Print Inspection: 6E6R

Based on interview and record review, conducted during a site visit on 11/25/24, the facility's failure to fully implement and update an Acuity Based Staffing Tool (ABST) was substantiated for 3 of 3 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to:

A review of the Facility ABST and the facility census indicated there were seven residents with incomplete or no ABST profiles entered into the tool.

A review of Resident 2's ABST profile indicated it was last updated on 01/26/22. The most recent service plan was dated 11/24/24.

Resident 2's service plan indicated resident required assistance with eating three times a day. The ABST did not have time allotted for supporting while eating.

In an interview on 11/25/24, Resident 2 stated if s/he was unable to eat the food due to his/her Parkinson's, the staff would assist him/her with eating.

Resident 3 moved in on 08/01/24 and did not have an ABST profile at the time of site visit on 11/25/24.

A review of Resident 4's ABST profile indicated it was last updated on 01/26/22. The most recent service plan was dated 08/26/24.

In an interview on 11/25/24, Staff 1(Administrator) stated s/he started in the Administrator position in 05/2024 and had to request access to the ABST online portal and had not been back in to update is since being granted access.

The facility was consistently staffed according to the posted staffing plan and no missed needs were observed.

The facility failed to fully implement and update an Acuity Based Staffing Tool.

The findings were reviewed with and acknowledged by Staff 1 on 11/25/24.