Print Inspection: X609

The findings of the re-licensure survey, conducted 01/24/23  through  01/26/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 first revisit to the re-licensure survey of 01/26/23, conducted 06/15/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (#3) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 05/2019 with diagnoses including lymphedema.

Review of the resident's 01/01/23 through 01/24/23 MAR, signed physician orders, progress notes, and temporary service plans, as well as staff interviews, identified the following:

* The resident had an order for Furosemide (a diuretic) 20 mg twice daily, which s/he could self-administer without supervision.

* On 12/20/22 the resident's physician requested the facility take over administering the resident's medications.

* A temporary service plan dated 12/20/22 informed staff they would be administering the resident's medication, as the resident was "unable to manage" his/her medications "at this time."

* The 01/01/23 through 01/24/23 MAR revealed staff had been documenting "U-SA" for both the 8:00 am and 8:00 pm doses of Furosemide, which indicated staff did not know if the resident had taken it because s/he self-administered the medication.

In interview on 01/26/23, the surveyor advised Staff 3 (RCC) the Furosemide showed as self-administered on the MAR. Staff 3 stated the resident no longer self-administered medications and had not been receiving the diuretic as ordered. Staff 3 stated she would fax the resident's physician about the medication error and to request further instruction.

On 01/26/23, the need to ensure medications were being administered as prescribed was discussed with Staff 1 (ED), Staff 2 (Health & Wellness Director/RN), and Staff 3. They acknowledged the medication error and indicated they would be increasing their MAR audits from monthly to weekly to better address potential concerns.

1.Immediate action was taken the day the violation was found. The Staff #3 RCC faxed the physician about the medication error and requested further instruction.

2. MAR audits will now be performed weekly vs. monthly as previously performed.

3. Correction are will be evaluated weekly.

4. Staff #2 RN and Staff #3 RCC will audit weekly and monitor for errors.   

Based on interview and record review, it was determined the facility failed to consistently document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records dated 08/22/22 through 01/24/23 were reviewed on 01/24/23. The following was identified:

Fire drill documentation did not consistently include one or more of the following required elements:

* Time of fire drill;

* Location of simulated fire origin;

* Escape route used;

* Evacuation time-period needed; and

* Evidence alternate routes were used during fire drills.

The need to follow all OFC requirements pertaining to fire drills and documentation was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/RN), and Staff 3 (RCC) on 01/24/23. They acknowledged the findings. No additional information was provided.

1. Fire drills and fire & life safety training will now be recorded with complete information and documention.

2. Drill & training will now include the following:

*Time of fire drill

*Location of simulated fire origin

*Escape route used

*Evacuation time-period

*Evidence that alternate routes were used during fire drills.

3. Monthly

4. Staff #1 ED will monitor and complete future drills and training.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the facility pathways and seating areas on 01/25/23 showed the following:

* Multiple drop-offs of 2-4 inches were noted along pathway edges and resident personal patios.

The need to ensure pathways around the facility, and around the residents' individual patios did not have potential tripping hazards was reviewed with Staff 1 (Executive Director) on 01/24/23. She acknowledged the findings and her plan to address the areas.

1.Multiple drop-offs of 2-4 inches were noted and those areas have been addressed by adding mulch to bring the receding pathway and resident personal patios up to required level.

2. Additional mulch has been ordered and weekly Staff #1 ED will walk the pathways to measure the levels and write work orders to have the additional mulch to be spread.

3. Once per week,the correction of additional mulch will be evaluated by Staff #1 ED.

4. Staff #1 ED will be respnsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:

Observations of the facility on 01/24/23 through 01/25/23 showed the following areas in need of cleaning or repair:

* Multiple walls on both floors had scrapes, chipped paint, drips or gouges;

* Multiple dining room tables and chairs had large sections where the finish was significantly worn or gone. Chair arms and table legs had scrapes and gouges;

* The cupboards, drawers and walls in the activity room had spills, stains and splatters. The refrigerator had spills inside the refrigerator, along the front grate and debris was on the bottom shelf;

* The bathroom in the activity room had chipped counter top edges, missing and cracked laminate flooring and a large section of flooring that was pulling apart with a large gap between the two pieces of flooring;

* Scrapes, dings and deep gouges were noted on doors, door frames or nearby walls at rooms 102, 103, 104, 113, 122, 123, 142, 143, 147, 151, 156, 157, 222, 241, 247, 251 and 252;

* Window sills in the dining room, activity room and sitting room on the second floor had stains, debris, dead insects, bubbling and/or peeling paint or spills;

* The main laundry room was noted to have multiple large scrapes across doors and walls, the small washing machine had dark accumulation at the back of the machine on top of and behind the lid and walls had deep gouges and scrapes with pieces of drywall or plaster missing. Cupboards and drawers had debris on the shelves and spills/stains to the fronts and insides;

* The activity room, the area in front of the kitchen, the hallway alcove across from the kitchen, in front of the main laundry room, in front of the dining room and in front of rooms 223 and 224 had dark stains to the carpet of varying sizes;

* Two brown banquet tables in the hallways had long scrapes and gouges across the table top and along the edges.

The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) on 01/24/23. She acknowledged the findings.

1. All walls with scrapes, chipped paint, drips or gouges are being repaired. New dining room chairs, and tables will replace the old chairs and tables. Detailed cleaning of the activity room food area was performed immediately. In the Activity Area Bathroom a new countertop has been ordered. Flooring will also be replaced in the same bathroom. All scrapes, dings, and deep gouges on downstairs doors in process of being repaired. All window sills in common areas noted have been cleaned and repaired. Repairs and deep cleaning were performed in the main laundry room. Stains in carpet noted upstairs in front of #223 & #224 have been treated and removed, also stains in front of main laundry room and dining room have been treated and are in the process of being removed. New brown banquet tables have been ordered to replace the damaged.

2. The system was corrected by formal replacement of maintenance director.

3. The area(s) in need of correction will be evaluated weekly and then monthly thereafter.

4. Staff #1 ED will monitor corrections and work directly with maintenance director to see that the ongoing repair and replacement efforts are being completed.