Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:

During an interview on 11/2/2022, Staff #1 (S1) stated,  "I did not keep up with the required posting of the staffing plan when the acuity changed. "

During an unannounced site visit on 11/2/2022, Compliance Specialist (CS) observed 3 Caregivers (CG) and 1 Med Tech (MT) working during the day shift.

A review of the facility posted staffing plan and the facility ' s Acuity Based Staffing Tool (ABST) indicate that the facility staffing plan does not match the ABST.

The above information was shared and acknowledged by S1 and S2 on 11/2/2022.

Plan of Correction: S1 stated on11/14/2022 that the facility does staff to acuity, currently the posted staffing plan at the entrance has been updated to read 3 CG and 2 MT for day shift and going forward the designee will update this daily.