There are no detail notes for this visit.
Based on interview and record review, during a site visit conducted on 10/11/23, it was confirmed 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 include, but are not limited to:
In separate interviews on 10/11/23, Staff 1 (ED) and Staff 2 (MC ED) stated the call light response time was between 5-10 minutes.
CS was unable to obtain call light logs for April 2023. A review of the call light logs for 10/09/23-10/11/23 indicated 38 occurrences where response times exceeded 20 minutes. The staff schedule from 09/03/23-10/14/23 indicated multiple open uncovered shifts.
It was confirmed 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.
On 10/11/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility is constantly working on hiring staff, still using agency staff but trying to work on getting permanent staff. Will put more focus on call light response times on a daily and weekly basis.
Based on interview and record review, conducted during a site visit on 10/11/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:
In an interview on 10/11/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility is home to 58 residents. Staff 1 explained the facility had been staffing to two 12 hour shifts where two MT and two CG are scheduled for both shifts. Staff 1 stated s/he does not know how to convert their staffing levels using the acuity-based staffing tool.
On 10/11/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required six care staff on day shift, five care staff on swing shift, and two care staff on night shift. There were 39 residents' profiles that had not been updated quarterly.
A review of the posted staffing plan indicated for day shift there are to be three CG and two MT, on swing shift there are two CG and two MT, and on NOC shift there are to be two CG and one MT. The posted staffing plan does not match the ABST nor the current facility staffing.
It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.
On 10/11/23, the findings were reviewed with and acknowledged by Staff 1.
Based on observation, interview, and record review, during a site visit conducted on 10/11/23, it was confirmed the facility failed to provide a lockable storage space. Findings include, but are not limited to:
CS observed rooms 234, 240, 231, 217, and 244. One of five sampled apartments did not have a lockable storage space.
A review of maintenance logs indicated several resident apartments that did not have a lockable storage space installed and/or a key had not been provided to the resident.
In separate interviews on 10/11/23, Staff 1 (Executive Director) stated, "I believe maintenance has replaced all the locks about a month ago. Some locks were broken, and some apartments did not have a lock." Staff 3 (Maintenance) stated, "I installed locks in apartments that wanted them, most residents refused."
It was confirmed the facility failed to provide a lockable storage space.
On 10/11/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility has the locks and will install in all rooms. Should be completed "within the next two weeks."