Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. Findings include, but are not limited to:

Documentation of residents showers dated 07/13/24 through 07/15/24 was obtained and reviewed on 07/16/24. A review of the records revealed residents showers and nail care are documented by care staff.

During a phone interview on 07/19/24, Staff 6 (Administrator) stated the CGs fill out shower sheets and nail care daily and give them to the MT to review and sign. They are then given to RCC and RN for review and shredded. Staff 6 stated they do not document what was indicated on the shower sheets anywhere in the residents records prior to shredding.

The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.

The facility failed to ensure  the preparation, completeness, accuracy, and preservation of resident records.

Verbal plan of correction: Administrator will maintain shower documentation.

Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to promptly investigate all reports of abuse and suspected abuse and take measure to protect residents and prevent reoccurrence of abuse for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily.

A review of an incident report dated 01/08/24 noted "Since 12/04/23 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."

During an interview on 07/16/24, Staff 6 (Administrator) stated the entirety of the investigation was included in the Incident Report dated 01/08/24.

There was no documented evidence of the following required elements of the investigation:

*Time, date, place and individuals present;

*Description of events as reported;

*Response of staff at the time; and

*Follow-up action.

The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.

The facility failed to promptly investigate all reports of abuse and suspected abuse.

Verbal Plan of correction: Regional nurse will provide education on investigations to Administrator and facility RN by end of day 07/26/24.

Based on interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to report any suspected abuse to the local APS office for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily.

A review of an incident report dated 01/08/24 noted "Since 12/4 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."

A review of an email from Staff 6 (Administrator) to APS on 01/10/24 did not include the information that this error occured multiple times. The email stated, "It was discovered yesterday that [Resident 1] received .5 ML rather than 5 ML of Keppra."

The compliance Specialist referred the incident to Adult Protective Services on 07/17/24.

The facility failed to report any suspected abuse to the local APS office.

The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.

Verbal Plan of correction: Administrator to report any abuse or neglect that he can not be definitively ruled out within 24 hours.

Based on observation, interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to ensure the implementation of services for 2 of 2 sampled residents (#s 1 and 3). Findings include, but are not limited to:

During the site visit, Resident 1 and Resident 3 were not observed to be left in their pajamas or be left in soiled briefs or on soiled chucks.

Discrepancies between observations, resident and staff interviews, and Resident 1's service plan dated 04/11/24 were identified in the following areas:

*Toileting;

*Oral hygiene; and

*The use of a fall mat at Resident 1's bedside.

Resident 1's service plan indicated Resident 1 was to be toileted before and after meals. Resident 1 was observed to not be toileted before or after the morning meal and did not receive oral care on 07/16/24. A fall mat was observed at Resident 1's bedside on 07/16/24 and 07/17/24 but the service plan lacked direction for its use.

During an interview on 07/16/24, Staff 3 (MT/CG) stated Resident 1 was not toileted before the meal or provided oral care assistance due to "running out of time." S/he further stated that Resident 1 had falls out of bed so it was decided to place a fall mat at his/her bedside while s/he was sleeping for his/her safety.

Discrepancies between resident and staff interviews and Resident 3's service plan dated 05/10/24 were identified in the following areas:

*Toileting

Resident 3's service plan indicated Resident 3 was to be toileted before and after meals. Resident 3 was observed to not be toileted on 07/16/24 before or after the morning meal.

The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.

The facility failed to ensure the implementation of services.

Verbal plan of correction: Administrator will re-educate team members on service plans and will have lead MT audit the particular ADL needs with each resident.

Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily.

A review of an incident report dated 01/08/24 noted "Since 12/4 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."

During an interview on 07/15/24, Staff 8 (RN) confirmed the errors occurred.

The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.

The facility failed to carry out medication orders as prescribed.

Verbal plan of Correction: Nurse to audit physician orders, MAR and carts weekly.  MT meeting scheduled by end of day 07/26/24 and will provide education on adherence to five rights of medication administration.

Based on observation, interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

During the site visit the facility's posted staffing plan was observed and reviewed which indicated the need for the following staff:

Day: 4 CG, 2 MT

Evening: 4 CG, 1 MT

Night: 2 CG, 1 MT

Only 1 CG and 1 MT were noted to be working between the hours of 2:00 am and 5:00 am on 07/16/24.

During an interview on 07/16/24, Staff 2 (MT) stated there were four residents who required the assistance of two people for transfers and/or cares.

The following inconsistencies between resident ABST profiles and resident needs were identified during the site visit:

*Resident 1 required the assistance of two people for transfers and care, but his/her ABST profiled did not reflect this.

*Resident 2 could become agitated and staff were to provide redirection but zero minutes were reflected in ABST for cueing and redirection due to cognitive impairment and/or interventions for behaviors.

*Resident 3 had behaviors but  zero minutes were reflected in ABST for cueing and redirection due to cognitive impairment and/or interventions for behaviors.

Resident 1's service plan dated 04/11/24 indicated Resident 1 was to be toileted before and after meals. Resident dent 1 was observed to not be toileted before or after the morning meal and did not receive oral care on 07/16/24.

During an interview on 07/16/24, Staff 3 (MT/CG) stated Resident 1 was not toileted before the meal or provided oral care assistance due to "running out of time."

Resident 3's service plan dated 05/10/24 indicated Resident 3 was to be toileted before and after meals. Resident 3 was observed to not be toileted on 07/16/24 before or after the morning meal.

Additionally, the facility's shower documentation for 07/13/24 through 07/15/24 were reviewed which revealed an unsampled resident did not receive a  shower on 07/14/24 due to " no time, to much going on."

The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.

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