Based on interview and record review, conducted during a site visit on 01/16/25, 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. Some residents had not been updated in over a year.

In an interview on 01/16/25, Staff 1 (Executive Director) stated the following:

· They usually updated the tool when the service plan was reviewed.

· They were currently working on updating the service plans and tool since their recent survey.

The facility failed to update and document the ABST evaluation for each resident no less than quarterly and corresponding with resident service plan updates.

Findings were reviewed with and acknowledged by Staff 1.