Based on interview and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to ensure the completeness and accuracy of resident records for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

Resident 3 no longer resided in the facility. Compliance Specialist was unable to interview resident.

During an interview on 07/09/24, Staff 1 (Executive Director) indicated no knowledge of Residents POLST. Staff 1 could not explain why the information on Resident 3's POLST and service plan did not match and had not been accurate to Resident 3's preference.

A review of Resident 3's service plans dated 02/25/24 and 07/04/24 indicated resident was a do not resuscitate (DNR). Both service plans had not been signed off by the resident or resident's representative.

A review of Resident 3's POLST dated 03/23/21 indicated resident was not a DNR and would like to be resuscitated and given CPR. The resident's service plan and POLST status had not matched.

It was confirmed the facility failed to ensure the completeness and accuracy of resident records.

On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, during a site visit conducted on 07/08/24 and 07/09/24, it was confirmed the facility had not completed quarterly service plan evaluations. Findings include, but are not limited to:

During an interview on 07/09/24, Staff 1 (Executive Director) indicated there had been ten service plans that had not been updated quarterly.

An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date;

·Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.

·Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.

·Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.

·Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.

·Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.

·Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.

·Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24.

·Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24.

·Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24.

·Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24.

It was confirmed the facility had not completed quarterly service plan evaluations.

On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has been working on updating resident service plans to be up to date and person centered. Staff 1 indicated all service plans would be complete and updated in two weeks.

Based on observation, interview, and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

CS observed the following,

·Staff for Day shift (6:00 AM through 6:00 PM) on 07/08/24 and 07/09/24: two CG and two MT.

·Staff for Night shift (6:00 PM through 6:00 AM) 07/08/24: two CG and one MT.

During an interview on 07/09/24, Staff 1 (Executive Director) indicated the facility ABST was not in compliance. S/he indicated there had been ten service plans that had not been quarterly updated.

An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date;

·Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.

·Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24.

·Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.

·Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24.

·Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.

·Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24.

·Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24.

·Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24.

·Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24.

·Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24.

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 techs and two caregivers.

It was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST).

On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.