Based on interview and record review conducted during a site visit on 07/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

In an interview on 07/17/25 Staff 1 (Executive Director) and Staff 2 (Business Office Manager) indicated that the facility used a proprietary ABST called Bluestep which both staff stated should have been submitted to the department for approval.

The facility was unable to provide any documentation to verify the proprietary ABST had been submitted to the department.

In review of the ABST document, there was no indication of when the last time each resident had been updated.

The facility failed to ensure the proprietary ABST had been submitted to the department for review prior to implementation, and the facility failed to ensure the proprietary ABST met the required element of identifying the date the resident's ABST evaluation was last completed.

Findings were reviewed and acknowledged by Staff 1, Staff 2 and Staff 3 (LN) on 07/17/25.

Based on interview and record review conducted during a site visit on 07/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

In an interview on 07/17/25 Staff 1 (Executive Director) and Staff 2 (Business Office Manager) indicated that the facility used a proprietary ABST called Bluestep which both staff stated should have been submitted to the department for approval.

The facility was unable to provide any documentation to verify the proprietary ABST had been submitted to the department.

In review of the ABST document, there was no indication of when the last time each resident had been updated.

The facility failed to ensure the proprietary ABST had been submitted to the department for review prior to implementation, and the facility failed to ensure the proprietary ABST met the required element of identifying the date the resident's ABST evaluation was last completed.

Findings were reviewed and acknowledged by Staff 1, Staff 2 and Staff 3 (LN) on 07/17/25.