The findings of the re-licensure survey conducted 09/05/23 through 09/07/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

The findings of the first revisit to the re-licensure survey of 09/07/23, conducted on 12/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2023 with diagnoses including chronic pain.

The resident had an 08/10/23 signed physician order for oxycodone 2.5 mg every 30 minutes as needed for pain and for respirations over 25. Staff were instructed to call the hospice provider if the resident needed three doses in 90 minutes or five doses in one day.

Resident 2's Controlled Substance Disposition logs and MARS, reviewed from 8/10/23 through 09/06/23 showed the following:

* On 08/12/23 one dose of PRN oxycodone was signed as administered on the MAR but five doses were signed as given on the disposition log;

* On 08/13/23 there was no indication PRN oxycodone was administered on the MAR but four doses were signed as given on the disposition log;

* On 08/14/23, there was no indication PRN oxycodone was administered on the MAR but two doses were signed as given on the disposition log;

* On 08/15/23 one dose of PRN oxycodone was signed as administered on the MAR but three doses were signed as given on the disposition log: and

* On 08/26/23 one dose of PRN oxycodone was signed as administered on the MAR but two doses were signed as given on the disposition log.

b. Documentation on the disposition log showed multiple doses of PRN oxycodone were administered at the same time on 08/12/23, 08/13/23, 08/14/23, 08/15/23 and 08/26/23 not according the order which instructed staff to administer one dose every 30 minutes.

The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Administrator) and Staff 2 (RN Consultant) on 09/07/23. They acknowledged the findings.

1. Immediate re-education done with medication managers re:

a) Verification of eMAR against card(s) of medication(s), as well as recorded orders in Narcotic Control Book, before administration of medication.

b) Documentation of administered meds in eMAR and Narcotic Control Book.

2. Narcotic Control Book procedures reviewed and updated. a) Any time Narcotics are dispensed as other than a full tablet (e.g. each bubble's unit dose is only a half-tablet or is one-and-one-half tablets) these will now be counted in as such, and count in book decremented by actual tablet amounts, not just "1" for a bubble being popped.

b) Specific instructions to consult the RN if a new narcotic order is received but is not yet on hand, and a supply of the same medication for the same resident is on hand.

3. Varies.

a) At each shift change.

b) Weekly (review of Narcotic Control Book and verification against eMAR and written orders.)

c) Monthly (audit)

4. Facility Nurse will be responsible to see that:

a) On-coming and off-going Medication Manager will verify at each shift change during narcotic count.

b) Facility Nurse or Resident Care Manager will perform weekly review as listed above in section 3.

c) Facility Nurse or Resident Care Manager will perform monthly audit as listed above in section 3.