Print Inspection: WI0W

Based on interview and record review, conducted during a site visit on

06/13/24, it was confirmed the facility failed to carry out medication orders as

prescribed for 1 of 1 sampled resident (#1). Findings include, but are not

limited to:

During an interview on 06/13/24, Staff 1 (Executive Director) indicated

Resident 1 did not have a doctor's order to call 911 and to fax the doctor

regarding his/her insulin until recently. Staff 1 acknowledged the resident had

gone without Prilosec for a few days.

During an interview on 06/13/24, Resident 1 indicated, s/he was having issues

with his/her insulin. S/he indicated that his/her blood glucose levels would be

down, and staff would not contact the doctor stating that they did not have

doctor's orders to do so. S/he indicated s/he should be receiving Prilosec twice

a day for acid reflux, but the facility did not order the medication on time and

s/he has gone without for a few days now.

A review of Resident 1's doctor's orders indicated the following;

 An order on 09/25/23 the Hypoglycemia protocol orders were if CBG

was less than 70, see PRN glucose order, if not glucose, give 4 oz of

orange juice. Recheck CBG in 15 minutes, repeat above steps until CBG

is greater than 80. Once CBG is above 80 give insulin as directed. Call

911 if unresponsive or CBG is less than 50.

 An order on 08/03/23, Prilosec OTC 20 MG for acid reflux, one tablet by

mouth twice a daily at 9:00 AM and 5:00 PM.

A review of Resident 1's MARs for 04/01/24 through 06/13/24, indicated the

following;

 From 04/06/24 through 04/15/24 resident was to receive Insulin Lispro

15 units once a day at 11:30 AM. The insulin had been signed off as

given but no blood glucose had been recorded.

 Lantus Solostar 45-unit injections twice a day from 04/01/24 through

04/30/24 indicated five occurrences where the blood glucose had been

less than 50.

 Lantus Solostar 22 units twice daily had not been done on 05/18/24.

 Resident has not received eight doses of his/her Prilosec OTC 20 MG

tablet. The last dose had been provided at 9:00 AM on 06/09/24.

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

On 06/13/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Resident 1 has seen the doctor, and the insulin

dosage has changed leveling out his/her blood glucose levels. The facility has

reminded staff to contact doctor when levels are high or low.

Based on interview and record review, conducted during a site visit on

06/13/24, it was confirmed the facility failed to provide a full-time administrator

to be onsite 40 hours per week. Findings include, but are not limited to:

During an interview on 06/13/24, Staff 1 (Executive Director) indicated during

the month of April s/he had worked as a caregiver and/or med tech and had

attempted to do administrative work on the downtime however, s/he had not

worked 40 hours a week for that whole month doing administrative work.

A review of timecards from 04/01/24 through 04/30/24, indicated Staff 1 had

worked 166.50 hours as a care staff.

A review of the posted staffing plan indicated the following;

 Day shift from 6:00 AM to 2:00 PM had one caregiver and one shared

med tech with memory care.

 Swing shift from 2:00 PM to 10:00 PM had one caregiver and one

shared med tech with memory care.

 Night shift from 10:00 PM to 6:00 AM zero caregivers and one shared

med tech with memory care.

It was determined the facility failed to employ a full-time administrator on-site

in the facility at least 40 hours per week.

On 06/13/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 has not worked as frequently as a care staff

and has gotten agency staff in the facility. Per advice from OPA Staff 1 will be

adding a caregiver to work night shift.

Based on interview and record review, conducted during a site visit on

06/13/24, it was confirmed the facility failed to have qualified awake direct care

staff, sufficient in number to meet the 24-hour scheduled and unscheduled

needs of each resident. Findings include, but are not limited to:

During an interview on 06/13/24, Staff 1 (Executive Director) indicated the

following;

 The standard call light response time was 10 minutes.

 S/he did not audit call lights unless someone complains.

 There were occasions on the night shift when there were no staff on the

assisted living side of the building, due to having one shared med tech

and no caregiver working during the shift.

During an interview on 06/13/24, Resident 2 indicated call light response times

have taken up to 30 minutes.

A review of the posted staffing plan indicated the following;

 Day shift from 6:00 AM to 2:00 PM had one caregiver and one shared

med tech with memory care.

 Swing shift from 2:00 PM to 10:00 PM had one caregiver and one

shared med tech with memory care.

 Night shift from 10:00 PM to 6:00 AM zero caregivers and one shared

med tech with memory care.

A review of the call lights dated 04/25/24 through 05/01/24 and 06/08/24

through 06/10/24. On 06/08/24 Resident 1 pushed his/her pendent at 2:23

AM, the response time was 3 hours and 37 minutes.

It was confirmed the facility failed to have qualified awake direct care staff,

sufficient in number to meet the 24-hour scheduled and unscheduled needs of

each resident.

On 06/13/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will start auditing call light response times.

Per advice from OPA Staff 1 will be adding a caregiver to work night shift.

Based on interview and record review, conducted during a site visit on

06/13/24, it was confirmed the facility failed to update an acuity-based staffing

tool (ABST). Findings include, but are not limited to:

During an interview on 06/13/24, Staff 1 (ED) indicated the following:

 The facility used their own ABST.

 The current census was 19 residents.

 There were occasions on the night shift when there were no staff on the

assisted living side of the building, due to having one shared med tech

and no caregiver working during the shift.

A review of the posted staffing plan indicated the following;

 Day shift from 6:00 AM to 2:00 PM had one caregiver and one shared

med tech with memory care.

 Swing shift from 2:00 PM to 10:00 PM had one caregiver and one

shared med tech with memory care.

 Night shift from 10:00 PM to 6:00 AM zero caregivers and one shared

med tech with memory care.

A review of the ABST indicated the following;

 The points in the ABST did not match the points listed in Resident 1 and

Resident 2's service plans.

 The hours required for each shift were,

o Day shift: 10.7 hours.

o Swing shift: 7:93 hours.

o Night shift: 2.67 hours.

It was confirmed the facility failed to update an acuity-based staffing tool.

On 06/13/24, the findings were reviewed with and acknowledged by Staff 1.