The findings of the re-licensure survey, conducted 10/16/23 through 10/18/23, are documented in this report. The survey was conducted to determine compliance with 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 first revisit to the re-licensure survey of 10/18/23, conducted 12/27/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Resident 1's MARs, dated 09/01/23 through 10/16/23 and physician orders were reviewed and revealed the following:

Resident 1 had physician's orders as follows:

* Acetaminophen 325 mg two tablets every four hours as needed for pain; and

* Tramadol 50 mg 0.5 tablet every 12 hours as needed for pain not relieved by acetaminophen.

The MAR revealed the tramadol was administered nine times between 09/29/23 and 10/10/23 without administering acetaminophen first.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 2 (RN) on 10/17/23 and Staff 1 (Administrator) on 10/18/23. They acknowledged the findings.

POC: Medication and treatment orders carried out as prescribed.

Actions to Correct:

All resident physicians' orders will be reviewed to ensure medication and treatment orders are written as prescribed. The eMar will be updated to reflect any changes needed. Physicians will be contacted with any necessary updates to orders as needed.

Medication and treatment orders will include parameters as needed.

Orders will include clear instructions for the administration order if the resident is prescribed multiple medications for the same use. And clear directions for when a medication is given if the resident cannot self-direct or verbalize preference.

Future Prevention:

The administrator and RN will do the initial review and corrections with assistance from the lead med-aid. The lead med-aid and RN will review new orders as they are received to ensure medication and treatment orders are written as prescribed with proper steps and parameters.

Evaluation Frequency:

Physician orders will be reviewed quarterly and as needed for significant changes by the RN, lead med-aid, and administrator.

Consonus pharmacy staff will review all physician orders during the transition away from PharMerica, as they will be entering all new or updated orders. And finally, we will have a nurse consultant and pharmacy consultant review orders and systems quarterly.

Finally:

Admin will be responsible for ensuring corrections are completed and monitored.

2.  Resident 1 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease.

Resident 1's 09/01/23 through 10/15/23 MARs and current orders were reviewed.

a. Resident 1 had orders for:

* Hydrocortisone cream as needed at bedtime for itching;

* Hydroxyzine 25 mg tablet as needed three times a day for itching;

* Lidocaine cream as needed every eight hours for rash; and

* Miconazole antifungal cream as needed for itching and rash.

There were no specific parameters to guide non-licensed staff on which medication to use first when the resident experienced skin conditions or itching.

b. Resident 1 had a physician's order, dated 08/31/23, for hydrocortisone 0.5% topical cream (for itching) three times per day and one additional treatment at bedtime, as needed. The MAR did not include the instructions "at bedtime" for the PRN dose.

The need to ensure MARs were accurate and included clear parameters to direct non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 2 on 10/17/23 and Staff 1 (Administrator) on 10/18/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 2 of 2 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings included, but are not limited to:

1.  Resident 3 was admitted to the facility in 06/2021 with diagnoses including rheumatiod arthritis.

Resident 3's 09/01/23 through 10/15/23 MARs and current orders were reviewed.

Resident 3 had orders for:

* Miconazole Cream as needed to rectal area for fungal rash two times a day;

* Dimethicone Cream as needed to rectum for skin integrity;

* Mylanta 30 ml as needed for heartburn, indigestion or upset stomach; and

* Tums two tablets as needed for heartburn or indigestion.

The electronic medication record was reviewed with Staff 2 (RN) on 10/17/23. There were no specific parameters to guide non-licensed staff on which medication to use first when the resident experienced skin conditions or heartburn/indigestion.

The need to ensure MARs were accurate and included clear parameters to direct non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 2 on 10/17/23 and Staff 1 (Administrator) on 10/18/23. They acknowledged the findings.

POC: Ensure resident MARs are accurate and include resident-specific parameters and instructions for PRN medication.

Actions to Correct:

All resident physicians' orders will be reviewed to ensure PRN medications have accurate, resident-specific parameters and instructions. The eMar will be updated to reflect any changes needed. Physicians will be contacted with any necessary updates to orders as needed.

Medication and treatment orders will include parameters as needed.

Orders will include clear instructions for the administration order if the resident is prescribed multiple medications for the same use. And clear directions for when a medication is given if the resident cannot self-direct or verbalize preference.

Future Prevention:

The administrator and RN will do the initial review and corrections with assistance from the lead med-aid. The lead med-aid and RN will review new orders as they are received to ensure medication and treatment orders are written as prescribed with proper steps and parameters.

Evaluation Frequency:

Physician orders will be reviewed quarterly and as needed for significant changes by the RN, lead med-aid, and administrator.

Consonus pharmacy staff will review all physician orders during the transition away from PharMerica, as they will be entering all new or updated orders. And finally, we will have a nurse consultant and pharmacy consultant review orders and systems quarterly.

Finally:

Admin will be responsible for ensuring corrections are completed and monitored.