- Date
- 9/3/2024
- Report number
- CALMS - 00084908
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to use an ABST
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during an off-site review on 02/28/25, the facility’s failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the facility’s ABST indicated that not all resident-specific data had been updated at least quarterly. Two residents had not been updated since April 2024.
A review of the ABST indicated the following:
· Day shift: eight staff required;
· Swing shift: eight and a half staff required; and
· Night shift: two and a half staff required.
A review of the posted staffing plan indicated the following:
· Day shift: ten staff required;
· Swing shift: nine staff required; and
· Night shift: three staff required.
A review of the staffing schedule for 09/03/24 indicated the facility was not staffed to the posted staffing plan for day shift. The facility was short staffed by one direct care staff. Findings were reviewed with and acknowledged by Staff 1 on 02/28/25. The facility failed to update an ABST for each resident no less than quarterly, and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents.
As the new owner of this facility as of 1/1/25, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.