Inspection Details: 3NHT


Date
4/12/2023
Event ID
3NHT
Inspection type(s)
Licensure Complaint
Deficiencies cited
3

Citation Details

C0010
Severity Level: 2
Visits: 1
Scope
Isolated/Minimal harm or potential for moderate harm
Visit Number
1
Visit Date
4/12/2023
Corrected Date
N/A
Details

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 04/12/2023.  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


























































































































































































C0303
Severity Level: 2
Visits: 1
Scope
Isolated/Minimal harm or potential for moderate harm
Visit Number
1
Visit Date
4/12/2023
Corrected Date
N/A
Details

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include:

Review of Residents 1(R1) medication administration records (MARs) and progress notes for March 2023 revealed medication not given medication not available.  

Review of Medication Management Policy.

Interviews on 04/12/2023, Staff 1-3 stated there was concerns in March 2023 around medication being available due to reordering of medications.  

Plan of Correction:

Facility has hired a Nurse Consultant to review MARs, update procedures, and train staff.

C0361
Severity Level: 2
Visits: 1
Scope
Widespread/Minimal harm or potential for moderate harm
Visit Number
1
Visit Date
4/12/2023
Corrected Date
N/A
Details

Based on interview and record review it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:


During an interview on 04/12/2023 with Staff #1(S1) stated have not  updated the ABST.  Current census is 59.  The ABST has 50 residents listed.  S1 been working with ODHS to get staff access to the ABST.  


Review of ABST revealed 50 residents listed.  Review of resident census revealed 59 residents.