Print Inspection: PE47

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 10/10/2022.  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 facility record review it was determined the facility failed to carry out medication orders as prescribed. Findings include, but is not limited to:

On 10/10/2022, interview with Staff #1 (S1) wh reported with review that a medication error did occur on 9/16/2022. A resident was given the wrong dose of a scheduled medication.

Facility incidents reports for dates of 09/16/2022-10/03/2021 reviewed on 10/10/2022 by CS revealed the following:

 *On 9/19/2021, R1 received wrong dose of medication. The error was found on 9/20/2021 and family and medical doctor were notified. An internal investigation was completed and no adverse effects regarding wrong dosage given were found.  R1 was to receive 1 mg of her/his medication but received a 2 mg dosage.

Facility Plan Of Correction:

Resident and family were notified on 9/20/2022. Discussion with Medication aide regarding med error and process for triple checking each medication to prevent errors.

Based on interview and observations it was confirmed that facility failed to keep all equipment in good repair. Findings include, but is not limited to:

Separate interviews held on 10/10/2022 with Staff #1-2 (S1-S2) who reported that the facility had "a massive water leak", causing the sub floor and flooring needing to be replaced.

During unannounced site visit on 10/10/2022, observations by Compliance Specialist (CS) included the following:

 * New carpet is in the halls. The flooring in the dining room area is currently in the process of being replaced. There was a section of floor removed and there were no base boards in dining room area.

On 10/10/2022, Findings reviewed with and acknowledged with S2.

Facility Plan Of Correction:

S1 reports that the small section of flooring remaining has been ordered and once it arrives will be installed. S1 reported there have been delays with shipments and workers to provide the install. Repairs are expected in 30 days.

Based on interview and observations it was confirmed that facility failed to keep all equipment in good repair. Findings include, but is not limited to:

Separate interviews held on 10/10/2022, with Staff #1-2 (S1-S2) reported the following:

 *S1 that the call light system has some rooms that resident have removed them or were not working properly and is currently being fixed. Staff have walkie talkies to communicate to each other and facility has increased resident checks on the rooms that are currently having call light issues.

  *S2 reported entire system was down and the facility is in the process of having entire system replaced.

On 10/101/2022, findings were reviewed with and acknowledged with S2.

Facility Plan Of Correction:

Administrator reports that the system repairs are to be completed by 10/14/2022. All needed parts facility had in house and will be replacing some batteries.