Print Inspection: ZZBR

Based on observation, interview, and record review, conducted during a site on 10/16/24, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool for 6 of 7 sampled residents (#s 1, 2, 4, 5, 6, and 7). Findings include, but are not limited to:

The facility was observed to have two areas named "Larch" and "Tabor."

An observation of the posted staffing plan for Tabor indicated the following:

* Contract 6 am to 2 pm: one medication aide and six Universal Workers (UW);

* Non-Contract 6 am to 2 pm: two UWs;

* Contact 2 pm to 10 pm: one medication aide and six UWs;

* Non-Contract 2 pm to 10 pm: two UWs;

* Contract 10 pm to 6 am: one medication aide and five UWs; and

* Non-Contract 10 pm to 6 am: one UW.

In an interview on 10/16/24, Staff 1 (Administrator) stated the posted staffing plan was outdated and did not belong because the facility staff worked 12 hour shifts.

An observation of the posted staffing plan for Larch indicated the following:

* Contract 6 am to 6 pm: one medication aide, seven UWs;

* Non-Contract 6 am to 6 pm: one UW;

* Non-Contract 6 pm to 6 am: one UW; and

* Contract 6 pm to 6 am: one medication aide, five UWs.

An observation of night shift staffing showed two medication aides and only four UWs.

An observation of day shift staffing showed two medication aides and only six UWs.

A review of the facility's ABST revealed the ABST profiles for the following residents had not been updated in the last quarter:

* Resident 4;

* Resident 5;

* Resident 6; and

* Resident 7.

A review of Resident 1's service plan, dated 08/20/24, and ABST profile revealed the following discrepancies in care needs:

* Grooming;

* Treatments;

* Behavioral interventions;

* Non-pharmacological interventions for pain;

* Repositioning; and

* Dressing.

A review of Resident 2's service plan, dated 06/25/24, and ABST profile revealed the following discrepancies in care needs:

* Repositioning, and

* Bathing.

Observations and interviews with residents did not reveal any missed needs.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Community Manager) on 10/16/24.

The facility failed to fully implement and update an Acuity-Based Staffing Tool.

Based on interview and record review, conducted during a site visit on 10/16/24, it was confirmed the facility failed to make records available to the Department upon request for 1 of 1 sampled resident (#8). Findings include, but are not limited to:

A review of electronic communication showed the Department requested documents related to Resident 8 on 04/14/23. It further showed that by 05/05/23, the request for documentation had not been completely fulfilled by the facility.

In an interview on 10/16/24, Staff 1 (Administrator) acknowledged the records were not provided to the Department in a timely manner.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Community Manager) on 10/16/24.

The facility failed to make records available to the Department upon request.

Verbal Plan of Correction: Management will designate a person who can provide records in administrator's absence.