The findings of the on-site investigation, conducted 08/24/23, 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.

Based on interview and record review, conducted during a site visit on 08/24/23, 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 08/24/23, it was found there were 34 residents listed on the roster and only 32 residents were entered into the ABST.

In an interview on 08/24/23, Staff 1 (ED) stated the current census was 32 residents. S/he also stated they had two new move-ins on 08/16/23 and the ABST was not updated yet.

On 08/24/23, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.