Print Inspection: 5Y9P

Based on interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to develop and implement a policy on smoking. Findings include, but not limited to:

During an interview on 08/28/24, Staff 1 (Executive Director), Staff 2 (LPN), Staff 3 (RCC), and Staff 4 (RN) all acknowledged around seven residents including Resident 5 had been smoking methamphetamines in the facility. Staff 1 indicated the facility does have a policy and procedure for smoking however Resident 5 did not follow the policy.

A review of the facility's policy and procedure for smoking indicated the company prohibits smoking in the building or within 10 feet of the entrance.

A review of a facility internal investigation 04/08/24, regarding Resident 5's drug use indicated resident had brought illegal drugs into the community and was using methamphetamine on the premises. Resident had been given verbal warnings. Resident 5's behavior has resulted in other residents who were in recovery to relapse, setting off fire alarms, and invited homeless drug users into the community who have threatened staff, brought weapons, stolen food from the kitchen, and entered other resident's rooms.

It was confirmed the facility failed to develop and implement a policy on smoking.

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The executive director will continue to remind resident of the facility's policy and procedure for not smoking in his/her apartment.

Based on interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to provide a safe and homelike environment. Findings include, but not limited to:

During an interview on 08/28/24, Staff 1 (Executive Director), Staff 2 (LPN), Staff 3 (RCC), and Staff 4 (RN) all acknowledged around seven residents including Resident 5 had been smoking methamphetamines in the facility.

During an interview on 08/28/24, Resident 10 indicated knowledge of Resident 5's drug use and inviting homeless drug users into the facility. Resident 10 indicated the unwanted guests in the facility had threatened other residents and staff and people did not feel safe in the facility.

A review of a facility internal investigation 04/08/24, regarding Resident 5's drug use indicated resident had brought illegal drugs into the community and was using methamphetamine on the premises. Resident had been given verbal warnings. Resident 5's behavior resulted in other residents who were in recovery to relapse, setting off fire alarms, and invited homeless drug users into the community who have threatened staff, brought weapons, stolen food from the kitchen, and entered other resident's rooms.

It was confirmed the facility failed to provide a safe and homelike environment.

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has attempted to issue a 30-day's notice to resident. The staff have asked the homeless people to leave the facility. The facility changed the door codes.

Based on interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#4). Findings include, but not limited to:

During an interview on 08/28/24, Staff 1 (Executive Director), Staff 2 (LPN), Staff 3 (RCC), and Staff 4 (RN) all acknowledged that the facility had a difficult time filling Resident 4's medication and the resident had not been given his/her medication as prescribed.

During an interview on 08/28/24, Resident 4 indicated the facility had not provided his/her medication on multiple occasions due to them not reordering timely.

A review of Resident 4's MARs from 05/01/24 through 05/31/24 indicated the following medications that had not been administered;

·Atorvastatin 80MG once daily for antihyperlipidemic had not been given on 05/17/24.

·Baclofen 10MG three times daily for musculoskeletal therapy had not been provided on 05/17/24 at 10:00 PM.

·Eliquis 5MG twice daily for anticoagulants had not been given 05/17/24 at 10:00 PM.

·Gabapentin 600MG two tablets every eight hours had not been provided six times at 6:00 AM and once at 10:00 PM.

·Hydrocodone 325MG take one tablet by mouth every eight hours for 28 days for fibromyalgia. The start date had been 05/02/24. Resident had not received medication 52 times.

·Tamsulosin 0.4MG once daily for benign prostatic hyperplasia had not been given on 05/17/24.

·Topiramate 25MG once daily for anticonvulsants had not been given on 05/17/24.

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

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will follow the doctor's orders as prescribed and have a meeting with staff to remind them to order medication timely.

Based on interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#2). Findings include, but not limited to:

During an interview on 08/28/24, Staff 1 (Executive Director) indicated on or around 04/12/24 Resident 2 changed from self-administering medication to having the facility take over medication management.

During an interview on 08/28/24, Resident 2 indicated the facility had not provided his/her medication on multiple occasions due to them not reordering timely.  

A review of Resident 2's MARs from 06/01/24 through 07/31/24 indicated the following medications that had not been administered;

"Atorvastatin 40MG tablet once daily to lower risk of heart attack or stroke, on 06/24/24, medication had not been available or administered.

"Diclofenac topical gel for joint pain. Resident 2 missed medication on 06/20/24, 06/23/24, 06/24/24, and 06/26/24.

"Hydrocortisone cream twice daily for itchy skin had not been administered on 06/08/24 and 06/09/24.

"Hydrocortisone cream once daily for itchy skin had not been administered on 06/14/24, 06/15/24, 06/16/24, 06/18/24, 06/21/24, 07/09/24, 07/25/24, and 07/28/24.

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

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility had not provided a plan of correction.

Based on observation and interview, during a site visit conducted on 08/28/24, it was confirmed the facility failed to ensure the interior of the facility was free from unpleasant odors. Findings include, but are not limited to:

On 08/28/24, Compliance Specialist observed a strong odor of urine in the main common area spaces, throughout the hallways, and coming from Resident 1's apartment. Resident 1's apartment had multiple stains on the carpet and had not appeared recently cleaned. Compliance specialist had not observed the facility staff shampoo Resident 1's carpet.

During an interview on 08/28/24, Staff 1 (Executive Director) acknowledged Resident 1 had behaviors of pulling his/her pants down and peeing throughout the facility. Staff 1 indicated Resident 1 has urinated inside his/her apartment and left the apartment door open. The facility cleaned the residents carpet a couple times a week and shampooed the carpet at least once a week. The facility had intended to shampoo the resident's carpet today.  

During separate interviews on 08/28/24, Resident 6 and Resident 7 complained about the urine smell throughout the facility.

It was confirmed the facility failed to ensure the interior of the facility must be free from unpleasant odors.

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The executive director will continue to clean Resident 1's carpet weekly and will get a behavioral specialist for resident to help with refusals of showers and urinating throughout the community.

Based on observation and interview, during a site visit conducted on 08/28/24, it was confirmed the facility failed to provide a manually operated emergency call system in each toilet or bathing facility. Findings include, but are not limited to:

On 08/28/24, Compliance Specialist observed no manually operated emergency call system in resident's rooms nor facility bathrooms.

During an interview Staff 1 (Executive Director) indicated the facility had not installed a call system since Compliance Specialist last visit on 02/06/24. Staff 1 indicated the facility still had no pull cords in resident's rooms, resident bathrooms, or facility bathrooms.

It was confirmed the facility failed to provide a manually operated emergency call system.

On 08/28/24, the findings were reviewed with and acknowledged by Staff 1.

An immediate plan of correction: The safety checks will be done by Santiam staff every thirty minutes on all common bathrooms, shower rooms, and all resident bathrooms. Staff will also check each resident to ensure they are wearing their pendants every two hours. Staff will sign off for each check on a spreadsheet and the ED and or an assigned designee will review daily. Santiam will bring on an additional staff member for night shift. Permanent call fixtures will be placed in the two common bathrooms, 7 shower rooms and all 50 apartments. Santiam will meet compliance in 90-days.