Based on observation and record review conducted during a site visit on 01/27/25, the facility's failure to have sufficient staff to meet the scheduled and unscheduled needs of the residents was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

A review Resident 3's service plan dated 10/10/24 and ABST last updated 12/10/24 indicated Resident 3 required two-person transfers.

At 11:27 am Resident 3 was observed to be transferred by one staff member from his/her bed to wheelchair.

A review of the facility's posted staffing plan indicated the following:

·Day Shift: 2.5 Med-techs and 3.5 Caregivers;

·Swing Shift: 2 Med-techs and 3 Caregivers; and

·Overnight Shift: 1 Med-techs and 2 Caregivers.

A review of the facility ABST indicated the facility required seven staff on day shift.

A review of the facility staffing from 01/20/25 - 01/27/25 indicated the facility was not consistently staffed to the ABST required staffing. Four of seven day shifts were staffed under the posted staffing plan and seven of seven day shifts were staffed under the ABST required staffing.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 01/27/25.

Facility Verbal Plan of Correction:

Staff 1 was to hold an all-staff in-service meeting on 01/31/25 to review resident service plans and Staff 1 would be reviewing the ABST weekly to ensure staffing appropriately. The facility used the RCC and staffing coordinator to assist on the floor when necessary.

Based on observation, interview and record review, conducted during a site visit on 01/27/25, the facility's failure to adopt an acuity-based staffing tool to determine appropriate staffing levels was substantiated for 1 of 2 sampled residents (# 3). Findings include, but are not limited to:

A review Resident 3's service plan dated 10/10/24 and ABST last updated 12/10/24 indicated Resident 3 required two-person transfers.

At 11:27 am Resident 3 was observed to be transferred by one staff member from his/her bed to wheelchair.

An unsampled residents ABST was last updated on 10/05/24.

In an interview on 01/27/25, Staff 1 (Administrator) stated the unsampled residents service plan was last updated on 10/05/24.

A review of the facility's posted staffing plan indicated the following:

·Day Shift: 2.5 Med-techs and 3.5 Caregivers;

·Swing Shift: 2 Med-techs and 3 Caregivers; and

·Overnight Shift: 1 Med-techs and 2 Caregivers.

A review of the facility ABST indicated the facility required seven staff on day shift.

A review of the facility staffing from 01/20/25 - 01/27/25 indicated the facility was not consistently staffed to the ABST required staffing.

The facility failed to adopt an acuity-based staffing tool to determine appropriate staffing levels.

The findings were reviewed with and acknowledged by Staff 1 on 01/27/25.