Based on observation, interview and record review it was confirmed that the facility failed to exercise reasonable precautions. Findings include but not limited to:

During an unannounced site visit on 7/7/2022, Compliance Specialist (CS) observed multiple staff members not wearing surgical masks. Many more employees were not wearing masks appropriately, with the masks below their nose.

A review of the facility's screening records for 7/7/2022 indicate that two employees did not have their temperature taken and at least two employees, Staff #1 (S1) and Staff #2 (S2), were not screened at all.

These findings were reviewed with and acknowledged by S1 on 7/7/2022.

Facility Plan of Correction: Receptionist to review all screening sheets immediately and verify temperatures. Staffing Coordinator to be second set of eyes to verify. Executive Director to provide in-service and education on masking and screening policies to all staff.

Based on observation, record review and interview it was confirmed that the facility failed to have enough qualified awake direct care staff, sufficient in number to meet the scheduled and unscheduled need of each resident. Findings include but not limited to:

During an unannounced site visit on 7/7/2022, Compliance Specialist (CS) observed four caregivers (CG) and two Medication Technicians (MT) working on the floor upon arrival during day shift.

A review of the facility's posted staffing plan and Uniform Disclosure Statement dated 3/11/2022 indicates that there are to be seven CGs and two MTs working during the day shift.

In separate interviews with Staff #1 (S1) and Staff #4 (S4) indicated:

*There should be 5 caregivers working during the day.

*There are 75 hours of care needs during the day shift.

*At least one more CG is needed during day shift.

These findings were reviewed with and acknowledged by S1 on 7/7/2022.

Facility Plan of Correction: Executive Director and Staffing Coordinator to review Acuity Based Staffing Tool and arrange staff schedule so that their needed care hours are met.

Based on interview and record review it was confirmed that the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation or written testing. Findings include but not limited to:

During an interview, Staff #1 (S1) reported that all employees are Universal Workers and able to provide care to residents.

During an interview Staff #6 (S6) reported that they had worked on the floor one day providing care to residents.

A review of facility training records for Staff #6-#8 (S6-S8) indicates none have received any training in providing care to residents.

These findings were reviewed with and acknowledged by S1 on 7/7/2022.

Facility Plan of Correction: Executive Director and Staffing Coordinator to review all training records of current staff to identify staff who are not trained to provide care and provide updated job descriptions. Schedule training days for those staff qualified as universal workers who may be expected to provide care. Work on a system for documenting time spent providing care once trained, if not part of their regular duties.