Print Inspection: Q7IK

During observation and interview, conducted during a site visit on 07/29/24, it was confirmed the facility failed to ensure that the service plan must reflect the resident's needs as identified in the evaluation and be available to staff for 2 of 2 sampled residents (#s 9 and 10). Findings include, but are not limited to:

An observation of the first floor service plan binder revealed a current service plan for Resident 9 was not available to caregiving staff.

Resident 10's service plan dated 03/15/24 was available in the service plan binder, but was not current.

The findings were reviewed with and acknowledged by Staff 1 (Interim ED) and Staff 5 (RCC) on 07/29/24.

The facility failed to ensure that the service plan must reflect the resident's needs as identified in the evaluation and be available to staff.

Verbal Plan of Correction: An audit will be conducted weekly on Fridays (section by section), to setup service planning meetings for the following Thursdays to involve residents and their families. All service plans will be updated and current by the end of August 2024.

Based on interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

A review of Resident 5's MAR for 11/01/23 through 11/02/23 revealed an order for Oxycodone 20mg (a narcotic pain medication) take 2 tabs by mouth every 12 hours. Resident 5's MAR revealed the medication was not given on 11/02/23.

During an interview on 07/29/23, Staff 1(Interim ED) stated the medication was not given if it was not on the MAR.

The findings were reviewed with and acknowlegded by Staff 1 and Staff 5 (RCC) on 07/29/24.

The facility failed to carry our medication orders as prescribed.

Verbal plan of correction: The facility RCC had started checking missed medications, new medications and exceptions at daily standup meeting. Nurse then completed the investigation and follow up with MT. Re-training occurring with MTs who lack documentation of training.

Based on interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed carry out medication orders as prescribed for 2 of 4 sampled residents (#s 1 and 4). Findings include, but are not limited to:

A review of Resident 1's MAR for 09/01/23 through 09/30/23 revealed an order for Insulin Glargine (Diabetes medication) 100 unit/ML solution inject 14 units under the skin nightly. The MAR revealed the medication was not given 09/16/23.

A review of Resident 4's MAR for 09/01/23 through 09/30/23 revealed an order for insulin glargene (Diabetes medication) inject 30 units subcutaneously nightly. The MAR revealed the medication was not given on 09/12/23, 09/13/23, 09/14/23 or 09/15/23.

During an interview on 07/29/24, Staff 1 (Interim ED) stated the incidents occurred under the previous ownership as the facility had a change of ownership on 11/01/23.

The findings were reviewed with and acknowledged by Staff 1 on 07/29/24.

The facility failed to carry out medication orders as prescribed.

Verbal plan of correction: Facility leadership has started checking missed medications, new medications and exceptions at daily standup meeting. Nurse investigates and follows up with MT. Re-training occurring with MTs who lack documentation of training to be completed by 08/15/24.

Based on observation, interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled residents (# 10). Findings include, but are not limited to:

During the site visit on 07/29/24, the facility's posted staffing plan was observed and reviewed which contained the following staffing plan with a total of 20 direct care staff:

Day shift: 5 CGs and 3 MTs

Swing shift: 5 CGs and 2 MTs

Night shift: 4 CGs and 1 MT

A review of the facility's ABST indicated the facility had a need for 20.61 direct care staff.

During an interview on 07/29/24, Staff 1 (Interim ED) agreed the facility was staffed short of their ABST.

Resident 10's service plan dated 03/15/24 was reviewed and interviews were conducted revealing a discrepancy in the following ADL need:

*Toileting and incontinence care.

The facility failed to fully implement and update an ABST.

The findings were reviewed with and acknowledged by Staff 1 and Staff 5 (RCC) on 07/29/24.

Based on observation, interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 2 of 2 sampled staff (#s 3 and 10). Findings include, but are not limited to:

During the site visit on 07/29/24, Staff 3 (MT) was observed working independently.

A review of Staff 3's MT competencies checklist revealed Staff 3 was hired 09/28/21. Their MT training started on 10/02/21 and was signed by Staff 5 (RCC) on 07/29/24.

Training documents for Staff 10 (MT) were requested. There was no documented evidence that Staff 10 had completed any competency training.

During an interview on 07/29/24 Staff 1 (Interim ED) stated facility leadership had conducted an audit of all staff training documents and competencies around 07/19/24 and had determined many staff lacked documentation of training. Staff 1 further stated all staff were in the process of completing the competency checklists.

The findings were reviewed with and acknowledged by Staff 1 and Staff 5(RCC) on 07/29/24.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.

Verbal plan of correction: All staff will have training documents completed by 08/15/24.

Based on observation and interview, conducted during a site visit on 07/29/24, it was confirmed the facility failed to keep clean all interior and exterior materials and surfaces. Findings include, but are not limited to:

Observations of the first and second floor hallways and the facility elevator revealed multiple carpet stains of various sizes.

Observations of the first and second floor walls revealed multiple areas of peeling and chipped paint.

Observations of the second floor staffing station revealed part of the flooring was scraped off or removed.

In an interview a resident stated the facility was undergoing remodeling.

The findings were reviewed with and acknowledged by Staff 1 (Interim ED) and Staff 5 (RCC) on 07/29/24.

The facility failed to keep clean all interior and exterior materials and surfaces.

Verbal Plan of Correction: Carpet replacement and facility remodel will be completed by October 2024.