Print Inspection: BTIX

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to ensure 1 of 1 subject individuals (# 6) obtained background check prior to starting work. Findings include, but are not limited to:

During an interview on 05/09/24 at 11:22 am, Staff 1 (Executive Director) stated there was no documented evidence [Staff 6] had a completed background check prior to starting work on 03/14/24.

A review of the following facility's records indicated:

-A background check for Staff 6 was submitted and approved for preliminary employment on 03/27/24, after his/her start date of 03/14/24.

-Timecards, dated 03/01/24 through 03/15/24, indicated Staff 6 had worked 1.25 hours on 03/14/24.

A review of a text message on 12/26/23 at 11:01 am, between Staff (Anonymous) and Staff 1, in which Staff 1 stated: "I can't pay [Staff 6] because [s/he] is not actually hired."

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to obtain background checks on all subject individuals prior to starting work.

Verbal plan of correction: ED and COO will conduct an investigation into employee who worked without background check by end of next week 05/17/24. Follow up with OPA on OAR and review policy and procedure for conducting background checks on all employees prior to starting work at facility.

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to ensure 1 of 1 direct care staff (# 6) obtained background check. Findings include, but are not limited to:

A review of timecards, dated 03/01/24 through 03/15/24, and background check records indicated the following:

- Staff 6 had worked 1.25 hours on 03/14/24.

- ORCHARDS background check records indicated Staff 6 was not approved for preliminary employment until 03/27/24, permanent hire date 04/29/24.

A review of text message dated 12/26/23 between Staff 5 (Anonymous) and Staff 1 (ED) stated, "I can't pay [Staff 6] because [s/he] is not actually hired."

In an interview on 05/13/24 via telephone Staff  (Anonymous) stated s/he worked at the facility and provided care to residents two nights in December 2023 around Christmas, 03/06/24 and 03/07/24 on night shift. S/He stated Staff 1 (ED) knew s/he was working and told s/he would be paid for working in December, 03/06/24 through 03/07/24 dates. S/He stated they worked night shift and provided bathing and toileting assistance to residents. S/He stated they are afraid they will get fired for talking to the state.

In an interview on 05/09/24 at 11:22 am, Staff 1 (ED) indicated no documented evidence Staff 6 had a completed background check prior to starting work on 03/27/24. She/he stated she/he was aware Staff 6 was coming into the facility without a background check.

In an interview on 05/10/24 via telephone Staff 2 (COO) stated  "never allow family and friends to provide care, purpose of a background check is to keep residents safe. Staff should not have family and friends visiting the building."

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to obtain background checks on all subject individuals prior to starting work.

Verbal plan of correction: ED and COO will conduct an investigation into employee who worked without background check by end of next week 05/17/24. Follow up with OPA on OAR and review policy and procedure for conducting background checks on all employees prior to starting work at facility.

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility falsified records requested by the Department. Findings include, but are not limited to:

a. A review of facility's "Medication Incident Report and Investigation", dated 01/05/24, and the Controlled Substance Record Book, dated 12/04/23 indicated the following:

- Staff reported the incident on 01/05/24. Staff reports the incident was reported to Staff 3 on 01/06/24.

- " N/A medication was not given to resident. Nurse notified." Controlled Substance Disposition Logbook indicated Resident 5 was given Morphine ER 15mg one tablet all three prescribed times on 01/05/24.

- "Last pill on card was apparently accidentally thrown away believing the card was empty."  

-  Medication investigation report was initiated by Staff 7 and 9.

- Controlled Substance Record Book #71, page #093, indicated on line 27 was initialed by Staff 5 the date and time were crossed out more than once.

- Controlled substance logbook #71, page #093, indicated disposition date had been written over and unable to read date. Signed by Staff 3 and 1.

- Controlled substance logbook #71, page #093, indicated "last pill missing see med error report", signed by Staff 3 unable to read date.

- Controlled substance logbook #71, page #093, indicated line 29 - 31 with zero, pill count is showing 30.

- Controlled substance logbook #71, page #094, indicated Resident 5 received Morphine ER 15mg one tablet at 8pm on 01/05/24. Indicating new card was started on 01/05/24 at 8pm.

In an interview on 05/09/24 at 11:25 am, Staff 3 (Nurse) stated s/he "did not know how the morphine disappeared." S/He stated, "three pills were missing of morphine" and did not report to the department or police because s/he did not know s/he needed to. Staff 3 stated s/he "knew the narcotics log looked really bad."

In a telephone interview on 05/13/24 at 7:42 am, Staff 5 (Anonymous), stated "I did not sign the narcotics book. Those are not my initials on line 27, page 093 book 71. I did not write the information on line 27. There were three missing morphine pills, not one. I only signed my initials on the correct count varication log for 01/06/24 -01/08/24 because the count was off by three pills not one. The Narcotics book was falsified."

In a telephone interview on 05/13/24 at 1:31 pm, Staff 7 (Anonymous), stated "I was the last one to sign on line 26, page 093 book 71. I found the error, there should have been three morphine pills left. I called Staff 3 (Nurse) on 01/06/23 to report the three missing morphine pills. I only signed my initials on the correct count varication log for 01/06/24 -01/08/24 because the count was off by three morphine pills not one. Staff 3 (Nurse) never followed up with me about the missing morphine and never reviewed an incident report with me."

In a telephone interview on 05/14/24 at 1:22 pm Staff 9 stated "[s/he] was notified by Staff 3 (Nurse) on 01/06/24 that morphine pills were missing. Thinks s/he tossed the morphine pills in trash but doesn't remember. It was three morphine pills missing. I sign what Staff 3 (Nurse) tells me to sign. Staff 3 (Nurse) did not follow up with me about missing morphine pills or reviewed incident report dated 01/05/24."  

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility falsified records requested by the Department.

Verbal plan of correction: Training will be provided to all staff by APD for mandatory reporting and Consonus Pharmacy on 06/06/24 for medication. ED will oversee process. ED will start auditing MT competencies and training as of today 05/22/24.

b. On 05/09/24, at the exit conference, CS requested verification of staff training competencies when completed.

Between 05/09/24 through 05/17/24, CS recieved competency forms as requested.

A review of Medication and Treatment competencies for Staff 5, dated 05/10/24, and Staff 10, which the date was unable to be read, indicated the following:

- "Three error free medication passes observed ", initialed and dated by Staff and Nurse.

- "Licensed Nurse had observed and evaluated employee ' s ability to perform safe medication and treatment administration unsupervised ", initialed and dated by Staff and Nurse.

In a telephone interview on 05/20/24 at 12:24 pm,  Staff 1 (ED) stated Nurse has been completing observations and skills trainings with all med techs and no one is working without current competencies being completed.  

In a telephone interview on 05/21/24 at 1:31 pm, Staff (Anonymous) stated " Staff 3 left paper on counter with note saying to sign it ", s/he stated," Staff 3 did not observe or evaluate any training just told him/her to sign it." She/he stated they initialed it but refused to sign the bottom until the training was completed. She/he stated, have been working all scheduled shifts unsupervised. She/he stated they were afraid of getting fired if they didn ' t initial the form.

In a telephone interview on 05/21/24 at 1:57 pm Staff (Anonymous) stated "  Staff 3 left training form with a note saying to sign it". She/he stated Staff 3 did not watch a med pass or complete any trainings with them as the form indicated. She/he stated, have been working all scheduled shifts unsupervised. She/he stated," initialed and signed the form because s/he was afraid s/he would get fired if s/he didn ' t." Staff confirmed date form signed was 05/15/24.

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of Resident 4's MAR and progress notes, dated 12/01/23 through 01/31/24, indicated no documented evidence the facility had promptly conducted an internal investigation to rule out any incident of abuse or suspected abuse.

a. Resident 4 had not been administered the following medication as prescribed on 01/07/24 through 01/09/24:

- Furosemide 20 mg one tablet at 1200 for Edema;

- Potassium 8MEQ one tablet at 1200 to be taken with Furosemide.

b. On 12/07/23, Resident 4 had an unwitnessed fall with pelvic pain and was sent to emergency room and returned the same day.

c. On 01/10/24, Resident 4 reported to MT and CG that s/he could not breath or catch his/her breath, was sent to ER and returned to facility on 01/12/24.

Progress note entered on 01/10/24 indicated "lack of medication re-fill on 01/07/24 through 01/09/24 possibly related to sending resident to ER 01/10/24. "  

In an interview on 10/09/23 at 10:25 am, Staff 1 (ED) stated s/he was unable to locate records of any internal investigations that had been completed on any of the incidents that occurred on 12/07/23, 01/07/24 through 01/09/24 or 01/10/24 and no evidence a report was made to Adult Protective Services or local AAA office. CS directed Staff 1 to report the incident.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to promptly investigate all reports of abuse and suspected abuse and take necessary measures to protect residents and prevent reoccurrences.

Verbal plan of correction: COO reported she/he will conduct a mandatory reporter training with all staff this week, as well get out a staff wide email. S/He will go over policy and procedure for reporting to the department with Administration today. ED will contact local APS office and schedule a mandatory reporter training for all staff today. COO reports having Pharmacy Company/Consonus come in and do a re-training on narcotics log this month/May.

Exp 1

Based on interview, and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to provide stand by assistance for resident when showering for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

In a review of facility's shower schedule, dated 05/08/24, Resident 3's progress notes, dated 03/01/24 through 05/10/24, and Resident 3's task-list "Documentation Survey Report", dated 03/01/24 through 03/31/24, for dressing and bathing and Resident 3's service plan, dated 04/09/24, indicated the following:

- Resident 3 required full assistance in bathing one time weekly. [Resident 3] has asked when bathing "that staff stay in room for him/her to get in and out of shower for safety for fear of falling."

- Facility's shower schedule indicated Resident 3 required "Cueing only" with bathing one time weekly.

- The "Documentation Survey Report" indicated bathing assistance was not provided on 03/03/24. Resident 3 went 9 days without a shower. There was no evidence to indicate Resident 3 declined services during this time.

In an interview, Resident 3 stated s/he required assistance in bathing but does not get showers on a regular basis due to not enough staffing, and some care staff will leave the apartment to do other things when s/he is in shower.

In an interview, Staff 1 (ED) stated Resident 3 required stand-by assistance when bathing, but staff have left the apartment while resident was bathing to help others or give resident privacy. S/He stated resident can bath themselves.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to provide stand by assistance for resident when showering.

Verbal plan of correction: ED and Chief Operating Officer (COO) reported they will review resident service plans for needs and frequency. Update service plans and staffing schedule by the end of next week 05/17/24. ED will immediately add a third person to NOC shift and all shifts will have three care staff for two person assist and current care needs. ED, RCC and COO will audit call light logs daily. ED will create a new shower schedule for residents by end of next week 05/17/24.

Exp 2

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

A review of Resident 3's service plan, dated 04/09/24,  progress notes, dated 03/01/24 through 05/10/24, and the facility's shower scheduled, dated 05/08/24,and task list, called "Documentation Survey Report" for dressing and bathing, indicated the following:

- S/He required assistance in bathing and dressing. In the area of 'bathing', [Resident 3] has asked  "that staff stay in his/her room for [him/her] to get in and out of shower for safety and fear of falling."

- Facility's shower schedule indicated Resident 3 is "Cueing only" in bathing once weekly.

- Dressing assistance was not provided daily from 05/01/24 through 05/09/24.

- Bathing assistance was not provided the week of 03/03/24. Resident 3 went nine days without a shower. There was no documentation Resident 3 declined services.

In an interview, Resident 3 stated s/he required assistance in bathing and dressing but s/he does not get showers on a regular basis due to not enough staffing. When s/he is in shower, care staff will leave the apartment to do other things.

In an interview, Staff 1 (Executive Director) stated Resident 3 required assistance with bathing and dressing.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to implement a service plan that reflects the resident's needs.  

Verbal plan of correction: ED and COO will review resident service plans for needs and frequency and update service plans and staffing schedule by the end of next week 05/17/24. ED will immediately add a third person to night shift and all shifts will have three care staff for two person assist and current care needs. ED, RCC and COO will audit call light logs daily.

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to have a system for tracking controlled substances administered for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's MAR, dated 01/01/24 through 1/31/24, indicated the following:

* S/He is ordered morphine ER 15mg one tablet by mouth three times daily at 6am, 2pm, and 8pm.

* S/He was administered this medication three times on 01/05/24.

* S/He was administered this medication on 01/14/24 at 8pm.

A review of the facility's "Medication Incident Report and Investigation", dated 01/05/24, indicated the following:

-  "Last pill on card was apparently accidentally thrown away believing the card was empty."

- Staff reported the incident on 01/05/24.

-  In the section, "Care provided to resident and outcome:" stated: "N/A medication was not given to resident. Nurse notified."  

A review of the facility's "Controlled Substance Disposition Logbook #71" indicated the following:

- Morphine was signed as given on 01/06/24 then had been crossed out more than once and written over with: "01/05/24". The time given was unreadable due to cross outs on line 27.

- The disposition date had been written over and was unreadable, then signed by Staff 1 and 3.

- A handwritten notation with an unreadable date stated: "last pill missing see med error report "  and signed by Staff 3.

- On line 28, there were two doses that remained and were unaccounted for on the day of the site visit. Line 29 through 31 the pill count was  "zero".

- On 01/05/24, Resident 5's received his/her 8pm dose of Morphine ER 15mg one tablet when a new card was started. Resident 5 was given Morphine ER 15mg one tablet all three prescribed times

- On 01/05/24, Resident 5 was given Morphine ER 15mg one tablet all three prescribed times.

- There was no evidence the dose of morphine medication administered on 01/14/24 at 8pm had been recorded.

In text messages, dated 01/21/24, between Staff (Anonymous) and Staff #1 (ED) indicated a med tech needs to be removed from med room due to complaints from residents that they have not been getting scheduled narcotics on evening shift.

In an interview Staff 3 (Nurse) stated s/he "did not know why the morphine disappeared." S/He stated, "three pills were missing of morphine" and did not report to the Department or police because s/he did not know s/he needed to.

In an interview on 05/13/24 at 7:42 am via telephone Staff (Anonymous) stated "I did not sign the narcotics book, those are not my initials on line 27, page 093 book 71. There were three pills missing, not one. I only signed my initials on the correct count verification log for 01/06/24 -01/08/24 because the count was off by three pills not one."

In an interview on 05/13/24 at 1:37 pm via telephone Staff (Anonymous) stated "I was the last one to sign on line 26, page 093 book 71. There should have been three pills left. I only signed my initials on the correct count verification log for 01/06/24 -01/08/24 because the count was off by three pills not one. I called [Staff 3 (Nurse)] on 01/06/23 to report the missing pills not on 01/05/24."

In an interview on 05/13/24 at 1:37 pm Staff 6 stated that the incident was reported to [Staff 3 (Nurse)] on 01/06/24.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was determined the facility did not have a system in place for accurately tracking controlled substances administered by the facility.

Verbal plan of correction: ED, COO and RN will review OAR and facility policy and procedure. COO will conduct an all-staff re-training on how to complete an incident report and internal investigation report appropriately. ED will contact local APS office and schedule a mandatory reporter training for all staff today 05/09/24. COO will re-investigate the incident on 01/05/24 and report internal investigation to Department and applicable community partners as needed by end of week 05/17/24.

Exp 1

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to provide staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

A review of staff schedules, facility's posted staffing plan and call-light logs, dated January 2024, indicated the following:

·The posted staffing plan indicated there should be two and half caregivers on day and evening shifts and two caregivers on night shift. Posted staffing lacked the number of MT's needed on shift.

·Staff schedule, dated 05/01/24 through 05/09/24, indicated on nine of nine days and a total of 20 shifts, the facility was staffed below their posted staffing plan by one-to-two direct care staff.

·Call light logs on 01/03/24, 01/11/24, 01/12/24, 01/20/24, and 01/23/24 indicated call light response times from 20 minutes to an hour.  

In an interview Resident 2, stated recently and in the past s/he had waited sometimes an hour for help after pressing his/her call light.

In an interview on 05/09/24 at 10:38 am, Staff 1 (ED) stated the following:

·Was aware of short staffing in January 2024 and March 2024.

·They do not audit call light response times.

·The facility's expected call light response time was three - four minutes.

In an interview Staff 5 (anonymous) stated the following:  

·S/He often work short staffed or alone on night shift due to not enough care staff.

·Staff is not meeting residents' needs, including two persons assists due to short staffing and has told administration multiple times.

·   [Resident 1] is a two-person transfer and often has had needs missed due to lack of staff.

In an interview Staff 2 (Chief Operating Officer) stated the facility needs to have three caregivers on all shifts to accommodate residents needs due to providing two persons assist.  

On 05/10/24 via telephone, the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to provide staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents.

Verbal plan of correction:

ED and Chief Operating Officer (COO) will review resident service plans for needs and frequency, start updating service plans and staffing schedule by the end of next week, 05/17/24. ED will immediately add a third person to NOC shift and all shifts will have three care staff for two person assist and current care needs. ED, RCC and COO will audit call light logs daily.

Exp 2

Based on interview, and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to provide staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

A review of staff schedules, facility's posted staffing plan and call-light logs, dated March 2024 indicated the following:

·The posted staffing plan indicated there should be two and half caregivers on day and evening shifts and two caregivers on night shift. Posted staffing lacked the number of MTs needed on shift.

·Staff schedule, dated 05/01/24 through 05/09/24, indicated on nine of nine days and a total of 20 shifts, the facility was staffed below their posted staffing plan by one to two direct care staff.

·Call light logs on 03/12/24, 03/22/24 and 03/27/24 indicated call light response times from 20 minutes to an hour.  

In an interview with Resident 2, stated in recent months s/he has waited sometimes an hour for help when pressing call light.

In an interview on 05/09/24 at 10:38 am, Staff 1 (ED) stated the following:

·Was aware of short staffing in January 2024 and March 2024.

·They do not audit call light response times.

·The facility's expected call light response time is three - four minutes.

In an interview Staff 5, (anonymous) stated the following:  

·S/He often work short staffed or alone on night shift due to not enough care staff.

·Staff is not meeting resident ' s needs, including two persons assists due to short staffing and has told administration multiple times.

·   [Resident 1] is a two-person transfer and often has had needs missed due to lack of staff.

In an interview Staff 2, (Chief Operating Officer) stated the facility needs to have three caregivers on all shifts to accommodate residents needs due to providing two persons assist.  

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to provide staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents.

Verbal plan of correction:

ED and Chief Operating Officer (COO) will review resident service plans for needs and frequency, start updating service plans and staffing schedule by the end of next week, 05/17/24. ED will immediately add a third person to NOC shift and all shifts will have three care staff for two person assist and current care needs. ED, RCC and COO will audit call light logs daily.

Based on observation, interview, and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings include, but are not limited to:  

A review of resident roster indicated facility home to 33 residents.

A review of the facility's ABST indicated the following:

· Staffing levels on day shift should have been 10 care staff for 75 hours of care needs for Thursday. The facitliy's ABST indicated high-acuity hours for day and evening shifts.

· All residents were entered.

· All residents ABST profiles were updated wihin the last quarter.

The posted staffing plan indicated the following:

· Two and half caregivers for day and evening shift; and

· Two caregivers on night shift.

· Plan lacked the number of MTs needed on any shift.

A review of staff schedule, dated 05/01/24 through 05/09/24, indicated on nine of nine days and a total of 20 shifts, the facility was staffed below their posted staffing plan by one to two direct care staff.

On 05/09/24, the CS observed on day shift there were two caregivers and one MT, and one caregiver and one MT for evening shift.

In an interview on 05/09/24 at 5:15 pm, Staff 1 (ED) stated s/he did not know how to use ABST and could be entering the care hours wrong. S/He stated that ABST was not used to generate a current staffing plan, staffing is dictated by corporate office, and s/he is not able to staff more when needed.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.

Based on observation, interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to ensure direct care staff have demonstrated satisfactory performance in any duty they are assigned, and document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 3 of 3 sampled direct care staff (# 7, 8 and 9) whose training records were reviewed. Findings include, but are not limited to:

A review of the facility's staff roster indicated Staff 7, 8, and 9 were hired on 10/27/21, 04/13/23, and 12/20/23, respectively. Delegation records reviewed confirm Staff 7, 8 and 9 had current delegation.

CS observed Staff 7 (MT) was working and administered medication during site visit.

During an interview on 05/09/24 at 11:22 am, Staff 1 (Executive Director) confirmed there was no documented evidence above staff had completed demonstrated competency of all skills, including the safe administration of medication and treatments.

On 05/10/24 via telephone the above information was shared with and acknowledged by Staff 1 and 2 (Chief Operating Officer).

It was confirmed the facility failed to ensure direct care staff demonstrated competency of all skills in safe administration of medication and treatments.

Verbal plan of correction: ED, RN and COO will immediately pull MT ' s from floor until competencies can be completed. On 05/09/24, the RN will complete competencies with each MT at the start of their shift, beginning with evening and night shifts. All MT competencies will be completed by Tuesday, 05/14/24. The RN and ED will scan, and email all completed competencies for each MT to CS2 as they are completed. COO reports s/he will audit all employees '  competencies and training records to ensure that all employees are fully trained prior to working unsupervised. COO will review facility's policy and procedure with Administration today. ED will contact OPA regarding any questions or concerns.