Print Inspection: B18J

Based on observation and interview, conducted during a site visit on 06/18/24, it was confirmed the facility failed to keep medical and other records kept confidential. Findings include, but are not limited to:

During an onsite visit to the facility on 06/18/24, compliance specialist (CS) observed several stacks of boxes with resident's confidential information lined up against the walls at the base of the stairwell.

In an interview, Staff 1 (Executive Director) stated they had just moved them there temporarily while work was being done.

The findings were reviewed with and acknowledged by Staff 1 on 06/18/24.

It was confirmed the facility failed to keep medical and other records kept confidential.

Plan of correction: ED will have them moved back to secure storage by the end of the day.

Based on interview, and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

During an interview on 06/18/24, Staff 1 (Executive Director) stated there had been an improved training program that went over transfers and gait belts in the last six months since s/he had been at the facility.

Compliance specialist was unable to interview Resident 4 as s/he was no longer at the facility as of 03/29/24.

A review of Resident 4's service plan dated 10/02/23 and progress notes dated 10/27/23 through 12/02/23, indicated the following:

·Progress note dated 11/09/24 at 10:03am reported  "caregiver was not following resident care plan and transferring [Resident 4] by [his/her] self. Resident started to slip so [s/he] was assisted to the ground".

·Care plan stated, "Staff to use gait belt to assist [Resident 4] for stand-pivot transfer" and  "staff to call for a second caregiver for assistance for the safety of [Resident 4] and staff".

The findings were reviewed with and acknowledged by Staff 1 on 06/18/24.

It was confirmed the facility failed to ensure the implementation of services.

Plan of correction: ED had already started and will continue ongoing re-education of the two-person transfer procedures and gait belt use. They ordered more gait belts and were working on making sure all residents had an updated wellness plan.

Based on interview and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 3 sampled residents (#s 1, 3, and 6). Findings include, but are not limited to:

A review of Resident 6's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:

·Order updated 05/23/24 to "monitor weight monthly, PRN and if suspicious of weight gain or weight loss" and;

·Resident 6 was getting monthly and PRN weights completed for May 2024.

A review of Resident 1's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:

·Order updated on 05/07/24 to "monitor daily weights" and;

·On 05/25/24, Resident 1 did not get a daily weight documented.

A review of Resident 3's May 2024 MAR and progress notes, physician orders, and care history, indicated the following:

·Order updated on 05/12/24 to "take weight daily. Call MD if resident experience a weight gain of 3 pounds or more pound gain in 1 week" and;

·There were six days for May 2024 missing a daily weight.

In an interview, Staff 2 (RCC) stated the daily weights were documented in the MAR and they did not have any concerns about the staff not getting the daily weights.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/18/24.

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

Verbal plan of correction: The RCC's will start doing daily monitoring of the weights to make sure they are getting documented and follow up with staff if they are not completed.

Based on observation, interview and record review, conducted during a site visit on 06/18/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated the current census was 70 residents and only 62 residents were entered into the ABST.

A review of the ABST and staff schedule for June 2024 indicated the facility was staffing per the ABST.

In an interview on 06/18/24, Staff 1 (Administrator) stated the following:

·The current census was 70 residents, as they had one resident out of the facility.

·The ABST had not been updated with all of the residents.

·The posted staffing plan currently exceeded the ABST generated staffing, but it is not accurate.

In separate interviews with Resident 1, 2, and 5, they stated their needs were being met.

On 06/18/24, findings were reviewed with and acknowledged by Staff 1.

It was confirmed the facility failed to fully implement and update an ABST.