregivers.

·Night shift from 10:00 PM to 6:00 AM staffed with one med tech and two caregivers.

A review of the facility's staff schedule and timecards, dated 04/01/24 through 04/03/24, and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan.

A review of service plans indicated the following;

·Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls.

·Resident 2 service plan dated 04/22/24, indicated resident was a one-person full assist twice per week.

·Resident 3 service plan dated 04/30/24, indicated resident was a two-person full assist twice per week.

A review of the shower schedule indicated the following;

·Resident 1 scheduled for showers on swing shift for Monday and Wednesdays.

·Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.

·Resident 3 scheduled for showers on day shift for Wednesday and Saturdays.

A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following;

·Resident 1 had not been provided eighteen of twenty showers during the timeframe.  

·Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents'  hair was matted and scalp was irritated and scabby.

·Resident 3 had not been provided five of nineteen showers during the timeframe.

It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.

On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on

06/12/24, it was confirmed the facility failed to have a training program that

includes abuse and reporting requirements. Findings include, but are not

limited to:

During separate interviews on 06/12/24, Staff 1 (ED) indicated the facility was

cited during their survey conducted on 05/21/24 for incomplete training

records including abuse and reporting. The facility will have an all-staff training

on Friday 06/14/24 to go over abuse and reporting practices. When Staff 6

(MT) was asked the procedure for abuse and reporting, Staff 6's response was

to contact the RCC, and s/he was not familiar with the correct policy and

procedure for reporting.

A review of the facility policy and procedure for elder abuse, neglect, and

exploitation dated 12/09/21 indicated all personal care attendants will receive

in-service training on elder abuse incidents, signs and symptoms of abuse,

and reporting requirements during initial orientation.

A review of Staff 3 (MT), Staff 4 (MT), and Staff 5's (CG) 30-day competency

training records indicated Staff 3 and Staff 4 had complete training which

included when to fill out incident report and call 911. The facility could not

provide Staff 5's competency checklist. The three staff had completed the

Relias training which included preventing, recognizing, and reporting abuse.

It was confirmed the facility failed to have a training program that includes

abuse and reporting requirements.

On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The company and facility are working together to

create a more extensive training program to include knowledge of abuse and

reporting. ED will ensure all staff have completed required training within 30

days.