Print Inspection: I0QV

Based on interview and record review, conducted during a site visit on 06/23/25, 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 community staffing pattern, dated 03/10/25, indicated five staff and one-half shift on day shift, four staff and one-half shift on swing shift, and three staff on night shift.

A review of the facility's ABST dated 06/23/25 indicated the staff the facility would have needed to meet the scheduled needs of the residents was six staff for day shift, five staff for swing shift, and two staff for night shift.

A review of the facility's staff schedule from 06/17/25 - 06/23/25 indicated the facility was not staffed to their ABST time; each swing shift reviewed was short by one-half staff member.

In an interview on 06/23/25, Staff 2 (Health Services Director) stated s/he picked the day with the highest required care time for each shift from the ABST, rounded up and then divided by seven and a half to determine how many staff should be working.

The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 06/23/25.

Based on interview and record review, conducted during a site visit on 06/23/25, 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 community staffing pattern, dated 03/10/25, indicated five staff and one-half shift on day shift, four staff and one-half shift on swing shift, and three staff on night shift.

A review of the facility's ABST dated 06/23/25 indicated the staff the facility would have needed to meet the scheduled needs of the residents was six staff for day shift, five staff for swing shift, and two staff for night shift.

A review of the facility's staff schedule from 06/17/25 - 06/23/25 indicated the facility was not staffed to their ABST time; each swing shift reviewed was short by one-half staff member.

In an interview on 06/23/25, Staff 2 (Health Services Director) stated s/he picked the day with the highest required care time for each shift from the ABST, rounded up and then divided by seven and a half to determine how many staff should be working.

The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 06/23/25.