The findings of the re-licensure survey conducted 08/21/23 through 08/23/23 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 08/23/23, conducted 10/26/23, 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 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) who was recently admitted to the facility. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease.

The move-in evaluation, completed on 07/10/23, failed to address the following required elements:

* Cognition: decision making abilities;

* Personality: including how the person copes with change or challenging situations; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (ALF Administrator), Staff 2 (RN Case Manager), Staff 3 (RN Case Manager) and Staff 5 (Ministry Administrator) on 08/23/23. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

For the resident noted in this citation, the move-in evaluation will include the required elements:

* Cognition: decision making abilities

* Personality: including how the person copes with change or challenging situations

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, and room temperature.

Plan:

1.All evaluation forms have been revised, updated, and reviewed with RN to include required elements.

2.All existing evaluations have been updated to include required elements.

3.An audit will be conducted weekly on all move-in evaluations to ensure all required elements are included; monthly audits will be completed for three months following.   

4.The ALF Administrator is responsible.

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

Resident 2 was admitted to the facility in 08/2020 with diagnoses including congestive heart failure.

Resident 2's 08/01/23 through 08/20/23 MAR was reviewed, the following PRN medications lacked resident-specific parameters for administering:

* PRN acetaminophen 325 mg and PRN hydromorphone 2 mg were both prescribed to treat pain; and

* PRN acetaminophen 650 mg suppository and PRN acetaminophen 325 mg tablet were both prescribed to treat fever.

The need to ensure MARs included clear parameters for multiple PRN medications which were prescribed to treat the same condition, parameters were followed as indicated, and MARs included all required components was discussed with Staff 1 (ALF Administrator), Staff 2 (RN Case Manager), Staff 3 (RN Case Manager) and Staff 5 (Ministry Administrator) on 08/23/23. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

For the resident noted in this citation, PRN medications now includes resident-specific parameters for administering the following:

* PRN acetaminophen 325 mg or PRN hydromorphone 2 mg to treat pain.

* PRN acetaminophen 650 mg suppository or PRN acetaminophen

325 mg tablet to treat fever.

Plan:

1.All MARs include clear parameters when a PRN is prescribed to treat the same condition, parameters will be followed as indicated, and MARs will include all required components.

2.The RN Case Manager will ensure the MARs include clear parameters for multiple PRN medications that are prescribed to treat the same condition, parameters will be followed as indicated.

3.An In service will be conducted with all medication trained staff regarding PRN medication administration.

4.An audit will be conducted weekly on all PRN parameters to ensure all required elements are included; monthly audits will be completed for three months following.  

5.The ALF Administrator is responsible to ensure compliance with this requirement.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2020 with diagnoses including congestive heart failure. The resident was admitted to hospice in 01/2022.

Review of the resident's 08/01/23 through 08/20/23 MAR and current physician orders revealed an order for lorazepam 0.5 mg, one tablet to be administered every 2 hours as needed for anxiety, restlessness or agitation.

The facility administered lorazepam on twelve occasions between 08/01/23 and 08/20/23.

The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as agitation. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication.

In an interview on 08/22/23 with Staff 2 (RN Case Manager) and Staff 3 (RN Case Manager), they stated the parameter sheet for lorazepam was created by the hospice nursing team in 01/2022 and did not provide any additional information regarding behavior presentation or non-pharmacological interventions to attempt prior to medication administration.

The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and that non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 1 (ALF Administrator), Staff 2, Staff 3 and Staff 5 (Ministry Administrator) on 08/22/23 and 08/23/23. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

For the resident noted in this citation, the MAR now indicates resident-specific parameters for staff describing how the resident presents behaviors such as agitation with clear instructions on how to document what non-pharmacological interventions were attempted prior to administration of the medication.

Plan:

1.All PRN psychotropic medication used to treat resident behaviors will have written, resident-specific parameters and non-pharmacological interventions will be attempted and documented as not effective prior to administration of the medication.

2.The RN Case Manager will ensure the parameters include all noted resident-specifics.

3.An In service will be conducted with all medication trained staff regarding PRN medication administration.

4.All PRN psychotropic medications used will be audited weekly for two months to ensure there are resident-specific descriptions of how the resident behaviors present, and that non-pharmacological interventions (unless ordered differently by prescribing physician) will be attempted and documented as not effective prior to administration of the medication; monthly audits will be completed for three months following.

5.The ALF Administrator is responsible.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for February 2023 through August 2023 identified the following:

* There was no documented evidence fire and life safety instruction for staff had been consistently conducted and documented on alternate months; and

* The facility had not documented residents being relocated or evacuated during fire drills, and there was no documentation of the escape route used, problems encountered, comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated.

The need to ensure the facility conducted and documented fire drills as required and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (ALF Administrator) and Staff 6 (Maintenance and Environmental Supervisor) on 08/23/23 at 1 pm. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

For the facility citation, the facility will ensure fire drills are conducted and documented as required and fire and life safety instruction to staff on alternate months will be provided.

Plan:

1.Fire drills will be conducted in accordance with Oregon Fire Code with fire and life safety instruction given to staff documenting the occurrence on alternate months.

2.Facility fire drill forms have been updated to include documentation of:

* Residents being relocated or evacuated during fire drills

*Escape route used

*Problems encountered

*Comments relating to residents who resisted or failed to participate in the drills

*Number of occupants evacuated

3.Fire drill forms will be reviewed after drills.

4.An annual training calendar of Life Safety instruction has been developed.

5.The ALF Administrator is responsible.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually in fire and life safety in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records for 02/23 through 08/23 were reviewed on 08/23/23.

There was no documented evidence the facility provided annual fire and life safety training for residents that included:

* General safety procedures;

* Evacuation methods;

* Responsibilities during fire drills; and

* Designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need to ensure residents were trained annually on the required fire and life safety topics was discussed with Staff 1 (ALF Administrator) and Staff 6 (Maintenance and Environmental Supervisor) on 08/23/23. The acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

For the facility citation, all residents will be trained annually on the required fire and life safety:

*General safety procedures

*Evacuation methods

*Responsibilities during fire drills

*Designated meeting places outside the building or within the fire safe area in the event of an actual fire

Plan:

1.A written record of annual fire safety training, including content of the training will be completed with residents during annual evaluation and service planning meeting.

2.The annual evaluation form has been updated to include review of required elements.

3.A quarterly audit will be completed to ensure compliance.

4.The ALF Administrator is responsible.