Print Inspection: XD97

Based on observation and interview it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include but not limited to:

During an unannounced site visit on 10/04/2022 Compliance Specialist (CS) observed several staff members  to not be wearing their masks appropriately, exposing their nose and mouth while in close proximity to other staff members.

CS did not observe any feces covered bedding.

These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022.

Facility Plan of Correction: In-service staff on masking policies by 10/15/22.

Based on interview and record review it was confirmed that facility failed to provide services to assist the resident with activities of daily living. Findings include but not limited to:

In separate interviews during an unannounced site visit on 10/04/2022, Staff #1, Staff #3, Staff #5, Staff #7, Staff #8, and Staff #10 all stated that they are provided weekly shower and laundry schedules and are to sign their initials when those services have been provided.

A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff."

These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022

Facility Plan of Correction: Facility Management team to pull report and audit call light times 3x/week and discuss in standup meetings to identify patterns and concerns. Trouble shoot as necessary. Will in-service staff on documentation policies related to showers as well as procedures if a shower is missed or resident refuses by 10/15/22. Assigned caregiver to offer shower twice, if resident refuses, CG to notify MT who should offer shower. If refusal continues, MT to notify RCC and resident family/POA.

Based on interview and record review it was confirmed that the facility failed to ensure the implementation of services. Findings include but not limited to:

In separate interviews during an unannounced site visit on 10/04/2022, Staff #1, Staff #3, Staff #5, Staff #7, Staff #8, and Staff #10 all stated that they are provided weekly shower and laundry schedules and are to sign their initials when those services have been provided.

A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff."

These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022

Facility Plan of Correction: Facility Management team to pull report and audit call light times 3x/week and discuss in standup meetings to identify patterns and concerns. Trouble shoot as necessary. Facility will in-service staff on documentation policies related to showers as well as procedures if a shower is missed or resident refuses by 10/15/22. Assigned caregiver (CG) to offer shower twice, if resident refuses, CG to notify Med Tech (MT) who should offer shower. If refusal continues, MT to notify Resident Care Coordinator and resident's family or Power of Attorney.

Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:

A review of Resident #7 (R7) after visit summary dated 4/11/2022 and hospital orders dated 4/25/2022 revealed that resident R7 was to receive a medication four times/day for 14 days beginning 4/11/2022. A review of R7's progress notes and  Medication Administration Record (MAR) for April 2022 revealed that resident R7 only received medication twice a day beginning on 4/12/2022.

These findings were reviewed with Staff #1 and Staff #11 on 10/04/2022 who were in agreement:

Facility Plan of Correction: Education on triple check process to be provided to Med Techs and nurses by 10/15/22.

Based on record review and interview it was confirmed that the facility failed to maintain an accurate medication administration record (MAR). Findings include but not limited to:

A review of Resident #7 (R7)'s progress notes revealed that resident went to the hospital on 4/20/2022. A review of R7's MAR revealed inconsistent documentation occurred from 4/20/2022-4/25/2022 when resident was admitted to the hospital, including: medications on hold by physician, absent from home, hold/see nurse notes and hospitalized.

These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022 who were in agreement.

Facility plan of correction: In service on documentation to be provided to Med Techs and nurses by 10/15/22.

Based on interview and record review it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:

During an unannounced site visit on 10/04/2022, in separate interviews Staff #3 and Resident #4 stated:

*Sometimes we do not have enough staff.

*Swing shift is a struggle.

*If there are not enough people it is hard to get showers done.

*Sometimes they have to pull people from the floor to help with meal service.

*It can take an hour to get help.

A review of facility call light logs for 9/27/2022- 9/29/2022 revealed at least 9 instances of response times over 20 minutes.

A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff."

These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022.

Based on record review and interview it was confirmed that facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

A review of the facility's ABST revealed the need for 47.7 hours of care during their day shift. A review of facility staff schedule for October 2022 revealed that the facility has 40 hours of care scheduled.

During interview by phone on 10/06/2022, Staff #1 (S1) reported that a Resident Care Coordinator (RCC) comes in for day shift on Sundays and Mondays and works the floor and answers call lights as needed in addition to their normal tasks. They also indicated that day shift starts at 0600.

A review of facility's laundry and shower schedule for the week of Sunday 10/02/22 did not include initials or signatures for Staff #8 (S8). A review of S8's time card for 10/3/22 revealed they started work at 0729. The facility was unable to provide any additional documentation that S8 provided care to residents on 10/3/22.

These findings were reviewed with and acknowledged by S1 by phone on 10/06/2022.

Based on observation and interview it was confirmed that the facility failed to have staff with sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals. Findings include but not limited to:

During an unannounced site visit on 10/04/2022, Compliance Specialist (CS) observed an interaction between Resident #4 (R4), Staff #5 and Staff #6 in which staff had substantial difficulty communicating with resident in English.

Compliance Specialist was also unable to interview Staff #5-Staff #7 and required assistance from Staff #3 for translation.

These findings were reviewed with Staff #1 and Staff #11 on 10/04/2022 who were in agreement.

Facility Plan of Correction: Executive Director to work with HR and regional team to develop a plan for this. Facility Med Techs are able to communicate proficiently in English.