Based on interview and record review, conducted during a site visit on 09/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST report, with the last update dates, indicated there had been 27 of 40 residents who had not been quarterly evaluated.  

A review of the facility's ABST indicated the "minimum time needed based on acuity" on the day shift was 14.45 direct care staff, and less than one staff member for the swing and the night shifts.

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

·6:15 am to 10:00 am:

o3 CG, 1 MT, and a bath aide Mon-Fri;

·10:00 am to 2:30 pm:

o2 CG, 1 MT, and a bath aide Tues-Thurs;

·2:15 pm to 10:30 pm:

o2 CG and 1 MT;

·10:15 pm to 6:30 am:

o1 CG and 1 MT.

A review of the facility's staff schedule from 09/11/25 through 09/17/25 indicated the facility had been short-staffed for the day shifts per the staffing requirements indicated in the ABST.

An interview with Staff 3 (Resident Care Coordinator) was conducted, which indicated the facility had not known that residents needed to be reviewed quarterly in the ABST. S/He indicated the facility staffed the following:

·Day: 1 MT and 2 CGs;

·Swing: 1 MT and 2 CGs; and

·Night: 1 MT and 1 CG.

The facility failed to update and review the ABST evaluation for each resident no less than quarterly; the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs; and the facility failed to use the results of the ABST to develop and routinely update the facility's posted staffing plan.

The findings of the investigation were reviewed and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 09/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST report, with the last update dates, indicated there had been 27 of 40 residents who had not been quarterly evaluated.  

A review of the facility's ABST indicated the "minimum time needed based on acuity" on the day shift was 14.45 direct care staff, and less than one staff member for the swing and the night shifts.

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

·6:15 am to 10:00 am:

o3 CG, 1 MT, and a bath aide Mon-Fri;

·10:00 am to 2:30 pm:

o2 CG, 1 MT, and a bath aide Tues-Thurs;

·2:15 pm to 10:30 pm:

o2 CG and 1 MT;

·10:15 pm to 6:30 am:

o1 CG and 1 MT.

A review of the facility's staff schedule from 09/11/25 through 09/17/25 indicated the facility had been short-staffed for the day shifts per the staffing requirements indicated in the ABST.

An interview with Staff 3 (Resident Care Coordinator) was conducted, which indicated the facility had not known that residents needed to be reviewed quarterly in the ABST. S/He indicated the facility staffed the following:

·Day: 1 MT and 2 CGs;

·Swing: 1 MT and 2 CGs; and

·Night: 1 MT and 1 CG.

The facility failed to update and review the ABST evaluation for each resident no less than quarterly; the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs; and the facility failed to use the results of the ABST to develop and routinely update the facility's posted staffing plan.

The findings of the investigation were reviewed and acknowledged by Staff 1.