Print Inspection: V27O

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 03/18/25.  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

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

HS:Hours of sleep

LPN:Licensed Practical Nurse

MT:            Medication Technician or Med 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

SP:Service plan

SPT:Service Planning Team

TAR:Treatment Administration Record

Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to carry out medication orders as prescribed for 1 of 1 sampled resident (# 6) was substantiated. Findings include, but are not limited to:

Resident 6's service plan, dated 05/18/23, indicated the facility provided medication administration.

Resident Occurrence Report, dated 05/23/23, indicated Resident 6 was administered Donepezil 10mg and Melatonin 1mg, which was his/her neighbor's medication. Resident 6 was placed on alert and vitals were taken.

Resident 6's physician orders, dated 05/01/23, indicated Donepezil 10mg was not listed in Resident 6's medication orders.

Resident 6's charting notes, dated 05/25/23, the facility nurse assessed Resident 6 due to the medication error and noted s/he did not appear to have experienced any side effects.

Staff 1 (Executive Director) stated Resident 6 was no longer in the facility.

Resident 6 was no longer in the facility and could not be observed or interviewed.

It was determined the facility's failure to carry out medication orders as prescribed for Resident 6 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (# 1) was substantiated. Findings include, but are not limited to:

The facility's posted staffing plan and schedule was unavailable for the specified time period.

Staff 1 (Executive Director) stated a reasonable call light response time was between five and 12 minutes, and a long call light response time would be 30 minutes or longer.

Resident 1's service plan, dated 08/21/23 indicated s/he was able to use the call system.

The facility used the ODHS acuity-based staffing tool (ABST). The facility's ABST allotted time for call light responses 21 times a week for Resident 1.

Call light records for Resident 1's room, dated 04/01/24 through 04/30/24, indicated approximately 136 call light activations per week, including 59 instances where call light response times were over 30 minutes.

It was determined the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for Resident 1 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1.