Print Inspection: EJUL

Based on interview and record review, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to:

A review of the facility's ABST indicated the following deficiencies:

·Not evaluating all residents quarterly; and

·Not accurately capturing care needs and time reflected in Resident 1's service plan.

A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly.

A review of Resident 1's service plan dated 07/23/25 indicated the following:

·Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily;

·Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and

·Staff were to help brush the resident's hair daily in the am and pm.

A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs):

·Monitoring physical conditions and symptoms;

·Ambulating or escorting the resident; and

·Time spent assisting with grooming.

An interview with Staff 1 (Registered Nurse) indicated the following:

·Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25;

·Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and

·Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task.

The findings of the investigation were reviewed and acknowledged by Staff 1.

The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.

Based on interview and record review, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to:

A review of the facility's ABST indicated the following deficiencies:

·Not evaluating all residents quarterly; and

·Not accurately capturing care needs and time reflected in Resident 1's service plan.

A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly.

A review of Resident 1's service plan dated 07/23/25 indicated the following:

·Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily;

·Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and

·Staff were to help brush the resident's hair daily in the am and pm.

A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs):

·Monitoring physical conditions and symptoms;

·Ambulating or escorting the resident; and

·Time spent assisting with grooming.

An interview with Staff 1 (Registered Nurse) indicated the following:

·Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25;

·Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and

·Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task.

The findings of the investigation were reviewed and acknowledged by Staff 1.

The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.