Print Inspection: NKDM

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's August 2024 MAR and progress notes, incident report dated 08/14/24, and Interim Service Plan dated 08/15/24 indicated the following:

·Novolog 100-U/ML PEN 3ML to be injected 11 units before breakfast and 10 units before lunch and dinner for diabetes.

·Tresiba 100-U/ML PEN 3ML to be injected 18 units every day at 8 pm for diabetes.

·Resident 2 did not receive his/her Novolog 100-U/ML PEN 3ML on 08/14/25 at 7:30 am and 11:30 am and was administered Tresiba 100-U/ML PEN 3ML in error before breakfast and lunch.

In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25.

The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's November 2023 MAR and progress notes, incident report dated 11/09/23, and Interim Service Plan dated 11/10/23 indicated the following:

·Tramadol 50mg Tab to be given twice daily at 8 am and 2 pm.

·Resident 2 did not receive his/her scheduled doses of Tramadol on 11/09/23 at 8 am and 2 pm.

In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25.

The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.

A review of the ABST indicated the following:

·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.

·       Swing shift: AL 12.73 and MC 4.95 staff required.

·       Night shift: AL 6.02 and MC 2.4 staff required.

A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:

·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.

·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.

·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift.

In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:

·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.

·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.

Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.

The facility's failure to have a fully implemented and updated ABST was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.

A review of the ABST indicated the following:

·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.

·       Swing shift: AL 12.73 and MC 4.95 staff required.

·       Night shift: AL 6.02 and MC 2.4 staff required.

A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:

·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.

·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.

·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift.

In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:

·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.

·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.

Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.

The facility's failure to have a fully implemented and updated ABST was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.

A review of the ABST indicated the following:

·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.

·       Swing shift: AL 12.73 and MC 4.95 staff required.

·       Night shift: AL 6.02 and MC 2.4 staff required.

A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:

·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.

·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.

·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.

·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift.

In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:

·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.

·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.

Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.

The facility's failure to have a fully implemented and updated ABST was substantiated.