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 12/14/2022.  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 that the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include:

In interviews on 12/14/22, Staff #1 stated that they are usually pretty good about reporting to APS. Staff should be documenting on the incident report when it is reported to APS.

In review of the facility's policy and procedures for reporting to APS and an incident report dated 10/27/22 for Resident #2, there was no evidence to show that the information was actually reported to APS. Per policy, the administrator is responsible for notifying APS. No email verification was found. There is a note on the incident report that states "reporting incident to APS for further investigation"  however, there is no date or time reported that this was completed. APS did have a report, however, it did not come from the facility.

The above information was shared with Staff #1 on 12/14/22, who was in agreement.

Plan of correction:

Re-training to staff regarding APS reporting requirements and what information needs to be provided. Training on incident report documentation.