Print Inspection: 4BR1

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 02/01/22.  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, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to investigate and report an injury of unknown cause for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

An incident report, dated 12/14/23, indicated Resident 6 had an unwitnessed fall with injury and was unable to tell staff what had happened.

During an interview on 01/25/24, Staff 1 (Executive Director) stated the incident report "was recently found in the RN's desk" and the incident should have been reported to APS.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.

It was determined the facility failed to investigate and report an injury of unknown cause.

Verbal plan of correction: All incidents will be reviewed by RN and ED at daily clinical meetings. Staff will be trained on 1/31/24 to complete incident reports timely. Facility was in the process of reporting the incident to APS on 01/25/23.

Based on interview and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to ensure a resident receives regular bathing assistance for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

During an interview on 01/24/24, Resident 4 s/he had to "beg for showers on scheduled shower days."

Resident 4's service plan, dated 01/25/24, indicated "Staff will provide standby assist for showers twice a week."

A review of the facility's "Caregiver Daily Assignment Sheet" and "Shower Review" sheets, dated 01/09/24 through 01/24/24, indicated Resident 4 had not received a shower from 01/14/24 through 01/23/24.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.

It was determined the facility failed to ensure a resident receives regular bathing assistance.

Verbal plan of correction: Beginning 01/31/23, facility will be including shower sheets to clinical meeting.

Based on observation, interview, and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to follow physician orders as prescribed for 2 of 2 sampled residents (#s 3 and 5). Findings include, but are not limited to:

Resident 3's MAR, dated 10/01/23 through 10/31/23, indicated the following:

*Atorvastatin 40mg (heart medication) and Losartan 100mg (hypertensive) were not administered 10/01/23 through 10/04/23. Notes indicated the facility was "waiting for medication from the pharmacy;"

*Amlodipine 5mg (blood pressure) was not administered 10/14/23 through 10/17/23. Notes indicated the facility was "waiting for medication from the pharmacy;" and

*Donepezil 5mg (dementia) was not administered 10/27/23 through 10/30/23. Notes indicated "meds unavailable."

There was no documented evidence Resident 3's Atorvastatin, Losartan, Amlodipine, or Donepezil had been discontinued by a physician for any length of time in 10/2023.

During an interview on 01/25/24, Resident 5 stated s/he was supposed to receive his/her Carbidopa/Levo 25-100mg (Parkinsons medication) late, and that if s/he did not receive it on time his/her body would begin to "lock up".

Physicians order for Resident 5, dated 08/16/23, indicated s/he was to receive Carbidopa/Levo 25-100mg every two hours beginning at 8:00 am.

On 01/25/24, Resident 5 was observed to have his/her 10:00 am dose of Carbidopa/Levo 25-100mg administered at approximately 10:37 am.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.

It was determined the facility failed to follow physician orders as prescribed.