Living Springs Homes LLC

OAR 411-050-0750(2)(j) Resident Records: Significant Events

(j) SIGNIFICANT EVENTS AND INCIDENTS. A written report (using form SDS 344 or its equivalent) of all significant incidents relating to the health or safety of the resident, including how and when the incident occurred, who was involved, what action was taken by the licensee and staff, as applicable, and the outcome to the resident. A copy of the report must be sent to the resident's representative, and case manager, if applicable.
It was observed that Resident 1 had a significant event occur and there was no incident report completed or detailed narration on file regarding the incident.

OAR 411-050-0750(2)(k) Resident Records: Narratives

(k) NARRATIVE OF RESIDENT'S PROGRESS. Narrative entries describing each resident's progress must be documented at least weekly and maintained in each resident's individual record. All entries must be signed and dated by the person writing them.
It was observed that Resident 1 had printed narrative entries that did not all list the author of each narrative/were not signed by the author either physically or electronically.

There were no handrails for 1 step upstairs and 1 step downstairs leading into the caregiver living quarters at the time of the inspection.

There were trees in the backyard leaning towards the AFH and the fence needed repaired at the time of the inspection.

One of the resident bedrooms listed on the floor plan was being used as a caregiver bedroom and the door did not function with the master key at the time of the inspection.

The homes floor plan shows there are currently 5 resident bedrooms however one of the bedrooms was being used by staff at the time of the inspection.

The screening form for Resident #1 was missing information in the describe section at the time of inspection.

There were 3 routine medications that had an order to be administered every 12 hours for Resident #1 however the MAR shows these medications are being administered at 8am and 5pm each day at the time of the inspection.

There were 2 PRN medications for Resident #1 that were listed on the MAR but there was no order available for review for these medications at the time of the inspection.

There was another routine medication for Resident #1 that was written on the MAR however there were 3 conflicting orders for this medication and the MAR did not match the current order.

There was a routine medication for Resident #1 that was to be administered 2 tabs every 6 hours 1 day, then 2 tablets every 8 hours for 1 day then 1 tablet every 12 hours for 1 day then 1 tablet once daily for 1 day. The December 2024 MAR shows this medication was administered at 8am, 12pm, 5pm and 8pm on day 1, day 2 shows the medication was administered at 8am, 12pm and 4pm.

OAR 411-051-0130(2) Medication: Carry Out Orders

(2) WRITTEN ORDERS. The licensee or administrator must obtain and place a signed order in the resident's record for any medications, dietary supplements, treatments, or therapies that have been ordered by a prescribing practitioner. The written orders must be carried out as prescribed unless the resident or the resident's legal representative refuses to consent. The prescribing practitioner must be notified if the resident refuses to consent to an order.

This Rule is not met as evidenced by:

There was an order for a PRN medication for Resident #1 that was not available for administration at the time of the inspection.

There were 2 PRN medications listed on the MAR for Resident #1 but were not available for administration.

There was an order for 2 PRN medications for Resident #1 that were not listed on the residents MAR at the time of the inspection.

There was a routine medication in December 2024 for Resident #1 where the order was completed however there were still 4 pills remaining in the pill bottle at the time of the inspection.

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the follow-up visit conducted on 02/23/2024. The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified:

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregiver 3 had a background check approval that listed their position title as "household member". It was observed that Caregivers 4, 5, and 6 had background check approval letters that listed their position titles as "Other (AFH/Contracted Licensed Health Care)". Statement of Correction due by 3/5/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregivers 2, 3, and 4 did not have SAM exclusion list results available on file to review. Statement of correction due by 3/5/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregiver 1, 5, and 6 did not have a caregiver orientation form on file for review. Statement of Correction due by 3/5/2024.

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of an unscheduled onsite inspection for renewal conducted on 02/24/2024. The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified:

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that there were no narratives available for review for Resident 2 in their record book. It was observed that the administrator had current caregiver records stored on a personal computer and not available for review in the home at the time of the inspection. Statement of correction due by 02/29/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 1 did not have a completed screening form available for review in their file. Statement of correction due by 02/29/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 2 does not have a care plan written and on file. Statement of correction due by 02/29/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 2 had a PRN medication that was empty with no refill available in the home. Statement of correction due by 02/29/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that the current MAR for Resident 3 only had one signature with a corresponding set of initials when more than one person was signing off as administering medications. It was observed that the MAR for Resident 1 did not have any signature with corresponding initials to show who was administering medications. It was observed that Resident 1 had four doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. It was observed that Resident 2 had fourteen doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. It was observed that Resident 3 and Resident 4 each had seven doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. Statement of correction due by 02/29/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that both Resident 1 and Resident 2 had medication listed on their doctor's orders which were not being administered but there was no discontinue order on file for the medication. Statement of correction due by 02/29/2024.

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of an onsite inspection for renewal conducted on 06/09/2023 The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified:

Based on record review, interview, and documentation review, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 4's record revealed Caregiver 4's background check expired on 03/08/2023. Documentation did not include a current background check or background request form. 2. A review of Caregiver 5's record revealed Caregiver 6's background check expired on 04/20/2023. Documentation did not include a current background check or background request form. 3. In an interview, Caregiver 1 acknowledged Caregiver 4 and Caregiver 6 did not have current approved background checks and Caregiver 4's and Caregiver 6's records did not include a background request form. 4. In an interview, Caregiver 1 acknowledged Caregiver 4 and Caregiver 6 did not have a current, approved background checks. 5. A review of the home's posted staffing plan, dated June 1, 2023, revealed Caregiver 4 did not work alone during any shift.6. A review of the home's posted staffing plan, dated June 1, 2023, revealed Caregiver 5 did not work alone during any shift.7. A review of the Oregon Criminal History and Abuse Records Database System (ORCHARDS) website revealed no submission of a new background check for Caregiver 4.8. A review of the ORCHARDS website revealed Caregiver 5 submitted for a new background check on May 31, 2023. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 6's record revealed current First Aid certification. Documentation did not include current CPR certification. 2. In an interview, Caregiver 1 acknowledged Caregiver 6's record was missing current CPR certification. Correct by: 06/19/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. During a home tour, the licensors observed a bathroom on the second floor. The bathroom sink was tested for water. While being tested, the licensors observed water leaking onto the floor of the bathroom under the sink. 2. In an interview, Caregiver 1 acknowledged the sink was leaking. Caregiver 1 reported Caregiver 1 had already made a request to have the sink fixed. Correct by: 06/19/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. During a home tour, the licensors requested Caregiver 1 to test the resident room doors with the master key. 2. In an interview, Caregiver 1 reported Caregiver 2 had the master key. Caregiver 1 reported Caregiver 2 was not available during the inspection. There was no key accessible for the other caregivers in the home. Correct by: 06/19/2023

Based on documentation review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of the home's fire drill documentation revealed the last drill conducted was dated 02/21/23. Documentation did not include a drill conducted within 90 days.2. In an interview, Caregiver 1 acknowledged a fire drill was overdue and not conducted within 90 days. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 3's record revealed no documentation indicating Caregiver 3 was not listed on The U.S. Office of Inspector General's Exclusion List or the U.S. General Services Administration's System for Award Management Exclusion List.2. In an interview, Caregiver 1 acknowledged Caregiver 3's record did include documentation indicating Caregiver 3 was not listed on either of the Exclusion Lists.Correct by: 06/19/2023

Based on documentation review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of the home's documentation of monthly checks for smoke alarm, carbon monoxide alarm, and fire extinguisher testing revealed the last test was conducted in April 2023. There was no documentation of the testing for the month of May 2023. 2. In an interview, Caregiver 1 acknowledged the alarm tests were not current. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed weekly narratives; however, the last entry in the narratives was dated 05/19/2023.2. A review of Resident 2's record revealed weekly narratives; however, the last entry in the narratives was dated 05/03/2023.3. In an interview, Caregiver 1 acknowledged the narratives were not current. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed a care plan with updates; however, the last update for Resident 1's care plan was dated 04/08/2022. 2. A review of Resident 2's record revealed a care plan with updates; however, the last update for Resident 2's care plan was dated 10/04/2022.3. A review of Resident 3's record revealed a care plan with updates; however, the last update for Resident 3's care plan was dated 11/24/2022.4. In an interview, Caregiver 1 acknowledged the care plans were not updated every six months. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed no signed medication order for one over the counter (OTC) medication. 2. A review of Resident 1's record revealed a medication administration record, dated March 2023 through June 2023, included the OTC medication, and was provided to Resident 1 daily.3. In an interview, Caregiver 1 acknowledged a signed medication order for the OTC medication was not available for review. Correct by: 06/19/2023

Based on record review, observation, and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed no signed changed order for three "as needed" (PRN) over the counter (OTC) medications.2. A review of Resident 1's record revealed a medication administration record, dated March 2023 through June 2023, included the three OTC medications; however, there was no documentation to indicate Resident 1 was provided the medications. 3. A review of Resident 1's physical medications revealed no supply of the three OTC medications. 4. In an interview, Caregiver 1 reported Resident 1 no longer needed the medications. Correct by: 06/19/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 3's record revealed a signed order for a medication. The order indicated the medication was to be provided three times a day.2. A review of Resident 3's record revealed a medication administration record (MAR) dated March 2023 through June 2023. The MAR included the medication and stated to take the medication, "once daily".3. In an interview, Caregiver 1 acknowledged the error. Correct by: 06/19/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's medications revealed one medication was stored in Resident 1's room in an unlocked drawer in the nightstand.2. In an interview, Caregiver 1 acknowledged the medication was not stored in a locked, central location.Correct by: 06/19/2023

Based on observation, record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's physical medications revealed two PRN medications were expired. The expiration dates for the two medications were dated 03/03/2022 and 09/28/2022.2. A review of Resident 1's medication administration record, dated March 2023 through June 2023, revealed the medications were not provided to the resident. 3. In an interview, Caregiver 1 acknowledged the medications were expired. Correct by: 06/19/2023