Based on interview and record review, conducted during a site visit on 11/04/24, it was confirmed the facility failed to develop a service planning team that consists of the resident and any person of the resident's choice. Findings include, but are not limited to:

In an interview, Staff 1 (Administrator) stated there were only two service plans on file for Resident 8 for the year 2022.

In response to a records request, the facility was only able to provide two service plans for Resident 8, dated 04/05/22 and 11/19/22, which were unsigned by the resident or family member.

The findings were reviewed with and acknowledged by Staff 1 on 11/04/24.

The facility failed to develop a service planning team that consists of the resident and any person of the resident's choice.

Verbal Plan of Correction: Administrator stated she is leading care conferences now. Signatures of residents and/or families were available on current service plans we reviewed.

Based on interview and record review, conducted during a site visit on 11/04/24, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6). Findings include, but are not limited to:

The facility's posted staff plan (undated) indicated the follow:

* Day: two medication tech and three caregivers;

* Eve: two medication tech and three caregivers; and

* Night: one medication tech and two caregivers.

A review of the staff schedule, dated 10/27/24 to 11/02/24, revealed the facility was only staffing two people on night shift on Fridays and Saturdays.

In an interview, Staff 2 (MT) stated the facility only staffed two people on night shift on Fridays and Saturdays.

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

* Profiles for Resident 1, Resident 2, and Resident 3 had no been updated in the past quarter.

* Resident 1 and Resident 4's profiles were incomplete.

* Resident 5 and Resident 6 were missing from the tool.

Findings were reviewed with and acknowledged by Staff 1 (Administrator) on 11/04/24.

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