Print Inspection: 7E94

Based on interview and record review, conducted during a site visit on

05/02/25, the facility's failure to carry out medication orders as prescribed was

substantiated for 1 of 1 sampled residents (#1). Findings include, but are not

limited to:

The following documents had been reviewed:

 Resident 1's medication administration records (MARs) from 07/01/24

through 07/31/24;

 Incident report and investigation worksheet dated 07/29/24;

 Facility self-report dated 07/30/24;

 Resident 1's interim service plan (ISP) dated 07/30/24; and

 Home Health (HH) outside provider notes dated 07/29/25.

The documents indicated Resident 1 had an order for an oxygen mask placed

on 07/17/24 and inputted into the MARs on 07/18/24. Staff were to help assist

resident put on the oxygen mask at bedtime. Two med techs had falsified the

task as completed from 07/18/24 through 07/29/24.

An interview with Staff 2 (Lead Med Tech) indicated the facility had reported

the incident to Adult Protective Services (APS). The two staff members

received corrective action, and an in-service was completed on 08/02/24.

The facility's failure to carry out medication orders as prescribed was

substantiated. Findings were reviewed and acknowledged by Staff 1

(Business Office Manager).

Based on interview and record review, conducted during a site visit on 05/02/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST report, along with the last update dates, indicated the following:

·80 of 82 residents had not been updated quarterly; and

·Six residents were indicated as "new " with no completed ABST evaluation, indicating the time required for activities of daily living (ADLs).

A review of the resident roster indicated the six residents' move-in dates had been the following:

·Resident 3: 02/14/25;

·Resident 4: 04/11/25;

·Resident 5: 03/31/25;

·Resident 6: 01/31/25;

·Resident 7: 04/09/25; and

·Resident 8: 04/10/25.

An interview with Staff 1 (Business Office Manager) indicated that all six residents were currently residing in the facility.

It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on interview and record review, conducted during a site visit on 05/02/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST report, along with the last update dates, indicated the following:

·80 of 82 residents had not been updated quarterly; and

·Six residents were indicated as "new " with no completed ABST evaluation, indicating the time required for activities of daily living (ADLs).

A review of the resident roster indicated the six residents' move-in dates had been the following:

·Resident 3: 02/14/25;

·Resident 4: 04/11/25;

·Resident 5: 03/31/25;

·Resident 6: 01/31/25;

·Resident 7: 04/09/25; and

·Resident 8: 04/10/25.

An interview with Staff 1 (Business Office Manager) indicated that all six residents were currently residing in the facility.

It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.