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8.7506.F.6.b Alternative Care Facility Provider Agency Requirements a. Each Alternative Care Facility Provider Agency will divide the 24-hour day into two 12 hour blocks which will be considered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in the Alternative Care Facilities policy and disclosed in the written Member agreements. In determining appropriate staffing levels, the Alternative Care Facility Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members in the Alternative Care Facility. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the Member ' s needs, level of assistance, and risks of accidents. A staff person may have multiple functions, as long as they meet the definition of Direct Care Worker at Section 8.7402.F Staff counted in the staff-to-Member ratio are those who are trained and able to provide direct services to Members.b. Staffing at an Alternative Care Facility shall meet the following standards i. A minimum of 1 staff to 10 Members during the daytime. ii. A minimum of 1 staff to 16 Members during the nighttime. Based on record review and interview the facility failed to meet minimum staffing required in order to provide the services described in the Provider Care Plan, affecting two of four sample members (#1,#2). Findings include:1. Record Review Member #1 was admitted to the facility on 3/20/25 with a diagnosis of major depressive disorder, anxiety, polyneuropathy, and weakness. An undated document titled, Weekly Shower Schedule, read that Member #1 would receive a shower in the morning every Monday and Thursday of each week. An assessment, dated 3/22/25, read that Member #1 would need assistance with showering twice weekly.A staff communication log read that Member #1 received a shower on 4/7/25 and 4/14/25.A set staff schedule for April 2025 read that the facility day shifts were broken into two time blocks, 6:00 a.m. to 2:00 p.m. and.. A certification complaint, prompted by #CO39735, was completed on 4/22/25. A deficiency was cited.

A licensure complaint, prompted by #CO39733, was completed on 4/22/25. A deficiency was cited. Based on record review and interview the Residence failed to have a sufficient number of staff to help residents needing, or potentially needing assistance, affecting two of four sample residents (#1, #2). Findings include:1. Record ReviewResident #1 was admitted to the residence on 3/20/25 with a diagnosis of major depressive disorder, anxiety, polyneuropathy, and weakness. An undated document titled, Weekly Shower Schedule, read that Resident #1 would receive a shower in the morning every Monday and Thursday of each week. An assessment, dated 3/22/25, read that Resident #1 would need assistance with showering twice weekly.A staff communication log read that Resident #1 received a shower on 4/7/25 and 4/14/25.A set staff schedule for April 2025 read that the facility day shifts were broken into two time blocks, 6:00 a.m. to 2:00 p.m. and 9:00 a.m. to 5:00 p.m. The schedule read that from 6:00 a.m. to 2:00 p.m. one Qualified Medication Administration Personnel (QMAP) and one care giver were scheduled while for the 9:00 a.m. to 5:00 p.m. shift one care giver was scheduled. Between the hours of 6:00 a.m. and 9:00 a.m. there was a 1 to 17 staff to resident ratio. The same staff schedule for April 2025 read that the facility night shifts were broken into three time blocks; 2:00 p.m. to 10:00 p.m., 4:00 p.m. to 8:00 p.m., and 10:00 p.m. to 6:00 a.m. The schedule read that from 2:00 p.m. to 10:00 p.m. one QMAP and one caregiver were scheduled, the 4:00 p.m. to 8:00 p.m. had one care giver scheduled, and the 10:00 p.m. to 6:00 a.m. had two caregivers scheduled. Between the hours of 10:00 p.m. to 6:00 a.m. there was a 1 to 17 staff to resident ratio. 2. InterviewsOn 4/22/25 at 12:15 p.m., Resident #1 stated she required staff assistance for showering twice a week. However, since she moved in on 3/20/25, she was only getting one shower a week. Additionally, she was supposed to have a shower on the morning of 4/21/25; however, she did not get one. Resident #1 stated there were not enough staff which was why she was only receiving ..

A change of ownership survey was completed on 1/15/25. A deficiency was cited. Change of ownership occurred on 4/25/24. Based on observation and interview, the residence failed to notify the department of an intent of change with the administrator of record, affecting 17 current residents. Findings include:On 1/14/25 at approximately 9:30 a.m., a residence business card read the current administrator as different from the one listed with the department database. On 1/14/25 at approximately 9:30 a.m., the administrator said she had been the administrator at the residence since 6/10/24. On 1/15/25 at 7:07 a.m., an electronic message was received from a department representative that read the residence had not notified the department of change in the administrator of record.