Based on interview, observation, and record review, it was confirmed the facility failed to provide a daily program of social and recreational activities that was based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:
During an unannounced inspection on 05/05/2022, the Compliance Specialists (CS) observed the following:
*The facility was home to ten residents with cognitive impairments and were unable to self-initiate activities.
*No activities were occurring or scheduled.
*The April 2022 activity calendar was still posted.
*Residents were observed sitting in front of the television or residents remained in their rooms unengaged with no activities.
*Staff were observed providing caregiving and medication duties, housekeeping, laundry, cooking, serving, feeding assistance and cleaning.
In separate interviews on 05/05/2022, Staff #1-#4 (S1-S4) stated the following:
*Staff are "Universal Workers" and their responsibilities include caregiving and medication duties, activities, all housekeeping duties, laundry service, all meal service including, cooking, serving, feeding assistance and cleaning.
*Activities have not occurred consistently since approximately March 2022.
*Activities are not important to corporate.
A review of the April 2022 Activity Calendar indicated that there are six activities listed on the schedule, but occurring at no specified scheduled time, and the first four activities are the same throughout the week: Morning Motivation, Storytime, Pledge of Allegiance, This Day in History. There were no other records available for review and no scheduled activities for month of May 2022.
On 05/05/2022, these findings were reviewed and acknowledged by Staff #4.
1. Actions taken to correct the rule violation include:
a. Facility hired an Assistant Administrator to start on 06/27/2022 who will be in charge of activities.
b. Having the Assistant Administrator provide individual and group activities that meet the physical, mental, psychosocial needs of residents.
c. Providing in-servicing to staff on creating unscheduled activities, and how to follow scheduled/directions for after hours activities.
2. System will be corrected by following the activities calendars consistently review of activities during monthly staff meetings, and ensuring staffing and supplies are available to meet the activity programming needs.
3. The area will be evaluated weekly, and then monthly with the creation of the new calendar for the facility.
4. Administrator and Assistant Administrator will be responsible for corrections being complete and moitoring.
1. Actions taken to correct the rule violation includes;
a. Full Time Admin hired 05/23.
b. Administrator taking classes to get licensed 06/27-07/01.
2. The system will be corrected so this violation will not happen again by ensuring the Administrator will be licensed by the week ending 07/08/2022.
3. Regional Director of Operations will evaluate area needing to be corrected daily.
4. Regional Director of Operations and new Administrator will be responsible to see that the corrections are completed and monitored.
Based on interview, observation, and record review, it was confirmed the facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident; and failed to increase staffing when employing universal workers. Findings include, but not limited to:
During an unannounced inspection on 05/05/2022, the Compliance Specialists (CS) did not observe any activities taking place.
A review of the facility's posted staffing plan indicated that between 7a.m. -3p.m., there is one Med Tech (MT) and one short-shift caregiver (CG); between 3p.m. - 11p.m. there is one MT and one short-shift CG; and on night shift between 11p.m. and 7a.m. there is one MT.
In separate interviews on 05/05/2022, Staff #1-#4 stated the following:
*The facility was home to 10 residents.
*Activities are not occurring.
*The Activity Coordinator position has been vacant for over a month.
*The facility uses a universal worker (UW) model whose duties include direct resident care, activities, housekeeping, laundry, environmental cleanings, and all meal service including food preparation, cooking, serving, and cleaning.
*The facility has decreased its budget resulting in fewer staff hours.
*Care staff schedule leave the MT on duty for the whole shift, when the short-shift leaves, there is only 1 staff member on duty for three hours (between 3p.m. and 6p.m.).
*Dinner is scheduled for 5:30 p.m. and during that time gap where there is only one staff member is onsite, their responsibilities include toileting residents, food preparation, cooking, food service, and clean up.
*Concerns during that three-hour gap if the staff on duty is assisting a resident in their apartment, there is no supervision of the other residents who are at risk of choking.
On 05/05/2022, these findings were reviewed with and acknowledged by S4, who stated the facility has been using staff from other facilities.
1. Actions to correct the rule violation includes;
a. Unreliable staff was terminated and new staff was hired.
b. New Administrator was hired on 05/23/2022.
c. New Assistant Administrator hired to start on 06/27/2022.
d. Region Director of Operations and Administrator filling in shifts as needed.
2. Regional Director of Operations and Administrator will monitor daily to ensure this violation will not happen again.
3. The area needing correction will be evaluated daily, 7 days a week.
4. The Regional Director Operations, Administrator, and Assistance Administrator will be responsible to see that the corrections are completed and monitored.