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

In an interview on 08/17/22, S1 stated that their current census is 53 residents. They have not implemented an ABST or other methods to determine staffing levels at this time. They are going to be using the ODHS tool, however, they have not entered any resident information. S1 states that there are multiple residents with outdated service plans, the facility is working on updating them to be able to input the proper information into the ABST.

During an unannounced inspection on 08/17/2022, the Compliance Specialists (CS) did not observe a posted staffing plan.

In review of the ODHS ABST tool on 08/17/22, the facility has not updated or entered any resident information into the tool.

The above information was shared with Staff #1 on 08/17/22, who was in agreement with the findings.

Facility Plan of Correction:

Effective immediately, the Administrator will update resident service plans, contact, and consult with Department approved consultant, and begin using the ODHS ABST.