Inspection Report
Complaint Investigation
Capacity: 78
Deficiencies: 18
Aug 19, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-07 to 2024-08 with deficiency history and enforcement/licensing violations.
Findings
Across all inspections, the facility demonstrated multiple deficiencies including failure to carry out treatment and medication orders as prescribed, inadequate staffing and training, insufficient communication skills among staff, incomplete resident evaluations and service plans, and issues with facility cleanliness and maintenance. Some deficiencies were corrected over time, while others remained uncorrected at last visits.
Complaint Details
The complaint investigation conducted on 2024-08-19 through 2024-08-20 documented findings related to failure to carry out treatment orders and other compliance issues under OARs 411 Division 54 for Residential Care and Assisted Living Facilities.
Deficiencies (18)
| Description |
|---|
| C0010 - Licensing Complaint Investigation: Findings documented from on-site investigation for compliance with OARs 411 Division 54. |
| C0303 - Systems: Treatment Orders: Failure to carry out treatment orders as prescribed for Resident 1; whirlpool bath not available and no alternatives offered. |
| C0000 - Comment: Findings from kitchen inspection and revisit regarding compliance with OARs 411-054-0030 and Food Sanitation Rules OARs 333-150-0000. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Kitchen cleanliness issues including buildup of black matter and food debris on multiple surfaces and equipment. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide qualified awake direct care staff sufficient in number to meet 24-hour needs. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure staff have sufficient communication and language skills, including ASL proficiency. |
| C0000 - Comment: Findings from re-licensure survey and revisits regarding compliance with OARs 411 Division 54 and 004. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure resident move-in evaluations addressed all required components for Resident 4. |
| C0260 - Service Plan: General: Service plans not reflective of resident care needs or clear instructions for Residents 4 and 5. |
| C0270 - Change of Condition and Monitoring: Failed to ensure resident specific instructions/interventions for short-term changes of condition were developed, communicated, and monitored for Resident 4. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed for Residents 4, 7, and 8 including medication errors and unadministered orders. |
| C0310 - Systems: Medication Administration: MARs lacked resident-specific parameters and clear instructions for PRN medications for Residents 3, 4, and 5. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure non-pharmacological interventions were attempted and documented prior to PRN psychotropic medication administration for Resident 4. |
| C0340 - Restraints and Supportive Devices: Failed to ensure quarterly assessment for assistive devices with restraining qualities for Resident 5. |
| C0361 - Acuity-Based Staffing Tool: Failed to ensure resident entries were reflective of care needs and updated quarterly for Residents 3, 4, and 5. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills were conducted and documented according to Oregon Fire Code requirements. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to ensure all interior materials and surfaces were kept clean and in good repair with multiple areas needing cleaning or repair. |
Report Facts
Inspections on page: 4
Total deficiencies: 15
Total surveys: 4
Total licensing violations: 10
Notices: 1
Licensed beds: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Rickard | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 2 | RN | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 3 | LPN | Named in medication order findings |
| Staff 4 | Agency RA | Named in communication deficiency findings |
| Staff 5 | Maintenance Director | Named in whirlpool bath and fire drill findings |
| Staff 6 | Resident Care Coordinator | Named in whirlpool bath findings |
| Staff 8 | Maintenance Director | Named in fire drill and building maintenance findings |
| Staff 12 | Medication Technician | Named in medication administration and psychotropic medication findings |
| Staff 22 | Medication Technician | Named in compression stocking order findings |
| Staff 24 | Caregiver | Named in compression stocking order findings |
| Staff 25 | Regional Nurse Consultant | Named in compression stocking order findings |
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