Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:

Record review on 8/2/2022 of timecards for 6/16/2022-6/30/2022, posted staffing plan, ODHS ABST, and service plans for Resident #1-2 (R1 and R2). The posted staffing plan is not reflective of the ABST as it has not been fully implemented yet. Call light logs from 6/25/2022-6/30/2022 revealed multiple call light response times ranging from 25 minutes to 1 hour and 39 minutes. Both R1 and R2 indicate on the facilities ABST that these residents need 0 minutes for call light response time, reviewing them it indicates R1 pushed their button 26 times while R2 pushed it 33 times.

In an interview on 8/2/2022 Staff #1 (S1) stated that they are using the ODHS ABST, however, they were not aware that it generated a staffing plan based on amount of caregiving time indicated with the tool.

The above information was shared with S1 on 8/2/2022.

Plan of Correction: The facility will speak with Policy Analyst (PA) to get further clarification on how to generate the staffing plan to they are in compliance with the ODHS ABST.