rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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,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. Resident 38's normal routine was to get up early. b. In a 2/19/19 interview at 2:51 PM and 2/20/19 at 10:39 AM, Resident 38 stated the staff sent a sack lunch with her/him to [MEDICAL TREATMENT] treatments, but always made the sandwiches with wheat bread which she/he could not eat. When eating meals in the facility, staff brought wheat bread consistently to her/him, although Resident 38 had repeatedly told them she/he could not eat and did not want wheat bread. On 2/22/19 at 8:51 AM, the resident was overheard saying to a CNA I have told you repeatedly I do not want wheat toast - I would like white toast. Observation of the resident's breakfast tray revealed a double portion of eggs, hot cereal, milk and wheat toast. The tray card did not identify her/his request for no wheat toast. When interviewed on 2/26/19 at 9:53 AM, Staff 25 (CNA) stated the resident had told him she/he did not want wheat bread. Staff told the server from the kitchen and it was his understanding, the kitchen would make the changes on the tray card. In a 2/26/19 interview at 11:09 AM, Staff 13 (Chef) stated it was the responsibility of the CNA or servers to write resident changes on the tray card before returning it to the kitchen for input into the computer. It was not a perfect system and communications could break down. Staff 13 was unaware of the resident's request to have no wheat bread.",2020-09-01
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 her/his multiple missed medications and treatments for fluid restriction and CBG checks. In an interview on 2/27/19 at 11:25 AM, Staff 11 (LPN) stated the resident was out of the facility due to [MEDICAL TREATMENT] and other activities. Staff 11 stated for certain medications like supplements she would give the resident's medication when she/he returned. Staff 11 stated it was difficult to monitor her/his fluid restriction but would notify the physician if the resident was going over her/his restriction and if she/he was consistently missing medications. In an interview on 2/27/19 at 12:38 PM, Staff 10 (Resident Care Manager-LPN) stated she expected nurses to check Resident 199's blood sugars and administer missed medication, if appropriate, when she/he left and returned to the facility. Staff 10 stated she expected nurses to notify the resident's physician for any missed medications and any fluid overload. In an interview on 2/27/19 at 1:32 PM, Staff 2 (DNS) was informed of the lack of notification to the resident's physician for missed medications and treatments. Staff 2 confirmed Resident 199's physician should have been notified for any fluid overload and missed medications and treatments.",2020-09-01
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,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 (Resident Care Manager-LPN) stated when residents transferred from one part of the building to another, the care plan and medications were an important part in knowing the resident's needs and preferences for care. Staff 10 confirmed the care plan did not reflect the resident's individualized showering method until 2/11/19. 3. Resident 28 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Resident 28's revised 4/5/18 Care Plan that addressed mood, included a history of suicide 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, medications per physician orders, mental health evaluation as needed, and to notify DNS and/or Administrator at time of the incident after resident is safe. 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. Resident 28's Care Plan was not revised to reflect individualized interventions or approaches to address suicidal verbalizations. No revisions were made to the care plan since 4/5/18. In an interview on 2/25/19 at 10:11 AM, Staff 10 (Resident Care Manager-LPN), stated she thought approaches were on the resident's Care Plan. Upon review, she acknowledged no approaches were documented.",2020-09-01
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: 9/2018 - 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 evidence in the resident's clinical record to indicate the facility had attempted alternative care options, such as different medication times or other interventions, to ensure Resident 199 was taking her/his prescribe medications and maintaining fluid restrictions. In an interview on 2/27/19 at 12:38 PM, Staff 10 (Resident Care Manager-LPN) stated she recalled the resident being out of the facility and was on [MEDICAL TREATMENT]. Staff 10 stated if the resident was missing a lot of medications she would expect other interventions, such as changing the resident's medication schedule. Staff 10 was unable to answer why Resident 199 had missed so many medications and treatments. In an interview on 2/27/19 at 1:32 PM, Staff 2 (DNS) stated she expected all medications to be given and treatments provided even when out of the facility. Staff 2 stated she expected other interventions to be provided to ensure the resident received her/his medications and treatments. 2. 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 7 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]. The 1/25/19 Admission MDS specified the following: -Section C: Cognitive Patterns revealed a BIMS (brief interview of mental status) score of 15 which indicated Resident 312 was cognitively intact. -Section O: Special Treatments, Procedures and Programs indicated Resident 312 received IV (through the veins) medications. The 2/12/19 Admission Nursing Data Base was inaccurately marked none for IV access. Review of Resident 312's Physician's Orders revealed an order for [REDACTED]. There was no Physician's Order for PICC dressing changes. 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 complications such as bleeding, redness, warmth, tenderness, soilage, drainage, infiltration (leakage of medication into tissue), measurements and displacement. Review of Resident 312's Care Plan indicated IV interventions were created on 2/19/19, seven days after re-admit, for dressing changes per facility protocol and monitor IV site for swelling, redness, infiltration. 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 and denied pain at the PICC site. On 2/20/19 at 12:33 PM, Staff 4 (LPN) was observed to set up and start [MEDICATION NAME] IV medication through the PICC. The PICC dressing was observed and the dressing was clean, dry and intact and dated 2/19/19. In an interview on 2/20/19 at 12:43 PM, Staff 4 (LPN) stated on 2/19/19, she instructed the evening shift nurse to change the PICC dressing because it looked like the PICC dressing was dated 2/7/19. Staff 4 could not locate a physician's order for a PICC dressing change and stated there should have been an order in place. In an interview on 2/20/19 at 12:56 PM, Staff 5 (RNCM) stated she would expect the PICC dressing change order to be on the TAR and confirmed there was no order. She stated the facility PICC protocol was to change the PICC dressing every seven days. Staff 5 stated the facility staff should know the location of a resident's IV access from day one of admit. In an interview on 2/26/19 at 3:51 PM, Staff 2 (DNS) stated IV access should have been noted on the Admission Nursing Data Base Form and confirmed it was missed. She confirmed Resident 312 had a PICC and expected the PICC site to be assessed and monitored and the dressing changed every seven days per protocol. Staff 2 stated education was provided to nursing staff regarding accurate assessments.",2020-09-01
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,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 nurse checked her/his blood sugar levels before lunch. In a 2/25/19 interview at 11:15 AM, Staff 12 (LPN) stated the routine when residents returned from [MEDICAL TREATMENT] was to obtain the communication packet and review the information contained in it, document the weight from [MEDICAL TREATMENT] and follow up if there was anything of significance in the paperwork. When asked about a evaluation of the resident upon return from [MEDICAL TREATMENT], Staff 12 stated she would check in verbally with the resident, but usually the resident was tired and wanted to rest. Staff 12 reported checking the catheter site in the early morning, but generally did not check the catheter upon return from [MEDICAL TREATMENT]. On 2/26/19 at 10:20 AM, Resident 38 returned from [MEDICAL TREATMENT] and was greeted at her/his room door by the Staff 12 (LPN). The packet provided by [MEDICAL TREATMENT] was handed to Staff 12 and she returned to the nurses desk to begin reviewing the paperwork. The resident was assisted to her/his bed by a CN[NAME] No further assessment of the resident's condition occurred. When interviewed on 2/26/19 at 1:36 PM, Staff 10 (Resident Care Manager-LPN) stated she expected nurses to attend to the resident right away and check their access site for signs of bleeding or infection when they returned from [MEDICAL TREATMENT]. Then paperwork would be reviewed and follow up would occur. In a 2/27/19 interview at 1:52 PM, Staff 2 (DNS) stated pre and post-[MEDICAL TREATMENT], nursing staff should check on the access site and/or the dressing on it, assess for pain or any change in condition and complete a set of vitals after [MEDICAL TREATMENT]. Staff 2 stated this assessment should be documented.",2020-09-01
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 she/he wanted an electric wheelchair to get run over with in the street. On 2/21/19 at 12:27 PM, Resident 28 was observed with Staff 23 (Pastoral Care) and Staff 24 (Receptionist) expressing she/he wanted to die. In an interview on 2/19/19 at 10:45 AM, Resident 28 stated that she/he wanted an electric wheelchair so she/he could get run over in the intersection. In an interview on 2/21/19 at 12:20 PM, Witness 4 (Nurse Practitioner), stated she worked with Resident 28 for the past two years and resident expressed [MEDICAL CONDITION] on multiple occasions. During an interview on 2/22/19 at 12:44 PM, Staff 16 (CMA) stated she didn't know what to do for Resident 28 and would like to see more things done to help her/him. In an interview on 2/22/19 at 3:30 PM, Staff 17 (CNA) stated that she would look for specific interventions on the care plan or kardex. She demonstrated where she would locate information in EHR (electronic health record) but was unable to locate individualized interventions for Resident 28. Staff 17 continued to state she thought Resident 28 was often attention seeking and she could change the subject. She stated Resident 28's suicidal verbalizations would not be urgent unless she/he had a knife or something.",2020-09-01
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) located documentation to support Resident 16's refusals or intolerance and Resident 16 should have been weighed daily as ordered. Staff 2 stated a new system will be implemented to ensure daily weights are completed as ordered.",2020-09-01
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,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 and denied pain at the PICC site. On 2/20/19 at 12:33 PM, Staff 4 (LPN) was observed to set up and start [MEDICATION NAME] IV medication through the PICC. The PICC dressing was observed and the dressing was clean, dry and intact and dated 2/19/19. In an interview on 2/20/19 at 12:43 PM, Staff 4 (LPN) stated on 2/19/19, she instructed the evening shift nurse to change the PICC dressing because it looked like the PICC dressing was dated 2/7/19. Staff 4 could not locate a physician's orders [REDACTED]. In an interview on 2/20/19 at 12:56 PM, Staff 5 (RNCM) stated she would expect the PICC dressing change order to be on the TAR and confirmed there was no order. She stated the facility PICC protocol was to change the PICC dressing every seven days. Staff 5 stated the facility staff should know the location of a resident's IV access from day one of admit. In an interview on 2/26/19 at 3:51 PM, Staff 2 (DNS) confirmed Resident 312 had a PICC and expected the PICC site to be assessed and monitored and the dressing changed every seven days per protocol. Staff 2 stated education was provided to nursing staff regarding frequency of dressing changes to prevent infection. 2. Based on observation and interview, it was determined the facility failed to implement appropriate hand hygiene during medication administration for 1 of 9 staff (#7) observed during medication administration. Findings include: The 8/2018 Facility Medication Administration Policy and Procedure specified the following: -Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: * Before beginning a medication pass, * prior to handling any medications, * after coming into direct contact with a resident, * at regular intervals during the medication pass such as after each room . On 2/25/19 at 11:32 AM, Staff 7 (RN) performed capillary blood glucose (CBG) checks and Insulin administration to three residents and was observed in direct contact of each resident. Staff 7 did not perform hand hygiene before or after direct contact of each resident. On 2/25/19 at 11:43 AM, Staff 7 (RN) stated she should be performing hand hygiene between each resident and confirmed she did not wash her hands or use alcohol based hand rub. On 2/27/19 at 11:55 AM, Staff 2 (DNS) stated hand hygiene should be performed between every resident and not doing so was unacceptable.",2020-09-01
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 commode and cut her/his head. The resident was observed attempting to self transfer out of the bed and Staff 4 (CNA) assisted the resident to the bedside commode at her/his request. Staff 4 left the room to get clean bedding for the resident and when he returned the resident was on the ground and other staff were present. A witness statement from Staff 4 stated he gave the resident the call light and told her/him not to transfer back to bed until he returned. The investigation indicated no abuse or neglect was suspected. A comprehensive care plan dated 4/16/18 and an undated Kardex (CNA care plan) indicated the resident required two person assistance for transfers and toileting. No care plan information prior to 4/16/18 was located. Interview on 6/1/18 at 11:20 am Staff 2 (DNS) indicated the resident's fall was not reported to the state agency. Interview on 5/31/18 at 9:20 am Staff 4 (CNA) indicated he was not familiar with the resident or her/his care plan at the time of the fall. Staff 4 stated he did not check the care plan as he was in a hurry. When he entered the room the resident was already trying to get out of bed. Staff 4 offered the resident the bedpan but the resident requested the bedside commode. Staff 4 assisted the resident to the commode and then left the room for just a moment to get new bedding. Staff 4 stated he should have checked the care plan and stayed with the resident because he was not familiar with the resident. Staff 4 thought the resident would be ok for a few minutes. Interview on 6/1/18 at 12:12 pm Staff 5 (RN) indicated 4/14/18 was a very busy day with multiple admissions; Resident 1 admitted later in the day. She heard a loud noise and headed to the resident's room. The resident was on the floor with her/his brief around her/his knees and was found to have a wound to the back of the head. Staff 5 stated the physician was notified, the resident was sent to the hospital for evaluation and returned to the facility a few hours later with staples in place. Staff 5 stated prior to the resident's admission the hospital reported the resident was oriented only to person and had a [MEDICAL CONDITION]. The hospital did not report any behaviors. Staff 5 further indicated she was working on other admissions and had not interacted with the resident at all prior to responding to the resident's fall. Staff 5 stated when a new admission came in she normally reported the resident's basic information such as orientation, transfer status, continence and any other safety items to the charge nurse and CNAs prior to the resident arriving at the facility. Staff 5 was unsure if her reports regarding the resident were passed on to the evening shift staff. Staff 5 indicated the resident should not have been left alone on the bedside commode based on her/his orientation status and [MEDICAL CONDITION]. Refer to F-689",2020-09-01
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 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 commode and cut her/his head. The resident was observed attempting to self transfer out of the bed and Staff 4 (CNA) assisted the resident to the bedside commode at the resident's request. Staff 4 left the room to get clean bedding for the resident and when he returned the resident was on the ground and other staff were present. A witness statement from Staff 4 stated he gave the resident the call light and told her/him not to transfer back to bed until he returned. The investigation indicated no abuse or neglect was suspected. The resident's care plan dated 4/16/18 indicated the resident had an ADL performance deficit related to confusion, dementia and musculoskeletal impairment. The resident required two staff assistance to use the toilet and to transfer. The resident was noted to have experienced an actual fall with serious injury. The resident was noted to have a recent [MEDICAL CONDITION] and a history of falls. The resident's undated kardex (CNA care plan) indicated the resident was not to be left unsupervised in the bathroom or on the bedside commode, keep the bed in the locked position at all times and the resident was to wear non-skid foot wear at all times. The resident required two staff assistance for transferring, mobility and toilet use. No care plan information prior to 4/16/18 was located. A hospital after visit summary dated 4/14/18 indicated the resident was treated for [REDACTED]. The resident was started on antibiotics for the UTI and had three staples in place to the [MEDICAL CONDITION]. The resident's staples were to be removed in 10-14 days. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. No medications were documented on 4/14/18. The resident received one dose on 4/15/18 for a pain level of 3, two doses on 4/16/18 for a pin level of 7 in the morning and a pain level of 4 in the early evening. The resident continued to receive one dose of [MEDICATION NAME] each day for pain level varying from 5-9. The resident's pain was rated on a pain scale of 0-10, 0 being no pain and 10 being extreme pain. A nursing progress note dated 4/14/18 at 1:20 PM indicated the resident was admitted with a [DIAGNOSES REDACTED]. The resident's prior level of function was dependent. The resident arrived via a wheelchair and was transferred with the assistance of two staff. The resident was oriented x1 (person) had adequate hearing and clear speech. The resident was additionally noted as always incontinent of bowel and bladder. A nursing progress note dated 4/15/18 at 7:19 AM indicated the resident was admitted on late evening shift; initial contact with the resident was following a fall at 7:40 pm on 4/14/18. The resident was found on the floor on her/his back after attempting to get up form the commode without assistance. The resident sustained [REDACTED]. Interviews conducted 5/31/18 through 6/1/18 between 8:30 AM and 1:30 PM showed: Staff 4 (CNA) indicated he was not familiar with the resident or her/his care plan at the time of the fall. Staff 4 stated he did not check the care plan as he was in a hurry. When he entered the room the resident was already trying to get out of bed. Staff 4 offered the resident the bedpan but the resident requested the bedside commode. Staff 4 assisted the resident to the commode and then left the room for just a moment to get new bedding. When he returned the resident was on the ground and other staff were present. Staff 4 stated he should have checked the care plan and stayed with the resident because he was not familiar with the resident. Staff 4 thought the resident would be ok for a few minutes. Staff 7 (RNCM) indicated the resident arrived late in the day and it was determined the report from the hospital was not an accurate picture of the resident. The resident's care plan was not done within the first 24 hours which was their rule of thumb; the care plan information was all dated 4/16/18. Staff 7 stated it appeared both admission nurses completed the resident's admission which was not the normal procedure. Staff 4 (CNA) did not have a good understanding of the resident and after putting the resident on the bedside commode he left the room and the resident fell . Staff 7 indicated when the resident returned from the hospital, after the fall, a sitter was instituted to stay with the resident at all times. The resident was more confused, combative and made repeated attempts to get up on her/his own. Staff 7 was not sure what happened with the initial care information for the resident. Staff 6 (RN) indicated he had no interaction with the resident prior to the fall on 4/14/18. Staff 6 stated he had not received any information or reports about the resident and was unsure how long the resident was at the facility prior to the fall. CNA staff came and reported the resident was on the ground so he went to assess the resident. The resident's vital signs were stable but did have bleeding from the back of her/his head. Staff 6 was concerned about a bleed so the resident was sent to the hospital for a CT scan and evaluation. The resident returned to the facility several hours later with staples in place to the back of her/his head. Staff 8 (RN) indicated he was not working at the time the resident was admitted on Saturday 4/14/18. When he returned on 4/15/18 he was told the resident's admission needed to be completed so he finished the needed items. Staff 8 stated the resident answered questions but seemed confused so he contacted the resident's son for much of the information. Staff 5 (RN) indicated 4/14/18 was a very busy day with multiple admissions; Resident 1 admitted later in the day but she could not remember exactly when. She heard a loud noise and headed to the resident's room. The resident was on the floor with her/his brief around her/his knees and was found to have a wound to the back of the head. Staff 5 stated the physician was notified, the resident was sent to the hospital for evaluation and returned to the facility a few hours later with staples in place. Staff 5 stated prior to the resident's admission the hospital reported the resident was oriented only to person and had a [MEDICAL CONDITION]. The hospital did not report any behaviors. Staff 5 further indicated she was working on other admissions and did not interact with the resident prior to responding to the resident's fall. Staff 5 stated when a new admission was scheduled she normally reported the resident's basic information such as orientation, transfer status, continence and any other safety items to the charge nurse and CNAs prior to the resident arriving at the facility. Staff 5 was unsure if her reports regarding the resident were passed on to the evening shift staff. Staff 5 indicated the resident should not have been left alone on the bedside commode based on her/his orientation status and [MEDICAL CONDITION].",2020-09-01
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,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 and Resident 181's dental status was therefore not comprehensively assessed.",2020-09-01
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. 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 9/8/17 at 9:42 am, Staff 13 (CNA) stated Resident 181 had her/his own teeth, but had one broken tooth in the front. 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. Resident 181 never complained of pain or discomfort. On 9/11/17 at 11:15 am, Staff 15 (RN/Admissions Nurse) stated he would use a combination of observation, interview and record review to complete the Admission Nursing Data Base section on dental status. He reported marking both No natural teeth or tooth fragments and Natural teeth because the resident had one broken tooth, but there was no section on the admission form to code that kind of situation. 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. She would call the facility if there were any questions. She reported noting the discrepancy with the Admission Nursing Database form and contacted Staff 12 (MDS Coordinator) to clarify 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 confirmed Resident 181's Admission MDS was not accurately coded for Oral/Dental Status.",2020-09-01
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,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 instructed facility staff to not use geri sleeves (arm protectors) as the resident pulled them off causing skin tears Resident 58's 7/19/17 care plan indicated she/he wore geri sleeves to protect her/his skin and included the use of geri arms (arm protectors) as interventions to protect the resident's skin. Review of the resident's current Kardex instructed facility staff to use geri arms or long sleeves at all times as resident allows. During an interview on 9/11/17 at 9:08 am, Staff 3 (RNCM) confirmed geri arms and geri sleeves were the same thing. She also acknowledged Resident 58 had a physician's order to not use geri sleeves and confirmed the care plan was not updated.",2020-09-01
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 the siderail properly to the bed and indicated as long as the nursing staff told him of loose siderails he would fix them. He indicated he did not have a routine schedule to check the siderails. On 9/7/17 at 3:31 pm Staff 3 (RNCM) indicated if staff were to find a loose siderail they were to place the request in the environmental book to have them fixed. She also acknowledged that monitoring for loose siderails was not on Resident 75's careplan. 2. Resident 271 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The 7/14/17 Safety Device and Consent Form revealed the resident used the siderails for transfers and repositioning, required the siderail for bed mobility, transfers, decreased risk of serious injury from falls, and to prevent rolling out of bed. The resident had weakness, impaired mobility and sensory impairment. The risks included falls, incontinence and injury from attempting to climb over the rails. The benefits included less falls, increased bed mobility and increased ability to perform ADL's. The 7/14/17 Kardex indicated the resident had half rails in the up position and staff were to observe for entrapment or injury and were used to assist with bed mobility. The 8/11/17 careplan revealed the resident used assist rails to protect rolling out of bed during turning and care. Staff were to observe for entrapment or injury. On 9/7/17 at 2:03 pm the resident was in bed asleep with the siderail towards the window in the up position and the rail was wobbly and loose but did not pose an entrapment risk. On 9/7/17 2:05 pm the resident was observed sitting her/his room next to the bed. Resident 271 indicated the siderail was better because they fixed it. On 9/7/17 at 3:31 pm Staff 3 (RNCM) indicated if staff were to find a loose siderail they were to place the request in the environmental book to have them fixed. She also acknowledged that monitoring for loose siderails was not on the care plan. 3. Resident 120 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. On 9/5/17 at 12:31 pm Resident 120's bed was observed to have a mobility bar on the left side of the bed. The mobility bar was loose but did not impose the risk of entrapment. On 9/6/17 at 10:00 am Staff 4 (Director of Plant Operations) acknowledged the mobility bar was loose. On 9/8/17 at 2:23 pm Resident 120 stated she/used the mobility bar and at times staff would lower it for use as a side rail when she/he asked to have it lowered. On 9/11/17 at 9:40 am Staff 9 (RNCM) stated Resident 120 used the left side mobility bar to help roll side to side and for repositioning while in bed. Staff 9 acknowledged the mobility bar on the left side of the bed was not assessed or on the resident's care plan.",2020-09-01
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 progress. There was no documentation to indicate the resident's physician or nursing staff were notified of the resident's change in ability to walk. On 10/24/18 Staff 6 (Therapy Director) indicated the resident had increased pain and weakness starting on 9/28/18. Staff 6 indicated the nursing staff was responsible to communicate with the physician when there was a change in status. The resident's clinical record did not have documentation to indicate the resident's physician or nurse practitioner was notified of the change in the resident's decreased ability to walk after 9/27/18. The 9/29/18 at 9:13 am nursing Progress Notes indicated 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 but the note did not indicate the physician was notified. The 10/1/18 Physical Therapy Treatment Encounter Note indicated the resident was assisted with toileting and the resident was not able to correct the right leg external rotation. The nursing staff was notified and the nurse was to notify the physician. The 10/1/18 Progress Note by Staff 2 (Nurse Practitioner) indicated she was notified in the morning of 10/1/18 the resident had a new bruise to the right posterior thigh. The bruise was first noted on Friday but she was not notified until Monday. The note also indicated the resident had increased pain and therapy reported the resident had difficulty with the movement of the right leg. Staff were instructed to notify the orthopedic surgeon of the changes and an X-ray was ordered. On 10/24/18 Staff 4 (RNCM) indicated the therapy department communicated with nursing on the Daily 24 Hour Report. The therapy department reported concerns including issues related to decreased oxygenation levels or if a resident developed dizziness. Staff 4 indicated the RNCMs review the daily report and if a significant change was identified the physician was notified. Staff 4 stated it was not uncommon for a resident to have fluctuations in the ability to walk after hip surgery. Staff 4 indicated the resident's physician was not notified of the resident's right thigh bruise and decreased ability to walk until Monday 10/1/18. On 10/24/18 at 12:21 pm Staff 2 (Resident 1's Nurse Practitioner) indicated she was not aware the resident had a functional change with therapy, increased pain and the resident's right inner thigh bruise. Staff 2 indicated if she would have been notified of the location of the bruise and change in mobility on 9/28/18 she would have requested an X-ray of the resident's hip a few days earlier. Staff 2 stated the resident's outcome would not have changed but surgical interventions would have been able to be implemented sooner. The 10/9/18 hospital Discharge Summary indicated the resident was found to have a failed hip replacement. The resident was identified to have a pathological fracture (fracture caused by disease not trauma) due to [MEDICAL CONDITION] (bone weakening).",2020-09-01
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 pm Staff 5 (RN) stated he worked the day the bruise was identified on Resident 1's inner thigh. First thing in the morning on 9/28/18 the resident's family was in the resident's room and assisted the resident to the bathroom. The family member showed Staff 5 the bruise to the inner thigh. Staff 5 stated he did not see the bruise prior to 9/28/18. Staff 5 indicated the resident was able to report pain and when he palpated the bruise the resident denied pain. Staff 5 stated he was a new nurse, documented the bruise in the Progress Note but did not initiate an incident report or report the bruise to Staff 4 (RNCM). On 10/19/18 Staff 4 stated the bruise to Resident 1's right inner thigh was identified on Friday and was not reported to her until Monday; therefore she did not start her investigation until three days after the bruise was identified. Refer to F-580 for additional information.",2020-09-01
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 her/his home with home health services. The note only addressed the resident's ability to safely use the wheelchair for mobility but did not address if the resident would be safe to transfer independently. The Physical Therapy Discharge Summary by Staff 7 (Physical Therapist) dated 6/27/18 Discharge Status and Recommendations indicated the resident was to be discharged home with assist from others. The resident was to have stand by assistance for functional transfers and to walk. The resident's functional outcome indicated the resident required close supervision for the majority of task for safety but no physical contact was required. On 10/24/18 at 1:20 pm Staff 7 indicated when Resident 4 discharged from the facility the resident required cueing for safe mobility. It was recommended by therapy for the resident to have stand by assistance for transfers. Staff 7 indicated she would not have recommended the resident be discharged home alone. On 10/24/18 at 11:00 am Staff 6 (Therapy Director) indicated the resident was developmentally delayed, was cooperative with care but did not always follow weight bearing precautions and needed verbal reminders to perform tasks. The Progress Note dated 6/27/18 indicated the resident discharged from the facility at approximately 2:00 pm and was transported to her/his home via cab. On 10/23/18 at 1:55 pm Witness 7 (Resident 4's Friend) indicated Resident 4 was transported to her/his home on 6/27/18. Witness 7 indicated she arrived to the resident's home approximately 3 to 4 hours after the resident arrived. The resident was in her/his wheelchair with the leg rests on. The resident was not able to remove the leg rests in order to transfer. Witness 4 indicated she informed the facility she was able to assist the resident but would not be able to stay with the resident. On 10/24/18 at 12:45 pm Staff 4 (RNCM) indicated the resident's discharge was set by insurance non-coverage. Staff 4 reviewed the resident's PT discharge recommendations and acknowledged the resident was to have stand by assistance for transfers and the resident was sent home alone. Staff 4 indicated the resident wanted to go home and did not want to go to an assisted living facility. On 10/29/18 Witness 6 (Former Social Services Director) indicated she could not state if she saw the 6/26/18 PT recommendations for Resident 4 to have stand by assistance for transfers. Resident 4 Medicare benefits ended and the resident did not want to pay to stay at the facility. Witness 6 indicated if the therapist recommended stand by assistance for transfers the resident would need to have someone with her/him at home. If the resident did not have someone to stay with the resident and still wanted to be discharged the nurse and or social service person would need to document the resident's wish to go home and the potential risks. On 10/24/18 at 1:50 pm a request was made to Staff 1 (DNS) to provide documentation the staff addressed the PT recommendations for there resident to have stand by assistance for transfers after discharge. No additional information was received.",2020-09-01
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 discharge. Staff 4 indicated she was not sure the reason Resident 5's Discharge Summary was incomplete.",2020-09-01
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 left the medications at the bedside and went to the medication cart to sign off the medications in the computer. She immediately realized she administered the medications to the wrong resident, went into the resident's room but the resident swallowed the medications before she could stop the resident. Witness 1 immediately reported the error to the nurse manager. The resident's Nurse Practitioner was in the facility and immediately assessed the resident, reviewed the resident's medications and held some of Resident 3's medications. The other resident did not receive the wrong medications. Staff 1 indicated Witness 1 was removed from the floor pending investigation and no longer worked at the facility.",2020-09-01
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,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 information for Witness 1 was included in the local hospital discharge information so did not know why the contact information was not included in the resident's Admission Record/Face Sheet. On 3/8/18 at 10:22 AM Staff 2 (Administrator) provided written documentation to indicate the facility had no formal policy regarding family notification. Staff 2 indicated it was the facility's practice to notify emergency contacts if a resident was sent to the hospital or if there is some sort of incident On 3/12/18 at 2:00 PM Staff 1 (DNS) and Staff 2 (Administrator) stated documentation indicated the facility notified Witness 1 (caregiver/friend) the same day the resident went to the local hospital emergency department. The 12/21/17 progress note written at 1:55 PM documented Witness 1 (caregiver/friend) called the facility and was very upset about the transfer to the local hospital emergency department. There was no documentation the facility contacted Witness 1 (caregiver/friend). 2. Resident 2 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 10/19/17 physician's progress note written as a late entry at 6:47 PM indicated the resident had an acute fall and had a laceration across her/his left upper eye. Resident 2 was identified by the physician to be confused and was transported to the local hospital emergency department. The 10/19/17 Incident Investigation indicated the resident was found on the floor at 2:20 PM and the physician was notified at 2:55 PM by Staff 6 (RN). The 10/19/17 local hospital emergency department notes written at 3:41 PM indicated a right hip x-ray was negative for a fracture and a CT (computerized tomography) scan was negative for an [MEDICAL CONDITION]. The 10/19/17 Incident Investigation indicated Staff 6 (RN) contacted the resident's family member at 4:00 PM. The 10/26/17 progress note documented Witness 3 (family member) was upset the family did not receive a phone call until three hours after the resident's fall. The facility's progress notes indicated the time line of the fall and notification revealed the following: -Resident 2 fell at 2:40 PM -ambulance arrived at 3:30 PM -admitted to the hospital at 3:45 PM -phone call made to the family and voice message left for family member at 5:00 PM -phone call made to family members from the local hospital emergency department at 7:00 PM. On 3/5/18 at 10:09 AM Witness 3 (family member) stated the resident sustained [REDACTED]. Witness 3 stated the facility did not contact family members when the resident was transported to the local hospital emergency department. Witness 3 stated the resident had a [DIAGNOSES REDACTED]. On 3/6/18 at 4:24 PM Staff 6 (RN) stated she tried to call the resident's family as soon as possible. On 3/8/18 at 10:22 AM Staff 2 (Administrator) provided written documentation to indicate the facility had no formal policy regarding family notification. Staff 2 indicated it was the facility's practice to notify emergency contacts if a resident was sent to the hospital or if there is some sort of incident On 3/12/18 at 2:00 PM Staff 2 (Administrator) and Staff 1 (DNS) stated Staff 6 (RN) stayed with Resident 2 because she/he sustained a head injury and informed the physician who was at the facility. Staff 6 continued to stay with the resident until emergency transport service arrived. Staff 1 and Staff 2 were asked if there were other staff available to contact the resident's family. They stated they did not know the whereabouts of the other staff members.,2020-09-01
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 received 4 tablets of [MEDICATION NAME] at 6:50 PM. On 3/12/18 at 2:00 PM Staff 1 (DNS) verified the resident's (MONTH) (YEAR) MAR continued to reflect the 12/16/17 completed physician's orders. On 3/13/18 at 11:17 AM Staff 1 (DNS) stated the facility was able to provide medications one hour before and one hour after the scheduled time. Staff 1 verified the resident received [MEDICATION NAME] too early on 12/18/17 and received 4 tablets instead of 3 tablets of [MEDICATION NAME] on 12/19/17.",2020-09-01
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) stated she could not remember completing the resident's Admission Profile. Staff 8 was asked if the box was checked on the Admission Profile and there was no physician's order for [MEDICAL CONDITION] or the [MEDICAL CONDITION] was in use. Staff 8 stated she would leave a nurse's note for the next shift nurse to review the need for a [MEDICAL CONDITION]. Staff 8 was informed there was no nurse's note for the next shift about the resident's need for [MEDICAL CONDITION]. On 3/8/18 at 4:24 PM Staff 1 (DNS) stated Staff 8 (LPN) could not remember Resident 1. Staff 1 stated the resident and caregiver did not tell the facility during the care conference or to the physician during facility visits. 2. Resident 3 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 2/28/18 physician's orders documented the resident had a [MEDICAL CONDITION] at home. The local hospital discharge information documented the resident was bringing her/his [MEDICAL CONDITION] machine from home. The resident was on 2 liters of O2 through nasal cannula. The facility's 2/28/18 Admission Profile identified the resident used a [MEDICAL CONDITION] machine. The 3/1/18 physician notes documented the resident used her/his home [MEDICAL CONDITION] machine at night at home settings with no issues. The resident's vital signs to include O2 sats indicated the O2 sats of room air during the night shift of 3/2/18, 3/3/18, 3/4/18, 3/6/18, 3/7/18, 3/8/18 and 3/9/18. The (MONTH) and (MONTH) (YEAR) TAR included the direction to clean [MEDICAL CONDITION] mask with soap/water weekly and PRN. There was no documentation to monitor the resident's use of the [MEDICAL CONDITION]. On 3/12/18 at 12:24 Staff 1 (DNS) was asked to provide documentation Resident 3's [MEDICAL CONDITION] was used at night. No additional information was provided.",2020-09-01
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,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 should of replaced it.",2020-09-01
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 stated she/he was hit by Resident 285 while in the hallway. Resident 48 acknowledged the incident occurred on 2/3/19. Resident 48 indicated she/he was not hurt from being hit but her/his feelings were hurt when Resident 285 called her/him mean things. Resident 48 stated she/he stayed away from Resident 285 after the incident and indicated she/he did not want to be hit or called names in her/his home. Resident 85 was discharged in 3/2019. On 5/2/19 at 4:46 PM Staff 18 (CNA) stated Resident 285 had a history of [REDACTED]. Staff 18 stated Resident 48 indicated she/he did not want to be near Resident 285 after the incident on 2/3/19. On 5/3/19 at 2:22 PM Staff 10 (RN) acknowledged Resident 285 hit and made obscene comments to Residents 48 and 85 on 2/3/19. Staff 10 indicated Residents 48 and 85 were not physically hurt and neither wanted to be around Resident 285 anymore. On 5/6/19 at approximately 10:00 AM Staff 35 (RCM) acknowledged Resident 285 had a history of [REDACTED]. Staff 35 stated Resident 48 was afraid she/he would be hit again. On 5/6/19 at 12:23 PM Staff 1 (DNS) was informed of surveyor investigative findings regarding the incident on 2/3/19. Staff 1 requested additional staff interviews be conducted. On 5/6/19 at 3:12 PM Staff 28 (CNA) stated Resident 285 had it out for anyone who was overweight. Staff 28 acknowledged the incident on 2/3/19 and indicated Resident 285 called Resident 48 a derogatory name and told her/him to feed your face more. Staff 28 stated she witnessed Resident 48's face become bright red with embarrassment as she/he looked around the dining room which was full of residents. 2. Resident 39 readmitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Resident 39's 3/2019 Quarterly MDS revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident 286 readmitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Resident 286's 2/2019 Annual MDS coded the resident had a BIMS score of 15 out of 15 (cognitively intact). The 2/10/19 Resident/Resident incident report revealed the following: *Incident Description: - Resident 286 and Resident 39 were in a physical altercation; - Resident 286 punched Resident 39 and Resident 39 returned punches; - Resident 286 had a 3.5 cm by 2 cm puffy area to her/his left eye, a 2 cm by 1 cm bump to the left side of her/his head and a 1 cm by 0.5 cm red area under the right eye; - Resident 39 had a bruise on the top of her/his hand that was 7.5 cm by 3.5 cm and a 5.5 cm by 2 cm red area to the front right shin; *Witness statements: - Staff 27 (RN) stated when she returned from lunch Staff 34 (CNA) waved to her for help and that was when she saw Resident 286 and Resident 39 punching each other. Staff 27 stated she tried to separate them and Staff 7 (CMA) also came to help separate the residents. Staff 27 stated she called 911 because they could not separate the two and while on the phone to 911 the two residents stopped fighting. - Staff 7 stated she was not present at the beginning of the fight but saw the residents fighting. Resident 39 was behind Resident 286 and was hitting her/him in the head. Staff 7 stated she and Staff 27 could not get them separated and Staff 27 called the police. The residents stopped fighting on their own. - Staff 34 stated she was at the nurses' station when she heard Resident 286 say to Resident 39 ok fat boy what are you going to do now? and Resident 286 came toward Resident 39 and swung at her/him. Staff 34 stated she waved for help and Staff 27 came to help and they could not separate the two. Staff 27 called the police. The residents stopped fighting on their own. Staff 34 stated she heard Resident 286 cussing loudly earlier when she/he was talking to Resident 10. - Resident 10 stated Resident 286 and Resident 39 started arguing during smoke break related to waiting for pain medications. Resident 39 complained about Resident 286 and Resident 10 went and told Resident 286. Resident 286 cursed loudly at Resident 39 and Resident 10 reported she/he left and did not witness any additional interactions. Staff 34 was unable to be reached for an interview. Resident 286 was no longer a resident at the facility. On 5/2/19 at 10:20 AM Resident 10 refused to be interviewed. In an interview on 5/2/19 at 10:22 AM Resident 39 stated she/he and Resident 286 got into a fight due to a spontaneous issue. Resident 39 stated she/he was under a lot of stress due to unrelated issues and the fight just happened. Resident 39 stated she/he and Resident 286 had a verbal exchange and then hit each other. Resident 39 stated staff came immediately and staff could not have stopped them from fighting. In an interview on 5/2/19 at 4:07 PM Staff 1 (DNS) stated Resident 286 and Resident 39 were both alert, oriented and mobile. Staff 1 stated she learned from Resident 10 that Resident 286 and Resident 39 exchanged words during smoke break on 2/10/19. Later on 2/10/19 Resident 286 and Resident 39 engaged in a physical altercation, staff responded immediately but were unable to separate them and the police were called. The residents self-separated and the police took no action. In an interview on 5/3/19 at 8:50 AM Staff 7 verified the statement she provided in the incident report. Staff 7 also stated Resident 286 and Resident 39 had no prior history of fighting. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected residents to be free from abuse.",2020-09-01
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,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: Ambulation in parallel bars; - (MONTH) 7-13: AROM legs, Omnicycle and PROM to bilateral upper extremities; - (MONTH) 14-20: AROM legs, Omnicycle; - (MONTH) 21-28: AROM legs, Omnicycle. On 5/3/19 at 11:24 AM, Staff 20 (RA) reported the blank areas on the Restorative Tracking Form indicated Resident 8 did not receive restorative services or a resident refusal was not documentated. She was unable to recall if resident received or refused services. On 5/3/19 at 11:25 AM, Staff 21 (RA) could not recall if Resident 8 received services on the blank dates on tracking form. An interview on 5/3/19 at 12:07 PM with Staff 3 (LPN/resident care manager) revealed restorative aides were employed seven days per week and CNAs do not provide restorative therapy. If there were blank areas on the tracking form, the resident did not receive services or the services were not documented as refused.",2020-09-01
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 287 became less responsive and appeared sleepy and was sent to the hospital for evaluation. In an interview on 5/1/19 at 1:58 PM Staff 16 (CMA) stated on 10/28/18 she administered incorrect medication to Resident 287. She stated she realized her error and immediately reported to Staff 11 (LPN). Staff 16 stated Resident 287 was a new admit and a picture was not available and she identified Resident 287 by the room number. Staff 16 stated it was a mistake not to identify the resident by name and date of birth. Staff 11 stated she did not pass medications after the incident until she received two weeks of one on one training with Staff 37 (RN) and attended a four hour competency class for certified medication aides. Interviews conducted from 4/30/19 through 5/2/19 between the hours of 8:00 AM and 5:00 PM with Staff 4 (LPN), Staff 5 (LPN), Staff 6 (CMA), Staff 7 (CMA), Staff 8 (CMA), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (LPN), Staff 12 (CMA), Staff 13 (CMA), Staff 14 (LPN), Staff 15 (RN) and Staff 16 (CMA) identified all staff interviewed were aware of the five rights of medication administration. All staff stated it was expected and proper procedure to identify the resident with a picture, name band, name and date of birth before administering medications. On 5/2/19 at 10:49 AM and 3:39 PM Staff 1 (DNS) confirmed the medication error occurred and Resident 287 was sent to the hospital for evaluation. Staff 1 stated a Quality Assurance process was immediately implemented which included placement of identification wrist bands on newly admitted residents. Additionally, a four hour CMA training course was offered and Staff 38 (Staffing Coordinator/CMA) conducted skills audits to ensure medication pass competency of CMA and LPN staff. Staff 1 reported there were no further medication errors since the 10/28/18 incident. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F760. 2. The noncompliance occurred after the exit date of the last standard recertification survey (10/6/17) and before the date of this survey (5/6/19). 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F760 as evidenced by: -No deficient practice found at F760 with additional sampled residents -Evidence the deficient practice was identified by the facility, brought to quality assurance and a plan of correction was implemented on 10/29/18 to place a name band on newly admitted residents and educate and reinforce protocol to accurately identify residents. -DNS, RN, LPN and CMA interviews indicated knowledge and awareness of expectations and protocol to accurately identify residents.",2020-09-01
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 (Dietary Manager) stated when a resident identified a food dislike during the Dietary Profile Assessment, it would be reflected on the assessment and added to the meal card. Staff 30 was unaware of Resident 48's dislike of cooked vegetables and stated new dinner menus had resulted in small portions at the previous night's dinner. Additional vegetables and rice were going to be added to the dinner recipe in the future. 2. Resident 26 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. Upon admission, a therapeutic diet was ordered to address Resident 26's kidney disease. The diet order was revised on 2/1/19 to include Resident 26's preference to receive soy milk over regular milk. A 4/24/19 Dietary Profile indicated Resident 26 reported liking fruit, but did not like fish. Resident 26's care plan and Kardex (CNA care plan) did not include resident food preferences. On 4/30/19 at 12:06 PM, Resident 26 was observed with an untouched plate of food that included fish. Resident 26 stated she/he told the facility she/he did not eat fish and was tired of rice. Resident 26 ate a bag of candy and stated she/he would not ask for an alternative meal. Resident 26's meal card did not identify fish as a dislike. On 5/2/19 at 11:58 AM, Staff 33 (CNA) delivered a meal tray to Resident 26's room. Staff 33 reported Resident 26 received fish as the main dish. On 5/2/19 at 12:02 PM, Resident 26 was observed dining in her/his room. Resident 26's meal included fish, cooked zucchini, cooked corn, a dessert, a glass of soy milk. When asked about the meal, Resident 26 complained about having fish again and did not like the zucchini. Resident 26 ate the corn and took two bites of the fish, made a disapproving sound and pushed the plate away. Resident 26 proceeded to eat the dessert and drink the soy milk. Resident 26's meal card did not identify fish as a dislike. 5/3/19 at 3:59 PM, Staff 31 (CNA) reported if a resident had a food preference, it would be on the resident's meal card and sometimes on the Kardex. Staff 31 reported Resident 26 had not mentioned food preferences to him. 5/6/19 at 9:42 AM, Staff 32 (CNA) stated if a resident had a food preference, she/he would tell the nurse or the dietitian. Staff 32 reported the preference had to be on the meal card, because it was used to prepare the resident's tray and if it was not on there, it would not get done. 5/6/19 at 1:02 PM, Staff 30 (Dietary Manager) reported food preferences must be transferred to the meal card and verified this was not done for Resident 26. 3. Resident 2 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. admission orders [REDACTED]. Dietary Profiles dated 1/4/19 and 4/4/19 indicated Resident 2 reported disliking fish. Resident 2's diet meal card dated 5/6/19 listed cottage cheese and hard boiled egg as food preferences. In an interview on 4/30/19 at 10:16 AM Resident 2 reported weight loss because she/he preferred not to eat certain foods. Resident 2 reported the kitchen served her/him cottage cheese at lunch every day but she/he had not received hard boiled eggs with dinner as one of her/his requested food preferences. On 4/30/19 at 12:15 PM Resident 2 was served a plate of food which included fish. In an interview on 5/2/19 at 11:00 AM Staff 39 (CNA) reported the CNAs were responsible to ensure residents food requests and food preferences were communicated to the kitchen but the kitchen did not always have the food. On 5/2/19 at 12:04 PM Staff 40 (CNA) delivered a meal tray with fish as a main coarse to Resident 2. Resident 2 told Staff 40 she/he only wanted the cottage cheese and a beverage. Resident 2's meal card did not identify fish as a dislike. In an interview on 5/6/19 at 2:25 PM Staff 30 (Dietary Manager) reported the CNAs were responsible for submitting residents food requests and stated she was new and just learning the computer system.",2020-09-01
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,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,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,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,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 6/7/17, 7/12/17, 7/17/17, 7/26/17, 8/2/17, 8/14/17 Physician Assistant Progress Notes indicated Resident 9 reported the plan was to live in her/his truck but the resident acknowledged it was not safe. The notes indicated it was not safe for the resident to discharge to her/his truck and staff were to work with the resident to ensure there was a safe discharge plan in place. The Progress Notes for the interdisciplinary team meetings dated 6/21/17, 6/26/17, 7/5/17, 7/12/17, 7/19/17, 7/26/17 and 8/2/17 indicated the resident's state case worker worked on finding housing or a adult foster home for the resident at a lower level of care. The Social Service notes dated 7/6/17 indicated Witness 6 (State Transitional Case Worker) was in the process of looking for a lower level of care after skilled services ended. The 8/18/17 note indicated Staff 5 (Social Services) spoke with the resident about a lower level of care. The resident became upset and did not want to pay for a lower level of care and would leave the facility against medical advice. The note indicated staff would address discharge plans with the resident at a later time. The 8/23/17 note indicated the resident reported she/he would leave the facility before she/he paid for a lower level of care. The 8/7/17 Progress Note by Staff 20 (LPN) indicated the resident started to pack her/his belongings, the RNCM was notified and Staff 5 spoke with the resident. There was no note from Staff 5 to indicate what was communicated with the resident. The 8/28/17 Progress Note by Staff 20 (LPN) indicated Resident 9 reported she/he planned to leave on 8/29/17. The resident reported she/he planned to stay in her/his truck. There was no documentation to indicate staff attempted to educate the resident on a safe discharge, provide community resources and or provide the resident with alternative options. On 9/18/17 at 12:34 pm Staff 20 indicated the resident reported she/he planned to leave the facility because the resident did not want to pay the facility. Staff 20 indicated she asked the resident what she/he would do for wound care and the resident did not respond. Staff 20 indicated Resident 9 was difficult to teach and the resident made her/his own appointments. Staff 20 indicated she reported the resident's verbalization to leave to Staff 5. The 8/29/17 Social Service note indicated staff assisted the resident into her/his truck after the resident signed documents to indicate the resident was leaving against medical advice. The note indicated the resident was last seen sitting in her/his truck to warm it up. The 8/29/17 Progress Note indicated the resident left the facility against medical advice at 8:00 am. There was no documentation to indicate the resident was provided education on wound care or how to follow up with the physician to ensure prescribed medications were continued after discharge. The Discharge Against Medical Advice Release and Waiver dated 8/29/17 and signed by Resident 9 indicated the resident left the facility by choice and the resident left without a discharge order and written authorization by the physician. On 9/18/17 at 9:20 am Staff 5 (Social Services) indicated the resident was homeless prior to admission to the facility. The resident was pleasant at times but other times the resident was not cooperative. The resident was strong willed and only wanted care performed when the resident chose. The staff were aware the resident was likely to leave the facility against medical advice. Staff 5 indicated he communicated with the resident options for care outside of the facility but indicated it was not documented what was presented to the resident. Staff 5 indicated the day the resident left the facility Staff 5 assisted the resident to the resident's truck. The resident was able to self transfer from the wheel chair to the truck. Staff 5 did not see the resident drive away and was not able to determine if the resident drove in a safe manner. Staff 5 indicated the wound nurse may have communicated with the resident in regards to post discharge wound care. Staff 5 indicated he saw Resident 9 to have a state issued card but was not sure if it was a current drivers license or an identification card. On 9/18/17 at 12:50 pm Staff 21 (RN/Staff Wound Nurse) indicated he worked with Resident 9 and assessed the resident's wound weekly. Staff 21 indicated when Resident 9 verbalized a plan to leave the facility against medical advice he educated Resident 9 regarding self care of the ulcer. Staff 21 indicated there was no progress note to confirm education was provided. On 9/15/17 at 10:20 am Staff 22 (RN) indicated staff knew for weeks the resident wanted to leave the facility. Staff 22 indicated she asked the resident how she/he would be able to care for her/himself and the resident did not respond. On 9/18/17 at 9:10 am Witness 5 (Resident 9's State Case Manager) indicated he initially assessed Resident 9 while the resident was still in the hospital to ensure the resident qualified for services. Witness 5 indicated he did not communicate with the facility regarding Resident 9. Witness 5 indicated Witness 6 (Resident 9's State Transitional Care Manager) worked with Resident 9 regarding a post-facility discharge. On 9/18/17 at 11:13 am Witness 6 indicated he visited the resident at the facility at least six times during the resident's facility stay. The resident verbalized she/he would likely leave the facility against medical advice to live in her/his truck. Witness 3 indicated he reported Resident 9 comments to Staff 5. Witness 6 indicated the facility did not call him to ask about the discharge plan and did not inform him when Resident 9 left the facility against medical advice. On 9/15/17 at 1:00 pm Staff 2 (DNS) indicated from the day the resident was admitted to the facility the staff knew the resident would likely go against medical advice. The resident did not want to pay the facility. Staff 2 indicated Staff 5 worked with the resident for a safe discharge. A request was made to Staff 2 to provide documentation to indicate the facility provided Resident 9 education and alternative community services to ensure a safe discharge. No additional information was provided. The 9/1/17 hospital emergency room dictation indicated Resident 9 was brought to the hospital by ambulance. The resident was observed by police to be driving erratically. The resident drove on curbs and back onto the road. The resident was identified to have a low blood pressure and an irregular heart beat. The resident was dehydrated, had altered mental status and had signs of infection. The resident was admitted for treatment.",2020-09-01
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 7:30 am to 8:30 am. The investigation did not indicate if the resident was offered toileting after breakfast. Staff 1 also acknowledged the investigation was not completed within 5 days. b. The 7/10/17 Fall investigation indicated Resident 5 was observed on the floor. The investigation indicated the resident was last seen sitting at the edge of her/his bed and the resident did not request assistance. The investigation indicated the resident did not have footwear in place and was a factor in the fall. The investigation was completed on 8/2/17, 23 days after the fall. On 8/29/17 at 9:40 am Staff 1 (RNCM) acknowledged Resident 1 was last seen at the edge of the bed and the investigation did not address the reason the resident did not have nonskid foot wear in place. Staff 1 also acknowledged the investigation was not completed five days after the fall. c. The 7/19/17 Fall investigation indicated Resident 5 fell at 4:20 pm. The resident was outside on the patio, the wheels of the wheelchair went of the walkway and the resident's wheelchair tipped. The investigation was not completed until 8/2/17, 14 days after the fall. On 8/29/17 at 9:40 am Staff 1 (RNCM) acknowledged the investigation was not completed within five days of the resident's fall.",2020-09-01
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 been discontinued and a nonskid mat might be helpful to prevent the resident's feet from slipping if the resident attempted to transfer without assistance.",2020-09-01
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 (Housekeeping) indicated she did not monitor the resident refrigerators. On 8/31/17 at 10:00 am Staff 10 (CNA) indicated she did not check the resident room refrigerator temperatures. On 8/30/17 at 10:30 am with Staff 2 (DNS) and Staff 11(RNCM) Staff 11 indicated the personal refrigerators in the resident rooms were the responsibility of the residents. Staff 2 acknowledged Resident 1 was not able to monitor the refrigerator because the resident was confined to bed and was not able to check the food dates. Staff 2 indicated Resident 1 was alert and oriented and was able to choose the foods to eat. On 8/29/17 at 2:10 pm Resident 1 indicated she/he asked staff to mark the food before it was placed in the refrigerator. If the food was not marked she/he did not eat the food. On 8/31/17 at 11:20 am Staff 3 (Dietary Manager) acknowledged there was no system in place for monitoring resident room refrigerators.",2020-09-01
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, was a 30 day supply and did not have an order to refill the medication. The 7/5/17 Physician Assistant Progress Note indicated Resident 1 was on medications including Adderall for the treatment of [REDACTED]. The note indicated the resident reported she/he did not benefit from the Adderall and the resident was to discuss trialing off the medication. The 7/7/17 Progress Note indicated Resident 1 has been out of Adderall, last taken dose was 6-23-17. The note indicated Previously the prescribing provider would not refill the Adderall unless the resident was seen. The note indicated Resident 1 had a scheduled appointment on 7/12/17. This was 19 days after the medication was documented as not available. The note indicated staff called the mental health provider to try to refill the medication before the 7/12/17 appointment. On 9/7/17 at 5:00 pm Witness 4 (Mental Health Provider Staff) indicated the Adderall refill request was made on 7/7/17 and she did not see a request to refill the Adderall prior to 7/7/17. Witness 4 indicated the note did not indicate if the resident or facility made the request. Witness 4 indicated the medication was discontinued on 7/19/17. The 7/14/17 Progress Note indicated Resident 1's Adderall prescription was refilled but Resident 1 refused to take the medication. The resident reported she/he did not take the medication since mid to late June, felt it did not work and would discuss medications with Witness 3 at the scheduled appointment. On 8/29/17 at 2:20 pm Resident 1 indicated in (MONTH) or (MONTH) (YEAR), the Adderall ran out and staff did not administer the Adderall for 20 days. The Adderall was to assist with depression. Resident 1 indicated she/he had an appointment with Witness 3 (Mental Health Provider) in (MONTH) (YEAR) and Resident 1 reported Witness 3 was not aware the Adderall was not administered. Resident 1 indicated the Adderall was discontinued after the visit because the medication did not seem to change the way she/he felt. On 9/1/17 at 2:43 pm Staff 11 (RNCM) indicated staff were to communicate with the pharmacy when medications were low and before the medication ran out. Staff 11 indicated the facility and the pharmacy staff worked together to ensure the resident did not run out of medication. A request was made to Staff 11 for documentation to indicate the facility tried to refill Resident 1's Adderall before it ran out on 6/22/17. No additional information was provided. The 9/18/17 e-mail from Staff 2 (DNS) indicated staff requested a refill on 6/21/17. Staff 2 indicated the pharmacy did not send the refill request to the physician until 6/29/17.",2020-09-01
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 regarding the seatbelt. There was no further evaluation, assessment, or care planning for the devices, in regard to use of the devices when the devices should be released, and if the resident could release the devices on her/his own. No further documentation was found to identify the medical symptoms being addressed for the use of the devices. In interviews on 10/6/17 at 11:11 am and 1:45 pm, Staff 1 (DNS) confirmed Resident 51 was unable to undo the seatbelt or remove the lap tray on her/his own. She acknowledged the devices were not identified as restraints, and acknowledged the reasons why the devices were necessary and not considered restraints were not well documented.",2020-09-01
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,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 8/13/18 the MAR revealed the resident received three doses of 0.5 ml [MEDICATION NAME]. The NDDR revealed the resident received two doses. -On 9/9/18 the MAR revealed the resident received three doses of [MEDICATION NAME]. The NDDR revealed the resident received two doses. -On 10/3/18 the MAR revealed the resident received three doses of 0.5 ml [MEDICATION NAME]. The NDDR revealed the resident received two doses. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give 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. 3. Resident 7 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 1 ml every hour as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -The NDDR with a start date of 9/14/18 and end date of 10/5/18 had numerous scratch outs and staff wrote over existing numbers rendering the document inaccurate. -On 9/26/18 the facility documented on the NDDR they gave the resident .25 ml of [MEDICATION NAME] instead of the 1 ml. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give 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. 4. Resident 9 was admitted to the facility in 5/2017 with [MEDICAL CONDITION]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25-1 ml as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -On 9/15/18 the MAR revealed the resident received one dose of 0.25 ml [MEDICATION NAME]. The NDDR revealed there was no dose administered on 9/15/18. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give 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. 5. Resident 10 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25 ml every three hours as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -On 9/7/18 the MAR revealed the resident received one dose of 0.25 ml [MEDICATION NAME]. The NDDR revealed there was no entry on 9/7/18 for the [MEDICATION NAME]. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give 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.",2020-09-01
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 shaved the resident because shaving her/him was not on the in-room care plan. In an interview on 6/3/16 at 8:10 am Staff 4 stated shaving of a resident is a standard of care for all CNA's and she confirmed Resident 33 had stated to her she/he needed a shave on 6/2/16.",2020-09-01
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,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,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 indicate Resident 149 did not use tobacco. On 6/3/16 at 9:20 am Staff 8 (LPN) stated Resident 149 was a smoker since admission. On 6/3/16 at 12:46 pm Staff 3 (RNCM) stated she was aware the resident smoked. Staff 3 stated she determined smoking status by asking the resident or based on chart review. Staff 3 could not state why tobacco use was not coded and acknowledged Resident 149 smoked. b. Resident 149's 12/5/15 Admission MDS, completed by Staff 3 was coded to indicate Resident 149 had one unstageable pressure ulcer (skin covered with slough (yellow,tan or brown tissue) and/or eschar (dead tissue, usually black or dark brown) where the true anatomic depth of soft tissue damage cannot be determined). The corresponding Pressure Ulcer CAA indicated Resident 149 had an unstageable pressure ulcer on the right index finger. A 5/26/16 Weekly Observation Report indicated the resident had a wound to her/his right index finger from a previous cut which slowly healed. On 6/3/16 at 12:37 pm Staff 4 (RNCM) stated Resident 149's finger tip was totally necrotic prior to admission and she did not know the original cause of the injury. On 6/3/16 at 12:46 pm Staff 3 stated she had to review the chart to see why it was coded as pressure. Staff 3 stated she might have asked the resident the cause of the injury, but she could not recall talking to the resident about her/his finger. On 6/3/16 at 2:10 pm Staff 3 stated Resident 149's record indicated the resident was sent to a local hospital and diagnosed with [REDACTED]. When asked if she considered a finger tip as an area for a pressure ulcer, Staff 3 stated only if the resident said it was from pressure, but she could not recall what the resident told her. 3. Resident 117 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code dehydration if the resident presented 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 he or she took in. Resident 117's 4/22/16 Quarterly MDS section J1150 Problem Conditions coded the resident as dehydrated during the assessment period. The clinical record lacked documented evidence Resident 117 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. On 6/6/16 at 9:22 am Staff 6 (RNCM) stated the resident was unable to eat and had difficulty swallowing and choking. Staff 6 stated the resident had a catheter but she was not sure if intake and output were documented. On 6/6/16 at 10:45 am Staff 2 (DNS) reviewed Resident 117's medical record and acknowledged she was unable to provide documentation to support the coding of dehydration on the 4/22/16 Quarterly MDS. 4. Resident 187 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/6/15 Cognitive CAA revealed Resident 187 was on hospice services. The 11/6/15 SCSA (Significant Change in Status) MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. The 1/15/16 Quarterly MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. The 4/18/16 Quarterly MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. On 6/2/16 at 3:04 pm Staff 6 (RNCM) acknowledged Resident 187 was on hospice and the coding in Section J of the 11/6/15, 1/15/16, and 4/8/16 MDS assessments was incorrect. 5. Resident 226 was admitted to the facility in (YEAR) with a stage II pressure ulcer (Is a partial thickness loss of dermis presenting as a shallow open ulcer with a red and pink wound bed without slough. (MONTH) also present as an intact or open or ruptured blister) of the sacral region. Hospital records dated 1/16/16 through 1/19/16 indicated the resident had a stage II to III pressure ulcer of the presacral /coccygeal area in a T shape pattern that is approximately 8 x 6 cm. Operative report dated 1/19/16 indicated that resident 226 had debridement (A process of removing nonliving tissue) of the sacral area and buttocks. Resident 226's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] indicated the resident did not have any pressure ulcers. The M1041 section of the MDS indicated the resident had a surgical wound and skin tears on both the Admission MDS and Quarterly MDS. Skin wound weekly flow sheets dated 1/24/16 through 5/30/16 indicated Resident 226 was treated for [REDACTED]. On 6/1/16 at 12:50 pm Staff 2 (DNS) confirmed the Initial MDS on 1/27/16 and the Quarterly dated 4/22/16 should have been coded as a Stage II pressure ulcer and not a surgical wound.",2020-09-01
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,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,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, fever, diarrhea that exceeds fluid replacement). 1. Resident 21 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified the resident as having active [DIAGNOSES REDACTED]. No documentation of an active UTI or dehydration diagnoses, related laboratory findings or signs/symptoms indicated a UTI or dehydration was found in the clinical record. In an interview on 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged the 7/11/17 Quarterly MDS was miscoded. 2. Resident 60 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified the resident as having an active [DIAGNOSES REDACTED]. No documentation in the clinical record indicated dehydration, related laboratory findings or signs/symptoms the resident was dehydrated. In an interview on 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged the 5/7/17 Quarterly MDS was miscoded. 3. Resident 140 admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The 5/18/17 Significant Change MDS indicated Resident 140 received hospice services. The MDS indicated the resident did not have a terminal prognosis. On 7/27/17 at 12:27 pm Staff 8 (RNCM) acknowledged Resident 140 received hospice service and did have a terminal prognosis. Staff 8 stated the MDS was coded in error. 4. Resident 33 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. A 2/3/17 Braden Scale For Prediction of Pressure Sore Risk indicated Resident 33 was at risk for pressure ulcers. The 4/21/17 Annual MDS indicated Resident 33 was not at risk for pressure ulcers. On 7/31/17 at 1:21 pm Staff 8 (RNCM) stated Resident 33 was at risk for pressure ulcers and acknowledged the MDS was coded in error. 5. The CMS RAI Manual Section K: Swallowing/Nutritional Status, Coding Instructions for Weight stated, If a resident cannot be weighed .use the standard no-information code (-). Resident 26 admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. The 12/23/16 Annual MDS indicated Resident 26's weight was zero. On 7/27/17 at 2:17 pm Staff 8 (RNCM) stated Resident 26 was not weighed by facility staff but the resident's arm circumference was measured in order to monitor the resident's nutritional status. On 7/28/17 at 9:24 am Staff 9 (Dietitian) acknowledged the resident's weight was coded inaccurately on the 12/23/16 Annual MDS.",2020-09-01
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 facility in 8/2010 with [DIAGNOSES REDACTED]. a. A 10/13/16 Nutrition Assessment indicated Resident 26 was on swallowing precautions. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's nutritional needs. On 7/28/17 at 9:15 am Staff 2 (DNS) acknowledged Resident 26's care plan did not include objectives, timeframes and services provided to meet the resident's nutritional needs. b. The 7/20/17 Bedside Information Sheet indicated Resident 26 had a [MEDICAL CONDITION]. No information was found in the resident's record to indicate objectives, timeframes and services provided for the resident's needs related to the [MEDICAL CONDITION]. On 7/28/17 at 9:15 am Staff 2 (DNS) acknowledged Resident 26's care plan did not include objectives, timeframes and services provided to meet the resident's needs related to the [MEDICAL CONDITION]. 2. Resident 33 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. a. The 4/21/17 Annual MDS Pressure Ulcer CAA indicated a plan was in place to prevent pressure ulcers and stated, Risks for pressure ulcer addressed in care plan. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's risk for pressure ulcers. On 7/31/17 at 11:47 am Staff 8 (RNCM) acknowledged the resident's care plan did not include objectives, timeframes and services provided to meet the resident's needs related to pressure ulcer risk. b. The 4/21/17 Annual MDS indicated Resident 33 experienced a UTI in the past 30 days. On 7/28/17 at 12:55 pm Resident 33 stated she/he had a long history of UTIs including prior to admitting to the facility. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's risk for UTIs. On 7/31/17 at 11:47 am Staff 8 (RNCM) stated the resident had a history of [REDACTED]. related to UTIs. 3. Resident 15 admitted to the facility in 3/2010 with [DIAGNOSES REDACTED]. The 8/26/16 Significant Change MDS indicated the resident received antipsychotic, antidepressant, anticoagulant and diuretic medication. The 6/2017 and 7/2017 MARs indicated Resident 15 refused antidepressant medication seven times and refused diuretic medication 18 times from 6/1/17 through 7/30/17. On 7/28/17 at 12:58 pm Staff 10 (RN) stated Resident 15 frequently refused medication and staff used a variety of interventions to encourage the resident to take her/his medication. No information was found in the resident's record to indicate objectives, timeframes or services provided related to the resident's high-risk medication and medication refusal. On 7/31/17 at 11:47 am Staff 8 (RNCM) acknowledged the resident's care plan did not include objectives, timeframes or services provided to meet the resident's needs related to high-risk medication and medication refusal. 4. Resident 159 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. a. The resident's 6/1/17 Admission MDS identified the resident had unsteady balance, required one- person limited assistance with transfers and one-person extensive assistance with toilet use. The resident's Person-Centered Bedside Care Plan included the amount of assistance and devices needed for transfers but included no measurable goals for fall prevention. Progress notes indicated on 7/08/17 at 1:43 pm the resident sustained [REDACTED]. The fall investigation dated 7/8/17 indicated the resident was alone in the bathroom at the time of the fall and attempted to self-transfer from the wheelchair to the toilet. On 7/17/17 at 2:01 pm the progress note indicated the resident was found on 7/17/17 at 10:15 am sitting on the floor in front of the toilet in her/his bathroom again. The fall investigation dated 7/17/17 indicated the resident was alone in the bathroom at the time of the fall and attempted to self-transfer from the toilet to the wheelchair. No new fall prevention interventions were identified or added to the care plan until 7/21/17, four days after the second fall occurred. On 7/28/17 at 4:55 pm Staff 16 (RNCM) verified Resident 159's care plan contained no measurable goals for fall prevention and the care plan was not revised related to falls and toileting until after the second fall occurred. b. On 7/25/17 at 10:14 am Resident 159 was observed with a bruise on her/his left elbow and steri-strips on her/his right forearm. Progress notes indicated the resident sustained [REDACTED]. There was no progress note related to the resident's left elbow bruise. The resident's care plan identified the resident had a history of [REDACTED]. The resident's clinical record did not include measurable goals to prevent breakdown or injuries and did not indicate staff responsible to provide the interventions. On 7/28/17 at 5:36 pm Staff 16 (RNCM) verified the resident's care plan contained no measurable goals related to fragile skin or bruising or the staff responsible to provide the interventions. c. The resident's 6/1/17 Admission MDS identified the resident had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter CAA associated with the 6/1/17 Admission MDS included the resident's diagnoses, history of urinary tract infections, urinary catheter use and need for one-person extensive assistance with toileting. A progress note dated 7/8/17 indicated the resident was found on the floor of the bathroom with the catheter drainage bag attached to her/his wheelchair. On 7/09/17 at 11:13 pm the progress note related to the fall with injury indicated the resident had no apparent injuries, denied pain, but a red and irritated skin injury was noted. On 7/17/17 the resident was found again on the floor of the bathroom with the catheter drainage bag attached to her/his wheelchair. The resident's clinical record included the use of the indwelling urinary catheter but included no measurable goals to prevent urinary tract infections or injury related to the catheter and did not indicate staff responsible to provide the interventions. On 7/28/17 at 5:36 pm Staff 16 (RNCM) verified the resident's care plan had no measurable goals related to injuries from pulling of the catheter and did not indicate the staff responsible for interventions. 5. Resident 24 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. A progress note dated 6/22/17 indicated the resident had a 8.5 cm x 7.5 cm bruise on the left upper arm, a history of bruising and took oral blood thinners. On 7/24/17 at 12:14 pm Resident 24 was observed with a bruise on her/his right arm and diffused bruising on the back of both hands. The progress notes included no information or identification of the resident's right arm bruise. The resident's 7/2017 physician orders [REDACTED]. On 7/26/17 the resident's Person-Centered Bedside Care Plan indicated the resident received high risk medications. However, the resident's clinical record did not identify the medication or adverse side effects of the medication. The resident's record identified the resident bruised easily but included no measurable goals or interventions to protect the resident from bruising. On 7/28/17 at 5:00 pm Staff 16 (RNCM) verified the resident's care plan had no measurable goals related to bruising and use of high risk medications. Staff 16 verified the care plan did not indicate the staff responsible for interventions. 6. Resident 21 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. A Significant Change MDS dated [DATE] and a Quarterly MDS dated [DATE] indicated the resident had [DIAGNOSES REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's UTI, Foley catheter or dehydration needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 21's care plan did not include objectives, timeframes and services provided to meet the resident's UTI, Foley catheter or dehydration needs. 7. Resident 60 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified an active [DIAGNOSES REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's dehydration needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 60's care plan did not include objectives, timeframes and services provided to meet the resident's dehydration needs. 8. Resident 72 was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Resident 72's physician orders [REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's high risk medication needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 72's care plan did not include objectives, timeframes and services provided to meet the resident's high risk medication needs. 9. Resident 118 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Resident 118's physicians orders dated 6/27/17 revealed orders for [MEDICATION NAME] (sedative), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (anticonvulsant also used for mood), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] R (insulin) and [MEDICATION NAME] (insulin). No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's high risk medication needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 118's care plan did not include objectives, timeframes and services provided to meet the resident's high risk medication needs. 10. Resident 167 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. The resident's Admission MDS dated [DATE] indicated the resident required extensive assistance with transfers and ambulation. The resident's Personalized Bedside Care Plan revised 6/19/17 identified the resident was a fall risk related to medication use, tremors, coordination shuffling and environment. Staff were to assist, supervise and visually check the resident. No further information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's fall risk needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 167's care plan did not include objectives, timeframes and services provided to meet the resident's fall risk needs. 11. Resident 144 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. The 5/27/17 Annual MDS indicated Resident 144 received antipsychotic and antidepressant medication. The 6/7/17 [MEDICAL CONDITION] Drug Use CAA indicated the resident received antipsychotic and antidepressant medication. Resident 144 had advancing [MEDICAL CONDITION] with behavioral disturbances which had advanced since her/his stroke. It was identified Resident 144 had behaviors including agitation, impulsiveness, frustration and anger. A review of the resident's clinical record revealed no information regarding measurable goals, objectives or timeframes and what approaches would be used to meet those goals related to Resident 144's behaviors and use of [MEDICAL CONDITION] medications. On 7/28/17 at 12:21 pm Staff 4 (RNCM) acknowledged there was no information regarding measurable goals, timeframes or what approaches would be used to meet those goals for Resident 144's behaviors and use of [MEDICAL CONDITION] medication in Resident 144's care plan. 12. Resident 153 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. The 7/14/17 Significant Change MDS indicated Resident 153 was frequently incontinent of bowel and bladder. The resident required two person extensive assistance with toileting. The 7/25/17 Urinary Incontinence CAA indicated Resident 153 had advanced Alzheimer's dementia and was incontinent of bladder and bowel with occasional continent episodes. The resident had difficulty making her/his needs known and staff provided frequent toileting and incontinence care. The family requested Resident 153 receive comfort measures only. A review of the resident's clinical record revealed no information regarding measurable goals, objectives or timeframes and what approaches would be used to meet those goals related to Resident 153's incontinence. On 7/28/17 at 10:31 am Staff 8 (RNCM) acknowledged there was no information in the care plan regarding measurable goals, timeframes or what approaches would be used to meet those goals for Resident 153's urinary incontinence. 13. Resident 46 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The resident's clinical record did not include measurable objectives, timeframes and staff responsible to meet the resident's medical, nursing, and mental and psychosocial needs. In an interview on 7/28/17 at 8:58 am Staff 2 (DNS) confirmed Resident 46's care plan did not include measurable objectives and timeframes.",2020-09-01
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,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,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,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,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 7/24/17 at 12:21 pm Staff 15 was observed to handle the resident's fork while assisting the resident. This surveyor then intervened. On 7/24/17 at 12:24 pm Staff 15 stated she was familiar with the requirement to wash hands before assisting residents. Staff 15 stated she didn't usually work in this part of the facility and she didn't see any hand sanitizer available. Staff 15 acknowledged she should have washed or sanitized her hands prior to assisting residents. 3. On 7/24/17 from 8:42 am to 8:49 am Staff 17 (CNA) and Staff 18 (CNA) were observed passing breakfast trays to resident's rooms. Staff 17 and Staff 18 were both observed to enter resident rooms, touch various objects inside the rooms and return to the cart in the hall in order to retrieve another breakfast tray. Staff 17 and 18 did not wash or sanitize their hands between meal delivery to resident's rooms. Staff 17 and 18 were stopped by this surveyor and asked about their handwashing policy while passing meal trays. Staff 17 and 18 both stated when they remembered they would wash or sanitize their hands while passing trays. On 7/24/17 at 8:49 am Staff 17 and 18 both acknowledged they touched the resident's personal belongings and had not washed or sanitized their hands before passing another tray for another resident. Staff 17 and Staff 18 both proceeded to the meal cart in order to retrieve another tray without washing or sanitizing their hands and this surveyor again intervened. The staff were then observed to wash their hands before continuing to deliver meal trays. 4. On 07/24/17 at 12:03 pm Staff 19 (CNA), Staff 20 (CNA) and Staff 21(CNA) were observed passing lunch trays from the meal cart to residents in the dining room. Staff 19 touched the resident's wheelchair and the resident. Staff 19, Staff 20 and Staff 21 each went to get another lunch tray from the meal cart and were stopped by this surveyor and asked when should hands be washed or sanitized while passing meal trays. Staff 19 stated she would wash or sanitize her hands after all the trays were passed. Staff 20 stated he would wash or sanitize his hands if he touched the resident's food. Staff 21 stated he washes or sanitizes his hands if he goes into the back room to get a drink for the resident. Staff 19 and Staff 20 stated they were not sure what the policy was for handwashing between passing meal trays. On 7/24/17 at 12:10 pm Staff 19, 20 and 21 acknowledged they did not wash or sanitize their hands between passing meal trays. In an interview on 07/25/17 at 8:43 am Staff 2 (DNS) acknowledged the CNAs should wash or sanitize their hands between passing meal trays. Staff 2 stated the staff were not meeting expectations for proper hand hygiene during meals.",2020-09-01
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,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,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,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. On 12/11/18 at 1:09 PM Staff 1 provided an investigation of the 11/6/18 incident between Resident 61 and Witness 7 (Former CNA). The investigation began with a staff report of the event on 11/7/18 at 2:50 pm (almost one day after the incident occurred). There was no specific documentation regarding Resident 61's status and the primary focus of the investigation was on the termination of Witness 7's employment. On 12/12/18 at 11:22 AM Staff 1 provided additional information regarding the 11/6/18 incident, including documentation of staff interviews who were present or nearby when the incident occurred with Resident 61. There was no information describing the resident's status during or after the incident nor interviews with other residents who may have had contact with Witness 7. On 12/12/18 at 3:33 PM Staff 31 (CNA) stated she was seated with Resident 61 when Witness 7 attempted to remove Resident 61's drink and the resident refused to let go of the container. Staff 31 further stated Witness 7 stated to Resident 61 she/he should just die. Staff 31 said she reported the incident to Staff 16 the next day. Staff 31 stated there were complaints about Witness 7 by other residents prior to this incident but she did not know if they were reported. On 12/13/18 at 4:19 PM Staff 32 (CNA) confirmed she was on duty the night of the incident between Witness 7 and Resident 61. Staff 32 stated she was in a resident room, heard screaming and when she came out of the room Witness 7 was talking loudly to Resident 61 saying she/he needs to die. Staff 32 further stated when she approached the resident she/he appeared angry and her/his body language was tense after the exchange with Witness 7. On 12/16/18 at 5:17 PM Staff 33 (CNA) stated on 11/6/18 she heard loud voices and yelling in the dining area before she observed Resident 61 and Witness 7 struggling with a drink container. Staff 33 stated Witness 7 was talking very loudly telling the resident no repeatedly and you need to die, you need to be slapped and she also used foul language toward the resident. Staff 33 said she and other staff were able to move the resident to a quiet spot and Witness 7 left the area. Staff 33 stated she thought Witness 7's words got to the resident in spite of her/his confusion because she/he had her/his eyes down and looked sad after the incident was over. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged the need to ensure incidents of abuse involving residents were properly reviewed, investigated and reported. According to the 11/7/18 investigation, Witness 7 was not scheduled to work on 11/7/18 or 11/8/18. On 11/9/18 Staff 16 informed Witness 7 she was placed on paid leave until further notice and resolution of the investigation.",2020-09-01
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 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 the 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 State Agency did not have a facility self report regarding the 11/2018 allegation Witness 2 inappropriately touched Resident 36 during incontinence care. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS), Staff 15 indicated if an allegation of abuse could not be ruled out the allegation was reported to the state. Staff 15 further stated the reporting timeframe depended on the amount of time it took to complete the allegation. Staff 15 indicated she was not aware the facility was responsible to report allegations of abuse immediately upon receipt of the allegation of abuse and also acknowledged Resident 36's allegation of abuse was not reported to the State Agency. 2. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility's 6/2018 policy on abuse prevention and reporting revealed employees must always report any suspected abuse to their supervisor, nursing administration or the administrator immediately. The investigation may include interviews of the resident and witnesses, an initial analysis of the information, what measures were taken to ensure resident safety and reporting to State Agencies. On 12/11/18 at 1:09 PM & 12/12/18 at 11:22 AM Staff 1 provided an investigation of the 11/6/18 incident between Resident 61 and Witness 7 (Former CNA). The investigation began with a staff report of the event on 11/7/18 at 2:50 pm (almost one day after the incident occurred). The facility's investigation lacked the following required information: * Staff failed to report verbal abuse of a resident by a staff in a timely manner. * The investigation lacked documentation of an interview of Resident 61 and other residents who may have had contact with Witness 7. * There was no information describing how Resident 61 was kept safe following the incident. * There was no indication State Agencies were notified within the 24 hour time frame. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged there was a failure to implement their abuse policy to ensure staff reported incidents timely, a thorough investigation was completed, the resident's safety was maintained and reporting requirements were met. 3. Resident 423 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 42 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. The facility's 6/2018 policy on abuse prevention and reporting revealed investigations may include interviews of the resident and witnesses, an initial analysis of the information, what measures were taken to ensure resident safety and reporting to State Agencies. An Event Overview dated 8/7/18 revealed Resident 423 was exhibiting agitation and verbal behaviors. Resident 423 suddenly slapped Resident 42 on the upper abdomen causing Resident 42 to be startled and yell out. There were no interviews of either resident, staff who were present or other residents who may have interacted with Resident 423. There was no indication the incident was reported to the State Agency. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 (Administrator) acknowledged their abuse policy was not implemented appropriately to ensure a thorough investigation was completed or reported to the State Agency. 4. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility's 6/2018 Abuse Prevention policy includes the following: Employees must always report any suspected abuse to their supervisor, nursing administration or the administrator immediately. An investigation will be done on all allegations of abuse. Resident 7's 9/12/18 MDS revealed her/his BIMS (Brief Interview for Mental Status) score was 12/15 indicating moderate cognitive impairment. During an interview on 12/13/18 at 4:19 PM Staff 32 (CNA) stated Witness 7 (Former CNA) grabbed Resident 7 and caused bruises when she yanked her/him up in the wheelchair. Staff 32 further stated Witness 7 was rough with other residents in front of staff and visitors. Staff 32 indicated she informed Staff 16 (Assistant DNS) about her concerns with Witness 7. On 12/14/18 at 9:35 AM Resident 7 stated she/he had been treated roughly at times but denied feeling unsafe. On 12/17/18 at 10:55 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) stated they were not aware of Witness 7's rough treatment of [REDACTED]. 5. The facility's reporting requirements in the 6/2108 Abuse Prevention policy revealed any incidents of alleged abuse involving serious bodily injury or sexual abuse will be reported to local law enforcement and State Survey Agency immediately (or no later than two hours). The policy did not include guidance for reporting alleged violations that do not involve abuse or do not result in serious bodily injury and must be reported to the State Agency no later than 24 hours. During interviews on 12/12/18 at 8:50 AM and 10:43 AM and 12/13/18 at 2:00 PM Staff 1 (DNS), Staff 15 (Administrator) and Staff 16 (Assistant DNS) acknowledged the Abuse Prevention policy did not include reporting requirements for allegations that did not result in serious bodily injury or did not involve abuse.",2020-09-01
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 include information related to reporting to State Agencies. During interviews on 12/12/18 at 3:33 PM, 12/13/18 at 4:19 PM and 12/16/18 at 5:17 PM Staff 31 (CNA), Staff 32 (CNA) and Staff 33 (CNA) confirmed they witnessed or heard the verbal abuse and did not report the incident immediately after it occurred. All three staff notified Staff 16 (Assistant DNS) on 11/7/18, the following day. On 12/13/18 at 8:53 AM Staff 1 stated since they were unable to rule out abuse they called the OSBN to report the incident. Staff 1 stated she could not say why other State Agencies were not notified and agreed it should have been reported. 2. Resident 423 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 42 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. An Event Overview dated 8/7/18 revealed Resident 423 was exhibiting agitation and verbal behaviors. Resident 423 suddenly slapped Resident 42 on the upper abdomen causing Resident 42 to be startled and yell out. The Event Overview did not indicate whether the resident-to-resident incident was reported to State Agencies. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 confirmed the incident was not reported to the State Agencies. 3. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 7's 9/12/18 MDS revealed her/his BIMS (Brief Interview for Mental Status) score was 12/15 indicating moderate cognitive impairment. During an interview on 12/13/18 at 4:19 PM Staff 32 (CNA) stated Witness 7 (Former CNA) grabbed Resident 7 and caused bruises when she yanked her/him up in the wheelchair. Staff 32 further stated Witness 7 was rough with other residents in front of staff and visitors. Staff 32 indicated she informed Staff 16 (Assistant DNS) about her concerns with Witness 7. On 12/14/18 at 9:35 AM Resident 7 stated she/he had been treated roughly at times but denied feeling unsafe. On 12/17/18 at 10:55 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) stated they were not aware of any issues related to Resident 7 and staff did not report any problems. 4. Resident 36 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. 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. As of 12/14/18 the State Agency did not have a facility self report regarding the 11/2018 allegation Witness 2 inappropriately touched Resident 36 during incontinence care. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS), Staff 15 indicated if an allegation of abuse could not be ruled out the allegation was reported to the state. Staff 15 further stated the reporting timeframe depended on the amount of time it took to complete the allegation. Staff 15 indicated she was not aware the facility was responsible to report allegations of abuse immediately upon receipt of the allegation of abuse and also acknowledged Resident 36's allegation of abuse was not reported to the State agency.",2020-09-01
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 unable to answer any of the interview questions. On 12/11/18 at 1:09 PM Staff 1 provided an investigation of the 11/6/18 incident between Resident 61 and Witness 7 (Former CNA). The investigation began with a staff report of the event on 11/7/18 at 2:50 pm (almost one day after the incident occurred). There was no specific documentation regarding Resident 61 and the primary focus of the investigation was on the termination of Witness 7's employment. On 12/12/18 at 11:22 AM Staff 1 (DNS) provided additional information regarding the 11/6/18 incident. There was no documentation of Resident 61's reaction to the incident or how she/he was kept safe following the incident. There were not interviews with other residents who may have had contact with Witness 7. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged incidents of resident abuse must be thoroughly thoroughly investigated, including interviews with other residents and ensuring the resident who was affected was kept safe. 3. Resident 423 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 42 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. An Event Overview dated 8/7/18 revealed Resident 423 was exhibiting agitation and verbal behaviors. Resident 423 suddenly slapped Resident 42 on the upper abdomen causing Resident 42 to be startled and yell out. Review of Resident 423's and Resident 42's records revealed no documentation of a thorough investigation of the 8/7/18 incident. There were no interviews of staff or other residents who may have been present when the incident occurred. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 confirmed the investigation was not thorough and lacked interviews with staff or other residents who may have been present or interacted with Resident 423. 4. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 9/12/18 MDS revealed her/his BIMS (Brief Interview for Mental Status) score was 12/15 indicating moderate cognitive impairment. During an interview on 12/13/18 at 4:19 PM Staff 32 (CNA) stated Witness 7 (Former CNA) grabbed the resident and caused bruises when she yanked Resident 7 up in the wheelchair. Staff 32 further stated Witness 7 was rough with other residents in front of staff and visitors. Staff 32 indicated she informed Staff 16 (Assistant DNS) about her concerns with Witness 7. On 12/14/18 at 9:35 AM Resident 7 stated she/he had been treated roughly at times but denied feeling unsafe. There was no documentation of any investigations completed regarding concerns of inappropriate treatment of [REDACTED]. On 12/17/18 at 10:55 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) stated they were not aware of any issues related to Resident 7 and no staff reported any problems.",2020-09-01
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 indicated the resident had an unstageable pressure ulcer on her/his right foot. On 12/13/18 at 2:56 PM Staff 22 (RNCM) confirmed the resident's 9/12/18 MDS was coded incorrectly and the pressure ulcer should have been coded as a Stage 3.",2020-09-01
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) stated Resident 49 had mental health [DIAGNOSES REDACTED]. Staff 2 indicated the resident was seen by a dentist on a regular basis and the dentist recommended the staff use children's toothpaste because the resident swallowed toothpaste. Staff 2 further stated three weeks ago she purchased the resident's toothpaste and staff did not report the toothpaste was empty. On 12/13/18 at 8:51 AM Staff 5 (CNA) indicated she was familiar with Resident 49. Staff 5 indicated she used a sponge brush and mouthwash to brush the resident's teeth because the resident swallowed the toothpaste and would become agitated. Staff 5 indicated she did not see the children's toothpaste in the resident's room for approximately three to four months. On 12/13/18 at 10:09 AM with Staff 20 (CNA) the resident's bedside drawer was observed to have one unopened two pack of soft bristle toothbrushes, one unopened children's toothpaste with the safety seal intact, one children's toothpaste nearly full and one non-children's toothpaste which was half full. On 12/13/18 at 10:17 AM Staff 23 (CNA) indicated she was assigned to work with Resident 49. The resident's teeth were not brushed but when the resident allowed she used mouthwash on a sponge brush to clean the resident's teeth.",2020-09-01
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 was observed with short sleeves and there was bruising to both lower arms. On 12/12/18 at 10:47 AM Staff 2 (RNCM) indicated the resident had fragile skin and often rubbed her/his arms which was likely the cause of the resident's arm bruises. Staff 2 indicated the protective sleeves took a while to obtain and when the order arrived the arm sleeves were too big but the next size smaller was too small. Staff 2 attempted to resize the sleeves and did not complete the correct fit until 12/12/18. Staff 2 acknowledged the care plan did not include the arm sleeves and/or direct the staff to ensure the resident wore long sleeves. On 12/12/18 at 12:12 PM Staff 5 (CNA) indicated she worked with the resident since 12/1/18 and she never saw the arm sleeves in the resident's room. This was the first day she saw the sleeves in the resident's room. On 12/12/18 at 12:23 PM and 1:30 PM Staff 1 (DNS) stated the arm sleeves for Resident 20 were not implemented in a timely manner. The sleeves were identified to be a possible intervention in (MONTH) and the sleeves were provided almost two months later. Staff 2 indicated the sleeve protectors and the use of long sleeves should have been placed on the care plan for the CNAs.",2020-09-01
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,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 cleaned the concentrators. She was unaware of what to do about the dirty filter and thought the staff who worked in central supply would replace the filter. On 12/14/18 at 1:28 PM Staff 3 (Central Supply) indicated they cleaned all the concentrators once the resident was discharged and would replace the dirty filters if the nursing staff let them know.",2020-09-01
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,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 treatment when required. On 12/14/18 at 9:09 AM Staff 19 (RD) stated Resident 70 had lots of dental problems and had a difficult time chewing. On 12/14/18 at 9:54 AM Staff 21 (RNCM) identified herself as one of the RN Care Managers for the 200 hall, where Resident 70 currently resided. Staff 21 stated Resident 70's tooth broke off and the resident had pain and trouble eating. Staff 21 stated this issue was identified prior to the resident moving to the 200 hall and the resident's previous RNCM (Staff 22) was working on getting dental treatment while the resident resided in the other hall. Staff 21 stated she was not aware of any current plan for obtaining dental treatment for [REDACTED]. On 12/14/18 at 9:58 AM Staff 22 stated she was in the process of obtaining dental treatment for [REDACTED]. Staff 22 stated she was not sure what occurred since that time with regard to the resident's dental needs.",2020-09-01
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 51 resided on the long term care unit and did not have a [DIAGNOSES REDACTED]. On 12/13/18 interviews with the licensed nurses (#s 25, 26, 27 and 28) on the additional three facility units (Enhanced Care Unit, Cedar Lane and Transitional Care Unit) revealed the licensed staff used the germicidal wipes to clean the glucometers after each resident use. On 12/14/18 at 8:52 AM Staff 1 (DNS) indicated it was standard of practice to use the germicidal wipes to clean the community use glucometers. The nurses were educated upon hire and the procedure was reviewed during infection control training. The germicidal wipes were available for the medication/treatment carts and/or at the nurse's station.",2020-09-01
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,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,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 [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what their order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how she/he called for help, but did. The same nurse which administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and her/his blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 (LPN) stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he felt shaky. She stated she took the resident's blood sugar and the reading was low, and then she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 (LPN) to not administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. 2. Resident 24 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] CAA revealed Resident 24 received both scheduled and PRN pain medication. Resident 24 had frequent pain with a nine pain level from a scale of one to 10 with 10 the highest level of pain. Resident 24 had shortness of breath with exertion or lying flat. It was hard for Resident 24 to stay asleep and to complete day to day activities. A [DATE] physician signed Skilled Nursing Facility Transfer Orders instructed staff to administer 1 to 3 tablets of [MEDICATION NAME] (to relieve pain) every three hours PRN for pain. A [DATE] at 1:54 PM Nursing Note revealed Resident 24's pain continued to be addressed with her/his PRN pain medications. A ,[DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 7:37 PM Staff 29 (LPN) stated to Resident 24 all of her/his [MEDICATION NAME] medications were discontinued. No documentation was found in the clinical record. Resident 24's [MEDICATION NAME] was discontinued. On [DATE] at 7:42 PM Staff 29's voice was raised and was heard two rooms down the hall from Resident 24's room. Staff 29 stated Resident 24 did not have an order for [REDACTED]. On [DATE] at 12:05 PM Resident 24 stated her/his pain was a seven out of 10 on [DATE] in the evening. Resident 24 stated Staff 29 was unprofessional and she/he went to Staff 2 (DNS) to complain. Resident 24 stated Staff 29 came back later on [DATE] and placed a cup with pills in it on her/his bedside table but she did not apologize. On [DATE] at 11:40 AM Staff 2 confirmed Staff 29 should have validated the medication and not argued with Resident 24.",2020-09-01
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,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,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 14 was missing two AARP cards, a social security card, a silver script card, and a piece of paper with a Medicare number on it. Resident 14 stated she/he placed them in a sealed envelope and gave them to the social service director to place in the facility safe. Immediate action taken was the RCM and nursing staff were interviewed. The form revealed some items were stored in Resident 14's locked cabinet but not the items the resident reported missing. No documentation was found in clinical records which RCM or staff were interviewed and if misappropriation was confirmed or not. On 6/6/19 at 10:50 AM Staff 1 (Administrator) stated he thought there was additional information regarding to Resident 14's missing personal items. No additional information was provided. 3. Resident 16 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 5/1/19 Damaged/Missing Item Report revealed Resident 16 was missing $100 in cash. The money was found missing the evening of 4/30/19. The investigation included an undated, unsigned typed RCM Investigation which revealed a friend transported Resident 16 to the bank and withdrew $100 and she/he placed it in her/his room. The friend and Resident 16 left the room and approximately 45 minutes later it was discovered missing. On 5/30/19 at 12:30 PM Resident 16 stated she/he believed the facility put the amount owed towards her/his bill but she/he was not sure as she/he did not hear from the facility. On 6/6/19 at 11:23 AM Staff 1 (Administrator) stated he would provide more information regarding the investigation and if misappropriation was substantiated or unsubstantiated. Staff 1 stated social services attempted to reimburse Resident 16 but she/he would not accept. On 6/11/19 at 7:17 AM Staff 1 stated the investigation revealed misappropriation was substantiated for Resident 16's missing money. 4. Resident 21 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. A 5/9/19 Damaged/Missing Item Report revealed Resident 21 was missing $135 and a RCM and CNA were interviewed on 5/9/19. The missing money was not found and Resident 21 was reimbursed for the missing amount of money. On 5/21/19 at 10:14 AM Resident 21 stated she/he gave the money to the facility for safe keeping and when she/he wanted the money the facility could not find the money. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated the investigation determined misappropriation was substantiated for Resident 21's missing money. 5. Resident 22 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. A 5/10/19 Damaged/Missing Item Report revealed Resident 22 was missing $120. The cash was not located and Resident 22 was reimbursed for her/his money. An undated Resident 22 statement revealed Resident 22 had a total of $120 in her/his room which went missing. On 6/3/19 at 8:03 AM Resident 22 stated she/he was unsure what happened with her/his money. The money was in her/his room and then the money was gone. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated the investigation revealed misappropriation was substantiated for Resident 22's missing money.",2020-09-01
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 amount written on the front of the envelope. On 5/22/19 at 10:43 AM Resident 8 stated the facility did not contact her/him regarding reimbursement of her/his missing money. The investigation did not include the date it was completed. On 6/11/19 at 7:17 AM Staff 1 confirmed the investigation was not completed within the five days as per policy and the determination was substantiated for misappropriation. 2. Resident 16 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 5/1/19 Damaged/Missing Item Report revealed Resident 16 was missing $100 in cash. The money was found missing the evening of 4/30/19. The investigation included an undated, unsigned typed RCM Investigation which revealed a friend transported Resident 16 to the bank and withdrew $100 and she/he placed it in room. The friend and Resident 16 left the room and approximately 45 minutes later the money was discovered missing. On 6/6/19 at 11:23 AM Staff 1 (Administrator) stated he would provide more information in regard to the investigation when the investigation was completed, and if misappropriation was substantiated or unsubstantiated. Staff 1 stated social services attempted to reimburse Resident 16 but she/he would not except. On 6/11/19 at 7:17 AM Staff 1 (Administrator) confirmed the missing money was reported on 4/30/19 and the investigation was completed on 5/9/19. The facility policy revealed investigations would be completed after five days.",2020-09-01
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 and Staff 44 was advised to send the resident to the hospital. -Hospital x-rays revealed a mildly displaced right intertropchanteric (hip) fracture, a non-displaced (the broken bones remain aligned) right proximal (just below the knee) fibular (the smaller shin bone) fracture and further indicated an irregularity in the posterior aspect of the medial tibial (large shin bone) plateau may represent a nonspecific fracture. Record review revealed the resident readmitted to the facility on [DATE]. The Comprehensive Care Plan revealed the following: -A Comprehensive Care Plan initiated on [DATE] (six days after the resident readmitted on [DATE]) indicated Resident 5 had a [MEDICAL CONDITION] related to a fall and [MEDICAL CONDITION] ([MEDICAL CONDITION] joints). Staff were directed to monitor and document pain. On [DATE] (nine days after the resident readmitted on [DATE]) a revision staff were directed to bridge and off load the right hip due to the fracture. -A Comprehensive Care Plan revised on [DATE] (17 days after the resident readmitted ) indicated Resident 5 had a self care deficit related to decreased mobility, reconditioning and obesity. The resident was a two person assist and staff were directed to utilize a Hoyer during transfers and toileting. The resident was a three person assist with bed mobility. -A Comprehensive Care Plan revised on [DATE] (17 days after the resident readmitted ) indicated Resident 5 was a moderate risk for falls related to cognitive problems, gait and balance issues, incontinence and medication drug use. The resident was a two person assist and staff were directed to utilize a Hoyer during all transfers. -A review of the Comprehensive Care Plan revealed no documentation regarding Resident 5's POLST (Provider Orders for Life-Sustaining Treatment) or Advance Directive (A written statement of a person's wishes regarding medical treatment) status. On [DATE] at 11:55 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the care plan was not updated timely. Staff 2 stated care plans should be updated within 48 hours. She further stated the POLST and advance directive should have been on the resident's care plan. 2. Resident 6 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident 6 was cognitively intact. The Comprehensive Care Plan indicated the resident had behavioral, cognitive, psychiatric diagnosis ([MEDICAL CONDITION], anxiety and dementia) and was experiencing [MEDICAL CONDITION] of [MEDICAL CONDITION] disorder when she would yell, cry, verbalize belief in conspiracies and would get agitated easily with staff and other residents. Staff were directed to monitor behaviors every shift, ask permission prior to moving or handling any of the resident's items and ensure all of resident's belongings were labeled. Interventions in place included redirection, change of position, return to room, one to one interaction, toileting, assess for pain and offer soft drink. A revision on [DATE] indicated the resident had change in behavior and was yelling at staff, making statements of staff not caring and no one would care for her/him. Staff were directed to notify the nurse of behaviors and redirect the resident. On [DATE] at 1:47 PM Staff 52 (CNA) stated the resident was able to state her/his needs, was highly sensitive and was often very accusatory of staff. The resident often indicated that staff did not provide care for her/him when they had just completed ADLs or a specific request. Staff 52 stated she would prefer two staff in the room when providing care due to the accusations. On [DATE] at 8:45 AM, 9:07 AM and 1:25 PM Staff 17 (CNA), Staff 42 (CNA) and Staff 37 (CNA) all stated the resident was able to state her/his needs. The resident was known to make false accusations regarding staff not providing care, when in fact the staff provided the care or request. The resident was known to be hyper-focused and hyper-sensitive. They preferred to have another staff person in the room when providing ADL care, due to the resident's accusations. On [DATE] at 1:15 PM Staff 11 (RNCM) and Staff 51 (LPN/RCM) acknowledged and agreed the resident care plan should be updated to reflect the resident was known to make accusations and staff would prefer too staff persons in the room while providing ADL care. 3. Resident 15 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] care plan revealed Resident 15 had mixed incontinence and she he used a bedpan if requested. A [DATE] Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx which reached both the left and right buttocks. Resident 15's bed pan was changed to a fracture pan (has tapered end for easier placement). On [DATE] at 10:32 AM Staff 11 (RNCM) stated the fracture pan would need to be included somewhere to communicate to staff to use the fracture pan. Staff 11 stated she would check if the information was added somewhere in the documentation. No additional information provided the fracture pan was added to the care plan.",2020-09-01
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), [MEDICAL CONDITION] activity with [DIAGNOSES REDACTED] (low potassium in the bloodstream). Resident 4 indicated she/he was given too much insulin at the nursing facility. - Resident 4 developed [MEDICAL CONDITION] (abnormal heart rhythm characterized by rapid and irregular beats) and her/his lactic acidosis (an overproduction of lactic acid) was elevated, likely due to her/his low blood sugar. 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. On [DATE] the nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what the order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how (she/he) called for help, but did. The same nurse that administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he feeling shaky. She stated she took the resident's blood sugar and the reading was low, that's when she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 not to administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. On [DATE] at 11:42 AM Staff 2 (DNS) stated she would expect staff to utilize subjective data especially related to physician orders. She stated when a resident tells the nursing staff a medication does not look right or dosage does not sound right staff should stop and follow up on the questioning before administering the medication. 2. Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. 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]. -The investigation indicated Staff 36 spoke with the Witness 5 (Complainant) and she reported Resident 5 was placed in the sit to stand (used to assist with mobility for patients that are unable to transition from a sitting position to a standing on their own) to be toileted and only one CNA, Staff 43 (CNA) was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called the witness and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed 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 died . Staff 40 had to go down and exchange the batteries. Upon Staff 40's return the resident stated My legs are giving out and instead of using the sit-to-stand machine Staff 43 and Staff 40 both controlled lowered the resident to her knees and then laid the resident with pillows under her head . A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 (LPN) revealed Resident 5 continues to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist . Hospital records dated [DATE] revealed Resident 5 had a mildly displaced right [MEDICAL CONDITION]. On [DATE] at 9:51 AM Staff 43 (CNA) stated she worked night shift, which started 10:00 PM at night and she recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 (CNA) got the resident up in the sit to stand and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either, so Staff 40 had to go a little farther down the hall to get a second battery and that one was not good either. Staff 43 stated two sets of batteries and both were dead. She indicated the batteries were often dead in the sit-to stands you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower her back down into the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about 2 minutes before she and Staff 40 lowered the resident to the ground manually, we took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer (mechanical lift) sling (a device used to suspend a resident in the Hoyer and move them appropriately) that was not underneath the resident when they lowered her manually to the floor, so we had to log roll the resident on the floor to get the Hoyer sling underneath the resident. We then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand station prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time that she was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 (LPN) came into the room and sent the resident out to the hospital. An observation on [DATE] at 8:34 AM revealed the sit to stands, hoyers, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. On [DATE] at 5:17 PM Staff 44 (LPN) worked night shift was familiar with Resident 5 and indicated she was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 (CNA) and Staff 43 (CNA) reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the battery died in the sit to stand machine and they had to manually lower the resident to the floor as they lowered the resident to the floor, the resident's hip could have spontaneously fractured her/his hip. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. On [DATE] at 11:33 AM Staff 1 (Administrator) acknowledged they did not have a system in place at the time of the incident related to assuring batteries were charged out appropriately after each shift. On [DATE] at 3:14 PM he stated maintenance does weekly checks to assure batteries are working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated this was implemented last week. -Refer to F689, F908",2020-09-01
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,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 would offer to shave the resident facial hair if she noticed any on her/his face hair. On 6/3/19 at 1:25 PM Staff 37 (CNA) stated she had showered the resident and liked to know her/his bathing days. The resident preferred her/his facial hair to be trimmed with scissor and could be sensitive regarding this area. She stated she did not recall the last time she trimmed the resident's facial hair. On 6/5/19 at 1:38 PM Staff 50 (CNA) stated she worked with Resident 6 often and the resident would get upset when her/his whiskers were too long, the resident would ask for them to be trimmed. Staff 50 indicated she had completed this recently. She further indicated the resident was very sensitive about her/his facial hair. On 6/6/19 at 1:15 PM Staff 11 (RNCM) and Staff 51 (LPN/RCM) stated CNAs should offer to shave facial hair when the resident were provided a shower and showers were typically a minimum of two times a week. Both acknowledged the concern regarding Resident 6's facial hair. 3. Resident 8 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. a. A 1/15/19 care plan revealed Resident 8 had an ADL self-care performance deficit and limited mobility. The care plan instructed staff to offer assistance with shaving daily in the morning. A 2/28/19 Quarterly MDS revealed Resident 8 brief interview of mental status score was a 15 indicating she/he was cognitively intact. The current Kardex (instructions for direct care staff) revealed Resident 8 required one person extensive assistance with personal hygiene care. The Kardex instructed staff to offer shaving in the morning. A 4/2019 Documentation Survey Report revealed Resident 8 was shaved on 4/13/19 and 4/27/19 for the month of April. A 5/2019 Documentation Survey Report revealed Resident 8 was shaved on 5/4/19 and 5/11/19 for the month of May. On 5/22/19 at 10:43 AM Resident 8 stated she/he had to beg to get shaved. On 6/3/19 at 8:32 AM Resident 8 was in her/his wheelchair in the hall with facial hair approximately a quarter of an inch long. On 6/4/19 at 9:02 AM Resident 8 was observed with facial hair approximately a quarter of inch long. On 6/5/19 at 8:05 AM Resident 8 was observed in her/his wheelchair in the hall wearing the same clothes as the previous day and continued to have facial hair. On 6/5/19 at 8:32 AM Staff 25 (CNA) stated she thought staff were afraid to shave her/him. On 6/5/19 at 9:55 AM Staff 11 (RNCM) stated Resident 8 did refuse care and for each refusal CNAs should obtain a signed form from the resident for the refusal. On 6/6/19 at 8:17 AM Staff 11 stated no refusal forms were signed by Resident 8 for refusal of shaving. b. A 1/15/19 care plan revealed Resident 8 had an ADL self-care performance deficit and limited mobility. A 2/28/19 Quarterly MDS revealed Resident 8 brief interview of mental status score was a 15 indicating she/he was cognitively intact. The current Kardex (instructions for direct care staff) revealed Resident 8 required one person extensive assistance with personal hygiene care and to provide supervision with brushing teeth. A 4/2019 Documentation Survey Report revealed from 4/1/19 through 4/30/19 it was documented Resident 8 refused oral care 26 instances out of 42 opportunities. A 5/2019 Documentation Survey Report revealed from 5/1/19 through 5/21/19 it was document Resident 8 refused oral care 25 instances out of 42 occurrences. On 5/22/19 at 10:43 AM Resident 8 stated she/he had to beg to receive oral care. On 5/31/19 at 10:01 AM Staff 5 (CNA) stated Resident 8 did not refuse care. Staff 5 stated when she did not have enough time to assist Resident 8 with oral care she would document oral care as refused. On 6/5/19 at 8:32 AM Staff 25 (CNA) stated Resident 8 would refuse oral care sometimes. Staff 25 stated when she did not have enough time to assist Resident 8 with oral care she would document oral care refused. On 6/5/19 at 9:55 AM Staff 11 (RNCM) stated Resident 8 did refuse care and for each refusal CNAs should obtain a signed form from the resident for the refusal. On 6/6/19 at 8:17 AM Staff 11 stated no refusal forms were signed by Resident 8 for refusal of oral care.",2020-09-01
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 4/16/19.",2020-09-01
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 Staff 37 was in the assisted dining when Staff 38 checked on the resident and called 911. An Accident/Incident Interview Form dated [DATE] revealed Staff 39 was alerted, by Staff 38 while she was in the residents room to check her/his blood sugars. Staff 39 entered the room with Staff 38 and the resident was making a gurgling sound. Staff 39 was asked to get the crash cart (a wheeled container carrying medicine and equipment for use in resuscitation) and by that time Staff 36 (Interim DNS) joined her in the room. Staff 36 and Staff 39 removed the resident's many pillows, laid the resident's head down enough to roll the resident onto her/his side. Staff 39 cupped the resident's back and performed finger sweeps per Staff 36's instruction and removed the resident's dentures and mucus. Two other CNAs were holding the resident and nurses were getting the suction machine together. Resident 5 stopped making noise as medics entered the room. An undated form typed out and signed by Staff 38 indicated on [DATE] she was working on the 200 hall and around 7:00 AM the nurse from the 300 hall needed assistance with treatments and Staff 37 reported to Staff 39 the resident was breathing heavily. Staff 39 was very busy and did not pass the message on to me (Staff 38). Staff 38 stated she entered Resident 5's room at approximately 8:00 AM as the breakfast trays were coming down the hallway. Staff 38 indicated she discovered the resident needing immediate attention, as the resident was unable to clear the fluid in her/his throat. An Investigation Note dated [DATE] conducted by Staff 36 (Interim DNS) revealed the following: -At approximately 8:00 AM on [DATE] Resident 5 had a change of condition with wet respiration's at a rate of 24 to 26 respirations per minute. The residents heart rate was 80 to 84 beats per minute. -Staff 37 last saw the resident at 7:00 AM and reported to Staff 39 Resident 5 was breathing hard. Interview of Staff 39 stated she/he was snoring, this was normal. -Staff 36 believed it was approximately 8:20 AM and Staff 38 alerted him Resident 5 needed suctioning. Staff 36 went to the resident's room and Staff 39 assisted to turn the resident on her/his right side while Staff 36 went to get the suction machine and AED (automated external defibrillator). -Staff 39 removed the resident's false teeth and cleared the resident's mouth. Prior to Staff 36 leaving the room to retrieve the suction machine and AED the resident's heart rate was 80 to 84 beats per minute with wet respirations at 24 to 26 respirations per minute. The resident was not responding even when repositioned. -Staff 36 was headed down the hall to get the suction machine and AED, the paramedics arrived and were given a report. Staff 39 indicated Resident 5 took her/his last breath just as the paramedics entered her/his room. -The paramedics performed life saving procedures which were unsuccessful and Resident 5 passed away. In an interview on [DATE] at 8:00 AM Staff 17 (CNA) stated she worked the night shift on [DATE] and stated she recalled the resident having a difficult time breathing and her/his breaths were closer together. In an interview on [DATE] at 1:32 PM Staff 37 stated the morning of [DATE] she remembered checking on the Resident 5 around 6:30 AM to see if the resident was awake and the resident's breathing sounded like a chain smoker, the resident would stop breathing for a moment and then start up again. The resident was making a moaning sound and this breathing pattern repeated. She stated the night shift reported to her Resident 5 was having a hard time breathing and restless sleep. Staff 37 tried to ask the resident if she/he was ok, however the resident would not respond. It was like the resident was in a deep sleep, like an unconsciousness state. She stated she reported this to Staff 39 and Staff 39 was going to report to the nurse right away. In an interview on [DATE] at 11:01 AM Staff 38 (RN) stated the morning of [DATE] Staff 37 did not report anything to her regarding Resident 5 having difficulty with breathing. Staff 38 entered Resident 5's room around 8:00 AM to administer her/his insulin and the resident was unresponsive, breathing but very heavy and wet breathing. Staff 38 attempted to arouse Resident 5 but she/he was unresponsive. She immediately went and got help. She first spoke with Staff 39 and stated the resident did not sound good and then retrieved Staff 36. Staff 36 stayed in the room to assist with the resident while she called 911. Paramedics arrived and took over. The paramedics stopped life saving procedures at approximately 8:20 AM. In an interview on [DATE] at 2:44 PM Staff 36 stated Staff 38 came to his office at approximately 7:55 AM and indicated Resident 5 was not acting right. He arrived and entered the resident's room and the resident's breathing was 18 to 20 breaths per minute, very wet and her/his heart rate was 80 to 84 beats per minutes. Multiple staff were in the room and the resident was not responding to anything verbal. He directed an RN to check the resident's blood sugar and he went to retrieve the AED and suction machine. On his way back to the room the paramedics arrived, took over and began cardiopulmonary resuscitation (CPR). Staff 36 further stated in his investigation he recalled Staff 37 reported to Staff 39 Resident 5 was breathing funny. When he spoke with Staff 39 she indicated Resident 5 always snored and breathed heavy in the morning and that was normal. He further indicated after his investigation he felt Resident 5 had no change of condition and felt the incident happened suddenly and staff responded appropriately. On [DATE] at 12:54 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the failure to promptly identify and intervene for an acute change of condition for Resident 5. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately protect residents from having a delay in assessment when an acute change of condition occurred which could result in a resident's death. On [DATE] at 8:37 PM a final immediate plan of correction was received from the facility. The facility's abatement plan of correction included: -Inservices to be completed with all CNA and CMA staff regarding alerts in the electronic system and that all identified changes are put into an alert for Licensed Nurse (LN) follow-up and for significant changes of condition (resident short of breath, stopped breathing, loss of consciousness, had a critical vital sign) to walk the nurse to the room. -Inservices to be completed with all LN staff regarding change of condition, including notification to the responsible party and provider, to check the dashboard (the electronic medical record) frequently, at a minimum every shift and to monitor for alerts triggered by CNA/CMA staff. -Inservice to be completed with Resident Care Manager (RCM) regarding monitoring of 24 hour report daily to ensure all noted changes have a change of condition completed and follow up is addressed and all education to be provided by DNS or RN designee via face to face or phone/verbal prior to clocking in or being present in resident areas. -Date of compliance [DATE]. -DNS responsible for assuring compliance. On [DATE] at 2:30 PM the facility's implementation of the abatement plan was verified with staff interviews to ensure the staff were educated on a change of condition. On [DATE] at 10:19 AM the Staff 1 and Staff 2 were notified the immediate jeopardy was implemented removing the immediate risk to resident's health and welfare. 2. Based on interview and record review it was determined the facility failed to implement and follow physician orders [REDACTED].#s 1, 14 and 20) reviewed for pressure ulcers and medications. This placed residents at risk for delayed treatments and unmet needs. Findings include: a. Resident 1 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A review of the ,[DATE] TARS revealed the following: -A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the right ischial tuberosity (the sit bones) and cover with a non-adhesive foam dressing every day shift, evening shift and as needed. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the coccyx (the tailbone) every shift. -Records revealed on evening shift no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (antifungal) cream two percent to the face topically two times a day for seborrheic (crust or scale on the skin) [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (corticosteroid) .025 percent topically to the face two times daily for seborrheic [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE],,[DATE],,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to check oxygen saturation every shift. -Records revealed no checks were completed on evening shift or night shift for ,[DATE] or ,[DATE]. A ,[DATE] TAR instructed staff to administer oxygen at two liters per nasal cannula continuous every shift. -Records revealed no oxygen saturations were checked or completed on evening shift ,[DATE], ,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected to follow physician orders. A review of the ,[DATE] TARs revealed the following: A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] cream to the scrotum, inner thighs topically every shift for irritation, fungal infection and itching until resolved. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] to the coccyx (the tailbone) every shift for preventative care and a history of skin break down. -Records revealed no treatments were provided on ,[DATE], ,[DATE] and ,[DATE]/. A ,[DATE] and ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (a mild antiseptic) [MEDICATION NAME] to the Left Hallux (big toe) topically every day and evening shift for skin care. -Records revealed no treatments were provided on: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to document sleep every shift while the resident was on a stimulant. -Records revealed not documentation was completed on ,[DATE],,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments noted above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected staff to follow physician orders. b. Resident 20 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the facility's Bowel Care Protocol, revealed residents who did not have a bowel movement (BM) would be identified and placed on a BM report. -Evening shift would run the look back report for residents who did not had a bowel movement for two consecutive days. -Evening shift staff would administer Milk of Magnesia (a laxative) if no results, then; -Day shift would administer a suppository if no results, then; -Fleet enema would be given. If no results, complete a focused assessment of the abdomen and complete a digital exam and notify the doctor if needed. -Suppositories and enemas are not to be given on night shift unless it is a resident's request. Review of Resident 20's bowel records revealed from [DATE] through [DATE] (four days) and [DATE] through [DATE] (four days) Resident 20 did not have BMs documented. Review of the ,[DATE] MARs revealed Resident 20 did not receive Milk of Magnesia (MOM) per Bowel Care Protocol. On [DATE] at 1:02 PM Staff 11 (RNCM) acknowledged the bowel protocol was not followed. c. Resident 14 was admitted to the facility in with [DIAGNOSES REDACTED]. [DATE] and [DATE] physician orders [REDACTED]. A ,[DATE] MAR indicated [REDACTED]. On the following days Resident 14's blood pressure or heart rate was not checked before administering the medication: -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. No other documentation was found in the clinical record Resident 14's blood pressure or heart rate was checked as ordered on the above dates. On [DATE] at 10:27 AM Staff 11 (RNCM) stated she would review for additional information. No additional information was provided.",2020-09-01
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 admission opened to reveal a Stage 3 (full thickness tissue loss, slough may be present but does not obscure the depth to tissue loss). A skin and Wound Evaluation was not completed until 15 days after Resident 20 admitted to the facility. A Skin and Wound Evaluation dated 5/21/19 indicated an unstageable pressure ulcer with slough and eschar. Wound measurements were 3.3 cm x 2.5 cm x 0.5 cm. The wound bed had 60 percent granulation, 30 percent slough and 10 percent eschar. There was evidence of infection with increased drainage, a moderate amount of exudate, and [MEDICAL CONDITION] (a mixture of serum and pus). Odor was moderate after cleansing. The resident was noted to have intermittent pain. Additional notes indicated a moderate purulent odor after cleansing the wound when performing the weekly wound assessment. The provider was notified and a new order was placed for Keflex (antibiotic). Resident 20 was referred to a wound center. A 5/2019 TAR instructed staff to complete the following treatment to the coccyx: - Order date of 5/13/19 directed staff to cleanse pressure wound to the coccyx with wound cleanser place calcium alginate (an absorbent wound dressing) to the wound bed and cover with a [MEDICATION NAME] (a moist dressing/bandage)every three days on day shift with a discontinue date of 5/14/19. -The treatment was not completed until 5/14/19 and no treatment was in place until 15 days after Resident 20 admitted to the facility. On 6/5/19 at 1:19 PM Staff 11 (RNCM) acknowledged no wound orders, treatments or weekly skin wound evaluations were in place for Resident 20 until 5/14/19 (15 days after the resident admitted to the facility). She acknowledged the wound worsened since the residents admission. She further stated Staff 15 (LPN) should have put an order in for the treatment of [REDACTED]. 2. Resident 15 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. a. A 4/19/19 Admissions MDS revealed Resident 15 was at risk for pressure ulcers and she/he did not have any wounds. Interventions included a pressure relieving device for the chair and the bed. 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. The scabbed shearing was a 2 x 7 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks, the bed pan was changed to a fracture pana (shallow vessel used for defecation or urination by patients confined to bed). A 5/2019 TAR instructed staff to complete the following treatments to the bilateral buttocks/coccyx: -Order date of 5/2/19 monitor healing every shift and report signs and symptoms of infection or worsening with a discontinue date of 5/8/19. -Order date of 5/8/19 cleanse shear wound with wound cleanser and cover with foam dressing. No treatments were completed as resident was out of the facility on 5/9/19. A 5/8/19 Skin and Wound Evaluation revealed Resident 15 had a facility aquired unstageable pressure ulcer to the coccyx with a start date of 5/1/19 covering an area of 9.4 square cm. Measurements were 6 cm length x 4.4 cm width x .3 cm depth, with slough (a layer or mass of dead tissue). Notes stated it was likely due to a shear injury from using a slide-board to transfer the resident. No documentation was found in the clinical records an assessment was completed for the skin impairment before 5/8/19 by an RN. On 6/5/19 at 10:43 AM Staff 11 (RNCM) stated she would look for additional information on the wound. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated there were discrepancies in the wound description and the first staff member who described the wound was an LPN, who was not authorized to stage pressure ulcers. b. 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. The 5/7/19 notes described the wounds as scabbed shearing with a 2.0 x 7.0 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks. On 6/5/19 at 10:40 AM Staff 11 (RNCM) stated the investigation was completed on 5/7/19 and she would expect an investigation to be completed within five days of the start of the investigation. 3. Resident 23 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. a. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 Physician order [REDACTED]. A 4/2019 TAR instructed staff to cleanse the coccyx wound, apply skin prep and medicated gel then cover with foam dressing every day shift every other day. On 4/27/19 the treatment was not completed. A 5/2019 TAR instructed staff to cleanse the coccyx with wound cleanser, apply collagen to the wound base then cover with foam dressing every day shift every other day with a order date of 4/29/19. On 5/5/19 the treatment was not completed. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. b. A 3/20/19 physician progress notes [REDACTED]. A 4/7/19 physician order [REDACTED]. A 4/12/19 Skin and Wound Evaluation revealed Resident 23 had a facility acquired Stage 2 pressure ulcer to the left heel with an area of 6.4 square cm and measurements of x 3.5 cm length x 2.6 cm width x .2 cm depth with 40 percent granulation (new tissue), 50 percent slough (dead tissue) and 10 percent eschar (cast off dead tissue). A 4/2019 TAR instructed staff to cleanse the left heel with wound cleanser, apply medicated gel and cover with foam dressing every day shift every other day, with an order date of 4/5/19. On 4/9/19 the TAR indicated to refer to nurses notes. On 4/18/19 the treatment was not completed to the left heel. A 4/9/19 Nurses Note revealed Resident 23 was not in her/his room. No documentation was found in clinical records Resident 23 received physician ordered treatment to her/his left heel on 4/9/19 and 4/18/19. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. Multiple attempts should be completed for wound care and if missed the physician should be notified. c. A 3/20/19 physician progress notes [REDACTED]. No documentation was found in clinical records Resident 23's Stage 2 pressure ulcer was investigated within the five days as per policy. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed. d. A 3/20/19 Skin Impairment revealed upon assessment by the physician Resident 23 was found to have a suspected deep tissue injury on her/his left heel measuring 4 cm by 2.2 cm by unknown depth. Notes dated 6/3/19 included in the investigation revealed on 4/2/19 there was an open area to the left heel. On 4/5/19 the RNCM assessed the wound and a new order for routine wound care implemented. Abuse and neglect was not substantiated. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. e. A 3/14/19 Admissions MDS revealed Resident 23 was at risk of developing a pressure ulcer, did not have a pressure ulcer with interventions of pressure reducing device for the chair and the bed. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 physician order [REDACTED]. A review of the resident's clinical record revealed no explanation, root cause analysis or investigation related to the development of the Stage 2 pressure ulcer identified on 3/20/19 to rule out abuse or neglect. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed.",2020-09-01
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 about 3:30 AM Staff 43 (CNA) was walking to take the resident to the bathroom. Staff 43 went into the room and the resident started yelling like in pain. Resident 58 heard the resident state she was falling and stated it was after this the resident started yelling. -The investigation indicated Staff 36 was informed Resident 5 was sent out to the hospital at 3:30 AM and the day shift nurse stated the emergency department informed the staff the resident would not return due to a right [MEDICAL CONDITION]. -Per chart review Witness 5 reported Resident 5 was placed in the sit to stand lift to be toileted and only one CNA, Staff 43 was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called Witness 5 and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed on [DATE] indicated Staff 43 and Staff 40 (CNA) were both transferring the resident to the bedside commode when the battery on the sit-to-stand machine died . Staff 40 left the room to 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 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. -The resident was in bed for approximately 20 to 30 minutes and began calling out in pain and Staff 44 was advised to send the resident to the hospital. Staff 44 reported to Staff 36 that Staff 40 and 43 indicated to her the resident did not fall. Staff 44 indicated to Staff 36 she did not know how to use the sit to stand machine. -X-rays from the hospital revealed a mildly displaced right intertropchanteric (hip) fracture. Non-displaced (the broken bones remain aligned) right proximal (just below the knee) fibular (the smaller shin bone) fracture. The report indicated irregularity in the posterior aspect of the medial tibial (large shin bone) plateau may represent a non-specific fracture, given the amount of osteopenia, consider non-emergent MRI (magnetic resonance imaging) of the right knee for further characterization. -The root cause: Fracture during transfer. It is reasonable to believe related to statements that the fracture occurred either upon rising with sit to stand or lowering to floor related to [MEDICAL CONDITION] (degeneration of the joints) and osteopenia (reduced bone mass). The care plan and Kardex (a tool utilized for CNAs to provide care) were followed and abuse and neglect could not be substantiated or unsubstantiated related to the sit to stand machine and Staff 40 leaving the room to get the battery. An undated form had three separate statements from Staff 44, Staff 40 and Staff 43 and revealed the following: -Staff 43 stated she and Staff 40 were using the sit to stand machine to get the resident up and transferred to the bathroom. The battery on the machine died . Staff 40 went down the hall to exchange the battery. The resident stated to Staff 43 my legs are giving out and at that point Staff 40 returned and instead of using the machine they both manually lowered the resident to her/his knees and then laid the resident out with a pillow under her/his head. Staff 44 arrived and helped move the resident's bed away from the wall so they could used the Hoyer lift instead. -Staff 40 stated he went to the end of the hall to obtain a new battery for the sit to stand machine. When he returned he helped Staff 43 slowly lower the resident to her/his knees and then to the ground with pillows under the resident's head. Staff 40 stated they had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave her/him a pain pill. The resident was still in pain after they moved the resident into bed. -Staff 44 stated she came around the corner and saw Staff 40 down the 200 hall and could hear the resident yelling at the end of the hall. Staff 40 was getting a new battery for the sit to stand machine. Staff 44 entered the room and the resident was on the floor with the Hoyer sling by her/his bed. The resident was complaining of leg pain. Staff 44 assisted the two CNAs with getting the resident back into bed. Resident 5 was watching TV comfortably for ,[DATE] minutes until the resident began calling out in pain. Staff 44 called the on call physician and was advised to send the resident to the hospital. Staff 44 stated the aides told her the resident did not fall, and Staff 44 did not know how to use the sit to stand machine. A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 revealed Resident 5 continued to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand machine to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist. No noted injury at this time. Resident continue to complain of pain, 'pain all over honey.' Observed bilateral lower extremity for injury, increased [MEDICAL CONDITION], redness and heat. No noted changes. Resident does not use her/his lower extremity so no range of motion was not observed. Reassured and redirected without success. Pain medication was given, yet resident continues to yell and states staff doesn't like her. Call made to on call physician and resident was sent out to the emergency department for evaluation and treatment. Resident was aware of the plan, Witness 5 was notified. Hospital records dated [DATE] through [DATE] revealed Resident 5 had a history of [REDACTED]. The resident resided at an assisted living facility and said that she/he had an incident when they were transferring her/him to the bathroom. According to Witness 5 the resident had been non-ambulatory since 2012. On [DATE] at 9:51 AM Staff 43 stated she worked night shift, which started at 10:00 PM. She recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 got the resident up in the sit to stand machine and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either. Staff 40 had to go a little farther down the hall to get a second battery and that one was also not working. She indicated the batteries were often dead in the sit-to stand machine you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower the resident back down onto the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about two minutes before she and Staff 40 lowered the resident to the ground manually, and they took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer sling that was not underneath the resident when they lowered the resident manually to the floor, so they log rolled the resident on the floor to get the Hoyer sling underneath the resident. They then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand machine prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time, that she/he was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 came into the room and sent the resident out to the hospital. On [DATE] at 8:00 AM Staff 17 (CNA) stated she worked night shift and worked on the evening of [DATE] when Resident 5 had her/his fall, however she was assigned another hallway. She indicated she had worked with the resident on multiple occasions and the resident was alert and oriented and on occasion would have some confusion. Staff 17 stated the resident did not scream and holler to her knowledge during the night shift. The resident was a two person sit to stand transfer and indicated the batteries for the sit to stand machine were located at the front of the hallway next to the scale and the resident's room was at the very end of the hall. She indicated when the batteries start to run low the machine would stop and go. She always carried an extra battery pack with her for a back up. On [DATE] at 9:29 AM Staff 5 (CNA) stated she worked with Resident 5 on multiple occasions, however was not present on [DATE]. She stated the resident was a two person sit to stand transfer. She stated they utilized an under arm sling for the resident when in the sit to stand, the resident bared weight with her legs, although could not for very long. If the batteries in the sit to stand ran low the machine would get more sluggish and a few of them would make a chirping noise. She stated if the batteries died the sit to stand had an emergency lever to utilize and you could get the resident back to a safe area and lower the resident back down safely. She indicated the batteries were to be changed at beginning of every shift, however this did not always happen. An observation on [DATE] at 8:34 AM revealed the sit to stand, and hoyer lifts, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. Resident 5's room was at the very end of the hallway on the right hand side. On [DATE] at 9:11 AM Witness 18 (Family Member) visited Resident 5 often and indicated she went to the hospital after Resident 5 had a fall on [DATE] and Witness 18 was told the resident needed to use the bathroom and only one CNA was present. The CNA attempted to get the resident up in the sit to stand machine, which the resident required two CNAs for a transfer. She stated Resident 58, who was up that night, heard what was going on and recorded the incident. Witness 18 stated apparently the batteries went dead on the sit to stand machine and the resident was only half way in the sit to stand machine and screaming she was falling. Resident 5 was 300 pounds and there would be no way the resident would have a graceful fall to the floor. Witness 18 stated a call was placed to Witness 5 regarding the resident having a possible infection and the facility sent the resident out to the hospital. Witness 18 indicated she found the facts disturbing and not adding up. The recording she listened to she could hear the resident screaming in pain and only heard one CNAs voice on the recording. On [DATE] at 5:17 PM Staff 44 worked night shift, was familiar with Resident 5 and indicated she/he was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. She did not recall seeing any other staff with Staff 43 at that time. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her/his low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. In an interview and observation on [DATE] at 8:39 AM Staff 41 (CNA) stated she was familiar with Resident 5 and indicated she/he could direct her/his own care but at times could be forgetful. She was not present when the fall occurred on [DATE] though indicated the resident was a two person sit to stand for all transfers. They would utilize the sit to stand to get the resident to the bathroom. The resident could bear weight on her/his feet when in the sit to stand and also utilized her/his arms for support. She indicated the sit to stand lifts are battery operated and she would personally change the batteries out at the beginning of her shift. When the batteries are getting low some would make a beeping noise. She further stated they also had an emergency lever you could utilize to lower the resident down safely if the battery went dead. Staff 41 showed the surveyor the sit to stand machine and the red emergency lever that was on each one and demonstrated how to utilize the button. The machine lowered down once a CNA pressed the emergency lever. On [DATE] at 2:09 PM Resident 58 stated she/he was awake the night of [DATE] when Resident 5 fell . She/he stated her/his door was partially cracked open and she/he saw Staff 43 walking in front of the resident who was in her/his electric wheelchair and they were going to the resident's room. Resident 58 stated she/he was across the hall and down a couple doors. She/he indicated she/he could hear the resident hollering I am falling, I am falling and Staff 43 stated your not falling, you always say this. She/he then heard Staff 43 hollering that she needed help and stated this a couple of times. The resident saw Staff 40 running down the hall towards the resident's room. The resident was crying out in pain and asking for Witness 5 so Resident 58 phoned the witness and alerted her of what she/he heard. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 and Staff 43 reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the batteries died in the sit to stand machine and they had to manually lower the resident to the floor. Staff 36 stated as the CNAs lowered the resident to the floor, the resident's hip could have spontaneously fractured. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. Staff 36 further indicated both CNAs got the resident back into bed and Staff 44 administered pain medication to the resident and the resident had pain for approximately ,[DATE] minutes and then the resident started screaming in pain and the resident was sent out to the hospital. On [DATE] at 11:33 AM Staff 2 (DNS) was present and Staff 1 (Administrator) stated he helped with the investigation and interviews. Staff 40 and 43 had similar statements regarding the controlled fall on [DATE]. He indicated neither Staff 40 or 43 explained how they removed Resident 5 from the sit to stand machine other than they manually lowered the resident to the floor. He acknowledged they did not have a system in place to ensure batteries were charged appropriately or changed out after each shift by CNAs. He also indicated maintenance should check the batteries on a regular basis but was unable to find any documentation this occurred. On [DATE] at 3:14 PM Staff 1 stated maintenance did weekly checks to assure batteries were working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated that was implemented the week prior to [DATE].",2020-09-01
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 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 and changed the resident's brief and reposition the resident. On 6/5/19 at 1:19 PM Staff 11 (RNCM) stated her expectation was for staff to answer call lights timely and indicated if a CNA tells a resident they will be right back for a brief change then this should be prioritized and staff should follow through. On 6/19/19 at 2:38 PM Staff 1 (Administrator) and Staff 2 (DNS) stated that for residents that have incontinence issues they expected staff to check on those residents anytime they are doing rounds and make sure they are clean and dry. Staff 2 further stated Staff 45 who checked on Resident 20 at 1:45 PM should have returned, changed the resident's brief and repositioned the resident.",2020-09-01
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 from 11/2018, 12/2018 through 1/2019 revealed the following: -From 11/1/18 through 11/5/18 no oxygen saturations were monitored (five days). -On 11/6, 11/9, 11/12, 11/13 and 11/26/18 oxygen checks saturation were only completed one time. -From 11/30/18 through 12/9/18 no oxygen saturations were monitored (10 days). -From 12/17/18 through 12/21/18 no oxygen saturations were monitored (five days). -From 1/1/19 through 1/3/19 no oxygen saturations were monitored (three days). -From 1/7/19 through 1/11/19 no oxygen saturations were monitored (five days). 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 5 appropriately.",2020-09-01
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 and changed the resident's brief and reposition the resident. On 6/5/19 at 1:19 PM Staff 11 (RNCM) stated her expectation was for staff to answer call lights timely and indicated if a CNA tells a resident they will be right back for a brief change then this should be prioritized and staff should follow through. On 6/19/19 at 2:38 PM Staff 1 (Administrator) and Staff 2 (DNS) stated that for residents that have incontinence issues they expected staff to check on those residents anytime they are doing rounds and make sure they are clean and dry. Staff 2 further stated Staff 45 who checked on Resident 20 at 1:45 PM should have returned, changed the resident's brief and repositioned the resident. b. On 5/22/19 at 10:43 AM Resident 8 stated she/he to beg to get shaved and to receive oral care. Resident 8 stated she/he had waited for assistance to use the toilet and could not wait any longer and urinated her/himself. On 5/24/19 at 9:43 AM Staff 32 (CMA) stated she worked on all the halls however on 100 hall she often ran behind with her medication pass. She stated they run short of staff regularly and staff called in or did not show up for work. On 5/29/19 at 2:40 PM Staff 48 (LPN) stated they were short staffed a lot, especially CNAs for day shift and night shift. On 5/29/19 at 3:05 PM Staff 8 (CNA) stated she worked on 100 and 200 halls and the facility was understaffed on 5/29/19 with not enough CNA coverage. Call lights were up to a 30 minute wait for residents and she stated I try to give great care. She further stated meal times were difficult because one of the CNAs was pulled from the hall to assist in the dining area and it took away a CNA on the floor to provide ADL care. On 5/31/19 at 10:01 AM Staff 5 (CNA) stated on 5/30/19 the facility mandated an day shift to stay into evening shift to cover to make sure there was enough staff for evening shift but after she left there was only two people for 26 to 27 residents. Staff 5 stated it was very common for residents to complain about long call light wait times. Staff 5 further stated when there was not enough staff residents did not receive their showers and oral care. On 5/31/19 at 1:31 PM Staff 49 (CNA) stated she worked all halls, however the 200 hall was the hardest due to the residents needs on the hall, most were extensive assist with two person assist and use of the Hoyer. She indicated they were always behind and call lights wait times could be up to 15 minutes or longer. On 6/3/19 at 8:03 AM Resident 22 stated there was no sound with the call lights and she/he just turned off her/his call light after 30 minutes of waiting as it upset her/him to wait that long. Resident 22 stated she/he soiled her/himself multiple times when she/he had diarrhea and the staff would not come quick enough. On 6/3/19 at 8:45 AM Staff 17 (CNA) stated she worked on the 100 and 200 hall and various shifts. The 200 hall was very difficult due to the acuity of residents and their ADL care needs. From a safety standpoint it was very challenging. She further stated call lights could take up to 20 minutes or longer to answer. On 6/3/19 at 9:07 AM Staff 5 (CNA) stated she worked swing shift and they were short staffed often. Call light wait times could be up to a 30 minute wait. The 200 hall had high acuity residents with extensive one and two person assist. Many of the residents on the 200 hall required the use of the hoyer and that took additional time because two staff were needed for those transfers. On 6/5/19 at 8:32 AM Staff 25 (CNA) stated the facility was short staffed and she would be assigned to eight or nine residents on day shift. Residents complained about long call lights wait times. Staff 25 also stated she was mandated to work overtime due to the facility being short staffed. On 6/5/19 at 12:05 PM Resident 24 stated she/he waited 45 minutes for a call light to be answered and could wait no longer and ended up using the garbage can to urinate in. Resident 24 stated another instance before going to therapy she/he turned on the call light and when she/he returned from a therapy session the call light was still on. Resident 24 stated she/he waited another 20 minutes after returning to the room for assistance.",2020-09-01
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,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,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 monitoring was discontinued on 2/8/19. A 2/2019 Documentation Survey Report revealed the following for Intervention/task for Resident 8: -Behaviors: Verbally aggressive to staff, sexually inappropriate, refused care, swears, calls names and physically aggressive to other residents. -Triggers: lonely, bored, jealously and agitation with others. -Interventions: Redirect to quiet area, change position, return to room, leave room and return, one on one interaction and toilet. -On 2/6/19 no behavior was documented. From 2/8/19 through 2/28/19: -Two instances of abusive language. -Four instances of yelling and screaming. -Two instances of sexually inappropriate behavior. No information was found in the clinical records Resident 8 care planned interventions were implemented for her/his behaviors after 2/8/19. On 6/5/19 at 9:55 AM Staff 11 (RNCM) stated she would expect staff to continue to complete interventions for behaviors for Resident 8.",2020-09-01
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,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,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