Based on interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

During an interview on 09/27/23, Staff 2 (Administrator) stated the facility is currently working with the district team to ensure that all 22 Activities of Daily Living (ADLs) are listed, for each resident in the tool.

On 10/02/23, a record review of the facility's ABST report, dated 10/02/23, showed only 17 ADLs were listed for each resident. The occupancy listed on the tool was 49 and the census on 10/02/23 was 49.  

The findings of the investigation were reviewed with and acknowledged by Staff 2 on 09/27/23.

It was determined the facility failed to fully implement an Acuity-Based Staffing Tool.

Verbal Plan of Correction: The district team is working to include all 22 ADLs in the tool. Projected date of compliance unknown.