The findings of the on-site investigation, conducted 08/19/24 through 08/20/24, 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 observation, interview, and record review, conducted during a site visit on 08/19/24 and 08/20/24, the facility's failure to carry out treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

Resident 1's physician orders, dated 05/23/24, indicated "[Resident 1] may use whirlpool bath as needed to treat chronic shoulder pain."

During an interview on 08/19/24, Staff 1 (Executive Director) stated the whirlpool bath was broken, but was in the process of being fixed.

During an interview on 08/19/24, Staff 4 (Director of Health Services) stated the whirlpool was not available right now, and Resident 1 had a physician order to use the whirlpool bath.

During an interview on 08/20/24, Staff 6 (Resident Care Coordinator) stated the facility had not offered alternatives for the whirlpool bath that s/he was aware of.

On 08/20/24, At approximately 11:50 am, Staff 5 (Maintenance Director) was observed turning on the whirlpool bath. The lights on the machine lit up, but the tub did not fill. Staff 5 examined the whirlpool bath controls further and said it was "locked out," and s/he was unable to operate the whirlpool.

During an interview on 08/20/24, Resident 1 stated:

-S/He had a physician order for the whirlpool;

-Resident 1 had needed to use the whirlpool for shoulder pain, but hadn't had access; and

-The facility had not offered an alternative or options.

It was determined the facility failed to carry out treatment orders as prescribed for Resident 1.

Findings were reviewed with Staff 1 (Executive Director) on 10/18/24.

Verbal plan of correction: The facility had scheduled a technician to assess and repair the whirlpool on 08/22/24.