Print Inspection: 694H

Based on observation, interview, and record review, conducted during a  site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to notify the Department's Central Office and Local Public Health Authority of an occurrence of epidemic disease in the facility. Findings include, but are not limited to:

On 04/16/24, the Compliance Specialist (CS) observed the following:

* A facility sign on the door that stated "Community Respiratory Virus Status - The following measures are in place: Universal Masking in resident areas. Current potential exposure within the community."

* There were four residents had personal protective equipment stations outside of their apartment.

* One of the four residents had signage to indicate s/he was on "Droplet[-based] Precautions" .

In an interview on 04/16/24 at 9:20 am, Staff 1 (Administrator) stated the following:

* On 04/05/24, the first positive case for COVID -19 was identified in a staff member.

* On 04/10/24, a resident tested positive for COVID-19.

* On 04/11/24, a second resident tested positive for COVID-19.

* On 04/14/24, a second staff member tested positive for COVID-19; and

* On 04/15/24, three additional residents tested positive for COVID-19.

* The facility's Infection Control Specialist is Staff 24 (Health Wellness Director) who was not in the facility today.

* The Infection Control Specialist is responsible for notifying local public health and the Department Central office of outbreaks, but this had not been done yet "because the rules have changed."

A review of the facility's Infection Control Policy and Procedure, dated 11/2023, indicated "communicable diseases are reported as required to the local health authority... The executive director or designee is responsible for reporting potentially communicable diseases to the appropriate licensing authorities and local health jurisdiction, as well as the regional wellness director, as soon as possible."

On 04/16/24, at CS directed Staff 1 to notify the required entities and reviewed the "Infection Prevention and Control Guidance for Long Term Care Facilities", dated 08/28/23, that defined outbreaks of communicable diseases that occur when two or more are identified within a seven-day period and from the same unit, floor, shift, or worksite.

A review of facility records including electronic correspondences, dated 04/16/24 through 04/18/24, confirmed the required notifications were completed.

The facility failed to notify the Department's Central Office and Local Public Health Authority of an occurrence of epidemic disease in the facility

On 04/16/24, these findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Immediately, the Administrator will report the occurrence of epidemic disease in the facility and review facility's policy and procedures with the published guidance.

Based on  interview and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to ensure the accuracy and preservation of resident records for 3 of 3 sampled residents (#s 6, 7, and 8) whose records were reviewed. Findings include, but are not limited to:

In an interview on 04/18/24 at approximately 3:07 pm, Staff 1 (Administrator) confirmed Resident 6, 7, and 8 no longer lived in the community.

A review of Resident 6's MARs and progress notes, dated 12/01/22 through 12/31/22,  indicated the following:

* A total 11 medication administrations and 3 treatment administration were blank..

* On 12/12/22, 12/16/22, and 12/18/22, there was no documented evidence his/her vitals were taken as part of alert charting for a urinary tract infection.

A review of Resident 7's MARs and progress notes, dated 12/01/22 through 12/31/22,  indicated the following:

* A total of three medication administrations and three treatments were blank.

* Three of the blank treatments occurred on 12/13/22 and 12/15/22 and the three blank medications occurred on 12/15/22.

A review of Resident 8s' MARs and progress notes, dated 12/01/22 through 12/31/22, indicated the following:

* Resident was ordered "oxybutynin, 5 mg tablet (500 ea). Give 1 tablet by mouth 3 times a day." There were no parameters included.

* On a total of seven different occasions the resident did not receive his/her "oxybutynin" due to "hold per PCP orders" and on one occasion listed the reason as "waiting delivery".

* MAR indicated this medication was administered before and/or after med tech documented medication was withheld per PCP orders.

* Resident was ordered "methocarbamol 500mg tablet (500 mg). Give one tablet by mouth 4 times a day."

* On a total of seven different occasions the resident did not recieve his/her "methocarbamol" due to "new order/awaiting delivery", or "waiting for delivery".

* MAR indicated this medication was administered before and/or after med tech documented medication was not provided.

On 04/18/24, these findings were reviewed with and acknowledged by Staff 1.

The facility failed to ensure the accuracy and preservation of resident records.

In an emails between 07/12/24 through 07/25/24, CS requested a copy of the physician orders that were active at 12/2022 for Resident 6, 7, and 8. On 07/15/24, 07/16/24, and 07/25/24, Staff 1 stated s/he is still trying to locate the requested records for Residents 7 and 8.

Based on observation, interview and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to perform quarterly evaluations for 1 of 1 resident (#2) whose records were reviewed. Findings include but are not limited to:

A review of Resident 2's records indicated the following:

* Resident 2 moved in to the facility on 12/20/23.

* On 01/11/24, Resident 2 experienced a change in condition related dental status and oral care.

* On 04/01/24, Resident 2's service plan was updated.

* There was no evidence to indicate an evaluation was completed to coincide with the service plan update on 04/01/24.

On 04/17/24 at 4:58 pm, the Compliance Specialist observed Resident 2 did not have teeth or dentures.

In an interview on 04/17/24 at 4:58 pm, Resident 2 stated the following:

* S/He has lived here for three months.

* In "early January" s/he was sitting in his/her chair and placed his/her dentures onto his/her walker with 'tray stuff". Staff came in to clean up and  "swept all of it away. Before I realized it, they were gone."

* S/He doesn't eat in the dining room because [food] came out of his/her mouth when eating without dentures.

* His/Her gums are sore.

* The estimated date of arrival for new dentures was "any day now."

* S/He currently eating soft foods, mashed at the roof of his/her mouth, and bread can be lightly toasted and eating some fruits.

In an interview on 04/18/24 at 1:18 pm, Staff 1 (Administrator) stated the doesn't have quarterly evaluations for service plan updates. S/He reviews all pieces of the service plan as s/he runs through the plan while Staff 1 does it on his/her computer.

On 04/18/24 at 4:50 pm, these findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Senior Executive Director).

Verbal Plan of Correction:

The Administrator will work with community nurse to update Resident 2's service plan. Nurse to communicate at stand up and document updates on changes. The TSP was re-implement

Based on observation, interview, and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to have a service plan reflective of residents' needs for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to:

A review of Resident 2's records including progress notes, dated 12/20/23  through 04/10/24, service plan, dated 04/01/24, provider correspondences, and temporary service plans, indicated the following:

* On 01/11/24, s/he was reportedly missing his/her dentures.

* S/He is on a "regular/general house diet" and is independent in grooming and hygiene.

* Current service plan lacked any evidence of Resident 2's status and use of assistive devices such as glasses and had no dentures, oral care, and current diet order.

On 04/17/24 at 4:58 pm, the Compliance Specialist observed of Resident 2 the following:

* S/He wore clean clothing appropriate for time of day and season.

* S/He was well groomed.

* S/He wore glasses.

* S/He did not have teeth or dentures.

In an interview on 04/17/24 at 4:58 pm, Resident 2 stated the following:

* S/He has lived here for three months.

* In "early January" s/he was sitting in his/her chair and placed his/her dentures onto his/her walker with 'tray stuff". Staff came in to clean up and  "swept all of it away. Before I realized it, they were gone."

* It was an accident when it was thrown out.

* S/He doesn't eat in the dining room because [food] came out of his/her mouth when eating without dentures.

* His/Her gums are sore.

* S/He currently eating soft foods, mashed at the roof of his/her mouth, and bread can be lightly toasted and eating some fruits.

In an interview on 04/17/24 at 09:59 am, Staff 1 (Administrator) stated s/he performed Resident 2's quarterly evaluation and created Resident 2's current service plan.

On 04/18/24 at 4:50 pm, these findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Senior Executive Director).

The facility failed to have a service plan reflective of residents' needs

Verbal Plan of Correction:

Effective immediately, the Administrator will work with the facility nurse and update resident's service plan.

Based on observation, interview, and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to implement policies to ensure resident monitoring and reporting system is implemented 24-hours a day for 1 of 1 sampled resident (#2) whose records were reviewed.  Findings include, but are not limited to:

A review of the facility's Change of Condition policy, dated 04/2015, indicated the following:

* Whenever there is a significant change in the status of the resident, the health care provider is to be notified.

* When there is a noticeable change in the mental, medical, or functional status of a resident, the wellness director or licensed nurse will assess the resident's condition and document the findings.

* Notification of resident's healthcare provider must be documented with date and time.

* Implement a TSP or update the service plan for changes in services and ensure associates are made aware of the updated document.

A review of the facility's records including, Diet Order Change form and "[Resident 2's] Timeline of Events" (undated) indicated the following:

* On 01/11/24 at 09:20 pm, Staff 1 was informed that Resident 2's dentures had been lost. At which time, Staff 1 directed facility staff to conduct a search. No dentures were found.

* On 01/30/24, facility communicated to the kitchen a "Diet Order/Change" and indicated s/he remained a regular diet with "soft textures due to no dentures".  

In an interview on 04/17/24 at 4:58 pm, Resident 2 stated the following:

* In "early January" s/he was sitting in his/her chair and placed his/her dentures onto his/her walker with 'tray stuff". Staff came in to clean up and  "swept all of it away. Before I realized it, they were gone."

* S/He doesn't eat in the dining room because [food] came out of his/her mouth when eating without dentures.

* His/Her gums are sore.

* The estimated date of arrival for new dentures was "any day now."

* S/He currently eating soft foods, mashed at the roof of his/her mouth, and bread can be lightly toasted and eating some fruits.

On 04/17/24 at 4:58 pm, the Compliance Specialist observed Resident 2 wore clean clothing appropriate for time of day and season, was well groomed, wore glasses,  and did not have teeth or dentures.

A review of Resident 2's records including, service plan, TSPs, weights and vitals, dated 12/20/23 through 04/10/24, and progress notes dated 12/20/23 through 04/10/24, indicated the following:

*Resident 2 moved into the community on 12/20/23.

* On 01/13/24, a TSP was created due to "missing dentures" that directed staff to monitor for inadequate intake, weight loss, meal refusals; offer soft textured foods, and monitor for mouth pain/open areas in mouth, then notify the nurse of any concerns.  There was no evidence the TSP was implemented.

* A review of progress notes lacked any indications the residents change of condition was monitored until 01/29/24.

* A progress note, dated 01/29/24, indicated a nurse assessed Resident 2's "mouth due to complaints of pain related to missing dentures." Resident "ate 50% of his/her dinner meal and was finishing lemon pudding for dessert." Resident reported his/her "gums to be sore and slightly swollen. Gums do have mild redness present, unable to confirm swelling due to no baseline to compare to. Will continue to monitor."

* On 01/30/24, the facility requested from Resident 2's primary care physician's office diet order and provided a list of what the facility accepts. The primary care physician's office responded and approved "regular, no add salt."

* On 02/06/24, the facility was ordered by Resident 2's outside provider: "1) daily weight to be taken and weekly faxed; 2) diet - extra soft food to be cut into bite size; and 3) [brand] nutritional drink to be offered up to three bottles a day" and processed by the facility on 02/29/24.

* On 04/10/24, alert charting for missing dentures was discontinued.

The facility failed evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed .

On 04/17/24 at 5:55 pm, these findings were reviewed with and acknowledged by Staff 1, and on 04/18/24 at 4:50 pm, these findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Senior Executive Director).

In a telephone interview on 05/29/24 at 10:47 am, Witness 2 (Primary Medical Assistant) confirmed Resident 2's primary care physician has no record of being notified of Resident 2's missing dentures and had they been aware of this in the faxed correspondence on 01/30/24, the diet ordered would've been different.

Based on observation, interview and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was determined the facility failed to maintain infection prevention and control protocols to prevent the development and transmission of communicable disease. Findings include, but are not limited to:

In an interview on 04/16/24 at 9:20 am, Staff 1 (Administrator) stated the following:

* On 04/05/24, the first positive case for COVID -19 was identified in a staff member.

* On 04/10/24, a resident tested positive for COVID-19.

* On 04/11/24, a second resident tested positive for COVID-19.

* On 04/14/24, a second staff member tested positive for COVID-19; and

* On 04/15/24, three additional residents tested positive for COVID-19.

* The facility's Infection Control Specialist is Staff 24 (Health Wellness Director) who was not in the facility today.

* The Infection Control Specialist is responsible for notifying local public health and the Department Central office of outbreaks, but this had not been done yet "because the rules have changed."

On 04/16/24, upon entrance and throughout the site visit on 04/16/24, the Compliance Specialist (CS) observed the following:

* There were four residents with PPE stations outside the apartment while they were on droplet precautions.

* One of the four PPE stations contained precautionary signage and donning/doffing PPE instructional signage.

* Only large sized gloves were available at PPE station #1.

* Only medium sized gloves were available at PPE station #2.  

* Gloves did not fit staff and thus did not provide a protective barrier.

* Staff donned double gloves

* Staff donned and doffed PPE without performing hand hygiene.

* Staff donned N95 masks upside down.

* No environmental disinfections were taking place at and after times of high communal interactions/activities.

On 04/16/24, at 3:45pm, in an interview, Staff 1 (Administrator) stated the facility has provided in-service training to staff in January and March.

A review of the provided in-service attendance records indicated training on topics of 'Hand Hygiene, MRSA-Staph, PPE' and "[In-Home Provider] Refresh" records, dated 01/18/24 and 03/21/2024, respectively.

A review of the in-service record, dated 01/18/24, omitted confirmation that Staff 9 (MT) and Staff 11 (MT) were provided this training.

A review of the in-service record, dated 03/21/24, omitted confirmation that Staff 9 (MT) received training and omitted in any indications that this in-service training pertained to infection prevention and controls.

A review of the facility's Infection Control Policy and Procedure, dated 11/2023, indicated the following:

* In the case of a communicable disease "enhanced cleaning and disinfection will be implemented..."

* "Routinely disinfect throughout the day frequently touched surfaces, such as doorknobs, handles, telephones, elevator buttons, etc..."

In separate interviews on 04/16/24, Staff 3 (HSKP), Staff 4 (HSKP), Staff 21 (HSKP) and Staff 22 (HSKP), stated the following:

* No directions have been given to increase environmental disinfection.

* Common areas are cleaned 1-2 days per week or as needed.

* Elevator is scrubbed inside and sanitized once week or every two weeks.

* Resident apartments are cleaned once a week or more as needed.

In an interview on 04/16/24, Staff 8 (Plant Operations Director) stated s/he disinfects with a fog machine five days a week before start of day shift and NOC shift is assigned to disinfect common areas.

The facility failed to maintain infection prevention and control protocols to prevent the development and transmission of communicable disease.

On 04/16/24, these findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Effective immediately, Memory Care Nurse provided training and evaluated on duty care staff who are dedicated to residents who are confirmed positive for COVID-19.

Based on observation, interview, and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to provide pre-service orientation to 4 of 4 sampled (#11, 13, 25, 26) direct care staff whose training records were reviewed; the facility failed to provide pre-service dementia training prior to providing care and services independently for 4 of 4 direct care staff (#11, 13, 25, 26) and the facility failed to determine competency in any task assigned for 1 of 4 sampled staff (#26).  Findings include, but are not limited to:

A review of the facility's training records indicated the following:

a. There was no evidence Staff 11 (MT) hired on 03/04/24, Staff 13 (CG) hired on 02/28/24, Staff 25 (MT) hired on 02/13/24, and Staff 26 (MT) hired on 05/17/23, had completed an approved Home and Community Based Setting course.

b. There was no evidence Staff 11, 13, 25, and 26 had completed Pre-Service Dementia training in one or more of the following required topics:

(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.

(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.

(IV) Use a person-centered approach.  

c. Staff 26's training records indicated s/he completed required training and was evaluated for competency in their role as a unlicensed medication technician on 08/15/23 and lacked any indications that appropriate facility staff documented and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.

In an interview on 04/18/24 at 12:03 pm, Staff 1 (Administrator) stated the following:

* The training program starts on day one with new hire packets and beginning video training.

* Then day two through four is completing the online video training and food hander's card and first aid.

* On the floor training begins after the online training and includes shadowing day shift caregivers.

* Shadow days occur for four - five days, in which the trainee shadows experienced CG and different shifts, then a lead CG will shadow the trainee while they provide care.

* By the last of shadow days, their orientation and training checklist is completed and/or if additional training is required.

* If the trainee is a MT, then they will do an additional four to seven days of MT shadowing.

* After the MT-trainee shadows, then nurse will document and evaluate competency.

On 04/18/24, these findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Within 30 days, the Administrator or designee will audit employee training records to identify areas of non-compliance and schedule individuals for training and conduct training via the next All - Staff meeting.

Based on observation, interview, and record review, conducted during a site visit on 04/16/24 through 04/18/24, it was confirmed the facility failed to provide pre-service orientation to 4 of 4 sampled (#11, 13, 25, 26) direct care staff whose training records were reviewed; the facility failed to provide pre-service dementia training prior to providing care and services independently for 4 of 4 direct care staff (#11, 13, 25, 26) and the facility failed to determine competency in any task assigned for 1 of 4 sampled staff (#26).  Findings include, but are not limited to:

A review of the facility's training records indicated the following:

a. There was no evidence Staff 11 (MT) hired on 03/04/24, Staff 13 (CG) hired on 02/28/24, Staff 25 (MT) hired on 02/13/24, and Staff 26 (MT) hired on 05/17/23, had completed an approved Home and Community Based Setting course.

b. There was no evidence Staff 11, 13, 25, and 26 had completed Pre-Service Dementia training in one or more of the following required topics:

(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.

(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.

(IV) Use a person-centered approach.  

c. Staff 26's training records indicated s/he completed required training and was evaluated for competency in their role as a unlicensed medication technician on 08/15/23 and lacked any indications that appropriate facility staff documented and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.

In an interview on 04/18/24 at 12:03 pm, Staff 1 (Administrator) stated the following:

* The training program starts on day one with new hire packets and beginning video training.

* Then day two through four is completing the online video training and food hander's card and first aid.

* On the floor training begins after the online training and includes shadowing day shift caregivers.

* Shadow days occur for four - five days, in which the trainee shadows experienced CG and different shifts, then a lead CG will shadow the trainee while they provide care.

* By the last of shadow days, their orientation and training checklist is completed and/or if additional training is required.

* If the trainee is a MT, then they will do an additional four to seven days of MT shadowing.

* After the MT-trainee shadows, then nurse will document and evaluate competency.

On 04/18/24, these findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Within 30 days, the Administrator or designee will audit employee training records to identify areas of non-compliance and schedule individuals for training and conduct training via the next All - Staff meeting.