Based on interview and record review, conducted during a site visit on 12/18/24, the facility's failure to fully implement and update an Acuity-Based Staff Tool (ABST) was substantiated. Findings include, but are not limited to:

The facility's ABST was reviewed on 12/18/24, which revealed multiple resident profiles that had not been updated in the last quarter.

During an interview, Staff 1 (Executive Director) stated he was responsible for updating the ABST. He further explained, that he reviewed resident profiles with any changes of condition or service plan reviews, but that he did not save changes in the tool to notate it was reviewed if there were no changes in a resident's care.

There was no evidence of missed needs during the site visit. All residents were entered into the tool and the facility was staffed in accordance with their posted staffing plan and ABST.

The facility failed to fully implement and update an ABST.

The findings were reviewed with Staff 1 and Staff 2 (Director of Health Services).