Print Inspection: WSYX

Based on observation, interview and record review it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

During an unannounced site visit on 03/09/2023, Compliance Specialist (CS) observed a pink binder, provided by Staff #3 (S3) labeled 'Acuity-Based Staffing."

A review of documents inside of the binder revealed an acuity report, which did not contain any resident names and was dated 12/27/2022.

A review of the facility's ABST for 3/9/2023 did not contain any resident names and revealed the need for:

*58 hours/care on Day shift

*7 hours 42 minutes of care on evening shift

*21 hours of care on noc shift

A review of the facility's schedule for March 2023 revealed that only 42-52.5 hours of care was scheduled on day shift  between 03/03/2023 and 03/05/2023.

During joint interview, Staff #1- Staff #3 (S1-S3) stated:

*They were not familiar with the ABST.

*The ABST had not be reviewed since December 2022.

*An unknown resident had 35 hours of shaving included in their ABST profile.

*Point Click Care auto-programs times for some tasks that they can not change.

*Staff have had difficulty fixing time required for tasks in service plans, which then effects the ABST.

*The facility is staffed as follows for The Square and The Lane:

Day: 2-3 caregivers (CGs), 1 Medication Technician (MT) each

Swing: 2-3 CGs, 1 MT each

Noc: 1 CG each and 1 shared MT

These findings were reviewed with and acknowledged by S1-S3 on 03/09/2023 who were in agreement.

Plan of Correction: Facility stated they will begin reviewing ABST with every new move-in, quarterly update and change of conditions as well as during clinical meeting every Tuesday.