Inspection Reports for Miramont Pointe
11520 SE Sunnyside Rd, Clackamas, OR 97015, United States, OR, 97015
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Inspection Report
Complaint Investigation
Census: 149
Capacity: 186
Deficiencies: 41
Oct 30, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2024 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility was found to have numerous deficiencies including staffing shortages, failure to investigate abuse promptly, inadequate medication administration systems, environmental maintenance issues, and failure to comply with licensing and health care rules. Some deficiencies were corrected over time, but several remained uncorrected at the time of the latest inspections.
Complaint Details
Multiple complaint investigations documented including failure to promptly investigate abuse reports, failure to protect residents, and failure to conduct timely investigations of injuries of unknown cause.
Deficiencies (41)
| Description |
|---|
| C0260 - Service Plan: General: Failed to review initial service plan within 30 days of move-in for sampled residents. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient qualified awake direct care staff to meet 24-hour needs; delayed call light responses. |
| C0000 - Comment: Findings of re-licensure and re-visit surveys documented compliance status and regulatory references. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety due to insufficient overnight staffing. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate related to order transcription and changes for sampled residents. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient direct care staff to meet 24-hour needs and two-person assistance requirements. |
| C0361 - Acuity-Based Staffing Tool: Failed to update ABST to specify total minutes required to meet 24-hour resident needs. |
| C0420 - Fire and Life Safety: Safety: Failed to keep written fire drill records with required information and document staff training on alternate months. |
| C0511 - General Building Interior: Failed to ensure handrails installed on one or both sides of resident-use corridors. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair including worn handrails, dust accumulation, missing fixture covers, and exterior damage. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide exit door alarms or acceptable systems to alert staff when residents exited. |
| H1515 - Physical Setting: Individual Accessible: Technical assistance provided regarding physical accessibility of setting. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired and long-term staff completed required pre-service orientation, dementia, and infectious disease training. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0168 - Outside Area: Failed to ensure access to secured outdoor space allowed residents to enter and return without staff assistance. |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure fences were at least six feet high, maintained, and outdoor furniture did not aid elopement. |
| C0010 - Licensing Complaint Investigation: Findings of on-site investigation documented. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate abuse reports and take protective measures for sampled resident. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient staff to meet scheduled and unscheduled resident needs; delayed call light responses. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement an ABST and document staffing plan changes based on resident needs. |
| C0000 - Comment: Findings of kitchen inspection and compliance with food sanitation rules documented. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols complied with Food Sanitation Rules; repeat citation. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied Department. |
| C0000 - Comment: Findings of kitchen inspection documented; compliance status noted. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food preparation, service, storage, and dish machine temperatures met Food Sanitation Rules. |
| Z0142 - Administration Compliance: Failed to follow licensing rules; referred to C240. |
| C0000 - Comment: Findings of kitchen inspection documented; compliance status noted. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food preparation and service met Food Sanitation Rules. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to conduct immediate investigation and report injuries of unknown cause and suspected abuse. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate on-site health services with outside providers for sampled resident. |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances administered for sampled resident. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate residents' ability to self-administer medications quarterly for sampled residents. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied Department. |
| C0510 - General Building Exterior: Failed to maintain exterior pathways in good repair and prevent trip hazards. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain interior and exterior materials and surfaces in clean and good repair. |
| C0515 - Resident Units: Failed to ensure operable windows prevented accidental falls when sill heights were low and above first floor. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure all exit doors had alarms or acceptable alert systems. |
| Z0142 - Administration Compliance: Failed to follow licensing rules; referred to multiple citations including C231, C510, C513, C515, and C555. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referred to C290, C302, and C325. |
| Z0164 - Activities: Failed to evaluate Memory Care Community residents for activities and develop individualized activity plans based on evaluations. |
Report Facts
Inspections on page: 7
Total deficiencies: 37
Licensing violations: 10
Notices: 1
Facility licensed beds: 186
Facility census: 149
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to staffing, abuse investigations, and compliance acknowledgments |
| Staff 2 | Regional Director of Health Services/RN | Named in findings related to staffing, medication administration, and compliance acknowledgments |
| Staff 3 | Director of Nursing/RN or Quality Coordinator | Named in findings related to medication administration, staffing, and compliance acknowledgments |
| Staff 4 | Caregiver or RCC | Named in findings related to call light response and abuse reporting |
| Staff 5 | LPN or RCC | Named in findings related to abuse reporting and activity planning |
| Staff 6 | Medication Technician or Maintenance Director | Named in findings related to medication administration and facility maintenance |
| Staff 7 | Activity Assistant | Named in findings related to activity evaluations |
| Staff 8 | Maintenance Director | Named in findings related to facility maintenance and safety |
| Staff 9 | CG (Caregiver) | Named in findings related to staff training |
| Staff 11 | MT (Medication Technician) | Named in findings related to staff training |
| Staff 12 | CG (Caregiver) and Administrator in one finding | Named in findings related to service plan and staffing deficiencies |
| Staff 19 | Resident Care Coordinator | Named in findings related to staff training |
| Staff 21 | Quality Coordinator | Named in findings related to medication administration and staff training |
| Staff 22 | Housekeeping Assistant | Named in findings related to staff training |
| Staff 23 | Maintenance Assistant | Named in findings related to fire and life safety |
| Staff 24 | Assistant Chef | Named in findings related to staff training |
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