Based on interview and record review, conducted during a site visit on 08/07/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

During an interview on 08/07/23, Staff 1 (Administrator) stated the following:

*Resident 2 moved in on 07/24/23 and Staff 1 had not yet entered Resident 2 into the ABST; and

*She had not yet entered care needs for Resident 3 into the ABST.

A review of the facility's ABST revealed the following:

*Resident 1's ABST profile had not been updated since 06/28/22.

*Resident 2 was not entered into the ABST.

*Resident 3 did not have time for care needs entered into the ABST.

The findings were reviewed with and acknowledged by Staff 1 on 08/07/23.

The facility failed to fully implement an ABST.

Verbal plan of correction: The Administrator will update ABST in conjunction with the residents service planning meetings. The Administrator will update the posted staffing plan by end of day on 08/07/23.