Print Inspection: OB3C

The findings of the relicensure survey conducted 04/01/24 through 04/04/24 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 04/04/24, conducted 09/16/24 through 09/18/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules.

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

A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following area:

OAR 411-054-0300 (11-13): Call System

The facility put an Immediate Plan of Correction in place during the survey.

The findings of the second revisit, to the re- licensure survey of 04/04/24, conducted 12/30/24 to 12/31/24, 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and was receiving hospice services.

Interviews with staff and observations identified Resident 3 had a fall mat under the bed.

Staff indicated the mat was used while Resident 3 was in bed.

Resident 3's current service plan, dated 03/23/24, did not provide clear direction regarding the use of the fall mat.

The need to ensure service plans included clear instruction to staff for the delivery of care was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current status and care needs, and provided clear direction to staff regarding the delivery of services for 3 of  5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's Disease, hypothyroidism, and heart failure.

The resident's service plan, dated 01/11/24, was not reflective of the resident's current needs, or did not provide clear direction to staff in the following areas:

* Assistance needed for activities;

* Nutrition/ hydration, and eating assistance;

* Side rails on bed;

* Safety checks; and

* Fall interventions.

On 04/03/24, the need to ensure service plans were reflective of current status and provided clear directions for staff was discussed with Staff 1 (ED). She acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance.

Observation of care from 04/01/24 through 04/04/24, interviews with facility staff, and review of the current service plan, dated 03/19/24, revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:

* Physician orders for life sustaining treatment status;

* Number of staff needed to assist with grooming and eating;

* Mobility equipment precautions and instructions for proper maintenance;

* Skin integrity and instructions on skin care;

* Instructions for signs and symptoms of infection to report when providing skin care;

* Non-pharmaceutical interventions for pain, including how the resident expressed pain or discomfort;

* Nutrition habits and fluid preferences;

* Instructions on edema management;

* Instructions on fall prevention;

* Instructions on weight management; and

* Social and leisure activities.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Resident #5- Service plan will be updated with the following details:

-Thorough life story details and current activity interests listed as well as detailed assistance measures to ensure safe participation in activites program.

-Specified nutrition/hydration plan with preferences and scheduling expectations

-Update level of assistance needed for meals- specifying when he's eating in the dining room vs. his apartment

-Added side-rails on DME listing and their purpose for his bed mobility needs.

-Clear parameters listed for safety check timing and observations needed

-Fall interventions that are specified for resident #5 are listed.

Resident #3- Service plan will be updated with the following details:

-Fall mat listed on DME and instructions given to staff for delivery of care.

Resident #2- Service plan will be updated with the following details:

-POLST information verified and cross-referenced/updated on service plan.

-Dining level of assistance detailed

-Grooming level of assistance detailed

-DME listed updated with precautions and instructions for proper maintenance.

-Instructions on skin care and what to alert med-techs/management on.

-When to report signs/symptoms of infection

-Non-Pharm interventions for pain and how the resident expresses pain.

-Specified nutrition/hydration plan with preferences and scheduling expectations.

-Instructions on edema management

-Fall prevention plan and detail

-Monitoring for monthly weights and if any significent changes appear

-Thorough life story details and current activity interests listed as well as detailed assistance measures to ensure safe participation in activities program.

2. After correcting these current residents listed, our internal guidelines with service plans will reflect the detail expecations given to use in this SOD moving forward. Each area will be given sufficent time and effort in providing the detail that will best support our care given. Service plans will be reviewed by RN or Administrator upon completion for support.

3. Evaluation of the details in Service Plans will be done upon significant change, new admit, quarterly and as needed.

4. Licensed nurse and/or ED during quarterly updates.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and/or provided clear direction regarding the delivery of services for 4 of 4 sampled residents (#s 6, 7, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 04/2018 and had diagnoses including Alzheimer's Disease and rheumatoid arthritis.

Observations of the resident, interviews with staff, review of temporary service plans, progress notes, and incident reports from 06/13/24 through 09/16/24, and review of the service plan, dated 08/13/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Fall risk;

* Ability to communicate;

* Ability to use call system;

* Pain, to include location and non-pharmacological interventions;

* Toileting assistance as needed, including instructions;

* Dressing, grooming, and hygiene assistance;

* Bathing;

* Resistance to ADL cares with instructions; and

* Use of eye glasses.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. The staff acknowledged the findings.

2. Resident 9 was admitted to the facility in 07/2023 with diagnoses including vascular dementia.

Observations of the resident, interviews with staff, review of temporary service plans, progress notes, and incident reports from 06/13/24 through 09/16/24, and review of the service plan, dated 08/01/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* One- to two-person assist with dressing, grooming, hygiene, and bathing;

* Resistance to ADL cares with instructions for staff;

* Sleep area of preference;

* Communication;

* Staff to anticipate needs; and

* Ability to use call system.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. The staff acknowledged the findings.

3. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease.

Review of the resident's current service plan, updated 09/12/24, and interviews with staff revealed it was not reflective and/or did not provide clear direction to staff in the following areas:

* Recent fall history;

* Ability to use the call light; and

* Hearing aid care.

The need to ensure resident service plans were reflective of residents' current status and care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

4. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.

Review of the resident's current service plan, updated 06/08/24, and interviews with staff revealed it was not reflective of the resident's current status and care needs in the following areas:

* Fall history; and

* Ability to use the call light.

The need for service plans to be reflective of residents' current status and care needs and provide clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. There will be a complete audit of all service plans for the items in the OARS. Regarding resident #8, #9, #6 and #7- service plans will be revised to include the following information:

#8- fall risk, ability to communicate; ability to use call system; her pain (including location and non-pharmological interventions); toileting assistance as needed, including instructions; dressing, grooming and hygiene assistance; bathing; resistance to ADL cares with instructions; use of eye glasses.

#9- their one- or two-person assist with dressing, grooming, hygiene and bathing; resistance to ADL cares with instructions for staff; sleep area of preference; communication; staff to anticipate needs; ability to use call-system.

#6- recent fall history; ability to use the call-light; hearing aid care

#7- resident passed away on 9/23/24

2. An outline of OAR specific details that are required for service plans will be provided to the RCC's for their reference with an emphasis on including all resident specific details that are important for care staff to provide person-centered care. During the 90 day period between service plan updates, we will be requiring the service plan to be revised if there are several updates or a change of condition, rather than just TSP updates.

3. LN will alert RCC's to official changes of condition as they occur. Service plans will be updated quarterly or as needed.

4. LN and ED will be responsible to ensure the corrections are kept up to date and completed.   

Based on interview and record review, it was determined the facility failed to monitor resident injuries with weekly progress noted until the condition resolved, for 2 of 3 sampled residents (#s 1 and 4) with skin wounds. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia.

The resident's record was reviewed and interviews were conducted with the resident and staff during the survey.

On 02/09/24 a facility Progress Note indicated "Resident has a very small cut on [his/her] right hand. The cut is about less than a [centimeters] long in the shape of a C..."

A Temporary Service Plan dated 02/09/24 was created for the injury and noted "Inner wrist right hand. About 2 cm long in the  shape of the letter C."

There was no documented evidence the injury was evaluated to determine the accurate size.

There was no documented evidence the injury had been monitored weekly to resolution.

The need to ensure the changes in condition were evaluated and monitored with weekly progress noted until the condition was determined to be resolved was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

2. Resident 1 moved into the facility in 10/2022 with diagnoses including dementia.

The resident's clinical record was reviewed and interviews were conducted with the resident and care staff during the survey. A review of progress notes indicated the following:

a. 01/30/24: "no pain from skin tear, no signs of infection, skin tear not bleeding..." A temporary service plan (TSP) dated 01/29/24 documented "3 cm long skin tear on left shoulder. Ask PRN for pain pill if needed."

There was no further documentation the skin tear had been monitored with weekly progress noted until the condition resolved.

b. 03/14/24: "on alert for picking sites on both upper arms..." and on 03/16/24, "sores are present but not actively bleeding..." A TSP dated 03/12/24 documented "skin tear, abrasion, picking sites to both upper arms. Staff was instructed to "encourage to apply lotion or ointment. Apply lotion after shower or when needed."

The record lacked documentation the wounds had been monitored with weekly progress noted until the condition resolved.

The need to ensure the short term changes in condition were monitored with weekly progress noted until the conditions were resolved was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/04/24. They acknowledged the findings.

1. Regarding #4

-IR and APS self-report completed on 4/2/24

Regarding #1

-IR completed on 1/29/24. Abuse/neglect ruled out as resident had been able to tell what had happened.

2. Med-tech meeting on 4/10/24. There was significant discussion and education on placing residents on alert and notifying nurse in addition to progress noting new findings or skin concerns.

3. Alert charting monitored daily by LN or RCC.

4. LN & ED  

3. Resident 8 was admitted to the facility in 04/2018 with diagnoses including Alzheimer's disease and rheumatoid arthritis.

The resident's clinical record, including progress notes, dated 06/03/24 through 09/16/24, and incident reports were reviewed, and interviews with staff were conducted. The following was identified:

* 07/03/24 - Fall with bump and bruising to forehead. Intervention implemented was safety checks eight times a shift or as often as possible; and

* 08/25/24 - Fall with head strike with hematoma and bleeding from left side of the forehead. The intervention implemented was to increase safety checks to six times a shift.

There was no documented evidence the interventions in place after the resident's 07/03/24 fall were evaluated for effectiveness and determined if further actions/interventions were indicated.  

In addition, the following was identified:

* 07/06/34 - Resident-to-resident altercation. The intervention implemented was to redirect Resident 8 when near rooms close to the other resident involved; and

* 08/13/24 - Resident-to-resident altercation with the same unsampled resident. Interventions implemented were to re-direct Resident 8 from entering the involved resident's room and offer snacks and/or drinks to decrease agitation.

There was no documented evidence the intervention in place after the resident's 08/13/24 altercation was evaluated for effectiveness.

The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure actions and interventions were determined and monitored for effectiveness for all short-term changes of condition for 3 of 4 sampled residents (#s 6, 7, and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.

The resident's 06/19/24 through 09/16/24 progress notes, temporary service plans, incident reports, investigations, and current service plan were reviewed, and interviews were conducted. The following was identified:

* 07/08/24 - Resident 7 fell and interventions were implemented, including performing safety checks and anticipating needs, toileting schedule, and habits; and

* 09/06/24 - The resident experienced another fall and no new interventions were implemented.

There was no documented evidence the interventions implemented after the resident's 07/08/24 fall were evaluated for effectiveness or that new interventions were determined and implemented after his/her fall on  09/06/24.

The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

2. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease.

The resident's 06/21/24 through 09/16/24 progress notes, temporary service plans, incident reports, investigations, and current service plan were reviewed, and interviews were conducted. The following was identified:

* 08/18/24 - The resident experienced a non-injury fall.

The interventions listed on the investigation were for ". . . staff to increase toileting rounds to 6 times a shift and ask [the resident] if [s/he] needs anything before leaving [his/her] apartment." These interventions were on the service plan with an effective date of 07/15/23.

There was no documented evidence previous interventions were evaluated for effectiveness or new interventions were determined and implemented after the resident's 08/18/24 fall.

The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. Regarding residents #7, #6, #8 and the monitoring of their changes of condition.

#7- resident passed away on 9/23/24.

#6- referencing falls: LN will evaluate the interventions in place for effectiveness and determine whether new interventions are needed.

#8- referencing falls and res to res altercations: LN will evaluate the interventions in place for effectiveness and determine whether new interventions are needed.

2. Before removing residents from alert-charting, sufficient evaluations need to be completed to ensure the interventions are effective. LN will progress note her findings of evaluation for Med Techs, RCC's and ED. We will also hold a Med Tech meeting where the focus will be on change of condition and the role the Med Tech's communication to the LN and RCC's plays.

3. Alert charting monitored daily by LN or RCC.

4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 3 of 5 sampled residents (#s 2, 4, and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia and high blood pressure.

Resident 4's MARs for 03/01/24 and physician's orders were reviewed.

Resident 4 had physician's orders for Metoprolol Tartrate 25 mg twice daily, to be held for systolic blood pressure less than 100.

Resident 4's systolic blood pressure was documented to be below 100 in the morning on March 5th and 9th, and below 100 in the afternoon on March 9th and 19th.

The Metoprolol Tartrate was not held as ordered.

The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN). They Acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, heart failure, and atrial fibrillation.

Review of Resident 5's MAR, dated 03/01/24 through 04/01/24, and physician orders, dated 03/25/24, identified the following deficiencies:

There was an order for monthly vital signs, which included instructions to "Fax primary care provider and RN if: blood pressure top number is greater than 140 or less than 100, if blood pressure bottom number is greater than 90".

On 03/01/24, the monthly blood pressure was recorded as 147/96, indicating both values were above the acceptable range.

There was no documented evidence the physician was informed the blood pressure values were above the acceptable parameters.

On 04/03/24, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED). She acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance.

Resident 2's current physician orders and MARs from 03/01/24 through 04/01/24 were reviewed. Interviews with facility staff were conducted. The following was revealed:

* Hospice admission orders contained instructions to administer hydromorphone 10 mg/ml oral solution every hour as needed for pain. However, there was no documented evidence the order was included in the MAR, or the medication was administered as ordered; and

* Hydromorphone 20mg was ordered to be administered one tablet every hour as needed for "moderate-severe pain, dyspnea." The resident also had a concurrent order for oxycodone 5 mg to be administered every hour as needed for pain with a instructions to "give oxycodone before giving hydromorphone for pain." The MAR indicated hydromorphone was administered prior to oxycodone on 03/20/24, 03/25/24, and 03/26/24.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding #4

-Med error IR completed and reported to APS

Regarding #5

-Education was given to staff on 4/11/24 regarding the importance of monthly vitals and the communication that is expected moving forward.

Regarding #2

-Medications have been reviewed and the med listed has been discontinued on 3/27/24.

2.

#4-Med-tech meeting on 4/10/24 reviewed/educated staff on following hold parameters.

#5-Med-tech's educated on 4/11/24 to notify providers after monthly vitals if BP readings are outside of paramenters noted in MAR.

#2-LN or RCC to review orders during hospice admit to ensure no duplicates of narcotics or other meds.

3.

#4-

#5-Monthly

#2- Upon hospice admission and as needed

4.

#4- LN & ED

#5- LN & ED

#2- LN & ED

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 4 sampled residents (#s 6 and 7) whose MAR and physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease.

A review of the resident's 09/01/24 through 09/16/24 MAR and current signed physician orders revealed the following:

The resident had a signed physician order for mirtazapine 15 mg, one tab nightly, effective 08/28/24, which was an increase of his/her previous dose of 7.5 mg nightly. The MAR indicated the following:

* 09/01/24 - resident refused;

* 09/02/24 - med not available;

* 09/05/24 - resident refused; and

* 09/08/24 - resident refused.

On 09/03/24, 09/04/24, 09/06/24, 09/07/24, and 09/09/24 through 09/13/24 the MAR indicates the medication was administered.

On 09/15/24 a MT noted on the MAR that the "wrong dosage" was in the medication cart.

In an interview on 09/17/24 at 12:50 pm, Staff 2 (RN) reported she was not sure what dosage was actually administered to the resident. She stated she would investigate the matter further.

At 1:21 pm the same day, Staff 2 reported she had looked at the resident's mirtazapine medication card and the MAR. She stated it appeared the resident was administered 7.5 mg on some days and 15 mg on other days, but she wasn't able to determine when the incorrect dose of 7.5 mg was administered versus the correct dose of 15 mg. Staff 2 reported she would create an incident report for a medication error. A copy of the incident report was provided on 09/18/24.

There was no documented evidence the resident received the prescribed dose of 15 mg of mirtazapine each night.

The need to ensure physician orders were carried out as written was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.

The resident's 09/01/24 through 09/16/24 MAR, physician orders, and 06/19/24 through 09/16/24 progress notes were reviewed. The following was identified:

* The resident was admitted to hospice services on 09/09/24.

* Resident 7 had an order for haloperidol 0.5 ml every hour as needed for delirium, nausea, and/or vomiting.

* The resident also had an order for lorazepam 0.5 mg every hour as needed for anxiety or dyspnea.

* A MT documented on 09/14/24 speaking with hospice about the resident being very aggressive during care. The MT wrote, "hospice asked med techs to please utilize PRN's for aggression and agitation. every [sic] 30 mins- 1 hour before [resident] gets [his/her] depend [sic] changed."

* The MAR shows that the resident was administered haloperidol five times on 09/14/24 and one time on 09/15/24. Staff documented the reason for administration was "Delirium."

In an interview with Staff 2 (RN) on 09/17/24 at 12:57 pm, she reported there was no signed physician order to administer a PRN psychotropic medication to the resident prior to brief changes. She provided documentation of parameters for both the PRN haloperidol and the PRN lorazepam, which did not include administration of either medication prior to providing care to the resident.

The need to carry out physician and other legally recognized practitioner orders as written was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. Regarding the physician's orders are carried out as written for residents #6 and #7.

#6- Med error IR was created and given to survey team. There were no negative affects from this med error.

#7- resident passed away 9/23/24.

2. LN spoke with Med Techs that had hands in this situation, individually about the importance of asking questions when they are unsure of dosage or the physician orders.

3. Daily reports on missed or held medications will be reviewed by the RCC's, LN or ED and any concerns will be brought to attention.

4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure resident MARs included specific parameters and instructions for PRN medications, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2023 with diagnoses which included dementia and anxiety.

Residents 3's orders and 03/01/24 through 04/01/24 MARs were reviewed.

Resident 3 had orders for:

* Acetaminophen 500 mg as needed for moderate pain;

* Morphine Sulfate solution 5 mg as needed for pain;

* Buspirone 5 mg as needed for anxiety; and

* Lorazepam 0.5 mg as needed for anxiety.

There were no resident specific parameters and instructions for which PRN medication to use first.

The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia.

Residents 4's orders and 03/01/24 through 04/01/24 MARs were reviewed.

Resident 4 had orders for:

* Biofreeze gel 5%, apply to lower back as needed for low back pain; and

* Voltaren gel 1%, APPLY 2 grams to lower back as needed for pain.

There were no resident specific parameters and instructions for which PRN medication to use first.

The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, atrial fibrillation, and heart disease.

Review of Resident 5's MAR, dated 03/01/24 through 04/01/24, and physician orders, dated 03/25/24, identified the following deficiencies:

a. Resident 5 was prescribed the following PRN medications for constipation:

* Bisacodyl 10 mg suppository "daily as needed for constipation";

* Enema (phosphate/saline) "daily as needed for constipation";

* Glycerin adult 2 GM supp (fleet) "daily as needed for constipation; and

* Milk of Magnesia 473 mL "daily as needed for constipation.

b. Resident 5 was prescribed the following PRN medications for pain:

* Acetaminophen 650 mg supp "every four hours as needed for fever or mild pain";

* Diclofenac gel 1% "four times daily as needed for pain";

* Morphine sulfate 20mg/mL "every hour as needed for moderate to severe pain or dyspnea";

* Tramadol HCL 50 mg "every eight hours as needed for moderate or severe pain"; and

* Tylenol 325 mg gel caps "every six hours as needed for mild pain".

There were no resident-specific parameters for any of the PRN medications listed above, regarding the sequential order of use.

On 04/03/24, the need to ensure clear parameters for unlicensed staff, when multiple PRN medications were prescribed for the same condition was discussed with Staff 1 (ED). She acknowledged the findings.

4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance.

Resident 2's MAR from 03/01/24 through 04/01/24 and physician orders were reviewed and revealed the following:

a. The following PRN medications lacked instructions for sequential order of use:

* Acetaminophen 500 mg (for pain);

* Acetaminophen 650 mg suppository (for mild pain);

* Hydromorphone 20mg (for moderate-severe pain); and

* Oxycodone 5 mg (for pain).

b. The following PRN medications lacked resident specific parameters for use:

* Haloperidol 20mg/ml (for delirium, nausea and/or vomiting);

* Hydromorphone 20mg (for dyspnea);

* Lorazepam 20mg/ml (for anxiety, restlessness, shortness of breath); and

* Seroquel 25 mg (for anxiety and agitation).

The need to ensure MARs were accurate, contained medication specific instructions, and provided resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding #3- Added verbiage for signs of anxiety and we have faxed hospice for request to DC one of the PRN anxiety meds. For the morphine- parameters were added to give for severe pain.

#4- Faxed for DC order on one of the PRN back pain meds. RN put parameters for which one to use first.

#5- Updated bowel meds with parameters on order of use. Also faxed to DC some of the bowel meds. Orders updated to clarify order of use for pain management meds. Also faxed to DC some of the pain management.

#2- Updated MAR with parameters for which order to give PRN pain medications. Added resident specific signs of anxiety/delirium . Faxed to DC one of the anxiety PRN's.

2. LN/RCC will be the only ones approving pending order review in order to ensure all parameters and details are accurately depicted.

3. Orders reviewed quarterly by pharmicist and quarterly when physician orders are faxed. As needed when orders change.

4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident-specific parameters and instructions for PRN medications, for 2 of 4 sampled residents (#s 6 and 8) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 04/2018.

Residents 8's MARs were reviewed from 09/01/24 through 09/16/24, and the following was noted:

* Acetaminophen 500 mg every four hours as needed for mild to moderate pain and/or fever; and

* Hydrocodone/APAP 5/325 mg every 12 hours as needed for pain.

There were no documented parameters for when to administer the hydrocodone and/or which medication to administer first for pain.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

2. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease.

Review of the resident's 09/01/24 through 09/16/24 MAR and physician orders revealed the resident had the following PRN pain medications:

* Acetaminophen 325 mg, two tables every four hours as needed for mild pain or fever over 100 degrees;

* Acetaminophen 500 mg, one tablet every six hours as needed for mild pain or fever;

* Ibuprofen 400 mg, one tablet every eight hours as needed for moderate to severe pain; and

* Morphine 20 mg/ml, 0.25 ml (5 mg) every hour as needed for pain or shortness of breath.

There were no documented parameters instructing staff in which order to administer the PRN pain medications.

The need to ensure all PRN medications had resident-specific parameters and instructions was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. MARs needing revision or added instruction for the following residents: #8 & #6

#8- Parameters were added to MAR for her acetaminophen and hydrocodone.

#6- Parameters for all listed pain meds were specified. A DC request (2 times) was made for the duplicate orders of Tylenol.

2. PRN med audits will be completed every week by LN.

3. Every week.

4. LN & ED   

2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and was receiving hospice services.

Resident 3's 03/2024 and 02/2024 MARs and orders were reviewed.

Resident 3 had orders for Buspirone 5 mg and Lorazepam 0.5 mg, both to be given as needed for anxiety.

Written, resident-specific parameters and the specific reasons for the use of the psychotropic medication for Resident 3, how anxiety was expressed, were not documented.

The need to ensure clear resident specific reasons for use and parameters were available to guide non-licensed, non-certified staff in the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24 and 04/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all direct care staff administering psychotropic medications knew the specific reasons for the use of the psychotropic medication for that resident, medications had written, resident-specific parameters, and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who had received psychotropic medications. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance.

Review of Resident 2's clinical record indicated the following:

* Resident 2 was prescribed haloperidol 0.5 ml as needed for delirium, nausea, and/or vomiting, and lorazepam 0.25 ml as needed for anxiety, restlessness, and shortness of breath; and

* The MAR from 03/01/24 through 04/01/24 indicated staff administered four doses of PRN lorazepam and one dose of PRN haloperidol. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication.

The need to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

3. Resident 1 moved into the facility in 10/2022 with diagnoses including dementia and had a behavior support plan, dated 11/17/23 that included resident-specific interventions for behaviors. The resident's 03/01/24 to 03/31/24 MAR and physician's orders were reviewed. The following was identified:

Resident 1 had an order for PRN Haldol to be administered as needed for agitation. Review of the MAR showed staff administered the medication on two occasions on 03/22/24. There was no documented evidence the PRN medication was used only after documented, non-pharmacological interventions had been tried with ineffective results.

The need to ensure non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (ED) Staff 2 (RN) and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

1. Regarding resident #2 & #1- Med-tech's instructed to progress note or write a comment in the MAR that prior non-med interventions were ineffective before administering the PRN.

#3- Entered in resident's specific signs of anxiety.

2. Training med-tech's to prog note or write a comment in the MAR that prior non-med interventions were ineffective before administering the PRN.

3. RCC's to check daily when they review PRN's given.

4. LN monthly at QAPI review completed with ED.  

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 7, 8, 9 and 10) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Director) on 04/02/24.

Staff 7 (CG), hired 12/14/23, Staff 8 (CG), hired on 02/16/24, Staff 9 (CG), hired 02/23/24, and Staff 10 (CG), hired 02/22/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire.      

Staff 6 acknowledged the staff had not been trained in First Aid or abdominal thrust.

The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (ED) on 04/02/24. She acknowledged the findings.

1. Regarding staff #7,8,9,10

Staff members were given the deadline of 4/15/24 to complete their First Aid and abdominal thrust training.

2. All members of staff will have their pre-service/first 30-day training records reviewed by the Business Office Director before they complete their first week of training.

3. Records will be checked before the staff hit the on-the-floor training and verified at their 30-day mark for completion.

4. Business Office Director & ED

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 04/02/24 identified the following deficiencies:

There was no documented evidence that annual training on fire safety was provided to residents.

On 04/02/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

1. We will be requiring new residents to be instructed within 24 hrs of admission and re-instructed annually, in general safety procedures.

2. Our Maintenance Director's move-in checklist will include the instruction on general safety procedures. Our MD will have a resident census kept on file with admission dates to give the annual training. Annually, there will be documentation on the completed education.

3. Upon admission and annually thereafter.

4. Maintenance Director & ED

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

Refer to C 260, C 270, C 303, C 310, and Z 164.

Refer to C260, C270, C303, C310 and Z 164

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. The current call system did not have a way to consistently alert caregiving staff when a call light was activated, which constituted a threat to the health, safety, and welfare of residents. Findings include, but are not limited to:

During an interview on 09/17/24 at 11:00 am, Resident 10 revealed his/her call system in his/her room failed to work, and s/he used a wooden clapper to get the staff's attention because the call lights went unanswered. On 09/17/24 at 11:30 am, the pull cord in Resident 10's room was pulled.  At 12:15 pm the surveyor asked staff how they were alerted to resident call lights. Staff reported when a resident pulled a cord for assistance, the notification went to a call light panel located behind a locked door, and the MTs informed the caregivers of the call through their walkie talkies. When staff were asked if they had received notification Resident 10 had activated his/her call light, they stated no. No one responded to the call from 11:30 am to 1:00 pm.

In an interview about the call system 09/17/24 at 12:25 pm, Staff 16 reported when she was near the call light panel, she would alert the caregivers of the room numbers that needed assistance.

On 09/17/24 at 2:18 pm, surveyors discussed the call light system with Staff 1 (Executive Director). She reported tablets had been ordered for each neighborhood and they were "supposed to be able to download" an app to the tablets connecting them to the call system. She said that app would cue staff on each neighborhood that a resident's call light had been activated. Staff 1 stated the tablets were "enroute," and the system should be "up and running by the end of the week." She indicated some of the residents had call buttons worn on their wrist and some had call pendants, and that these devices were part of a "stand-alone system." Surveyors requested a list of all residents who had a wrist button or call pendant.

Staff 1 reported the current call system had no way of tracking response time to call lights. She said the new system using the tablets would be able to track response time. Staff 1 indicated "someone was at the front" desk during "business hours," and it was part of the receptionist's duties to monitor the call panel and notify staff of call lights and follow-up to ensure they were answered. She said "all staff" should have walkie talkies so the MT, RCC, and receptionist could reach care staff to alert them to call lights.

On 09/17/24, an observation of the call light panel showed that thirteen resident room emergency pull cords had been activated.

There was no evidence the call system panel was being consistently monitored to alert staff when call lights went off. Call lights left unanswered placed the residents' health, safety, and welfare at risk.

At 2:40 pm on 09/17/24 the facility was asked to provide an invoice or other documentation to show the tablets had been purchased. At 3:30 pm, Staff 1 reported she would have the list of residents with call buttons independent from the main system, as well as the documentation the tablets had been purchased, on the morning of 09/18/24.

On 09/18/24 at 9:30 am a list of 10 of the 64 residents in the facility with call buttons independent from the main system was received, as well as an invoice for the tablets. The facility also provided an email from the corporate IT specialist, who wrote they would "have the ability to add more applications such as the call-light system in the future." When asked what "in the future" meant, Staff 1 said the app would be installed as soon as the tablets were received. She indicated that in the meantime hourly checks on every resident had been implemented. Surveyors requested a plan regarding how the facility would ensure residents' needs were met until the call system was consistently connected to the care staff center or staff pagers. A plan to have one staff responsible to check on all residents every 15 minutes, as well as scheduling the vendor to make the current call system audible on 09/23/24, was received on 09/18/24 at 12:47 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failures(s) associated with the licensing violation.  

The need to ensure the facility provided a call system that consistently connected resident units to the care staff center or staff pagers was discussed with Resident 1 (Executive Director) and Resident 13 (Asset Manager) on 09/18/24. They acknowledged the findings.

1. The system was repaired on September 23rd and is in good working condition.

2. Any issues that arise will be directed to the installation company for immediate assistance. The Rawlin will implement a "Fire Watch" system where residents will have eyes-on safety checks every 15 minutes if the call-light system has a failure.

3. Call-light system will be checked continuously for operation. Maintenance Director will do weekly panel inspection.

4. Maintenance Director and ED.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 372 and C 422.

Refer to C 372 and C 422

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 555.

Refer to C555

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260, C 270, C 303, C 310 and C 330.

Refer to C 260, C 270, C 303, C 310 and C 330

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260, C 270, C 303, and C 310.

Refer to C260, C270, C303 and C310

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, heart failure, and atrial fibrillation. In an acuity interview on 04/01/24, the resident was identified as needing physical assistance with eating.

Review of Resident 5's service plan, dated 01/11/24, observations, and interviews with staff identified the following deficiencies:

The dining portion of Resident 5's service plan lacked the following information:

* Food and fluid preferences;

* Individual needs or adaptations, to allow the resident the greatest independence possible; and

* A set process or program, to provide hydration and nutrition to the resident between meals.

On 04/03/24, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED). She acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance.

Observations of lunch on 04/02/24 and 04/03/24 and breakfast on 04/03/24 and 04/04/24 indicated Resident 2 needed cueing and encouragement from staff with fluid intake.

Resident 2's service plan dated 03/19/24 was reviewed. The resident's service plan lacked information regarding a daily program for hydration based upon the resident's preferences and needs.

The facility provided snack carts including beverages to residents in the common area who participated in facility activities. Resident 2 was not part of the activities and therefore did not have access to the beverages on the snack carts, nor did facility staff offer any hydration options to the resident during his/her waking hours.

The need to provide a daily program for hydration based upon the resident's preferences and needs throughout the resident's waking hours was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding residents #5, #2- service plan will be updated with food and fluid preferences with processes of implementation and delivery detailed for staff. This will include detail for meal times, snack times and will contain resident specific needs and adaptations.

2. Upon admission and significant changes service plans will be updated to include a resident specific nutrition/hydration strategy.

3. Upon admission, significant change and quarterly as needed.

4. RCC, LN & ED

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3, 4, and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect the following required components:

*Residents' current preferences;

*Abilities and skills;

*Emotional/social needs and patterns;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

*Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.

The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/02/24 and 04/03/24. They acknowledged the findings.

1. Regarding residents #1, #2, #3, #4, #5- Individualized activities plans will be written into the service plans detailing:

-what, when, how and how often

-resident current preferences, abilities and skills

-emotional and social needs and patterns

-physcial abilities and limitations, adaptations needed for resident participation

-indentification of activities needed for behavioral interventions

2. Upon admission, at 30-day new admit assessment and significant changes the individualized activities plans will be updated reflecting the currrent needs of each resident.

3. 30-day new admit assessment, upon significant change and quarterly as needed.

4. Life Enrichment Director, RCC & ED.  

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 6, 7, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 6, 7, 8, and 9's records were reviewed during the survey. There was no documented evidence activity evaluations had been completed that addressed the following elements:

* Current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

There were no specific individualized activity plans which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.

On 09/18/24 at 1:10 pm, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN). The staff acknowledged the findings.

1. Regarding residents #6, #7, #8 & #9- Individualized activities plans will be written into the service plans detailing:

-what, when, how and how often

-resident current preferences, abilities and skills

-emotional and social needs and patterns

-physcial abilities and limitations, adaptations needed for resident participation

-indentification of activities needed for behavioral interventions

2. Upon admission, at 30-day new admit assessment and significant changes the individualized activities plans will be updated reflecting the current needs of each resident.

3. 30-day new admit assessment, upon significant change and quarterly as needed.

4. Life Enrichment Director, RCC & ED.  

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#4) with documented behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia.

Resident 4's record documented behaviors including physical altercations with other residents.

The resident's service plan, dated 01/04/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 04/02/24 and 04/03/24, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.

1. Regarding resident #4- service plan will be updated to reflect the specifc behaviors and interventions to be utlized to minimize the behaviors and their negative impact on the resident and the community. Known triggers for the resident will also be noted.

2. As behaviors arise, we will update service plans with appropriate interventions specific to the resident in order to minimize.

3. Quarterly and as needed.

4. RCC, LN & ED