Based on interview and record review, conducted during a site visit on 03/25/24, 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 03/25/24, Staff 1 (ED) indicated the facility currently staffed the following;

·Day: one MT, one treatment aid, and three CG's.

·Swing: one MT, one treatment aid, and three CG's.

·Night: one MT and two CG's.

During an email correspondence on 03/25/24, Staff 1 indicated the breakdown of the facility's ABST had 5893 minutes, divided by 60 minutes, divided by 7.5 working hours. Equaling 13.09. The facility scheduled 13 care staff a day.

The facility's ABST was reviewed on 03/25/24, the tool had total minutes needed: 5893 minutes, divided by 60 minutes, divided by 7.5 working hours, which equaled 13.09 care staff needed for the day. There were 5 of 45 residents' profiles that had not been updated quarterly.

The posted staffing plan indicated on day and swing shift the facility had one MT, four CG's, and one treatment aide, on night shift there is one MT and two CG's.

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

On 03/25/24, the findings were reviewed with and acknowledged by Staff 1.