The findings of the on-site investigation, conducted on 07/26/23, 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 07/26/23, 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 07/26/23, it was determined there was 32 residents listed on the roster and only 31 residents were entered into the ABST.

In an interview on 07/26/23, Staff 1 (Executive Director) stated the current census was 32 residents. S/he also stated they had a new move-in and the ABST was not updated yet.

On 07/26/23, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.