The findings of the re-licensure survey, conducted 07/22/24 through 07/24/24, 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 07/24/24, conducted 10/14/24 through 10/15/24, 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 second revisit, to the relicensure survey of 07/24/24, conducted 11/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 2 of 4 sampled residents (#s 2 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2024 with diagnoses which included pain.

Resident 2 had an order for oxycodone (narcotic analgesic) 10 mg every six hours as needed for pain.

Resident 2's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/24 through 07/22/24, revealed six occasions when staff signed on the drug disposition log that the oxycodone 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 (Executive Director) on 07/23/24 at 3:15 pm. She reviewed the documentation and acknowledged the discrepancies.

2. Resident 4 was admitted to the facility in 01/2024 and had diagnoses which included pain.

Resident 4 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every eight hours as needed for pain.

Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/24 through 07/22/24, revealed staff signed on the drug disposition log that the hydrocodone was given on 07/18/24. However, the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MAR and Controlled Substance Disposition Log were reviewed with Staff 1 (Executive Director) on 07/24/24 at 9:30 am. She reviewed the documentation and acknowledged the discrepancy.

C302 - OAR 411-054-0055

Tracking Control Substances

1. Avamere Hermiston staff have fixed the areas of concern for resident 1 and 2.  Full narcotic audit completed to ensure documentation in MAR matches administration and controlled substance disposition log.

2. Clinical staff have been trained on documentation of controlled substances and EMAR documentation. RCC, DHS will be auditing controlled substance log weekly.

3.  Weekly auditing  

4. This will be montitored by RCC, DHS and Executive Director  

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 2 of 2 sampled residents (#s 5 and 7) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 08/2024 with diagnoses which included pain.

The resident had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mgs every four hours as needed for pain.

Resident 5's Controlled Substance Disposition Logs and MARs, dated 09/22/24 through 10/14/24, were reviewed and revealed two occasions when staff signed on the drug disposition log that the hydrocodone-acetaminophen was administered, but the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition Logs were reviewed with Staff 1 (ED), Staff 2 (Region Nurse Consultant), Staff 3 (Director of Health Services), and Staff 17 (RCC) on 10/15/24 at 1:45 pm. They acknowledged the findings.  

2. Resident 7 was admitted to the facility in 02/2023 and had diagnoses which included pain.

The resident had an order for Oxycodone (narcotic analgesic) 10 mgs every six hours as needed for pain.

Resident 7's Controlled Substance Disposition Logs and MARs, dated 09/22/24 through 10/14/24, were reviewed and revealed three occasions when staff signed on the drug disposition log that the Oxycodone was administered, but the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition Logs were reviewed with Staff 1 (ED), Staff 2 (Region Nurse Consultant), Staff 3 (Director of Health Services), and Staff 17 (RCC) on 10/15/24 at 1:45 pm. They acknowledged the findings.  

C 302 - OAR 411-054-0055

Tracking control substances

1. Late entries have been made by the staff who administerd the medications for resident #5 and resident #7 to reflect the administration on the dates/times that were missed. A full audit has been completed to ensure that all medications signed out of the of the controlled substance disposition log are also signed as administerd on the MAR.

2. Med Techs have been re-trained and counseled on the proper procedure for signing the MAR at the same time as preparing the controlled substance to be given. Upon hire, new Med Techs will also be trained on this process. Documentation of controlled substances will be audited daily  Mon-Fri until Director of Health Services (DHS) and Executive Director (ED) are confident that everyone is following the correct process. Controlled substance audits will continue to be done weekly and any discrepancies will be immediately reported to the DHS for investigation and follow up.

3. This system will be audited weekly through a controlled substance audit. Audits will also be reviewed as part of the monthly Continuous Quality Improvement (CQI) process.

4. The DHS and ED will be responsible for monitoring this system.

2. Resident 2 was admitted in 06/2024 with diagnoses which included kidney failure, edema, and hypertension.

Resident 2's progress notes, PCP orders, and MARs were reviewed from 07/01/24 through 07/22/24, and the following was revealed:

- On 07/11/24, Resident 2's PCP ordered Torsemide (diuretic) 5 mg daily.

- According to the MAR, reviewed from 07/01/24 - 07/22/24, s/he did not receive the medication until 07/20/24 (nine days after it was ordered).

- A progress note dated 07/18/24, indicated staff contacted the pharmacy to inquire about the medication. The pharmacy reported they never received an order for the medication.

- A progress note dated 07/18/24 indicated staff found the order in the "to be filed," and it had not been faxed to the pharmacy to be filled.

In an interview with Staff 1 (Executive Director) and Staff 2 (Regional RN) on 07/23/24 at 4:10 pm, Staff 2 verified the medication had not been given as ordered. She stated a med error report would be generated and the PCP would be notified.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including high blood pressure.

Resident 1's MAR for 07/2024 and physician's orders were reviewed.

Resident 1 had physician's orders for Metoprolol Tartrate 25 mg once daily, to be held for systolic blood pressure less than 100.

There was no documented evidence Resident 1's systolic blood pressure was measured on July 6th and 10th to determine if the medication should have been held. The medication was signed as administered. On July 19th, the residents systolic blood pressure was documented to be 93. The medication was signed as given, not held as directed.

The Metoprolol Tartrate was not held as ordered, and the resident's blood pressure was not consistently documented as monitored to determine administration.

The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) on 07/24/24. She acknowledged the findings.

C303- OAR 411-054-0055

Treatment orders

1. Avamere Hermiston staff have been retrained in processing ordrers and faxing to pharmacy timely. Also retrained in following BP paramenters and documenting on EMAR. Full audit of residents with parameters completed.  

2. New orders received will be activated on EMAR vs, queued in order to know if a med has not come in.

24 hour report will be reviewed at standup which will identify any medications out of stock. Facility will follow up with pharmacy daily until medication received. Parameter audit to be completed weekly to ensure all parameters are being followed.

3. 24 hour report to be reviewed at standup 5 days a week and parameter report reviewed weekly.   

4. This will be monitored by DHS, RCC and Executive Director.  

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 3 of 3 sampled residents (#s 5, 6, and 7) whose medication administrative records were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 08/2024 with diagnoses including hypertension, atrial fibrillation, and osteoarthritis.

The resident's 09/01/24 through 10/14/24 MARs and physician's orders were reviewed and the following inaccuracies were identified:

* There were two PRN medications for pain without parameters to direct unlicensed staff on which medication to administer first;

* There were two conflicting parameters on a PRN hydrocodone-acetaminophen, a pain medication. One directed staff to "give one tablet by mouth every [six] hours as needed". The second directed staff to administer "one to two tablets every [six] hours PRN";

* Resident 5 had an order for amlodipine (for hypertension). There were parameters on the signed order of when staff should hold the medication, but they were not transcribed onto the MAR; and

* There was a parameter for staff to hold the resident's metoprolol (for atrial fibrillation) for a heart rate less than five beats per minute. There was no documented evidence staff had clarified the parameter with Resident 5's physician.

The need for resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED), Staff 2 (Region Nurse Consultant), Staff 3 (Director of Health Services), and Staff 17 (RCC) on 10/15/24 at 1:45 pm. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2024 with diagnoses including hypertension.

The resident's MARs, dated 09/01/24 through 10/14/24, physician's orders, and progress notes, dated 09/17/24 through 10/14/24, were reviewed.

Resident 6 had a physician's order for indapamide (for hypertension).  

On 10/15/24 at 1:45 pm, Staff 1 (ED) confirmed that there were issues with obtaining the medication and the facility had not been able to administer it. The following inaccuracies were identified on the MARs:

* Staff initialed the MAR on 12 out of 34 days that the indapamide had been administered; and

* There were blanks on the MAR on 09/14/24 and 09/15/24 relating to the indapamide.

The need to ensure MARs were accurate was discussed with Staff 1, Staff 2 (Region Nurse Consultant), Staff 3 (Director of Health Services), and Staff 17 (RCC) on 10/15/24 at 1:45 pm. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 02/2023 with diagnoses including pain and lung disease.  

The resident's 09/01/24 through 10/14/24 MARs, physician's orders, and progress notes, dated 09/14/24 through 10/14/24, were reviewed and the following inaccuracies were identified:

* There were two PRN medications for pain without parameters to direct unlicensed staff on which medication to use first;

* Resident 7 had two PRN medications for diarrhea, loperamide and lomotil. There were parameters to direct unlicensed staff for the two separate physician's orders relating to the loperamide, but there were no parameters directing staff on when to administer the lomotil; and

* Staff were directed to document resident's pain levels using a numerical pain scale from one to ten on the resident's budesonide (for lung disease), celecoxib (for arthritis), and a Fentanyl patch (for pain). Staff documented "[Not applicable]" on multiple occasions.

The need for resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED), Staff 2 (Region Nurse Consultant), Staff 3 (Director of Health Services), and Staff 17 (RCC) on 10/15/24 at 1:45 pm. They acknowledged the findings.

C 310 OAR 411-054-0055

Medication Administration

1. Physician Orders and MAR have been reviewed and updated for resident #5, #6, and #7.  A full MAR audit has been completed and parameters have been reconciled to orders to ensure accuracy. A full audit of all PRN medications has also been completed to ensure all PRNs medications have clear indication for use and clear parameters to direct unlicensed staff on which medication to use first if multiple PRNs for the same reason.

2. All new orders, or changes to existing orders will be triple-checked with the 3rd check being a Licensed Nurse to ensure that any parameters that are included in the order get transcribed appropriately on the MAR. This triple-check process is also to ensure that all PRN medications have clear parameters as well as order of use if applicable. A parameter audit will be completed weekly to ensure parameters for holding a medication or notifying a provider are being followed. All PRN medications will be audited monthly as part of our CQI process. and Monthly at QCI meetings with  clinical staff  RN, RCC and Executive Director.

3. This system will be evaluated weekly through parameter audits as well as monthly as part of CQI process.

4. The DHS and ED will be responsible for monitoring this system.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

Review of the current census revealed not all facility residents were entered into the ABST and multiple residents had not been reviewed or updated quarterly.

No staffing concerns were identified.

The need to ensure all residents were entered into the tool and reviewed no less than quarterly was discussed with Staff 1 (Executive Director) on 07/23/24. She acknowledged the findings.

361 OAR 411-054-0037

Staffing tool ABST

1. Clinical and Admin staff have received training of acuity based tool to determine appropriate staffing. ABST tool has been updated so that all residents have been updated/reviewed within the last 90 days.  All residents are in the ABST tool.  

2. RCC will be trained on ABST tool and ongoing documentation. ABST will be completed prior to a resident moving in. ABST will also be updated any time a service plan is updated. (30days, quarterly, Sig change) or any time a resident is out of facility or discharges.

3.  Will be reviewing ABST weekly when schedule is created to ensure we have enough staffing hours, or anytime a significant change is made to the ABST. (new move in or higher acuity).   

4. This will be monitored by DHS, RCC and Executive Director.   

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed prior to staff providing direct care to residents, for 4 of 4 newly-hired caregiving staff (#s 7, 8, 10, and 11). Findings include, but are not limited to:

Review of the facility's training records on 07/23/24 indicated the following:

Staff 7 (MT), hired 3/20/24, Staff 8 (MT), hired 3/18/24, Staff 10 (CG), hired 6/5/24, and Staff 11 (CG) hired 6/7/24, lacked documented evidence they had completed pre-service orientation and pre-service dementia training prior to providing direct care to residents.

The training program and requirements were discussed with Staff 1 (Executive Director) on 07/23/24. She acknowledged the findings.

370-OAR 411-054-0070

Staffing requirments and training: Caregiver requirments.

1.  A complete audit of all trainings have been done and are scheduled for completion. Training grid has been updated and will be maintained by BOM.  

2. New staff will not be allowed to work on the floor until pre service trainings are completed.  

3. Will be audited montly at CQI meetings.

4. This will be monitored by Business office and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 7, 10, and 11) demonstrated satisfactory performance in all job duties and been trained in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 07/23/24.

There was no documented evidence Staff 7 (MT), hired 03/20/24, Staff 10 (CG), hired 06/05/24, and Staff 11 (CG), hired 06/07/24, had demonstrated competency all job duties. Staff 8 and 11 had no evidence of being trained in First Aid and abdominal thrust.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid and abdominal thrust training was reviewed with Staff 1 on 07/23/24. She acknowledged the findings.

372- OAR 411-054-0070

30 day direct care staff

1. A full audit has been completed to identify any missing trainings. Training grid has been updated and will be maintained by BOM.  

2. Daily stand up report include a review of any outstanding trainings. Staff will be scheduled for all required trainings within 30 days of hire.

3. Will be audited 5 days a week at stand up meeting's and monthly at CQI.

4. This will be monitored by BOM and Executive Director.   

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records for 02/2024 through 07/23/24 were reviewed and lacked the following components:

* There was no documented evidence fire and life safety training was conducted on alternating months of fire drills.

The need to ensure the facility provided fire and life safety instruction to staff on alternate months of fire drills was discussed with Staff 1 (Executive Director ) on 07/23/24 at 3:30 pm. She acknowledged the findings.

C420- OAR 411-054-0090

Safety

1. Fire, life and safety training will be provided at next all staff meeting.

2. A rotating agenda for all staff meetings has been implemented to ensure adequate training has been provided on alternating months from fire drills.

3. Will be reviewed monthly as part of CQI.

4. This will be monitored by Maintenance Director and Executive Director.  

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C302.

C 455 OAR 411-054-0105

Inspection and investigation - faciliy failed to ensure their re-licensure survey plan was implemented and satisfied

Refer to POC for C302

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

On 07/23/24 at 1:00 pm, the facility courtyard was toured and the following was observed:

* Loose lawn and maintenance tools in multiple areas;

* A tall ladder leaned against the building;

* Numerous empty pots or pots with dead plants were scattered throughout;

* Black trash bags filled with dead plant matter;

* A garden hose laid across the sidewalk, causing a potential tripping hazard;

* The wooden seat of a sitting bench was rough and had numerous splintered areas; and

* Pet feces was observed in the grass in multiple areas.

The need to ensure facility grounds were kept orderly and free of litter and refuse was observed and discussed with Staff 1 (Executive Director) on 07/23/24 at 4:00 pm. She acknowledged the findings.

C610- OAR 411-054-0300

Bulding Exterior

1. All the areas identified have been corrected. A complete walk through of the exterior has been done to identify any other concerns.

2.  Maintenance Director will do a weekly walk through to identify areas of concern.

3. Review of walk through audit weekly.

4.  Maintenance Director, Executive Director

Based on observation and interview, it was determined the facility failed to ensure all interior surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 07/23/24 at 1:00 pm revealed the following:

* Gouged and scraped doors and/or jambs were observed in the following areas:

- Resident rooms 102, 139, 144, 146, and 147;

- Doors to courtyard from television room;

- Resident laundry room;

- Dining room double doors; and

- Entrance door to kitchen.

* The spa room had a scraped wall corner near the toilet;

* The common women's bathroom in the hallway had discolored caulking around the toilet base and an approximate 12-inch split seam in the flooring on both sides of the toilet;

* The common men's bathroom in the hallway had caulking missing from a section surrounding the sink basin;

* The common men's bathroom, located near the Executive Director's office, had discolored caulking around the toilet base;

* The resident laundry room had an accumulation of debris in the sink basin and used paint supplies and roller on the shelf; and

* The dining beverage buffet had brown matter and loose debris on the interior of several cabinets.

The surveyor toured the environment with Staff 1 (Executive Director) on 07/23/24 at 4:00 pm. She acknowledged the findings.

C613 - OAR 411-0300

Building: Doors- Wall, Cleanable

1. All areas identified have been corrected. Areas of suggestion have requested bids for bathroom flooring.

2. Maintenance Director will do a weekly walk through to identify areas of concern.  

3. Reivewing of walk through audit weekly.

4. Maintenance Director, Executive Director