The findings of the on-site investigation, conducted 04/08/25 to 04/09/25, 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 04/30/25, the facility's failure to update and review the Acuity Based Staffing Tool (ABST) evaluation for each resident was substantiated. Findings include, but are not limited to:

A review of ABST records dated 04/30/25 indicated that 27 residents' ABST evaluations had not been updated in the last quarter.

In an interview, Staff 3 (Senior Executive Director) stated that the Resident Services Coordinator had left, and the ABST evaluations may not have been updated around that time.

The facility failed to update and review the Acuity Based Staffing Tool (ABST) evaluation for each resident, no less than quarterly, at the same time the resident's service plan was updated. An investigation determined the licensing the licensing violation occurred.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Director of Health Services), Staff 3, and Staff 4 (Health Services Administrator) on 04/30/25.