The findings of the on-site investigation conducted 10/11/2023 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, OARs 411 Division 57 for Memory Care Communities.

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 10/11/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled resident, (#1, 2, and 3), whose ABST was reviewed. Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated there were 31 residents listed on the roster and only 30 residents were entered into the ABST.  

A review of residents' ABST quarterly updates indicated the following: Resident #1 was last updated 01/24/23, Resident #2 was last updated 11/05/22, and Resident #3 was last updated 11/05/22.

In an interview on 10/11/23, Staff 1 (ED) stated the ABST tool had not been updated quarterly or when a significant change in condition occurred.  S/he had planned training with ODHS ABST team on 10/16/23.

On 10/11/23, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.

Based on observation, interview, and record review, conducted during a site visit on 10/11/23, it was determined the facility failed to ensure residents may not enter a room through another resident's bedroom Findings include, but are not limited to:

The CS walked through one resident's bedroom to get to the second resident's bedroom and common living room.

In interviews on 10/11/23, Staff 1 (ED) stated Resident 3's POA requested a change of rooms because resident had to enter their bedroom through another resident's bedroom or use shared bathroom.

A review of Resident 3's Status Change Form indicated on 10/09/23, Resident 3 moved rooms.

On 10/11/23, findings were reviewed with and acknowledged by Staff 1.

It was determined the facility failed to ensure residents may not enter a room through another resident's bedroom.

Verbal plan of correction:

Staff 1 will reach out to OPA for following the rules to make room a dual occupancy.  The facility had only one room set up like this.