The findings of the on-site investigation, conducted 07/20/23 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 interview and record review, conducted during a site visit on 07/20/23, 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 not limited to:

Resident 1's signed physicians orders, April 2023 Medication Administration Record (MAR), and April 2023 progress notes, indicated that on 04/16/23, Resident 1 missed his/her 11:00 am dose of Furosemide 20 mg tablet. Progress note dated 04/17/23 reported  "awaiting refills from provider."

During an interview, Staff 1 (Executive Director) stated medications should have been refilled one week prior to running out on the "blue cards", if they were not on cycle fill. S/he stated the facility was waiting on orders and the medication was not given.

The findings were reviewed with and acknowledged by Staff 1 on 07/20/23.

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

Verbal plan of correction: Starting in May 2023 the RN did education with staff regarding med passes, orders, documentation, and re-ordering timely. They are monitoring the Yardi system daily (clinicians and administration) after their stand-up meetings. Continuous med training ongoing, and they have hired 2 new LPNs.