Based on observation, interview, and record review conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to have a service plan that reflects the resident's needs for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

On 02/22/24, CS observed the following:

·Staff assisted Resident 4 with ambulation and bathroom assistance.

·An erase board in the medication room indicated Resident 4 needed one-hour checks.

During shift change from day shift to swing shift on 02/22/24, CS interviewed Staff 3 (CG), Staff 4 (CG), Staff 5 (CG), Staff 6 (CG), Staff 7(CG), and four additional unsampled staff who all indicated Resident 4 was not independent with transferring/ambulation, toileting, and bathing. Staff indicated Resident 4 was on frequent checks to assist with his/her toileting needs.

During an interview on 02/22/24, Resident 5 indicated Resident 4's service plan had not properly reflected his/her needs.

A review of Resident 4 service plan dated 01/20/24, indicated the following:

·Receive one person assistance with bathing twice a week.

·Independent with bladder management, sometimes wearing briefs and was independent with changing those.

·Independent with transferring and mobility.

A review of a temporary service plan (TSP) dated 12/10/24, indicated resident must have help with ambulation to the bathroom, bed, and wheelchair. An additional TSP on 01/10/24 indicated staff to encourage the resident to use call pendent for transfers.

A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays.

A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24.

On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED and RCC plan to have a care conference with residents' daughter to reflect the resident current care needs and a TSP will be created for resident in the meantime.

Based on observation, interview, and record review, conducted during a site visit on 02/21/24 through 02/22/24, 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. Findings include, but are not limited to:

On 02/22/24, CS observed the following:

·The elevator was still broken.

·Three CGs and two MTs working.

·During lunchtime from 1:00 PM through 2:00 PM, one CG took a resident across the street to the hospital while the other two CG's were assisting residents up and down the elevator.

The facility's posted staffing plan was observed and reviewed on 02/21/24, which included the need for the following staff:

·Day shift: two MTs and three CGs

·Swing shift: two MTs and three CGs

·Night shift: one MT and two CGs

During an interview on 02/21/24, Staff 1 (ED) indicated the facility's main elevator had been broken since the end of December 2023. There was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors staff members had been assisting. There must be one staff member stationed on the first floor and one on the second floor. Due to this, s/he had added an additional staff member to assist. The additional staff had not been added to the schedule until 02/15/24. Staff 1 stated, "There had been a few residents who had fallen on the stairs, however it had been a direct result of the elevator being broken."

A review of timecards for 02/05/24 through 02/06/24, indicated the facility had been staffed lower than the posted staffing plan listed above.

A review of call light logs from 02/05/24 through 02/06/24, indicated 56 call light response times exceeded 15 minutes, and of those, 36 exceeded over 20 minute response times.

A review of the staff schedule for 01/07/24 through 02/22/24 indicated the facility had not been consistently staffing an additional staff member to meet the additional needs with the broken elevator.

A review of Resident 4s service plan dated 01/20/24, indicated resident was to received assistance with bathing twice a week.

A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays.

A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24.

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.

On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week, the facility will continue to add an additional staff personal for assistance. There had only been one person who showered a resident, the RCC had that person train a few additional staff in the hopes of the resident receiving showers twice a week like their service plan stated. ED will continue to monitor call light response times and conduct additional training to staff within the next week. Staff have in place to give reminders to residents to take the elevator.

Based on observation and interview, conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair. Findings include, but are not limited to:

On 02/21/24 and 02/22/24, CS observed the main elevator was broken and not in use.

During separate interviews on 02/21/24 and 02/22/24, staff indicated the elevator was broken and had been since the end of December 2023. Staff 1 (ED) indicated there was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors, staff members had to assist.

It was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair.

On 02/22/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week.