Print Inspection: F7W5

The findings of the on-site investigation, conducted 09/01/2023, 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.

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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, conducted during a site visit on 09/01/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

On 09/01/23, the facility's ABST was reviewed. There were 13 resident's profiles, out of 18 residents, that had not been updated quarterly.

In an interview on 09/01/23, Staff 1 (Executive Director) stated the facility was using the ODHS ABST. Staff 1 stated, "We have 12 hour shifts and only have Day and NOC shift with one MT and three CG that work both shifts."

The facility failed to update an acuity-based staffing tool.

On 09/01/23, the findings were reviewed with and acknowledged by Staff 1.