Print Inspection: TWQR

The findings of the re-licensure survey, conducted 03/25/24 through 03/26/24, 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 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

MCCMemory 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 re-visit to the re-licensure survey of 03/26/24, conducted on 08/12/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure resident altercations were reported to the local SPD office for 1 of 1 sampled resident (#1) who was involved in altercations. Findings include, but are not limited to:

Resident 1 was admitted to the facility in August 2023 with diagnoses including Wernicke's Encephalopathy, a form of dementia.  

The resident's service plan, dated 03/07/24, behavior plan, and interviews with care staff between 03/25/24 and 03/26/24 indicated the resident ambulated independently throughout the facility and was aggressive and agitated at times.

Facility Progress Notes were reviewed and noted:

* 01/28/24 - "After dinner [Resident 1] proceeded to pick on [resident room number] again. [S/he] began shoving the side table over toward [room number]...and unplugging [his/her] chair..."  

Staff explained Resident 1 unplugged an electric recliner, restricting the other resident.

* 03/04/24 - "Resident came out of [his/her] room raising [his/her] voice at [room number] to move. [Resident 1] stated "If you don't move I'm going to beat your ass! Move now! Staff attempted to redirect by informing [Resident 1] there were 6 other available seats in the living room to which [Resident 1] stated [s/he] didn't care...[Resident 1] grabbed a coffee cup intending to throw coffee on [room number]. The cup happened to be empty and [Resident 1] then grabbed a cup of juice to throw on [room number] which staff took from [him/her]..."

In an interview with Staff 1 (Regional Director of Operations) on 03/26/24, she explained the incidents had not been reported to the local SPD.

The need to ensure incidents of threatening significant physical harm and intimidation were reported to the local SPD was reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the findings

The facility was asked to report the incidents. Case intake numbers were provided prior to survey exit.

PLC of Bend will implement the following: Self report 2 verbal Res to Res altercations.

All resident incident reports will be reviewed and if abuse and neglect can not be ruled out so self reports were done.

2) EDIRN will review daily,

3) RDO will review weekly

EDIAED and RDO

4  EDIAEDIRDOIRN

Based on observation, 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 2 and 3) whose medications, MARs, and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

1. Resident 2 was admitted in 03/05/24 with diagnoses including pain.

Resident 2 had an order for Hydrocodone/APAP 5-325 mg one tablet every six hours as needed for severe pain.

Review of Resident 2's Controlled Substance Disposition Logs and MARs, from 03/01/24 to 03/26/24, and pills, revealed 11 occasions when staff signed on the drug disposition log the medication was given, however, the MAR lacked documentation the resident received the medication. The medications were in a bottle and the count matched the dispensation log.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the discrepancies.

2. Resident 3 was admitted to the facility in May 2023 with diagnoses including dementia and anxiety.

Resident 2 had an order for Lorazepam 0.5 mg one tablet every six hours as needed for anxiety.

Resident 2's Controlled Substance Disposition Logs, medication bubble packs, and MARs, reviewed from 03/01/24 to 03/26/24, revealed the medication was documented on the MAR as administered on 03/07/24. There was not documentation of the medication being given on the Controlled Substance Disposition log. The Disposition Log and medication in the bubble pack count matched.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the discrepancies.

1) ED and AED will do a daily MAR to cart to Narcotic Book audit on all residents

2) By auditing daily and addressing any concerns

Daily for the next 30 days then weekly

ED AED RDO

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#1) with multiple medication refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in August 2023 with diagnoses including Wernicke's Encephalopathy, a form of dementia.

Resident 1's MARs from 03/01/24 through 03/25/24 were reviewed. Resident 1 refused some or all medications on 16 days.

There was no documented evidence each incident of Resident 1's multiple medication refusals had been reported to the practitioner.

The need to notify the practitioner when Resident 1 refused ordered medications was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the physician had not been informed of the refusals.

1) All PCP's have been faxed refusal orders and how often they want to be notified. All orders received and added to the EMAR

2) New move in orders include how often to report to refusals.

3) Monthly ED and AED will review ALL residents orders to ensure they have a refusal order. also to be done upon admit and quarterly

4) ED and AED

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

A tour of the facility on 03/25/24 revealed the following:

* The shared bathroom in the common area had water that when turned on, was hot to the touch. The hot water temperature, taken by the surveyor with the facility digital thermometer, was 125 degrees Fahrenheit; and

* Various residents' bathroom sinks' hot water was between 123 and 125 degrees Fahrenheit.

Signs were posted at all sinks warning of hot water.

In an interview with Staff 1 (Regional Director of Operation) on 03/25/24, she reported the facility had identified the issue and had been adjusting the temperature. She acknowledged the water temperatures were exceeding 120 degrees Fahrenheit.

1) Our Maintenance person is looking into the system and if he is unable to resolve the issue he will be looking to bring in an outside company for a water heater specialist.

2) Maintenance will evaluate and if he is not able to correct problem he will call in a specialist to fix

3) ED and AED will continue hot water temp checks weekly to maintain a steady temp with in the OAR rules and Reg

ED, AED and Maitence

Based on observation, 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 231 and C 545.

Please refer to Refer to C 231 and C 545.

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 302 and C 305.

Refer to C 302 and C 305.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to:

The facility was toured on 03/25/24. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included areas as low as 63 inches, or five feet three inches, in height.

The facility had cameras to monitor the courtyard. The door alerted staff when residents exited the facility into the courtyard.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Regional Director of Operations) on 03/25/24 and 03/26/24. Staff 1 reported a fencing company was scheduled on 03/27/24 to increase the height of the fence.

1) Quotes are being obtained

2) we have a company making a model of what an extension would look like to reach our height requirement

3) Until extension or repair is made to the current fencing

ED/AED RDO