Based on interview and record review, conducted during a site visit on 02/21/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST) for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include but, are not limited to:

A review of the facility's ABST and facility documents revealed:

1. Resident 1 moved into the facility on 02/07/24. Resident 1 had not been entered into the facility's ABST on 02/21/24.

2. Resident 2 moved into the facility on 02/05/24. Resident 2 had not been entered into the facility's ABST on 02/21/24.

3. Resident 3 moved into the facility on 06/28/21. Resident 3 had not been entered into the facility's ABST on 02/21/24.

4. Resident 4 moved into the facility on 02/19/24, Resident 4. had not been entered into the facility's ABST on 02/21/24.

During an interview on 02/21/24, Staff 4 (Executive Director) and Staff 2 (Memory Care Administrator) confirmed the four residents were not entered into the tool.

The facility failed to fully implement an Acuity-Based Staffing Tool.

The findings were reviewed with and acknowledged by Staff 2 and Staff 4 on 02/21/24.