Based on interview and record review, conducted during a site visit on 02/11/25, the facility's failure to develop and maintain an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

In an interview, Staff 1 (Administrator) stated the facility was using a proprietary tool, called Bluestep.

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

The facility's posed staffing plan indicated the following:

* Day: two med techs and three caregivers;

* Evening: two med techs and three caregivers; and

* Night: one med tech and one caregiver.

A review of the facility's staff schedule, dated 02/05/25 to 02/11/25, revealed the facility was not consistently staffed to their posted staffing plan on the following dates:

* 02/05/25;

* 02/06/25; and

* 02/07/25.

In an interview, Staff 2 (caregiver) stated s/he was unsure night shift staff would be able to evacuate the residents in the event of a fire or life safety emergency.

The findings were reviewed with and acknowledged by Staff 1 on 02/11/25.

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