Print Inspection: LB07

The findings of the re-licensure survey, conducted 04/24/23 through 04/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

MCC:Memory 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 first re-visit to the re-licensure survey of 04/27/23, conducted 07/26/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

MCC:Memory 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 second re-visit to the re-licensure survey of 04/27/23, conducted 10/13/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure all resident-to-resident altercations were immediately reported to the local SPD office for 2 of 7 sampled residents (#s 7 and 8). Findings include, but are not limited to:

Resident 7 was admitted to the facility in 06/2017 with diagnoses including epilepsy and depression. Resident 8 was admitted to the facility in 07/2022 with diagnoses including diabetes and chronic pain.

During group and individual interviews on 04/25/23, Residents 7 and 8 stated they had been involved in a verbal altercation with an un-sampled resident.

A document titled "Concerns / Grievances / Compliments" and dated 04/07/23 documented Resident 7 and 8's report to the facility that they felt threatened by and were afraid of the other resident.

The grievance form documented an investigation completed on 04/13/23; however, there was no documentation abuse or neglect were immediately ruled out or the incident was reported to the local SPD office as a resident-to-resident altercation.

In an interview with Staff 1 (Executive Director) on 04/27/23, she acknowledged the altercation was not reported to SPD.

The need to report resident-to-resident altercations to the local SPD office and investigate them as suspected abuse was discussed with Staff 1 (Executive Director) and Staff 7 (Regional Director of Operations) on 04/27/23. They acknowledged the findings and immediately reported the incident to the local office.

On 4/27/2023 the community reported incident regarding resident # 7 and # 8 to APS due to resident to resident altercation. In adddtion this incident was placed as in Incident Report, placed both residents on alert charting, following ISP's for interventions.

The community will review and investigate all incidents and accidents per OAR 411-054-0028 requirements.

Incidents of unknown origin will be reported within 24 hour requirement and a complete investigation documented.

All staff in-service on investigating and  reporting will take place on 5/4/2023 and 5/10/2023.

Reviews will occur during daily clinical meeting and overseen by the HSD and ED.

Based on interview and record review, it was determined the facility failed to monitor short-term changes of condition through resolution, with at least weekly documentation, for 1 of 3 sampled residents (#1) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2021 with diagnoses including hypertensive retinopathy and Charcot-Marie-Tooth Disease.

The resident's clinical record was reviewed and the following was identified:

* On 01/11/23 Resident 1 was evaluated to be able to safely self-administer his/her medication, with his/her family assisting.

* S/he experienced a right femur fracture on 03/09/23 and was admitted to the hospital for treatment, returning to the facility on 04/04/23.  Upon return, the resident required full staff assistance with all ADLs and two staff to transfer him/her out of bed with a Hoyer lift.

* A Charting Note dated 04/09/23 indicated the resident's daughter "called with concerns about resident self administering medications with changed condition of broken leg." The note states the resident had pain in his/her feet and was not taking his/her gabapentin (for nerve pain). Staff investigated and found the gabapentin in the resident's bathroom, as well as a bottle of medication under the resident's bed. The resident told staff s/he "did not know how often or when the last time [s/he] took the medication."

Although a licensed nurse completed a "Self-Medication Evaluation" on 04/10/23, which determined the resident's daughter was capable of setting up his/her mediset weekly, there was no documented evidence the resident's increase in confusion and ability to continue to use a pre-filled mediset was monitored at least weekly.

The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Executive Director) on 04/27/23. She acknowledged the findings.

On 5/3/2023 and 5/12/2023 LPN completed a self medicaiton assestment and RN compelted change of condtion. On 5/3/2023 and 5/12/2023, the resident passed self medication assestment.

The community will review and investigate resident short term and long term change of condition per OAR 411-054-0045 Resident Health Service.

Short and Long Term change of conditions will be initiated within 24 hour requirement and RN to complete change of condition with documentation within 48 hrs to refrence back to the Service Planning Team expectations.  

All staff in-service on change of condition and documentation will take place on 5/4/2023 and 5/10/2023.

Reviews will occur during daily clinical meeting and overseen by the HSD and ED.  

2. Resident 5 was admitted to the facility in April 2018 with diagnoses including chronic pain.

Review of Resident 5's physician orders, MAR, and Controlled Substance Disposition log, dated 04/01/23 through 04/24/23, revealed the following:

Resident 5 was ordered hydrocodone/APAP 5-325 mg, 1 tablet four times daily as needed for pain.

Review of the Controlled Substance Disposition log and the MAR revealed two occasions on which staff signed the medication out on the disposition log but the MAR lacked documentation the medication had been administered to the resident.

The discrepancies between the MAR and Controlled Substance Disposition log were reviewed with Staff 2 (RN) on 04/26/23 and discussed with Staff 1 (Executive Director) on 04/27/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 3 and 5) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2018 with diagnoses including peripheral neuropathy and fibromyalgia.

Resident 3 had an order for Morphine (narcotic pain medication) 20 mg/ml, 0.25 ml every hour as needed for pain or shortness of breath.

Resident 3's MAR and Controlled Substance Disposition log, reviewed from 04/01/23 to 04/24/23, included the following discrepancies:

* 04/04/23 - 1:05 am dose initialed as administered on the MAR, but not signed out on the disposition log;

* 04/08/23 - 12:15 am dose signed out on the disposition log, but not initialed as administered on the MAR;

* 04/09/23 - (no administration time documented) 0.25 ml dose initialed as administered on the MAR, but not signed out on the disposition log;

* 04/13/23 - 9:27 pm dose signed out on the disposition log, but not initialed as administered on the MAR; and

* 04/18/23 - (no administration time documented) 0.25 ml dose initialed as administered on the MAR, but not signed out on the disposition log.  

On 04/27/23, inconsistencies between the MAR and the Controlled Substance Disposition log were discussed with Staff 2 (Health Services Director). She reviewed the documentation and acknowledged the discrepancies.

On 5/5/2023 the community conducted a Med Room and Substance Controll Audit. This aduit did show compliance of count and documentation as required.

The community will conduct weekly audits and review audits for tracking control substance as required per OAR 411-054-055 requirements.

The community will conduct weekly audits for all controlled substance medication and documentation as required.  

All-staff in-service on tracking controlled substance and documentation will take place on 5/4/2023 and 5/10/2023.

RCC, LPN and RN will be responsible to oversee and conduct weekly audits for controlled substance medication.  

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#10) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 02/2017 with diagnoses including a history of arthritis. Records indicated s/he underwent a total knee replacement in 06/2023.

A review of the resident's 06/15/23 through 07/26/23 MARs, physician orders, and medication cards and log pages relevant to his/her narcotic medication was completed, and staff were interviewed. It was determined the resident had a physician order for Hydrocodone/APAP 5-325 mg tab (a narcotic pain reliever), 1 tablet every four hours as needed for breakthrough pain.

The following inconsistencies between the documentation on the MARs and in the Controlled Substance Disposition log were identified:

* On nine occasions the time staff documented as having removed the tablet from the medication card was after the time staff documented administering the PRN hydrocodone/APAP on the MAR.

* On two occasions (07/11/23 and 07/17/23) the Controlled Substance Distribution log indicated a tablet was removed from the medication card, but there was no corresponding entry on the MAR the resident was administered the medication.

* There was an entry on the log which was initialed, but had no date or time recorded, and indicated one dose was removed from the medication card and subtracted from the total number of tablets remaining.

* On 07/19/23 there were five entries in the Controlled Substance Disposition log for both PRN and scheduled doses of hydrocodone/APAP, in the following order:

- Line 1: "8 am";

- Line 2: "6 pm";

- Line 3: "9:30 pm";

- Line 4: "1 pm"; and

- Line 5: "1 pm."

In an interview with Staff 2 (Health Services Director) on 07/26/23, she acknowledged the inconsistencies and stated she did not know how they were missed on their weekly audits of the MAR and Controlled Substance Disposition log.

On 8/3/2023 the community completed a Medication Technician meeting to review Substance Control count and documentation within 5 minutes between log out time and administration to resident. Errors on narc book were corrected by the assigned technician.

The community will transition and implement to an electronic inventory system for controlled substances.

Controlled substance counts will be reconciled at the end of every shift electronically, inventory and narcotic counts will be monitored twice weekly. In addition, inventory will be logged into EMAR with a running inventory of controlled substances in the community.

Health Services Director, Executive Director, LPN, RCC will be responsible to oversee and complete audits twice per week on controlled substance medication.

C455 - Please see POC for C302

Based on interview and record review, it was determined the facility failed to ensure fire drills were documented in accordance with Oregon Fire Code (OFC) and that fire and life safety instruction was provided to staff on alternate months and documented. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for 10/01/22 through 04/25/23 identified the following:

1. The facility had not documented the following areas related to fire drills conducted:

* escape route used;

* problems encountered;

* comments relating to residents who resisted or failed to participate in the drills;

* evacuation time period needed;

* evidence alternate routes were used; and

* number of occupants evacuated.

2. The facility did not consistently conduct and document fire and life safety instruction for staff on alternate months.

The need to ensure the facility documented fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Executive Director) and Staff 7 (Regional Director of Operations) on 04/27/2023. They acknowledged the findings.

On 4/27/2023 the community completed a fire drill in assisted living, utlizing updated form to show routes, resident participation and evacuation routes. Form does include documentation as required. In additon on 5/10/2023, the community held an All staff In-service regarding life stafey training, we reviewed Power Outage and expectations.

The community will conduct fire drills and life safety training as required per OAR 411-054-0090  requirements.

The community will conduct fire drills every other month and life safety trainings every 3rd month, with complete documentation as required.

All staff in-service on fire drills and life safety will take place on 5/4/2023 and 5/10/2023.

ED and ESD will be reponsible to oversee and conduct fire drills and life safety trainings.

Based on interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 302.

Please see POC for C302

Based on observation and interview, it was determined the facility failed to keep all  equipment needed for the health, safety, and comfort of the residents in good repair. Findings include, but are not limited to:

The assisted living consisted of three floors and was home to 88 residents at the time of the survey.

The facility dining room was located in the center of the building on the ground floor, and two wings contained the resident apartments. One elevator was located in each wing for residents on the second and third floors to travel to the first floor to get to the dining room for meals and attend activities occurring in that area.

In a group interview on 04/25/23, residents stated one of the elevators was out of order and had been for "months."  All residents stated they had to walk to the other wing of the building and wait in line to use that elevator or use the stairs.

In an interview on 04/25/23, Staff 1 (Executive Director) confirmed the elevator had been out-of-order since 02/13/23 and required specialized services to repair.

On 04/26/23, Staff 1 (Executive Director) provided documentation the elevator repair had been approved and was moving forward. The need to ensure all equipment needed for resident health, comfort, and safety was maintained was reviewed with Staff 1 (Executive Director) and Staff 7 (Regional Director of Operations). They acknowledged the findings.

On 4/27/2023 this ED communicated to Policy Analyst and to FPS regarding our non- working elevator. The community currently anticipates for the elvator to be back in working conditon by June 15, 2023. TKE elevator communited on 5/9/2023 the part is in order. ED is to check in weekly for update and repair date.

The community will report in a timely manner when equipment is out of order to appointed Policy Analyst and FPS with documentation per OAR -411-054-0300 requirements.

The community will conduct weekly audits of all community equipment.  

All staff-inservice of community equipment audits and reporting will take place on 5/4/2023 and 5/10/2023

ED and ESD will be responsible to complete weekly audit and oversee all equipment is in working condition per requirement.