Based on observation, interview, and record review, during a site visit conducted on 07/10/23 and 07/17/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

During an interview on 07/10/23, Staff 1 (RN) and Staff 2 (RCC) stated they were unable to access the facility's ABST tool. Both stated Staff 3 (Administrator) and Staff 4 (Business Office Manager) were both out of the facility and would be the two who could access the ABST.

During an email correspondence on 07/17/23, Staff 4 explained the tool the facility used is Frontier. Staff 4 stated to get the staffing numbers they take the total minutes and divide that by 60 (60 minutes in an hour), then divide that total number by 7.5 (amount of working hours in a shift) and that gave them the number of staff needed for the building per day. Staff 4 was unable to explain how the tool determined individual staffing numbers for each shift.

The facility's ABST was reviewed on 07/17/23, the tool had total minutes needed: 10367. Based on the calculation provided above, CS took 10367 divided by 60= 172.783 then divided that by 7.5= 23.03 care staff needed for the day. The posted staffing plan indicated on day and swing shift the facility scheduled one MT, three CG, and one treatment aide, on NOC shift there is one MT and two CG. The tool did not address all 22 ADLs for each resident and the amount of staff time needed to provide care. The tool addressed 15 of the required 22 ADLs.

The facility failed to implement and update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident.

On 07/17/23, the findings were reviewed with and acknowledged by Staff 2.

Verbal plan of correction: Not provided.

Based on observation, interview, and record review, conducted during a site visit on 07/10/2023, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:

During interviews on 07/10/23, Staff 1 (RN) and Staff 2 (RCC) stated the facility had an ongoing issue with bed bugs that started around January 2023. Staff 1 identified a group of apartments that continued to be infested with the bed bugs, including apartments 220, 219, 201, 202, 131, and 204. S/he also stated they had reduced the bed bugs to only three rooms, 220, 219 and 202. Staff 2 stated the bed bugs were currently only on the second floor and had not extended to other areas of the facility. Staff 2 stated treatments used to control the bed bugs included, a bed bug sniffing dog, heat treatments in the affected rooms, and had suggested residents move to a vacant room while their rooms were treated for bed bugs. Resident 2 declined moving to another room. Resident 1 stated Resident 2 had bites from the bed bugs all over his/her body for months when the bed bug infestation started.

A review of the pest control company invoices indicated two different past control companies had been out to the facility multiple times since 12/30/22. The last time a pest control company had been in the facility to treat for bed bugs was 05/18/23, reporting the facility still had bed bugs.

It was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.

On 07/10/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.

Verbal plan of correction: Staff 3 (Administrator) stated to the policy analyst had been notified on 07/25/23, all the bed bugs have now been eradicated from the facility and they have replaced the furniture in the rooms that had the infestations.