Print Inspection: 3D3O

The findings of the on-site investigation, conducted 09/25/2023, 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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, during a site visit conducted on 09/25/23, 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 (#2) who was reviewed. Findings include, but are not limited to:

In an interview on 09/25/23, Staff 2 (RN) stated, "Showers are documented in our computer system, however, I do not see any entries for this resident. I know the resident should be getting stand-by assistance with showers every Monday, Wednesday, Friday, and Sunday. I cannot provide a document that shows the facility has been assisting the resident."  

In an interview on 09/25/23, Resident 2 stated, "I had a hip replacement and I get seizers, this is why I need stand-by assistance with showers. I have showered many times with no staff standing by and that is extremely scary to me because I do not know when I might have a seizer. I should be getting stand-by assistance every Monday, Wednesday, Friday, and Sunday. Today is Monday and I have not received assistance yet, the last time I had someone assist me was last Wednesday."  

A review of Resident 2's service plan, dated 09/06/23, and the shower schedule, updated on 08/21/23 indicated Resident 2 was scheduled for stand-by assistance every Monday, Wednesday, Friday, and Sunday on night shift.

It was confirmed the facility failed to ensure Resident 2's service plan was implemented.

On 09/25/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The community has implemented an immediate ISP to reflect resident showers with stand by assist by a caregiver. In addition, caregivers are to document electronically to show that bathing services were completed. The facility has also Implemented a form that will allow for resident and staff to sign off at the service provided.  

Based on observation, interview, and record review, conducted during a site visit on 09/25/23, it was confirmed the facility failed to have a staff person who administers the medication visually observe the resident take the medication for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During a site visit on 09/25/23, CS observed multiple medications in small paper cups around Resident 6's apartment.

In an interview on 09/25/23, Resident 2 stated, "I am concerned about my friend. S/he should be getting medication administered from the facility; however, the med techs come into his/her room and drop the medication off without watching him/her take them and now the facility is blaming him/her for all the medication found in his/her room."  

In an interview on 09/25/23, Resident 6 stated, "The med tech came in earlier and dropped off this cup of medication. I have lots of medication around my apartment and have been trying to speak with the RN about it. I moved here to receive help with my medication management and when they drop the medication off it is confusing to me." CS asked Resident 6 if she/he could identify the medication in the cups around the room. Resident 6 stated, "Trazadone, Oxycodone, and Lamotrigine."

A review of Resident 6's 09/01/23 through 09/25/23 MARs showed the medications Trazadone, Oxycodone, and Lamotrigine to be administered by the facility. In the comment section of the MARs there were several entries noted where the resident had declined medication because "I already have some." On 09/25/23 at 2:36 am staff documented "no" on the MAR, indicating medication administration had not been witnessed. A review of Resident 6's service plan, dated 07/10/23, indicated under medication, resident is was not safe to administer his/her own medication.

It was confirmed the facility failed to have a staff person who administers the medication visually observe the resident take the medication.

On 09/25/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal Plan of Correction:  The community has completed an immediate ISP for all med techs to review and sign regarding Medication and Administration. Regarding this incident, a form has been created to document resident has been given medications and verified they were taken by resident prior to exiting apartment. In addition, resident is to verbally and have written consent medications are not being left in apartment and both Med tech and resident are to sign off. This apartment will be audited daily per shift, to verify medications are not left unattended, if Medications are found, they are to be removed, report to RN or Nurse, complete and IR/APS report, and communicate to MD. In addition, RN will hold an In-service on 10/3/2023 with all Med techs.

a. Based on interview and record review, conducted during a site visit on 09/25/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4) sampled resident (#1). Findings include, but are not limited to:

In an interview on 09/25/23, Staff 2 (RN) stated, "On 08/30/23, a medication error was reported. The facility filed a self-reported medication error form to APS, pulled the med tech off the med cart, and conducted additional training. The resident's medication had recently changed from 100mg to 50mg. The med tech was looking at the correct MARs but popped the old medication pack."

On 09/25/23, CS attempted to interview Resident 4, however, resident was not in their room at the time.

A review of the facility self-report, dated 08/30/23, indicated Resident 4 had been administered 100mg Pregabalin three doses of his/her scheduled 8:00 pm medication pass after the order had been discontinued. The resident should have been administered 50 mg of Pregabalin.

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

On 09/25/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting. In addition, regarding this incident; the community placed the med tech on suspension and demoted from med tech role day of medication error, in addition, this staff member was also terminated. These steps are to be followed in addition to provide additional training following OAR's Medication Administration and Frontier policies and procedures. RN is scheduled to obtain a Med Tech training on 10/3/2023.

b. Based on interview and record review, conducted during a site visit and email correspondence on 09/25/23 and 09/28/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#7). Findings include, but are not limited to:

In an interview on 09/28/23, Staff 3 (ED) stated, "On 09/22/23, a medication error was reported. The facility filed a self-reported medication error form to APS. A med tech gave a resident a different residents medication."

A review of the facility self-report dated 09/22/23, indicated Resident 7 had been given another residents Levothyroxine. A TSP indicated staff were instructed to ensure Resident 7 had increased water intake. Resident 7 was placed on alert charting for 72-hour monitoring, PCP, POA, and APS notified.

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

On 09/25/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting, proceeded with documented corrective action on staff member, provide additional training following OAR's Medication Administration and Frontier policies and procedures. RN is scheduled to obtain a Med tech training on 10/3/2023.

Based on interview and record review, conducted during a site visit and email correspondence on 09/25/23 and 09/28/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

On 09/25/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required 28.30 care staff for the day.

A review of the posted staffing plan and staff schedule for August and September 2023, indicated for day and swing shift there are five CG's and two MT's scheduled and on NOC shift there are three CG's and one MT. Totaling 18 care staff scheduled per day.

In an interview on 09/25/23, Staff 2 (RN) stated, "The facility uses our own ABST tool, it generates points for each ADL for every resident. Those points are converted into the total number of minutes and that tells us the required staff per day."  

In an email correspondence on 09/28/23 Staff 3 (Executive Director) stated, "We take the total number of minutes which for the date of the site visit was 12739 and divide that by 7.5 to get 1698.53, then divide that number by 60 and that gives us the total of staff needed for that day, which is 28.30."  

The facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.

On 09/28/23, the findings were reviewed with and acknowledged by Staff 3.