Based on interview and record review, conducted during a site visit on 11/13/23, it was confirmed the facility failed to implement services in accordance with resident service plan for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

In an interview on 11/13/23, Staff 1 (Executive Director) stated all caregivers tasks are electronically charted. Caregivers have access to residents' service plans electronically and all tasks appear on the charting dashboard according to service plans and are highlighted for caregiving staff to chart on if they are required to complete a task on that shift.

A review of Resident 1's service plan, dated 01/28/22 indicated resident required one-person assistance with toileting upon waking, before and after meals.

Resident 1's archived monthly charting, dated 02/05/22, indicated several areas were not signed off on as completed specifically around toileting assistance on day shift.

A review of the facility's self report indicated facility staff reviewed camera footage from the day and found "caregiver or nurse did not check on Member [Resident 1] between 6:30 am to 10 am, which is not in accordance with the service plan."

The facility failed to implement services in accordance with resident service plan.

The findings of the investigation were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 11/13/23, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool. Findings include, but are not limited to:

In an interview on 11/13/23, Staff 1 (Executive Director) reported the ABST was populated by the resident service plan and task sheets with time allotted to complete each task on each shift.

A review of the facility's ABST indicated the facility tool did not contain all required 22 ADL's including the following:

* Providing additional care service, such as smoking assistance or pet care; and

* Medication administration, passing out medications.

The facility failed to fully implement and update an acuity-based staffing tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 11/13/23.

Based on interview and record review, conducted during a site visit on 11/13/23, it was confirmed the facility failed to ensure direct care staff had received orientation to residents for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

In an interview Staff 1 (Executive Director) stated all caregivers have access to resident service plans electronically and any updates highlight for them to review and staff have to select highlighted information to review at the start of each shift. Staff are then prompted to complete highlighted tasks that relate to resident service plan that are required to be completed on the shift.

A review of Resident 1's service plan, dated 01/28/22, and progress notes, dated 01/28/22 - 02/07/22, indicated staff working on 02/05/22 to provide care for Resident 1 had not reviewed or signed off on Resident's service plan or ISPs.

A review of the facility self-report dated 02/11/22 indicated caregiver did not review or sign-off on the service plan/ISPs. The secondary caregiver had signed off on Resident 1's service plan and ISPs on 02/05/22, but it was not clear at what time these documents had been signed off on.

The facility failed to ensure direct care staff had received orientation to residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1.