Based on interview and record review, conducted during a site visit on 02/28/25, the facility's failure to fully implement an acuity-based staffing tool was substantiated for 1 of 2 (#2) sampled residents. Findings include, but are not limited to:

In an interview Staff 1 (Resident Care Manager Assistant) stated Staff 4 (Administrator) updated the ABST and confirmed the facility used the ODHS ABST.

A review of the facility's resident roster indicated the facility is home to 30 residents.

A review of the facility's ABST "Facility Section Details" indicated there were 32 residents entered. A review of the facility's ABST exported data indicated there were six current residents' whose profiles had not been updated at least quarterly; three residents listed in the tool no longer resided in the facility, and one resident (Resident 2) was not entered into the tool.

Resident 2's service plan dated 01/23/25, indicated s/he was dependant on staff to provide assistance with ADLs including two-person transfer and did not have an ABST profile.

In an interview Staff 1 stated Resident 2 moved into the facility on approximately 01/26/25.

A review of the ABST care times indicated the facility needed approximately 11 staff on day shift, 9 staff on swing shift and 4 staff on night shift.

A review of the posted staffing plan indicated the following:

·Day shift 6:45 am to 3:00 pm: 1 nurse, 1 medication aide and 7 caregivers;

·Swing shift 2:45 pm to 11:00 pm: 1 nurse, 1 medication aide and 7 caregivers; and

·Noc shift 10:45 pm to 7:00 am: 1 nurse/ medication aide and 6 caregivers.

A review of the facility's staffing schedule for 02/22/25 - 02/28/25 indicated the facility was not staffed according to the posted staffing plan for eight of 56 shifts and the facility was not staffed to the ABST time for nine of 56 shifts reviewed.

The facility failed to implement and update and Acuity Based Staffing Tool.

Findings were reviewed and acknowledged by Staff 1 (Resident Care Manager Assistant) and Staff 2 (Administrators Assistant) on 02/28/25.

Based on interview and record review, conducted during a site visit on 02/28/25, the facility's failure to fully implement an acuity-based staffing tool was substantiated for 1 of 2 (#2) sampled residents. Findings include, but are not limited to:

In an interview Staff 1 (Resident Care Manager Assistant) stated Staff 4 (Administrator) updated the ABST and confirmed the facility used the ODHS ABST.

A review of the facility's resident roster indicated the facility is home to 30 residents.

A review of the facility's ABST "Facility Section Details" indicated there were 32 residents entered. A review of the facility's ABST exported data indicated there were six current residents' whose profiles had not been updated at least quarterly; three residents listed in the tool no longer resided in the facility, and one resident (Resident 2) was not entered into the tool.

Resident 2's service plan dated 01/23/25, indicated s/he was dependant on staff to provide assistance with ADLs including two-person transfer and did not have an ABST profile.

In an interview Staff 1 stated Resident 2 moved into the facility on approximately 01/26/25.

A review of the ABST care times indicated the facility needed approximately 11 staff on day shift, 9 staff on swing shift and 4 staff on night shift.

A review of the posted staffing plan indicated the following:

·Day shift 6:45 am to 3:00 pm: 1 nurse, 1 medication aide and 7 caregivers;

·Swing shift 2:45 pm to 11:00 pm: 1 nurse, 1 medication aide and 7 caregivers; and

·Noc shift 10:45 pm to 7:00 am: 1 nurse/ medication aide and 6 caregivers.

A review of the facility's staffing schedule for 02/22/25 - 02/28/25 indicated the facility was not staffed according to the posted staffing plan for eight of 56 shifts and the facility was not staffed to the ABST time for nine of 56 shifts reviewed.

The facility failed to implement and update and Acuity Based Staffing Tool.

Findings were reviewed and acknowledged by Staff 1 (Resident Care Manager Assistant) and Staff 2 (Administrators Assistant) on 02/28/25.