Based on observation, interview, and record, conducted during a site visit on 11/12/24, the facility's failure to appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator was substantiated. Findings include, but are not limited to:

A "Manager on Duty" sign showed the med tech was the designee in charge in the abence of an administrator.

During an interview attempt at 6:15 am, the med tech refused to speak to the Compliance Specialist.

In an interview at 6:30 am, Staff 6 (Chef) stated Staff 4 (RCC) was the designee in charge.

In an interview at 9:25 am, Staff 4 stated Staff 2 (Human Resources) was the designee in charge.

In an interview at 10:15 am, Staff 2 stated s/he had "just found out" via text message s/he was appointed designee in charge for the day.

The findings were reviewed with and acknowledged by Staff 2 and Staff 3 (Consultant) on 11/12/24.

The facility's failure to appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator was substantiated.

Verbal Plan of Correction: Re-training was provided to the med tech on the responsibilities of the designee in-charge.

Based on observation, interview, and record review, conducted during a site visit on 11/12/24, the facility's failure to ensure residents had the right to have visitors of the resident's choosing at anytime was substantiated. Findings include, but are not limited to:

Upon arrival to the facility at 5:40 am, the facility's doors were locked. There was no code posted to gain access to the building.

Compliance Specialists attempted to call facility staff between 5:43 am and 6:00 am but calls went unanswered.

Compliance Specialists attempted to call facility staff via a secondary phone number at 5:46 am. The respondent denied being affiliated with the facility. A second phone call was placed to the same number, but the call went straight to voicemail.

The door bell was rung multiple times but went unanswered.

In an electronic communication on 11/14/24, Staff 8 (CEO) stated the door bell's chime was set to "inaudible."

In an interview, Staff 7 (CG) stated, "it [was] always hard to get into the building" and that s/he had problems getting into the facility the day before.

The findings were reviewed with and acknowledged by Staff 2 (Human Resources) and Staff 3 (Consultant) on 11/12/24.

The facility's failure to ensure residents had the right to have visitors of the resident's choosing at anytime was substantiated.

Verbal Plan of Correction: The facility's website will be updated with the correct facility phone number.

Based on observation, interview, and record review, conducted during a site visit on 11/12/24, the facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated for 5 of 5 sampled residents (#s 1, 2, 3, 6, and 7). Findings include, but are not limited to:

An observation of the facility's posted staffing plan indicated the following:

* 6:00 am to 2:00 pm: one Universal Worker (UW);

* 6:30 am to 2:30 pm: two UWs;

* 2:00 pm to 10:00 pm: one UW;

* 2:30 pm to 10:30 pm: two UWs; and

* 10:00 pm to 6:00 am: two UWs.

In an interview, Staff 4 (RCC) stated the following:

* The posted staffing plan was outdated and not reflective of the current staffing schedule;

* Staff worked 12 hour shifts;

* Day shift was 6:00 am to 6:00 pm;

* Night shift 6:00 pm to 6:00 am; and

* Staff took one hour breaks.

The facility's ABST showed the following required staff hours for Tuesday:

* Day: 36.58 hours; and

* Night: 17.17 hours.

An observation of day shift staffing revealed only 33 hours of scheduled staff time on 11/12/24.

A review of the facility's ABST resident data showed the profiles for the following residents had not been updated in the last quarter:

* Resident 6's profile was last updated on 06/20/24.

* Resident 7's profile was last updated on 07/12/24.

A review of Resident 1's ABST profile and service plan, dated 09/20/24, showed the following discrepancies in care time:

* Monitoring behavioral conditions or symptoms;

* Monitoring physical conditions or symptoms;

* Non-drug interventions for behaviors; and

* Non-drug interventions for pain management.

A review of Resident 2's ABST profile and service plan, dated 08/19/24, showed the following discrepancies in care time:

* Safety checks and fall prevention.

A review of Resident 3's ABST profile and service plan, dated 10/22/24, showed the following discrepancies in care time:

* Personal hygiene;

* Monitoring physical conditions and symptoms; and

* Grooming.

The findings were reviewed with and acknowledged by Staff 2 (Human Resources) and Staff 3 (Consultant) on 11/12/24.

The facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated.