The findings of the on-site investigation, conducted 04/02/24, 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 04/02/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:
A review of the facility's Census Room List, dated 03/29/24, indicated the facility is home to 51 residents.
A review of the facility's ABST indicated there were 52 current residents. Sunny Lane residents indicated seven of the 11 entered residents were not updated within the last 90 days for quarterly review, and one resident was last updated as of 07/2022.
In an interview on 04/12/24 via over the telephone, Staff 1 (ED) confirmed s/he did not set up the tool and was unaware all residents needed to be updated quarterly.
The above information was shared with Staff 1 on 04/12/24 via over the telephone. S/he acknowledged the findings.
It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool.
The findings of the on-site investigation, conducted 04/02/24, 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