Print Inspection: PJYN

Based on observation, interview, and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Compliance Specialist (CS) observed the following on 05/30/24;

·Residents 3 and 4 were in the dining room eating lunch at 12:38pm

·At 5:50 pm Resident 1, Resident 3, and Resident 4 were up in the dining room eating dinner,

·5 staff were present in the facility and supervising dinner service,

·Staff 2 (CG/Shower aide) was getting Resident 2's dinner cooled down to assist with feeding in his/her room.

In an interview on 05/30/24, Staff 1 (ED) stated the following:

·Showers were documented in the EMAR,

·Nobody was auditing the showers lately to make sure they were getting documented,

·The bath aide was in from 12pm-8pm to do showers,

·Staff were feeding the residents,

·There was one resident that got fed in bed and another 3 residents that were supervised.

In an interview on 05/30/24, Staff 3 (CG/MT) stated the following:

·We supervised three of the residents in the dining room,

·Resident 2 was fed in his/her room,

·"They always get fed. No concerns about them not getting fed",

·" Showers get done when we have a shower aide [here]".

In an interview with Resident 2 on 05/30/24, s/he stated the following:

·"I get three meals a day if I want them" ,

·"They always help me get up to eat my meals",

·"I had breakfast this morning"

A review of Resident 1, Resident 2, Resident 3, and Resident 4's service plans and shower sheets for 05/01/24 through 05/31/24, indicated the following:

* All three residents' service plans show baths needed at least twice per week,

* Resident 1's only documented showers were on 05/18/24 and 05/25/24,

* Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24,

* Resident 4's only documented showers were on 05/18/24 and 05/25/24,

* Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024.

The findings were reviewed with and acknowledged by Staff 1 on 05/30/24.

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

Plan of correction: Facility is considering moving the shower aide shift from 7am-3pm instead of 12pm-8pm. Frequent auditing will be done by management to ensure that staff are completing and documenting showers or any refusals.

Based on observation, interview and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In an interview on 05/30/24, Staff 1 (Executive Director) stated the current census was 15 residents. Resident 5 moved in two days ago, and there was a resident that passed away, but the ABST had not been updated yet. Staff 1 stated staff were universal workers with additional tasks of cooking, serving food, housekeeping, activities, etc.

A review of the facility's ABST and resident roster on 05/30/24, indicated the following:

* There was 15 residents listed on the roster.

* Resident 5 who moved in on 05/28/24 was not listed on the ABST.

* On day shifts, 3.35 caregivers were needed; for swing shifts 3.19 caregivers were needed; and for night shift, 1.25 caregivers were needed.

* Ten residents' ABST profiles had not been updated since 10/04/23.

A review of the facility's posted staffing plan indicated the following:

* Day shift 7am-3:15pm: one CG,  one MT;

* Swing shift 3pm-11:15pm: one CG, one MT;

* Noc shift 11pm-7:15am: one CG, one MT;

* Activities 10am-6pm; and

* Bath aide 12pm-8pm.

A review of the facility's staff schedules, dated April 2024 and May 2024,  indicated the facility was staffing per their posted staffing plan.

In an interview on 05/30/24, Staff 4 (CG/Activities) stated: "I do activities and help out wherever needs help".

Compliance Specialist observed the following:

* Day and swing shifts had a MT, a CG, an activities staff member, and a shower aide working.

* At 12:04pm, the Staff 4 (Activities) was assisting with other caregiving duties such as transfering and assisting residents to the dining room for lunch and assisting with eating.

* At 5:50pm, the Staff 2 (shower aide) was assisting with meals/feeding.

A review of Resident 1, 2, and 4s'  service plans, dated 03/13/24, 03/26/24, 04/18/24, respectively, and shower sheets from 05/01/24-05/31/24, indicated the following:

* All three residents' service plans show baths needed at least twice per week,

* Resident 1's only documented showers were on 05/18/24 and 05/25/24,

* Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24,

* Resident 4's only documented showers were on 05/18/24 and 05/25/24,

* Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024.

On 05/30/24, findings were reviewed with and acknowledged by Staff 1.

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