Based on interview and record review, conducted during a site visit on 01/31/25, the facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST revealed multiple residents' profiles had not been updated in the last quarter.

In an interview, Staff 1 (Administrator) stated s/he was aware of the outdated profiles and was working on updating them.

The findings were reviewed with and acknowledged by Staff 1 on 01/31/25.

The facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated.