Print Inspection: WWNN

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the licensee failed to ensure adequate administrative oversight of facility operations including supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:

Administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of confirmed allegations.

1. On 12/08/23 Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

OAR 411-054-0025 (1)(b) Facility Administration; Operation

OAR 411-054-0025 (4) Reasonable Precautions

OAR 411-0054-0027 (1) Resident Rights and Protections

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

OAR 411-054-0055 (1)(f-h) Systems: Tracking Control Substances

OAR 411-054-0070 (1)(g) and (6)(G) Staffing Requirements and Training

OAR 411-057-0160 (2)(c) Nutrition and Hydration

2. Monitoring visits conducted by the Licensing Complaint Unit on 12/09/23 and 12/10/23 indicated the facility had not implanted all changes requested in the immediate plan of correction requested on 12/08/23.

3. Refer to the allegations in the report.

It was determined the facility failed to ensure adequate administrative oversight of facility operations including supervision and training of staff

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:

1. During a Licensing Complaint Unit (LCU) site investigation, multiple licensing violations were identified that placed the health, safety and welfare of residents living in the facility at risk:

OAR 411-054-0025 (1)(b) Facility Administration; Operation

OAR 411-0054-0027 (1) Resident Rights and Protections

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

OAR 411-054-0055 (1)(f-h) Systems: Tracking Control Substances

OAR 411-054-0070 (1)(g) and (6)(G) Staffing Requirements and Training

OAR 411-057-0160 (2)(c) Nutrition and Hydration

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the immediate jeopardy was abated.

2. During LCU facility monitoring visits, conducted on 12/09/23 and 12/10/23, issues were identified that continued to threaten the health, safety, or welfare of residents. These included, but were not limited to:

* On 12/09/23 Resident 2, a COVID positive resident, lacked any documented evidence staff had been instructed on the specific care needs of the resident. Witness 20 (Agency Staff) stated there was a PPE bin outside of the resident's room but was unsure if "there is anything else they are supposed to do for [him/her] related to COVID."

* On 12/10/23 at approximately 11:30 am, Resident 7 was observed sitting on his/her soiled bed "half" dressed, with his/her feet on the floor. Resident's room smelled heavily of fecal matter. Brown smeared matter was visible on the exterior of the resident's toilet bowl.

* On 12/10/23 observations of Resident 15, conducted between 11:04 am and 2:00 pm, indicated Staff did not cue resident to go to the dining room for lunch, offer a meal tray, or provide any care services.

* On 12/10/23 observations of Resident 3, showed no staff entered the resident's room between 11:55 am and 1:55 pm. Resident 3 was not provided or assisted with lunch or offered fluids.

It was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, it was confirmed the facility failed to treat residents with dignity and respect, provide a safe and homelike environment, and ensure residents were free of neglect. Multiple residents were left soiled for hours and were not provided basic care. Findings include, but are not limited to:

On 12/08/23 at approximately 5:50 am, the night shift caregiver for the hall where Residents 2, 7, and 38 resided was observed to be wearing flip flops, sitting on a couch on his/her phone, and not wearing a mask despite two positive Covid cases in the facility.

On 12/08/23, at approximately 8:30 am, Residents 2, 7, and 38 were observed to have been left wet and soiled by night shift.

During an interview on 12/08/23, Staff 21 stated the following:

-S/he had changed and cleaned the room of Resident 38 after s/he had been left wet and soiled by night shift; and

-S/he had changed Resident 2 but had not changed his/her wet bedding because Resident 2 required a two person assist due to weakness from Covid.

After the interview with Staff 21, feces were observed smeared across the floor of Resident 38's apartment.

On 12/08/23, the stench of feces was observed in the hallway outside of Resident 7's room at approximately 10:30 am.

A binder labeled "200 Hall ADL Binder" indicated  "Every MT and care staff must initial off on every shift, every day as part of the caregiving routine. If you do not initial, you did not complete the task." Every page in the binder for every resident was blank.

During interview on 12/04/23 through 12/08/23, staff members stated the following:

-Staff 7 stated "it's not infrequent to find people wet and soiled;"

-Staff 8 (MT) stated Resident 39 was often left wet and soiled;

-Staff 14 (MT stated the morning of 12/05/23 Residents 17, 19, and 40 had been found left wet and soiled by the night shift;

-Staff 15 (MT) stated s/he finds wet and soiled residents "all the time" when s/he starts his/her shift. S/he stated she usually finds residents 17 and 20 wet and soiled;

-Staff 10 (MT) stated Residents 7, 22, and 42 were regularly left wet and soiled;

-Staff 17 (Activities) stated "there's never enough hands," s/he had observed residents left soiled for long periods of time and confirmed "it happens with a handful of residents" on a regular basis; and

-Staff 18 (MT) stated Resident's 19 and 20 were frequently left wet and soiled.

During an interview on 12/08/23, Witness 14 (Outside Agency RN) stated the following:

-S/he had found Resident 20 and his/her bedding "abnormally" soiled that morning; and

-His/her agency staff "regularly" found Resident 20 soiled and wet, including the previous three days.

During an interview on 12/08/23, Witness 16 (Family Member) stated his/her biggest complaint was showers, and that Resident 4 was supposed to be showered on Tuesdays, Thursdays, and Saturdays. The last two Saturdays Resident 4 had not received his/her shower. S/he further stated it had been an issue "for months" and at one point the facility had told Witness 16 "didn't have enough staff to give [Resident 4] a shower."

Resident 4's service plan, dated 10/16/23, indicated s/he was to be showered twice a week on Mondays and Fridays. It also indicated "Staff to encourage [Resident 4] to shower three times a week."  

A sign posted on the refrigerator in the 300 wing indicated Resident 4 was to receive showers on Saturday nights.

A review of "End of Shift Reports" for 11/2023 and 12/2023 indicated the following regarding Resident 4:

-There was no indication Resident 4 was showered from 11/08/23 through 11/17/23;

-There was no indication Resident 4 was showered from 11/22/23 through 12/02/23. Notes on 11/25/23 indicated "Could not do shower as swing was not available to cover hall;" and

-No indication Resident 4 was showered from 12/04/23 through 12/08/23. Notes on 12/05/23 indicated "water is cold water heater not working" and on 12/07/23 "resident not showered. (No hot water)."

The facility's failure to provide basic care, treat residents with dignity and respect, and provide a safe and homelike environment resulted in neglect.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

Monitoring visits conducted by the Licensing Complaint Unit on 12/09/23 and 12/10/23 indicated the facility had not implanted all changes requested in the immediate plan of correction requested on 12/08/23.

During a monitoring visit on 12/11/23 at approximately 10:38am, Resident 7 was observed by LCU in his/her room naked from the waist down. Resident 7's brief was soiled and on the floor. No care staff was observed assisting Resident 7 until approximately 12:14pm.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to determine or document actions or interventions, communicate actions or interventions to staff, monitor a residents condition, or evaluate the resident and refer to the facility RN for 2 of 2 sampled residents (#s 2 and 12) who experienced a change of condition. Resident 12 experienced a significant decline in health when routine medication was not administered. Findings include, but are not limited to:

1. On 12/08/23, Witness 1 (Family Member), approached the LCU team during their site visit. S/he stated s/he was very concerned and had "never seen a decline" for Resident 12 before.

A review of Resident 12's record indicated the following:

Hospice provider notes, dated 12/05/23, indicated Resident 12 had experienced a decline in his/her health status, to include increased shortness of breath, wheezing, bilateral lower-extremity edema, and anxiety.

On 12/06/23, "Outside Agency Documentation" left by the hospice RN indicated "worsening of [heart failure], adjusted furosemide (may be [routine] meds not given)."  "...increase Furosemide to 40mg for 3 days..."

There was no documented evidence the facility had reviewed the documentation left by hospice on 12/05/23 or 12/06/23.

During an interview on 12/08/23, Witness 6 (Family Member) stated s/he was "worried" about Resident 12 because s/he did not seem to be him/herself, that s/he was usually "alert" and "cheerful," and that Resident 12's "demeanor and breathing had changed drastically."  

On 12/08/23 at approximately 10:30 am Resident 12 was observed to be slouched over in his/her wheelchair, visibly short of breath, somnolent, and barely verbal, unable to answer questions.  

On 12/08/23 Staff 3 (LPN) stated s/he was aware Resident 12 "was out of baseline," however s/he had received his/her "first dose [of Furosemide] this morning." There was no documented evidence Resident 12 had received any Furosemide on the morning 12/08/23. MAR documentation indicated the medication was "pending refill."

On 12/08/23, outside provider notes from hospice indicated "Worsening [bilateral lower extremity] edema and now up thighs, thready radial pulses, irregular [heart rate]. Cardiac meds had not been administered by staff since 11/20...continues to have significant [bilateral lower extremity] edema, dyspnea at rest, audible congestion in lungs, denies pain, furosemide increase (ordered 12/6) started today 12/8."

A review of Resident 12's MAR, for the period 11/01/23 through 12/08/23, indicated the following routine medications had not been administered from 11/19/23 through 12/08/23:

* Atorvastatin (cholesterol)  80mg;

* Furosemide (diuretic) 20mg;

* Losartan (high blood pressure) 25mg; and

* Metoprolol (heart medication) 12.5mg.

The following was documented in the Resident's progress notes:

* 11/20/23, staff documented, "many medications we had run out of for [Resident 12]" and "they will be here on the next delivery later today."

* On 12/06/23, staff documented Resident 12's pharmacy had been contacted to refill Furosemide, however there were no refills left, and hospice was called to send refills to pharmacy.

* On 12/07/23 staff documented hospice had been called to confirm the new furosemide order and the hospice nurse confirmed [Resident 12] was to take 40mg furosemide for three days starting 12/08/23.

There was no documented evidence the facility had monitored the resident's condition between 11/19/23 and 12/08/23 related to the missed doses of medication, had determined actions or interventions and communicated those actions or interventions to staff when the resident's health declined, or had evaluated the resident and referred to the facility RN when the resident's health continued to decline.

2. During an interview on 12/07/23 Staff 12 (MT) confirmed Resident 2 had tested positive for Covid.

On 12/08/23, Staff 21 (CG) stated Resident 2 "felt very hot to the touch" and was "very weak" and required two staff assist. Staff 21 was not aware of any updated care or services to be provided to Resident 2.

On 12/08/23 Staff 3 (LPN) stated the residents on COVID protocols "should be" on two-hour checks and confirmed Resident 2's service plan had not been updated to reflect increased care needs.

On 12/08/23 Staff 12 stated "Resident 2 [not scheduled for two-hour checks] as far as I know."

There was no documented evidence the facility determined actions or interventions, communicated the actions or interventions to staff, or monitored Resident 2.  

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

It was determined the facility failed to document actions or interventions, communicate actions or interventions to staff, monitor a residents condition, or evaluate residents and refer to the facility RN when a resident experienced a change of condition.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 1). Resident 1 was put at risk when unlicensed and undelegated staff were improperly trained or delegated. Findings include, but are not limited to:

1. A review of Resident 1's delegation records and MARs indicated the following:

On 12/04/23 Staff 30 (MT) documented Resident 1's CBG reading was 289 mg/dl. The MAR instructed staff to administer 5 units of Humulog Kwikpen (insulin) if Resident 1's CBG was greater than 200. There was no documented evidence indicating the insulin had or had not been administered as prescribed. There was also no documented evidence Staff 30 (MT) had been delegated to administer insulin for Resident 1.

2. An RN delegation record, dated 11/25/23, signed by Staff 28 (RN) indicated Staff 10 (MT) had been delegated to administer insulin to Resident 1.

During interviews on 12/05/23 and 12/07/23, Staff 10 confirmed Staff 28 had not observed Staff 10 administer insulin. Staff 10 further stated Staff 28 could not have observed Staff 10 administer insulin on 11/25/23 because Resident 1's CBG reading was below 200.

Resident 1's recorded CBG on 11/25/23 was 116. MAR notes by Staff 10 indicated  "outside parameters."

Resident 1's 11/01/23 through 12/11/23 MAR indicated Staff 10 had administered Resident 1's insulin on 12/01/23, 12/02/23 and 12/09/23. On 12/01/23 Resident 1's CBG was documented as 319, and on 12/02/23 the CBG was documented as 309. Staff 10 (MT) administered 5 units of Humulog Kwikpen (insulin) to Resident 1 on both dates.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

It was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, and an interview on 12/13/23, it was confirmed the facility failed to ensure adequate professional oversight of the medication and treatment administration system, carry out medication orders as prescribed, and keep an accurate Medication Administration Record (MAR) for 18 of 18 sampled residents (#s 1, 2, 5, 6, 8, 9, 12, 14, 15, 18, 21, 24, 29, 31, 32, 34, 35, 36). Resident 12 experienced a decline in health when routine medications were not administered as prescribed.

1) On 12/08/23, Witness 1 (Family Member), approached the LCU team during their site visit. S/he stated s/he was very concerned and had "never seen a decline"  for Resident 12 before.

A review of Resident 12's record indicated the following:

Hospice provider notes, dated 12/05/23, indicated Resident 12 had experienced a decline in his/her health status, to include increased shortness of breath, wheezing, bilateral lower-extremity edema, and anxiety.

On 12/06/23,  "Outside Agency Documentation"  left by the hospice RN indicated  "worsening of [heart failure], adjusted furosemide (may be [routine] meds not given)."   "...increase Furosemide to 40mg for 3 days ..."

During an interview on 12/08/23, Witness 6 (Family Member) stated s/he was "worried" about Resident 12 because s/he did not seem to be him/herself, that s/he was usually "alert"  and  "cheerful,"  and that Resident 12's "demeanor and breathing had changed drastically."  

On 12/08/23 at approximately 10:30 am Resident 12 was observed to be slouched over in his/her wheelchair, visibly short of breath, somnolent, and barely verbal, unable to answer questions.  

On 12/08/23 Staff 3 (LPN) stated s/he was aware Resident 12  "was out of baseline,"  however s/he had received his/her "first dose [of Furosemide] this morning."  There was no documented evidence Resident 12 had received any Furosemide on the morning 12/08/23. MAR documentation indicated the medication was "pending refill."

On 12/08/23, outside provider notes from hospice indicated "Worsening [bilateral lower extremity] edema and now up thighs, thready radial pulses, irregular [heart rate]. Cardiac meds had not been administered by staff since 11/20  ... continues to have significant [bilateral lower extremity] edema, dyspnea at rest, audible congestion in lungs, denies pain, furosemide increase (ordered 12/6) started today 12/8."

Resident 12's MAR, dated 11/01/23 through 12/08/23, indicated the following:

-11/19/23 through 11/23/23 Atorvastatin 80mg, Furosemide 20mg, Losartan 25mg, Metoprolol 12.5mg, not administered, pending refill;

-11/24/23 all four medications, not administered, refused, when medication was not available;

-11/25/23 all four medications, not available;

-11/26/23 all four medications, not administered, pending refill;

-11/27/23 all four medications, administered,when medication was not available ;

-11/28/23 all four medications, not administered, pending refill;

The following was documented in the Resident's progress notes:

* 11/20/23, staff documented, "many medications we had run out of for [Resident 12]" and "they will be here on the next delivery later today."

* On 12/06/23, staff documented Resident 12's pharmacy had been contacted to refill Furosemide, however there were no refills left, and hospice was called to send refills to pharmacy.

The facility's failure to administer medications as prescribed led to a decline in Resident 12's health and placed the resident at risk for further decline.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

2) A review of Resident 1's physician orders, dated 11/01/23 through 11/30/23, indicated the following:

*A physician order, dated 11/15/23, indicated Resident 1's Jardiance (antidiabetic) was to be increased from 10mg to 25mg beginning 11/15/23. There was no documented evidence the increased dose had been administered until 11/21/23.

*A physician order dated 11/17/23, indicated Resident 1was to continue 100mcg Levothyroxine (thyroid agent).

Resident 1's MAR, indicated the following:

* Resident 1 received 88mcg Levothyroxine and 100mcg Levothyroxine on 11/10/23 and 11/11/23;

*Levothyroxine 100mg was not administered November 12th and 13th, notes indicated  " do not have correct strength dose " ; and

*11/15/23 Levothyroxine not administered; notes indicated  " med tech walked out" .

3) Resident 2's, MAR, dated 12/01/23 through 12/13/23, indicated the following:

*Missed doses of Amlodipine (blood pressure) on 12/07/23 through 12/09/23. Notes indicated  "medication unavailable "or "pending refill" ; and

*No documented evidence 8:00 pm medications had been administered on 12/11/23.

4) A review of Resident 5's MAR, dated 11/01/23 through 11/30/23, indicated the following:

*On 11/07/23, Levothyroxine (thyroid) was not administered, notes indicated  "pending refill";

*There was no documented evidence Resident 5 received Levothyroxine on 11/02/23 or 11/10/23;

*On 11/28/23, 2:00 pm dose of Morphine ER 15mg had not been administered. Staff documented "med not passed by previous shift"; and

*There was no documented evidence Resident 5 received his/her Morphine ER at 9:00 pm on 11/29/23 and 11/30/23.

5) A review of Resident 6's physician orders and 11/01/23 through 11/30/23 MAR indicated the following:

*A physician order dated 11/03/23, indicated a decrease in quetiapine (psychotropic) from 100mg to 50mg;

*Between 11/04/23 and11/06/23 the resident was administered 100mg quetiapine; and

*There was no documented evidence Resident 6 received quetiapine on 11/07/23.

6) A review of Resident 8's MAR, dated 11/01/23 through 12/18/23, indicated the following:

*Lidocaine 5% (pain reliever) had a  "start date"  of 10/11/23;

*There were thirty five instances where Lidocaine had not been administered with MAR notes indicating "pending refill;",  "refused" when medication was not available,  "unavailable", or  "discontinued."

*There were 17 instances where Lidocaine was marked as administered, in between the instances where the medication had been noted as "refused",   "unavailable", or  "discontinued."

*Four instances where Resident 8 was not administered Acetamin (pain reliever). Staff documented  "Other: Cannot find. Looked through entire cart,"  "Other: Day shift", "Other: Morning dose not administered," and "Med not available-not in pharmacy formulary";

*Three instances where Resident 8 was not administered Carbamazepine 100mg/5ml (for behaviors). Staff documented  "pending refill,"  "Other: Staffing issue, morning pass too late to administer before last dose, "  and "Other: Unable to locate meds; "

*Twenty-eight instances where Venlafaxine ER 150mg (anti-depressant) had not been administered. Staff documented, "pending refill," "Other: Cannot find in cart,"  and "Other: Cannot find will order,". There were several instances where staff documented the medication had been administered and/or refused when the medication had not been available.

*Eighteen missed doses of Cephalexin 500mg (antibiotic). Staff documented " pending refill, "  "Other: No more cards," "Other: Could not find,"  " not available, "  "Other: 7 days over," "Other: Cannot locate; "  and "Med not available-not in pharmacy formulary";

*Three instances where Quetiapine 50mg (psychotropic) was not administered, notes indicated  " pending refill "  and  " other: reordering; "  and

*At least one missed dose of Divalproex 125mg (anticonvulsant) at 8am, Briviact 10mg (anticonvulsant), Atorvastatin 80mg (cholesterol medication), Doxycycline Monohydrate (antibiotic) Lisinopril 40mg (blood pressure medication, and Buspirone 5mg (psychotropic medication). Notes indicated  " pending refill, "  "Other: Staffing issue, morning pass too late to administer before last dose, "  "Not available, "  "Med not available-not in pharmacy formulary, "  and "Med not available - backorder."

7) A review of Resident 9's MAR, dated 11/01/23 through 12/07/23, indicated the following:

*Fifteen instances where Resident 9's Oxycodone IR 5mg (pain reliever) was not administered. Notes indicated  "pending refill," "Other: Med not passed by previous shift," "Not available, "  and "Other: Resident stated doctor wanted her to stop taking medication;"

*Four instances where Resident 9's daily vitals were not taken. Notes indicated "No MT here at the time,"  "Other: Med not passed by previous shift,"  or there were no notes.

*Two instances where Cephalexin 500mg (antibiotic) was not administered, notes indicated "No MT here at the time" and "pending refill."

*Four instances where Mirtazapine 15mg (for dementia) was not administered, notes indicated  " pending refill; "

*One missed dose of Propanolol 10mg (anxiety medication). Notes indicated "Other: Med not passed by previous shift " ; and

*One missed dose of Acetaminophen 325mg (for fracture). Notes indicated "Not available."

8) Resident 14's clinical record was reviewed and indicated:

*Physician orders for Resident 14, dated 11/16/13, instructed the facility to discontinue routine dose of Lorazepam and change his/her diet to mechanical soft. There was no documented evidence the order had been implemented until 11/22/23, when a temporary service plan was put in place.  

A review of Resident 14 ' s MAR, dated 11/01/23 through 11/30/23, indicated:

*Resident 14 had not received any doses of Lorazepam between 11/01/23 and 11/20/23 when staff were instructed to discontinue the medication.

*There were eight occurrences where Resident 14 did not receive Levetiraceta Sol (anticonvulsant). Notes indicated  "Not available,"  "New RX needed-MD Faxed"  "Pending refill"  "Other: Med tech walked out;"

*On 11/15/23, the following am medications were not administered: Acetaminophen 500mg (scoliosis), Amlodipine 2.5mg (blood pressure), Levetiraceta Sol, and Metoprolol (blood pressure). Notes indicated  " Other: Med tech walked out " ;

9) A review of Resident 15's physician orders and 09/01/23 through 11/30/23 MAR's indicated the following:

*A 09/08/23 physician order instructed staff to " Start Clonazepam 1 whole tablet (0.5mg) twice a day for agitation. Discontinue all prior clonazepam orders and remove them from MAR. "

The MAR, dated 09/01/23 through 09/30/23, indicated:

*Clonazepam orders had been entered nine different times on the MAR;

*On 09/11/23, the MAR indicated Resident 15 was administered Clonazepam three times, instead of the twice daily ordered;

*There was no indication Resident 15 received Clonazepam on 09/15/23.

*Physician orders, dated 11/03/23, indicated Resident 15's Donepezil 10mg was to be discontinued, and Memantine 10mg dose (Alzheimer medication) discontinued.  Memantine 5mg was to start on 11/07/23.

Documentation on the MAR indicated Resident 15 was administered Donepezil on 11/04/23 and 11/05/23, after it had been discontinued.

*Seven missed doses of Memantine 5mg, notes indicated  " Other: Do not have this med in new dose strength,"  " Other: We do not have new dose strength,"  " Med not available - Backorder";

*On 11/15/23, MAR indicated Resident 15's routine am medications had not been administered, which included Risperidone 0.5mg (psychotropic) Citalopram 20mg (psychotropic), Clonazepam 0.5mg (for agitation);and Memantine 5mg. Notes indicated  "Other: Med Tech walked out."  

*A physician order, dated 11/07/23, indicated Resident 15 was prescribed Haloperidol 1mg" take 1 tablet by mouth every 4 hours as needed for agitation or nausea and/or vomiting."

An "End of Shift Report"  dated 11/23/23 indicated Resident 15 had vomited prior to dinner, had not eaten, and MT was notified. There was no documented evidence Resident 15 had been administered Haloperidol as prescribed.

10) A review of Resident 18's MARs, dated 11/01/23 through 11/30/23 indicated the following:

*Resident 18 ' s blood pressure had not been taken on 11/14/23. Staff documented "Pending refill";

*11/14/23 9:00 am routine dose of Amlodipine was not administered. Notes indicated  "Pending refill" ;

*Atorvastatin 10mg at 9:00 am dose had not been administered on 11/04/23 through 11/06/23, and on 11/14/23. Staff documented "Pending refill " ;

*9:00 am dose of Lisinopril 30mg and Metoprolol Succ ER 50mg  had not been administered on 11/14/23. Notes indicated  "Pending refill" and .

*No monthly weight was recorded during the month of November 2023.

11) A review Resident 21's clinical records indicated the following:

*On 12/01/23 the hospice RN documented Resident 21 had not been administered routine Seroquel and Omeprazole for a "period of time " and confirmed with a facility MT "no supply was available"  The hospice RN also documented " As pt has gone sometime (>2 wks?) w/o Seroquel, new orders will be updated. Please call us - if refills are not arriving from Pharmerica."

* A Medication Incident Report, dated 11/30/23, indicated Resident 21 had been administered the "wrong dose" of Quetiapine Fumarate 50mg (psychotropic). (The prescribed dose was 12.5mg, twice daily at 9:00 am and 6:00 pm).

-Staff 3 (LPN) asked Staff 10 (MT) how s/he was administering the 12.5mg tabs. Staff 10 stated s/he was  " cutting the 50mg tablets in half and then cutting the [halves] into half. " The medication was not scored to be broken into quarters.

*Resident 21's 09/01/23 through 09/30/23 MAR indicated:

-Four instances of Cyclobenzaprine 10mg (prescribed for pain) not being administered. Notes indicated  " Med not available - backorder "  and  " Pending refill;"  and

* Residents 21's 10/01/23 through 10/31/23 MAR indicated:

-One instance of Allopurinol 100mg (for osteoporosis) not being administered. Notes indicated  " Med not available - backorder " ;

-One instance of SMZ/TMP 800mg/160mg (anti-infective agent) not being administered. Notes indicated  " Other: Cannot find " ; and

-One instance of Quetiapine 50mg not being administered. Notes indicated  " Pending refill. "

* Resident 21's 11/01/23 through 11/30/23 MAR indicated:

-Eight instances of Omeprazole 20mg (gout agent) not administered. Notes indicated  " Pending refill; "

-Seven instances of Quetiapine 50mg not administered. Notes indicated  " Pending refill,"   "Not available,"  "Med not available - backorder;"  and

-Ten instances of Quetiapine 25mg (psychotropic medication prescribed for distressing paranoia) not administered. Notes indicated  "Not available" and  "Pending refill."  

12) A review of Resident 24's clinical records indicated:

*A physician order from June 2023 regarding Warfarin (anticoagulant) dosages indicated Resident 24 was to receive one 5mg tablet on 06/12/23. There was no documented evidence Warfarin was administered on 06/12/23.

*Resident 24's 06/01/23 through 06/30/23 MAR indicated 3 missed doses of Sertraline (for depression) 25mg on 06/28/23, 06/29/23, and 06/30/23. Notes indicated  "Pending refill."

A review of Resident 24's 08/01/23 through 08/31/23 MAR indicated:

*Warfarin 2.5mg was to be administered three times a week on Tues, Thurs, & Sat effective 08/07/23 through 08/21/23. There was no documented evidence Warfarin 2.5mg was administered on 08/15/23;

*Warfarin 2.5mg was to be administered in addition to the 5mg dose given the morning of 08/28/23. There was no documented evidence the dose had been administered.

*Resident 24 ' s INR (International Normalized Ratio) was to be completed on 08/14/23. There was no documented evidence the INR had been completed.

*On 08/24/23, 08/26/23 and 08/29/23, Warfarin 5mg had not been administered. Notes indicated  "Pending refill."

During an interview on 12/04/23, Witness 1 (Family Member) stated the following:

*The facility had once double dosed Resident 24 with Warfarin in October 2022;

*The facility had once not given Resident 24's Warfarin to him her for four days in a row around the same time;

*The facility had been unable to get Resident 24's medications right, and "screwed it up so many times we had to take [Resident 24] off Warfarin."

13) Resident 29's clinical records indicate the following:

Resident 29's MAR, dated 08/01/23 through 08/31/23, indicated:

*Two instances of Memantine 10mg not given, notes indicated pending refill;

*Two instances of Pantoprazole 40mg not given, notes indicated pending refill.

Resident 29's MAR, dated 10/01/23 through 10/31/23, indicated:

*Three instances of Morphine 20mg not given, notes indicated  " other: one bottle empty, second bottle contaminated "  and  " resident difficult to wake during lunch; "

*Two instances Pantoprazole not given, notes indicated pending refill;

*Two instances Acetaminophen not given, notes indicated pending refill;

*Four instances Senna 8.6mg tab not given, notes indicated pending refill;

*10/14/23-10/16/23 Sertraline 100mg not given, notes indicated pending refill;

*10/17/23 Sertraline 100mg not given, notes indicated refused (when the facility was out of the medication); and

*10/18/23 through 10/30/23 Sertraline 100mg not given, notes indicated pending refill.

Resident 29's MAR, dated 11/01/23 through 11/31/23, indicated the following:

*Ten instances of Senna 8.6mg not given, notes indicated pending refill

*Seven instances of Sertraline 100mg not given, notes indicated pending refill

*15 instances of Acetaminophen 500mg not administered;

*Five instances where it was not indicated whether or not Resident 29 had received Levothyroxine 125mcg with no notes;

*All 9:00 am medications on 11/15/23 indicated as not given: staff walked out;

*Two instances of donepezil 10mg not administered, notes indicated pending refill and "cannot find".

Resident 29's MAR, dated 12/01/23 through 12/11/23, indicated the following:

*Five instances where there was no documented evidence Resident 29 had received Levothyroxine 125mcg;

*Pantoprazole 40 mg not given 12/07/23 through 12/10/23, notes indicated pending refill or unavailable;

*Sertraline 100mg not given 12/09/23 and 12/10/23, notes indicated pending refill;

*2 instances there was no documented evidence Resident 29 had received his/her regularly scheduled Morphine;

Progress notes for Resident 29, dated 12/11/23, indicated the following:

*Late entry for 12/09/23;

*"Reason for visit: comfort check, see if morphine orders have been started;"

*"Identified concerns and recommended actions taken to resolve: Morphine 20mg/ml by mouth every 4 hours in addition to PRN order for MS. Ordered on November 22nd, still has not been [implemented]. Please start ASAP resent to  ... facility & fax on 12/09".

There was no documented evidence Resident 29's increase in Morphine had been implemented until 12/11/23.

14) Resident 31 ' s MAR, dated 08/01/23 through 08/31/23 indicated the following:

*Seven instances of quetiapine 25mg not given, notes indicated pending refill; and

*Two instances of metoprolol 25mg not given, notes indicated pending refill.

15) Resident 32's MAR, dated 08/01/23 through 08/31/23, intructed staff to weigh Resident 32 every two weeks for weight loss. On 08/15/23 Resident 32 was not weighed, notes indicated  "unable to obtain."

16) Resident 34 ' s MAR dated 11/01/23 through 11/30/23 indicated Eucerin Oring LOT Healing (topical agent) marked as pending refill 11/06/23 and 11/07/23, then "refused" until it was marked "unable to safely swallow" on 11/21/23.

17) Clinical records for Resident 36 indicated:

*A physician order dated 11/17/23, Donepezil (for dementia) to be increased to 10mg from 5mg.

*There was no documented evidence Resident 36 received Donepezil 10mg until 12/01/23.

18) During an interview on 12/04/23, Staff 9 (Activities) former Resident Care Coordinator, stated the facility protocol for processing medication orders was as follows:

*The facility received a physician order;

*The physician order was then faxed to the pharmacy;

*The order was then put into MT's "first check box", and MT would ensure pharmacy populated the medication onto the MAR so the medication could be administered;

*Once the medication was "profiled" on the MAR, the RCC would ensure the MAR matched the physician order; and

*The RN would then conduct "third checks" to ensure the medication on hand matched the order and the MAR.

Staff 9 further stated s/he had "found a bunch of orders" and had begun processing them. The facility had been behind on orders for a while because an old RCC was putting orders in his/her desk and not completing the second checks. Staff 9 confirmed Resident 15 had several medications pending refill that had not been refilled and Resident 27's Olanzapine had been discontinued by a physician order, but had not been discontinued on his/her MAR.

19) Staff, witnesses, and outside providers stated the following during interviews conducted during the site visit:

On12/04/23, Staff 7 (CG) stated s/he had been asked by a med tech to pass medication to a resident with no supervision or training.

On 12/05/23, Staff 8 (Med Tech) stated the following:

-Residents miss medications because the facility is out of stock;

-Med techs do "first checks" for physician orders by reviewing the orders and seeing if they're in the system, then moving them to "second checks". S/he further stated the medications have to go through all three checks before med techs can administer the medication.

-"Half the time we have the order and not the meds;"

-"I've seen [staff] mark meds as given when we were out of stock;"

-S/he had seen meds marked as refused without an attempt to administer medications;

-There had been a time when medications received from the pharmacy had been misplaced and staff had to search the building to locate them;

-S/he had seen an employee give a resident another resident's medication when the first resident was out of stock on a medication; and

-S/he had been called in on 11/15/23 at 10:30 am to cover a shift because both morning med techs had left. No residents in the 100 or 200 halls received am medication that day.

On 12/05/23, Staff 14 (Med Tech) stated the following:

-A "couple of weeks ago" the facility had run out of CBG test strips. An employee had brought more in at the end of Staff 14's shift.

-S/he has found medications in the wrong drawer;

On 12/05/23, Staff 3 (LPN) stated s/he was behind on processing physician orders, and had about 40 to process.

On 12/07/23, Staff 15 (Med Tech) stated the following:

-S/he had observed med techs popping pills into their bare hands;

-S/he was told by management "we could take meds for other residents if it was the same dose, [management] told me that when I first started";

-Med techs would mark medications as "not found" when the medications were available and "given" when they were not available;

-A couple med techs "will only try to give meds once to difficult residents then give meds to a [caregiver] and leave;" and

-S/he had finished the 9 am med pass "a little past 10" in the 300 hall and "later" in the 400 hall.

On12/07/23, Staff 18 (Med Tech) stated the following:

-Medications were marked as administered when they were not because the facility was out of stock;

-There were medications that would have dates to pop the pills out of the card, such as antibiotics, and s/he would come back from his/her weekend and find the pills un-popped;

-There were around 70 physician orders pending review;

-"We were just told Tuesday to approve orders;"

-"I figured out how to [discontinue] orders but I can't approve;"

-If medications were not approved, they could not be administered; and

-One time the housekeeper put "all the meds in random spots and we couldn't find them."

On 12/07/23 Staff 10 (Med Tech) stated s/he had seen a medication card for Ibuprofen with the resident's name ripped off in the med cart. S/he further stated s/he had cut an unscored medication in order to administer the correct dose to Resident 15.

On 12/08/23, Witness 14 (Hospice RN) stated the following:

-His/her biggest challenge over the last six months was orders being given to the facility and big delays in their implementation. Med techs had told her they had to wait for approval before enacting changes;

-Resident 16's diet requirements had been changed from mechanical soft to puree on 10/04/23, and the change had not been made until 10/11/23;

-There had been a huge delay in starting Resident 20 on his/her Tizanidine; and

-The facility had not notified him/her of medication errors for Resident 20.

On 12/13/23, Witness 17 (Hospice Compliance Specialist) stated the following:

-His/her hospice agency had 13 primary care patients at the facility, including two patients on hospice;

-The hospice agency was sending a care provider on a daily basis because of ongoing concerns with the facility;

-Resident 25 had not received coumadin in August and September;

-Resident 25's personal care provider (PCP) had tried to get ahold of the facility for about month;

-Resident 25 was admitted to the hospital on 09/12/23 with an INR of 1;

-Upon Resident 25's return to the facility on 09/14/23, the facility had called the pharmacy asking how to acquire INR test strips;

-Resident 25 had been receiving a hypertensive despite a hold order;

-The facility had started an order for Risperidone for Resident 36 on 11/08/23. Resident 36's hospice nurse and PCP did not know where the order had originated from;

-The hospice agency had discovered the order for Risperidone was from November 2022;

-The facility discontinued the order on 12/05/23;

-On 11/07/23, the hospice agency's nurse manager submitted a refill for sertraline for Resident 29;

-Resident 29 was not administered sertraline for seven days;

-Resident 29's order for morphine was changed 11/22/23, the facility did not make the change until 12/07/23;

-Resident 19 had missed doses of Warfarin multiple times in September 2023 and October 2023, including from 09/20/23 through 09/27/23;

It was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration system, carry out medication orders as prescribed, and keep an accurate Medication Administration Record (MAR) .

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 9 of 9 sampled residents (8, 10, 15, 18, 20, 28, 30, 32, 35, and 42) whose MARs, Controlled Substance medications and Controlled Substance Drug Disposition logs were reviewed. The lack of a system in place for tracking and storing of controlled substances put residents at risk of potential harm related to misuse.

1. During an interview on 12/05/23, Staff 14 (MT) stated it was facility policy for the outgoing and incoming med techs to count the narcotics on hand together during shift change, and note counts had been verified in the narcotic disposition log.

A review of a facility narcotic disposition log for September 2023 indicated 20 instances where only one staff member had signed the log, or the log was unsigned.

A review of a facility narcotic disposition log for October 2023 indicated 41 instances where only one staff member had signed the log, or the log was unsigned.

2. During an interview on 12/05/23, Staff 18 (MT) stated the previous facility RN had destroyed expired narcotics or narcotics for residents who no longer lived in the facility, but had not documented the destruction, so the narcotics log was "messed up."

On 12/05/23 Resident 8's Briviact (anti convulsant) was observed to have approximately 100ml. The narcotic disposition log indicated there was 25ml. It was also observed that Resident 8 had two medication cards for Briviact in pill form. Medication had been popped for administration from both cards.

On 12/05/23 Resident 18 was observed to have Lorazepam 0.5mg in his/her section of the medication cart that had expired on 11/03/23.

On 12/05/23 two bottles of Resident 35's liquid Lorazepam were observed in the facility's medication refrigerator. Resident 35 no longer resided at the facility. The facility's narcotic disposition log indicated that as of 08/29/23 at 5 pm there was a remaining quantity of 27.25ml Lorazepam remaining. The narcotics log did not indicate the strength of Lorazepam. As of 09/09/23 there were 23.5ml of Lorazepam 2mg/ml remaining.

During an interview on 12/07/23 Staff 10 (MT) stated Resident 42 had passed away "two to three months ago." Narcotics log for Resident 42 indicated the following:

-Staff were to "apply 1 patch [of Fentanyl 12/mcg]  ... every 72 hours for pain."

-Resident 42 received a patch on 08/05/23 at 8:00 am, again on 08/06/23 at 10:30, and again on 08/08/23 at 10:00 am. Notes on 08/08/23 indicated  "gave 1 day ahead?"

-Resident 42 received Fentanyl on 08/11/23 and then did not receive it again until 08/15/23.

-Directions for Resident 42's Morphine 20mg/ml were "take 0.25ml (5mg) PO/sublingual every 2hrs PRN for pain/shortness of breath."

-On 07/21/23 at 9:30 am there were 28.25ml of Morphine remaining. The next time it was marked as administered on 07/27/23 there was a remaining amount of 27ml. There were no notes accounting for the four doses missing.

-On 07/31/23 there was 25.75ml of Morphine remaining, on 08/03/23, the next time Morphine was administered, there was 25.25ml remaining.

-As of 05/01/23 at 4pm there was 28.5ml of Morphine 20mg remaining for Resident 42. There was no Morphine observed for Resident 42 in the medication cart, there was no documented evidence Resident 42's Morphine had been destroyed.

A medication disposition record, dated 12/05/23 and signed by Staff 3 (LPN) and Staff 9 (Activites), indicated the facility had destroyed 22ml of Morphine and 1 patch of Fentanyl for Resident 42 on 10/31/23. Staff 3 had not been working in the facility on 10/31/23.

A medication disposition record, dated 12/05/23 and signed by Staff 3 (LPN) and Staff 9 (Activites), indicated the facility had destroyed Resident 32's Morphine and Ativan on 10/31/23. Staff 3 had not been working in the facility on 10/31/23.

A medication disposition record dated 12/05/23 indicated Hydrocodone had been destroyed. The resident's name listed on the record had the first name of one resident and the last name of another resident.

A medication disposition record dated 12/05/23 indicated the facility had destroyed a quantity of "3" of an "unknown" medication for Resident 15.

A medication disposition record dated 12/08/23 for Resident 15 indicated the facility had destroyed one tab of Clonazepam 0.5mg. The record was not signed by anyone.

A medication disposition record for Resident 10 indicated his/her quetiapine had been destroyed. There was no date on the document.

The facility's narcotic disposition log indicated there were 14 remaining tabs of Hydrocodone 5-325 for Resident 28 as of 12/10/22. The following page of the narcotics log indicated 30 remaining tabs of Hydrocodone 5-325 for Resident 28 under a different prescription number. There was no documented evidence Resident 28's Hydrocodone had been destroyed. There was not observed to be any narcotics for Resident 28 in the medication cart.

On 12/07/23 a Bupenorphrine patch for Resident 30 was observed loose and unlocked in the medication cart. Resident 30 no longer resided at the facility.

During an interview on 12/08/23 Staff 2 (Regional Director of Health Services) stated an unlabeled bottle of morphine had been discovered during a facility self-audit of the med cart.

During an interview on 12/08/23, Witness 14 (Hospice RN) stated Resident 20 should not have received his/her morphine on 12/04/23 through 12/06/23 because there was no label on his/her morphine.

The facility's failure to have a system in place for accurately tracking controlled substances administered by the facility placed multiple residents at risk.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2, Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to provide adequate staff to meet the scheduled and unscheduled needs of residents for 11 of 11 sampled residents (#s 2, 7, 17, 19, 20, 22, 33, 38, 39, 40, and 42). Resident 2 was observed laying in soiled sheets. Resident 7 was observed to be left wet and soiled for an extended period of time. Resident 38's room was observed to be left covered in fecal matter. Findings include, but are not limited to:

The facility census on 12/04/23 was 46 residents, 10 of whom were on hospice and approximately five to seven residents who were two person assists, including at least one two person assist in each of the four halls.

The facility's posted staffing plan indicated:

-Two med techs and six caregivers for day and swing shifts; and

-One med tech and four caregivers for night shift.

On 12/04/23, 12/05/23, 12/07/23, and 12/08/23, during the day shift, it was observed the facility had four caregivers, one assigned to each of the four halls, and one "float." The facility had two med techs, one assigned to the 100 and 200 halls, and one assigned to the 300 and 400 halls.

On 12/04/23, 12/05/23, 12/07/23, and 12/08/23, during the swing shift, it was observed the facility had four caregivers, one assigned to each of the four halls, and one "float." The facility had two med techs, one assigned to the 100 and 200 halls and one assigned to the 300 and 400 halls.

During an interview on 12/04/23, Staff 8 (MT) stated the following:

- Staffing was "awful", staff wouldn't show up for work, and the facility was constantly understaffed;

- "No one really pays attention to what residents are doing"; and

- Resident 39 was regularly found wet and soiled.

In an interview on 12/04/23, Staff 6 (CG) stated the following:

-There "should" be two caregivers per hall;

-The other caregiver scheduled to work with Staff 6 was covering breaks in another hall;

-There have been times when Staff 6 had to work alone in a hall;

-On 11/30/23 Staff 6 was the float for all four halls;

-There were three two person assists in the 200 hall.

During an interview on 12/04/23, Staff 7 (CG) stated the following:

-Over the last month or two the facility had "frequently" been understaffed;

-On 10/29/23 residents in one of the halls had been left alone from 6:00 am until approximately 8:45 am because the previous shift had left without waiting for the day shift to show up, the day shift had called out, and no one on the floor had been notified.

-Residents were regularly left wet and soiled.

Time cards dated 10/29/23 indicated three caregivers and one med tech worked the day shift.

During an interview on 12/04/23, Staff 16 (CG) stated s/he was still in training on his/her second day, and that s/he was alone in the 300 hall while his/her trainer was on lunch.

During an interview on 12/04/23, Witness 1 (Family Member) stated "I've been here at all times and there are rarely people [in the 300 wing]". S/he further stated s/he had hired a personal caregiver from an outside agency to provide care to her family member in the facility because staffing was so inconsistent.

During an interview on 12/05/23, Staff 14 (Med Tech) stated the following:

-Staffing was "poor";

-The facility typically had enough staff for one caregiver per hall with one float.

-There had been a day when both morning med techs had called out and Staff 14 had been assigned to work as a caregiver that day. S/he was asked by management to act as a med tech; and

-The morning of 12/05/23 Resident's 17, 19, and 40 had been found wet and soiled.

On 12/05/23, Witness 12 (Family Member) stated she had concerns about staffing and "constant turnover".

During an interview on 12/05/23, Witness 14 (Outside Agency RN) stated s/he has seen a "lack of staffing" over the last two years, and has had caregivers share that concern. In hall 400 she was aware of at least one two person assist and had observed caregivers were frequently working by themselves.

During an interview on 12/07/23, Staff 15 (MT) stated staffing has "fluctuated a lot,"  that one week there had been four walk outs, and yesterday a staff member had walked out. S/he further stated she finds wet and soiled residents "all the time" when s/he starts her shift. S/he stated she usually finds residents 17 and 20 wet and soiled.

During an interview on 12/07/23 Staff 10 (MT) stated the following:

-New staff would come in one or two days then stop coming in;

-Staff 10's understanding was there should be two caregivers per hall and two floats. Recently there had been one caregiver per hall and one float; and

-Residents 7, 22, and 42 were regularly left wet and soiled.

During an interview on 12/07/23, Staff 25 (CG) was the only caregiver in the 100 hall and stated s/he was aware of one two-person assist.

During an interview on 12/07/23, Staff 17 (Activities) stated "there's never enough hands," s/he had observed residents left soiled for long periods of time and confirmed "it happens with a handful of residents" on a regular basis. S/he also stated during group activities, residents would often soil themselves, and Staff 17 would need to leave the activity with the resident to find an available staff to provide care.

During an interview on 12/07/23, Staff 18 stated the following:

-The facility regularly "...had four staff working";

-Resident's 19 and 20 were frequently left wet and soiled, as well as another unsampled resident who no longer lived at the facility; and

-Staff 18 stated residents being left wet and soiled was a "staffing issue."

During an interview on 12/08/23, Witness 14 (Outside Agency RN) stated the following:

-S/he had found Resident 20 and his/her bedding "abnormally" soiled that morning; and

-His/her agency staff "regularly" found Resident 20 soiled and wet, including the previous three days.

On 12/08/23, at approximately 6:00 am, Staff 21 (CG) stated s/he had changed Resident 2 but had not changed his/her wet sheets. Resident 2 required a two-person assist due to increased weakness after contracting COVID, and there was not another caregiver available to assist Staff 21. Staff 21 further stated s/he didn't know how many two person assists there were but "most of the men" required two person assists.

On 12/08/23, Staff 21 stated Resident 38 had been left naked and covered in feces from the night shift and s/he was cleaning him/her up. The LCU team observed Resident 38's floor to be covered in smeared fecal matter after Staff 21 exited the room.

The facility's failure to provide adequate direct care staff resulted in multiple residents being left wet and soiled for extended periods of time.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

It was determined the facility failed to provide adequate staff to meet the scheduled and unscheduled needs of residents.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to ensure direct care staff had demonstrated satisfactory performance in any duty they were assigned prior to performing work duties independently, for 5 of 5 sampled staff (#s 6, 8, 10, 16 and 18). Residents' care needs were put at risk related to lack of training. Findings include, but are not limited to:

On 12/05/23 CS requested training documents for Staff 6 (CG), 16 (CG), 8 (MT), 10 (MT), and 18 (MT). The facility was unable to provide documented evidence Staff 6, 8 and 16 had completed competencies. Documented competencies for Staff 10 and 18 were incomplete. All five sampled staff were observed providing direct care to residents, including med techs administering medication.

During an interview on 12/05/23, Staff 9 (Activities) stated s/he had been the RCC and confirmed training documents for 6, 8, 10 and 16 were either incomplete or missing. Staff 9 further stated the facility process of demonstrating competencies for direct care staff included a competency checklist and confirmed staff should not be providing care unsupervised until they had completed the required training.

During an interview on 12/04/23, Staff 8 (MT) stated s/he never filled out a competency checklist.  

During an interview on 12/05/23, Staff 16 stated it was his/her second day, his/her trainer had gone to lunch, and she would be alone in the hall for half an hour. S/he further stated that orientation had been "four hours of videos [and the] girl with me slept through them."

During an interview on 12/05/23, Staff 3 (LPN) stated caregivers received five days of training, and that 12/06/23 was to be Staff 16's final day of training.

During an interview on 12/05/23, Staff 14 (MT) stated that recently "we've had trainees training trainees." Staff 14 further stated when s/he first started, the facility had designated trainers and now they don't.

During an interview on 12/07/23, Staff 15 (MT) stated the two people training him/her got Covid and s/he had to pass meds by his/herself on his/her third day.

During an interview on 12/07/23, Staff 12 (MT) stated s/he had been a med tech for one month and had only been trained "two times" and then "they put me on a cart by myself" because the facility was "short staffed." Staff 12 further stated "If I have questions, I ask questions. If I'm not sure, I don't do it."

The facilities failure to ensure direct care staff had demonstrated competency prior to performing work duties resulted in multiple staff being unaware of resident care needs and multiple medication errors.

On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

It was determined the facility failed to ensure direct care staff had demonstrated satisfactory performance in any duty they were assigned prior to performing work duties independently.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to develop an individualized nutrition plan based on the resident's needs for 1 of 1 sampled resident (# 3). Resident 3 experienced a decline in health when s/he was not hydrated or fed. Findings include, but are not limited to:

On 12/08/23, at approximately 6:00 am, Resident 3 was observed lying in bed with dry, cracked lips. There was no water available bedside for Resident 3.

A review of Resident 3's most recent service plan, dated 11/22/23, indicated Resident 3 was unable to feed him/herself, required one staff member to assist him/her, indicated s/he "enjoys all three meals" and "doesn't really have any foods [s/he] dislikes."

The facility was unable to provide an individualized hydration plan for Resident 3 which included how frequently staff were to provide meal assistance or assist resident with hydration.

During an interview on 12/08/23 Staff 21 (CG) stated Resident 3 had not been able to eat recently due to build up of plaque and "stuff" in her mouth. Staff 21 also stated the facility's process for tracking resident meals was to circle "y" or "n" (yes or no) for breakfast, lunch, and dinner on the " Meal Attendance Tracking Log".

Instructions on the "Meal Attendance Tracking Log" indicated "if ANY meal is not attended, please explain: why, when resident was checked on, how, and BY WHOM."

Resident 3's "Meal Attendance Tracking Logs," dated 11/18/23 through 12/07/23, indicated the following:

-Eighteen instances where staff failed to document if meals were provided;

-Four instances where staff circled "n" and provided no notes;

-On 11/29/23 staff circled "n" and notes indicated [Resident 3] "can't eat" for two meals; and

-On 12/02/23 nothing was circled, comments indicated "asleep".

During an interview on 12/07/23, Staff 3 (LPN) stated it was facility policy to weigh residents once a month between the 1st and 4th of the month. A review of Resident 3's recorded weights indicated the following:

-07/18/23, 156lbs;

-10/17/23, 141.5lbs; and

-12/14/23, 125.4lbs.

The facility was unable to provide the requested weights for Resident 3 for June, August, September, or November 2023.

The facility's failure to provide staff with an individualized nutrition plan based on Resident 3's needs resulted in Resident 3 missing multiple meals, a lack of hydration, and weight loss.

On 12/08/23 at 12:02 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated.

On 12/10/23, during an LCU monitoring visit, no staff members were observed feeding Resident 3 lunch or providing water to Resident 3 between 11:39 pm and 2:10 pm.

It was determined the facility failed to develop an individualized nutrition plans based on resident's needs.

Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.