Based on observation, interview, and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

A review of staffing schedules, facility's posted staffing plan, and timecards for 02/05/24 it was confirmed the facility failed to ensure the scheduled and unscheduled needs of the residents.

The posted staffing plan showed the care staff levels for dayshift to be three care partners and one MT for dayshift.

A review of the staff schedule and timecards for 02/05/24 confirmed inconsistent staffing levels for dayshift with staffing of 2 caregivers and 1 MT.

A review of the facility's ABST on 04/30/24 indicated staffing levels on day shift were three caregivers and one MT.

Compliance Specialist (CS) observed the facility was staffed with three care partners and one MT for dayshift on the day of site visit.

In an interview on 04/30/24 at 2:45 pm, Staff 1 (ED) confirmed that in February 2024 the facility was short staffed and using agency to fill in callouts and vacation.

In an interview with Staff 2 stated that the facility was short staffed in February 2024 due to residents and staff coming down with the flu and "staff not wanting to come to work".

The above information was shared with Staff 1 on 04/30/24. S/he acknowledged the findings.

It was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents.