The findings of the on-site investigation, conducted 08/22/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, during a site visit conducted on 08/22/23, it was confirmed the facility failed to terminate employee immediately once a failed background check was received. Findings include, but are not limited to:

In an interview on 08/22/23, Staff 1 (Executive Director) stated, "The staff member in question was hired back in January by an old ED. The company's background checks get ran twice. On the first, the employee came back as passed and was hired. On the second run the staff did not pass the background check. The facility did not immediately fire the employee which is where we went wrong. Once I was made aware, the staff member was terminated on 07/18/23."  

A review of Staff 6's background check and termination paperwork showed the following:

·On 01/03/23, Staff 6 passed the first round of the background check.

·On 01/20/23, the background check unit sent a letter to the facility which stated, the decision was effective on the date of the notice. The subject individual may not hold the position listed above effective immediately. The staff member must be terminated or removed from your agency immediately.

·On 07/18/23, Staff 6 was issued a termination of employment due to the denied background check.

It was confirmed the facility failed to terminate employee immediately once a failed background check was received.

On 08/22/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will follow their policy and procedure for background checks with employees. They demonstrated this a couple weeks ago where they had a separate employee not pass the second round of background checks and that staff was terminated from employment immediately.