Based on interview and record review, conducted during a site visit on 09/16/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 2 of 3 sampled residents (#'s 2 & 4). Findings include, but are not limited to:

A review of the facility implemented ABST indicated 17 residents were entered into the tool. A review of the resident roster indicated 17 residents lived in the facility. 6 of the 17 residents on the roster were not entered into the ABST.

Resident 2 moved in on 02/07/24 and was not entered into the tool until 09/16/24.

Resident 4 moved in on 08/07/24 and was not entered into the tool.

In an interview on 09/16/24 at 1:30 pm, Staff 1 (Assistant Administrator) stated s/he had not added Resident 4 to the ABST yet.

A review of the facility's posted staffing plan indicated the following:

·Day - 5 caregivers, 1 med tech;

·Swing - 4 caregivers, 1 med tech; and

·Night - 2 caregivers, 1 med tech.

A review of facility 09/2024 schedule indicated facility was consistently staffing at the posted staffing plan.

During interviews on 09/16/24, Resident 2, Resident 3 and Resident 4 did not express any missed needs.

The facility failed to fully implement and update an ABST.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (Administrator) on 09/16/24.