Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:
Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.
A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.
In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.
A review of the facility's posted staffing plan indicated the following:
Day Shift (6:30 am - 2:30 pm)
·Med tech - 2
·Care Partner - 6
Evening Shift (2:30 pm - 10:30 pm)
·Med tech - 2
·Care Partner - 6
Night Shift (10:30 pm - 6:30 am)
·Med tech - 1
·Care Partner - 4
A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."
A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.
The facility failed to fully implement an ABST.
Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).
Based on interview, observation and record review, conducted during a site visit on 04/08/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 2 of 3 sampled residents (# 1 and 6) Findings include, but are not limited to:
Compliance Specialist requested Resident 1 press his/her pendant at 2:26 pm, no staff responded to resident's pendant by 2:46 pm. A review of a staff member's call light notifications did not indicate an active call for Resident 1.
Compliance Specialist requested Resident 6 press his/her pendant at 1:49 pm, no staff responded to resident's pendant by 2:12 pm. A review of a staff member's call light notifications indicated Resident 6's call light was marked as completed.
In an interview on 04/08/25, Resident 1 stated s/he struggles to get staff to respond to his/her call light. Recently s/he needed assistance with toileting and could not find staff to assist.
A review of facility's posted staffing plan indicated the following:
Day Shift (6:30 am - 2:30 pm)
·Med tech - 2
·Care Partner - 6
Evening Shift (2:30 pm - 10:30 pm)
·Med tech - 2
·Care Partner - 6
Night Shift (10:30 pm - 6:30 am)
·Med tech - 1
·Care Partner - 4
A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.
A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift." Based on the Specific Needs Contract the facility should have had a minimum of 11 direct care staff during day and swing shifts and seven direct care staff at night.
A review of the facility's schedule from 04/02/25 - 04/08/25 indicated the facility was consistently not meeting the Specific Needs Contract staffing requirements and 12% of reviewed shifts were staffed below the posted staffing plan.
The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.
Findings were reviewed and acknowledged by Staff 1(Regional Director of Operations), Staff 2 (LPN) and Staff 3 (Regional Consultant RN).
Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:
Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.
A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.
In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.
A review of the facility's posted staffing plan indicated the following:
Day Shift (6:30 am - 2:30 pm)
·Med tech - 2
·Care Partner - 6
Evening Shift (2:30 pm - 10:30 pm)
·Med tech - 2
·Care Partner - 6
Night Shift (10:30 pm - 6:30 am)
·Med tech - 1
·Care Partner - 4
A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."
A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.
The facility failed to fully implement an ABST.
Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).
Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:
Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.
A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.
In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.
A review of the facility's posted staffing plan indicated the following:
Day Shift (6:30 am - 2:30 pm)
·Med tech - 2
·Care Partner - 6
Evening Shift (2:30 pm - 10:30 pm)
·Med tech - 2
·Care Partner - 6
Night Shift (10:30 pm - 6:30 am)
·Med tech - 1
·Care Partner - 4
A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."
A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.
The facility failed to fully implement an ABST.
Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).