Based on observation, interview, and record review, conducted during a site visit on 08/05/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to:

In an interview on 08/05/24, Staff 1 (Administrator) stated the building consisted of an RCF with two floors named "Manor Care 1 and 2" and a memory care named "Manor Care West."

A review of the facility's Posted Staffing Plan stated the following:

* Manor Care

* Day: seven caregivers, two med techs, and one restorative aide;

* Evening: seven caregivers and two med techs; and

* Night: four caregivers and one med tech, who was shared with the memory care.

* Memory Care

* Day: five caregivers, one med tech, and one restorative aide;

* Evening: five caregivers and one med tech; and

* Night: three caregivers and one med tech, who was shared with Manor Care.

In an interview on 08/05/24, when asked how the facility determines the staffing plan, Staff 1 stated this was "the plan the facility has always had."

A review of the facility's ABST showed 312 total care hours, requiring 41.6 staff members for day shift.

A review of the posted staffing plan and staff schedule revealed the facility was not staffing to the plan required by the ABST.

In an interview on 08/20/24, Witness 2 (ABST Corrective Action Coordinator) stated the facility's high frequency count, which generated abnormally high staffing hours, was due to counting single ADL tasks across multiple ADLs in the ABST.

Interviews with residents did not reveal any missed needs.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Director of Nursing), Staff 9 (Facility Compliance Specialist), and Staff 10 (Executive Director).

It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.