Ohio Department of Health Division of Quality Assurance ...
Nursing Home Name Nursing Home Capacity
Ohio Department of Health
Division of Quality Assurance Minimum Daily Average Staffing Survey Tool
1/28/2002
Home Number
Provider Number
65
Exit Date
Type of Survey
Staffing Probes
1 Answers the following questions related to resident needs:
A. Are call lights unanswered? B. Are there smells of urine or other unpleasant odors? C. Are personal care needs of residents, such as assistance with ADLs, being neglected ? D. Are the nursing needs of the residents neglected ? (eg. catheter placement, body alignment, urinary drainage, incontinence,
ventilators, oxygen, intravenous fluids, etc.) E. Are residents restrained inappropriately? F. Are medications/treatments administered at the wrong times or missed? G. Are meals served at inappropriate times?
If Yes in this box, there is a Need to Check the Staffing Schedules
2 Answers the following questions related to resident outcomes:
A. Do any residents have fecal impactions? B. Does the nursing home have residents with any of the following avoidable outcomes: falls, fractures, pressure ulcers,
incontinence without toilet plan, restraints, UTI, dehydration, or weight loss. C. Other (needs or outcomes) - Please Explain
If YES in this box, there is a Need to Check the Staffing Schedules
Answer
No No No
Yes No No No YES Answer
No
No No YES
Obtain staffing schedules for today and the previous 6 days for all direct care staff if the answers to ANY of the above questions are 3 YES including: Director of Nursing, RN, LPN, Nurse Aide, OT, OT Assistant, PT, PT Assistant, Dietician, Social Worker, and
Activities Aides
4 Does the Nursing Home have a variance to use LPNs to meet the RN requirement?
No
5 What day of the week is today?
Monday
6
Census
Tuesday
58
Wednesday
62
Thursday
59
Friday
60
Saturday
61
Sunday
60
Monday
59
Direct Care
DON - 1st shift
RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - Volunteer
Direct Care
DON - 2nd shift RN - 2nd Shift
Tuesday Wednesday Thursday
Friday
Saturday
Sunday
Monday
Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tuesday
Nursing NAS
1
1
1
1
Wednesday
Nursing NAS
1
1
1
1
Thursday
Nursing NAS
1
1
1
1
Friday
Nursing NAS
1
1
1
1
Saturday
Nursing NAS
1
1
1
1
Sunday
Nursing NAS
1
1
1
1
Monday
Nursing NAS
1
1
1
1
Nursing Home Name
Home Number
Provider Number
Nursing Home Capacity
65
Exit Date
Type of Survey
RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - Volunteer
Direct Care
DON - 3rd shift
RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - Volunteer
Direct Care
LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - Volunteer
Direct Care
LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - Volunteer
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tuesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tuesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tuesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Wednesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Wednesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Wednesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Thursday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Thursday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Thursday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Friday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Friday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Friday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Saturday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Saturday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Saturday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sunday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sunday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sunday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Monday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Monday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Monday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Nursing Home Name
Home Number
Provider Number
Nursing Home Capacity
65
Exit Date
Type of Survey
Direct Care
LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - Volunteer
Tuesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Wednesday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Thursday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Friday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Saturday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sunday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Monday
Nursing NAS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Direct Care
Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Nursing Home Name
Home Number
Nursing Home Capacity
65
Exit Date
Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide Volunteer Nurse Aide Volunteer
Direct Care
Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide Volunteer Nurse Aide Volunteer
Direct Care
Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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1
1
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1
1
Provider Number Type of Survey
Nursing Home Name
Nursing Home Capacity
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide 3rd Shift
1
Nurse Aide Volunteer
1
Nurse Aide Volunteer
1
65
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Home Number
Exit Date
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Ancillary
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician
Dietician Dietician
Ancillary
OT OT OT OT OT OT OT OT OT OT OT OT OT OT OT
Ancillary
OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tues Wed Thur Fri
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sat Sun Mon
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Provider Number Type of Survey
................
................
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