Print Inspection: BA9Z

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 or 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:  

A review of the ABST Facility Entrance Questionnaire dated 05/07/25 indicated the facility used ODHS ABST. The facility had a resident census of 22.

a.Resident 1's service plan dated 01/22/25 and 05/07/25 was reviewed and compared to his/her ABST profile last updated on 04/11/25. Resident 1's ABST profile did not accurately reflect Resident 1's care needs in the following areas:

·In the area of transfers, the service plan indicated Resident 1 required full assistance with moving from bed to wheelchair and required two-person assistance. Resident 1's ABST indicated zero minutes of staff time was allotted to complete task.  

·In the area of eating, the service plan indicated Resident 1 required daily assistance and "will occasionally start crying and telling staff [s/he] can't feed [himself/herself] ". Resident 1's ABST indicated zero minutes of staff time was allotted to complete task.

·In the area of ambulation and escorts, the service plan indicated Resident 1 will be escorted in their wheelchair to and from meals, activities, toileting, and other common areas by staff. Resident 1's ABST indicated zero minutes of staff time was allotted to complete task.

b. Resident 2's service plan dated 04/03/25 was reviewed and compared to his/her ABST profile last updated on 04/03/25. Resident 2's ABST profile did not accurately reflect Resident 2's care needs in the following areas:

·In the area of bathing, the service plan indicated Resident 2 required full assistance. Resident 2 ' s ABST indicated zero minutes of staff time was allotted to complete task.

·In the area of personal hygiene, staff to provide support with all hygiene routines daily. Resident 2 ' s ABST profile indicated that ADL was provided 70 times per week.

In separate interviews, Staff 1 (MC Administrator) Staff 4 (CG), Staff 6 (CG), and Staff 11 (MT) stated Resident 1 and Resident 2 required total assistance with ADLs, except meal assistance and when hospice provided services. If hospice does not provide the service, staff are to provide assistance with bathing.

Compliance Specialists (CS) observed the following:

· Resident 1 and Resident 2 required assistance of two-staff persons for transfers and toileting.

· Resident 1 required cuing throughout his/her lunch meal and on occasion staff provided hand-over-hand assistance.

The facility failed to accurately capture care time and care elements that staff are providing to each resident.

On 05/07/25, those findings were reviewed with and acknowledged by Staff 1, Staff 2 (Wellness Director/LPN), and Staff 3 (Executive Director).