Based on interview and record review, conducted during a site visit on 04/24/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 3 of 3 sampled residents (#1, 2 and 4). Findings include, but not limited to:

A review of the facility's  ABST on 04/24/24, indicated the first floor had six residents entered and the second floor had eleven residents entered for a total of 17 residents.

A review of the facility census indicated the facility is home to 19 total residents.

Resident 1 was admitted to the facility on 10/04/23 and his/her ABST indicated the last update was made on 11/29/23.

Resident 2 was admitted to the facility on 01/16/24 and was not entered into the facility ABST.

Resident 4 was admitted to the facility on 01/25/24 and was not entered into the facility ABST.

In an interview on 04/24/24, Staff 1 (Med tech) confirmed there were 19 residents in the facility.

In an interview on 05/03/24, Staff 4 (Administrator) stated the facility used the Oregon Department of Human Services (ODHS) ABST and had not been updated the tool regularly.

The facility failed to fully implement and update an ABST.

The findings were reviewed with and acknowledged by Staff 4 on 05/03/24.