Based on interview and record review, conducted during a site visit on 01/22/24 and 01/25/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 2 of 2 sampled resident, (#1 and 2), whose ABST was reviewed. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated there were 27 residents who resided in this facility.

A review of residents' ABST and service plans indicated the following:

Residents 1's service plan, dated 11/25/23, indicated s/he required two-person assisted Hoyer transfer six times a shift.  The ABST indicated Resident 1 required a total of 15 minutes of staffing time for transfers per shift.

Residents 2's service plan, dated 01/02/23, indicated s/he required two-person assisted transfer for all transfers to and from bed to wheelchair or toilet, and reposition every two hours and toileting 6 times per shift.  The ABST indicated Resident 2 required a total of 15 minutes of staffing time for transfers per shift.

In separate interviews on 01/25/24 Staff 2 (MT), Staff 3 (CG), and Staff 6 (CG) stated two-person transfers take anywhere from 15 to 20 minutes per transfer.

On 01/25/24, these findings were reviewed with and acknowledged by Staff (ED).

The facility failed to fully implement and update an ABST.