complaint·February 23, 2024

Allegation: Staff are not following resident's care plan appropriately. It is alleged that the facility has been understaffed for several months and staff are falling behind on their work responsibilities i.e., shower assistance, distribution of medications in a timely manner, and checks on hospice and home health residents. Seven (7) residents were interviewed, of which four (4) stated that they are not being bathe as indicated in their care plans and admission agreements. Two (2) residents stated that they they had not been bathe in over 1 week, and they never know when they are going to be bathe because staff are not following their regular shower schedule. A total of seven (7) staff were interviewed. Four (4) out of seven staff confirmed that resident's care plans are not being followed as a result of staffing shortages. Staff reported that due to the staffing shortages staff are working 6 days a week, and they are still not meeting their needs. For example, a resident's wound was only being cleaned during day shift hours because there was insufficient staffing in the NOC shift, and other residents were not being provided incontinence care as required because when staff started their shift they were observing that the residents on the rotation log were not being changed because their clothes were soiled and wet. Staff stated that weekends and evenings are very challenging for staff because of staff shortages. It was reported that sometimes the NOC shift only had 1 staff in the Assisted Living floors, and 2 staff in the Memory Care unit, but at times 1 Memory Care staff has to be pulled to help the Assisted Living floors. Per document review, the findings indicate that facility caregiver staff have been working 12-hour shifts since at least November 2021, and has been using a total of 15 registry staff as a result of staffing shortages. Staff scheduling documents indicated that the Administrator and Wellness Director were scheduled to work as caregivers on at least 2 different dates. Per staff interviews, residents are to be showered a minimum of twice weekly. Allegation: Staff does not provide proper meal service to residents in care. It is alleged that staff are delivering the meals late to residents, the food is cold, and residents that require feeding assistance are awaiting at least 40 minutes after food is delivered to receive assistance from staff. Based on document review, the findings indicate that there are 5 residents that require feeding assistance. Three (3) out of seven (7) residents stated that their food has been delivered late. Per staff interviews, meals were being provided to residents in their rooms as a result of a COVID-19 virus outbreak. On 2/14/2022, residents resumed dining services in th e dining room. Administration staff stated that residents that require feeding assistance take approximately 30 minutes - 1 hour for meal consumption. Five (5) out of seven (7) staff stated that it is taking staff at least 30 minutes to go feed the residents that require assistance, because they are busy attending other resident needs. It was reported that on Sunday February 13, 2022, staff began passing breakfast meals at 9:15 am, and they finished at about 10:00 AM. The residents that needed assistance began eating their breakfast until past 10:00 AM, and on that day staff began serving lunch at an earlier time in order for lunch service to be on time. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited. Exit interview was conducted and a copy of the report and appeal rights were issued.