Based on interview and record review, conducted during a site visit on 12/09/24, the facility's failure to fully implement and update an Acuity Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the Facility ABST and the facility census indicated the facility census was 39.

A review of the facility's ABST Answer Export dated 12/09/24 indicated there were nine residents that had not been updated in the last quarter.

In an interview on 12/09/24, Staff 1(Administrator) stated s/he updated the ABST when a resident had a change of condition and when the service plan was updated.

The facility was consistently staffed according to the posted staffing plan and no missed needs were observed.

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

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Director of Ancillary Services) via email on 12/11/24.