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 02/26/24.  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 observation, interview and record review, conducted during a site visit on 02/26/24, it was confirmed the facility failed to ensure the staff person who administered the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise for 1 of 1 resident (# 8). Findings include, but are not limited to:

At 11:35 am a med tech was observed to deliver medications to Resident 8. The staff member handed resident his/her pill cup, talked and joked with resident for a minute or two and then left Resident 8's apartment. While conducting a private interview with Resident 8, resident was observed to pour pill cup into his/her hand, look at medications then proceeded to place medications in mouth and swallow with water.

In an interview on 02/26/24, Staff 1(Executive Director) stated many residents had been requesting staff to drop-off medications in their apartments to take. The facility had recently gone through and requested a lot of 'leave at bedside orders' from the physicians of the residents that were requesting those services, but s/he could not remember if Resident 8 was one of those residents.

A review of Resident 8's physician orders from 07/2023 to 02/2024 revealed there were no orders to leave medications at bedside. A review of Resident 8's 02/01/24 - 02/29/24 MAR indicated provider would like to be notified of refusals of (3) consecutive doses of any medications.

The facility failed to ensure the staff person who administered the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.

The findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:

Executive Director addressed the incident with the med tech involved and sent out a message to all med techs to ensure that they visually observe residents take medications. Additional training was completed by 03/12/24. The facility had medication audit pass tool that administrative staff use regularly.

Based on interview and record review conducted during a site visit on 02/26/24 and 03/12/24, it was confirmed the facility failed to have a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility. Findings include, but are not limited to:

A review of the facility's "Destruction of Controlled Substances" policy, (undated), indicated the following:

-"It takes two people to destroy and document the destruction of medications."

-"[One] individual must be a nurse".

-"[One] individual can be rsc or pa".

-"Never are narcs to be destroyed without an RN".

-"At change of every shift two team members will reconcile all controlled medication".

-"Each team member initial the controlled drug sheet noting all medications are accounted for."

During an interview on 02/26/24, Staff 3 (MT) stated the following:

-People are "pretty good" about signing the [narcotics] book and had not seen unsigned narcotics logs or sticky notes added to the log.

-Previous shift informed the oncoming shift of what took place and counted the narcotics together.

-During the narcotic count, previous shift handled the book, and oncoming shift handled the medication.

-Staff must have the RN present to destroy narcotics.

-Staff 3 had not destroyed narcotics yet.

During an interview on 02/26/24, Staff 4 (MT) stated the following:

- S/He had not seen staff leave the narcotics log blank or saw sticky notes added to the log.

- During shift change, staff asked prior MT if they had anything to report.

- Usually, staff counted narcotics together when convenient for shift change.

- Narcotic counts were correct.

- S/He didn't think s/he was allowed to destroy narcotics.

- S/He knows staff must have an RN present when destroying narcotics.

- S/He thought the RN destroyed narcotics.

A review of the facility's narcotic page for two individual residents dated 12/29/23 through 01/24/24, and 01/12/24 through 02/25/24, did not indicate blank spaces regarding narcotics.

A review of the Narcotic Count Log, dated 01/01/24 through 02/25/24, indicated 43 instances of one staff signing the narcotic count, and 28 instances of no staff signing the narcotic count.

It was confirmed the facility failed to have a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility.

The findings were reviewed and acknowledged with Staff 1 (Executive Director) on 02/26/24.

Based on interview and record review, conducted during a site visit on 02/26/24, it was confirmed the failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#13). Findings include, but are not limited to:

During an interview, Staff 1 (Executive Director) stated a medication error that involved Resident 13 did occur and described the implementation of a new process and changes for staff administering medications, including utilizing plastic cups with resident photos on them and medication organizers labeled with resident room numbers.

A review of facility's records, including a Facility Self-Report, dated 05/28/23, and an incident report, dated 05/28/23, indicated the following:

- An investigation into the medication error revealed Resident 13 was administered six medications belonging to another resident. Medications taken in error included tart cherry supplement, tylenol 500mg, cephalexin 500mg, vitamin c, vitamin e, and docycline 100mg.

- The incident report indicated Staff 1 reported the medication error to the local Adult Protective Services office on 05/28/23 and Resident 13 was then placed on two-hour checks for monitoring.

- The Facility Self-Report stated Resident 13 was administered six medications that were not prescribed to him/her, including tart cherry, tylenol 500mg, cephalexin 500mg, collagen, cranberry with vitamin c and e, and docycline 100mg.

A review of Resident 13's records, including physician orders, dated 05/22/23, and MAR, dated 05/2023, indicated the following:

- Five of six medications given in error were not prescribed to Resident 13.

- The dosage of acetaminophen (Tylenol) administered to Resident 13 in error was 500mg.

- Resident 13 was prescribed acetaminophen 325mg.

- No other medication errors or discrepancies were identified.

Resident 13 no longer resided in the facility and could not be interviewed or observed.

The findings were reviewed and acknowledged with Staff 1 on 02/26/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed for Resident 13.

The facility's plan of correction included implementing an intervention that has changed how staff distribute medications. Staff now utilize plastic cups with resident photos on them to administer medications. The facility has also implemented the use of medication organizers that are labeled with resident's room numbers.

Based on interview and record review, conducted during a site visit on 02/26/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

On 02/26/24, a review of the facility's resident roster indicated there are 94 residents who resided in the facility.

On 02/26/24, a review of the facility's ABST indicated the following:

* The facility was using the ODHS tool which included all 22 required ADLs and generated a 24-hour staffing plan.

* Resident 17 was not entered into the ABST.

During an interview, Staff 1 (Executive Director) confirmed Resident 17 was not entered into the ABST and had moved into the facility on 02/13/24.

The ABST matched the posted staffing plan, and the facility was consistently staffed per the plan.

A review of the facility's posted staffing plan, dated 01/13/23, indicated the following:

-On morning shift: two MTs, four CGs;

-On evening shift: two MTs, four CGs; and

-On night shift: one MT, two CGs.

A review of the facility's staff schedule, dated 02/01/24-02/29/24, indicated on day and swing shifts there were a minimum of six direct care staff scheduled per shift, and on night shifts there was a minimum of three direct care staff scheduled.

During an interview on 02/26/24, Resident 10 stated s/he is able to use his/her call pendant to request staff assistance, including assistance with making his/her bed.

During an interview on 02/26/24, Resident 17 stated staff are in their apartment to assist Resident 18 and staff provide him/her with assistance to the restroom.

It was confirmed the facility failed to fully implement an ABST.

On 02/26/24, these findings were reviewed and acknowledged with Staff 1.

Based on interview and record review, conducted during a site visit on 02/26/24 and 03/12/24, it was confirmed the facility failed to conduct and record unannounced fire drills on night shifts. Findings include, but are not limited to:

A review of the facility's "Fire Drill and Life Safety Training Schedule 2023-2024" indicated the following:

- An interactive fire drill was scheduled for the following weeks:

* May 29-31;

* July 24-28;

* September 25-29;

* November 24-30;

* January 22-26; and

* March 25-29.

* The schedule lacked which shift the fire drill was to occur.

A review of the facility's "Emergency Evacuation Drills (Fire Drills)" and "Fire Safety Drill" forms, dated 05/2023 through 01/2024, indicated the following:

- Three fire drills were conducted on day shift and two fire drills were conducted on evening shift.

- There was no documented evidence a fire drill was conducted during night shifts.

During an interview on 02/26/24, Staff 1 (Executive Director) confirmed the facility had not performed a fire drill during night shift.

It was confirmed the facility failed to conduct and record unannounced fire drills every other month at different times of the day, evening, and night shifts.

The findings were reviewed and acknowledged with Staff 1 on 02/26/24.

Verbal Plan of Correction:

The Executive Director will ensure a fire drill is performed every three months including night shift.