Print Inspection: 4BBM

The findings of the re-licensure survey, conducted 08/22/22 to 08/23/22, 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

MCCMemory 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 revisit to the re-licensure survey of 08/23/22, conducted on 12/05/22, 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 observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2021 with diagnoses including dementia.

Observations of the resident, interviews with staff from 08/22/22 to 08/23/22, review of the service plan, dated 08/02/22, Charting Notes, incident reports, physician communication, and hospice documentation showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Sleeping pattern and preferences;

* The use of compression hose;

* Incontinent product use;

* Assistance with dressing;

* Hospices services; and

* Hearing Aid use.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 07/2022 with diagnoses including obesity.

Observations of the resident, interviews with staff, review of the updated service plan from 08/17/22, and subsequent temporary service plans were reviewed during the survey and showed the plan was not reflective of the resident's current status or failed to provide specific instruction and precautions to staff in the use of side rails.

On 08/23/22, the need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Resident 2 service plan updated on August 23, 2022 to reflect sleeping pattern and preferences; incontinent product use; assistance with dressing; Hospice services; and hearing aid use.

Resident 1 service plan updated on August 23, 2022 to provide specific instruction and precautions to staff in the use of siderails.

A service plan audit will be completed by October 15, 2022. Wellness Director will be responsible for ongoing compliance.  

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2022. Review of the residents MAR, between 08/01/22 - 08/22/22, identified the following deficiencies:

a. Resident 1 was prescribed the following PRN medications for constipation:

* Polyethylene Glycol 3350 powder; and

* Senna 8.6 mg.

Resident 1 was prescribed the following PRN medications for insomnia:

* Trazodone 50 mg; and

* Melatonin 10 mg.  

The MAR failed to include clear parameters and instructions to unlicensed staff for when each medication should be administered.

b. The following medications lacked reasons for use on the resident's MAR:

*Folic Acid 1 mg;

*QVAR Redihaler 40 mcg;

* Senna 8.6 mg;

*Thermotabs; and

*Vitamin B-12 2,500 mcg

c. Resident 1's PRN Albuterol 90 mcg lacked specific parameters for frequency of use.

d. Resident 1's service plan, dated 08/17/22, indicated the resident had allergic reactions to Prednisone. The MAR failed to identify Prednisone as an allergy.

On 08/23/22, the need to ensure MARs were accurate and included parameters for PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Resident 1: PRN constipation, insomnia, and Albuterol medication orders were clarified in MAR, with specific parameters and instructions to unlicensed staff for when medications should be administered, on August 24, 2022. Wellness Director L.P.N./R.N. will complete PRN medication audit. PRN audit will be completed by October 15, 2022. Wellness Director L.P.N./R.N. will be responsible for reviewing all new PRN medication orders upon receipt to ensure parameters are documented in the MAR. Wellness Director L.P.N./R.N. will be notified of new orders and will be responsible for ensuring parameters are appropriate and resident specific. Wellness Director L.P.N./R.N. will be responsible for reviewing all PRN medication orders quarterly to ensure resident specific parameters are documented in the MAR. Wellness Director L.P.N./R.N. will document PRN parameter review status on RN quarterly assessments. Wellness Director L.P.N./R.N. will be responsible for ongoing compliance

Resident 1 medications reasons for use were updated on August 23, 2022. Wellness Director L.P.N./R.N. will complete a MAR audit to ensure all medications have a reason for use.  MAR audit will be completed by October 15, 2022. Wellness Director L.P.N./R.N. will be responsible for ongoing compliance.

Resident 1 known drug allergies were entered into the MAR on August 23, 2022. Wellness Director L.P.N./R.N. will complete a MAR audit to ensure all drug allergies are entered into the MAR. The MAR audit will be completed by October 15, 2022. Wellness Director L.P.N./R.N. will be responsible for ongoing compliance.     

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:

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents and included all the required ABST elements.

The requirements of the ABST were discussed with Staff 1 (ED) on 08/22/22. She acknowledged the current acuity tool in use by the facility did not include all the required information and did not generate a staffing plan.

On August 30, 2022, The Oregon Department of Human Services ABST was implemented. Current staffing plan reviewed and confirmed compliance with consistently staffing to the levels, intensity, and qualifications indicated by the ABST.

The Wellness Director L.P.N./R.N., Executive Director, and/or designee will update the Oregon Department of Human Services ABST as outlined in OAR 411-054-0037 and ensure that current staffing plan is in compliance with consistently staffing to the levels, intensity, and qualifications indicated by the ABST.

Based on interview and record review, it was determined the facility failed to ensure Fire drills were conducted in accordance with Oregon Fire Code. Findings include, but are not limited to:

The facility Fire and Life safety records from March 2022 through July 2022, failed to consistently document the following required fire drill components:

*Escape route used;

*Number of occupants evacuated; and

*Evidence alternate routes were used during fire drills.

On 08/22/22, the need to ensure fire drills had documented evidence of all required components was discussed with Staff 1 (ED). She acknowledged the findings.

On August 23, 2022, Cascade Living Group "Oregon-Fire Drill Report" was updated to document the escape route used; and number of occupants evacuated; and evidence alternate routes were used during fire drills.

Plant Operations Director and/or Designee will implement the updated "Oregon-Fire Drill Report" for fire drills beginning in September 2022.

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

The facility grounds were toured on 08/22/22 and the following was observed:

* Drop-offs greater than 12 inches from the sidewalk to the adjacent lawn and planting beds; and

* Refuse and debris around the building and in resident window wells.

The building exterior was reviewed with Staff 1 (ED). She acknowledged the findings.

CS Construction, Botanical Landscaping Inc. and/or Cascades of Bend will install topsoil and/or landscaping product to ensure sidewalk drop-offs are not greater than 12 inches by October 15, 2022.

CS Construction and Cascades of Bend will remove refuse and debris around the building and in resident window/PTAC wells by October 15, 2022.

Plant Operations Director will be responsible conducting weekly audits to ensure the sidewalk drop-offs are not greater than 12 inches and exterior grounds and window PTAC are free of refuse and debris Plant Operations Director will be responsible for ongoing compliance.