The findings of the on-site investigation, conducted on 09/06/23, 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

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

Based on interview and record review, conducted during a site visit on 09/06/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In review of the facility's ABST and resident roster on 09/06/23, it was unclear how many of the 30 residents were entered into the tool. The facility was using their own tool, Point Click Care (PCC), which automatically pulled all the information from the service plans and generated a 24-hour staffing plan. PCC did not list the residents'  names next to the tasks and was not capable of generating a report for individual residents to show their care needs and times. There was also no way to determine when or how often the tool was being updated with any changes to the service plans.

In an interview on 09/06/23, Staff 2 (Health Services Administrator) stated the current census was 30 residents. S/he also stated that the facility was in the process of switching from PCC to the ODHS tool. Staff 2 stated the 22 ADLs are clumped together with the planned and unplanned needs.

On 09/06/23, findings were reviewed with and acknowledged by Staff 2.

The facility failed to fully implement and update an ABST.