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 10/13/2022.  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 follow their policies and procedures to assure the prevention and appropriate response to any incident. Findings include:

Compliance Specialist (CS) reviewed the facility's policies on fall management and incident/accident management, along with Resident #1s incident reports and progress notes for January-March 2022. Policy states that there should be an incident report completed for all falls, however, there were 2 falls that were documented on 01/31/22 and 02/22/22 in the progress notes but did not have an incident report filled out.

The above information was shared with Staff #1-2 on 10/14/22 via email.

In interviews with Staff #1-3 on 10/13/22, they all stated that incident reports should be filled out for any fall.

Plan of correction:

The facility has had multiple med aid meetings, there is a new wellness team, they have been changing programs and procedures so there has been a lot of training around incident reports and a check list was recently created.

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include:

CS reviewed Resident #1s medication administration records (MARs) and Alleged Abuse Investigation Summary for an incident on 10/03/22. Resident #1 was given a medication at 7:50pm, reported to another staff member that it was not given, and it was given a 2nd time in error at 8:15pm by another staff member. Staff did not follow the facility ' s medication administration and documentation policy and procedures which resulted in a medication error.

The above information was shared with Staff #1-2, who acknowledged the findings.

In interviews on 10/13/22, Staff #1-2 stated that the incident did occur. Staff #3 stated that medications should be documented when they are given and the MAR should be checked before giving a medication.

Plan of Correction:

In-service training to remind staff of the medication popping procedure and reminding staff to keep their med carts locked at all times. Also reminding med techs that they are not to administer medications from another medication cart that they are not assigned to.