Print Inspection: 871V

Based on observation, interview and record review, conducted during a site visit on 04/15/24, it was confirmed that facility failed ensure that the service plan was reflective residents' needs for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Resident 1's service plan  was located by a Compliance Specialist in Resident 1's hard chart in the chart room.

Resident 1 had a change of condition on 04/05/24 due to admission to hospice. As of 04/15/24, an RN assessment and service plan review were not completed.

Discrepancies between observations, resident and staff interviews, and Resident 1's service plan dated 12/06/23 were identified in the following areas:

*Transfers; and

*Toileting.

Resident 2's service plan could not be located in the chart room, was not available to staff and had to be printed by Staff 3 for the Compliance Specialists.

Resident 2 had a change of condition on 04/11/24 due to admission to hospice. As of 04/15/24, an RN assessment and service plan review were not completed.

Discrepancies between observations, resident and staff interviews, and Resident 2's service plan dated 11/10/23 were identified in the following area:

*Transfers.

Resident 3's service plan was located by a Compliance Specialist in Resident 3's hard chart in the chart room.

Discrepancies between resident and staff interviews and Resident 3's service plan were identified in the following areas:

*Dressing;

*Toileting;

*Escort to meals; and

*Transfers

The facility failed to ensure service plans were available to staff and reflective of needs.

The findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 2 (Executive Director) and Staff 3 on 04/15/24.

Verbal plan of correction: Health services all-staff meeting to occur on Thursday 04/18/24 in which service plan policy and procedure would be reviewed. Facility will implement a  "Quiz TSP"  to audit staff are reading TSPs and quiz about resident's service plan to test staff knowledge. Conducted an audit of second floor service binder and sent notice to  2nd floor Resident Services Coordinator about all missing service plans. Third floor audit to be completed and all service plans in binder by Friday 04/19/24.

Based on interview and record review, conducted during a site visit on 02/15/24, it was confirmed the facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day for 3 of 3 sampled residents (#s 1, 2 and 5). The findings include, but are not limited to:

Resident 1 had a change of condition on 04/05/24 due to admission to hospice. As of 04/15/24, an RN assessment and service plan review were not completed.

Resident 2 had a change of condition on 04/11/24 due to admission to hospice. As of 04/15/24, an RN assessment and service plan review were not completed.

Resident 5 had a change of condition on 04/08/24. There was no evidence that staff reported Resident 5's change of condition to the nurse until 9:14 am on 04/09/24 when Resident 5 was found on the floor and pale in color. Resident 5 later passed away.

The findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 2 (Executive Director) and Staff 3 on 04/15/24.

The facility failed to ensure a resident monitoring and reporting system was implemented 24-hours.

The findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 2 (Executive Director) and Staff 3 on 04/15/24.

Verbal plan of correction: Assistant ED to schedule a regional nurse to come into the facility and do a training on best practice for change of condition and related notifications. Assistant ED to email Compliance Specialist by Friday 04/19/24 with scheduled training date.

Based on interview and record review, conducted during a site visit on 02/15/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Resident 1 had a change of condition on 04/05/24 due to admission to hospice. His/her ABST profile had not been updated since 08/09/23.

Resident 2 had a change of condition on 04/11/24 due to admission to hospice. His/her ABST profile had not been updated since 08/09/23.

Resident 3 moved into the facility on 04/10/24 and had not been entered into the ABST as of 04/15/24.

The findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 2 (Executive Director) and Staff 3 (Director of Health Services, RN) on 04/15/24.

The facility failed to fully implement and update an Acuity Based Staffing Tool.