Based on observation, interview, and record review, conducted during a site

visit on 02/11/25, 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 and resident roster indicated all 51 residents

were included in the tool and had a completed ABST evaluation. There had

been 11 residents that had not been quarterly reviewed.

A review of the facility's ABST indicated the "minimum time needed based on

acuity" on day shift was 2.34 direct care staff and less than one direct care

staff for night shift.

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

 Day shift: Two caregivers and two med techs; and

 Night shift: Two caregivers and one med tech.

A review of the facility's staff schedule and timecards dated 02/04/25 to

02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift

and 02/11/25 for day and night shift.

An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse)

indicated the following;

 Staff 3 was in the process on updating resident's service plans that had

not been quarterly evaluated.

 Staff 1 acknowledged the residents whose acuity had not been quarterly

updated in the ABST.

It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An

investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site

visit on 02/11/25, 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 and resident roster indicated all 51 residents

were included in the tool and had a completed ABST evaluation. There had

been 11 residents that had not been quarterly reviewed.

A review of the facility's ABST indicated the "minimum time needed based on

acuity" on day shift was 2.34 direct care staff and less than one direct care

staff for night shift.

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

 Day shift: Two caregivers and two med techs; and

 Night shift: Two caregivers and one med tech.

A review of the facility's staff schedule and timecards dated 02/04/25 to

02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift

and 02/11/25 for day and night shift.

An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse)

indicated the following;

 Staff 3 was in the process on updating resident's service plans that had

not been quarterly evaluated.

 Staff 1 acknowledged the residents whose acuity had not been quarterly

updated in the ABST.

It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An

investigation determined a licensing violation had occurred.