Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 9/22/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
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 it was confirmed the facility failed to have service plans readily available to staff and provide clear direction regarding the delivery of services. Findings include:
In separate interviews on 9/22/2022, both Staff #1 and #3 (S1 and S3) stated Service Plans are located in Service Plan Binders. S1 stated there is a nursing team working on updating service plans since many of them were not updated quarterly.
Record review on 9/22/2022 of the service plan binders shows 7 service plans not readily available or located in the binder.
Facility Plan of Correction: Verbal POC: The facility has a nursing team working on updating all residents service plans and will be putting them into binders for all staff to be able to access when on duty.
Based on interview and record review it was confirmed the facility failed to orient direct care staff to the resident including the resident's service plan. Findings Include:
During onsite interview on 9/22/2022 Staff #3 (S3) stated there was a staff member who fed Resident #1 (R1) donuts and other solid foods because it calmed R1 down.
Record review on 9/22/2022 of R1 Service Plan indicates s/he is to have a pureed diet and no solid foods due to possible choking.
Facility Plan of Correction: Retraining of staff to insure they look at the MARs/ residents needs and the food menus for the residents before administering food to a resident to make sure every staff is aware of their needs and preferences.