Inspection Reports for Cedar Crest Alzheimer’s Special Care Center
OR, 97062
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Inspection Report
Capacity: 56
Deficiencies: 22
May 28, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2021 to 2024 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2024, the facility exhibited numerous deficiencies including failures in resident service plans, medication administration, change of condition monitoring, supportive device assessments, and environmental maintenance. Some deficiencies were corrected over time, while others were repeated or ongoing.
Complaint Details
Includes complaint investigations from 2021 with findings related to service plans, staffing, and change of condition monitoring.
Deficiencies (22)
| Description |
|---|
| C0000 - Comment: Findings of kitchen inspections documented with issues noted in cleanliness and compliance with food sanitation rules. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen cleanliness and proper food sanitation practices including glove use and hand hygiene. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure resident evaluation was complete and documented for assistive device use. |
| C0260 - Service Plan: General: Service plans were not reflective of residents' current needs or updated after significant changes. |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor actions or interventions following residents' changes of condition. |
| C0280 - Resident Health Services: Failed to complete timely RN assessments for significant changes of condition. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and professional oversight. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed and documented. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when residents refused medication or treatment orders. |
| C0310 - Systems: Medication Administration: Medication administration records lacked reasons for use and clear instructions for PRN medications. |
| C0315 - Systems: Treatment Administration: Failed to maintain accurate treatment administration records for wound care treatments. |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to administering PRN psychotropic medications and lacked resident-specific parameters. |
| C0340 - Restraints and Supportive Devices: Failed to assess, document, and instruct staff on use of supportive devices with restraining qualities. |
| C0420 - Fire and Life Safety: Safety: Fire drill records lacked required components and fire safety training was not provided on alternate months. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to implement and satisfy plan of correction for re-licensure survey. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair; pervasive odors noted. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans for residents. |
| Z0164 - Activities: Failed to evaluate residents for activities and develop individualized activity plans. |
| Z0165 - Behavior: Failed to develop individualized behavior plans for residents with challenging behaviors. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have qualified awake direct care staff sufficient to meet residents' needs. |
Report Facts
Inspections on page: 5
Total deficiencies: 26
Total surveys: 5
Licensing violations: 10
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| YVONNE ALEXANDER | Administrator | Named in relation to multiple findings and plans of correction |
| Staff 1 | Executive Director | Named in multiple inspection findings and interviews |
| Staff 2 | Health Services Director - LPN | Named in multiple inspection findings and interviews |
| Staff 3 | Resident Care Coordinator (RCC) | Named in multiple inspection findings and interviews |
| Staff 4 | Maintenance Director | Named in fire and life safety and environmental maintenance findings |
| Staff 16 | RN | Named in relation to RN assessment findings |
| Staff 18 | Activities Director | Named in activities evaluation findings |
| Staff 19 | Resident Care Coordinator (RCC) | Named in psychotropic medication and behavior plan findings |
| Staff 21 | Charge Nurse | Named in behavior and other findings |
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