cms_OR: 20

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
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