Print Inspection: H3HU

The findings of the on-site investigation, conducted 08/08/2023, 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, conducted during a site visit on 08/08/23, it was confirmed the facility failed to implement a system for the disposal of all unused, outdated, or discontinued mediation for 1 of 1 sampled resident (#1). Findings include, but not limited to:

During an interview on 08/08/23, Staff 3 (RN) stated, "The expired insulin was passed twice on 06/03/23, twice on 06/04/23, and once on 06/06/23."

A review of the facility self-report dated 06/07/23 indicated Resident 2's insulin had been opened and dated on 05/05/23, which meant the insulin would have expired 28 days later, on 06/03/23. The medication was passed five times after expiration date.

It was confirmed the facility failed to implement a system for disposal of all unused, outdated, or discontinued mediation.

On 08/08/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator).

Verbal plan of correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure.

Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In an interview on 08/08/23, Staff 3 (RN) stated, "On 05/24/23, the morning med tech marked resident as out of the facility when the resident went to a doctor's appointment. This is not a facility standard practice and did result in resident missing medication because the med tech did not mark resident back into the facility when resident returned from the appointment. A facility self-report was made."

A review of the facility self-report, dated 05/24/23, indicated the med tech had placed the resident "out of the community" at 11:04 am in the electronic MAR system, however staff did not update the system when the resident returned from his/her appointment, which would have triggered the system to alert staff Resident 1 had medications that were due to be administered at 2:00 pm and 4:30 pm. Resident 1 missed his/her 2:00 pm and 4:30 pm medications.

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

On 08/08/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator).

Verbal plan of correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure. The med tech was suspended and later terminated.

Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for multiple unsampled residents. Findings include, but are not limited to:

In an interview on 08/08/23, Staff 3 (RN) stated, "On 06/21/23 the noon medication pass was late due to the med tech sleeping past their break. Once the team noticed we had three staff quickly pass out the medication, however, some medication was administered outside the two-hour window. A facility self-report was made and the staff member who was sleeping was terminated."

A review of the facility self-report, dated 06/21/23, identified nine residents who had not received their noon medications until after 1:00 pm. The report stated three additional residents, during the noon medication pass, whose medications were signed off but not actually administer.

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

On 08/08/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator).

Verbal plan of correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure. The med tech was suspended from the cart immediately, sent home, and later terminated.