Based on interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in for 2 of 2 sampled residents (#s 5 and 6). Findings include, but are not limited to:

Resident 5's initial service plan was dated 07/13/23. Resident 5's next service plan was dated 09/04/23.

Resident 6's initial service plan was dated 07/13/23. Resident 6's next service plan was dated 09/04/23.

During an interview on 06/13/24, Staff 12 (Administrator) stated when the event occurred, they did not have a Resident Care Coordinator (RCC) and there was a lapse in the responsibility for service plans.

The facility failed to review the initial service plan within 30 days of move-in.

The findings were reviewed with and acknowledged by Staff 12 on 06/13/24.

Verbal plan of correction: The facility now has two fully trained RCCs who are responsible for coordinating all service plan reviews.

Based on observation, interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, 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 (#1). Findings include, but are not limited to:

During an observation and interview on 06/11/24, Resident 1 was observed to engage his/her call pendant. It took staff 13 minutes to respond to the call light.

During the interview, Resident 1 stated s/he had been left on the toilet many times and it frequently took staff over 30 minutes to respond to call pendant and that meal times, staff breaks and shift changes were the worst.

Resident 1's call light logs for August 2023 were requested, but were unavailable. Call light logs for 06/01/24 through 06/11/24 revealed 10 instances in which Resident 1 waited for more than 15 minutes for assistance. Three of those ten times were greater than 30 minutes.

It was determined 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.

The findings were reviewed with and acknowledged by Staff 12 (Administrator) on 06/13/24.

Verbal plan of Correction: Resident Care Coordinators will run call light log reports for their respective residents no less than weekly. Administrator will review these weekly and follow up with residents and staff on how to reduce wait times.