The findings of the on-site investigation conducted 10/31/23 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, 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 10/31/23, 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 10/31/23, it was found there were 20 residents listed on the roster and only 19 residents were entered into the ABST.

In an interview on 10/31/23, Staff 1 (ED) stated the current census was 20 residents. S/he also stated they had not updated the ABST in the past 30 days.  The last move in was 10/23/23, the last move out 10/29/23, and last service plan update was 10/23/23.

On 10/31/23, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.