Print Inspection: 0W0E

Based on interview and record review, conducted during a site visit on 08/08/24, it was confirmed the facility failed to have 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:

During an interview on 08/08/24, Staff 1 (ED) and Staff 2 (Maintenance Director) indicated the call light system had malfunctioned on or around 06/09/24 through 06/11/24. Staff 1 indicated when a resident would push his/her call light the system would not register the correct room going off. It would take staff awhile to figure out whose call light had been going off, resulting in residents needs not answered timely. Staff 1 indicated residents toileting needs had not been met during the issues with the call light system.

A review of the call light log report from 06/09/24 through 06/11/24 indicated multiple long response times. Maximum response times ranging from 20 minutes to two hours and 50 minutes, with 36 of 56 maximum response times exceeded 20 minutes.

A review of the facility posted staffing plan indicated the following staffing levels:

·Day shift: Three med techs and five caregivers.

·Swing shift: Three med techs and five caregivers.

·Night shift: One med tech and four caregivers.

A review of the staff schedule and timecards on 06/09/24 through 06/11/24 indicated the following staffing;

·06/09/24

oDay shift: three med techs and four caregivers.

oSwing shift: three med techs and three caregivers from 2:00 PM to 10:00 PM. One caregiver added at 6:00 PM.

oNight shift: one med tech and three caregivers.

·06/10/24

oDay shift: two med techs and five caregivers.

oSwing shift: three med techs and four caregivers from 2:00 PM to 10:00 PM. One caregiver added at 4:00 PM and another added at 6:00 PM.

oNight shift: one med tech and three caregivers.

·06/11/24

oDay shift: three med techs and five caregivers.

oSwing shift: three med techs and four caregivers 2:00 PM to 10:00 PM. One caregiver added at 6:00 PM.

oNight shift: one med tech and two caregivers.

It was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 08/08/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has fixed the call light system and staff are answering call lights in an appropriate timeframe. Staff 1 will continue to monitor call light response times.

Based on interview and record review conducted during a site visit on 08/08/24, it was confirmed the facility failed to ensure all equipment necessary for the health, safety, and comfort of the resident was in good repair. Findings include, but are not limited to:

During separate interviews on 08/08/24, Staff 1 (ED) and Staff 2 (Maintenance Director) indicated the call light system had malfunctioned on or around 06/09/24 through 06/11/24. Staff 1 indicated when a resident would push his/her call light the system would not register the correct room going off. It would take staff awhile to figure out whose call light had been going off, resulting in residents needs not answered timely.

A review of the call light log report from 06/09/24 through 06/11/24 indicated multiple long response times. Maximum response times ranging from 20 minutes to two hours and 50 minutes. Thirty six of 56 maximum response times exceeded 20 minutes.

It was confirmed the facility failed to ensure all equipment necessary for the health, safety, and comfort of the resident was in good repair.

On 08/08/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has fixed the call light system and staff are answering call lights in an appropriate timeframe. Staff 1 will continue to monitor call light response times.