Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, 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 (#2). Findings include, but are not limited to:

During the site visit on 05/13/24, the Compliance Specialist was alerted to a situation in which Resident 2 was seated in a wheelchair and experienced an unwitnessed fall.

On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only.

The use of a wheelchair was not mentioned in Resident 2's service plan dated 05/07/24.

During an interview by phone on 05/15/24, Staff 1 (Administrator), Staff 10 (RN) and Staff 22 (Consultant) were asked if the incident was investigated by the facility and how abuse or neglect was ruled out. Staff 1 explained that he assessed the resident and that the resident had been observed less than 10 minutes prior to being discovered. The CS stated the service plan did not mention the use of a wheelchair and asked for clarification on its use. Staff 22 stated abuse or neglect could not have been ruled out if the service plan was not being followed or was not reflective of Resident 2's needs.

A review of a fall investigation initiated on 05/11/24 confirmed Resident 2 had a fall after sitting in an unlocked wheelchair. The incident was reported by the facility to APS on 05/15/24 at the direction of the CS.

The findings were reviewed with and acknowledged by Staff 1, Staff 10, and Staff 22 by phone on 05/15/24.

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

Verbal plan of correction: Consultant was in the facility weekly, reviewed incidences from the previous week and working with clinical staff for follow-up.

Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plans were readily available to staff and provide clear direction regarding the delivery of services for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

During the site visit on 05/13/24, Resident 5's service plan available to staff on the floor only contained even pages and was incomplete.

During an interview on 05/13/24, Staff 1 (Administrator) stated he had printed a complete service plan and asked staff to put it in the binder the week prior. He further stated he would ensure a complete service plan was added to the binder immediately.

Upon return to the facility on of 05/14/24, Resident 5's service plan was complete and available to staff.

The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24.

The facility failed to make service plans readily available to staff.

Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and implemented by staff for 1 of 4 sampled residents (#2). Findings include, but are not limited to:

Inconsistencies were identified between Resident 2's service plan dated 05/07/24, observations of care and interviews with staff in the following areas:

*Ambulation; and

*Use of a wheelchair

During an observation on 05/14/24, Staff 7 (CG) was observed attempting to help Resident 2 stand. Staff 7 stated loudly s/he wasn't sure what to do. Staff 8 (CG) went to Resident 2 and Staff 7 and assisted Resident 2 to standing and assisted him/her in walking to the dining area with two handed assistance.

Resident 2's service plan noted Resident 2 "requires assistance from one care team member with mobility for safety per PT on 11/10/23. [Resident 2] is able to walk independently but needs guidance with [his/her] escorts due to poor safety awareness."

On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only.

A review of a fall investigation initiated on 05/11/24 revealed Resident 2 had a fall after sitting in an unlocked wheelchair. The use of a wheelchair was not mentioned in Resident 2's service plan.

During an interview on 05/14/24, Staff 8 stated Resident 2 needed a lot of cueing. Staff 8 further stated Staff 7 was a newer CG, and needed to be shown how to help Resident 2. Staff help Resident 2 walk to/from all meals and activities.

The facility failed to ensure the service plan was reflective of resident needs and implemented by staff.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24.

Verbal plan of correction:  Service plans will be reviewed by end of day 05/15/24 and ongoing in clinical meeting and weekly.

Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's progress notes dated 04/03/24 through 05/13/24 and Temporary Service Plans dated 04/06/24 through 04/30/24 revealed:

*On 04/18/24 Resident 2's PCP was contacted related to concern for a Urinary Tract Infection and genital herpes.

*On 04/20/24 Resident 2 started Miralax for constipation.

There was no documented evidence of written communication of Resident 2's change of condition, and any required interventions, for direct care staff on each shift.

During an interview on 05/15/24, Staff 1 (Administrator) stated he was alerted in the facility's stand-up meeting that staff were trying to get a urinalysis for Resident 2 on 04/18/24 because they "felt s/he was not his/herself". Staff 1 further stated that should have been documented by the MT, but was not and Resident 2 was not put on alert for monitoring the change of condition.

The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24.

The facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day.

Verbal plan of Correction: In clinical meeting the facility would review TSPs, alert charting and missed medications daily.     

Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to cary out medication orders as prescribed for 1 of 1 sampled residents (#3). Findings include, but are not limited to:

A review of Resident 3's signed physican orders dated 03/19/24 revealed an order for Levothryroid 100 mcg once daily.

A review of Resident 3's MAR dated 03/01/24 through 03/31/24 revealed Resident 3 missed one dose of the medication on 03/21/24.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24 who confirmed the error occured.

The facility failed to carry out medication orders as prescribed.

Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider.

Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facillity 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 physician order dated 02/02/24 revealed an order for: Lorazepam (anxiety medication) 0.5 mg tablet take one tablet by mouth once a day.

A review of Resident 1's MAR dated 02/01/24 through 02/29/24 revealed Resident 1 missed one dose of the medication on 02/03/24.

The findings were reviewed with Staff 1 (Administrator) on 05/13/24 who confirmed the error occured.

The facillity failed to carry out medication orders as prescribed.

Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider.

Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to administer medications as prescribed for 1 of 1 samped resident (#4). Findings include, but are not limited to:

A review of Resident 4's signed physician orders dated 11/12/23 revealed an order for: Donepezil (dementia medication) 6 mg tablet, take one tab by mouth once a day.

A review of Resident 4's MAR dated 02/01/24 through 02/29/23 revealed Resident 4 missed one dose of the medication on 02/12/24.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24, who confirmed the error occured.

The facility failed to administer medications as prescribed.

Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider.

Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to keep all interior materials and surfaces clean, and in good repair. Findings include, but are not limited to:

At approximately 11:39 am on 05/13/24, Staff 3 (CG) was observed assisting Resident 2 in ambulation to a table in the dining area. During the observation, the rubber threshold between a carpeted area and a linoleum area was loose from the floor and presented a tripping hazard to Resident 2.

During an interview on 05/13/24, Staff 1 (Administrator) stated a maintenance person would work to fix that by end of day.

Upon return to the facility on 05/14/24, the section of threshold that was previously loose was adhered to the floor.

The facility failed to keep all interior materials and surfaces clean, and in good repair.

The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24.