Based on interview and record review, conducted during a site visit on 09/18/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:

During an interview on 09/18/24, a staff member stated the facility had been staffed short of the facility's posted staffing plan on a few evening shifts in August 2024 and September 2024.

A review of the facility's posted staffing plans dated 08/01/24 and 09/01/24 both indicated a need for nine care staff on evening shift.

A review of facility time cards revealed only eight staff working on evening shift on 08/24/24, 08/26/24 and 09/15/24.

The facility failed to fully implement an ABST.

The findings were reviewed with and Acknowledged by Staff 1 (Administrator), Staff  6 (Operations Specialist, Seasons Management), Staff 7 (Director of Operations, Seasons Management), Staff 8 (Vice President of Clinical Operations, Seasons Management ), Staff 9 (Chief Operations Officer), Seasons Management) and Staff 10 (Facility Owner) by phone on 09/19/24.