The findings of the on-site investigation, conducted 09/19/23 though 09/20/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, conducted during a site visit on 09/19/23 though 09/20/23 it was confirmed the facility failed to obtain background checks on all subject individuals for 1 of 1 sampled staff member (# 2). Findings include, but are not limited to:

A review of Staff 2's (Former CG) ORCHARDS background check notice dated 03/13/23 revealed Staff 2 was not approved for employment.

During interview on 09/19/23, Staff 1 (Executive Director) stated the facility was using a different background check system called (JDP Spell out) prior to staff members employment with the facility. Staff 2 confirmed that Staff 1 was working in the facility until s/he termination. Staff 1 further stated the facility terminated Staff 2's employment when they received the notification that Staff 2 had not passed the appropriate background check.

The findings were reviewed with and acknowledged by Staff 1 on 09/19/23.

The facility failed to obtain background checks on all subject individuals.

Verbal plan of correction: The facility had a new business office manager who is responsible for verifying both pre-employment drug tests and background checks. Newly hired staff will have to clear both before begin pre-service training and orientation. All staff who did not clear ORCHARDS background check were terminated.

Based on record review and interview, conducted during a site visit on 09/19/23 and 09/20/23 it was confirmed the facility failed to fully implement and update an ABST for 1 of 1 sampled residents (# 1). Findings include, but are not limited to:

Resident 1 moved into the facility on 09/18/23 but was not yet included in the facility's ABST on 09/19/23.

In an electronic communication on 09/22/23, Staff 1 (Executive Director) stated "[Resident 1] did not show on the original ABST tool in Memory Care due to being a respite and the report had to be run differently. S/he was our first respite since having the ABST tool. "

The findings were reviewed with and acknowledged by Staff 1 on 09/19/23.

The facility failed to update their ABST.