Inspection Report
Capacity: 75
Deficiencies: 17
Jul 16, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-01 to 2024-07 with deficiency history and enforcement violations.
Findings
Across all inspections, the facility exhibited multiple deficiencies related to kitchen sanitation, resident service plans, medication administration, staffing training, fire and life safety, building maintenance, and call systems. Several deficiencies were corrected upon revisit, while others remained uncorrected as of the latest inspections.
Deficiencies (17)
| Description |
|---|
| C0000 - Comment: Findings of kitchen inspections documenting compliance and non-compliance with OARs 411-054-0030 and OARs 333-150-0000. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen cleanliness and proper food sanitation practices including cleaning of walls, vents, equipment, and use of hair/beard restraints by staff. |
| C0260 - Service Plan: General: Service plans were not reflective of residents' current care needs or did not provide clear direction to staff for multiple residents. |
| C0270 - Change of Condition and Monitoring: Failed to monitor short-term changes of condition with weekly progress notes until resolution for sampled residents. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and adequate professional oversight including lack of policy for medication administration times. |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances administered to a resident, with discrepancies between MAR and disposition logs. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed, including failure to notify prescriber and incorrect medication administration. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician/practitioner of medication refusals as ordered for sampled residents. |
| C0310 - Systems: Medication Administration: MARs lacked resident-specific parameters for PRN medications and had missing initials of medication aides. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate a resident's ability to safely self-administer medications. |
| C0361 - Acuity-Based Staffing Tool: Failed to update the Acuity-Based Staffing Tool quarterly and following significant changes of condition. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff demonstrated satisfactory performance within 30 days of hire. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure long-term staff completed required annual in-service training hours. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and document all required components. |
| C0610 - General Building Exterior: Failed to maintain exterior surfaces and pathways in good repair, presenting tripping hazards. |
| C0655 - Call System: Failed to ensure exit doors were equipped with operational alarms or systems to alert staff when residents exited. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure kitchen inspection survey plan of correction was implemented and satisfied the Department. |
Report Facts
Inspections on page: 3
Total deficiencies: 17
Total surveys: 3
Licensing violations: 15
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple findings related to service plans, medication administration, training, and fire safety |
| Staff 2 | Licensed Practical Nurse (LPN) | Named in multiple findings related to medication administration, monitoring, and refusals |
| Staff 5 | Chief Operating Officer | Named in multiple findings related to service plans, medication systems, and training |
| Staff 4 | Maintenance Director | Named in findings related to building maintenance and fire drills |
| Staff 3 | Registered Nurse (RN) | Named in monitoring changes of condition finding |
| Staff 8 | Medication Aide (MA) | Named in training deficiency |
| Staff 9 | Caregiver (CG) | Named in training deficiency |
| Staff 12 | Medication Aide (MA) | Named in training deficiency |
| Staff 6 | Medication Aide (MA) | Named in annual inservice training deficiency |
| Staff 10 | Medication Aide (MA) | Named in annual inservice training deficiency |
| Staff 13 | Caregiver (CG) | Named in annual inservice training deficiency |
| Staff 15 | Activities | Named in annual inservice training deficiency |
| Staff 2 | Food Service Director | Named in kitchen sanitation findings |
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