Based on observation, interview, and record review, conducted during a site visit on 04/21/25, the facility's failure to implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST indicated the following required staffing hours:

* Day: 33.8 hours;

* Evening: 28.2 hours; and

* Night: 9.8 hours.

A review of the facility's posted staffing plan indicated it was not consistent with the ABST:

* Day: three caregivers and one med tech;

* Evening: two caregivers and one med tech; and

* Night: one caregiver and one med tech.

An observation of day shift staffing showed the facility was not staffed to their ABST.

In an interview, Staff 1 (Administrator) stated residents' ABST profiles were updated regularly, including quarterly.

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

The findings were reviewed with and acknowledged by Staff 1.

The facility's facility's failure to implement an Acuity-Based Staffing Tool was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/21/25, the facility's failure to implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST indicated the following required staffing hours:

* Day: 33.8 hours;

* Evening: 28.2 hours; and

* Night: 9.8 hours.

A review of the facility's posted staffing plan indicated it was not consistent with the ABST:

* Day: three caregivers and one med tech;

* Evening: two caregivers and one med tech; and

* Night: one caregiver and one med tech.

An observation of day shift staffing showed the facility was not staffed to their ABST.

In an interview, Staff 1 (Administrator) stated residents' ABST profiles were updated regularly, including quarterly.

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

The findings were reviewed with and acknowledged by Staff 1.

The facility's facility's failure to implement an Acuity-Based Staffing Tool was substantiated.