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

During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas:

*Residents soiled clothing piled up in laundry room.

*Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and

*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift.

CS asked Staff #1 (S1-med tech) about the residents '  acuity and there was no documentation that contained information regarding the resident ' s individual care needs.  

During separate interviews with Staff #1-4 (S1-S4) the following was stated:

*We do not have an acuity tool;

*Not all Service Plans are accurate or up to date;  

*We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift;

*We can ' t complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry;

*We don ' t use agency staff and I don ' t know why;  

*Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and

The facility was unable to tell the CS how they get their staffing based on resident acuity.   

The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.