Inspection Details: 7NU9

Records Request Print
Date
5/21/2025
Event ID
7NU9
Inspection type(s)
Complaint Investig.
Deficiencies cited
2

Citation Details

C0360
Severity Level: 2
Visits: 1
Scope
Pattern/Minimal harm or potential for moderate harm
Visit Number
1
Visit Date
5/21/2025
Corrected Date
N/A
Details

Based on interview and record review, conducted during a site visit on 05/21/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

  

A review of the facility's ABST indicated the "minimum time needed based on acuity" for each segregated area was as follows:

·Oak side:

oDay shift: 3.55 care staff;

oSwing shift: 3.18 care staff; and

oNight shift: 1.54 care staff.

·Maple side:

oDay shift: 2.40 care staff;

oSwing shift: 2.26 care staff; and

oNight shift: 1.16 care staff.

 

A review of the facility's staff schedule dated 05/14/25 through 05/21/25 indicated the facility had been short-staffed to their ABST for every day. The facility had not scheduled two direct care staff at all times for residents who required the assistance of two direct care staff for scheduled and unscheduled needs.

 

An interview with Staff 1 (Executive Director) indicated that both segregated sides had residents who required multiple-person transfers.

 

It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

C0363
Severity Level: 2
Visits: 1
Scope
Pattern/Minimal harm or potential for moderate harm
Visit Number
1
Visit Date
5/21/2025
Corrected Date
N/A
Details

Based on interview and record review, conducted during a site visit on 05/21/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

  

A review of the facility's ABST indicated the "minimum time needed based on acuity" for each segregated area was as follows:

·Oak side:

oDay shift: 3.55 care staff;

oSwing shift: 3.18 care staff; and

oNight shift: 1.54 care staff.

·Maple side:

oDay shift: 2.40 care staff;

oSwing shift: 2.26 care staff; and

oNight shift: 1.16 care staff.

 

A review of the facility's staff schedule dated 05/14/25 through 05/21/25 indicated the facility had been short-staffed to their ABST for every day. The facility had not scheduled two direct care staff at all times for residents who required the assistance of two direct care staff for scheduled and unscheduled needs.

 

An interview with Staff 1 (Executive Director) indicated that both segregated sides had residents who required multiple-person transfers.

 

It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.