Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation.

A review of the facility's ABST indicated the following:

·The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff.

·Only 20 of 22 activities of daily living (ADL) had been addressed.  

A review of the facility's posted staffing plan indicated the following:

·Day shift: Four caregivers and two med techs;

·Swing shift: Three caregivers and one med tech; and

·Night shift: Two caregivers and one med tech;

A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan.

A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies.

Staff 1 (Executive Director) indicated the following;

·The facility used a proprietary ABST called PEAR. The tool had not been approved by the State.

·One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need.

·Five residents who had required two-person transfers.

·The facility's ABST failed to separately list all 22 required ADL questions for each resident.

·The facility ABST had only 20 of 22 required ADLs.

CS observed day shift was staffed with five caregivers and two med techs.

It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation.

A review of the facility's ABST indicated the following:

·The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff.

·Only 20 of 22 activities of daily living (ADL) had been addressed.  

A review of the facility's posted staffing plan indicated the following:

·Day shift: Four caregivers and two med techs;

·Swing shift: Three caregivers and one med tech; and

·Night shift: Two caregivers and one med tech;

A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan.

A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies.

Staff 1 (Executive Director) indicated the following;

·The facility used a proprietary ABST called PEAR. The tool had not been approved by the State.

·One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need.

·Five residents who had required two-person transfers.

·The facility's ABST failed to separately list all 22 required ADL questions for each resident.

·The facility ABST had only 20 of 22 required ADLs.

CS observed day shift was staffed with five caregivers and two med techs.

It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.