Based on interview and record review, conducted during a site visit on 08/13/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's ABST report, with the last update dates indicated the following:

·There were 66 of 66 residents who had not been evaluated quarterly; and

·Four residents who had not been entered into the tool before move-in.

An interview with Staff 1 (Executive Director) was conducted, which indicated the facility had not known to update residents quarterly and acknowledged the new residents had not been entered into the ABST before moving into the facility.

The findings of the investigation were reviewed and acknowledged by Staff 1.

The facility failed to update and document the ABST evaluation for each resident no less than quarterly, and before a resident moved in.