The findings of the on-site investigation, conducted 09/19/23 though 09/20/23 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

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 record review and interview, conducted during a site visit on 09/19/23 and 09/20/23 it was confirmed the facility failed to fully implement and update an ABST for 1 of 1 sampled residents (# 1). Findings include, but are not limited to:

Resident 1 moved into the facility on 09/18/23 but was not yet included in the facility's ABST on 09/19/23.

In an electronic communication on 09/22/23, Staff 1 (Executive Director) stated "[Resident 1] did not show on the original ABST tool in Memory Care due to being a respite and the report had to be run differently. S/he was our first respite since having the ABST tool. "

The findings were reviewed with and acknowledged by Staff 1 on 09/19/23.

The facility failed to update their ABST.