Based on observation, interview and record review, conducted during a site visit on 07/01/24, it was confirmed the facility failed to provide a daily program of social and recreational activities. Findings include, but are not limited to:

During the site visit on 07/01/24 the facility's activity schedule for July 2024 was observed and reviewed. Sundays and Mondays were noted to contain only one activity each day:

Sunday: Church at 1pm; and

Monday: Movie Matinee with no time listed.

During separate interviews, unsampled residents stated:

*The facility had activities Tuesday through Saturday when the activity director was scheduled;

*S/he would like to see more activities. S/he would like a van or bus to do group outings like parks or

picnics, and would like to be able to shop; and

*There are not a lot of activities available so s/he doesn't participate.

No activities were observed during the site visit.

The facility failed to provide a daily program of social and recreational activities.

The findings were reviewed with and acknowledged by Staff 6 (Administrator), Staff 7 (Regional RN) and Staff 8 (Regional Operations) on 07/01/24.

Verbal plan of correction: Over the next 30 days, Activities Director to complete 1:1 visits with residents to better identify what activities residents want. Administrator will be responsible to ensure activities occur on Sundays and Mondays in the absence of activities staff.

Based on interview and record review, conducted during a site visit on 07/01/24, it was confirmed the facility failed to carry out medication and treatment 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 orders revealed Vitamin D3 1000ui 1 cap by mouth once a day.

A review of Resident 1's records revealed a fax to physician dated 05/07/24 that indicated, "[Resident 1] is on Vitamin D3 1000 ui, the vitamin D3 family provided is Vitamin D3 2000 ui... not sure how long [s/he] was gettng 2000 ui insread of 1000 ui. [S/he's] on alert to monitor.

During an interview on 07/01/24, Staff 7 (Corportate RN) confirmed Resident 1 received the wrong dose of Vitamin D3 for some time.

The findings were reviewed with and acknowledged by Staff 6 (Administrator), Staff 7 and Staff 8 (Regional Operations) on 07/01/24.

The facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: The facility had corrected the issue and had the correct doseage on hand during to the site visit.

Based on observation, interview and record review, conducted during a site visit on 07/01/24, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 3 of 3 sampled staff (#s 1, 3 and 4). Findings include, but are not limited to:

Staff 1 was observed working independently on 07/01/24.

A review of Staff 1's training documents including Part II Direct Care staff due on 11/8/23 were unsigned by Staff 1 and the trainer. Staff 6 (Administrator) signed the documents on 07/01/24 during the site visit. Staff 1's medication and competencies checklist were completed on 01/26/24 and were not signed by the trainer.

Staff 3 was observed working independently on 07/01/24.

A review of Staff 3's training documents including Care Partners Job Skills training was completed on 12/05/23 and was signed by the trainer on 12/13/23 and signed by Staff 3 on 07/01/24. Staff 3's Orientation Part II - Direct Care Staff due on 12/28/23 were signed by Staff 3 and Staff 6 on 07/01/24 and were not signed by the trainer.

Staff 4 was observed working independently on 07/01/24.

A review of Staff 4's training documents including Care Partners Job Skills Training revealed training began on 01/04/24 and was not signed by Staff 4 or the trainer until 07/01/24. Staff 4's Orientation - Part II: Direct Care Staff due on 03/02/23 was signed by Staff 4, the trainer and Staff 6 on 07/01/24.

During an interview on 07/01/24, Staff 8 (Regional Operations) was asked why training documents completed 6 or more months ago were signed today, she stated she spoke with Staff 6 who realized she hadn't signed the training documents back then, so she signed them today. Staff 8 stated she re-educated Staff 6 on the importance of completing training documents timely.

The findings were reviewed with and acknowledged by Staff 6, Staff 7 (Corporate RN) and Staff 8 on 07/01/24

The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing.

A written plan of correction was requested and accepted during the site visit.

Based on interview, conducted during a site visit on 07/01/24, 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 for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

During an interview on 07/01/24, Staff 8 (Regional Operations) stated she had self-reported the incident in which Resident 4's toilet seat was left broken and fired the maintenance director because of the incident.

Resident 4 no longer resided in the facility and was unable to be interviewed or observed.

The findings were reviewed with and acknowledged by Staff 6 (Administrator), Staff 7 (Corporate RN) and Staff 8 on 07/01/24.

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