Based on observation, interview, and record review, conducted during a site visit on 12/11/24, the facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

An observation of the facility showed two distinct and separate neighborhoods named Villa Maria and Caritas.

An observation of the entrance to Villa Maria revealed there was no posted staffing plan.

An observation inside the entrance of Caritas revealed a posted staffing plan based on a ratio.

In an interview, Staff 1 (Nurse Manager) stated the facility did not have a posted staffing plan.

A review of the facility's ABST showed the following required staffing hours for Caritas on Wednesdays:

* Day: 65.34 hours;

* Evening: 53.69 hours; and

* Night: 19.48 hours.

An observation of day shift staffing for the Caritas neighborhood revealed the facility was not staffed to the hours required by their ABST.

A review of the facility's ABST revealed multiple resident's profiles had not been updated in the last quarter.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Assistant Nurse Manager), and Staff 3 (Resident Care and Scheduling Manager).

The facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated.