The findings of the re-licensure survey, conducted  06/13/22  through  06/15/22 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 06/15/22, conducted 8/18/22 through 8/19/22, 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 ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 1 of 2 sampled residents (#4) whose records were reviewed.  Findings include, but are not limited to:

Resident 4 was admitted to the facility 12/2021 with diagnoses including hypertension, Diabetes, and acute respiratory failure.

Review of Resident 4's MAR, dated 06/01/22 through 06/12/22, and physician orders, dated 04/07/22 identified the following:

*The MAR listed carvedilol 25 mg (for blood pressure), with instructions to withhold administration if the resident's heart rate was below 60. There were five occasions where the medication was given, following a pulse reading below 60.

On 06/14/22 the need to ensure all orders from a physician or other legally recognized prescriber were documented in resident MARs and carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Resident 4's medication order settings on MAR updated to alert Med Tech if they enter a pulse less than 60 with the message: "Do not give med".

2. All Med Techs that had given Resident 4's blood pressure medication in error have been counseled one-on-one by Administrator about this error and re-instructed on correctly administering medications according to physician's orders, including withholding parameters.

3. In-services will be held the week of 7/18-7/22/22 for all Med Techs about administering medications according to physician's orders, including instruction specifically about parameters and when to withhold medications. In-services to be conducted by Administrator and Facility RN.

4. Med pass procedures will be updated to have Med Techs check any required vital signs for medications with withholding parameters an hour before starting their med pass (e.g. check blood pressures at 3:00 PM for the 4:00 PM med pass). This is to ensure Med Techs have blood pressure data readily on hand before dispensing medications. All med techs will review and sign the procedure update.

5. Increase frequency of facility's Clinical Review Meeting to weekly and include review of vital signs as part of the meeting process to identify errors. To be done by RCC, Administrator, and/or Facility RN.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 4) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with a diagnosis of Alzheimer's disease.

Resident 1's 06/01/22 through 06/12/22 MARs were reviewed during the survey. The following PRN medications lacked clear parameters for administration:

* PRN Morphine 20 mg/1 ml and PRN tramadol 50 mg were both prescribed to treat pain and lacked clear parameters for the sequence of administration.

* PRN Tramadol 50 mg and PRN Trazodone 50 mg were both prescribed for sleep and lacked clear parameters which medication was to be administered first.

The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) on 06/14/22. She acknowledged the findings.

2. Resident 4 was admitted to the facility 12/2021 with diagnoses including hypertension, Diabetes, and acute respiratory failure. Review of Resident 4's MAR, dated 06/01/22 through 06/12/22 identified the following:

*The MAR lacked a reason for use of magnesium oxide 400 mg (for constipation); and

*The MAR listed two instances where Resident 4 refused Pepto Bismol (oral liquid for indigestion). However, this was not a routine medication, but a PRN which the resident was approved to self-direct.

On 06/14/22 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. PRN parameters have been added to Resident 1's PRN Morphine and PRN Tramadol medications, indicating the sequence of administration: PRN Tramadol to be given first for pain, and if ineffective give PRN Morphine.

2. PRN parameters have been added to Resident 1's PRN Trazodone and PRN Tramadol medications, indicating the sequence of administration: PRN Trazodone to be given first for sleep. If resident still having trouble sleeping after an hour, give PRN Tramadol.

3. Reason for use added to MAR for Resident 4's magnesium oxide 400 mg medication.

4. Facility MAR settings updated to require a reason for use for any medication, in order for the MAR to accept the order.

5. Resident 4's PRN Pepto Bismol order settings updated on MAR as "self-administered" so that it will no longer show up on the medication pass. Since Resident 4 has a current order to self-administer this medication and keep at bedside, med techs do not need to chart if it was given or refused.

6. Include review of missing PRN parameters as part of the weekly Clinical Review Meeting. Facility RN will write PRN parameters.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Review of facility records on 06/14/22 identified the following deficiencies:

There was no documented evidence fire and life safety instruction was provided to staff on alternating months.

On 06/15/22 the need to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 3 (Marketing Director). They acknowledged the findings.

1. Facility-wide in-service about fire and life safety will be conducted on 7/26/22. Instruction will be given by Administrator and/or RCC.

2. Administrator and/or RCC will document that the training was given and have all staff sign that they were in attendance. For any staff member unable to attend the live training on 7/26/22, they will have a separate 1:1 in-service that covers the same information during the live training by 7/31/22.

3. Facility will schedule future fire and life safety in-services every other month, on months that a fire drill is not done. This will be done by RCC and/or Administrator.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Review of facility records on 06/14/22 identified the following deficiencies:

There was no documented evidence that annual training on fire safety was provided to residents.

On 06/15/22 the need to provide and document fire and life safety instruction for residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 3 (Marketing Director). They acknowledged the findings.

1. All residents who have not received a fire and life safety instruction within the past year (7/1/21-7/11/22) will receive fire and life safety instruction by 7/31/22. This will not apply to residents whose mental capability does not allow for following such instruction.

2. Annual fire and life safety instructions will be scheduled for each resident due by their admission date anniversary. RCC and/or Administrator will track and schedule this using facility's electronic calendar.

3. Upon receiving this training, residents will sign the training form which will be filed in their physical chart.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs, to prevent a tripping hazard for residents. Findings include, but are not limited to:

The facility's outdoor courtyard/patio area was toured on 06/13/22. Drop-off's, up to three inches in depth were observed along the patio and pathways.

The need to ensure all exterior pathways were maintained free of drop-offs was discussed with Staff 1 (Administrator) on 06/13/22. She acknowledged the findings.

1. Courtyard drop-offs are scheduled to be re-filled with soil along the patio and all pathways on 7/16/22 by a yard maintenance company.

2. Facility will monitor the courtyard dropoffs on a monthly basis and schedule soil refills as needed. To be done by building manager.