Based on observation, interview, and record review, conducted during a site

visit on 10/09/24 and 10/10/24, the facility's failure to update an acuity-based

staffing tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 28 residents

were included in the tool and had a completed ABST evaluation.

A review of the facility's ABST indicated the following:

 The "minimum time needed based on acuity" on day shift was 3.59

direct care staff; on swing shift was 3.01 direct care staff; and less than

one direct care staff on night shift.

 Two residents who required two person transfers had no additional time

allotted for the second staff to assist with the transfers. The tool listed an

"X" under two-person transfer.

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

 Day shift: Four caregivers and one med tech;

 Swing shift: Three caregivers and one med tech; and

 Night shift: Two caregivers and one med tech.

A review of the facility's staff schedule and timecards dated 09/29/24 through

10/09/24, indicated the facility was staffing to their posted staffing plan except

on 10/09/24.

Compliance Specialist observed the following staff:

 Day shift:

o On 10/09/24, three caregivers and one med tech.

o On 10/10/24, four caregivers and one med tech.

 Swing shift:

o On 10/09/24, three caregivers and one med tech.

 Night shift:

o On 10/09/24, two caregivers and one med tech.

A review of Resident 1, 2, and 4's records and ABST profile indicated the

following:

 Resident 1 service plan dated 09/06/24 and ABST last updated 10/09/24

indicated the following:

o Service plan indicated resident required two-person transfer;

minutes are not reflected on the ABST. There was an "X" with no

time allotted for the second staff to assist with transferring.

o Service plan indicated resident required staff to redirect and cue

resident, minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

 Resident 2's service plan dated 08/30/24 and ABST last updated

09/16/24 indicated the following:

o Service plan indicated resident required staff to redirect and cue

resident, minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

o Service plan indicated resident required staff to laundry and

housekeeping once a week, minutes were not reflected on the

ABST.

 Resident 4's service plan dated 09/05/24 and ABST last updated

10/09/24 indicated the following:

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with bathing,

minutes were not reflected on the ABST.

o Service plan indicated resident required staff to laundry and

housekeeping once a week, minutes were not reflected on the

ABST.

Staff 1 (Executive Director) indicated the following:

 The facility used a proprietary ABST.

 The facility ABST did not account for additional time for two-person

transfers.

 The proprietary tool had been down companywide for up to five days, all

communities were unable to access and update the ABST. The

company had been working to get the system back up and running.

 S/He was unable to explain how the points allotted in the tool converted

into care time.

It was determined the facility failed to update an acuity-based staffing tool.

Findings were reviewed and acknowledged by Staff 1. An investigation

determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site

visit on 10/09/24 and 10/10/24, the facility's failure to update an acuity-based

staffing tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 28 residents

were included in the tool and had a completed ABST evaluation.

A review of the facility's ABST indicated the following:

 The "minimum time needed based on acuity" on day shift was 3.59

direct care staff; on swing shift was 3.01 direct care staff; and less than

one direct care staff on night shift.

 Two residents who required two person transfers had no additional time

allotted for the second staff to assist with the transfers. The tool listed an

"X" under two-person transfer.

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

 Day shift: Four caregivers and one med tech;

 Swing shift: Three caregivers and one med tech; and

 Night shift: Two caregivers and one med tech.

A review of the facility's staff schedule and timecards dated 09/29/24 through

10/09/24, indicated the facility was staffing to their posted staffing plan except

on 10/09/24.

Compliance Specialist observed the following staff:

 Day shift:

o On 10/09/24, three caregivers and one med tech.

o On 10/10/24, four caregivers and one med tech.

 Swing shift:

o On 10/09/24, three caregivers and one med tech.

 Night shift:

o On 10/09/24, two caregivers and one med tech.

A review of Resident 1, 2, and 4's records and ABST profile indicated the

following:

 Resident 1 service plan dated 09/06/24 and ABST last updated 10/09/24

indicated the following:

o Service plan indicated resident required two-person transfer;

minutes are not reflected on the ABST. There was an "X" with no

time allotted for the second staff to assist with transferring.

o Service plan indicated resident required staff to redirect and cue

resident, minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

 Resident 2's service plan dated 08/30/24 and ABST last updated

09/16/24 indicated the following:

o Service plan indicated resident required staff to redirect and cue

resident, minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

o Service plan indicated resident required staff to laundry and

housekeeping once a week, minutes were not reflected on the

ABST.

 Resident 4's service plan dated 09/05/24 and ABST last updated

10/09/24 indicated the following:

o Service plan indicated resident required assistance with grooming,

minutes were not reflected on the ABST.

o Service plan indicated resident required assistance with bathing,

minutes were not reflected on the ABST.

o Service plan indicated resident required staff to laundry and

housekeeping once a week, minutes were not reflected on the

ABST.

Staff 1 (Executive Director) indicated the following:

 The facility used a proprietary ABST.

 The facility ABST did not account for additional time for two-person

transfers.

 The proprietary tool had been down companywide for up to five days, all

communities were unable to access and update the ABST. The

company had been working to get the system back up and running.

 S/He was unable to explain how the points allotted in the tool converted

into care time.

It was determined the facility failed to update an acuity-based staffing tool.

Findings were reviewed and acknowledged by Staff 1. An investigation

determined a licensing violation had occurred.