Print Inspection: ZM1Q

Based on observation, interview and record review, conducted during a site visit on 07/03/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 2 sampled residents (#1). Findings include, but are not limited to:

In separate interviews, Staff 1 (Administrator) stated the following:

* The facility used a proprietary ABST called "Service Alignment;"

* The tool was separated by "assisted living" and "memory care;"

* The tool reported staffing hours in total minutes per 24 hours;

* The posted staffing plan was built off the ABST.

A review of the facility's proprietary ABST indicated the need for 5,970.51 staffing minutes for the "assisted living."

A review of the facility's posted staffing plan for the "assisted living" indicated it was not built off the ABST, for a total of 5,400 minutes:

* Day: four direct care staff and two medication aides;

* Evening: two direct care staff and two medication aides;

* Night: one direct care staff and one medication aide.

Additionally, observation and interviews indicated discrepancies in the ABST profile for Resident 1 for the following ADLs:

* Personal hygiene;

* Grooming;

* Transfering;

* Repositioning;

* Eating; and

* Monitoring for physical conditions or symptoms.

The findings were reviewed with and acknowledged by Staff 1 via electronic communication on 07/30/25.

The facility's failure to develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents, was substantiated.