Print Inspection: EX1F

The findings of the on-site investigation, conducted 07/10/23 and 07/13/23, 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, OARs 411 Division 57 for Memory Care Communities.

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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, during a site visit conducted on 07/10/23 and 07/13/23, it was confirmed the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Findings include, but not limited to:

During an interview on 07/13/23, Staff 1 (Executive Director) stated, "Before I was the ED there was a staff member who did smoke marijuana outside the property on their break and came back to the facility to provided services to residents. No repercussions were given to the staff member for this however, the staff member was later terminated for other reasons. The facility did not follow their policy on drug use at the facility."  

A review of the facility's policy and procedure signed by all staff members when hired stated the following, "The company has adapted an alcohol and drug-free work site policy. Our policy prohibits the use, sale, distribution, manufacture, or possession of alcohol or drugs, paraphernalia, and the unauthorized use of prescription drugs. This policy forbids reporting to work or working while under the influence of alcohol or drugs. Any violation of this policy will result in disciplinary action, up to and including termination."

It was confirmed the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties.

On 07/13/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will follow the facility's policy and procedure.