Print Inspection: HNV5

Based on interview and record review, conducted during a site visit on 04/16/24, it was confirmed the facility failed to ensure the resident's right to receive proper notification if requested to move-out of the facility for 1 of 1 sampled residents. (# 1). Findings include, but are not limited to:

Staff 1 (Interim Executive Director) stated in an interview on 04/16/24, that an assessment for Resident 1 had not occurred, prior to the decision that Resident 1 will not return to his/her apartment at the facility. Resident 1 was admitted to the hospital on 01/31/24 and stayed there until his/her death on 03/20/24.

Witness 1 (Case Manager) stated in an interview on 04/15/24, that S/he had not received a less than 30 days move out notice for Resident 1 and the facility refused to take the resident back, once the resident was ready for discharge.  

A record review of Oregon Department of Human Services Direct Contact notes, indicated that on 03/13/24, efforts were being made to secure a placement for Resident 1, within the state of Oregon. The Case Manager and Diversion Transition team searched for placement. Resident 1 passed away at the hospital on 03/20/24.

A records request of all move-out notices for 2024, revealed that zero "Less Than 30 Days Move Out Notices" had been issued in the year 2024.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Interim Executive Director), Staff 2 (Campus Director) Staff 3 (LPN) and Staff 4 (Regional Operations Support) on 04/16/24.

It was determined the facility failed to ensure Resident 1's right to receive proper notification if requested to move-out of the facility.

Verbal plan of correction: The facility to follow systems by going out and conducting an assessment within 24 hours of notice of hospital discharge.

Based on interview and record review, conducted during a site visit on 04/16/24, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse for 2 of 2 sampled residents. (# 1 and 2). Findings include, but not limited to:

Resident 1's incident report dated, 02/22/24 at 10:49 PM, indicated information related to a resident to resident altercation had occurred earlier that evening. The altercation resulted in yelling, two areas of open skin/scratches to Resident 2 and open handed hit to the head of Resident 1. First aid was given. The incident was self reported to the local Seniors and People with Disabilities office on 02/28/24, six days after the incident occurred.

On 04/16/24, Staff 3 (LPN) stated in an interview, a complete internal investigation, including interviews with witnesses to the incident, tracking patterns leading up to the event and specific steps of how abuse was ruled out, had not occurred.  

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Interim Executive Director), Staff 2 (Campus Director) Staff 3 (LPN) and Staff 4 (Regional Operations Support) on 04/16/24.

It was determined the facility failed to immediately notify the local Department office of an incident of abuse or suspected abuse.

Verbal Plan of correction: The facility will complete investigations with every incident report. If abuse cannot be ruled out, it will be reported. Training for MTs will be held every Monday.

Based on interview and record review, conducted during a site visit on 04/16/24, it was confirmed the facility failed to have an RN assess all residents with a significant change of condition in a timely manner for 1 of 3 sampled residents (#6). Findings include, but are not limited to:

A review of Resident 6's progress notes revealed Resident 6 was admitted to hospice services on 03/18/24. Records revealed that Resident 6 was assesed for change of condition on 03/22/24, four days after the change of condition.

During an interview on 04/16/24, Staff 3 (LPN) confirmed that Resident 6 was admitted to hospice on 03/18/24 and was not assessed by the nurse or have his/her service plan updated until 03/22/24.

The findings were reviewed with and acknowledged by Staff 1 (Interim Executive Director), Staff 2 (Campus Director) Staff 3 (LPN) and Staff 4 (Regional Operations Support) on 04/16/24.

The facility failed to have an RN assess all residents with a significant change of condition in a timely manner.

Verbal Plan of Correction: The facility has hired an RN who will provide oversite two days a week.

Based on interview and record review, conducted during a site visit on 04/16/24, it was determined the facility failed to keep an accurate Medication Adminstration Record (MAR) of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber for 15 of 15 sampled residents (#s 2, 3, 4, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) whose MARs were reviewed. The findings include, but are not limited to:

A review of Resident 2's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Cefpodoxime used to treat infection on 03/06/24.

* One dose of Melatonin used to treat delayed sleep on 03/06/24.

A review of Resident 3's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Trazodone used to treat insomnia on 03/06/24.

* One dose of Preparation H cream used to treat rectal itching and pain on 03/06/24.

* One dose of Salicylic Acid patch used to treat skin disorder on 03/06/24.

* One dose of Carbidopa used to treat Parkinson ' s disease on 03/13/24.

A review of Resident 4's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Depakote used to treat seizure disorder on 03/06/24.

* One dose of Quetiapine used to treat Alzheimer ' s disease on 03/06/24.

A review of Resident 7's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Metformin used to treat diabetes on 03/06/24.

* One dose of Olanzapine used to treat agitation on 03/06/24.

* One dose of Senna used to treat constipation on 03/06/24.

* One dose of Trazodone used to treat insomnia on 03/06/24.

* One dose of Fluoxetine used to treat depression on 03/30/24.

* One dose of Lisinopril used to treat hypertension on 03/30/24.

* One dose of Melatonin used to treat insomnia on 03/30/24.

* One dose of Trazodone used to treat insomnia on 03/30/24.

A review of Resident 9's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Atorvastatin used to treat cholesterol on 03/06/24.

A review of Resident 10's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Quetiapine used to treat Alzheimer's disease on 03/06/24.

* One dose of Acetaminophen used to treat osteoarthritis on 03/13/24.

A review of Resident 11's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* Six doses of Refresh Optive Opthalmic Gel used to treat eye irritation on 03/06/24, 03/14/24, 03/20/24, 3/27/24, 3/28/24, and 3/30/24.

* Three doses of Camphor-menthol lotion used to treat dry skin on 3/20/24, 3/27/24, and 3/28/24.

* Three doses of Eucerin Cream used to treat dry skin on 3/20/24, 3/27/24, and 3/28/24.

A review of Resident 12's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Clopidgrel used to treat stroke prevention on 03/06/24.

* One dose of Donepezil used to treat Alzheimer ' s disease on 03/06/24.

* One dose of Melatonin used to treat delayed sleep on 03/06/24.

* One dose of Namenda use to treat dementia on 03/06/24.

* One dose of Hydragaurd Silicone cream used to treat skin breakdown on 03/06/24.

* Two doses of Clotrimazole cream used to treat chronic dermatitis on 03/27/24 and 03/28/24.

A review of Resident 13's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Enulose Solution used to treat constipation on 03/06/24.

A review of Resident 14's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Tamsulosin used to treat enlarged prostate on 03/06/24.

A review of Resident 15's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Donepezil used to treat Alzheimer ' s disease on 03/06/24.

A review of Resident 16's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* Three doses of Acetaminophen used to treat arthritis pain on 03/04/24, 03/05/24, and 03/06/24.

A review of Resident 17's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Cosopt Opthamalic used to treat glaucoma on 03/06/24.

* One dose of Melatonin used to treat delayed sleep on 03/06/24, 3/14/24, 3/24/24, 3/30/24.

* One dose of Memantine used to treat dementia on 03/06/24.

* One dose of Methylphenidate used to treat depression on 03/06/24.

A review of Resident 18's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* One dose of Memantine used to treat dementia on 03/06/24.

* One dose of Mirtazapine used to treat major depressive disorder on 03/06/24.

* One dose of Trazodone used to treat delayed sleep on 03/06/24.

* Three doses of Camphor-menthol lotion used to treat dry and itching skin on 3/26/24 and 3/27/24.

A review of Resident 19's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications:

* Six doses of skin cleanse treatment used to treat candidiasis of skin on 03/06/24, 3/20/24, 3/24/24, 03/27/24, 03/28/24, and 03/30/24.

An interview with Staff 1 (Interim Executive Director) recognized the above errors and that management had been re-training med tech staff.

The findings were reviewed with and acknowledged by Staff 1 on 05/03/24.

The facility failed to keep an accurate Medication Administration Record (MAR) of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber.

Verbal Plan of Correction:

Med Tech training had been completed as of 05/03/24, and the previous med-room manager no longer works at the facility. The facility nurse is providing more oversight and one-on-one training.