Based on observation, interview, and record review, conducted during a site visit on 05/20/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the ABST indicated the following:

·Day shift: Clover 2.06 staff, Acorn 2.20 staff, Sunflower 2.01 staff, Blackberry 2.53, and Dandelion 1.86 staff required;

·Swing Shift: Clover 1.75 staff, Acorn 2.02 staff, Sunflower 1.78 staff, Blackberry 2.62 staff, and Dandelion 1.69 staff required; and

·Night Shift: Clover 0.47 staff, Acorn 0.43 staff, Sunflower 0.37 staff, Blackberry 0.61 staff, and Dandelion 0.29 staff required.

A review of the posted staffing plan and staffing schedules for 05/14/25 through 05/20/25 indicated the following:

·Day shift: two caregivers and one med tech in each cottage;

·Swing shift: two caregivers and one med tech in each cottage; and

·Night shift: one caregiver in each cottage and two shared med techs.

·The posted staffing plan did not account for multi-person transfer or care needs.

·The facility had eleven residents (in four out of five cottages) requiring two-person transfers or care needs and was not consistently scheduling two care staff in each segregated area on the night shift.

In an interview on 05/20/25, Staff 1 (Executive Director) stated the following:

·Staff 1 was unaware they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.

·Staff 1 included the shared med techs as the second staff member available for two-person transfers on the night shift.

Findings were reviewed with and acknowledged by Staff 1.

The facility's failure to have a fully implemented and updated ABST; and to have enough staff to meet the scheduled and unscheduled needs of the residents was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 05/20/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the ABST indicated the following:

·Day shift: Clover 2.06 staff, Acorn 2.20 staff, Sunflower 2.01 staff, Blackberry 2.53, and Dandelion 1.86 staff required;

·Swing Shift: Clover 1.75 staff, Acorn 2.02 staff, Sunflower 1.78 staff, Blackberry 2.62 staff, and Dandelion 1.69 staff required; and

·Night Shift: Clover 0.47 staff, Acorn 0.43 staff, Sunflower 0.37 staff, Blackberry 0.61 staff, and Dandelion 0.29 staff required.

A review of the posted staffing plan and staffing schedules for 05/14/25 through 05/20/25 indicated the following:

·Day shift: two caregivers and one med tech in each cottage;

·Swing shift: two caregivers and one med tech in each cottage; and

·Night shift: one caregiver in each cottage and two shared med techs.

·The posted staffing plan did not account for multi-person transfer or care needs.

·The facility had eleven residents (in four out of five cottages) requiring two-person transfers or care needs and was not consistently scheduling two care staff in each segregated area on the night shift.

In an interview on 05/20/25, Staff 1 (Executive Director) stated the following:

·Staff 1 was unaware they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.

·Staff 1 included the shared med techs as the second staff member available for two-person transfers on the night shift.

Findings were reviewed with and acknowledged by Staff 1.

The facility's failure to have a fully implemented and updated ABST; and to have enough staff to meet the scheduled and unscheduled needs of the residents was substantiated.