Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

HS:Hours of sleep

LPN:Licensed Practical Nurse

MT:            Medication Technician or Med Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

SP:Service plan

SPT:Service Planning Team

TAR:Treatment Administration Record

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to ensure the completeness and accuracy of resident records for 3 of 3 sampled residents (#s 1, 16, and 19). Findings include, but are not limited to:

A review of the facility's Electronic Medical Record (EMR) system revealed 26 occurrences of incidents being struck out between 3/30/24 through 06/12/24.

In separate interviews, Staff 3 (Director of Nursing) and Staff 20 (RN) stated the following:

* Documented incidents were struck out if they did not meet facility criteria for an incident report or if there was a documentation error in the entry.

* Updated or corrected entries were expected to be entered regarding incidents that occurred but did not meet criteria or contained an error.

On 06/01/24, two entries were struck out for Resident 19 who was sent out to the hospital on 05/21/24.

On 06/01/24, an entry was struck out for Resident 1, who was sent out to the hospital on 05/29/24.

The Resident 1's progress notes, dated 05/26/24-06/01/24, did not contain an updated or corrected entry for that event.

In an interview on 06/13/24, Staff 6 (Anonymous) stated the following:

* On 06/02/24, Resident 16 made verbal threats to him/her regarding a firearm.

* When asked about filling out an incident report, a facility nurse told him/her not to document the incident and that they would strike-out an entry if documented.

A review of Resident 16's progress notes, dated 06/02/24 through 06/09/24, did not contain an entry detailing the event by the staff member who witnessed the incident or on the day the incident occurred.

In an interview with Staff 17 (Anonymous), stated the following:

* S/he had heard of staff being told not to document incidents in progress notes.

* Nursing staff struck-out multiple entries from residents' progress notes.

* The facility did not have a policy on strike-outs.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 3 on 07/11/24.

The facility failed to ensure the completeness and accuracy of resident records.

VPOC: Now only the ED and Assistant ED can strike out entries. Facility will provide ongoing training regarding APS reporting, reviewing the abuse tree, and create easier, more accessible APS forms for all staff so that the staff who was present for the reportable issue will fill out the form, or a supervisor. They will be reporting in  "real time"  and documenting incidents in  "real time."  When medication errors occur, staff will alert nurse, resident's primary care physician, and then self-report. Facility will also provide additional education on medication error correction and documentation in the MAR.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24-06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

In an interview on 06/13/24, Staff 6 (Anonymous) stated the following:

* On 06/02/24, Resident 16 made verbal threats to him/her regarding a firearm.

* When asked about filling out an incident report, a facility nurse told him/her not to document the incident.

A review of Resident 16's progress notes, dated 06/02/24-06/09/24, did not contain an entry detailing the event by the staff member who witnessed the incident or on the day the incident occurred.

A review of a Portland Police Report showed the incident was not reported to law enforcement until 06/04/24.

The findings were reviewed with and acknowledged by Staff 1  (Administrator) and Staff 3 (Director of Nursing) on 07/11/24.

Verbal Plan of Correction: Facility will provide ongoing training regarding APS reporting, reviewing the abuse tree, and create easier, more accessible APS forms for all staff so that the staff who was present for the reportable issue will fill out the form, or a supervisor. They will be reporting in  "real time"  and documenting incidents in  "real time."

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was determined the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

During an interview on 06/16/24, Staff 3 (Director of Nursing) stated if a resident experiences an injury, fall, medication error, any smoking violation, resident to resident altercation, or any incident that happens "outside the norm," an incident report would be generated.

Resident 4's records indicated:

-Service plan, dated 04/04/23, indicated "[Direct Care] staff will administer all medications per PCP orders (and res' preference)".

-Quarterly physician medication review, dated 07/10/23, indicated Asenapine (antipsychotic) 10mg tab was prescribed with the instructions to "Take 1 tablet under tongue every night at bedtime" starting on 03/15/23.

-An Incident Report and progress notes dated 06/12/23, indicated Resident 4 was administered three Asenapine 10mg tablets by staff and was placed on alert for the medication error.

-MAR dated 06/01/23 through 06/30/23 indicated Asenapine was administered as prescribed on 06/12/24.

Resident 4 was out of the facility and could not be interviewed.

It was determined the facility failed to carry out medication and treatment orders as prescribed for Resident 4.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility had begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility implemented a new medication error policy with a form which included the necessary information for medication errors. Facility provided extra training and ensured all Direct Care/Med Tech staff had their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#s 9 and 10). Findings include, but are not limited to:

1. Resident 9's service plan, dated 09/26/23, indicated "Staff to assist with all medication administration. Staff to order/reorder medications."

Resident 9's quarterly physician medication review, dated 09/07/23, indicated "Ingrezza oral capsule 80MG (Valbenazine Tosylate) Give [one] tablet by mouth one time a day for involuntary movements" starting 04/07/23.

Resident 9's MAR, dated 11/01/23 through 11/30/23, indicated 13 instances of Ingrezza not administered due to "Med not available" on 11/16/24 and 11/18/24 through 11/30/24. Progress notes, dated 11/18/24, indicated Resident 9 had been out of Ingrezza.

On 06/16/24, Staff 12 (Anonymous) stated the direction when reordering medications was to reorder when there were 14 pills left, or on the indicated order date.

On 06/26/24, Witness 3 (RN Consultant) stated the facility had issues with reordering medications in a timely fashion and s/he thought it was a training issue. S/he further stated by the time staff reordered medication, the medication arrived late.

An interview was attempted with Resident 9, but s/he could not be interviewed.

2. Resident 10's service plan, dated 02/13/24, indicated "[Resident 10] requires 'Delegated staff' educated by nursing to administer and manage [his/her] medications."

Resident 10's, Physician orders, dated 09/07/23, indicated "Ingrezza 40MG Cap [one] capsule by mouth every day for ... involuntary movements)," starting 08/24/23.

Resident 10's MAR, dated 11/01/23 through 11/30/23, Ingrezza was not administered due to "Med not available" on 11/18/23 and 11/20/23, and one instance where the MAR was blank on 11/11/23.

Progress notes, dated 11/19/23, indicated "Resident on alert for hospital return and being out of Ingrezza. Resident was sent out to the hospital due to tremors."

On 06/26/24, Staff 3 (Director of Nursing) stated Resident 10 was sent out to the hospital because s/he was experiencing tremors and there had been issues receiving the medication because the facility had to order Ingrezza from a special pharmacy.

Resident 10 was no longer at the facility and could not be observed or interviewed.

It was confirmed the facility failed to carry out medication orders as prescribed for Residents 9 and 10.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility had begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility implemented a new medication error policy with a form which included the necessary information for medication errors. Facility provided extra training and ensured all Direct Care/Med Tech staff had their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#11). Findings include, but are not limited to:

On 06/26/24, Staff 22 (Anonymous) stated s/he had administered one Suboxone (chemical dependence) to Resident 11 instead of two. That was the only medication error s/he could remember regarding Resident 11.

Resident 11's records revealed the following:

-Service plan, dated 01/08/24, indicated "Staff will administer medications per MD orders."

-Physician orders, dated 09/06/23, indicated resident 11 was to receive one Suboxone 2-0.5 mg every evening and two Suboxone 2-0.5 mg every evening, starting on 08/12/23.

-MAR indicates Buprenorph/Nalox was administered as prescribed on 11/22/23.

-An incident report, dated 11/22/23, indicated "Direct care staff reported finding a medication error in the Narc Book for [Suboxone] on 11/23/23 at 1325. One tablet of medication administered instead of [two] as ordered."

-Progress notes, dated 11/01/23 through 11/30/23, indicated on 11/24/23, "Direct care staff reported finding a medication error in the Narc Book for [Suboxone] on 11/23/23 at 1325. One tablet of medication administered instead of [two] as ordered."

Resident 11 was approached for an interview regarding his/her care but declined.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 11.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 (Director of Nursing) on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 12). Findings include, but are not limited to:

On 06/16/24, Staff 3 (Director of Nursing) stated when a resident experienced a medication error an incident report would be generated.

Resident 12's records indicated:

-Physician orders, dated 12/26/23, indicated "Oxycodone 10MG tab [one] tablet by mouth every [six] hours as needed for severe pain." Starting 09/22/23.

-MAR, dated 12/01/23 through 12/31/23, indicated Oxycodone was administered as prescribed on 12/19/23.

-Facility self-report, dated 12/19/23, indicated "Resident received an Oxycodone ... from a different resident's medication card. Resident received an inadequate dose of [his/her] Oxycodone. Resident received Oxycodone 5mg instead of Oxycodone 10mg."

During an interview on 06/26/24, Resident 12 stated the facility assisted him/her with medications, s/he has had issues receiving his/her pain medications, and "they never order them on time." S/He further stated when the facility hadn't ordered his/her medication, s/he had experienced "bad" pain.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#8). Findings include, but are not limited to:

During an interview on 06/16/24, Staff 3 (Director of Nursing) stated if a resident experienced a medication error an incident report would be generated.

Resident 8's records indicated:

-Physician orders, dated 12/07/23, indicated:

*"Methadone 10MG Tab [one] tablet by mouth [three] times daily at 12am, 6am, and 12pm (Indications for use: PAIN)." Starting 09/21/23.

*"Methadone 10MG Tab [two] tablets (20MG) by mouth every day at 6pm" starting 08/21/23.

-MAR, dated 12/01/23 through 12/31/23, indicated Methadone 5MG four tablets were administered as prescribed on 12/21/23 at 6pm, and Methadone 5MG two tablets was administered as prescribed at 0000, 0600, and 1200 on 12/21/23.

-Facility self-report, dated 12/21/23 indicated "Resident received a double dose of Methadone at 0515 this morning. Physician order is for Methadone 5mg [two] tabs [three] times daily at 12am, 6am, and 12pm, and [four] tablets at 6pm. Resident was given [four] tablets ([his/her] 6pm dose at 6am (0515))".

On 06/26/24, Staff 21 (Anonymous) stated Resident 8's medication error was due to a misinterpretation of the MAR and how the staff member had read the MAR.

On 06/13/24, Resident 8 stated the facility managed his/her medications and there had been errors.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 8.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#14). Findings include, but are not limited to:

During an interview on 06/16/24, Staff 3 (Director of Nursing) stated if a resident experiences a medication error an incident report would be generated.

Resident 14's records indicated:

-Physician orders, dated 12/28/23, indicated "Cyclobenzaprine 10MG tab [one] tablet by mouth [three] times daily as needed for pain" starting 10/12/23.

-MAR, dated 12/01/23 through 12/31/23, indicated four separate instances where Cyclobenzaprine was administered four times a day (12/06/23, 12/07/23, 12/09/23, and 12/29/23).

-Facility self-report, dated 01/04/24, indicated "[Resident 14] received [four] doses instead of [three] doses of Cyclobenzaprine."

An interview was attempted with Resident 14, but s/he could not be interviewed.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 14.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 (Director of Nursing) on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#6). Findings include, but are not limited to:

During an interview on 06/16/24, Staff 3 (Director of Nursing) stated if a resident experiences a medication error an incident report would be generated.

Resident 6's records indicated the following:

-Medication self-administration safety screen, dated 12/22/23, indicated Resident 6 was able to administer medications unsupervised.

-An incident report, dated 01/07/24, indicated Resident 6 reported to facility staff s/he had received another resident's medications from staff and self-administered them.

-Progress notes, dated 01/01/24 through 01/31/24, indicated on 01/07/24, "Resident on alert for self-administering wrong medication and [emergency department] return. Resident denied having any side effects from taking the wrong medication, stated [s/he] felt fine."

Resident 6 was no longer at the facility and could not be observed or interviewed.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 6.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

On 06/16/24, Staff 3 (Director of Nursing) stated if a resident experienced a medication error an incident report would be generated.

Resident 1's records indicated:

-Physician orders, dated 10/19/23, indicated:

*"Buprenorphine HCL 2MG tab subl Take [one] tablet under tongue [three] times daily as needed for pain. Total day dose: 30MG." Starting 08/31/23.

*"Buprenorphine-Nalox sl 8-2MG T Dissolve [one] tablet under tongue [three] times daily" (chemical dependence). Starting 08/19/23.

-MAR, dated 09/01/23 through 09/30/23, indicated Buprenorphine HCL 2MG was not administered on 09/06/23, and Buprenorphine-Nalox 8-2MG was administered as prescribed on 09/06/23 at 8:00 am and 5:00 pm. The 12:00 pm dose was not administered due to "[Resident 1] absent from home without meds."

-Facility self report, dated 09/06/23, indicated "Resident received a Buprenorphine/Nalox 8/2mg [four] times instead of [three] times as order stated."

-Incident Report, dated 09/06/23, indicated "Resident received a Buprenorphine/Naloxone 8/2mg instead of Buprenorphine 2MG pm."

Resident 1 was approached for an interview regarding his/her care but declined.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

During an interview on 06/16/24, Staff 3 (Director of Nursing) stated if a resident experienced a medication error an incident report would be generated.

Resident 1's MAR, dated 06/01/24 through 06/30/24, indicated:

*"Clonidine HCI Oral Tablet 0.1MG (Clonidine HCI) Give [two] tablet by mouth at bedtime for sleep hold for Systolic Blood Pressure below 100, Pulse below 50". Starting 06/21/24.

*"Clonidine HCI Oral Tablet 0.1MG (Clonidine HCI) Give [one] tablet by mouth as needed for as needed for anxiety once a day hold for Systolic Blood Pressure below 100, Pulse below 50". Starting 06/21/24.

*One dose of scheduled Clonidine was administered on 06/22/24 at 2300 and two doses of PRN Clonidine were administered on 06/22/24 at 0512 and 1916.

The Facility self-report, dated 06/14/24, indicated "Nursing found that an extra dose of clonidine had been given on 06/22/24. The resident has a schedule dose of [two] tabs at bedtime (2300) and a PRN order for [one] tab [one] time a day as needed for anxiety. A PRN dose had been given at 0512 and another PRN dose was given at 1916. The scheduled dose was given at 2300."

Resident 1 was approached for an interview regarding his/her care but declined.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24, 06/17/24, 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 21). Findings include, but are not limited to:

On 06/16/24 and 06/17/24, Staff 3 (Director of Nursing) stated:

-If a resident experiences a medication error an incident report would be generated.

-Staff administered Resident 21 an additional Oxycodone outside the parameters of his/her prescription.

Resident 21's records indicated:

-Service plan, dated 02/09/24, indicated "[Resident 21] requires assistance in managing medications. [S/He] is able to self-direct [his/her] PRN medications."

-Physician orders, signed 06/04/24, indicated Resident 21 was prescribed one tablet of Oxycodone 10mg (pain management) two times a day, and 1.5 tablets of Oxycodone 10mg two times a day starting 08/07/23.

-MAR, dated 06/01/24 through 06/30/24, indicated Oxycodone 10mg was scheduled for 7:00 pm and 10:30 pm and Oxycodone 10mg (1.5 tablet) was scheduled for 8:00 am and 1:00 pm.

A facility self-report, dated 06/14/24, indicated Resident 21 was administered a dose of Oxycodone 10mg at 9:45 pm and 10:10pm.

A temporary service plan, dated 06/14/24, indicated Resident 21 had received an extra dose of oxycodone.

It was confirmed the facility failed to carry out medication orders as prescribed for Resident 21.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 on 07/11/24 via virtual conference.

Facility's plan of correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#13). Findings include, but are not limited to:

A Facility Self Report, dated 12/20/23, stated Staff 6 (Anonymous) "gave [Resident 13] 30mg instead of 15mg as prescribed."

A review of Resident 13's physician orders, dated 12/01/23, contained two medication orders as follows:

* Morphine ER 15mg tab 12HR, 1 tablet by mouth twice daily in the morning and afternoon to treat pain; and

* Morphine Sulfate ER 30mg tab, 1 tablet by mouth every evening to treat chronic pain.

A review of the Narcotic Log for Resident 13's 30mg tab, dated 12/13/23, showed the following:

* Morphine Sulfate ER 30mg tab was logged on 12/19/23 as administered at 7:48 and 12:00.

* Directions were to give 1 tablet by mouth every evening.

A review of the Narcotic Log for Resident 13's 15mg tab, dated 12/13/23, showed the following:

* Morphine ER 15mg tab 12hr had no entry for the two administrations due on 12/19/23.

* Directions were to give 1 tablet by mouth twice daily in the morning and afternoon.

In an interview on 06/13/24, Staff 6 stated the following:

* S/he was responsible for the medication error.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 3 (Director of Nursing) on 07/11/24.

The facility failed to carry out medication orders as prescribed.

Verbal Plan of Correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on interview and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#13). Findings include, but are not limited to:

A Facility Self Report, dated 03/06/24, stated "[Resident] was given a 30mg tab at 8am and 12pm instead of the 15mg tab."

A review of Resident 13's physician orders, dated 12/01/23, contained two medication orders as follows:

* Morphine ER 15mg tab 12HR, 1 tablet by mouth twice daily in the morning and afternoon to treat pain.

* Morphine Sulfate ER 30mg tab, 1 tablet by mouth every evening to treat chronic pain.

A review of Resident 13's progress notes, dated 03/03/24-03/31/24, stated the following:

* The resident was given a 30mg Morphine tablet at 8am and noon.

* The order was for 15mg Morphine at 8am and noon.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 3 (Director of Nursing) on 07/11/24.

The facility failed to carry out medication and treatment orders as prescribed.

Verbal Plan of Correction: Facility has begun the retraining process for Direct Care/Med Tech staff through Oregon Care Partners regarding medication administration. Facility has implemented a new med error policy, in which staff fill out the forms so they will know what details to include in the documentation for medication errors. Facility will provide extra training and ensure all Direct Care/Med Tech staff have their training completed before working the floor.

Based on observation, interview, and record review, conducted during a site visit on 06/13/24, 06/16/24 through 06/18/24, 06/26/24, and 07/03/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

During an interview on 06/13/24, Staff 13 (Resident Care Coordinator/RCC) stated s/he completed the most recent ABST update, and the ABST was updated when residents returned from the hospital or experienced a change in condition.

A review of the facility's ABST revealed the following:

- The facility adopted an ABST and utilized the ODHS tool, which included all 22 distinct ADLs.

- The census was 54.

- All residents were entered into the tool.

- Acuity was updated in the tool at the required frequencies for all but three residents (Resident 1 and two unsampled residents).

- The ABST was last updated on 05/29/24.

The facility's posted staffing plan indicated the following:

-For day shift, five CGs and three MTs.

-For swing shift, five CGs and three MTs.

-For night shift, three CGs and three MTs.

The facility's posted staffing plan exceeded the ABST, and the facility was consistently staffing to the levels indicated on the posted staffing plan.

During an interview on 06/17/24, Staff 13 (RCC), stated if the facility is short on in-house staff, they utilized agency. The facility had three agencies they regularly contracted with to fill staffing gaps when they occur.

On 06/26/24, the Compliance Specialist (CS) observed the following:

-During day shift, there were six CGs, and three MTs on shift.

-During swing shift, there were five CGs, and three MTs on shift.

Resident 1 was approached for an interview regarding his/her care but declined.

During an interview on 06/26/24, Staff 21 (Anonymous) stated Resident 1 is "pretty independent" with care needs and ADLs. The facility assisted him/her with medication. Staff checked his/her room twice a day for food. Resident 1 could be forgetful if s/he orders food.

A review of Resident 1's service plan, dated 03/22/24, indicated the following:

-"Independent with toileting and use of incontinent products."

-"Independent with transferring."

-"Requires assistance for medication ordering, reordering, and administration. Staff will order/reorder medications for [Resident 1] as necessary and will administer all medications as ordered by [Resident 1's] PCP."

A review of Resident 1's acuity in the ABST  indicated there were task times entered for helping with bowel and bladder management (2.33 hours weekly) and transferring in or out of bed or a chair (1.75 hours weekly). There was no task time entered for medication administration or passing out medications.

During an interview on 06/26/24, Resident 2 stated as for care needs, "[Facility staff] give [him/her] what [s/he] asks for." S/He transferred by him/herself. Staff assisted him/her with washing his/her back. S/He toileted independently. The facility managed his/her medications. Resident 2 did not have concerns with his/her care.

During an interview on 06/26/24, Staff 22 (Anonymous) stated Resident 2 needed assistance with a lot of ADLs, including showers. Resident 2 was "pretty independent" with everything other than ADLs.

During an interview on 06/26/24, Resident 3 stated as for care needs, s/he could do everything except for toileting. The facility assisted him/her with medication. S/He didn't need help transferring and could do that independently. Resident 3 had no concerns with his/her care.

It was confirmed the facility failed to fully implement and update an acuity-based staffing tool for Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 3 (Director of Nursing) on 07/11/24 via virtual conference.