Print Inspection: 4ZMI

Based on interview and record review, conducted during a site visit on 02/12/24, 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. Finding include, but are not limited to:

A review of the facility's posted staffing plan indicated:

* Day shift: 6:00 am - 2:00 pm: five caregivers;

* Day shift: 5:45 am - 2:15 pm: two health care coordinators;

* Swing shift: 2:00 pm - 10:00 pm: five caregivers;

* Swing shift: 1:45 am - 11:15 pm: two health care coordinators;

* NOC shift: 10:00 pm - 6:00 am: three caregivers; and

* NOC shift: 10:00 pm - 6:00 am: one health care coordinator.

A review of staff schedules, dated 09/01/23 through 02/12/24 indicated 23 shifts in 09/2023, 11 shifts in 10/2023, 6 shifts in 11/2023, and 3 shifts in 12/2023 that were staffed below the posted staffing plan. There were 4 shifts in 09/2023 where only agency staff were scheduled.

In an interview on 02/12/24, Staff 1 (Executive Director) indicated December 2023 was really short staffed and the facility hours for December was about 46% agency staff.  

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.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 02/12/24.

Facility Plan of Correction: The facility has hired new staff and has been able to reduce the usage of agency staff to closer to 15% - 20% for the month of February and have been able to prioritize agency staff that are familiar with the residents and know a little American Sign Language.

Based on observation, interview and record review, conducted during a site visit on 02/12/24, it was confirmed the facility failed to ensure staff have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to:

In an interview on 02/12/24, Resident 5 stated s/he had been unable to communicate with staff about his/her care needs. There are facility staff that do not know sign language and the facility uses staff from outside of the facility that do not know sign language.

In an interview on 02/12/24, Staff 4 (Agency RA) stated s/he was on a contract with the facility through an agency for several months. S/He stated there is an app for staff to use to communicate to residents, but residents are not able to communicate needs to staff. S/He stated when s/he first came to the facility s/he was just thrown in and has since developed trust with the residents. The facility started American Sign Language (ASL) classes a few weeks ago, but they are for facility staff not for agency staff.

On 02/12/24 at 11:25 am, CS observed Staff 4 entered Resident 1's room. Staff 4 was not able to communicate with Resident 1 about what service s/he was there to provide. Witness 1 and Witness 2 were used by Staff 4 to inform Resident 1 that Staff 4 wanted to take the trash out for Resident 1.

In an interview on 02/12/24, Staff 1 (Executive Director) stated the facility does use agency staff and there is an app that staff can use to communicate with residents. The facility does request that agencies send staff that are comfortable working with deaf and hard of hearing residents, but there is no expectation for agency staff to know ASL.

A review of staff schedules dated 09/01/23 through 02/12/24 indicated 4 instances in 09/2023 of only agency staff scheduled.

The facility failed to ensure staff have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 02/12/24.

Facility Plan of Correction: The facility has hired new staff and has been able to reduce the usage of agency staff to closer to 15% - 20% for the month of February and have been able to prioritize agency staff that are familiar with the residents and know a little American Sign Language. The facility has mandated that 100% of staff know ASL within 3 months. Hiring Job Descriptions have been updated to reflect the requirement to be fluent in ASL.