Print Inspection: H80F

The findings of the on-site investigation, conducted 05/05/25, 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

Based on interview and record review, conducted during a site visit on 05/05/25, the facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to:  

A review of the current resident roster and an interview with Staff 5 (Resident Services Director) and Staff 6 (Resident Services Director) determined that Resident 2 no longer resided at the facility.

Between 07/01/23 and 09/28/23, Incident Reports indicated that Resident 2 had 15 injury falls. There was no documented evidence that the facility notified the Department for 14 out of the 15 injury falls.

In an interview Staff 1 (Executive Director) stated that they were not aware that every fall with injury needed to be reported to the Department.

The facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated. An investigation determined that the licensing violation occurred.

The findings were reviewed with and acknowledge by Staff 1 (Executive Director), Staff 2 (Wellness Specialist, LPN), Staff 3 (Regional Wellness Director), Staff 4 (LPN) on 05/05/25.