Print Inspection: KXJT

Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

A review of staffing schedules, facility's posted staffing plan, and ABST it was confirmed the facility was not meeting the scheduled and unscheduled needs of the residents.

The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts.     

A review of the staff schedule confirmed inconsistent staffing levels from 11/02/23 through 11/31/23 that do not match posted staffing plans or ABST for all shifts.

A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: in Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff.

Compliance Specialist (CS) observed the facility was staffed with the following: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers.  

In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) confirmed the facility was short staffed during 11/02/23-11/31/23 and the day of site visit.  

The above information was shared with Staff 1 on 09/28/23. S/he acknowledged the findings.

It was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents.

VPOC: ED reports they are actively hiring care staff for all positions including multiple care staff positions. ED had three interviews today 03/11/24. ED reported they were filling positions immediately and using agency staff to fill positions on the floor. ED reports that administration is actively working the floor as needed to fill in and cover any callouts.

Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings include, but are not limited to:  

Onsite facility observation confirmed the following staff were in care pods: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers.  

A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: In Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff.

The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts.   

The tool did not match the posted staffing plan and was not consistent with staffing schedule dated 03/11/24. The facility was staffing inconsistently to the levels indicated by their ABST.

In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) stated the facility was not staffing based on ABST.

The above information was shared with Staff 1 on 03/11/24. S/he acknowledged the findings.

It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool.