Based on interview and record review, conducted during a site visit on 08/26/25, 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 indicated the "minimum time needed based on acuity" on the day shift was 4.28 direct care staff, on the swing shift was 3.83 direct care staff, and on the night shift was 0.80 direct care staff.

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

·Day shift: five caregivers and one med tech;

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

·Night shift: two caregivers and one med tech.

A review of the facility's staff schedule from 08/20/25 through 08/26/25 indicated the facility had been short-staffed for five shifts.

An interview with Staff 1 (Executive Director) indicated the facility had been short-staffed during the timeframe.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.  

The findings of the investigation were reviewed and acknowledged by Staff 1.