Based on record review and interview it was confirmed that the facility failed to adopt and fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

A review of the facility's ABST revealed that:

*The facility's ABST does not include all 22 Activities of Daily Living as

required by rule.

*The facility does not generate a staffing plan based on the amount of

caregiving time indicated in their tool.

*The facility's ABST-based staffing plan does not match the facility's posted

staffing plan.

*The facility's ABST calculates care hours/shift/month. The current needs are:

AM CG: 754.02

PM CG: 161.19

NOC CG: 618.95

AM Medication Technician (MT) : 32.46

PM MT 312.24

The facility's posted staffing plan on 08/04/2022 indicated the following:

Day: 1 CG, 2 MT

Evening: 1 CG 2 MT

Noc: 1 CG and 1 MT

The facility's staffing schedule indicated they are not staffing to this as there are NOC shifts in which there is only 1 MT for several hours.

Findings reviewed with Staff #1, Staff #4 and Staff #5 on 08/04/2022, who were unable to explain how to take the information from their ABST to generate a staffing plan and that there are likely mistakes in their current ABST data.