Based on interview and record review, conducted during a site visit on 02/14/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 3 of 3 sampled residents (#'s 1, 4 and 5). Findings include, but are not limited to:

During an interview on 02/14/24, Staff 1 (ED) indicated when chart notes are duplicated or written incorrectly, staff have removed them, this would result in an error message but would still have a timestamp that a chart note had been made.

During separate interviews on 02/14/24, staff indicated the following:

·There was controversy over allegations of deleting chart notes a couple months ago.

·I had made chart notes regarding residents with behaviors in which I have come in the next day and have seen the notes had been deleted.

· When chart notes were deleted there still had been a timestamp of when the chart was made with an error message in place of where the chart notes had been origianlly created.  

·The chart notes deleted were of residents with behavioral concerns.

A review of pictures provided and Resident 1, 4, and 5's progress notes dated 10/05/23 through 11/05/23, showed chart notes that had an error message.

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

On 02/14/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED educated staff regarding chart notes and how to properly edit information without jeopardizing content.

Based on interview and record review, conducted during a site visit on 02/14/24, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

During an interview on 02/14/24, Staff 1 (ED) stated, "There have been reports that were not immediately turned in."  

A review of Resident 3's incident reports dated 12/05/23 and 12/07/23, which involved resident to resident altercations, showed incidents which occurred on 11/26/23, 11/28/23, 11/30/23, 12/05/23, and 12/07/23 had not been reported until 12/15/23.

It was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

On 02/14/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED will review reportable events daily at standup meeting with RN and MCD to ensure reportable events are completed timely.

Based on observation, interview, and record review, conducted during a site visit on 02/14/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

On 02/14/24, CS observed the following,

·Resident 2 had aggressive behavior during day, swing, and night shift. Behaviors included the following,

oPushing and throwing over items in the facility.

oPouring hot coffee on the ground.

oCursing and yelling.

oYanking a resident dog ' s leash and attempting to pull the dog away.

oUnsampled residents expressing that they were scared and felt unsafe.

·One MT and one CG worked night shift. Resident 2 needed one staff to monitor during his/her aggressive behavior.

·An unsampled resident had an unwitnessed fall and had been yelling for help.

During separate interviews on 02/14/24, staff indicated the following,

·The facility was home to 27 residents.

·There were three two-person transfers.

·There had been multiple residents with behavioral issues and who had exhibited volent tendencies.

·There had been multiple resident-to-resident altercations that occurred.

·At night, Resident 2 needed consistent staff monitoring. Staff had been unable to complete tasks while monitoring Resident 2. These tasks included the following:

oResidents have waited longer than 20 minutes for their needs to be met, such as toileting assistance.

oWeekly housekeeping such as cleaning and resident laundry have been delayed or missed.

The facility's posted staffing plan was observed and reviewed on 02/14/24, which included the need for the following staff:

·Day shift: one MT and three CGs

·Swing shift: one MT and three CGs

·Night shift: one MT and one CG

A review of Resident 2's temporary service plans indicated the resident had aggressive behaviors documented on 01/10/24, 01/12/24, 01/17/24 01/21/24, 01/23/24, 02/04/24, 02/05/24, 02/07/24, and 02/09/24.

A review of Resident 2's progress notes from 01/16/24 through 02/14/24, a chart note on 02/12/24 stated potential for one-on-one caregiver to come support resident between 8:00 AM through 6:00 PM to reduce resident on resident events and falls.

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

On 02/14/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED brought on an additional staff member to assist Resident 2 with one-on- one assistance.

Based on observation and record review, conducted during a site visit on 02/14/24, it was confirmed the facility failed to evaluate behavioral symptoms which negatively impact the resident and others in the community and initiate and coordinate outside consultation or acute care when indicated for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 was admitted to the memory care on 01/10/24 with diagnoses including dementia.

Resident 2's service plan dated 01/08/24 described the resident as "cooperative" and stated the resident had "No behavior issues" "[Residents name] does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior."

The following behaviors were documented in the resident's progress notes, dated 01/16/24 through 02/14/24, and TSP's:  

·01/10/24-  "Aggressive behaviors with staff."  

·01/12/24-  "Resistant to care- presenting in aggressive/ defensive matter."

·01/12/24-  "Resident throwing dishes."

·01/17/24-  "Resident was physical with staff during re-direction."  

·01/21/24-  "Resident to resident event."

·01/23/24-  "Resident to resident event with room 7."

·02/04/24-  "Resident entered room 8, pushed resident on left shoulder."  

·02/05/24-  "Resident touched room 8's hat resulting in a physical altercation,"  and "Resident approached room 34 from behind and squeezed arm."

·02/07/24-  "Resident does not respond to redirection."  

·02/13/24-  "Resident to resident events and falls between 02/09/24 through 02/13/24."

A review of Resident 2's progress notes from 01/16/24 through 02/14/24, and a chart note written on 02/12/24 stated a potential for a one-on-one caregiver to support resident between 8:00 am through 6:00 pm to reduce resident to resident events and falls.

On 02/05/24 a TSP stated, "Care conference held following interventions to be in place for resident." Interventions include:  

·Use gentle even toned voice when talking to resident.

·Avoid "no," "can't," "wont," and "shouldn't."  

·Redirect instead of "negative words."

·Offer chocolate, sweets, apple juice, hot cocoa, and peanut butter for snacks.

·Offer fidget basket in activities closet during activities and after meals.

On 02/14/24 the following behaviors were observed:

·Wandering up and down hallways entering other resident's rooms, touching other individuals without warning.

·Approaching other residents swearing and yelling at them.

·Repeatedly pushing items on the floor.  

·Resident 2 grabbing items from other residents.

There was no documented evidence the interventions had been working nor new interventions had been put into place after each incident had occurred. There was no evidence the facility updated the residents service plan after multiple change of conditions had been noted in the progress notes dated 01/16/24 through 02/14/24.

It was confirmed the facility failed to evaluate behavioral symptoms which negatively impact the resident and others in the community and initiate and coordinate outside consultation or acute care when indicated.

On 02/14/24, the findings were reviewed with and acknowledged by Staff 1 (ED).

Verbal plan of correction: Not provided.

Based on observation and interview, conducted during a site visit on 02/14/24, it was confirmed the facility failed to individually identify residents' rooms to assist residents in recognizing their room, for 1 of 1 sampled resident (#7) and multiple unsampled residents. Findings include, but are not limited to:

On 02/14/24, CS observed nine resident rooms with no personal identifiers outside the rooms to assist residents to recognize his/her rooms.

During an interview on 02/14/24, Resident 7 indicated frustration with his/her room not being labeled with his/her name. S/he was new to the building and found it hard to know where his/her room was.

It was confirmed the facility failed to individually identify residents' rooms to assist residents in recognizing their room.

On 02/14/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The reception will reach out to families to bring in special trinkets for the resident's shadow box by 2/23/24. Ensure that residents have name outside of room indicating whose room it belongs to by 2/23/24.