Based on observation, interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated the following:

·All 38 residents were listed on the tool (26 MC and 12 SNC).

·Resident 3 moved into the MC on 08/22/24 and did not have any care needs entered.

·Resident 4 moved into the MC on 08/24/24 and did not have any care needs entered.

·Resident 5 moved into the MC on 08/13/24 and did not have all care needs entered.

A review of the staffing schedules for 08/13/24-08/27/24 indicated the following:

·SNC indicated a one to four staffing ratio needed for day/swing shifts and one to six on Noc shift.

·Facility was staffing per the SNC and ABST for the SNC side.

·MC ABST indicated 4.14 staff needed for day shift, 3.9 needed for swing shift, and 1.12 for Noc shift.

·Facility was not exceeding staffing per the ABST for the MC on dayshift on two separate days.

Compliance Specialist observed the MC was staffed with three caregivers and one MT for day shift on 08/28/24. The SNC was staffed with four direct care staff for day shift.

In an interview on 08/28/24, Staff 1 (Executive Director) and Staff 2 (Staffing Coordinator) stated the following:

·They were not aware of any staffing concerns or needs missed.

·They did not know they needed to look at the day with the highest staffing need and round up for the ABST, or that they needed to exceed the ABST to account for unscheduled needs.

·  If there was a call out in the SNC, we would send staff from the other side, however, would still be staffed at the minimum.

On 08/28/24, findings were reviewed with and acknowledged by Staff 1.

It was confirmed the facility failed to fully implement and update an ABST.