Inspection Reports for The Springs at Happy Valley
13160 SE 172nd Ave, Happy Valley, OR 97086, United States, OR, 97086
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Inspection Report
Original Licensing
Capacity: 92
Deficiencies: 15
Sep 26, 2024
Visit Reason
State-compiled facility profile showing 2 inspections from 2023-11 to 2024-09 with deficiency history
Findings
The facility underwent an initial licensure survey and a prior state licensure inspection. Multiple deficiencies were identified across inspections, including failures in fire and life safety, medication administration, resident evaluations, service plans, change of condition monitoring, and controlled substance tracking. Some deficiencies were corrected over time, with the most recent inspection indicating substantial compliance.
Deficiencies (15)
| Description |
|---|
| C0000 - Comment: Initial licensure survey findings including failure to comply with OAR 411-054-0090 (1-2) Fire and Life Safety with immediate plan of correction. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failure to promptly investigate injuries of unknown cause and controlled substance documentation discrepancies, and failure to report incidents to local SPD office. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failure to ensure evaluations described resident's physical and mental status and environmental factors relevant to current needs for 3 of 5 sampled residents. |
| C0260 - Service Plan: General: Failure to ensure service plans reflected residents' needs and provided clear direction for staff for 5 of 5 sampled residents. |
| C0270 - Change of Condition and Monitoring: Failure to monitor short-term changes and significant changes of condition with resident-specific directions and documentation for 3 of 5 sampled residents. |
| C0280 - Resident Health Services: Failure to ensure RN assessed significant changes of condition timely and documented findings and interventions for multiple residents; repeat citations noted. |
| C0301 - Systems: Medication Administration: Failure to ensure staff who administered medication observed resident take medication and documented properly for 2 sampled residents. |
| C0302 - Systems: Tracking Control Substances: Failure to have a system for tracking controlled substances administered by the facility for sampled residents; discrepancies between MAR and Controlled Substance Distribution Log. |
| C0303 - Systems: Treatment Orders: Failure to ensure signed physician orders for all medications and treatments were documented and carried out as prescribed for multiple residents; repeat citations noted. |
| C0305 - Systems: Resident Right to Refuse: Failure to notify physician/practitioner when residents refused medications or treatments for sampled residents; repeat citations noted. |
| C0310 - Systems: Medication Administration: Failure to ensure MARs were accurate and included resident-specific parameters for PRN medications for sampled residents. |
| C0361 - Acuity-Based Staffing Tool: Failure to update acuity-based staffing tool before resident move-in; residents missing from tool. |
| C0420 - Fire and Life Safety: Safety: Failure to conduct fire drills per Oregon Fire Code, provide life safety instruction on alternate months, and have evacuation plans for residents unable to use stairs; immediate jeopardy abated. |
| C0422 - Fire and Life Safety: Training For Residents: Failure to ensure residents received fire and life safety procedures within 24 hours of admission. |
| C0455 - Inspections and Investigation: Insp Interval: Failure to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
Report Facts
Inspections on page: 2
Total deficiencies: 14
Total licensed beds: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to fire safety, medication administration, and resident care |
| Staff 2 | Health Services Administrator | Named in multiple findings related to abuse reporting, medication administration, resident evaluations, and fire safety |
| Staff 6 | Director of Health Services, RN | Named in findings related to controlled substance discrepancies, resident health services, and medication administration |
| Staff 7 | Assistant Director of Health Services, RN | Named in findings related to resident health services and medication administration |
| Staff 10 | Resident Services Coordinator | Named in findings related to fire safety and resident service plans |
| Staff 11 | Resident Services Coordinator | Named in findings related to fire safety and resident service plans |
| Staff 35 | RN Quality Support | Named in findings related to medication administration and physician order compliance |
| Staff 36 | Regional RN | Named in findings related to resident health services and RN assessments |
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