The findings of the on-site investigation, conducted 06/24/25 through 06/25/25 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
cc:cubic centimeter
CG:caregiver
cm:centimeter
F:Fahrenheit
HH:Home Health
HS or hs:hour of sleep
LPN:Licensed Practical Nurse
MA:Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
O2 sats:oxygen saturation in the
blood
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
RN:Registered Nurse
SP:service plan
TAR:Treatment Administration
Record
tid:three times a day
Based on interview and record review, conducted during a site visit on 06/24/25 and 06/25/25, the facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to:
The facility was placed on license condition ALFCD24-00204 on 05/24/24, which indicated the facility was to staff according to a mandated staffing plan of:
·Three caregivers and one med tech on day shift;
·Three caregivers and one med tech on swing shift; and
·Two caregivers and one med tech on night shift.
A review of the facility's staff schedule, facility timecards, and labor detail information, dated 07/12/24 through 07/18/24, indicated the facility was not staffed to the condition-mandated staffing plan for 7 of 21 shifts reviewed.
It was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.
The findings of the investigation were reviewed with and acknowledged by Staff 3 (District Director of Operations) on 06/25/25.