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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 558 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to provide a trapeze needed for bed mobility for 1 of 1 sampled resident (#38) reviewed for accommodation of needs. This placed residents at risk of ADL decline. Findings include: Resident 38 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. According to the 1/2019 Admission Nursing Data Base, the resident was admitted to the facility for rehabilitation in order to better care for her/himself. A physician's orders [REDACTED]. A 1/5/19 Progress Note identified the trapeze was installed on her/his bed and the resident was moving well with trapeze in bed. On 2/1/19, the resident moved to a new room on a different floor of the facility. On 2/20/19 at 11:30 AM, the resident was observed in bed with bilateral quarter side rails at the head of the bed. No trapeze was in place. On 2/22/19 at 7:44 AM, the resident was again observed in bed with a trapeze placed at the head of the bed. Resident 38 stated she/he had just received the trapeze. When interviewed on 2/25/19 at 11:05 AM, the resident stated she/he appreciated the use of the trapeze as it allowed her/him to move more and reposition in bed. Resident 38 further stated you needed to be persistent at the facility and become the squeaky wheel to get what you needed. It took a while to get the trapeze. In a 2/26/19 interview at 1:36 PM, Staff 10 (Resident Care Manager-LPN), stated the trapeze order was initially missed and then maintenance did not think they could use the trapeze with the position of the bed. According to Staff 10, there was miscommunication between staff which delayed the delivery of the trapeze to the room. | 2020-09-01 |
| 2 | 2 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 561 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to provide choice in shower schedule and follow food choices for 1 of 2 sample residents (#38) reviewed for choices. This placed residents at risk for reduced quality of life. Findings include: Resident 38 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. a. The 1/9/19 Admission MDS coded the need for the physical help of one person with part of the bathing activity. The ADL Care plan, revised on 2/5/19, identified the resident's need for one person to provide some physical assistance with bathing. On 2/11/19, the care plan was further updated with the resident's preferred equipment to use during bathing. A 2/11/19 Social Service Note identified the resident's preferred days for showers on Sunday and Wednesday, but no mention of the resident's preferred time of day for showers was reflected in the notes. The Bathing/Shower task documentation from 2/8/19 through 2/20/19 identified the resident was documented as received showers between 10:30 AM and 2:05 PM. On 2/20/19 at 9:58 AM, Resident 38 was observed sitting on her/his bed in pajamas. The resident stated she/he didn't have much choice when showers were provided. The resident stated you needed to wait your turn and until a CNA was ready. Resident 38 stated she/he would rather schedule the time for a shower, so free time was available in her/his day. According to the resident, the day was decided for her/him. On 2/20/19 at 11:16 AM, the resident remained in her/his pajamas with items needed for the shower stacked at the bedside. In a 2/25/19 interview at 11:15 AM, Staff 12 (LPN) stated showers were assigned on specific days and shifts, but in no particular time within that shift. When interviewed on 2/26/19 at 1:36 PM, Staff 10 (Resident Care Manager-LPN) stated she generally talked to residents when they were admitted and if the resident mentioned a specific time, she would arrange it.… | 2020-09-01 |
| 3 | 3 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 580 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to notify the physician for fluid overload and multiple missed medications and treatments for 1 of 1 sampled resident (#199) reviewed for death. This placed residents at risk for unmet medication and treatment needs. Findings include: Resident 199 was admitted to the facility in 9/2018, with [DIAGNOSES REDACTED]. On 10/25/18, Resident 199 was sent to the hospital and later passed away. Resident 199's 10/1/18 signed physician orders [REDACTED]. -[MEDICATION NAME] Solution 100 unit/ml (insulin) sliding scale subcutaneously with meals for diabetes; -Aspirin 81 mg every afternoon for heart health; -Nephro-Vit (B Complex-C-Folic Acid) tablet 1 mg every afternoon; -[MEDICATION NAME] (an antidepressant) 12.5 mg every morning for [MEDICAL CONDITION]; -[MEDICATION NAME] Solution 30ml TID for hepatic [MEDICAL CONDITION] (a decline in brain function due to liver disease); -Sevelamer (a [MEDICATION NAME] binder) HCL 800 mg TID with meals; -Fluid restriction 1000 ml-1200 ml/day every shift; and -Check CBG (capillary blood glucose) BID. Resident 199's 9/2018 and 10/2018 MARs and DARs (Diabetic Administration Record) documented the following number of missed medications as out of the facility: -[MEDICATION NAME] Solution: 9/2018 - 20 times and 10/2018 - 29 times; -Aspirin: 9/2018 - eight times and 10/2018 - 15 times; -Nephro-Vit: 9/2018 - eight times and 10/2018 - 15 times; -[MEDICATION NAME]: 9/2018 - eight times and 10/2018 - 9 times; -[MEDICATION NAME] Solution: 9/2018 - 16 times and 10/2018 - 23 times; -Sevelamer: 9/2018 - 16 times and 10/2018 - 26 times; and -Check CBG BID: 9/2018 - eight times and 10/2018 - 10 times. Resident 199's 9/2018 and 10/2018 TAR and Fluid Intake Flowsheet recorded 14 days where the resident was over her/his fluid intake of 1200 ml/day. There was no documented evidence in Resident 199's clinical record the resident's physician was notified regarding … | 2020-09-01 |
| 4 | 4 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 637 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to complete a significant change assessment for 1 of 2 sampled residents (#8) reviewed for a decline in status. This placed residents at risk for unmet needs. Findings include: Resident 8 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. The 11/2018 signed physician's orders [REDACTED]. [MEDICATION NAME] [MEDICATION]) and [MEDICATION NAME] (antipsychotic medication) were ordered for the resident's [DIAGNOSES REDACTED]. The 11/20/18 Admission MDS coded no feeding tube was used and an antipsychotic medication was given the past seven days. On 11/27/18, Resident 8 was hospitalized . The 12/8/19 hospital discharge summary identified the resident was likely experiencing end-stage dementia with chronic dysphagia (difficulty swallowing). A NG (Nasogastric) tube was placed. The 12/2018 signed physician's orders [REDACTED]. The orders also reflected [MEDICATION NAME] and [MEDICATION NAME] were discontinued. When interviewed on 2/26/19 at 2:09 PM, Staff 25 (CNA) stated the resident had asked for assistance to get in her/his wheelchair prior to the hospitalization , but now stayed in bed. The resident also came back from the hospital not eating. In a 2/26/19 interview at 1:59 PM, Staff 10 (Resident Care Manager-LPN) confirmed a Significant Change in Status Assessment should have been completed due to the multiple changes the resident had experienced. | 2020-09-01 |
| 5 | 5 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 657 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to revise care plans in the areas of nutrition, food preferences and mood for 3 of 21 sampled residents (#s 8, 28 and 38) whose care plans were reviewed. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. The 11/2018 signed physician's orders [REDACTED]. On 12/8/18, the resident was readmitted to the facility. The 12/2018 signed physician's orders [REDACTED]. The previous diet orders were discontinued. The current nutritional care plan, last revised on 12/13/18, and the current Kardex Report (CNA Care Plan) continued to reflect the CCHO diet order as well as the orders for the tube feeding. In a 2/26/19 interview at 1:59 PM, Staff 10 (Resident Care Manager-LPN) confirmed both orders were reflected on the care plan. 2. Resident 38 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. On 2/1/19, the resident moved to a new room on a different floor of the facility. A 2/10/19 progress note identified the resident became upset because staff did not allow a slide board transfer into a shower chair. The nurse counseled the resident and stated the sliding board transfer was unsafe. The resident refused the offered Hoyer lift transfer and shower. On 2/11/19, a follow-up care conference was held with the resident. The 2/10/19 shower refusal was discussed with a plan to update the care plan to state the resident could use a drop arm bedside commode as a shower chair as the resident had already been using this in her/his previous unit within the facility. On 2/11/19, the ADL Self Care Care Plan was updated to reflect the resident's preference to use the commode chair with drop arm for showering, using a sliding board transfer, approximately 10 days after the resident was moved to a different room and floor in the facility. In a 2/26/19 interview at 1:36 PM, Staff 10 (Resi… | 2020-09-01 |
| 6 | 6 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 684 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on interview and record review, it was determined the facility failed to provide alternative care options related to multiple missing medications and treatments for 1 of 1 sampled resident (#199) reviewed for death. This placed residents at risk for medical complications. Findings include: Resident 199 was admitted to the facility in 9/2018, with [DIAGNOSES REDACTED]. On 10/25/18, Resident 199 was sent to the hospital and later passed away. Resident 199's care planned identified she/he was at risk for fluid overload due to end stage [MEDICAL CONDITION] and at risk for hyper/[DIAGNOSES REDACTED] due to diabetes. Interventions included [MEDICAL TREATMENT] and medications per physician orders. Resident 199's 10/1/18 signed physician orders included the following medication and treatment orders: -[MEDICATION NAME] Solution 100 unit/ml (insulin) sliding scale subcutaneously with meals for diabetes; -Aspirin 81 mg every afternoon for heart health; -Nephro-Vit (B Complex-C-Folic Acid) tablet 1 mg every afternoon for supplement; -[MEDICATION NAME] (an antidepressant) 12.5 mg every morning for [MEDICAL CONDITION]; -[MEDICATION NAME] Solution 30 ml TID for hepatic [MEDICAL CONDITION] (a decline in brain function due to liver disease); -Sevelamer (a [MEDICATION NAME] binder) HCL 800 mg TID with meals; -Fluid restriction 1000 ml-1200 ml/day every shift; and -Check CBG (capillary blood glucose) BID. Resident 199's 9/2018 and 10/2018 MAR and DAR (diabetic administration record) documented the following number of missed medications as out of the facility: -[MEDICATION NAME] Solution: 9/2018 - 20 times and 10/2018 - 29 times; -Aspirin: 9/2018 - eight times and 10/2018 - 15 times; -Nephro-Vit: 9/2018 - eight times and 10/2018 - 15 times; -[MEDICATION NAME]: 9/2018 - eight times and 10/2018 - 9 times; -[MEDICATION NAME] Solution: 9/2018 - 16 times and 10/2018 - 23 times; -Sevelamer: 9/2018 - 16 times and 10/2018 - 26 times; and -Check CBG BID: 9/201… | 2020-09-01 |
| 7 | 7 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 697 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to manage pain for 1 of 3 sampled residents (#30) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include: Resident 30 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident 30's Care Plan for chronic pain instructed staff to provide pain medication per physician order. Resident 30 received palliative care from Elder Place. Elder Place managed the resident's medications and the facility administered the resident's medications. The 9/2018 Palliative Care Plan revealed the resident did not want pain [MEDICATION NAME] Gel was included as an intervention for pain. The 12/2018 Quarterly MDS Assessment revealed Resident 30 experienced pain which limited her/his day to day activities. The 12/2018 Pain Evaluation revealed Resident 30 experienced pain daily and received [MEDICATION NAME] gel as a scheduled pain medication. There were a total of 18 times on the 1/2019 TAR the [MEDICATION NAME] Gel was not documented as being administered: -1/4/19, 1/7/19, 1/11/19, 1/13/19, 1/14/19, 1/16/19, 1/18/19, 1/20/19, 1/21/19, 1/25/19 to 1/29/19, 1/30/19 (three times) and 1/31/19. There were a total of 15 times on the 2/2019 TAR the [MEDICATION NAME] Gel was not documented as being administered: -2/1/19, 2/3/19, 2/4/19, 2/6/19, 2/10/19, 2/11/19 (two times), 2/12/19, and 2/14/19 to 2/20/19. On 2/26/19 at 8:42 AM, Staff 2 (DNS) confirmed multiple blanks on the 1/2019 and 2/2019 TAR and acknowledged physician orders [REDACTED]. On 2/26/19 at 10:55 AM, Resident 30 stated she/he experienced pain in her/his left knee when the [MEDICATION NAME] Gel medication was not applied. On 2/26/19 at 11:00 AM, Staff 3 (LPN) indicated if the TAR was blank the administration of the order was missed. | 2020-09-01 |
| 8 | 8 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 698 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to provide post-[MEDICAL TREATMENT] care and assure accurate fluid restrictions for 1 of 1 sampled resident (#38) reviewed for [MEDICAL TREATMENT]. This placed residents at risk for [MEDICAL CONDITION] complications. Findings include: Resident 38 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. The 1/3/19 [MEDICAL TREATMENT] Care Plan identified the resident received [MEDICAL TREATMENT] treatments out of the building on Tuesday, Thursday and Saturday. The care plan directed staff to monitor for symptoms of fluid overload and electrolyte imbalance with emergency procedures provided. Nursing staff were to monitor the [MEDICAL TREATMENT] catheter every shift for signs of infection, [MEDICAL CONDITION], ischemia, bleeding, dislodgement and presence of a catheter cap. A 1500 ml/day fluid restriction was identified. Progress notes identified monitoring of the catheter after [MEDICAL TREATMENT] on 1/3/19, 1/10/19, 1/17/19, 1/24/19 and 1/31/19. There was no evidence of routine monitoring of the [MEDICAL TREATMENT] catheter in February. The 2/2019 TAR directed nursing staff to ensure the [MEDICAL TREATMENT] form was sent to and returned from the [MEDICAL TREATMENT] center, and to monitor the [MEDICAL TREATMENT] catheter every shift. The 1500 ml/day fluid restriction was monitored and initialed as completed every shift. On 2/20/19, the Hydration Pass monitor identified the resident consumed 1800 ml within a 24 hour period. There was no evidence in the medical record nursing staff recognized or responded to the over-consumption of fluids on 2/20/19. In a 2/20/19 interview at 10:39 AM, Resident 38 who was alert and oriented stated the facility nurse did not regularly check her/his access site upon return from [MEDICAL TREATMENT] and often times, the first nursing contact she/he had was with the CMA who brought the noon medication pills or when the … | 2020-09-01 |
| 9 | 9 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 740 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to assess and develop individualized interventions specific to expression of [MEDICAL CONDITION] for 1 of 1 sampled resident (#28) reviewed for behavioral-emotional health. This placed resident at risk for a decline in mood resulting in potential risk for reduced quality of life. Findings include: Resident 28 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The 12/9/18 Quarterly MDS under Section C: Cognitive patterns indicated Resident 28's BIMS (Brief Interview for Mental Status) score of 12 (8 to 12 indicates moderate impairment) and no mood or behavior concerns. Resident 28's Care Plan (revised on 4/5/18) addressed mood, included history of suicidal behavior, threats, outbursts when frustrated, negative verbalizations and frequent complaints. Interventions included initiating 15 minute checks as needed, interviewing the resident per suicide policy protocol to assess suicide intent, medication per physician orders, mental health evaluation as needed, and to notify the DNS and/or Administrator at time of the incident after resident is safe. The 11/17/17 Suicide Ideation and Precautions Policy directed the interdisciplinary team to assess and develop interventions to address behavior. Resident 28's Care Plan had no individualized interventions or approaches to address the resident's suicidal verbalizations. Resident 28's current Visual/Bedside Kardex (system used by CNA staff to communicate important information) included no interventions to address verbalizations of suicidal ideation. Progress notes on 2/27/18, 3/15/18, 6/11/18, 2/19/19, 2/20/19, 2/21/19 and 2/23/19 documented Resident 28's verbalizations of suicide. On 2/21/19 at 12:11 PM, Resident 28 was observed conversing with Witness 4 (Nurse Practitioner) in the fourth floor dining room stating she/he wished the staff had a gun to shoot her/him. In addition, Resident 28 stated … | 2020-09-01 |
| 10 | 10 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 757 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to adequately monitor weights for 1 of 5 sampled residents (#16) reviewed for unnecessary medications. This placed residents at risk for inaccurate weight status and medication dose. Findings include: Resident 16 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 2/8/19 Admission MDS Section C: Cognitive Patterns specified a BIMS (brief interview for mental status) score of 12. This score indicated Resident 16 was moderately impaired. Resident 16's 2/1/19 physician's orders [REDACTED]. Resident 16's 2/1/19 physician's orders [REDACTED]. The 2/2019 TAR for daily weights was reviewed. The following 10 out of 19 days did not have a weight recorded: -2/4/19 to 2/6/19; -2/12/19; -2/14/19 to 2/16/19; and -2/18/19 to 2/20/19. There was no information on the TAR regarding a reason for failure to obtain Resident 16's daily weight. A review of progress notes revealed no information related to Resident 16's daily weight. In an interview on 2/21/19 at 1:43 PM, Resident 16 stated she/he took [MEDICATION NAME] (a medication used to treat fluid retention) for the fluid around her/his heart. Resident 16 stated she/he was supposed to get weighed every day. She/he stated staff used to take her/his weight every day but it had not been done lately. In an interview on 2/22/19 at 1:43 PM, Staff 5 (RNCM) stated Resident 16 took [MEDICATION NAME] for [MEDICAL CONDITION] and should be weighed daily. She stated staff should be monitoring Resident 16 for weight gain and notifying the physician as ordered. Staff 5 stated it was the nurse's responsibility with RNCM oversight to ensure daily weights were completed and confirmed Resident 16's weight was not obtained and recorded daily. In an interview with on 2/26/19 at 3:57 PM, Staff 2 (DNS) stated Resident 16 was pretty sick, bed bound and possibly unable to tolerate a daily weight. Staff 2 added she nor Staff 5 (RNCM) locate… | 2020-09-01 |
| 11 | 11 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 838 | F | 1 | 1 | 71NL11 | > Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment to determine what resources were necessary to care for its residents competently during both day to day operations and emergencies. This placed residents at risk of unmet needs. Findings include: On 2/26/19, the undated Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following: -Facility staffing levels; -Staff competencies that were necessary to provide the level and types of care needed for the resident population; -The physical environment, equipment, services, and other physical plant considerations that were necessary to care for this population; -The facility's resources, including but not limited to, all buildings and/or other physical structures and vehicles; equipment (medical and non-medical); all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; and contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. On 2/26/19 at 3:50 PM, Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive. Staff 1 was unable to provide information or documentation that addressed the missing information for the Facility Assessment. | 2020-09-01 |
| 12 | 12 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 880 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on observation, interview and record review, it was determined the facility failed to assess and perform dressing changes to an intravenous (IV) access line for 1 of 2 sampled residents (#312) reviewed for infections. This placed residents at risk for infection. Findings include: The Centers for Disease Control and Prevention Section VI: Central Venous Catheters outlined the following procedures: B. Peripherally Inserted Central Catheters (PICCs) *Frequency of dressing change: -Transparent dressing: change every five to seven days unless soiled or loose. The Facility's Catheter Insertion and Care Policy and Procedure for central line dressing changes (no date) specified the following: -Change central and midline catheter dressing 24 hours after catheter insertion, every seven days, or if it is wet, dirty, not intact, or compromised in any way. Resident 312 admitted to the facility in 1/2019 and was discharged at the end of the month with a return to the facility anticipated. Resident 312 returned to the facility in 2/2019 with [DIAGNOSES REDACTED]. Review of the 2/2019 TAR indicated no documentation of PICC dressing changes. Review of Resident 312's Progress Notes indicated no documentation related to ongoing assessment and monitoring of the PICC for infection such as redness, warmth, tenderness, soilage, drainage and infiltration (leakage of medication into tissue). An observation on 2/19/19 at 10:12 AM was made of Resident 312's right arm. A PICC with clear dressing dated 2/7/19 was observed on Resident 312's right upper arm. There was no bleeding or redness observed at the PICC insertion site and the dressing was clean, dry and intact. In an interview on 2/19/19 at 10:12 AM, Resident 312 stated she/he received IV medication for a bone infection. She/he stated staff did not change the PICC dressing as often as they should and verified the 2/7/19 date on the dressing. She/he stated this is my lifeline because I have no veins left … | 2020-09-01 |
| 13 | 13 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-06-01 | 609 | D | 1 | 0 | 4O6P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to report potential neglect of care to the state agency for 1 of 3 sampled residents (#1) reviewed for falls. This put residents at risk for potentially avoidable incidents. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on 5/3/18 which indicated the resident was left unattended on the bedside commode and fell . Witness 1 (Complainant) indicated the resident previously experienced a fall at her/his memory care facility and sustained a [MEDICAL CONDITION]. Witness 1 stated within three hours at the facility the resident was left on the bedside commode, fell and sustained a 2-3 inch laceration which required stitches. A nursing facility form labeled HOSPITAL REPORT dated 4/14/18 at 3:30 PM indicated the resident had a right [MEDICAL CONDITION], was forgetful with dementia and had mixed continence/incontinence. The resident was noted to be weight bearing as tolerated and required two person transfer assistance to the commode. A hospital discharge summary dated 4/14/18 indicated the resident had severe dementia and previously resided in a memory care facility where she/he sustained a fall with a resulting [MEDICAL CONDITION]. The resident stabilized and was discharged to a skilled nursing facility for continued physical therapy with the plan to return to her/his previous memory care facility. A facility admission nursing data base with an effective date of 4/14/18 indicated the resident was oriented to person and lethargic. The resident's prior level of function was marked as dependent and admitted related to a ground level fall with a [MEDICAL CONDITION]. The assessment indicated the resident had three falls in the last month and 4-5 falls in the last six months per the resident's family. A facility incident investigation dated 4/14/18 at 7:41 pm indicated the resident fell from the bedside … | 2020-09-01 |
| 14 | 14 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-06-01 | 689 | G | 1 | 0 | 4O6P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident received adequate supervision to prevent a fall for 1 of 3 sampled residents (#1) reviewed for falls. This put residents at risk for potentially avoidable incidents. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on 5/3/18 which indicated the resident was left unattended on the bedside commode and fell . Witness 1 (Complainant) indicated the resident previously experienced a fall at her/his memory care facility, sustained a [MEDICAL CONDITION] and was hospitalized . The resident was discharged from the hospital to the nursing facility. Witness 1 stated within three hours of admission to the nursing facility the resident was left on the bedside commode, fell and sustained a 2-3 inch laceration which required stitches. A nursing facility form labeled HOSPITAL REPORT dated 4/14/18 at 3:30 PM indicated the resident had a right [MEDICAL CONDITION], was forgetful with dementia and had mixed continence/incontinence. The resident was noted to be weight bearing as tolerated and required two person transfer assistance to the commode. A hospital discharge summary dated 4/14/18 indicated the resident had severe dementia and previously resided in a memory care facility where she/he sustained a fall with a resulting [MEDICAL CONDITION]. The resident stabilized and was discharged to a skilled nursing facility for continued physical therapy with the plan to return to her/his previous memory care facility. A facility admission nursing data base with an effective date of 4/14/18 indicated the resident was oriented to person and lethargic. The resident's prior level of function was marked as dependent and the resident was admitted related to a ground level fall with a [MEDICAL CONDITION]. The assessment indicated the resident had three falls in the last month and 4-5 falls in the last s… | 2020-09-01 |
| 15 | 15 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 176 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure a resident was assessed for safe self-administration of medication for 1 of 1 sampled resident (#285) who self-administered medication. This placed the resident at risk for unsafe medication administration. Findings include: Resident 285 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. On 9/5/17 at 9:27 am Resident 285 was observed lying in bed. A plastic cup containing three pills was observed on the resident's overbed table. On 9/5/17 at 9:31 am Staff 10 (CMA) stated she left the pills with Resident 285 at the resident's request and did so often. Staff 10 stated the pills included two cranberry tablets and a multivitamin. Review of Resident 285's record did not indicate Resident 285 was assessed to administer medications on her/his own. On 9/5/17 at 11:40 am Staff 2 (DNS) acknowledged Resident 285 was not assessed to self-administer the medications. | 2020-09-01 |
| 16 | 16 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 272 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to comprehensively assess dental status for 1 of 2 sampled residents (#181) reviewed for dental status. This placed residents at risk for unmet needs. Findings include: Resident 181 admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Resident 181's Admission Nursing Data Base form dated 8/10/17 was completed by Staff 15 (RN/Admissions Nurse). Staff 15 identified Resident 181 as having both No natural teeth or tooth fragment(s) (edentulous) and Natural teeth. No dentures were documented. Resident 181's Admission MDS, dated [DATE], was completed by Staff 16 (RN/MDS Coordinator) and identified the resident as edentulous (having no natural teeth or tooth fragments). The corresponding Dental Care CAA described the resident as having no natural teeth on admission and had a full set of dentures with no concerns. On 9/7/17 at 2:52 pm, Resident 181 reported she/he had her/his own natural teeth, but had one broken tooth. Resident 181 was observed to have all natural teeth, but one broken upper front tooth with tooth fragments present. Resident 181 denied any pain or discomfort. On 9/11/17 at 9:36 am, Staff 14 (RN) reported Resident 181 had her/his own teeth, but one broken tooth in the front. She stated Resident 181 never complained of pain or discomfort. On 9/11/17 at 11:38 am, Staff 16 (RN/MDS Coordinator) confirmed she assisted the facility in completing MDS assessments, but did not come to the facility in person. She worked remotely and would gather information from the resident's records to complete the MDS and CAAs. She would call the facility if there were any questions. She stated Staff 12 (MDS Coordinator) reported the resident had no teeth and had dentures. On 9/11/17 at 11:46 am, Staff 2 (DNS) reported Staff 12 was an interim MDS coordinator, but no longer worked at this facility. Staff 2 verified the Dental Care CAA did not match the resident … | 2020-09-01 |
| 17 | 17 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 278 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to correctly code the MDS to reflect the urinary incontinence and dental status for 2 of 4 sampled residents (#112 and 181) reviewed for urinary incontinence and dental status. This placed residents at risk for unmet needs. Findings include: 1. Resident 112 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. According to the Long-Term Care Facility RAI 3.0 User's Manual for coding urinary continence, a resident is coded as always incontinent if incontinent of urine on all occasions during the seven-day look-back period. If a resident was continent of urine more than once during the look-back period she/he would be coded as frequently incontinent. According to bladder records on 6/11/17, 6/12/17, 6/13/17 and 6/14/17 the resident was continent of urine. On 6/21/17 the facility completed a quarterly assessment with an assessment reference date of 6/16/17. The quarterly MDS assessment was coded to reflect the resident was always incontinent of urine rather than frequently incontinent. In an interview on 9/11/17 at 12:13 pm Staff 2 (DNS) stated the nurse who completed Resident 112's 6/2017 quarterly MDS assessment no longer worked at the facility. During interview on 9/11/17 at 12:23 pm Staff 3 (RNCM) and Staff 2 acknowledged Resident 112's quarterly assessment was inaccurately coded for urinary continence. 2. Resident 181 admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Resident 181's Admission Nursing Data Base form dated 8/10/17 was completed by Staff 15 (RN/Admissions Nurse). Staff 15 identified Resident 181 as having both No natural teeth or tooth fragment(s) (edentulous) and Natural teeth. No dentures were documented. Resident 181's Admission MDS, dated [DATE], was completed by Staff 16 (RN/MDS Coordinator) and she identified the resident as edentulous (having no natural teeth or tooth fragments) in Section L: Oral/Dental Status… | 2020-09-01 |
| 18 | 18 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 279 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to develop a comprehensive care plan related to fluid restriction for 1 of 4 sampled residents (#120) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 120 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Admission MDS Nutrition CAA dated 6/30/17 indicated Resident 120 was on a fluid restriction related to chronic heart failure. Resident 120's care plan did not indicate she/he was on a fluid restriction. On 9/8/17 at 1:08 pm Staff 8 (CNA) stated she thought Resident 120's fluid restriction was 1000 mls daily. On 9/11/17 at 10:03 am Staff 9 (RNCM) acknowledged Resident 120's fluid restriction was not on the resident's care plan. | 2020-09-01 |
| 19 | 19 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 280 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined the facility failed to update the care plan for 1 of 3 sampled residents (#58) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 58 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. a. Review of the resident's 10/8/16 Nutrition CAA revealed the resident required total assistance with meals. Review of the 10/19/16 RD Assessment revealed Resident 58 was ordered a regular dysphagia diet with nectar consistency. The RD revealed the resident would occasionally feed her/himself and needed total assistance with meals. Review of the resident's 6/15/17 Comprehensive Plan of Care Review revealed the resident required a regular puree texture diet and total assistance with meals. The resident's current care plan dated 7/19/17 instructed staff to set up the resident's meal tray and assist if needed. Review of the resident's current Kardex (CNA care plan) revealed the resident had two physician ordered diets as follows: *Regular texture diet with nectar thick liquids, nutritionally enhanced meals, finger foods and was able to eat independent with staff set up; and *Regular diet with puree texture, nectar thick liquids and the resident verbal cues and encouragement for eating. During an observation on 9/5/17 and 9/6/17 at the noon meal service, Resident 58 was observed to be fed her/his lunch meal by staff. The resident's meals were pureed. During an interview on 9/8/17 at 11:16 am, Staff 6 (CNA) stated Resident 58 received a mechanical soft diet and was fed by staff. During an interview on 9/8/17 at 1:56 pm, Staff 7 (RN) stated Resident 58 received a regular pureed diet with full assistance by staff. During an interview on 9/11/17 at 9:08 am, Staff 3 (RNCM) acknowledged Resident 58 was ordered and received a regular puree diet with full assistance and confirmed the care plan was not reflective. b. A physician order dated 12/4/14 i… | 2020-09-01 |
| 20 | 20 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2017-09-11 | 323 | D | 0 | 1 | 8N9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure assistive devices and siderails were assessed, monitored for safety and care planned for 3 of 4 sampled residents (#s 75, 120 and 271) reviewed for accidents. This placed the residents at increased risk for accident hazards. Findings include: 1. Resident 75 was readmitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. The 10/27/16 Safety Device and Consent form revealed the resident required bilateral assist rails for the use for bed mobility and assisting with transfers and positioning. The resident had impaired mobility and sensory impairment. The risks of the assist rails included strangulation, death and climbing over the rails. The benefits included increased bed mobility, security and the ability to perform ADL's. The 10/27/16 care plan revealed the resident used bilateral assist rails to help maximize independence with bed mobility, positioning and transfers. The 6/17/17 Kardex (CNA care plan) revealed the resident had bilateral assist rails on the bed for mobility, positioning, transfers and spatial awareness. The bedrails were to help maximize independence with bed mobility, positioning and transfers. On 9/5/17 at 12:53 pm the resident was in her/his room sitting next to the bed. The bed had bilateral half siderails and the side closest to the window was lopsided and appeared detached from the bed, but did not pose an entrapment risk. The resident indicated she/he liked to use the siderail closest to the window for mobility but the rail was loose and she/he wanted the rail fixed. On 9/5/17 at 12:53 pm Staff 5 (CNA) was in the room and stated she would try to tighten the siderail but indicated she was unable to fix it and would put a request into the maintenance department. On 9/5/17 at 1:28 pm Staff 4 (Director of Plant Operations) indicated the bed was a rental and the siderail was not properly mounted to the bed. Staff 4 mounted … | 2020-09-01 |
| 21 | 21 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 580 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to notify a resident's physician of a decline in mobility and a new bruise for 1 of 5 sampled residents (#1) reviewed for change in condition and injury of unknown origin. This placed residents at risk for delayed care. Findings include: Resident 1 was admitted to the facility in (YEAR) after surgical repair of a [MEDICAL CONDITION]. The resident's Admission Nursing Data Base dated 9/20/18 indicated the resident was alert and oriented to person, place and time. The resident was assessed to have bruises to the arms and was not assessed to have functional impairment to the legs. The Physical Therapy Treatment encounter notes indicated PT services started on 9/21/18. The resident had pain and the pain limited the resident's functional activities. The resident required close supervision when the resident walked to ensure safety was maintained. The resident was able to walk 300 feet on a level surface. The 9/22/18 notes indicate the resident did not have pain, walked in the hall for 300 feet on two occasions, used the four wheeled walker and required stand by assistance. On 9/24/18 the resident walked 40 feet with a walker and hands on assistance and staff were required to provide cues for the majority of the task. On 9/25/18 the resident reported no pain and walked 25 feet with hands on assistance. On 9/26/18 the resident had improved stability with the use of the walker, walked 25 feet and reported right groin pain. On 9/27/18 the resident denied pain and was able to walked 57 feet with minimal assistance. The 9/28/18 note indicated the resident had severe pain, fatigue and strength deficits. The resident was only assisted to transfer and did not walk. On 9/29/18 the resident again reported severe pain to the right hip when the resident attempted to bear weight. The note indicated the pain limited the resident's functional activities and the resident did not make progre… | 2020-09-01 |
| 22 | 22 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 610 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to immediately initiate an investigation when a bruise of unknown origin was identified for 1 of 3 sampled residents (#1) reviewed for injury of unknown origin. This placed residents at risk for neglect of care. Findings include: Resident 1 was admitted to the facility in (YEAR) after the surgical repair of a [MEDICAL CONDITION]. The Admission Nursing Data Base dated 9/20/18 indicated Resident 1 was admitted to the facility from the hospital after surgical repair of the right hip. The resident was identified to have bruises to the arms and a skin tear to the abdominal region. The Progress Notes indicated on 9/28/18 the resident was identified to have a new bruise to the right thigh. The note indicated the bruise was light purple and approximately seven cm by eight cm. The note revealed the resident's family was aware of the bruise. The Skin Impairment investigation was initiated on 10/1/18, three days after the bruise was identified. The investigation indicated the resident's family assisted the resident to use the bathroom. The family member showed the nurse a bruise to the right inner thigh. The bruise was faded purple, giving it an older bruise appearance. The resident denied pain when the bruise was palpated. The resident was not aware of how the bruise occurred. The investigation indicated the bruise was not reported to Staff 4 (RNCM) for three days. The investigation further indicated the resident was on a blood thinner and may have sustained the bruise when she/he sat on the toilet. The bruise was in the approximate location of the toilet seat edges. The resident was also identified to have 1:1 staff after admission to the facility related to the resident's poor safety awareness. The 1:1 staff were interviewed and the staff reported no falls or incidents which may have caused the bruise. The physician was notified of the bruise on 10/1/18. On 10/19/18 at 1:10 … | 2020-09-01 |
| 23 | 23 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 660 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident was discharged with adequate supervision for transfers after the resident was discharged for home for 1 of 3 sampled residents (#4) reviewed for facility discharge. This placed residents at risk for falls. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's admission CAAs dated 5/5/18 indicated the resident broke her/his foot and was non-weight bearing. The resident was at moderate risk for falls related to cognitive issues, pain and balance issues. The Care Plan initiated on 4/28/18 indicated the resident was at risk for falls related to developmental delay, generalized weakness and the use of pain medications. The resident was also identified to be at risk for ADL decline. Interventions included the staff were to assist the resident with toileting and the resident was to be assisted with one staff and the use of a walker. The care plan was not revised to indicate the resident was independent to walk. The care plan indicated the anticipated discharge plan was for the resident to be discharged to the community. The plan was for staff to communicate with the resident's family/support to determine if the resident was safe to be discharged to home or to an assisted living facility. The 6/21/18 Progress Notes by Witness 6 (Former Social Service Director) indicated the resident's Medicare benefits were to end for skilled services on 6/26/18 and the resident did not want to appeal the decision. The plan was to discharge the resident on 6/27/18. The notes also indicated the resident reported mobility restrictions and impaired ability to perform all mobility related ADLs and wheelchair was to be used. The resident demonstrated the physical and mental abilities to operate a wheelchair in the home setting safely through practice with therapy and nursing staff. The resident was to be discharged to he… | 2020-09-01 |
| 24 | 24 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 661 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident's discharge summary was thoroughly completed for 1 of 3 sampled residents (#5) reviewed for facility discharges. This placed residents at risk for an ineffective transition to a lower level of care. Findings include: Resident 5 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Progress Notes indicated on 7/17/18 a date was set for when Resident 5 was to be discharged to an assisted living facility. On 7/18/18 the notes indicated the resident signed the Voluntary Consent form for leaving the nursing facility and was notified of the details of her/his move. The resident was to receive home health services with a start dated of 7/20/18. The resident was discharged on [DATE]. The Discharge Summary and Plan form initiated on 7/17/18 and completed on 7/19/18 did not include the following information: Resident 2's mental and psychosocial status, cognitive status, dietary requirements, pursuit for activity potential and/or involvement, any critical labs or diagnostic tests including the resident's [MEDICATION NAME] level (measures the concentration of medication found in the blood to ensure medication was therapeutic) and [MEDICAL CONDITION] function test results, current [DIAGNOSES REDACTED]. The recapitulation of the facility stay included the resident was admitted to the facility from the hospital for skilled services on 4/29/18. The note did not include the services provided. The resident's skilled services ended on 6/13/18. There was no additional information to describe in detail the services/treatments the resident received and the current health and functional status before discharge. On 10/24/18 Staff 4 (RNCM) indicated the Discharge Summary should be completely filled out and a detailed summary of the resident's stay at the facility including skilled services, treatments and current level of care before discha… | 2020-09-01 |
| 25 | 25 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 684 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident was administered the correct medications for 1 of 3 sampled residents (#3) reviewed for medication administration. This placed residents at risk for adverse medication reactions. Findings include: Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's (MONTH) (YEAR) MARs revealed the resident was to be administered medications including blood pressure and narcotic pain medication. The MAR indicated [REDACTED]. The facility Medication Error report indicated on 7/30/18 Witness 1 (Former CMA) administered Resident 3 another resident's medications. The medications included an iron supplement, anti-gout medication, blood pressure medication, diuretic, narcotic pain medication, potassium and an anti-reflux medication. The resident's Resident Care Manager and Nurse Practitioner were immediately notified and assessed the resident in person. Resident 3's blood pressure medications and diuretics were held, blood tests were ordered and the resident's vital signs were to be monitored closely. The resident's Nurse Practitioner note indicated Resident 3 was assessed after the resident was accidentally administered the incorrect medications. Several of the resident's medications were held, laboratory studies were obtained and there resident was to be monitored. The resident was otherwise stable. The (MONTH) (YEAR) Blood Pressure Summary indicated on 7/30/18 the residents blood pressure did not go below 120/60 (normal is below 120/80). The Resident's 7/30/18 laboratory results revealed there were not critical laboratory results. On 10/19/18 at 1:35 pm Staff 1 (DNS) indicated Witness 1 was familiar with all the residents and was not new to the facility. Witness 1 was outside of Resident 3's room door, prepared medications for another resident and administered the medications to Resident 3. Resident 3 was on the phone so she le… | 2020-09-01 |
| 26 | 26 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 773 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a discharged resident's laboratory results were communicated with the ordering physician and/or primary care physician for 1 of 3 sampled residents (#4) reviewed for laboratory tests. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 6/26/18 Progress Note indicated the resident reported burning with urination. The nurse collected a urine sample and laboratory results were pending. The resident was discharged to her/his home on 6/27/18. The 6/28/18 final Laboratory results indicated the resident had a UTI and the identified bacteria was susceptible to antibiotics. The resident's record did not have documentation to indicate the resident's physician and/or resident was notified of the results. On 10/24/18 at 1:50 pm a request was made to Staff 1 (DNS) to provide documentation the resident's urine analysis results were communicated to the resident's physician. No additional information was provided. | 2020-09-01 |
| 27 | 27 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-03-13 | 580 | D | 1 | 0 | CI9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record reviews it was determined the facility did not immediately inform the resident representatives of significant change of condition for 2 of 3 sampled residents (#s 1 and 2) reviewed for significant change of condition. This placed the residents at risk for unmet needs. Finding include: 1. Resident 1 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 12/21/17 progress notes written at 9:12 AM documented by Staff 3 (LPN) stated the resident had an altered mental status and hands in the air trying to grab something. Resident 1 kept dozing off during conversations and had no fever. Vital signs were stable though low O2 sats of 79. The resident was placed on 2 liters of oxygen and O2 sats stayed between 82-86 percent. The local emergency medical transportation service was contacted and the resident was transported to the local hospital emergency department. Staff 3 documented there was no phone contact listed for notification. Interviews conducted on 3/6/18 at 3:18 PM through 3/7/18 at 2:51 PM revealed the following: Staff 3 (LPN) stated on 12/21/17 when the resident was sent to the local hospital emergency department Resident 1's record did not list any family members or emergency contact information. Staff 3 stated the information regarding Witness 1 (Caregiver) was entered into the system after Resident 1 was transferred to the local hospital. Staff 3 stated Staff 9 (Admissions Coordinator) usually entered the contact information in the resident's Admission Record/Face Sheet. Staff 9 (Admissions Coordinator) reviewed the resident's electronic record and determined the contact information was submitted in the computer program on 12/21/17. Staff 9 stated he entered what was available to him when the resident was admitted to the facility. Staff 9 stated Staff 10 (Social Services) followed up to ensure the information was included in the resident's record. Staff 10 (Social Services) stated contact informati… | 2020-09-01 |
| 28 | 28 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-03-13 | 684 | D | 1 | 0 | CI9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to follow physician's orders regarding narcotic pain medication for 1 of 2 sampled residents (#1) reviewed for narcotic pain medication. This placed the resident at risk for increased pain medication. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 12/13/17 physician's order indicated the resident was to receive 1-3 tablets of [MEDICATION NAME] every 6 hours and the facility was to document the amount given. The 12/16/17 physician's order received by the facility at 9:08 AM for [MEDICATION NAME] 5-20 mg (1-4 tablets) po every six hrs (hours) pain for 2 days. The completion of 2 days was 12/18/17 at 9:08 AM. From 12/18/17 through 12/20/17 the (MONTH) (YEAR) MAR contained one page containing the 12/13/17 physician's order for 1-3 tablets of 5 mg of [MEDICATION NAME] (5-15 mg) to be provided every 6 hours and another page with the 12/16/17 physician's order completed on 12/18/17 for 1-4 tablets of 5 mg of [MEDICATION NAME] to be provided every 6 hours. The page with the completed physician's order did not contain an area for the facility staff to document the amount of medication provided. On 3/12/18 at 12:24 PM Staff 1 (DNS) was asked about the physician's orders to document the amount of [MEDICATION NAME] provided. At 1:56 PM Staff 1 (DNS) provided the narcotic medication record for Resident 1's [MEDICATION NAME] usage. The narcotic medication record also contained the 12/16/17 physician's orders for 1-4 tablets by mouth every 6 hours for 2 days. The (MONTH) (YEAR) MAR and narcotic record on 12/18/17 documented the resident received 3 tablets of [MEDICATION NAME] at 12:26 PM and then received 3 tablets of [MEDICATION NAME] at 4:46 PM, this constituted a four hour and twenty minute period of time between doses of [MEDICATION NAME]. The (MONTH) (YEAR) MAR and narcotic record on 12/19/17 documented the resident … | 2020-09-01 |
| 29 | 29 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-03-13 | 695 | D | 1 | 0 | CI9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility did not follow up with information about the resident's need for a [MEDICAL CONDITION] (continuous positive airway pressure machine) or to provide documentation of the use of a [MEDICAL CONDITION] for 2 of 2 sampled residents (#s 1 and 3) reviewed for [MEDICAL CONDITION] usage. This placed the resident at risk for unmet needs. Findings include: 1. Resident 1 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The local hospital transfer orders contained no physician's orders for a [MEDICAL CONDITION]. The facility's Admission Profile completed by Staff 8 (LPN) indicated the Admission Assessment information was obtained from the resident and local hospital records. The Admission Profile checked the box to indicate the resident used a [MEDICAL CONDITION]. There was no follow up about the usage of [MEDICAL CONDITION] by the facility staff. The 12/21/17 progress notes documented the resident had altered mental status and hands in the air trying to grab something. Resident 1 kept dozing off during conversations and had no fever. Vital signs were stable with low O2 sats of 79. The resident was placed on 2 liters of oxygen and O2 sats stayed between 82-86 percent. The local emergency medical transportation service was contacted and the resident was transported to the local hospital emergency department. The 12/26/17 progress notes documented the resident's caregiver called the facility about the concern the resident did not use a [MEDICAL CONDITION] while at the facility. Staff 12 (RNCM) reviewed the resident's discharge records and there was no orders for resident to have a [MEDICAL CONDITION]. Staff 12 called the local hospital to inquire about the [MEDICAL CONDITION] and the local hospital was to send the facility the [MEDICAL CONDITION] setting for physician's order for a [MEDICAL CONDITION] when she/he returned to the facility. On 3/7/18 at 10:36 AM Staff 8 (LPN) state… | 2020-09-01 |
| 30 | 30 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 550 | D | 0 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to maintain cleanliness of a positioning harness for 1 of 1 sampled residents (#18) reviewed for dignity. This placed residents at risk for loss of dignity. Findings include: Resident 18 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The 9/14/18 Enabler Review indicated Resident 18 used a chest harness while in her/his wheelchair. Random observations during a three day period were made from 4/29/19 through 5/1/19 between the hours of 8:00 AM and 2:30 PM. During these observations, Resident 18 was in her/his wheelchair in the dining room and common areas. Resident 18's chest harness was soiled with the same large patches and smears of dried food and beverage. On 5/01/19 at 8:42 AM Staff 2 (CNA) stated she was unsure if Resident 18's harness was soiled. She stated Resident 18 used the chest harness while in her/his wheelchair throughout the day. Staff 2 stated if the chest harness was soiled, it would get sent to laundry at night. On 5/1/19 at 8:49 AM Staff 3 (RNCM) confirmed Resident 18's chest harness was soiled. Staff 3 stated her expectations included the harness be wiped clean after meals and should not be soiled for days. | 2020-09-01 |
| 31 | 31 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 585 | D | 0 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure reports of missing funds were thoroughly addressed for 1 of 2 sampled residents (#24) reviewed for personal property. This placed residents at risk for unresolved concerns. Findings include: Resident 24 was readmitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Resident 24's 2/2019 Annual MDS revealed the resident had a Brief Interview of Mental Status score of 11 out of 15 (moderately impaired). The Trust-Transaction History revealed on 1/11/19 and 1/18/19 the resident withdrew 50 dollars on each occasion. The 1/25/19 Missing Item Report revealed the following: -The resident reported she/he was missing 20 dollars on either 1/19/19 or 1/20/19 and was missing 45 dollars on 1/24/19; -The items were not listed on the resident's personal inventory; -The follow up stated the money was not found, and staff were unable to verify there was lost money. In an interview on 4/29/19 at 2:01 PM Resident 24 stated she/he was missing 20 dollars and 40 dollars and nothing was done. In an interview on 5/1/19 at 3:05 PM Staff 22 (Social Services Director) stated the resident made a grievance in 1/2019 and the facility was unable to verify the funds were lost and the response to the grievance was to make an effort to secure future funds. In an interview on 5/2/19 at 9:11 AM Staff 23 (Business Office Manager) stated the resident reported missing funds in 1/2019. Staff 23 stated Resident 24 withdrew larger amounts of money in 1/2019 and she tried to explain the facility would not replace funds if lost or missing. Staff 23 stated she asked the resident to take out less money because she/he could access additional funds at any time at the nurses' station. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected staff to bring grievances to her so they can be addressed appropriately. Staff 19 stated when Resident 24's money went missing the facility… | 2020-09-01 |
| 32 | 32 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 600 | D | 1 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure resident safety for 3 of 6 sampled residents (#s 39, 285, 286) reviewed for abuse. This placed residents at risk of being abused. Findings include: 1. Resident 285 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. A 2/3/19 facility investigation revealed Resident 285 was in the main dining room when she/he became agitated. Resident 285 hit Resident 85 three times before staff intervened. While staff moved Resident 285 to her/his room, she/he reached out and hit Resident 48 in the hallway and called her/him a derogatory name. The investigative report revealed Resident 85 indicated she/he was not hurt but never wanted to speak to Resident 285 again. The report revealed Resident 48 indicated she/he was not hurt and did not want to be near Resident 285. A physician order [REDACTED]. Resident 285's 12/2018 Admission MDS Assessment Section C: Cognitive Pattern coded her/him to have a Brief Interview for Mental Status (BIMS) score of 05 out of 15 (severe cognitive impairment). Resident 85's 1/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 14 out of 15 (cognitively intact). Resident 285 was care planned with interventions for physical aggression towards others. The interventions included: - Administer medications as ordered; - Provide rest, toileting assistance, pain medication, favorite snack or activities of interest when behaviors occur; - Removing resident from the situation to a quiet setting, resident should not be left unattended, keep her/him in the line of sight prior to meals. A 2/3/19 progress note revealed Resident 48 denied pain as a result of the altercation, but she/he would not dine with Resident 285. Resident 48's 3/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 15 out of 15 (cognitively intact). On 5/1/19 at 11:01 AM Resident 48 sta… | 2020-09-01 |
| 33 | 33 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 656 | D | 0 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to implement the comprehensive care plan for 1 of 3 sampled residents (#14) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 14 admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. The care plan initiated on 10/19/17 and in use on 4/29/19 revealed the following: -The resident was totally dependent on staff for eating; -One-on-one assistance while eating, sips of liquids between bites to clean oral cavity and small bites; -Position upright in her/his wheelchair at all meals. On 4/29/19: -Observed at 12:11 PM a tray was delivered to Resident 14 in her/his room. The resident was alone and started eating independently without staff present; -Obsevered at 12:23 PM Staff 25 (CNA) entered the room, stopped the resident from eating and removed the tray from her/his bedside; -In an interview at 12:23 PM Staff 25 stated it was not safe for Resident 14 to eat alone. Resident 14 had no observed distress or concerns while eating alone on 4/29/19. On 5/1/19 and 5/2/19 the resident was observed eating in the dining room in her/his wheelchair with one-on-one assistance and was encouraged by the attending CNA to cough to clear secretions. In an interview on 5/2/19 at 1:40 PM Staff 26 (Registered Dietitian) stated when residents, including Resident 14, were charted as dependent on staff for eating it meant residents would receive one-on-one assistance. Staff 26 stated staff should not drop off a tray and let Resident 14 eat alone because she/he needed help at all times and should not be left alone. In an interview on 5/2/19 at 4:18 PM Staff 1 (DNS) stated she expected staff to follow the resident's care plan. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected staff to follow the care plan. | 2020-09-01 |
| 34 | 34 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 688 | D | 0 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide restorative services at the frequency ordered to maintain or prevent a decline in range of motion for 1 of 3 sampled residents (#8) reviewed for range of motion. This placed residents at risk for worsening contractures. Findings include: Resident 8 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. A 4/7/18 OT assessment noted worsening contractures of the right hand. A 4/12/18 physician order [REDACTED]. A 6/20/18 physician order [REDACTED]. The 1/29/19 Quarterly MDS Section G: Functional Status, indicated Resident 8 had impairments on both sides of upper body extremities and one side of the lower body. The Section O: Special Treatments, Procedures and Programs, indicated Resident 8 had seven days of active and passive range of motion (AROM and PROM) for restorative nursing during the look back period. The 3/4/19 Restorative Evaluation and Summary indicated Resident 8 received restorative services for ambulation and range of motion with goals to maintain current functional level and prevent decline of bilateral upper extremities. The 4/29/19 Contracture Screening indicated Resident 8 had contractures of the right shoulder, elbow, wrist, fingers and thumbs. On 4/29/19 Resident 8 was observed to have contractures of all five fingers on her/his right hand and stiff appearing arm and fingers on the left side. She/he was in a wheelchair and used her/his legs for locomotion. Resident 8's current Restorative Care Plan included: - Ambulation within parallel bars (minimal assist) as tolerated up to two times per week; - Active ROM (range of motion) legs, Omnicycle (a lower body exercise device) two times per week for 15 minutes; - PROM of bilateral upper extremities all joints/planes two sets of 10 up to three times per week. The (MONTH) 2019 Restorative Tracking Form lacked any documentation for the following interventions. - (MONTH) 1-6… | 2020-09-01 |
| 35 | 35 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 760 | D | 1 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled residents (#287) identified with a medication error. As a result, Resident 287 received an antipsychotic medication on 10/28/18 and required admission to the hospital for monitoring. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in staff awareness and education to ensure accurate identification of residents and no further medication errors occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: The facility General Dose Preparation and Medication Administration policy, last revised 1/2013, included the following: -Staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Resident 287 admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Resident 287 discharged from the facility in 10/2018. On 10/28/19 at 6:00 PM Staff 16 (CMA) erroneously administered [MEDICATION NAME] (an antipsychotic medication) 100 mg to Resident 287. Staff 16 realized her mistake and immediately reported the error to Staff 11 (LPN). Staff 11 evaluated Resident 287 and notified the physician, the resident and Resident 287's family. The physician directed Staff 11 to monitor Resident 287 for adverse effects and send the resident to the hospital for any change of condition. Resident 287 later became sleepy and Staff 11 sent the resident to the hospital for evaluation. In an interview on 4/30/19 at 3:40 PM Staff 11 (LPN) stated on 10/28/18 Staff 16 erroneously administered [MEDICATION NAME] 100 mg to Resident 287. Staff 11 stated she immediately evaluated Resident 287 and notified the physician, the resident and the resident's family. Staff 11 stated Resident… | 2020-09-01 |
| 36 | 36 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 806 | D | 0 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to honor food preferences for 3 of 9 sampled residents (#2, 26, 48) reviewed for food concerns. This place residents at risk for unintended weight loss and decreased quality of life. Findings include: 1. Resident 48 was admitted in 12/2017 with [DIAGNOSES REDACTED]. An 11/9/18 Dietary Profile Assessment noted the resident did not like cooked vegetables. The 12/20/18 Cognitive Loss/Dementia CAA identified the resident was able to verbally communicate with others and made her/his needs known. Resident 48 advocated for her/himself and was involved in care decisions. A 3/13/19 Dietary Profile Assessment identified the resident received chef salads each lunch, but had no food items which she/he disliked. At the time of the survey, the resident's meal card (which identified diet orders and resident preferences on the meal tray) showed Resident 48 received a controlled carbohydrate diet with no added salt and no allergies [REDACTED]. In interviews on 4/30/19 at 11:52 AM and 5/6/19 at 11:16 AM, Resident 48 stated she/he hated cooked vegetables but was getting tired of the chef salads she/he had requested. The resident also voiced concerns about the small portions served of the main course which left her/him unsatisfied with the meal. When interviewed on 5/2/19 at 9:08 AM, Staff 36 (Kitchen Staff) stated staff did not always have sufficient food ingredients to serve all residents the same menu or to provide additional servings when residents requested. Frequent food substitutions were made. In a 5/6/19 interview at 9:36 AM, Staff 28 (CNA) stated Resident 48 often asked for more food. Staff 28 could generally offer cottage cheese, sandwiches or if available, more of the main course. The resident complained about the small main course portion the previous night which consisted of two small pieces of meat and onions. When interviewed on 5/6/19 at 12:28 PM, Staff 30 (… | 2020-09-01 |
| 37 | 37 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2016-08-16 | 309 | D | 0 | 1 | XWCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders [REDACTED].#66) reviewed for medications. This placed residents at risk for potential medical complications. Findings include: Resident 66 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. The resident's 6/22/16 Admission MDS indicated the resident received daily anticoagulant medication (medication used to prevent blood clots.) A 7/5/16 physician order [REDACTED]. The resident's 7/2016 MAR indicated [REDACTED]. A 7/7/16 Progress Note indicated the resident was to resume the [MEDICATION NAME]. Resident 66's 7/2016 MAR indicated [REDACTED]. A 7/11/16 Medication Error/Adverse Drug Reaction Report indicated Resident 66's [MEDICATION NAME] was not administered from 7/7/16 to 7/10/16 because the physician's orders [REDACTED]. On 8/12/16 Staff 2 (DNS) stated the error occurred because the nurse forgot to transcribe the [MEDICATION NAME] order into Resident 66's electronic record. | 2020-09-01 |
| 38 | 38 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2016-08-16 | 371 | E | 0 | 1 | XWCM11 | Based on observation and interview it was determined the facility failed to maintain the kitchen and unit refrigerators in a clean and sanitary manner for 1 of 1 kitchen and 1 of 3 unit snack refrigerators reviewed. This placed residents at risk for food borne illness. Findings include: On 8/15/16 at 10:00 am observations of the kitchen revealed the following conditions: - the cappuccino and juice machines were soiled with built-up dried splatter and residue. - the range hood over the stove cook-top was soiled with an accumulation of dust and hanging cobwebs. - a large running fan, placed on the countertop in front of a ground level window, had a build-up of dust on the fan blades and metal guard. Dust particles were observed flying from the fan into the kitchen. - the window screen behind the fan contained an accumulation of dust and debris. - another ground level window contained an air conditioner unit which had an accordion baffle to fill the remaining open space. There was an approximate 1 inch gap between the baffle and window opening creating an uninhibited entrance for rodents and insects. On 8/15/16 at 10:11 am, Staff 3 (Dietary Manager) confirmed the areas needed to be cleaned and the window air conditioner gap should be enclosed. On 8/15/16 at 10:47 am the Station 1 snack refrigerator was observed with Staff 4 (CNA/RA) and contained the following opened undated food items: - brown paper loosely wrapped deli style sandwich. - dish of partially dried yellow pudding. - 1/2 sandwich containing meat and cheese in a plastic bag. - Milk approximately 1/4 full in a plastic gallon container with an expiration date 8/10/16. Staff 4 confirmed it was not clear when the foods were placed in the refrigerator, the food items were for resident use, and should be disposed. | 2020-09-01 |
| 39 | 39 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2016-08-16 | 431 | D | 0 | 1 | XWCM11 | Based on observation, interview and record review the facility failed to discard expired medications from 1 of 2 medication storage rooms reviewed. This placed residents at risk for receiving medications with decreased efficacy. Findings include: On 8/15/16 at 11:45 am an inspection of the second floor medication storage room refrigerator revealed six vials of Lorazepam 2 mg/lm injectable medication with expiration dates of 11/2015 listed on each vial. On 8/15/16 at 11:52 am Staff 5 (LPN) confirmed the expiration date on each vial. On 8/16/16 at 12:28 pm Staff 2 (DNS) stated the Lorazepam should be disposed and reordered when expired. | 2020-09-01 |
| 40 | 40 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2016-08-16 | 500 | D | 0 | 1 | XWCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility did not have a [MEDICAL TREATMENT] agreement in place with the [MEDICAL TREATMENT] provider for 1 of 1 sampled resident (#66) receiving [MEDICAL TREATMENT] services. This placed residents at risk for lack of care coordination related to [MEDICAL TREATMENT] treatment. Findings include: Resident 66 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. A 6/9/16 physician's orders [REDACTED]. The facility's Policy & Procedure for [MEDICAL TREATMENT] Agreement document directed, (the facility) will have the [MEDICAL TREATMENT] center sign the attached agreement which clarifies each providers' responsibilities in regards to the [MEDICAL TREATMENT] and access site. On 8/11/16 at 12:11 pm Staff 2 (DNS) was asked for a copy of Resident 66's [MEDICAL TREATMENT] agreement. Staff 2 stated it should be in the resident's medical record. A review of the resident's medical record did not reveal a [MEDICAL TREATMENT] agreement. On 8/11/16 at 1:48 pm Staff 7 (RNCM) stated she could not locate a completed [MEDICAL TREATMENT] agreement for Resident 66. | 2020-09-01 |
| 41 | 41 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 204 | D | 1 | 0 | 5RH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to provide post discharge resources and document a safe plan for a resident with intent to leave the facility against medical advice for 1 of 3 sampled residents (#9) reviewed for discharge. This placed residents at risk for lack of medical treatment. Findings include: Resident 9 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 6/1/17 hospital Inpatient Progress Note indicated Resident 9 was chronically homeless and was admitted to the hospital for failure to thrive. The resident was brought to the hospital due to public concern for the resident's safety. The note indicated the resident was in the emergency department for the third time in one month. The resident left against medical advice on one emergency room visit. The resident was assessed to have a non-healing ulcer to the left heel likely related to diabetes. It was unknown how long the resident had the ulcer. The resident was on medications including a blood thinner for an irregular heart beat. The 6/9/17 Admission MDS and associated CAAs indicated it was anticipated the resident would be discharged to the community. The resident was previously homeless and not able to care for her/his heel wound. The resident was assessed to be cognitively intact and independent with all ADLs except for transferring. The resident required the use of a mechanical lift in order to prevent the resident from putting pressure on the heel. The Care Plan initiated on 6/5/17 indicated Resident 9 discharge plan was to discharge to congregate housing (independent living). The resident had [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The interventions included staff were to provide community resources to support independence post-discharge. The 6/7/17 Progress Note indicated the resident's discharge plan was not determined. The note indicated the resident was previously homeless and lived in her/his truck. The 6… | 2020-09-01 |
| 42 | 42 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 225 | D | 1 | 0 | 5RH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to thoroughly investigate falls and complete investigations in a timely manner for 1 of 3 sampled residents (#5) reviewed for falls. This placed residents at risk for neglect of care. Findings include: Resident 5 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2016 Abuse/Neglect/Misappropriation/Exploitation policy indicated incidents were to be thoroughly investigated, staff were to ensure witness interviews were obtained and data collection was to be completed including care plan review. The policy directed staff to complete the investigation within five days of the incident. The 1/10/17 Admission CAAs indicated Resident 5 had dementia and a history of falls. The resident was assessed to have poor balance, weakness and was at a moderate risk for continued falls. The resident was also identified to be incontinent of bowel and bladder and did not always use the call light to request assistance. The current Care Plan indicated Resident 5 was incontinent and staff were to offer the resident toileting every two hours and the resident was to be assisted to the bathroom after meals and at bedtime. To prevent falls and injury the resident was to have interventions including a mat on the floor by the side of the resident's bed and the resident was to wear non-skid footwear. a. The 7/6/17 Fall investigation indicated Resident 5 fell at 8:55 am. The resident was found on the floor in the shower room located in the resident's room. The resident reported she/he wanted to take a shower. The CNA last observed the resident in the wheelchair in the front lobby by the television. The investigation did not address if the resident was assisted to the bathroom after breakfast as directed by the care plan. The investigation was not completed until 8/2/17, 27 days after the resident fell . On 8/29/17 Staff 1 (RNCM) acknowledged breakfast was from approximately 7:… | 2020-09-01 |
| 43 | 43 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 323 | D | 1 | 0 | 5RH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure fall interventions were implemented for 1 of 3 sampled residents (#5) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 5 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 1/10/17 Admission CAAs indicated Resident 5 had dementia and a history of falls. The resident was assessed to have poor balance, weakness and was a moderate risk for continued falls. The resident was also identified to be incontinent of bowel and bladder and did not always use the call light to request assistance. The 7/11/17 Physician order [REDACTED]. The current Care Plan indicated to prevent falls and injury Resident 5 was to have interventions including a mat on the floor by the side of the resident's bed. The 8/16/17 Fall investigation indicated the resident was found on the floor by the transfer pole. The summary included New order for mat on floor . The investigation did not indicate the fall mat was on the floor by the resident's bed. The resident did not sustain an injury. On 8/28/17 at 1:05 pm with Staff 13 (CNA) Resident 5's room was observed to not have fall mat. The resident had the left side of the bed against the wall and a transfer pole to the right side near the head of the bed. Staff 13 indicated Resident 5 was recently moved to a different room due to facility remodel and the resident no longer had a fall mat. On 8/28/17 at 1:18 pm and on 8/29/17 at 9:40 am Staff 1 (RNCM) indicated Resident 5 frequently tried to stand without assist. Therapy evaluated the resident and determined a transfer pole might help the resident transfer to the wheelchair and not fall. The mat was not able to be placed by the pole and would potentially interfere with the transfer. Staff 5 acknowledged the order was still in place for a fall mat to prevent injury and the mat was not currently in use. Staff 1 indicated the mat should have b… | 2020-09-01 |
| 44 | 44 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 371 | F | 1 | 0 | 5RH111 | > Based on observation, interview and record review it was determined the facility failed to ensure the kitchen was kept in a sanitary manner for 1 of 1 kitchens and failed to ensure a process was in place to monitor resident use refrigerators for 1 of 3 sampled residents (#1) reviewed for call light response times. This placed residents at risk for foodborne illnesses. Findings include: 1. On 8/28/17 at 10:50 am two kitchen windows were observed to be open. The window on the left side of the wall did not have a screen to prevent debris and insects from entering the kitchen. The window on the right side of the wall had a screen but the screen did not fit securely in the window and a gap was present to allow outside debris from entering the kitchen. The screen also had a layer of dust and cobwebs accumulated on the outside of the screen. The counter in front of the window did not contain food but had visible dust. On 8/28/17 at 11:00 am Staff 12 (Cook) acknowledged one window did not have a screen and another window had a gap and did not provide a secure seal. Staff 12 also acknowledged the counters were dusty. 2. The 9/2011 Record of Refrigeration Temperatures policy indicated a daily temperature record was to be kept of the refrigerators. The policy indicated nursing unit refrigerators and freezers and other refrigerators/freezers with resident food stored in it must be clean, food must be dated and have temperatures recorded. On 8/29/17 at 2:10 pm with Staff 9 (CNA) Resident 1's refrigerator was observed to have cups of food and drinks in her/his personal room refrigerator. There were three cups of milk with no dates and one boiled egg in a covered bowl. The refrigerator and items in the refrigerator felt cold but there was no thermometer observed to determine the temperature of the refrigerator. On 8/30/17 at 1:00 pm Staff 4 (Maintenance) indicated he assisted with resident personal use refrigerators as needed but the housekeeping staff were to monitor the temperatures. On 8/30/17 at 1:26 pm Staff 6 (Housekeep… | 2020-09-01 |
| 45 | 45 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 431 | D | 1 | 0 | 5RH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a medication was available for 1 of 3 sampled residents (#1) reviewed for ADL assistance. This placed residents at risk for depression. Findings include: Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The 7/12/17 Brief Interview for Mental Status form indicated Resident 1 was alert and oriented. The (MONTH) (YEAR) MARs indicated Resident 1 was administered Adderall (stimulates the nervous system) BID. The Adderall treatment was initiated 11/2016 and was to treat Resident 1's depression. The MAR indicated Resident 1 refused the medication 36 out of 60 opportunities. On 6/22/17 the MAR and associated notes indicated the medication was not given BID waiting on script. The 6/21/17 pharmacy Refill Order Form indicated the facility requested a refill of the Adderall. This was the same day the resident was administered the last dose. The physician progress notes [REDACTED]. The resident reported the provider refilled her/his prescription in the past without an office visit. The note also indicated the resident asked the staff to make an appointment for her/him to see the mental health provider but the staff did not make an appointment and the Adderall was not able to be refilled. The resident indicated she/he was NOT happy the Adderall was not filled because the resident did not want to go cold turkey. On 9/1/17 at 2:25 pm Witness 3 (Resident 1's Pharmacist) indicated the facility was to have a system in place to notify the pharmacy when resident medications were low and before the medication ran out. It was good practice to notify the pharmacy at least one week before the medication ran out in case the pharmacy had to communicate with the physician to refill the prescription. Witness 3 indicated the pharmacy was first notified the resident required a refill for the Adderall on 6/22/17. The resident's Adderall was last filled on 5/2/17,… | 2020-09-01 |
| 46 | 46 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-10-06 | 221 | D | 0 | 1 | 353X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, it was determined the facility failed to ensure 1 of 2 sampled residents (# 51) reviewed for restraints was free from restraints. This put residents at risk for decline in function. Findings include: Resident 51 admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. On 10/5/17 at 9:49 am, Resident 51 was observed up in her/his wheelchair with a seatbelt in place. When the seatbelt was pointed at, and when she/he was asked about the seatbelt, Resident 51 was unable to understand and unable to undo the seatbelt on her/his own. On 10/5/17 at 12:08 pm, Resident 51 was observed to have a clear lap tray fastened to her/his wheelchair across the top of her/his lap which could not be removed by the resident. The Restraint/Adaptive Equipment Evaluation was signed and dated by the resident's representative on 1/27/17. The form indicated the resident used a seatbelt as an adaptive device to improve safety while in wheelchair. The form indicated (using yes/no questions) the device did not cause distress, the device did not limit the resident's voluntary movement, medication did not appear to cause ASE (adverse side effects) contributing to problem, the resident was not experiencing new or untreated pain, and the resident did not have problems with equipment. The Narrative Nursing Evaluation on the form stated Resident to have seatbelt in wheelchair for improved in-chair safety and fall risk reduction. Lap tray was marked on the form as an adaptive device initiated on 5/1/17 to ease with feeding. There was no specific documentation/evaluation regarding the device. The (MONTH) and (MONTH) (YEAR) TARs directed to Confirm meal tray is cleaned off every meal by the CNAs. The fall risk care plan interventions, last updated 8/8/17, included the resident used seat belt while up in wheel chair due to fall risk. The comprehensive care plan did not mention the meal tray or have any further instruction rega… | 2020-09-01 |
| 47 | 47 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-10-06 | 514 | D | 0 | 1 | 353X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#55) for whom medications were reviewed. This placed residents at risk for unmet needs. Findings include: Resident 55 was admitted in 8/2017 with [DIAGNOSES REDACTED]. The 9/2017 signed physician's orders [REDACTED].) once a day, Proair (for shortness of breath) two times a day, [MEDICATION NAME] (for constipation) three times a day, [MEDICATION NAME]-[MEDICATION NAME] (for [MEDICAL CONDITION]) six times a day, [MEDICATION NAME] (for reflux) once a day and Entacapone (for [MEDICAL CONDITION]) three times a day. The 9/2017 MAR revealed no documentation the following medications were administered: -9/5/17: Ropinirole and the third dose of [MEDICATION NAME]. -9/6/17: The first dose of Proair and the second dose of [MEDICATION NAME]. -9/18/17: The first dose of [MEDICATION NAME]-[MEDICATION NAME]. -9/25/17: [MEDICATION NAME], the sixth dose of [MEDICATION NAME]-[MEDICATION NAME] and the first dose of Entacapone. On 10/6/17 at 12:20 pm Staff 2 (RNCM) confirmed the missing documentation in the 9/2017 MAR and stated staff had administered the medications and did not document the administrations. | 2020-09-01 |
| 48 | 48 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-10-15 | 842 | E | 1 | 0 | EFS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure records were accurate for 5 of 6 sampled residents (#s 2, 3, 7, 9 and 10) reviewed for medications. This placed residents at risk for inaccurate records. Findings include: 1. Resident 2 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25 ml every hour as needed for pain. Start 4/14/18 end 8/24/18 -[MEDICATION NAME] 20 mg/ml give 0.25 ml every four hours for pain. Start 6/28/18 end 9/19/18. -[MEDICATION NAME] 20 mg/ml give 0.5 ml every three hours for pain during awake hours. Start 9/19/18. Review of the 9/2018 and 10/2018 MAR and the Narcotic Drug Disposition Record (NDDR) revealed the following errors: - On 9/8/18 the MAR revealed the resident received six doses of 0.25 ml [MEDICATION NAME] every four hours. The NDDR record revealed the resident received four doses. -On 9/28/18 the MAR revealed the resident received seven doses of 0.5 ml [MEDICATION NAME] every three hours. The NDDR revealed the resident received eight doses. -On 10/6/18 the MAR revealed the resident received seven doses of 0.5 ml of [MEDICATION NAME]. The NDDR revealed the resident received six doses. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed they were to document on the MAR and narcotic book when they gave a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. 2. Resident 3 was admitted to the facility in 11/2006 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml 0.5 ml three times a day for pain. Review of the 8/2018, 9/2018 and 10/2018 MAR and the Narcotic Drug Disposition Record (NDDR) revealed the following errors: -On 8/13/1… | 2020-09-01 |
| 49 | 49 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 241 | D | 0 | 1 | NQJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide grooming services to maintain dignity for 1 of 1 sampled resident (#33) reviewed for ADLs. This placed resident at risk for unmet needs and negative self-esteem. Findings include: Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 5/31/16 at 7:47 am the resident was observed to have multiple facial hairs on her/his chin, approximately one quarter inch in length. A Comprehensive Admission MDS assessment dated [DATE] stated the resident needed extensive assistance with personal grooming activities which included being shaved. The ADL CAA dated 3/25/16 stated the resident was not ambulatory and was dependent upon staff for grooming setup and assistance. The resident's bedside care plan revised on 5/2/16 stated the resident required one person to provide maximum assistance for upper body grooming. In an interview on 6/2/16 at 8:33 am the resident was observed to run her/his hand over her/his chin and stated staff had not offered to provide a shave recently but that she/he needed to be shaved. On 6/2/16 at 8:42 am Staff 4 (RNCM) entered the resident's room. The resident was observed telling Staff 4 she/he needed a shave. When Staff 4 asked the resident if she/he was going to allow staff to shave her/him, the resident stated yes, she/he needed a shave. In an interview on 6/2/16 at 9:24 am Staff 13 (CNA) stated she was familiar with the resident's care up until the past month when the resident had been moved from her unit. She stated she had never experienced Resident 33 refuse to be shaved and the resident did not like to have hair on her/his face. She regularly shaved the resident when she/he was on her unit. In an interview on 6/2/16 at 1:19 pm Staff 13 stated she had just shaved the resident's face and the resident stated she/he was very happy. In an interview on 6/3/16 at 7:46 am Staff 14 (CNA) stated he had never sha… | 2020-09-01 |
| 50 | 50 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 272 | D | 0 | 1 | NQJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to comprehensively assess the use of a catheter for 1 of 2 sampled residents (#122) reviewed for urinary catheter use. This placed residents at risk for unnecessary catheter use. Findings include: Resident 122 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The MDS annual comprehensive assessment dated [DATE] included a [DIAGNOSES REDACTED]. The Urinary Incontinence and Indwelling Catheter CAA dated 2/19/16 stated [DIAGNOSES REDACTED]. A review of the resident's medical chart revealed 11 Interdisciplinary Focus assessments completed on a quarterly basis through 2/26/16 each of which stated foley catheter use was due to a [DIAGNOSES REDACTED]. A Urinary Incontinence/Indwelling Catheter assessment dated seven times from 2/8/13 through 1/28/15 listed chronic indwelling foley catheter use was due to the resident's [DIAGNOSES REDACTED]. No mention of urinary obstruction was found. On 6/2/16 at 12:39 pm Staff 5 (RNCM) and Staff 2 (DNS) provided the surveyor a copy of a statement from the resident's MD dated 5/31/16 which stated long term catheter use was necessary due to the resident's history of obstruction and [MEDICAL CONDITION] which led to kidney failure. In an interview on 6/3/16 at 10:34 am Staff 5 acknowledged the resident's current MDS assessment and CAA had not included the resident's [DIAGNOSES REDACTED]. | 2020-09-01 |
| 51 | 51 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 274 | D | 0 | 1 | NQJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to complete a significant change of condition assessment for 1 of 3 sampled residents (#117) reviewed for hydration. This placed residents at risk for unassessed needs. Findings include: Resident 117 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The RAI Manual, Chapter 2, Section 2.6 Required OBRA (Omnibus Budget Reconciliation Act) Assessments for the MDS indicates when a resident terminates hospice services a Significant Change in Status Assessment (SCSA) is required to be performed within 14 days of the expiration date of the certification of terminal illness or the date of the physician's or medical director's order stating the resident is no longer terminally ill. physician's orders [REDACTED]. There was no documented evidence the facility conducted a SCSA MDS after the resident discharged from hospice services. On 6/6/16 at 10:45 am and 11:18 am the failure to complete a SCSA MDS was discussed with Staff 2 (DNS). No additional information was provided. | 2020-09-01 |
| 52 | 52 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 278 | E | 0 | 1 | NQJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 7 sampled residents (#s 103, 117, 149, 187 and 226) reviewed for [MEDICAL TREATMENT], hospice, hydration and pressure ulcers. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 103 admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code dehydration if the resident presents with two or more of the following potential indicators for dehydration: takes in less than the recommended 1,500 ml of fluids daily; has one or more potential clinical signs of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values; or the resident's fluid loss exceeded the amount of fluids she/he took in. Resident 103's 4/14/16 Significant Change of Status Assessment MDS section J1150, Problem Conditions, coded the resident as dehydrated during the assessment period. The clinical record lacked documented evidence Resident 103 consumed less than 1500 ml, had fluid loss which exceeded intake, and lacked an assessment or laboratory values to indicate potential clinical signs of dehydration. In an interview on 6/3/16 at 12:13 pm Staff 4 (RNCM) stated Resident 103 went on hospice, did not want to drink and they had a hard time pushing fluids. Staff 4 was not able to provide documentation to support the coding of dehydration on the 4/14/16 SCSA MDS. 2. Resident 149 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code tobacco use as yes if the resident or any other source indicated the resident used tobacco in some form during the look-back period. Resident 149's 12/5/15 Admission MDS, completed by Staff 3 (RNCM) was coded to… | 2020-09-01 |
| 53 | 53 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 371 | F | 0 | 1 | NQJS11 | Based on observation and interview it was determined the facility failed to store and serve food under sanitary conditions for 1 of 1 kitchens and 1 of 1 ice machines. This placed resident's at risk for food-borne illness. Findings include: 1. On 5/31/16 at 7:57 am nine containers holding freezer burned food (freezer burn is a condition that occurs when frozen food has been damaged by dehydration and oxidation, due to air reaching the food) were observed in the upright freezer. On 5/31/16 at 7:57 am Staff 11 (Dietary Manager) confirmed food in the nine containers had frost on them. She stated she thought the food appeared to have been put in the freezer while still warm. 2. On 6/2/16 at 6:55 am the upright freezer was observed to have seven containers of freezer burned food as well as two packages of expired egg substitution product. On 6/2/16 at 6:56 am Staff 12 (Kitchen Aide) confirmed all containers in the upright freezer contained freezer burned food. She also confirmed the two packages of egg substitution products expired on 1/31/16. 3. On 6/2/16 at 7:17 am the ice machine was observed to have a brown residue on the inside rim directly above the ice. Staff 11 (Dietary Manager) acknowledged the brown residue inside the ice machine. On 6/2/16 at 8:14 Staff 7 (Maintenance Supervisor) acknowledged the brown residue inside the ice machine and confirmed it could contaminate the ice in the machine. | 2020-09-01 |
| 54 | 54 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2016-06-06 | 441 | D | 0 | 1 | NQJS11 | Based on observation and interview it was determined the facility failed to observe infection control practices for 1 of 1 CBG observations. This placed residents at increased risk for infectious disease. Findings include: On 6/6/16 at 7:44 am Staff 10 (LPN) checked Resident 70's CBG with the glucose monitor (glucometer). Staff 10 proceeded to put the glucometer away without cleaning it. On 6/6/16 at 8:05 am Staff 10 stated she cleaned the glucometer once a shift and verified she did not clean the glucometer after checking Resident 70's CB[NAME] | 2020-09-01 |
| 55 | 55 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 278 | E | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to accurately code MDS assessments related to resident weights, dehydration, UTIs, terminal prognosis and pressure ulcer risk for 5 of 13 sampled residents (#s 21, 26, 33, 60 and 140) reviewed for nutrition, UTIs, dehydration, pressure ulcers and hospice. This placed residents at risk for unmet needs. Findings include: The RAI 3.0 Manual dated 10/2016 requires the following four criteria be met for coding UTIs as an active Diagnosis: [REDACTED]. - Sign or symptom attributed to UTI, which may or may not include but not be limited to: fever, urinary symptoms (e.g., peri-urethral site burning sensation, frequent urination of small amounts), pain or tenderness in flank, confusion or change in mental status, change in character of urine (e.g., pyuria), - Significant laboratory findings (The attending physician should determine the level of significant laboratory findings and whether or not a culture should be obtained), and - Current medication or treatment for [REDACTED]. The RAI 3.0 Manual dated 10/2016 requires two or more of the following potential indicators when coding for dehydration: - Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. - Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, [MEDICATION NAME], blood urea nitrogen, or urine specific gravity). - Resident's fluid loss exceeds the amount of fluids he or she takes in (e.g., loss from vomiting… | 2020-09-01 |
| 56 | 56 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 279 | E | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to create a comprehensive care plan including measurable objectives, timeframes and services provided for 13 of 22 sampled residents (#s 15, 21, 24, 26, 33, 46, 60, 72, 118, 144, 153, 159 and 167) for whom care plans were reviewed. This placed residents at risk for unmet needs. Findings include: The facility's 4/2017 Resident Care policy states: The nursing department participates in the development of an interdisciplinary resident care plan to assure continuity and individualization of nursing care: 1. The care plan is completed within 21 days of admission by the interdisciplinary team, which includes the resident, nursing, life enrichment, social services and food and nutrition services. 2. The care plan includes problems, goals, objectives and approaches which nursing personnel use as guidelines in giving and recording the results of care. 3. The discipline(s) to initiate or carry out approaches, the frequency of approaches, and appropriate signatures are required on the care plan. 4. The care plan is reviewed and updated at least quarterly at an interdisciplinary team meeting. Residents or designees will be requested to participate. CARE PLAN: The entire resident record is understood to be the plan of care. More specifically, this includes any information that is used to carry out care and services for the resident: - The Bedside Information Sheet - Focus notes: written quarterly or as needed. These identify goals, measurements and descriptions. - physician's orders [REDACTED]. - Clinical monitoring: lab results, flow sheets (meal monitoring, snacks, restorative, etc.), therapy treatment notes - Medication and Treatment Administration Records - Progress Notes Because the entire record represents the care plan, all staff is aware of and engaged in the carrying out the (sic) goals of the care plan on a daily basis. 1. Resident 26 admitted to the facili… | 2020-09-01 |
| 57 | 57 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 309 | D | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to provide medication as ordered for 1 of 6 sampled residents (#s 15) reviewed for unnecessary medication. This placed residents at risk for unmet medical needs. Findings include: Resident 15 admitted to the facility in 5/2010 with [DIAGNOSES REDACTED]. A 6/20/17 physician's orders [REDACTED]. The 7/2017 MAR indicated [REDACTED]. On 7/31/17 at 10:17 am Staff 10 (RN) stated the medication was available in the medication cart. On 7/31/17 at 11:32 am Staff 8 (RNCM) stated Resident 15's medication was available in the medication cart and there was a backup supply of the medication available as well. Staff 8 stated the quetiapine was available on 7/30/17 and should have been administered to Resident 15. | 2020-09-01 |
| 58 | 58 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 329 | D | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure appropriate indication for use of medication for 1 of 6 sampled residents (# 129) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: Resident 129 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. Review of a nursing note dated 6/8/17 at 7:10 pm revealed Resident 129 was given two [MEDICATION NAME] which was ordered for another resident. It was noted Resident 129 had a history of [REDACTED]. The facility alerted the physician of the medication error and the physician directed staff to monitor Resident 129 and call if she/he had any adverse reactions. On 7/26/17 at 12:42 pm Staff 6 (RN) acknowledged on 6/8/17 two [MEDICATION NAME] were administered to Resident 129 in error and were intended to be administered to her/his roommate. On 7/26/17 at 4:05 pm Staff 2 (DNS) acknowledged the medication error of 6/8/17. | 2020-09-01 |
| 59 | 59 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 356 | F | 1 | 1 | LC2W11 | > Based on interview and record review it was determined the facility failed to accurately post the Direct Care Staff Daily Report for 13 of 30 days reviewed for staffing. This placed residents and visitors at risk for being uninformed. Findings include: A review of the Direct Care Staff Daily Report revealed the resident census was inaccurately documented for 13 of 30 days reviewed from 6/24/17 through 7/24/17. In an interview on 7/31/17 at 12:13 pm Staff 5 (Staffing coordinator) confirmed the Direct Care Staff Daily Report had inaccurate resident census information posted on 13 of 30 days reviewed. | 2020-09-01 |
| 60 | 60 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 371 | F | 1 | 1 | LC2W11 | > Based on observation, interview and record review it was determined the facility failed to prevent potential contamination for 1 of 1 sampled ice machines reviewed during kitchen inspection. This placed residents at risk for cross-contamination. Findings include: 1. According to Food Sanitation Rules, effective date 9/4/12, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 7/24/17 at 8:48 am the gap between the ice machine drain pipe and the floor was observed to be approximately one half inch. Staff 13 (Housing Manager) acknowledged the gap was less than one inch. 2. According to Food Sanitation Rules, effective date 9/4/12, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored . in the food with their handles above the top of the food and the container .In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous. On 7/24/17 at 8:48 am during inspection of the ice machine the ice scoop was observed to be located inside the ice machine, laying on top of the ice with the handle touching the ice cubes. Staff 13 acknowledged the scoop handle was touching the ice. Staff 13 stated the scoop was supposed to be located inside the ice machine, but not touching the ice. Staff 13 also stated staff wore gloves when getting ice in order to prevent the scoop from being contaminated. No gloves were observed in the vicinity of the ice machine. Staff 13 acknowledged no gloves were present. | 2020-09-01 |
| 61 | 61 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 441 | D | 1 | 1 | LC2W11 | > Based on observation, interview and record review it was determined the facility failed to ensure proper handwashing during meals for 2 of 5 dining areas observed during meal observations. This placed residents at risk for cross-contamination. Findings include: 1. On 7/24/17 at 12:14 pm Staff 14 (CNA) was observed to push a resident in her/his wheelchair into the main dining room. Staff 14 then provided a clothing protector to the resident. Staff 14 poured a cup of liquid into a cup from a pitcher on the table and served it to the resident and sat down next to the resident. Staff 14 was not observed during this time to wash or sanitize her hands. On 7/24/17 at 12:19 pm Staff 14 was observed touching her face with her hands while sitting with the resident. Staff 14 was not observed to wash her hands or sanitize her hands. On 7/24/17 at 12:21 pm Staff 14 was observed to touch a resident's cup with her bare hand around the rim of the cup when passing the cup to the resident. This surveyor then intervened. On 7/24/17 at 12:22 pm Staff 14 stated staff were to wash their hands in the bathroom in the hallway or use hand sanitizer when their hands were soiled. Asked about touching the resident's wheelchair, the resident, the pitcher, her face and the resident's cup without washing her hands, Staff 14 stated she wasn't paying attention to what she touched and acknowledged she should have washed her hands prior to assisting the resident. When asked about handling the resident's cup by gripping the rim of the cup, Staff 14 acknowledged she should not have touched the rim of the cup. 2. On 7/24/17 at 12:15 pm Staff 15 (CNA) was observed to push a resident in her/his wheelchair into the main dining room and sat down next to the resident. Staff 14 was not observed at any time to wash or sanitize her hands. On 7/24/17 at 12:16 pm Staff 15 was observed to touch the trash lid while throwing an item away before returning to the table where the resident sat. Staff 15 was not observed at any time to wash or sanitize her hands. On … | 2020-09-01 |
| 62 | 62 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 514 | D | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure accurate documentation of pressure ulcers for 1 of 3 sampled residents (#33) reviewed for pressure ulcers. This placed residents at risk for inappropriate care. Findings include: Resident 33 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Skin Wound Flow sheets dated 7/13/17 and 7/18/17 indicated Resident 33 had a suspected deep tissue injury (SDTI) to the right heel. A 7/20/17 Skin Wound Flow sheet indicated Resident 33 had a stage 1 pressure ulcer to the right heel. A 7/27/17 Skin Wound Flow sheet indicated Resident 33 did not have a pressure ulcer. On 7/31/17 at 11:47 am Staff 8 (RNCM) acknowledged Resident 33 had an SDTI to the right heel and stated the 7/20/17 and 7/27/17 Skin Wound Flow sheets were inaccurate. | 2020-09-01 |
| 63 | 63 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 577 | C | 0 | 1 | NNTH11 | Based on observation and interview it was determined the facility failed to ensure survey results were readily available to the public. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 12/10/18 at 9:35 AM the facility's survey results book was observed near the entrance to the facility. The report from the facility's most recent survey was not found. On 12/10/18 at 10:40 AM Staff 15 (Administrator) acknowledged the most recent survey results were not readily available. On 12/14/18 at 1:19 PM during a meeting with representatives of the resident council Resident 9 stated she/he had not seen the most recent state survey results. No other representatives of the resident council expressed seeing the most recent state survey results. | 2020-09-01 |
| 64 | 64 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 584 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide a clean and homelike environment for 3 of 26 sampled resident rooms (#s 406, 416, and 516) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: 1. Observations of room [ROOM NUMBER] on 12/10/18 at 10:34 AM and 12/17/18 at 10:37 AM revealed there was as a large section of tiles missing on the wall under the sink and some broken tiles were lying on the floor. On 12/17/18 at 10:49 AM Staff 14 (Maintenance Assistant) acknowledged the missing tiles and indicated he did not know the tiles were missing. 2. Observations of room [ROOM NUMBER] on 12/11/18 at 9:23 AM and 12/14/18 at 1:40 PM revealed there was a geri chair (reclining chair) with a head pad that had rips in the vinyl exposing the material underneath. The resident was observed to use the chair. On 12/14/18 at 1:40 PM Staff 4 (CNA) indicated she did not notice the tear in the head pad and would alert maintenance. On 12/17/18 at 10:49 AM Staff 14 (Maintenance Assistant) acknowledged the tears in the head piece and indicated he was just informed of the tear. 3. Observations of room [ROOM NUMBER] on 12/10/18 at 1:44 PM revealed there were two holes in the resident's wall next to the wall heater. One hole was covered with duct tape and the other hole was approximately eight inches long. On 12/14/18 at 1:34 PM Staff 13 (RNCM) indicated he was unaware of the holes and indicated they had a procedure for the CNAs to write up a maintenance ticket which did not occur. On 12/17/18 at 10:49 AM Staff 14 (Maintenance Assistant) acknowledged the holes in the walls and he was just notified of the holes. | 2020-09-01 |
| 65 | 65 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 600 | D | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident was free from verbal abuse for 1 of 6 sampled residents (# 61) reviewed for abuse. This placed residents at risk for verbal abuse. Findings include: The facility's 6/2018 Abuse Prevention policy indicated abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual of goods and services that are necessary to maintain physical, mental and psychosocial well-being. Abuse includes verbal and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 8/22/18 Annual MDS revealed a BIMS (Brief Interview for Mental Status) score of 99, which indicated she/he was unable to answer any of the interview questions. An 8/22/18 Cognitive Loss/Dementia CAA revealed the resident's cognitive decline and confusion increased her/his dependence on others and made it difficult to communicate her/his health and safety needs. According to complaint intake information, an 11/6/18 incident of verbal abuse by a CNA toward a resident was reported to the Oregon State Board of Nursing (OSBN) on 11/16/18 (ten days after the incident). OSBN subsequently forwarded the concern to Adult Protective Services (APS) and they notified the nursing facility survey unit. On 12/11/18 at 11:31 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) identified Resident 61 as the resident involved in an incident with a staff member related to verbal abuse on 11/6/18. Resident 61's record revealed no documentation of the incident regarding verbal abuse from a staff member, an assessment of the resident's status or ongoing monitoring after the incident. O… | 2020-09-01 |
| 66 | 66 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 607 | F | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to implement policies for the protection of residents to conduct thorough investigations and/or when to report allegations of abuse for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) and failed to develop a policy for reporting incidents not involving abuse or serious harm or injury. This placed residents at risk for ongoing abuse. Findings include: 1. Resident 36 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The facility 6/2018 Abuse Policy and Procedures revealed: -Employees must report all allegations of abuse and an investigation would be completed and would include: interviews with staff and residents, staff who may have knowledge of the incident and an analysis of findings. The 10/19/18 MDS indicated Resident 36 was cognitively intact. On 12/14/18 at 1:00 PM Resident 36 indicated some staff treated her/him badly. Resident 36 further stated a night shift female CNA was verbally abusive and told Resident 36 she hated her/his guts. The CNA still worked at the facility and continued to assist Resident 36 with care. Resident 36 indicated she/he did not report the incident to facility staff and would not provide the CNA's name. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS) were notified Resident 36 reported a female night shift CNA was verbally abusive toward the resident. Staff 1 indicated she just finished a telephone conversation with Resident 36's family and was notified of the same allegation. On 12/17/18 at 12:04 PM with Staff 1, Staff 15 and Staff 16, Staff 1 stated she did not follow up on the information of allegation of verbal abuse toward Resident 36 per facility policy. b. The facility 6/2018 Abuse Policy and Procedures revealed: -Any incidents of sexual abuse were to be reported to the State agency immediately or within two hours. The Resident 36's current Personalized Bedside … | 2020-09-01 |
| 67 | 67 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 609 | F | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure allegations of abuse or neglect were reported appropriately for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) reviewed for abuse. This placed residents at increased risk for ongoing abuse. Findings include: The facility's policy on Abuse Reporting (undated) indicated anyone who suspects abuse should immediately notify his or her immediate supervisor, the Director of Nursing or the Administrator. After receipt of a report of potential abuse an investigation should be started immediately. Once the initial investigation is completed, it will be given to the resident care manager for a final investigation, then to nursing administration or the administrator for continued investigation or follow-up. Nursing administration/Administrator will report to Adult Protective Services as appropriate. Any incidents of alleged abuse involving serious bodily injury or sexual abuse will be reported to local law enforcement and survey agency immediately (or within 2 hours). The Administrator and DNS should be notified immediately whenever local law enforcement is notified of an incident occurring at the facility. 1. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. According to complaint intake information, an 11/6/18 incident of verbal abuse by a CNA toward a resident was reported to the Oregon State Board of Nursing (OSBN) on 11/16/18 (ten days after the incident). OSBN subsequently forwarded the concern to Adult Protective Services (APS) and they notified the nursing facility survey unit. On 12/11/18 at 11:31 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) indicated Resident 61 was involved in an incident of verbal abuse from Witness 7 (Former CNA) on 11/6/18. On 12/12/18 at 11:22 AM Staff 1 provided an investigation regarding the 11/6/18 incident. The documentation began on 11/7/18 and concluded on 11/15/18. The investigation did not includ… | 2020-09-01 |
| 68 | 68 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 610 | F | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure investigations for allegations of abuse were thoroughly investigated for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: 1. Resident 36 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 10/19/18 MDS indicated Resident 36 was cognitively intact. The resident's current Personalized Bedside Care Plan indicated the resident was incontinent of bowel and bladder and two staff were required to assist the resident with bed mobility. One staff was to stand directly in front of the resident when the resident was assisted to roll in order to reassure she/he would not roll out of bed. The 11/8/18 Investigation by Staff 1 (DNS) indicated Resident 36 reported Witness 2 (Former CNA) touched me. Whenever he is changing me, he feels me up. Resident 36 further reported the female CNAs giggled when Witness 2 touched her/him and did not intervene. The resident reported the incident occurred the other day. Resident 36 did not provide the female CNA's names. Staff who worked with Witness 2 were interviewed and Staff 1 ruled out abuse. The investigation did not include documentation to indicate additional residents were interviewed to ensure Witness 2 did not inappropriately touch other residents. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS), Staff 1 indicated she interviewed staff regarding Witness 2's interactions with residents but did not interview additional residents. Staff 1 further indicated Witness 2 submitted his resignation in (MONTH) (YEAR), no longer worked at the facility and was not interviewed. 2. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 8/22/18 Annual MDS revealed a BIMS (Brief Interview for Mental Status) score of 99, which indicated she/he was unabl… | 2020-09-01 |
| 69 | 69 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 641 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately assess a resident's pressure ulcer status for 1 of 4 sampled residents (#7) reviewed for pressure ulcers. Findings include: CMS Appendix PP defined the following pressure ulcer stages: Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 9/12/18 MDS indicated Resident 7 was at risk for pressure ulcers and coded the resident as having an unstageable pressure ulcer. The CAA indicate… | 2020-09-01 |
| 70 | 70 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 677 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure resident oral hygiene was provided as directed by the care plan for 1 of 5 sampled residents (#49) reviewed for ADLs. This placed residents at risk for decline in oral hygiene. Findings include: Resident 49 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The 3/2018 Annual CAAs indicated the resident had mild intellectual disorder and mental health diagnoses. The resident at times was delusional, agitated and demonstrated aggressive behaviors. The resident required assistance with ADLs. The 6/30/18 Dental Care note indicated the resident had poor oral hygiene. The resident had extreme gingivitis and root exposure. The resident did not have signs or symptoms to indicate the resident's oral condition bothered her/him. The Bedside Information Sheet last reviewed on 11/17/18 revealed the resident had natural teeth and her/his teeth were to be brushed twice a day. The staff were to use children's toothpaste and a soft toothbrush. On 12/12/18 at 9:16 AM and at 10:04 AM Staff 4 (CNA) indicated staff used soft sponge brushes with diluted mouth wash to brush the resident's teeth. Staff 4 indicated the resident tended to swallow the toothpaste and choked. The sponge brushes were used because the resident resisted oral care and at times bit down on the toothbrush. Staff 4 indicated the resident's oral hygiene supplies were kept in the bedside table. With Staff 4, the resident's bedside table drawer was observed and did not contain children's toothpaste. On 12/12/18 at 12:06 PM Witness 1 (Resident 49's Family) indicated the resident was to use children's toothpaste because Resident 49 swallowed toothpaste. On 12/13/18 at 8:33 AM Staff 3 (Central Stores Director) indicated the facility did not supply residents with children's toothpaste and he was never asked to purchase children's toothpaste. On 12/13/18 08:45 AM and at 10:01 AM Staff 2 (RNCM)… | 2020-09-01 |
| 71 | 71 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 684 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure interventions to prevent bruising to arms were implemented in a timely manner for 1 of 3 sampled residents (#20) reviewed for non-pressure skin conditions. This placed residents at risk for skin injury. Findings include: Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 9/20/18 CAAs indicated the resident had kidney disease and diabetes, the conditions worsened and comfort was the goal of the resident's care. The resident was at risk for skin breakdown due to immobility, skin folds and multiple chronic diagnoses. The skin was intact but at risk for breakdown. Progress notes dated 10/7/18 indicated the resident had very dry, thin and almost translucent skin. The resident was assessed to have bilateral arm bruising which appeared to be related to the resident rubbing and scratching her/his arms. The bruising was diffuse, scattered and varied in color from purple to light purple. The staff tried to ensure long sleeves and sweaters were used but the resident continued to rub her/his arms. The 10/20/18 note indicated arm sleeves would be ordered for the resident. The Packing slip invoice revealed the resident's arm sleeves were ordered on [DATE] and received by the facility on 10/29/18. On 12/12/18 at 11:19 AM Staff 3 (Central Stores Manager) indicated he ordered Resident 20's arm sleeves on 10/22/18, received the sleeves on 10/29/18 and immediately provided the sleeves to the nurse or RNCM on Resident 20's unit. The Personalized Bedside Care Plan dated 10/21/18 indicated the resident was to choose her/his clothing. The resident had skin issues related to recent weight loss and had areas of loose skin and rashes. The staff were to keep the resident's skin moisturized. There were no interventions to indicate staff were to use the arm sleeves or to ensure the resident wore long sleeves. On 12/10/18 at 1:42 PM Resident 20 … | 2020-09-01 |
| 72 | 72 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 689 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure fall prevention care plan interventions were implemented for 1 of 4 sampled residents (#20) reviewed for falls. This placed residents at increased risk for injury. Findings include: Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The CAA dated 7/20/18 revealed the resident had the [DIAGNOSES REDACTED]. The resident fell at home before the resident was admitted to the facility and the resident continued to be at risk for falls. Interventions to prevent falls included the resident's bed was to be at transfer height to allow a safe transfer and staff were to encourage the resident to use the call light. The Personalized Bedside Care Plan dated 10/21/18 revealed WHAT KEEPS ME SAFE AND SECURE and indicated the resident had a history of [REDACTED]. On 12/12/18 at 10:19 AM Resident 20 was observed in bed. The resident's walker was not within reach and was approximately six feet from the foot of the bed. On 12/12/18 at 10:41 AM Staff 5 (CNA) indicated at times Resident 20 tried to walk without assistance and did not use the call light to request staff assistance. The resident was able to use the walker and walked short distances. Staff 5 indicated she was not sure if the care plan directed staff to keep the walker near the resident. On 12/12/18 at 10:47 AM Staff 2 (RNCM) indicated at times the resident attempted to self-transfer from the bed to the chair and the current interventions directed staff to keep the walker near the resident. | 2020-09-01 |
| 73 | 73 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 695 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to obtain orders for the use of oxygen, update a care plan and ensure the respiratory equipment was clean for 2 of 2 sampled residents (#s 20 and 422) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: 1. Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The Progress Notes dated 12/7/18 at 12:47 AM indicated the resident's oxygen saturation level was 88 to 90 percent on room air (Normal is 95 to 100 percent). The resident was administered oxygen and the resident's oxygen saturation level stabilized at 94 to 98 percent. The 12/7/18 at 10:02 PM note indicated the resident was administered oxygen and was lethargic and appeared to be fatigued. The 2:00 PM note indicated the resident's physician was notified of the resident's condition. The note did not include an order for [REDACTED].>On 12/11/18 at 2:36 PM Resident 20 was observed in bed. Next to the bed was an oxygen concentrator (medical device takes in air, modifies the air and delivers oxygen). The machine was not on and the resident was not being administered oxygen. The 10/21/18 Personalized Bedside Care Plan was not updated to address the use of oxygen. On 12/12/18 at 10:47 AM Staff 2 (RNCM) acknowledged the resident had a change in condition and required the use of oxygen. The staff did not obtain an order for [REDACTED].>2. Resident 422 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. Observations on 12/14/18 at 1:24 PM revealed the resident was using an oxygen concentrator (medical device takes in air, modifies the air and delivers oxygen). The filter on the concentrator had a large build up of dust. Resident 422 indicated the filter was not changed since she/he was admitted to the facility. On 12/14/18 at 1:26 PM Staff 24 (CNA) indicated that once a resident was discharged staff in central supply … | 2020-09-01 |
| 74 | 74 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 758 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure gradual dose reductions were considered, appropriate indication for use were provided and end dates were in place for [MEDICAL CONDITION] medications for 1 of 5 sampled residents (#28) reviewed for medication. This placed residents at risk for receiving unnecessary medication. Findings include: Resident 28 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 12/10/18 at 10:12 AM Resident 28 was observed and did not exhibit any symptoms of anxiety or depression. a. Resident 28's 11/2018 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A 11/14/18 physician's orders [REDACTED]. The order did not include a rationale for why the medication was increased. No evidence was found in Resident 28's clinical record to indicate the 0.25 mg PRN [MEDICATION NAME] was ineffective. The 11/2018 MAR indicated [REDACTED]. During interviews with Staff 22 (RNCM) on 12/17/18 at 10:56 AM and 11:42 AM Staff 22 stated she was unsure why the PRN [MEDICATION NAME] was increased. Staff 22 acknowledged there was no rationale to indicate why the [MEDICAL CONDITION] medication was increased. b. A 11/14/18 physician's orders [REDACTED]. The order did not include an end date for the PRN [MEDICAL CONDITION] medication. On 12/17/18 at 11:42 AM Staff 22 (RNCM) acknowledged there was no end date for the resident's PRN [MEDICATION NAME] order. c. Resident 28's 11/2018 MAR indicated [REDACTED]. No evidence was found in the resident's clinical record to indicate a gradual dose reduction (GDR) was attempted or considered since the 9/23/17 order for duloxetine was implemented. On 12/17/18 at 11:42 AM Staff 22 (RNCM) acknowledged no GDR was attempted or considered for Resident 28's use of duloxetine since 9/23/17. | 2020-09-01 |
| 75 | 75 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 790 | D | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a resident received necessary dental treatment for 1 of 3 sampled residents (#70) reviewed for dental care. This placed residents at risk for continued pain and a lessened quality of life. Findings include: Resident 70 admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 8/25/18 Admission MDS indicated Resident 70 had difficulty chewing. The 8/25/18 Dental CAA indicated Resident 70 had some loose teeth and would see the dentist when she/he felt better. The CAA stated staff were to assist with appointments if the resident's teeth worsened. A 12/3/18 Nutrition Observation indicated Resident 70 had difficulty eating because of teeth problems and the resident's diet was changed to a mechanical soft diet. The current care plan, updated 12/7/18, indicated one of Resident 70's teeth broke off recently. Resident 70 was to receive a mechanical soft textured diet. The care plan indicated Resident 70 was to receive dental evaluations and interventions as needed. On 12/10/18 at 2:15 PM Resident 70 stated she/he broke a tooth and needed to see the dentist. Resident 70 stated she/he gave the tooth to staff but did not hear anything back. Resident 70 stated she/he was unable to see a dentist outside of the facility due to her/his non-weight bearing status and inability to transfer into a dentist chair. On 12/13/18 at 10:41 AM Staff 18 (Social Services) stated Resident 70 had private insurance and any dental needs were coordinated through Witness 6 (Case Manager). Staff 18 stated facility staff would need to talk with the case manager to request a dentist come to the facility instead of sending the resident out. Staff 18 stated she was unaware Resident 70 needed dental treatment. On 12/13/18 at 11:29 AM Witness 6 stated she was not aware Resident 70 needed dental treatment. Witness 6 stated it was possible for a dentist to come to the facility for urgent dental … | 2020-09-01 |
| 76 | 76 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 880 | E | 0 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to clean and sanitize a community use glucometer according to manufacturer recommendations for 1 of 4 units (Harmony Hall) reviewed for infection control. This placed residents at risk for exposure to bloodborne pathogens. Findings include: The facility glucometer operator's manual for multiple resident use revealed the glucometer was to be cleaned after each resident use with a germicidal disposable wipe to clean the back, front and around the test strip slot. The meter was to be dried. The meter was then to be sanitized with a fresh germicidal wipe to disinfect by gently wiping the front, back and sides of the meter three times horizontally then vertically. The test strip slot was also to be disinfected with the wipe. The meter was to then be dried. The Blood Glucose Monitoring Nursing Department Policy revised on 6/23/18 revealed the glucometers were to be cleaned after each resident use with the germicidal disposable wipes. The 12/2017 facility Nursing Center Orientation list revealed glucometer cleaning was to be reviewed with staff upon hire. On 12/33/18 at 11:35 AM Staff 6 (LPN) was observed to don gloves and check Resident 26's CBG with the community use glucometer. The glucometer did not come in contact with Resident 26's skin. After the CBG was checked, Staff 6 was observed to clean the glucometer with an alcohol pad. At 11:38 AM Staff 6 stated she cleaned the glucometers with either the germicidal wipes or with the alcohol wipes. The sanitary wipes were observed at the nurses station and were EPA/Environmental Protection Agency approved to be effective against bloodborne pathogens. Staff 6 indicated she previously checked Resident #s 4, 14, 20, 26, 27 and 51's CBGs. Two residents were near the nurses station at the time she checked the CBG and used the germicidal wipes to clean the glucometer. Record review indicated Resident 4, 14, 20, 26 and 5… | 2020-09-01 |
| 77 | 77 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2018-05-24 | 727 | D | 1 | 0 | 96GF11 | > Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 9 out of 54 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 4/1/18 through 5/23/18 revealed there were 9 days without 8 consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 5/23/18 at 10 am Staff 2 (DNS) confirmed the facility hired RNs, there were a few nurses who resigned and there was a problem with RN coverage. | 2020-09-01 |
| 78 | 78 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2018-05-24 | 825 | D | 1 | 0 | 96GF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to provide the frequency of ordered Physical Therapy for 1 of 3 (#2) sampled residents reviewed for therapy services. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The care plan dated 3/15/18 revealed the resident required one staff for extensive assistance with bed mobility, transfers, bathing and dressing. The PT Evaluation and Plan of Treatment dated 3/16/18 performed by Staff 17 (PT) indicated the resident needed PT five times a week for four weeks. On 3/19/18 at 3:42 pm the Nurse Practitioner (Staff 18) documented Witness 2 (Family) communicated she/he wanted Resident 2 to go home, she wrote discharge orders and made arrangements for the resident to have PT though a homecare organization. On 3/19/18 the progress notes revealed the resident was discharged home at 4:57 pm with Witness 2. On 5/8/18 at 2:00 pm Witness 2 (Family) indicated on 3/16/18 the PT said the resident would have PT five days per week, the resident did not have PT for three days in a row and late in the day on 3/19/18 she/he brought the resident home after the facility arranged for PT at the resident's home. On 5/23/18 at 11:00 am Staff 17 (PT) stated he evaluated the resident on 3/16/18 and determined the resident needed PT five days per week, it was scheduled to start on 3/20/18 and it was likely the plan was miscommunicated with the resident's family. On 5/23/18 at 11:30 am Staff 2 (DNS) confirmed during Resident 2's facility stay PT was received one time. She stated the resident had OT on 3/16/18 and 3/19/18. | 2020-09-01 |
| 79 | 79 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 552 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to ensure resident's be informed, participated in treatment and were treated with dignity and respect for 2 of 8 sampled resident (#s 4 and 24) reviewed for medications and dignity. This placed residents at risk for lack of dignity and Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the Resident 4's room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. She checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and called the emergency department. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar and indicated a reading of 118. At 5:50 AM Resident 4 exited the building. On [DATE] at 9:31 AM Resident 4 stated she/he admitted to the facility on [DATE] from the hospital. During her/his hospital stay she/he recalled being administered 30 units of [MEDICATION NAME] two times daily. The nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATIO… | 2020-09-01 |
| 80 | 80 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 554 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assess self-administration of a medication for 1 of 3 sampled residents (#5) reviewed for accidents. This placed residents at risk for unsafe medication administration. Findings include: Resident 5 admitted to the facility 6/2012 with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A review of the 12/2018 and 1/2019 Diabetic Administration Records revealed Resident 5 received her/his insulin per physician order. On 6/3/19 at 11:01 AM Staff 38 (RN) stated the resident was on insulin and drew the correct amount of insulin and then the resident would self-administer her/his own insulin. Staff 38 stated Resident 5 administered her/his own insulin for as long as she could remember. A review of Resident 5's medical record revealed an assessment was completed in (YEAR) and identified the resident was not to administer medication on her/his own. No other assessments were located regarding self-administration of medication. On 6/6/19 at 1:28 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the resident was administering insulin medication without being an assessed as safe to do so. | 2020-09-01 |
| 81 | 81 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 580 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to notify the family for 1 of 3 sampled residents (#15) who were reviewed for pressure ulcers. This placed residents at risk for unmet needs. Findings include: Resident 15 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/14/19 care plan revealed Resident 15 had skin impairment and was at risk for further skin breakdown. Interventions included to notify the resident and the family of any new issue and treatment orders. A 5/1/19 Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx that reached both the left and right buttocks. Resident 15 and the physician were notified on 5/1/19. A 5/8/19 Skin and Wound Evaluation revealed Resident 15 had a facility acquired unstageable pressure ulcer to the coccyx with a start date of 5/1/19. On 5/22/19 at 1:31 PM Witness 12 (family member) stated the facility would notify her for meetings and other concerns but she was not notified of Resident 15's unstageable pressure ulcer. On 6/5/19 at 10:32 AM Staff 11 (RNCM) confirmed, if care planned, family was expected to be notified even if the resident was her/his own representative. | 2020-09-01 |
| 82 | 82 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 602 | E | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 5 of 6 sampled residents (#s 8, 14, 16, 21 and 22) reviewed for misappropriation. This placed residents at risk for loss of property. Findings include: 1. Resident 8 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. An undated document revealed Staff 2 (DNS), Staff 9 (Social Service Director) and an unidentified RCM interviewed Resident 8 who stated she/he had approximately $4,000 in the facility safe. Staff 28's (Scheduler) statement was Resident 8 had over $5,000 in the facility safe. A 5/2/19 documented statement revealed Staff 9 reported Staff 10 (Administrator in Training) inquired if Resident 8 had money in the facility safe. The safe was opened and on an envelope was written Resident 8's name and $5,195 with $60.00 signed out as withdrawn in 9/2018. It was discovered $4,300.00 was unaccounted for in regard to the amount written on the front of the envelope. On 5/22/19 at 10:41 AM Staff 9 stated she had not completed an inventory of the safe until the week of 5/8/19. On 5/22/19 at 10:43 AM Resident 8 stated she/he did not feel safe with her/his money in the facility. Resident 8 further stated the administration came into her/his room with a master key and went through her/his personal drawer without notification. Resident 8 stated the facility did not contact her/him in regard to reimbursement of her/his missing money. On 6/4/19 at 9:00 AM Resident 8 stated he/she was upset about being robbed in the facility. On 6/6/19 at 11:02 AM Staff 1 (Administrator) and Staff 2 stated the facility did not have a good inventory system for the money and Resident 8 was not reimbursed for his/her money. Staff 1 confirmed misappropriation of Resident 8's money. 2. Resident 14 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 3/1/19 Grievance Communication Form revealed Resident… | 2020-09-01 |
| 83 | 83 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 610 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure incidents of suspected resident misappropriation were investigated timely for 2 of 3 sampled residents (#s 8 and 16) reviewed for misappropriation. This put residents at risk for potentially avoidable incidents. Findings include: The facility's Abuse Prevention Policy and Procedure dated 3/2017 revealed the following: As soon as a report of alleged or suspected abuse was received, the investigation would begin in order to rule out or identify abuse. The investigation will include at a minimum the following: -Identification of the parties involved. -Sign and symptoms, or the complaint received that requires investigation. -Identification of witnesses. -Interview of all parties involved, including the resident if interview able. -Assessment of the involved for injury and the need for medical and emotional support. -The investigation will be completed within five days. -Refer to the investigation procedure for further information on investigative process for all accidents and incidents. The facility's Abuse Investigations policy revised dated 4/2010 revealed the following: -Witness reports would be obtained in writing. -Witnesses would be required to sign and date the reports. 1. Resident 8 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. An undated document revealed Staff 2 (DNS), Staff 9 (Social Service Director) and an unidentified RCM interviewed Resident 8 who stated she/he had approximately $4,000 in the facility safe. Staff 28's (Scheduler) statement was Resident 8 had over $5,000 in the facility safe. A 5/2/19 documented statement revealed Staff 9 reported Staff 10 (Administrator in Training) inquired if Resident 8 had money in the facility safe. The safe was opened revealing an envelope marked with Resident 8's name and $5,195 with $60.00 signed out as withdrawn in 9/2018. It was discovered $4,300 was unaccounted for regarding the amo… | 2020-09-01 |
| 84 | 84 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 657 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to revise and update care plans for 3 of 9 sampled residents (#s 5, 6 and 15) reviewed for accidents, pressure ulcers, respect and dignity. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. A complaint was received on [DATE] indicating Resident 5 had a fall on [DATE] in the facility that resulted in a [MEDICAL CONDITION]. An undated Kardex (a form utilized by CNAs to guide care provided to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. Witness 5 (Complainant) reported the resident had a fall. Interviews completed on [DATE] indicated Staff 43 (CNA) and Staff 40 (CNA) were both transferring the resident to the bed side commode when the battery on the sit-to-stand machine died . Staff 40 had to go down and exchange the batteries. Upon Staff 40s return the resident stated My legs are giving out and instead of using the sit-to-stand machine to lower the resident Staff 43 and Staff 40 both manually lowered the resident to her/his knees and then laid the resident down with pillows under her/his head. -Staff 44 (LPN) came down the hall and saw Staff 40 getting new batteries for the sit to stand machine. When Staff 44 entered the room the resident was on the floor with a Hoyer (mechanical lift) sling (a device used to suspend the resident in the Hoyer) by the resident's bed. They had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave the resident a pain pill after they used the Hoyer to get the resident back into bed. Resident 5 began calling out 20 to 30 minutes after being in bed … | 2020-09-01 |
| 85 | 85 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 658 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined facility staff failed to ensure professional standards were followed related to equipment safety and medication administration for 2 of 8 sampled residents (#s 4 and 5) reviewed for medications and accidents. Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A physician order [REDACTED]. The resident received 70 units on [DATE] at 7:00 PM. A physician order [REDACTED]. The residents blood sugar at 9:00 PM was 427 and she/he was administered 12 units of Humalog per sliding scale. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the residents room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. Staff 30 checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and the hospital emergency department was contacted. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar level which was 118. At 5:50 AM Resident 4 left for the hospital. Hospital records dated [DATE] through [DATE] indicated the following: -Resident 4 admitted for significant hypoglycemic (low blood sugar), [MED… | 2020-09-01 |
| 86 | 86 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 660 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to update a discharge plan of care and ensure discharge needs were met for 1 of 3 sampled residents (#11) reviewed for a safe discharge. This placed residents at risk for an unsafe discharge. Findings include: Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 1/16/19 care plan revealed Resident 11's discharge plan was to remain at the facility long term for care. The care plan also indicated Resident 11 did not wish to look for another placement. A 1/24/19 Social Service note revealed a transitional coordinator was to attend the care conference on 1/29/19. A 2/4/19 Social Service note revealed social services discussed discharge plans with Resident 11 to move to an assisted living facility on 2/5/19. A 2/7/19 Social Service note revealed social services was still waiting for authorization for Resident 11's medical equipment. A 2/21/19 Discharge Summary revealed Resident 11 was discharged to an assisted living facility. On 6/11/19 at 7:54 PM Staff 2 (DNS) acknowledged the resident discharge plan of care was not updated to reflect the resident's discharge to an assisted living facility. | 2020-09-01 |
| 87 | 87 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 677 | E | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming, oral care and hygiene for 3 of 9 sampled residents (#s 1, 6 and 8 ) reviewed for ADLs and misappropriation. This placed residents at risk for unmet needs. Findings include: 1. Resident 1 admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. On 5/23/19 at 12:08 PM Witness 1 (Complainant) stated she visited the resident on 12/5/18 and the resident did not have her/his bottom dentures in her/his mouth. She stated the resident had her/his own top teeth, however they were not clean and had debris on them. She located her/his bottom dentures which were not in a denture cup. The dentures had dried food on them and were sitting on the sink in the resident's bathroom. On 5/23/18 at 2:00 PM Witness 17 (Agency Nurse) stated she visited the resident on 12/7/18 and stated the resident had her/his lower dentures in although the resident's teeth were visibly dirty with built up debris. Record review indicated oral care was to be completed on day and evening shift. A review of the 12/2018 oral care task documentation revealed the following: -From 12/5/18 through 12/7/18 indicated oral care was completed. -On 12/2, 12/10 and 12/17 no oral care was provided. On 6/3/19 at 11:55 AM Staff 11 (RNCM) stated oral care should be provided day and evening shift and acknowledged Resident 1 was not provided with adequate oral care. 2. Resident 6 admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident 6 was cognitively intact and required extensive assistance of one person with personal hygiene. Random observations on 5/21/19, 5/22/19 and 6/3/19 revealed Resident 6 had dark black hair above her/his upper lip and on her/his chin. On 6/3/19 at 8:45 AM Staff 17 (CNA) stated she had not showered Resident 6, however had assisted with personal hygiene. Staff 6 stated she w… | 2020-09-01 |
| 88 | 88 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 679 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, and record review, it was determined the facility failed to provide an ongoing activity program to support the mental and psychosocial well-being for 2 of 4 sampled residents (#s 13 and 22) reviewed for activities. This placed residents at risk for decrease in their quality of life. Finding include: 1. Resident 13 was admitted to the facility in 4/1/2019 with [DIAGNOSES REDACTED]. An 4/8/19 Admission MDS revealed Resident 13 enjoyed activities with groups of people, and it was somewhat important to do her/his favorite activities. A 4/10/19 care plan revealed Resident 13 would participate in activity of choice for the next 30 days. No documentation was found in clinical record Resident 13 participated or refused any activities. On 5/22/19 at 11:47 AM Witness 9 (Complainant) stated while Resident 13 was residing at the facility there was no Activity Director. The calendar would indicate an activity was scheduled but there were no activities. On 6/3/19 at 10:28 AM Staff 16 (Activity Director) confirmed in the beginning of 4/2019 there was no one providing activities to the residents. On 6/6/19 at 11:41 AM Staff 2 (DNS) provided a handwritten note which revealed the previous Activity Director was no longer employed as of 4/2/19 and Staff 16 started on 4/16/19. 2. Resident 22 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. On 6/3/19 at 8:03 AM Resident 22 stated there were no hands-on activities and she/he did not receive the (MONTH) activity calendar. Resident 22 also stated there were no activities available on the weekends. On 6/3/19 at 10:28 AM Staff 16 (Activity Director) confirmed in the beginning of 4/2019 there was no one providing activities to the residents. Staff 16 stated he was currently working on the 6/2019 activity calendar. On 6/6/19 at 11:41 AM Staff 2 (DNS) provided handwritten note which revealed the previous Activity Director was no longer employed as of 4/2/19 and Staff 16 started on 4… | 2020-09-01 |
| 89 | 89 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 684 | J | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on interview and record review it was determined the facility failed to promptly identify and intervene for an acute change of condition for 1 of 3 sampled residents (#5) reviewed for accidents. As a result of this deficient practice Resident 5 experienced a delay in being assessed and treated for [REDACTED]. An immediate jeopardy situation was called. Findings include: Resident 5 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED]. Transfer to the hospital and or intensive care unit if indicated. All treatments including breathing machine. An Investigation dated [DATE] revealed the following: -At approximately 8:00 AM Staff 38 (RN) entered Resident 5's room, prior to breakfast, to check her/his blood sugars and administer insulin. The resident was discovered breathing heavily, unable to clear her/his throat. -Resident 5 was on two liters of continuous oxygen, her/his heart rate was 84 beats per minute and the resident was unresponsive, unable to sit forward to clear her/his throat. -Staff were alerted and came to assist, worked to clear Resident 5's airway while the charge nurse called 911 and prepared paperwork. -The ambulance arrived by approximately 8:05 AM and the investigation revealed The resident stopped breathing as paramedics entered. -CPR was performed for approximately 15 to 20 minutes by the paramedics and by 8:30 AM paramedics ceased lifesaving efforts. -Relatives were notified of the resident's passing and physician was notified. -The police conducted an investigation as the death was unexpected and the resident was not resuscitate (DNR). An Accident/Incident Interview Form dated [DATE] revealed Staff 37 (CNA) checked on Resident 5 at 6:30 AM and the resident was in the bed. The incident report indicated Staff 37 reported to Staff 39 (CMA) at 7:00 AM that Resident 5 was breathing heavy and Staff 39 indicated she would talk to Staff 38 (RN). The incident report further indicated… | 2020-09-01 |
| 90 | 90 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 686 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to implement, follow and maintain pressure ulcer treatments for 3 of 4 sampled residents (#15, 20 and 23) reviewed for pressure ulcers. Resident 20 admitted to the facility with a DTI (deep tissue injury) to the coccyx (tailbone), and the treatment was not implemented timely resulting in a worsening of the pressure ulcer wound. Findings include: 1. Resident 20 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. In an interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and it was difficult finding staff for assistance. He felt Resident 20 was not repositioned enough, had to wait longer than 20 minutes before getting her/his brief changed and the brief would often be soaked. Witness 19 stated the wound on the resident's bottom got worse as a result. A 4/29/19 Admission Nursing Data Base indicated a dark blanchable spot to the coccyx, measuring 0.5 cm x 0.5 cm with shearing to the crease. A 5/7/19 Pressure Ulcer CAA indicated Resident 20 admitted with a DTI to her/his coccyx, she/he was at risk for skin breakdown related to urinary incontinence, decreased mobility and diabetes. The resident required extensive assist of two staff with bed mobility. Preventative measures were in place to protect the resident's skin. The coccyx wound was being monitored by nursing. A Skin and Wound Evaluation Dated 5/14/19 indicated an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer with slough (dead tissue) and eschar (dry, dark scab) to the sacrum. The wound was present upon admission. Wound measurements were 4.6 cm x 3.2 cm x 0.3 cm, the wound bed was 20 percent granulation, 60 percent slough and 20 percent eschar. A moderate amount of serous (pale yellow fluid) exudate (fluid) was noted. The resident was noted to have intermittent pain. Additional notes indicated suspected DTI upon adm… | 2020-09-01 |
| 91 | 91 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 689 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to ensure resident care equipment was in safe operating condition for 1 of 3 sampled residents (#5) reviewed for falls. This resulted in Resident 5 being sent out to the hospital for uncontrolled pain and a right [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. A complaint was received on [DATE] indicating Resident 5 had a fall on [DATE] in the facility that resulted in a [MEDICAL CONDITION]. Witness 5 (Complainant) indicated in the letter she received a phone call around 4:00 AM from Resident 58 and the resident was in distress. She found out Staff 43 (CNA) was in the resident's room to assist the resident to the bathroom by herself. The resident was suppose to be a two person assist when utilizing the sit to stand machine (an assistive device to be transferred between a bed and a chair or other similar resting places). Witness 5 called the resident and while talking with the resident she/he stated All I know is that one leg went this way and one leg went that way. And then the resident started screaming like crazy for help and was in terrible pain. She/he then said, Here talk to the nurse and handed the phone to Staff 44 (LPN). Staff 44 indicated the resident was complaining of pain in her/his leg and thought it might have been a blood clot and was sending the resident to the emergency department for further evaluation. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. Witness 5 (Complainant) reported the resident had a fall. -The investigation indicated Resident 58 stated … | 2020-09-01 |
| 92 | 92 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 690 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to provide adequate incontinent care for 1 of 3 sampled residents (#20) reviewed for incontinent care. This placed residents at risk for unmet needs. Findings Include: Resident 20 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A Urinary Incontinence and Indwelling Catheter CAA dated 5/7/19 indicated the resident was frequently incontinent of urine due to a decrease in the resident's mobility, pain and need for assist with toileting. The resident was at risk for skin break down and urinary tract infections related to incontinence. Pad and briefs were to be utilized. A Pressure Ulcer CAA dated 5/7/19 indicated Resident 20 admitted with a DTI to her/his coccyx was at risk for skinbreak down related to urinary incontinence, decreased mobility and diabetes. The resident required extensive assist of two staff with bed mobility. Preventative measures were in place to protect the resident's skin. The coccyx wound was being monitored by nursing. A complaint was received on 5/20/19 indicating the facility was not providing timely incontinent care. An interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and it was difficult finding staff for assistance. He felt Resident 20 was not repositioned enough and had to wait longer than 20 minutes before getting her/his brief changed and the brief would often be soaked. The witness stated the wound on the resident's bottom had gotten worse due to untimely brief changes. An interview on 5/22/19 at 9:31 AM Resident 20 stated she/he waited greater than 20 minutes to receive ADL care and often sat in wet briefs. The resident indicated she/he needed assistance and could not utilize the toilet due to her/his broken leg. She/he stated I pay attention to time. An observation on 5/22/19 at 1:34 PM revealed Resident 20 was asleep in bed and the door was o… | 2020-09-01 |
| 93 | 93 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 695 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure respiratory care was consistently provided and monitored for 2 of 6 sampled resident (#s 2 and 5) reviewed for respiratory care and accidents. This placed residents at risk for inadequate oxygen levels. Findings include: 1. Resident 2 admitted to the facility 12/2018 with [DIAGNOSES REDACTED]. Resident 2's medical record revealed a physician order [REDACTED]. The resident's 12/12/18 through 12/15/18 TAR revealed oxygen saturations were not checked on 12/13/18 on day or evening shift. A review of the resident Weights and Vitals Summary revealed the following: -From 12/16/18 through 12/27/18 no oxygen saturations were monitored (12 days). -On 12/28/18 oxygen saturations were only completed one time. -From 12/29/18 through 1/6/19 no oxygen saturations were monitored (nine days). On 5/22/19 at 8:52 AM Staff 34 (LPN) stated she recalled the resident utilized oxygen and had breathing difficulties. She indicated she would remind the resident to keep her nasal cannula in place. On 5/24/18 at 9:41 AM Staff 32 (CMA) stated she recalled the resident had a difficult time breathing and utilized oxygen. She stated they would have to remind the resident not to remove her/his nasal cannula. On 6/7/19 at 10:50 AM Staff 2 (DNS) stated any high risk resident should have oxygen saturations checked every shift. She acknowledged staff were not monitoring Resident 2 appropriately. 2. Resident 5 admitted to the facility 6/2012 with [DIAGNOSES REDACTED]. Resident 5's medical record revealed a physician order [REDACTED]. Resident 5's medical record revealed a physician order [REDACTED]. A review of the resident's 12/2018 and 1/2019 TARS revealed oxygen saturations were checked on 12/26/18 through 12/28/18 for three days, however no other information was located on the TARs regarding monitoring of Resident 5's oxygen saturations. A review of the resident Weights and Vitals Summary fr… | 2020-09-01 |
| 94 | 94 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 725 | E | 1 | 0 | 90J611 | > Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Resident Council Meeting notes dated 4/24/19 revealed residents concern with long call light wait times. Resident Council Meeting notes dated 5/29/19 revealed residents concern for long call light wait times. A complaint was received on 5/20/19 indicating the facility was short staffed and was difficult to find nursing staff when assistance was needed. a. In an interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and the facility was often short of staff and staff were difficult to find when needing assistance. He stated Resident 20 had to wait longer than 20 minutes before getting her/his brief changed. In an interview on 5/22/19 at 9:31 AM Resident 20 stated she/he had to wait greater than 20 minutes to receive ADL care and sat in wet briefs. The resident indicated she/he needed assistance and could not utilize the toilet due to her/his leg being broken. She/he stated I pay attention to time. During an observation on 5/22/19 at 1:34 PM revealed Resident 20 was asleep in bed, the door was open. At 1:45 PM Staff 45 (CNA) woke the resident and stated she was going to change the resident's brief and get the resident some water. Staff 45 returned with fresh ice water and exited the room. During an observation and interview on 5/22/19 at 2:50 PM Resident 20 stated Staff 45 came into her/his room around 2:00 PM and stated she was going to change the resident's brief, however Staff 45 never came back and I am still in my wet brief. The resident turned on her/his call light at 2:52 PM. The resident stated she/he could wait up to greater than 30 minutes around meal times and shift change to get her/his brief changed and this was very frustrating. At 3:02 PM Staff 46 (CNA) came in answered the call light a… | 2020-09-01 |
| 95 | 95 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 727 | E | 1 | 0 | 90J611 | > Based on interview and record review it was determined the facility failed to use the services of an RN during a 24 hour period for 24 of 86 days reviewed for RN staffing. This placed residents at risk for unassessed needs. Findings include: A review of the Direct Care Staff Daily Reports for the months of 12/2018, 1/2019, 4/2019 and 5/2019 revealed the following days with no RN coverage during the 24 hour period: December (YEAR): 12/11, 12/12, 12/19, 12/22 and 12/24. January 2019: 1/5, 1/7, 1/8, 1/9 and 1/15. April 2019: 4/7, 4/8, 4/9, 4/11, 4/16, 4/23, 4/28, 4/29 and 4/30. May 2019: 5/5, 5/7, 5/11, 5/14 and 5/19. On 6/5/19 at 11:23 AM Staff 1 (Administrator) acknowledged the lack of RN coverage for 24 out of the 86 days reviewed and indicated this was an area they were focused on but were having a difficult time with recruitment. | 2020-09-01 |
| 96 | 96 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 732 | E | 1 | 0 | 90J611 | > Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 26 out of 86 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports for the months of 12/2018, 1/2019, 4/2019 and 5/2019 revealed 26 instances when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included numbers of hours worked by staff, daily census numbers, authorization signature and if the facility had appropriate staffing coverage. In an interview on 6/5/19 at 11:27 AM Staff 1 (Administrator) acknowledged the Direct Care Daily Staff Report forms were incomplete for the 26 days and should have been completed by the staff. | 2020-09-01 |
| 97 | 97 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 740 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to comprehensively assess, to monitor effectiveness of behavior interventions and to re-evaluate behavior/emotional needs for 1 of 4 sampled resident (#8) reviewed for accidents. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: Resident 8 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. A 11/2018 care plan revealed Resident 8 exhibited inappropriate behavior including resistiveness to treatment, verbally aggressive to staff and residents, sexually inappropriate, swearing and calling staff and other residents names and being physically aggressive to other residents. Resident 8 reported staff did not care about her/him. The plan included the following interventions: -Approach Resident 8 calmly and unhurriedly. -Monitor behaviors every shift. -Provide flexible ADL routine and opportunities for choices. -Speak in calm voice and allow Resident 8 to process. A 2/6/19 Physical investigation revealed Resident 8 was in the hallway and Resident 9 self-propelled her/his wheelchair toward Resident 8. Resident 8 was yelling at Resident 9 and punched Resident 9 in the arm. A 2/2019 Behavior Monitoring Record revealed the following: -Behaviors: Verbally aggressive to staff, sexually inappropriate, refused care, swears and calls names. -Triggers: lonely, bored and agitation with others. -Interventions: Redirect to quiet area, change position, return to room, leave room and return, one on one interaction and toilet. From 2/1/19 through 2/7/19 the following behaviors and interventions were documented: -Two instances of sexually inappropriate with interventions included and outcome improved. -Two instances of verbally aggressive to staff with interventions and no change in outcome. -One instance of refusing care with interventions included and no change in outcome. The monito… | 2020-09-01 |
| 98 | 98 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 745 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure medically related social services were provided related to discharge for 1 of 3 sampled residents (#11) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include: Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 2/4/19 Social Service note revealed social services discussed discharge plans with Resident 11 to move to an assisted living facility on 2/5/19. A 2/7/19 Social Service note revealed social services was still waiting for authorization for Resident 11's medical equipment. A 2/21/19 Discharge Summary revealed Resident 11 was discharged to an assisted living facility. On 6/3/19 at 2:53 PM Staff 20 (Social Service Director) stated Resident 11's discharge was delayed for two weeks due to medical equipment ordered for discharge was not ready. On 6/6/19 at 1:14 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there was difficulty in the medical equipment supplier used during Resident 11's discharge process. | 2020-09-01 |
| 99 | 99 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 807 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure adequate hydration was monitored for 1 of 3 residents (#1) reviewed for hydration. This placed residents at risk for dehydration. Findings include: Resident 1 admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. On 12/6/18 a public complaint was received and indicated Resident 1's lips and skin were visibly dry and the resident could not always access her/his water. A comprehensive care plan dated 12/4/18 indicated the resident was at nutritional risk related to diabetes and staff were to monitor hydration pass as ordered. A review of Resident 1's Hydration Pass from 12/2018 through 1/2019 revealed the following: -Staff were to monitor and document the resident's hydration intake three times a day. -from 12/4/18 through 1/9/19 no documentation was located regarding the resident's hydration intake. On 5/23/19 at 12:08 PM Witness 1 (Complainant) stated she visited the resident on 12/5/18 and her/his lips were very dry and the resident asked for some water. Resident 1's water was in the corner of the room where she/he was unable to reach it. On 5/23/18 at 2:00 PM Witness 17 (Friend of the Complainant) stated she visited the resident on 12/7/18 and her/his lips were extremely dry, cracked and peeling. She indicated the resident was too weak to bring the water up to her/his lips for a drink without assistance. On 5/28/19 at 2:05 PM Staff 33 (CNA) stated at times the resident had difficulty holding onto cups in order to drink water. On 6/5/19 at 8:55 AM Staff 19 (CNA) stated she thought Resident 1 was on a hydration pass and she recalled monitoring how much water the resident would drink. On 6/3/19 at 12:30 PM Staff 11 (RNCM) stated she could not find any documentation of staff monitoring Resident 1's hydration intake from 11/29/18 through 1/9/19 and thought the resident was on a hydration pass. | 2020-09-01 |
| 100 | 100 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 838 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to update the comprehensive facility wide assessment on an annual basis. This placed residents at risk for unmet needs. Findings include: The most recent Facility assessment dated ,[DATE] revealed the resident population profile was completed from 10/31/16 through 10/31/17. On 6/6/19 at 10:36 AM Staff 2 (DNS) stated the Facility Assessment was reviewed in 11/2018 and she would look for any updates. No further information was received. | 2020-09-01 |
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CREATE TABLE [cms_OR] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );