Print Inspection: 358C

The findings of the on-site investigation, conducted 06/01/23 through 06/02/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

LPN:Licensed Practical Nurse

MT:            Medication 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

Based on observation, interview and record review, during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation for 1 of 1 sampled resident (# 5) whose service plan was reviewed. Findings include, but are not limited to:

On 06/01/23 at 1:30 pm, Resident 5 was observed in his/her apartment in a his/her wheelchair. Resident was clean and dressed appropriately for time of day and season in jeans and a t-shirt. Resident was noted to be stepping on the back of his/her shoes.

On 06/02/23 at 1:20 pm, Resident 5 was observed to self-propel in his/her wheelchair throughout the facility and resident was stepping on the backs of his/her sneakers.

In an interview on 06/01/23, Resident 5 stated s/he needs help putting his/her shoes on, but s/he doesn't get help with their shoes. Resident stated they are unable to reach their feet easily and lack the full use of his/her dominant hand and therefore also needs assistance with toileting.

In an interview on 06/02/23, Staff 6 (CG) stated s/he helps Resident 5 with showers, especially with washing and drying his/her feet as s/he is unable to reach them, then assists resident with getting dressed. Staff 6 stated s/he does not assist resident with putting on his/her shoes because s/he steps on the backs of them.

Resident 5's service plan dated 03/21/23, indicated  for AM Care "resident will sometimes need help with ADL's but is normally able to perform all ADL's independently." Resident 5's service plan lacked specific guidance for assistance with dressing and putting on shoes.

The facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

Verbal Plan of Correction:

The RCC, Administrator and RN will review Resident 5's current service plan against his/her current condition and update as appropriate.

Based on interview and record review during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure they had written, signed physician orders documented in the resident's facility record for all medications and treatments that the facility is responsible to administer for 1 of 1 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2's clinical records were reviewed. An Oregon Medical Marijuana Program application and an Oregon Medical Marijuana Program Patient Card were located in his/her chart. There was no signed physician order located for the facility to administer resident's medical marijuana.

Review of Resident 2's 10/2022 MAR indicated the facility was administering residents cannabis medicated caramel candies. Progress note created by Staff 3 (RCC) dated 10/20/22 states "removed resident cannabis candies from the narcotic drawer and gave them to resident to keep in his/her possession."

In an interview on 06/01/23, Resident 2 stated the facility used to administer his/her cannabis, but now s/he keeps it in their room to self-administer and uses it as needed.

In an interview on 06/01/23, Staff 5 (MT) stated that s/he used to administer cannabis candies to Resident 2 but has not worked that floor or shift in a long time so is unsure if the facility still administers resident's cannabis.

In an interview on 06/02/23, Staff 1 (Administrator) and Staff 3 confirmed the facility used to administer the cannabis candies for Resident 2, but after it was brought to their attention that the practice was unacceptable the facility RN discontinued the practice.

The facility failed to ensure they had written, signed physician orders documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 06/02/23.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on interview and record review during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure physician orders were carried out as prescribed for 2 of 2 sampled residents (#'s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. A review of Resident 1's clinical records noted an order, dated 09/01/22 to receive Lorazepam one tablet twice daily as needed for anxiety with at least four hours in between doses.

Review of Resident 1's 11/2022 MAR indicated the resident received Lorazepam three times on 11/14/22 and 11/15/23.

Review of Incident #1722, dated 11/18/22, indicated Resident 1's Lorazepam was given three times instead of as prescribed.

In an interview on 06/01/23, Resident 1 stated s/he has had issues with their medications off and on at the facility but does not recall specific details.

In an interview on 06/01/23, Staff 1 (Administrator) and Staff 3 (RCC) confirmed the facility has had a lot of medication errors, but they have been doing a lot of training with staff in order to reduce these occurrences.

2. A review of Resident 3's clinical records noted an order, dated 12/05/22 to receive Vascepa two tablets twice daily for 90 days.

Review of Resident 3's 11/2022 MAR  indicated the resident did not receive medication from 11/18/22 until evening 11/26/22. Medication was noted as "Med not here from pharmacy, pharmacy has been notified."

On 06/01/23 and 06/02/23, CS attempted to interview Resident 3 who was unavailable.

In an interview on 06/01/23, Staff 1 (Administrator) and Staff 3 (RCC) confirmed the facility has had a lot of medication errors, but they have been doing a lot of training with staff in order to reduce these occurrences.

The facility failed to ensure physician orders were carried out as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 06/02/23.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on interview and record review, during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (# 1) whose orders were reviewed. Findings include, but are not limited to:

A review of Resident 1's clinical records noted an order, dated 03/01/23, for lorazepam to take 1 tablet by mouth twice daily as needed for anxiety not to exceed 180/90 days and four hours between doses.

Review of Resident 1's 05/2023 MAR indicated resident received PRN lorazepam on 05/01/23 at 1:34 pm and 4:43 pm, less than the ordered four hours between doses. On 05/04/23 Resident 1 received lorazepam three times.

Review of Incident #94 and #96, dated 05/09/23, indicated Resident 1 received a third dose of lorazepam on 05/09/23.

In an interview on 06/01/23, Resident 1 stated s/he has had issues with their medications off and on at the facility but was not able to give specific details around these instances.

In an interview on 06/02/23, Staff 4 (Director of Nursing) confirmed there have been a lot of medication errors and specifically with Resident 1.

The facility failed to ensure physician orders were carried out as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on interview and record review during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled residents (# 7) whose orders were reviewed. Findings include, but are not limited to:

A review of Resident 7's clinical records noted an order, dated 05/05/23, for ciprofloxacin to be administered twice daily for 7 days and to hold tizanidine for duration of ciprofloxacin. On 05/10/23, an order was received to discontinue ciprofloxacin and to start a new order for levofloxacin for three days.

Review of Resident 7's 05/2023 MAR indicated resident received nine doses of ciprofloxacin from 05/06/23 - 05/10/23, and received 16 doses of discontinued order for tizanidine from 05/06/23 - 05/10/23.

The CS attempted to interview Resident 7 on 06/01/23 and 06/02/23, but resident was unavailable.

In an interview on 06/02/23, Staff 4 (Director of Nursing) stated Resident 7 refused to discontinue taking his/her tizanidine medication and stated they would rather not take the antibiotic ciprofloxacin than to stop taking the only medication that makes him/her feel comfortable therefore the facility requested that the physician prescribe a different antibiotic that would not interfere with Resident 7's tizanidine.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

The facility failed to ensure physician orders were carried out as prescribed.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on interview and record review, during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled residents (# 6) whose orders were reviewed. Findings include, but are not limited to:

A review of Resident 6's clinical records noted an order, dated 04/16/23, to start taking oxycodone one to three tablets every four hours as needed for severe pain. Facility received a faxed discontinue order for oxycodone dated 05/02/23 time stamped 1:56 pm.

Review of Resident 6's 05/2023 MAR indicated resident received PRN oxycodone on 05/02/23 at 4:27 pm.

Review of Incident #70, dated 05/02/23, indicated Resident 6 received one dose of his/her oxycodone after it was discontinued.

The CS attempted to interview Resident 6 on 06/02/23 but s/he stated they were busy and did not have time to answer questions.

In an interview on 06/02/23, Staff 4 (Director of nursing) stated Resident 6 was administered a discontinued medication.

The facility failed to ensure physician orders were carried out as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on interview and record review, during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled residents (# 5) whose orders were reviewed. Findings include, but are not limited to:

A review of Resident 5's clinical records indicated an order was received, dated 01/04/23, to change his/her pregabalin medication by increasing the dosage from 50mg to 75mg twice daily.

Review of Resident 5's 02/2023 MAR indicated resident orders were input correctly to administer 75mg of Pregabalin twice daily.

Review of Incident #1963, dated 02/12/23, indicated Resident 5 received his/her old dose of pregabalin at 50mg instead of 75mg on 02/12/23. Incident report indicates the determined cause to be med tech "grabbed the wrong medication card."

In an interview on 06/01/23, Resident 5 stated s/he has had issues with their medications but does not recall this specific event with his/her pregabalin.

In an interview on 06/02/23 Staff 1 (Administrator), Staff 3 (RCC) and Staff 4 (Director of Nursing) stated the facility has had a lot of medication errors, but they have been doing a lot of training with staff in order to reduce these occurrences.

The facility failed to ensure physician orders were carried out as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

Verbal Plan of Correction:

The facility has begun bringing in an RN consultant to provide regular training for med techs to help reduce medication errors. The most recent training occurred on 05/25/23. This was the second training conducted and there are more scheduled. The facility has also changed their charting system to Point Click Care in April and this system should help reduce errors as all staff are adjusting to the new system.

Based on observation, interview and record review, during a site visit from 06/01/23 through 06/02/23, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool for 3 of 3 sampled residents (#'s 6, 7 & 8) whose records were reviewed. Findings include, but are not limited to:

1. Resident 6's Acuity Based Staffing Tool (ABST) and service plan dated 05/30/23 were reviewed. ABST indicated resident required 638.05 hours of care. Resident's service plan indicated resident required a minimum amount of staff assistance with ADL's indicating 'as needed', resident able to direct care.

On 06/02/23 at 1:32 pm Resident 6 was observed to be able to self-transfer and ambulate. Resident was observed to be groomed and clean, s/he was cognizant and able to direct wants and needs.

The CS attempted to interview Resident 6 on 06/02/23 but s/he stated they were busy and did not have time to answer questions.

In an interview on 06/02/23, Staff 6 (CG) stated Resident 6 has memory issues, typically does not want shower assistance, and needs more emotional assistance rather than hands on assistance.

2. Resident 7's ABST and service plan dated 04/25/23 were reviewed. ABST indicated resident required 916.25 hours of care. Resident service plan indicated resident ADL needs were written as "staff to assist as needed" or "if resident requests". Resident Service Plan did not indicate resident required nail care or staff to monitor skin issues.

A review of Resident 7's Interim Service Plan, dated 05/27/23, indicated s/he attempted to cut his/her toenails and caused his/her toe to bleed. Staff are to assist in changing band aid when needed and check right great toe daily.

ABST indicated zero minutes spent on providing treatments.

The CS attempted to interview Resident 7 on both 06/01/23 and 06/02/23, but resident was unavailable.

3. Resident 8's Acuity Based Staffing Tool (ABST) and service plan dated 05/23/23 were reviewed. ABST indicated resident required 502.5 hours of care. Resident service plan indicated resident requires staff assistance for ADL's except oral hygiene, resident also required EMT lift assistance for falls.

On 06/02/23 at 12:55 pm, Resident 8 was observed sitting upright on the side of his/her bed, dressed without shoes on.

In an interview on 06/02/23, Resident 8 stated s/he uses his/her call light when s/he needs assistance. Staff come to ask if s/he needs assistance with showers. S/he will use incontinence supplies on bed rather than wait for staff to respond to call light.

In an interview on 06/01/23, Staff 3 (RCC) stated s/he had been out on vacation for three weeks and had not noted changes in the ABST for Resident's 6, 7, and 8 since s/he had been back. Staff 3 confirmed s/he had made a mistake entering information into the ABST and was inputting time required to complete tasks rather than the frequency the task was required to be completed resulting in more care hours being shown in the ABST than actually required.

The facility failed to fully implement an Acuity Based Staffing Tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 06/02/23.

Facility Verbal Plan of Correction:

Staff 3 had the ABST updated for all residents before exit on 06/02/23.