Print Inspection: LY13

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 01/04/2023.  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 is not providing medication and treatment records to off-site providers. Findings include:

Review of sample resident records on 01/04/23 indicate that residents on off-site services, have information on procedures, treatments and out-comes related to off-site services that are prescribed or recommended.

In an interview on 01/04/23 with Staff #1 (S1) it was stated that resident records are provided to relevant off-site providers. Records shared include Service Plans, MAR, Chart notes, BSS plans and other information that may be requested. S1 was aware of a couple of agencies that were not getting records that had been requested.

In an interview on 01/04/23 Witness 1-2, (W1-2) state that they have needed records on residents for evaluations and programs and have waited weeks for requested documents, visiting the facility many times and several emails to facility for requested records.

POC:

S1 stated that the RCC is no longer employed at the facility and that they will be reviewing the rule during their All Staff meeting on 01-10-23 to make all employees aware of the rule.