Based on observation, interview and record review, conducted during a site visit on 04/24/25, the facility's failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

At 12:48 pm, Resident 5 was observed in his/her shared restroom with an activated call light.

At 12:55 pm, Staff 9 (Caregiver) was observed to enter Resident 5's room and exit within one minute.

At 1:02 pm, Staff 9 returned to Resident 5's room.

At 1:20 pm, Resident 5 was observed laying in his/her bed and fall mat was tucked completely under resident's bed.

In an interview on 04/24/25, Resident 5 stated s/he needed help and that s/he needed to use the toilet.

In an interview on 04/24/25, Staff 9 stated Resident 5 needed toileting assistance, but there were not enough staff to transfer the resident to the toilet and s/he was advised to use the brief s/he was wearing. S/he stated s/he transferred Resident 5 into bed and then changed his/her briefs.

A review of Resident 5's service plan, dated 02/24/25, indicated Resident 5 had mixed continence of bladder and bowel with a goal to be able to maintain bladder and bowel function with assistance. Under the section of transferring indicated Resident 5 required the assistance of two staff members for all transfers via sit to stand. Service plan had no information regarding Resident 5's fall mat. There was no evidence a temporary service plan was implemented for Resident 5's fall mat.

The facility failed to ensure the implementation of services according to the resident's service plan.

On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).  

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation.

The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts.

In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan.

In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST.

A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required.

The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident.

On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).  

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation.

The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts.

In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan.

In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST.

A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required.

The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident.

On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).  

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation.

The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts.

In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan.

In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST.

A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required.

The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident.

On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).