Inspection Reports for Monterey Court Memory Care
8915 SE Monterey Avenue, Happy Valley, OR 97086, OR, 97086
Back to Facility Profile
Inspection Report
Complaint Investigation
Capacity: 48
Deficiencies: 43
May 6, 2024
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2024 with deficiency history and licensing violations.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failure to maintain accurate resident records, medication administration errors, inadequate infection control, insufficient staffing, and failure to implement effective behavior and safety plans. Several deficiencies were repeated and some posed immediate threats to resident health and safety.
Complaint Details
Complaint investigations were conducted on 1/24/2023 and 5/6/2024 related to licensure complaints and medication administration issues.
Deficiencies (43)
| Description |
|---|
| C0155 - Facility Administration: Records: Failed to ensure preparation, completeness, accuracy of resident records for 1 sampled resident. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed for 1 sampled resident. |
| C0410 - Medicaid Personal Incidental Funds: Failed to have accounting records for handling residents' personal incidental funds for 3 sampled residents. |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were posted in accessible and conspicuous locations. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety, including elopement risks. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to conduct investigations and report injuries of unknown cause as suspected abuse for multiple residents. |
| C0243 - Resident Services: ADLs: Failed to provide assistance with activities of daily living for sampled and unsampled residents. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required components for 1 sampled resident. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs and provided clear service descriptions for multiple residents. |
| C0270 - Change of Condition and Monitoring: Failed to ensure short-term changes of condition were identified, interventions developed, and monitored for multiple residents. |
| C0280 - Resident Health Services: Failed to ensure RN conducted significant change of condition assessments for sampled residents. |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks in accordance with OSBN rules for sampled residents. |
| C0295 - Infection Prevention & Control: Failed to establish and maintain effective infection prevention and control protocols for sampled resident. |
| C0301 - Systems: Medication Administration: Failed to ensure medications were set-up and documented by the same person who administered them for multiple residents. |
| C0310 - Systems: Medication Administration: Failed to ensure resident-specific parameters for PRN pain medications on MAR for 1 sampled resident. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and documented non-drug interventions prior to administration. |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulations. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills 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. |
| C0510 - General Building Exterior: Failed to ensure outside surfaces were maintained in good repair. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure interior and exterior materials were kept clean, in good repair, and free from unpleasant odors. |
| C0540 - Heating and Ventilation: Failed to ensure wall heaters did not exceed 120 degrees Fahrenheit in locations subject to incidental contact. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure call system connected resident units to care staff center or staff pagers. |
| H1518 - Individual Door Locks: Key Access: Failed to ensure only resident and appropriate staff had key access to resident's unit. |
| Z0142 - Administration Compliance: Failed to follow licensing rules and provide non-health care services in accordance with licensing rules. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service orientation training and demonstrated satisfactory performance. |
| Z0162 - Compliance With Rules Health Care: Failed to follow licensing rules for Residential Care and Assisted Living Facilities and provide health care services accordingly. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans for sampled residents. |
| Z0165 - Behavior: Failed to evaluate behavioral symptoms, update service plans, and develop individualized behavior plans for sampled residents. |
| Z0168 - Outside Area: Failed to provide access to secured outdoor space allowing residents to enter and return without staff assistance. |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure outdoor furniture was of sufficient weight and design to prevent aiding elopement. |
| Z0176 - Resident Rooms: Failed to ensure residents were not locked out of or inside their rooms at any time. |
| C0010 - Licensing Complaint Investigation: Facility must operate in compliance with applicable laws and regulations. |
| C0152 - Facility Administration: Required Postings: Failed to have staffing plan posted. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate reports of abuse and suspected abuse. |
| C0243 - Resident Services: ADLs: Failed to assist resident with toileting and bowel/bladder management. |
| C0260 - Service Plan: General: Failed to complete quarterly service plans and provide care as listed in service plan. |
| C0303 - Systems: Treatment Orders: Medication administration delays and errors due to staffing and documentation issues. |
| C0310 - Systems: Medication Administration: Failed to keep accurate MAR. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient direct care staff to meet resident needs and failed to use Acuity-Based Staffing Tool. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement Acuity-Based Staffing Tool. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed (2021 complaint). |
Report Facts
Inspections on page: 6
Total deficiencies: 43
Licensing violations: 10
Notices: 7
Total licensed beds: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jewell White | Administrator | Named as Executive Director in multiple findings and acknowledgements |
| Staff 1 | Executive Director | Named in multiple findings and acknowledgements related to administration and compliance |
| Staff 2 | Health Service Director/RN | Named in findings related to medication errors, abuse investigations, and health services |
| Staff 3 | Resident Care Coordinator (RCC) | Named in findings related to service plans and medication administration |
| Staff 6 | Environmental Services Director | Named in findings related to building maintenance and fire safety |
| Staff 9 | Medication Technician (MT) | Named in call system and resident supervision findings |
| Staff 14 | Caregiver (CG) | Named in infection control and behavior findings |
| Staff 18 | Caregiver/Medication Technician (CG/MT) | Named in medication administration and resident room locking findings |
| Staff 25 | Executive Director | Named in findings and acknowledgements from 2024 inspections |
| Staff 26 | RN/Health Services Director | Named in findings and acknowledgements from 2024 inspections |
Loading inspection reports...
