Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

Six direct care staff were observed to be working during day shift on 04/17/25.

A review of the ABST indicated the following:

·Day shift: 6.41 staff required;

·Swing shift: 5.67 staff required; and

·Night shift: 2.05 staff required.

A review of the posted staffing plan and staffing schedules for 04/11/25 through 04/17/25 indicated the following:

·Day shift: six staff required;

·Swing shift: six staff required;

·Night shift: three staff required;

·The posted staffing plan did not exceed the ABST care time for day shift; and

·The facility was not staffed per the ABST for two of 21 shifts.

In an interview, Staff 1 (Executive Director) stated s/he had been taking an average of the daily hours on the ABST instead of using the highest care need times.

Findings were reviewed with and acknowledged by Staff 1 on 04/17/25.

The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

Six direct care staff were observed to be working during day shift on 04/17/25.

A review of the ABST indicated the following:

·Day shift: 6.41 staff required;

·Swing shift: 5.67 staff required; and

·Night shift: 2.05 staff required.

A review of the posted staffing plan and staffing schedules for 04/11/25 through 04/17/25 indicated the following:

·Day shift: six staff required;

·Swing shift: six staff required;

·Night shift: three staff required;

·The posted staffing plan did not exceed the ABST care time for day shift; and

·The facility was not staffed per the ABST for two of 21 shifts.

In an interview, Staff 1 (Executive Director) stated s/he had been taking an average of the daily hours on the ABST instead of using the highest care need times.

Findings were reviewed with and acknowledged by Staff 1 on 04/17/25.

The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.