cms_OR: 87
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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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 |