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 09/19/2022.  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 document review, it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of records. Findings include:

Compliance specialist (CS) reviewed Medication Administration Records (MAR) and progress notes for residents #1-2, policy and procedures regarding falsification of records, and Narcotic logs for July and August 2022. Resident #1 had a medication discontinued in July 2022 (which was not destroyed) and Staff #3 transferred Narc books and started a new entry for the medication. They documented 20 pills when there should have been 27.

The above information was confirmed by Staff #1 on 09/19/22.

In an interview on 09/19/22, Staff #1 stated that there need to be 2 staff members present to transfer narcotic books. Staff #3 was not following policy and procedures. This discrepancy was found when the logs were being audited for another resident ' s missed medications.

Plan of correction:

Full audit of medications and narcotic logs. Retraining for staff on med counts and accurate record keeping. More frequent oversight and auditing of the medication system.

Based on interview, observation, and record review, it was confirmed that the facility failed to prepare and serve food in accordance with the food sanitation rules. Findings include:

Compliance Specialist (CS) observed the kitchen and dining room on 09/19/22. Observed lunch service and did not see any food that looked undercooked or spoiled being served. Food being prepared on clean surfaces. CS observed pictures emailed and pictures from residents '  camera with dates and times of food that was served in the facility. Observations include grapes with brown and yellow spots on them, chicken with a white film and a pink discoloration on them, beef with a very pink color to it, a baked potato with black spots, and beef stroganoff that does not look very appealing to the eye.

CS reviewed food temp logs for 09/17/22-09/19/22 and did not find any discrepancies. Reviewed email dated 9/17/22 from Staff #2 addressing food concerns regarding the pictures received. Staff #2 will address each concern and ensure that employees are serving quality items and not sending out unsatisfactory food to the residents as well as provide additional training.

The above information was shared with Staff #1-2, who acknowledged and agreed that some of the food items did not look appealing or edible.

In interviews with Staff #1-2 on 09/19/22, they stated that they have recently received concerns regarding the food and were provided with emailed pictures of some of the food that was served. They have reminded staff not to serve food that doesn ' t look presentable.

In an interview with Resident #1, they stated that food has been served raw, burnt, and spoiled. There is no follow up from the food meetings.

Plan of correction:

They will discuss food quality at tomorrows meeting, reminders to staff about not serving food that doesn ' t look presentable or isn ' t fresh, continue with the menu chat meetings, and recently switched produce providers.

Based on interview and record review, it was confirmed that the facility failed to ensure adequate professional oversight of the medication and treatment administration system. Findings include:

In review of the facility ' s medication training policy and procedures, Resident #1-2s Medication Administration Records (MAR) and progress notes for August 2022, July and August narcotic logs, and Team member counseling notice dated 08/31/22. Staff #3 received written counseling for missing narcotics on 08/31/22. 2 Staff members were not signing of the med counts and Staff #3 started a new narc book alone, when 2 staff members are suppose to be present.

In an interview on 09/19/22, Staff #1 stated that they did have some narcotics go missing. A resident reported that they did not receive a PRN narcotic that they requested, even though the staff member documented that it was given. The resident is an accurate reporter. Upon further review of the narc logs, it was found that another resident had a narcotic discontinued (which was not destroyed timely) and some of the medications were off on the count. Staff #3 was not following policy and procedures for narcotic counts, documentation of medication administration, or procedures for passing meds.

Plan of correction:

The staff member was suspended for internal investigation and then was let go. Police and APS were notified of the missing narcotics. There was a audit of the narc book, MT meeting this Friday, and staff are to immediately notify the nurse of any discontinued meds so they can be destroyed timely.