Based on interview and record review, conducted during a site visit on 06/12/24 and 06/14/24, it was confirmed the facility failed to update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

During an interview on 06/12/24, Staff 1 (Executive Director) stated the following:

·The facility used a proprietary ABST.

·S/He was unable to explain how the points allotted in the tool converted into care time.

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

·There were 30 residents entered into the tool which matched the resident roster.

·Twenty of the 30 residents had not been updated quarterly.

·The "minimum time needed based on acuity" on day shift was 3.84 direct care staff; on swing shift was 3.18 direct care staff; and less than one direct care staff.

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

·Day shift: four CGs and one MT;

·Swing shift: four CG and one MT; and

·Night shift: two CG and one MT.

A review of the facility ' s staff schedule dated 04/28/24 through 06/15/24, and timecards, dated 05/30/24 through 06/12/24, indicated the facility was consistently staffing to their posted staffing plan.

A review of Resident 4, 5, and 6's records and ABST profile indicated the following:

·Resident 4 had no time added in the ABST for his/her care needs. Resident 4 moved into the facility at 06/01/24.

·Resident 5 listed an "X" with no time allotted for the second staff to assist with the transfers.

·Resident 6 had zero minutes for intervention or behaviors.   

During an interview on 06/14/24, Staff 1 (Executive Director) confirmed Resident 4's time had not been added into the ABST tool and Resident 6 required interventions for behaviors from resident-to-resident altercations.

It was confirmed the facility failed to update an acuity-based staffing tool.

On 06/14/24, the findings were reviewed with and acknowledged by Staff 1.