Complaint #AR00024019 unsubstantiated.
PRLU or OLTC
OLTC Complaint Suvey
PRLU or OLTC
Visit Compliance Report
- Viewed all areas accessible to residents; Staff/child ratio met in all areas.
- Regs out of compliance –
- R1011.7 – Lights not working in some West unit bedrooms (corrected on site due to thrown breaker from remodeling repairs in progress). Two bunk beds need sanded on rails where rough wood is showing.
- R911.15.f – Shorts/jeans with pull ties were observed in the East unit (Correction date 12/13/19).
- TA –
- Epoxy removed in progress of bathroom. Wood wall treatment being installed in North dayroom and hallway. Sheet rock repair in progress in two of the dayrooms. Fence update (removing all metal fencing) is expected to begin 1/2020. Paper darts (2) need to be removed in ceiling vent in cafeteria.
PRLU or OLTC
Licensing Compliance Record
- Regs out of compliance –
- 1011.7 – Ceiling tile in admin area needs replaced in CL2. Small section with peeling paint in CL3. In kitchen area, clean food compartment areas, vacuum rugs. In South unit, laundry room wall should be cleaned. In East unit, hole in sheetrock by room 2 and floor needs cleaned in bathroom. In North unit, a rough spot needs sanded on cabinet in bathroom. In West unit, room 6 has piece of trim missing and sheetrock needed in hallway due to hole (Compliance date 12/30/19).
- 1012.4 – In South unit, room 5 paint is peeling and bubbling on bathroom wall. In East unit, bathroom in room wall needs painted or repaired for dark spots. In West unit, room 4 has nail sticking out in bathroom cabinet.
- TA –
- Viewed all rooms w/average temperature. Clean mirrors in seclusion room. All bathrooms in progress of remodel. Painting main areas still in progress. South unit painting completed.
Police Report
Missing Person
Two female clients ran away.
PRLU or OLTC
Corrective Action Agreement
- Non-compliance areas cited over the past six months –
- 1005.1 Behavior Management – “The agency shall have a written discipline policy that is consistently followed”
- 1005.2 Behavior Management – “Discipline shall be directed toward teaching the child acceptable behavior and self-control”
- 1005.3 Behavior Management – “Discipline shall be appropriate to the child’s age, development, and history”
- 1005.4b Behavior Management – “The following actions shall not be used, including as discipline: Physical injury or threat of bodily harm”
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R1011.7 – Small section carved out of sheetrock in bedroom on South unit, hole in wall in bedroom 403 (work order provided, Correction date 12/4/19).
- R1012.4 – Room 204 has pieces of trash in bathroom after cleaning, bathroom wall in room 305 needs painted where repair occurred.
- TA –
- Observed completed painting on South unit, epoxy coating in progress for bathrooms and seclusion rooms. Discussed wall behind mop sink in cleaning closet – current contractors on site will repair this area. Cafeteria door dragging. New vent cover on order for seclusion rooms.
PRLU or OLTC
Visit Compliance Report
- Viewed all areas accessible by children.
- Regs out of compliance –
- R1010.1 – Loose board on fence needs repaired (Correction date 11/22/19).
- R1011.7 – Ceiling tile needs repaired on CL1, graffiti on bed rails need removed, broken cover on wall in phone room needs repaired (Correction date 11/26/19).
- R1012.4 – Admin bathroom has chipped lid, MPR room has cracked wood trim in bathroom, check South unit for mildew substance on ceiling in bathroom, room 2 in East unit has loose tank cover, room 6 wall needs painted where area has been repaired (Correction date 11/15/19).
- TA –
- Replaced several pillows with torn pillowcases.
Police Report
Missing Person
Two clients ran away from facility; one located, other still missing. Filed as Missing Person.
Police Report
Sex Offence
No Info.
Police Report
Sex Offence
No Info.
PRLU or OLTC
Visit Compliance Report
- Reviewed all areas accessible by residents and reviewed 2 personnel files.
- Regs out of compliance –
- R1011.7 – Small place of trim missing in computer room, rooms 303 & 101 bedroom odor, phone missing and wires exposed in phone room (corrected on site), room 105 has wrong size mattress (Correction date 11/26/19).
- R1012.4 – Loose sink in admin bathroom (Correction date 11/11/19).
- TA –
- Gap above door on North unit, peeling paint where hand sanitizer unit was replaced. Evac plan needs replaced in classroom 5. Light needs replaced in classroom 2.
Police Report
911 Hang Up
Silent open landline; sound of buttons being pressed; called back and spoke with Kate no emergency, children’s unit doing phone calls.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R1011.7 – Crack where recent sheet rock repair has occurred, loose ceiling tile in computer room, classroom has graffiti, peeling paint/sheetrock needs to be cleaned up, room 102 needs mattress replaced (wrong size), room 105 has loose trim (Correction date 11/8/19).
- R1012.4 – Check bathroom for mildew substance in room 301, bathroom vents need cleaned in room 306, graffiti and drawing on bathroom wall needs removed in room 206, West unit dayroom bathroom has hole in wall and graffiti that needs repaired (Correction date 11/8/19).
- TA –
- Agency is looking into replacing exit doors with doors that are powder coated (that would not require constant repainting). Deep cleaning scheduled in cafeteria and kitchen. Order more items for sensory room. Improvement on housekeeping and cosmetic repairs noted.
Police Report
911 Hang Up
Landline hangup; contact facility no emergency.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC
- Multiple concerns noted during the visit due to a complaint received. Based on the findings of this investigation due to complaint, AFMC recommends a follow-up Inspections of Care at facility within the next month.
Police Report
911 Hang Up
Landline hangup; contact facility no emergency.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R1011.7 – Gym classroom has ceiling tile that needs repaired, replace ripped mattress in room 101, bunk bed splintering edge in room 103, wrong size mattress in room 104, loose bed rails need tightened in room 105, peeling mattress in room 202, sheet rock needs repaired in North unit dayroom, East unit door frame needs repaired (Correction date 11/26/19).
- R1012.4 – Urine odor in Honors room, Admin (male) gym, rooms 301, 303, and 305 has urine odor. Housekeeping was still making cleaning rounds during walkthrough (Correction date 10/22/19).
Police Report
911 Open Line
Landline hangup; sounds of tapping and buttons being pressed; contact facility no emergency; possible prank dial.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R1011.7 – Hole in classroom needs repaired, paint chips in classroom and by sensory room needs cleaned up. Light needs repaired in room 201. (Correction date 11/14/19)
- TA –
- Several areas have been repainted, others in progress. Holes are being created in some areas that have been previously patched. Shower curtain needs replaced in room 201. Bathroom odor has improved.
Police Report
Welfare Concern
Client left facility and would not talk to staff member that found him walking away from facility; staff recovered client PD not needed.
PRLU or OLTC
Visit Compliance Report
- Unannounced monitoring visit; Partially viewed building and grounds, viewed medication room and logs.
- Regs out of compliance –
- R1011.7 – Hole in classroom in admin building (created on 10/10/19). One bathroom each on East & South units have urine odor (agency using several different chemicals to combat this odor). Wall in bathroom 201 needs to be cleaned, busted pipe in day room bathroom on East unit (work order in place, waiting on new part order to be delivered). (Correction date 11/26/19)
- TA –
- The agency has been repainting several areas in the facility this week (several areas have already received scratching within 24-48 hours of painting). Windows that needs replaced (some have been replaced and some are still on order). Agency plans to keep additional windows on hand to avoid six-week delay in the future. Agency trying several new chemicals for bathroom cleaning and looking into putting epoxy flooring/wall in all bathrooms.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR23618 substantiated with deficiencies cited at:
- N 131 Protection of Residents – Failed to ensure a chemical restraint and seclusion were not used simultaneously used to assure the safety of 9 residents.
- N 209 Facility Reporting – Failed to ensure a serious occurrence report was maintained in the clinical record for easy reference for 2 residents.
- Plan of Correction – Director of Nursing reviewed records, in-serviced nurses, and updated the ESI policy and checklists. Director of Nursing/Administrative Assistant will monitor to ensure compliance.
- 11.26.19 Revisit for 10.11.19 deficiencies. All deficiencies have been corrected, and no new noncompliance was found.
Police Report
Abuse
Oregon DHS reported facility unclean and smelled of urine; PD went to facility and reported it was in reasonable condition.
Police Report
911 Hang Up
Silent open landline; facility contacted, stated no emergency
PRLU or OLTC
Licensing Compliance Record
- TA –
- Administrative Area – bathroom lid chipped, sink not working, walls needing painting and repairs; TA provided 11.7.19.
- Gym – hole in wall, vent needs cleaning.
- Computer Room – hole in wall needs repair.
- Exit Door – frame needs repair and painting.
- Cafeteria/Dining Area – wall needs painting and repair, fire alarm cover needed, windows need cleaning, napkins on ceiling needs removal.
- Honor’s Room – loose door hinge, walls need painting, doorstop hanging off door needs repair.
- Bathroom (South Unit) – needs cleaning, walls need painting.
- Laundry Room (South Unit) – hole in wall needs repair.
- Room 400 (South Unit) – Window boarded needs repair.
- Hallway windows boarded needing repair (South Unit).
- Sensory Room (South Unit) – Needs cleaning; Compliance date 11.7.19.
- Bathroom at end of hall has urine smell (South Unit).
- Doors need painting and bathroom wall needs painting and repair (West Unit).
- Room 102 (West Unit) – Bathroom door needs painting, has urine smell.
- Room 104 (West Unit) – window boarded needing repair.
- Room 105 (West Unit) – bathroom baseboard loose, painting needed.
- Room 106 (West Unit) – mattress needed for top bunk bed.
- Room 202 (West Unit) – pajama strings and wire in bedroom; Corrected.
- Room 203 (West Unit) – Bathroom baseboards coming off need replacing behind toilet.
- Room 205 (West Unit) – Wall needs painting.
- Room 206 (West Unit) – Bathroom has urine smell, strings in room; Corrected.
- Doors needs painting (North Unit)
- Exit door (North Unit) needs to be operational (has key broken in lock), laundry room door frame needs repair; Compliance date 11.7.19.
- Laundry room needs cleaning (East Unit)
- Bathroom in day area has urine smell (East Unit)
- Room 303 (East Unit) – Baseboards needs repair & bed is splintered with edges.
- Room 305 (East Unit) – Bed is splintered with edges.
- Room 306 (East Unit) – Bathroom has urine smell.
- Multi-Purpose Room (East Unit) – Needs painting.
- Hallway (East Unit) – Window boarded needs repair.
- Phone Room – Hole in wall needs repair.