Failure to Administer Facility Operations Effectively and Efficiently
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. Observations, record reviews, and staff interviews revealed multiple deficiencies, including inadequate staffing, incomplete performance evaluations, an incomplete facility assessment, malfunctioning resident call systems, inconsistent water temperature monitoring, and failure to provide scheduled therapeutic activities. The Administrator and Director of Nursing were found to lack effective systems to timely identify and correct these quality, care, and environmental concerns. Staffing issues were evident through direct care observations and interviews. Several residents were left in soiled clothing and bedding for extended periods, with staff confirming that incontinence care was not provided in a timely manner due to insufficient staffing. Residents were not assisted with meals promptly, and staff reported ongoing challenges in meeting care needs, including timely checks, showers, medication administration, and treatments. The facility's staffing plan and facility assessment were incomplete, lacking details on direct care staff assignments and failing to accurately reflect the facility's certified bed capacity. Performance evaluations for several CNAs were overdue, as confirmed by the Human Resource Manager. Environmental and activity-related deficiencies were also identified. The resident call system on the secured unit was found to have its volume turned down, preventing audible alerts for staff when residents required assistance. Water temperature monitoring was inconsistent, with some rooms having water that was too hot or too cold, and gaps in the temperature log indicated a lack of regular checks. Scheduled therapeutic activities, particularly in the evenings, were not provided as planned, with staff unaware of their responsibilities and key positions vacant, resulting in residents not receiving the activities listed on the facility calendar.