Based on interview and record review, conducted during a site visit on 06/12/25, the facility's failure to update, review, and document the Acuity-Based Staffing Tool (ABST) evaluation for each resident no less than quarterly and corresponding with resident service plan updates was substantiated. Findings include, but are not limited to:

A review of facility's resident roster and ODHS ABST indicated 33 of 33 residents were entered into the tool and 28 of the 33 residents entered had not been updated in the last quarter.

In an interview on 06/12/25, Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and had not been updating it recently.

The facility failed to update resident profiles at least quarterly.

Findings were reviewed and acknowledged by Staff 1.