Based on interview and record review, conducted during a site visit on 02/05/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool. Findings include, but are not limited to:

A review of the facility's ABST indicated the tool did not contain all required 22 ADLs. The following ADLs were not included:

·Assisting with communication, assistive devices for hearing, vision, speech;

·Responding to call lights;

·Safety checks, fall prevention;

·Completing resident specific housekeeping or laundry services performed by care staff;

·Assisting with leisure activities;

·Monitoring physical conditions or symptoms;

·Providing non-drug interventions for pain management; and

·Providing treatments (e.g., skin care, wound care, antibiotic treatment).

In an interview on 02/05/24, Staff 1 (Administrator) stated the facility uses a state tool that is on an excel spreadsheet. Staff 1 was unable to demonstrate how the tool addressed all required 22 ADL's.

In an interview via phone on 02/08/24, Staff 2 (Operations Manager) stated the tool was provided by the state when the ABST rule went into effect in July of 2022, but was unable to provide clarifications of how all 22 ADL's were addressed by the facility's current tool.

The facility failed to fully implement and update an acuity-based staffing tool.

The findings were reviewed with and acknowledged by Staff 1.

Based on observation and interview, conducted during a site visit on 02/05/24, it was confirmed the facility failed to ensure the RCF grounds are kept orderly and free of litter and refuse. Findings include, but are not limited to:

During a walkthrough around the facility's exterior on 02/05/24 at 10:00 am, a pile of discarded furniture including mattresses, multiple chairs and wooden shelving was observed on the side of the dumpster structure. Two piles of discarded items such as a bed frame, cabinets and broken down scraps of cabinets were lined up against the facility exterior wasll across from the dumpsters and the second pile was unconvered next to the dumpster .

In an interview on 02/05/24, Staff 1 (Administrator) stated the maintenance persons truck has not been working and hasn't been able to take things to the dump.

The facility failed to ensure the RCF grounds are kept orderly and free of litter and refuse.

The findings were reviewed with and acknowledged by Staff 1.

Facility Verbal Plan of Correction: Administrator will look into renting a truck to haul away piles to the dump, to be completed within 2 weeks.

Based on observation and interview, conducted during a site visit on 02/05/24, it was confirmed facility failed to keep clean and in good repair all interior and exterior materials and surfaces. Findings include, but are not limited to:

During a walkthrough of the facility, between 10:00 am and 2:15 pm, dark staining was observed on the carpets outside of rooms 8 and 15. Rough wood surfaces were observed on the handrails in the hallway near room 8. A hole in the drywall was observed in the dining area behind the insulated food cart. The walkway to the facility courtyard contained refuse and yard debris.

* Large dark stains on the carpet outside of rooms 8 and 15.

* Rough wood surfaces with gouges on handrails near room 8.

* Hole in drywall in dining area behind the insulated food cart the size of a fist.

* Courtyard contained refuse and yard debris.

* Smoking shelter had a light wobble when pressing on the support posts.

Resident 2's shared shower room was observed, his/her transition strip was missing between the shower and the rest of the room.

In an interview on 02/05/24, Resident 2 confirmed the transition strip was missing.

The facility failed to keep clean all interior materials and surfaces, and keep in good repair all exterior materials and surfaces.

The facility failed to keep clean and in good repair all interior and exterior materials and surfaces

The findings were reviewed with and acknowledged by Staff 1 (Administrator).

Facility Verbal Plan of Correction: The administrator will have maintenance clean the carpets and the administrator and operations manager will complete a walkthrough of the facility to create a list of repairs for maintenance, to be completed within 2 weeks.