Based on observation, interview, and record review, conducted during a site visit on 04/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

Compliance Specialist (CS) observed Two direct care staff working on day shift on 04/25/25.

A review of the ABST indicated the following:

·       Day shift: 3.16 (3) staff required.

·       Swing shift: 2.67 (3) staff required.

·       Night shift: .922 (1) staff required.

A review of the posted staffing plan and staffing schedules for 04/18/25 through 04/25/25 indicated the following:

·       Day shift: three staff required.

·       Swing shift: three staff required.

·       Night shift: one staff required.

·       The posted staffing plan did not exceed the ABST care time required for day shift or swing shift.

·       The facility was not staffed per the ABST for 11 of 21 shifts.

In an interview, Staff 1 (Interim Administrator) stated they had been taking an average of the daily hours on the ABST instead of using the highest care need times.

Findings were reviewed with and acknowledged by Staff 1 on 04/25/25.

The facility's failure to have a fully implemented and updated ABST was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

Compliance Specialist (CS) observed Two direct care staff working on day shift on 04/25/25.

A review of the ABST indicated the following:

·       Day shift: 3.16 (3) staff required.

·       Swing shift: 2.67 (3) staff required.

·       Night shift: .922 (1) staff required.

A review of the posted staffing plan and staffing schedules for 04/18/25 through 04/25/25 indicated the following:

·       Day shift: three staff required.

·       Swing shift: three staff required.

·       Night shift: one staff required.

·       The posted staffing plan did not exceed the ABST care time required for day shift or swing shift.

·       The facility was not staffed per the ABST for 11 of 21 shifts.

In an interview, Staff 1 (Interim Administrator) stated they had been taking an average of the daily hours on the ABST instead of using the highest care need times.

Findings were reviewed with and acknowledged by Staff 1 on 04/25/25.

The facility's failure to have a fully implemented and updated ABST was substantiated.