The findings of the re-licensure survey conducted 10/24/22 through 10/26/22 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 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

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 first re-visit to the re-licensure survey of 10/26/22, conducted on 01/25/23 through 01/26/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

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 1 sampled resident (#1) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was admitted in 05/2022 and had diagnoses which included pain.

Resident 1 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every 12 hours PRN pain.

Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 10/01/22 - 10/25/22, revealed three occasions when staff signed on the drug disposition log that the hydrocodone was given. However, the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Administrator) on 10/25/22 at 3:00 pm. She reviewed the documentation and acknowledged the discrepancies.

OAR 411-054-0055 (1)(e) Systems: Tracking Controlled Substances:

1.) An audit was completed for resideent #1's PRN pain medication, the medication record was corrected to refect accuracy between the narcotic log and the Mar.

2.) A 100% audit will completed to ensure all residetns scheduled and PRN narcotic medications are documented accurately and match the MAR and norcotic log, as well as identify any trends in narcotic administration.

Medication Technicians will be provided the traing regarding the policy for counting narcotics as well as documentation of narcotics on the MAR and narcotic log to ensure accuracy.

3.) The Administrator and/or Designee and Registered Nurse are responsible to ensure the system is corrected/monitored.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted in 2020 with diagnoses which included hypertension.

Resident 2's physician orders and MARs, reviewed from 10/01/22 through 10/25/22, revealed the following orders were not followed:

The resident had orders for Amlopidine (for hypertension) 10 mg one tablet daily and Lisinopril (for hypertension) 10 mg one tablet daily. Staff were instructed to hold the medication if the systolic BP (upper number) was less than 100 or pulse was less than 60. According to the MAR, staff administered the medication without obtaining the pulse to determine if the medication should have been held.

The need to ensure orders were followed was reviewed with Staff 1 (Administrator) on 10/25/22 at 2:30 pm. She reviewed the MAR and acknowledged the findings.

C 303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1. Resident #2's medications record were updated on 10/25/22 regarding the recording of Pulse documentation.

2. All resident medication and treatment records will be reconciled to ensure all medications and treatments have current signed orders, and accurate and dispensed as prescribed to the resident.

3. Medications reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff, Furter, daily audits to review missing medications, omissions and PRN usage will be completed.

4. The Administrator and/or Designee and Registered Nurse are respinsible to ensure the system is corrected/monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 3 of 3 long-term staff (#s 3, 5 and 6) whose training records were reviewed. Findings include, but are not limited to:

a. Staff 3 (MT/CG), hired 02/02/19, failed to have documented evidence of completing six hours of annual in-service training related to the care of the dementia resident, between 02/2021 and 02/2022.

b. Staff 5 (MT/CG), hired 02/20/14, failed to have documented evidence of completing six hours of annual in-service training related to the care of the dementia resident, between 02/2021 and 02/2022.

c. Staff 6 (CG), hired 05/05/12, failed to have documented evidence of completing six hours of annual in-service training related to the care of the dementia resident, between 05/2021 and 05/2022.

The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) on 10/25/22 at 2:25 pm. She acknowledged the findings. No further information was provided.

C 374 OAR 411-054-0070 (6-7) Annual Training and Other Requirements.

1. Staff #3, 5 and 6 will complete continued education to meet the required 12 hours of annual in-service traings including 6 hours related to the care of the Dementia resident.

2. All staff traing records will be audited to ensure documented evidence of 12 hours of annual inservice training including training related to the care of the dementia resident has been completed.

3. This system will be audited monthly through the Administrator Quarterly Assurance Audit.

4. The Administrator or Designee will be responsible to ensure the corrections are completed/monitored.  

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

During a walk-through of the facility on 10/26/22, the exit doors were found to have no consistently working audible alarm or system in place to alert staff when residents exited the building.

The surveyor observed the doors with Staff 1 (Administrator) on 10/26/22 at 11:20 am. She acknowledged the doors did not have working alarms or acceptable system to alert staff when a resident exited the building.

C 555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

!. Exit doors will be equipped with as alarming device to provide security and to alert the staff when residents exit building.

2. Exit door alarms checks will be added to staff and Administrator daily walk through task sheet to ensure proper functioning of alarms.  Stall will receive inservicing on door alarm policy, urgent and non-urgent repairs via facility maintenance log or Administrator.

3. The sysytem will be evaluated daily.

4. The Administrator and /or Designee and Maintenance Director to ensure the corrections are completed/monitored.