Based on interview and record review it was confirmed that the facility failed to fully adopt and implement an Acuity Based Staffing Tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but not limited to:

During an unannounced site visit on 8/18/2022, the facility was unable to produce a cumulative record of resident needs produced by their ABST. A review of Resident #1's (R1) ABST profile revealed it is incomplete.

During interview, Staff #1 and Staff #3 (S1 and S3) stated that they have begun entering residents into their elected ABST, however do not yet have all residents entered.

Findings reviewed with and acknowledged by S1 and S3 on 8/24/2022.