Print Inspection: 2TKN

Based on observation, interview, and record review, conducted during a site visit on 05/07/25, the facility's failure to update and implement an acuity-based staffing tool (ABST) was substantiated for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:  

a.A review of the ABST Facility Entrance Questionnaire dated 05/06/25 used the ODHS ABST. The facility resident census was 45.

A review of the facility's ODHS ABST indicated a total of 10 residents' ABST profiles had not been updated at the required frequency.

b.The residents' records were reviewed, interviews with staff and the residents were conducted, and observations of the resident were made.

Resident 1's service plan dated 04/10/25 was reviewed and compared to his/her ABST profile, last updated on 04/24/25. Resident 1's ABST profile did not accurately reflect Resident 1's care needs in the following areas:

·In the area of non-drug interventions for behaviors, the service plan indicated Resident 1 was diagnosed with anxiety, prescribed medication, and three non-pharmacological interventions must be attempted before administering. Resident 1's ABST profile indicated zero minutes of staff time were allotted to complete task.

Resident 2's service plan dated 02/06/25 was reviewed and compared to his/her ABST profile, last updated on 02/06/25. Resident 2's ABST profile did not accurately reflect his/her care needs in the following areas:

·In the area of communication/assistive devices for hearing and vision, the service plan indicated Resident 2 used hearing aids and glasses that required assistance from direct care staff. Resident 2's ABST profile indicated zero minutes of staff time were allotted to complete task.

·In the area of bathing, the service plan indicated hospice provided all shower needs and facility direct care staff as needed. Resident 2's ABST profile indicated zero minutes of staff time were allotted to complete task.

The facility failed to update the residents' ABST profiles at the required frequency; and failed to accurately capture care time and care elements that staff are providing to each resident.

On 05/06/25, those findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator - ALF), Staff 6 (Wellness Director/LPN), and Staff 9 (Resident Care Coordinator - MCC).

Based on observation, interview, and record review, conducted during a site visit on 05/07/25, the facility's failure to update and implement an acuity-based staffing tool (ABST) was substantiated for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:  

a.A review of the ABST Facility Entrance Questionnaire dated 05/06/25 used the ODHS ABST. The facility resident census was 45.

A review of the facility's ODHS ABST indicated a total of 10 residents' ABST profiles had not been updated at the required frequency.

b.The residents' records were reviewed, interviews with staff and the residents were conducted, and observations of the resident were made.

Resident 1's service plan dated 04/10/25 was reviewed and compared to his/her ABST profile, last updated on 04/24/25. Resident 1's ABST profile did not accurately reflect Resident 1's care needs in the following areas:

·In the area of non-drug interventions for behaviors, the service plan indicated Resident 1 was diagnosed with anxiety, prescribed medication, and three non-pharmacological interventions must be attempted before administering. Resident 1's ABST profile indicated zero minutes of staff time were allotted to complete task.

Resident 2's service plan dated 02/06/25 was reviewed and compared to his/her ABST profile, last updated on 02/06/25. Resident 2's ABST profile did not accurately reflect his/her care needs in the following areas:

·In the area of communication/assistive devices for hearing and vision, the service plan indicated Resident 2 used hearing aids and glasses that required assistance from direct care staff. Resident 2's ABST profile indicated zero minutes of staff time were allotted to complete task.

·In the area of bathing, the service plan indicated hospice provided all shower needs and facility direct care staff as needed. Resident 2's ABST profile indicated zero minutes of staff time were allotted to complete task.

The facility failed to update the residents' ABST profiles at the required frequency; and failed to accurately capture care time and care elements that staff are providing to each resident.

On 05/06/25, those findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator - ALF), Staff 6 (Wellness Director/LPN), and Staff 9 (Resident Care Coordinator - MCC).