Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to notify the Department of any incident of abuse or suspected abuse for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

A review of Resident 1's records including Medication Administration Record (MAR), dated 11/2023, and progress notes, dated 10/2023 through 11/2023, indicated the following:

* On 11/16/23 at 9:24 pm, a progress note entered stated: "Resident on alert for missed dental med. Resident [showed] no [complaints] of any this shift. Will continue to monitor."

* On 11/22/23 at 9:45 pm, a progress note entered stated: "Resident on alert for missed dental medication. Zero [complaint] side effects of missing [antibiotic] before dental visit...."

* On 01/05/23, "Cephlexin 500 mg capsule" was ordered to "give four capsules (2000 mg) by mouth 30 minutes prior to dental visit". There was no evidence this medication was provided.

* The Compliance Specialist requested the records related to this incident. At 12:30 pm, a document containing only the name of the Resident 1 was provided.

* At approximately 2:30 pm, an incident report was provided and stated "the medication had not been checked to verify it being here and available until after the [actual] dental appointment. It did get order and was administered as soon as it came to the facility."

* At 5:20pm, a incident summary, dated 11/15/23, stated: "Date of Incident 11/14/23 at 2:32 pm; Resident did have a dental appointment scheduled for yesterday and per doctor's orders should of had an antibiotic administered to [him/her] before the scheduled appointment. The medication had not been properly ordered and was not available till 7:00 am this morning....."

In an interview, Staff 1 (RN) stated Resident 1 had a dentist appointment on 11/13/23 and was prescribed an antibiotic to be given before his/her dentist appointment but he/she did not receive it. The incident report is incomplete and requested the involved staff member to complete the report.

A review of facility's records, including policy and procedures, and documented investigations,  indicated the following:

* The "Accidents, Incidents, and Unusual Occurrences" policy and procedure, dated 11/01/2014, indicated medications errors are considered an 'accident or incident' and 'whenever a accident or incident occurs: follow state and local laws regarding notification to authorities or agencies."

* A review of 10 separate incident reports, dated 11/2023, lacked evidence of administrator's review.  

On 01/10/24, via telephone, these findings were reviewed with and acknowledged by Staff 16 (Administrator) who stated s/he started in the role on 12/04/23 and did not have access to the incident reporting system to review incident report but that has been corrected.

Verbal Plan of Correction:

Since these incidents, the facility has hired a new Director of Health Services Nurse and has been focusing on staff training and will provide staff training on abuse reporting.

Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to ensure service plans were updated quarterly and readily available to staff for 2 of 2 sampled residents (#s 1 and 2) and several unsampled residents. Findings include, but are not limited to:

A review of the facility's service plan binders indicated eight residents service plans had not been updated quarterly. Resident 1's service plan was dated 08/24/23 and Resident 2's service plan was dated 07/27/23.

During separate interviews on 11/28/23, Staff 1 (Regional Cooperate Nurse) stated, "There are only four service plans that are out of date, the other four have been completed. The service plans just have not been added into the binders for staff to view." Staff 2 (RN) stated, "No service plans have gotten completed since the old LPN quit around the end of October."

It was confirmed the facility failed to ensure service plans were updated quarterly and readily available to staff.

On 11/28/23, the findings were reviewed with and acknowledged by Staff 1 (Regional Corporate Nurse).

Verbal plan of correction: Acting ED and new HSD will audit service plan binders to ensure service plans are all up to date.

I. Based on interview and record review, conducted during a site visit on 11/28/23, 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 medication administration records (MARs) indicated the following medications not provided due to medication not on hand at the facility:

·Travoprost for Glaucoma- one drop dose in each eye daily at bedtime was not given from 10/15/23 through 01/25/23.

·Temazepam for insomnia, 15MG capsule was not given on 10/04/23.

·Systane nighttime eye ointment was not given from 10/12/23 though 10/15/23.

·Levothyroxine for hypothyroidism, 88MCG tablet one daily was not given on 10/27/23.

During an interview on 11/28/23, Resident 1 stated, "I have not received some medications and/or have received my medication late on several occasions."

During an interview on 11/28/23, Staff 2 (RN) acknowledge when s/he has run medication audit reports there have been several occasions where medication had been administered late or not have been administered.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

On 11/28/23, the findings were reviewed with and acknowledged by Staff 1 (Regional Cooperate Nurse).

Verbal plan of correction: Retrain staff, disciplinary action if required.

II. Based on interview and record review, conducted during a site visit on 11/28/23, it was determined the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#1, 5, 6, 7) whose records were reviewed. Findings include, but are not limited to:

In an interview, Staff 2 (RN) stated eight residents missed their 7:00 pm medications on 11/08/23 in Cottage C after an "agency [staff member] popped meds for 7 pm, and another agency [staff member] was supposed to complete the pass but didn't."

a. A review of  Resident 7's records including, medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following:

* On 11/09/23 at 10:32 am, a progress note stated in the "[morning] medication technician (MT) observed a stack of medication cups with pills in them on top of the med cart this morning. Individual resident name was written on the cups. [S/He] called over RCC and RN. RCC contacted the agency MT who worked that shift and asked what happened. [S/he] stated that the agency MT asked [him/her] to pop all the 7pm medications before [s/he] left and [s/he] would come over and give them later. The agency MT who popped the medications also documented them as 'given' in the eMAR. The 2nd MT did not come pass them, as the pills were observed in the med cart this morning. No concerns with resident at this time...."

* On 11/14/23 at 5:33 pm, a progress note stated "received fax from PCP regarding med error on 11/07/23..... [Resident 7's] trazodone was missed."

* A facility incident report, dated 11/09/23 indicated on 11/08/23 at 7:00 pm, "agency med techs preparing medications" led to this med error. [Resident 7] was identified as having missed 1 medication.

b.  A review of Resident 5's records including medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following:

* "Carbamide Peroxide 6.5% Ear DP, instill 5 drops in the right ear twice daily for 5 days for impacted cerumen" was started on 11/15/23. This medication was not administered at 5 pm on 11/16, 11/17, and 11/18. The noted exception stated: "unable to locate medication", "med not available", and "medication is not in the box" respectively.

* "Mucus relief ER 600 mg tablet. Give 1 tab by mouth twice daily for secretions" was started on 08/23/23. This medication was not administered at 7:00 pm on 11/13 and 11/14. The noted exception stated: "med not available."

* A facility incident report, dated 11/27/23, indicated on 11/27/23 at 2:30 pm, Resident 5 was administered a dose of ear drops after the medication was discontinued.

c. A review of Resident 6's records including medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following:

* On 11/09/23 at 10:34 am, a progress note stated in the "[morning] medication technician (MT) observed a stack of medication cups with pills in them on top of the med cart this morning. individual resident name was written on the cups. [S/He] called over RCC and RN. RCC contacted the agency MT who worked that shift and asked what happened. [S/he] stated that the agency MT asked [him/her] to pop all the 7pm medications before [s/he] left and [s/he] would come over and give them later. The agency MT who popped the medications also documented them as "given" in the eMAR. The 2nd MT did not come pass them, as the pills were observed in the med cart this morning. No concerns with resident at this time...."

* A facility incident report dated 11/09/23 indicated on 11/08/23 at 7:00 pm, "agency prepouring medications" led to this med error. [Resident 5] was identified as having missed 4 different medications which included "calcium carbonate/vitamin D3", "loratadine", "melatonin", and "trazodone".

d. A review of Resident 1's records including Medication Administration Record (MAR), dated 11/2023, and progress notes, dated 10/2023 through 11/2023, indicated the following:

* On 11/16/23 at 9:24 pm, a progress note entered stated: "Resident on alert for missed dental med. Resident [showed] no [complaints] of any this shift. Will continue to monitor."

* On 11/22/23 at 9:45 pm, a progress note entered stated: "Resident on alert for missed dental medication. Zero [complaint] side effects of missing [antibiotic] before dental visit...."

* On 01/05/23, "Cephlexin 500 mg capsule" was ordered to "give four capsules (2000 mg) by mouth 30 minutes prior to dental visit". There was no evidence this medication was provided.

* The Compliance Specialist requested the records related to this incident. At 12:30 pm, a document containing only the name of the Resident 1 was provided.

* At approximately 2:30 pm, an incident report was provided and stated "the medication had not been checked to verify it being here and available until after the [actual] dental appointment. It did get ordered and was administered as soon as it came to the facility."

* At 5:20pm, an incident summary, dated 11/15/23, stated: "Date of Incident 11/14/23 at 2:32 pm; Resident did have a dental appointment scheduled for yesterday and per doctor's orders should of had an antibiotic administered to [him/her] before the scheduled appointment. The medication had not been properly ordered and was not available till 7:00 am this morning....."

In an interview, Staff 1 (RN) stated Resident 1 had a dentist appointment on 11/13/23 and was prescribed an antibiotic to be given before his/her dentist appointment but he/she did not receive it. The incident report is incomplete and requested the involved staff member to complete the report.

A review of facility's Med Error Incident reports, dated 11/09/23, indicated on 11/08/23, a total of seven residents missed medications for a total of 26 different medications that were missed.

On 11/28/23, these findings were reviewed with and acknowledged by Staff 1 (Regional Director of Health Services) and Staff 2.

Verbal Plan of Correction:

All medication technicians will be re-trained and disciplinary action may be required.

Based on interview and record review, during a site visit conducted on 11/28/23, 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, 3 of 3 sampled residents (#1, 2, 3). Findings include, but are not limited to:

During an interview on 11/28/23, Resident 1 stated the following:  

·"I have received medications late due to lack of staff."

·"The staff take a long time to respond to call lights."  

·"I went 11 days without a shower."  

During an interview on 11/28/23, Staff 3 (MT) stated the following,

·"I had to clock in early today because the night staff were sitting on their phones and residents were yelling for assistance."  

·"It is often that residents left soiled."  

·"I feel the facility is short staffed during swing and night shift, not typically during the day."  

·"If staff are assigned to a building they shouldn't need to go to another building unless covering for breaks."  

A review of the posted staffing plan showed the following,

·Building A

oDay, swing, and night: one MT and one CG  

·Building B

oDay and swing: one MT and one CG

oNOC: zero MT and one CG

·Building C

oDay and swing: one MT and two CG

oNOC: one MT and one CG

A review of the shower schedule for Resident 1 and Resident 3 were scheduled to receive two showers a week. Resident 1 was to receive showers on Monday and Fridays. Resident 1's September through November 2023 shower sheets indicated 12 of 26 showers were not provided.  Resident 3 was to receive showers on Wednesday and Fridays. Resident 3s shower sheets for November 2023 indicated the resident received three of nine showers on 11/01/23, 11/15/23, and 11/24/23.

A review of the call lights response log dated 11/05/23 and 11/28/23, indicated 39 call light response times that exceeded 15 minutes, 31 of which exceeded 20 minutes.

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 11/28/23, the findings were reviewed with and acknowledged by Staff 1

(Regional Corporate Nurse).  

Verbal plan of correction: None was provided.

Based on interview and record review, during a site visit conducted on 11/28/23, it was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty they were assigned. Findings include, but are not limited to:

A review of Staff 13 (Caregiver), Staff 14 (Caregiver), and Staff 15 ' s (Caregiver) competency training checklists indicated each staff had not completed the necessary training. Staff 13 hired on 10/19/23, Staff 14 hired on 10/21/23, and Staff 15 hired on 10/24/23. In looking at Staff 14 and Staff 15's training records, training in lifting and transferring had not been completed.

During separate interviews on 11/28/23, Staff 1 (Regional Corporate Nurse) acknowledged the facility had staff that had not completed all necessary training required. Staff 3 (MT) stated, "I did not believe caregivers nor med techs have received proper training."

It was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty they were assigned.

On 11/28/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The new HSD and RCC will audit staff to see who has received training and who has not and have those staff complete the necessary training.