The findings of the on-site investigation conducted 09/27/2023 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, 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 09/27/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's Incident report, November 2021 and "Medication Form" dated 11/19/21 stated: "Resident 1 missed [his/her] 2 doses of Lorazepam on 11/19/21 however did receive 3rd does for the day.  Medication was not ordered in a timely manner.  Medication was sent from pharmacy STAT and a delivery driver brought it to the facility.  New process for Narcotic is re-order date will be circled on the card.  When the medication is punched the Med Tech will re-order.  This should be when there is a seven-day supply left of the medication.   Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed.  Abuse and neglect were ruled out."

During an interview, Staff 1 (ED) confirmed s/he Staff 1 had not worked at the facility during the time of incident.  

The findings were reviewed with and acknowledged by Staff 1 (ED) on 09/27/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: New process for Narcotic is re-order date will be circled on the card.  When the medication is punched the Med Tech will re-order.  This should be when there is a seven-day supply left of the medication.   Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed.