Based on observation, interview, and record review, conducted during a site visit on 04/01/25, the facility's failure to maintain and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

The facility's posted staffing plan indicated the following:

* Day: one med tech and three caregivers;

* Evening: one med tech and three caregivers; and

* Night: one med tech and one caregiver.

A review of the facility's staff schedule, dated 03/25/25 to 04/01/25, revealed the facility was not consistently staffing to their posted staffing plan.

Additionally, in an observation of day shift, only two caregivers were working.

A review of the facility's ABST revealed multiple residents' profiles had not been updated in the last quarter.

The findings were reviewed with and acknowledged by Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), and Staff 3 (Wellness Director).

The facility's failure to maintain and implement an Acuity-Based Staffing Tool (ABST) was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/01/25, the facility's failure to maintain and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

The facility's posted staffing plan indicated the following:

* Day: one med tech and three caregivers;

* Evening: one med tech and three caregivers; and

* Night: one med tech and one caregiver.

A review of the facility's staff schedule, dated 03/25/25 to 04/01/25, revealed the facility was not consistently staffing to their posted staffing plan.

Additionally, in an observation of day shift, only two caregivers were working.

A review of the facility's ABST revealed multiple residents' profiles had not been updated in the last quarter.

The findings were reviewed with and acknowledged by Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), and Staff 3 (Wellness Director).

The facility's failure to maintain and implement an Acuity-Based Staffing Tool (ABST) was substantiated.