Based on interview and record review, conducted during a site visit on

06/02/25, the facility's failure to fully implement and update an Acuity-Based

Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1).

Findings include, but are not limited to:

A review of the facility's ABST report, with the last update dates indicated that

an unsampled resident had not been quarterly evaluated since 01/20/25.

An interview with Staff 1 (Executive Director) was conducted, and indicated

that s/he had not known residents needed to be reviewed quarterly in the

ABST.

It was determined the facility's failure to fully implement and update an ABST

was substantiated.

The findings of the investigation were reviewed and acknowledged by Staff 1.

An investigation determined a licensing violation had occurred.