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| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1657 | 1657 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2019-02-22 | 578 | E | 0 | 1 | J6TU11 | Based on interview and record review it was determined the facility failed to assist residents with advance care planning and to review advance directive information during resident's care conferences for 4 of 4 sampled residents (#s 2, 17, 23 and 35) reviewed for Advance Directives. This placed residents at risk for healthcare decisions in conflict with resident wishes. Findings include: During initial record reviews no Advance Directives or refusals were located for Residents 2, 17, 23 or 35. No documentation was found in the medical records to indicate if residents had requested assistance with an Advance Directive and received assistance or documentation if they had declined an Advance Directive. On 2/21/19 at 5:48 PM Staff 10 (Social Service Director) indicated there were no Advance Directives for Residents 2, 17, 23 or 35 and there was no documentation in the residents' medical records to indicate Advance Directives had been discussed with the residents. | 2020-09-01 |
| 1658 | 1658 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2019-02-22 | 580 | D | 1 | 1 | J6TU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure timely notification to a physician for a change of condition for 1 of 1 sampled resident (#29) reviewed for falls. This placed residents at risk for unmet needs. Findings include: Resident 29 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The care plan dated 9/12/18 for fall prevention included non-skid footwear, frequent safety checks and the use of bed and chair personal alarms (sounds with attempt to self transfer). An incident report dated 11/19/18 documented the resident had an unwitnessed fall from her/his wheelchair, the alarm sounded and the resident was found face-down on the floor. The physician was notified. A progress note dated 11/21/18 revealed the resident developed swelling in her/his right upper arm on 11/21/18. On 11/21/18 the facility sent a fax to the physician. The fax indicated the resident's right upper arm was swollen and the facility requested an order for [REDACTED].>On 11/27/18 (six days later) an order was received for the x-rays. An x-ray report on 11/29/18 indicated the resident had a fractured shoulder. On 2/21/19 at 10:36 AM Staff 5 (CNA) stated after the resident fell staff kept a pillow under the resident's right arm for support and repositioned the resident to protect her/his right shoulder. On 2/21/19 at 10:55 AM Staff 1 (Administrator) said the facility did not ensure the physician received the fax regarding the resident's swollen upper arm during the six-day period of time between 11/21/18 through 11/27/18. Staff 1 acknowledged the facility did not contact the facility's medical director when they received no response from the resident's physician or attempt further contact with the PCP. | 2020-09-01 |
| 1659 | 1659 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2019-02-22 | 677 | D | 0 | 1 | J6TU11 | **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 residents received the necessary services to maintain grooming for 1 of 1 sampled resident (#12) reviewed for ADLs. This placed residents at risk for unmet grooming needs. Findings include: Resident 12 was admitted to the facility in 4/2004 with [DIAGNOSES REDACTED]. The 11/26/18 ADL Care Plan indicated the resident required assistance from one staff member for personal hygiene. Observations on 2/20/19 through 2/22/19 revealed Resident 12 had visible chin hair. In an interview on 2/22/19 at 10:18 AM Resident 12 stated she/he wanted her/his chin hairs removed and had made staff aware. In an interview on 2/22/19 at 10:20 AM Staff 10 (CNA) confirmed the resident had visible hair growth on her/his chin. Staff 10 stated the resident was provided care related to removal of facial hair during her/his shower days and received a shower the day before but staff did not remove the resident's chin hair. In an interview on 2/22/19 at 3:18 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged resident's chin hair should have been removed. | 2020-09-01 |
| 1660 | 1660 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2019-02-22 | 758 | D | 0 | 1 | J6TU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to monitor behaviors for the use of [MEDICAL CONDITION] medications for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: Resident 20 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Resident 20's 2/2019 MAR indicated [REDACTED]. Resident 20's care plan indicated the resident received an antidepressant medication and an anti-anxiety medication related to an anxiety disorder. A review of Resident 20's Progress Notes between 10/1/18 and 2/22/19 revealed the resident demonstrated the following behaviors: - refused bowel care and bowel care protocols - refused skin assessments - refused treatment for [REDACTED].>- refused peri care - refused pain medication - kept medications in her/his room against facility policy - refused multiple medications requiring them to be discontinued - refused to participate in therapy - hid medications in blankets - refused repositioning - refused to get out of bed. On 2/22/19 at 8:25 AM Staff 9 (CNA) indicated Resident 20 never got out of bed. The resident thought if she/he stayed in bed she/he would get better. The resident refused personal cares and refused to use an incontinence pad and the bed would be soaked through. The resident also refused showers and refused to be weighed. During a review of Resident 20's medical record no monitoring of the resident's behaviors could be found. On 2/22/19 at 4:32 PM Staff 2 (DNS) acknowledged Resident 20 had behaviors such as refusing cares and medications and she was unable to find any behavior monitoring for Resident 20. | 2020-09-01 |
| 1661 | 1661 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2016-08-11 | 279 | D | 0 | 1 | I9HC11 | **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 pressure ulcers and the use of a diuretic for 2 of 7 sampled residents (#s 41 and 76) reviewed for pressure ulcers and medications. This placed residents at risk for worsening pressure ulcers and adverse medication reactions. Findings include: 1. Resident 41 was admitted to the facility in early (YEAR) with [DIAGNOSES REDACTED]. The initial comprehensive care plan was developed and included problems related to incontinence, limited mobility due to stroke and left-sided weakness, nutrition, dehydration and pain. It was revised in (MONTH) (YEAR) to include a pressure ulcer to the heel. The comprehensive care plan did not address the history of pressure ulcers, risk factors for Resident 41 to develop future pressure ulcers or interventions to reduce the risk. On 8/11/16 at 1:53 pm Staff 1 (RNCM) confirmed the comprehensive care plan did not include a problem statement related to pressure ulcer development. 2. Resident 76 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The comprehensive care plan included a problem related to the risk of dehydration due to inadequate intake of thickened fluids. The problem statement did not include the use of [MEDICATION NAME] as a risk for dehydration. On 8/10/16 Resident 76 started a new order for [MEDICATION NAME] 40 mg twice a day due to swelling in her/his lower legs. On 8/11/16 at 9:57 am Staff 2 (RNCM) confirmed the care plan did not include the use of [MEDICATION NAME] as a risk for dehydration. | 2020-09-01 |
| 1662 | 1662 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2017-10-06 | 314 | G | 1 | 1 | 8NPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to obtain orders and monitor the use of a medical device for 1 of 3 sampled residents (#74) reviewed for pressure ulcers. Resident 74 developed an unstageable (full thickness tissue loss in which the base of the wound is covered by dead tissue) pressure ulcer. Findings include: Resident 74 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Transfer Summary dated 8/30/17 included orders for physical and occupational therapy. The transfer form did not indicate Resident 74 had a dressing and a sling, include orders for the dressing and care of her/his fractured arm or the presence of a pressure ulcer. The Nursing Admit/Readmit Data Collection Tool dated 8/30/17 noted Resident 74's left arm had a surgical dressing, used a trough on her/his forearm (a hard device used to support a fracture), ace wrap and a sling. There was no indication Resident 74's skin was assessed under the dressing or she/he had a pressure ulcer. There is no evidence in Resident 74's medical record to show her/his skin was monitored underneath the dressing, use of the trough was clarified with the physician, whether the pressure ulcer was present on admission, treatments were provided or monitoring occurred prior to 9/5/17. No observations were made of Resident 74's wound during survey due to being hospitalized for [REDACTED]. A progress noted dated 9/5/17 documented the removal of the dressing and noted a 3 cm by 1.5 cm unstageable wound to the left elbow with slough (dead tissue that is cream or yellow in color). On 9/5/17 at 4:30 pm the facility obtained a physician's orders [REDACTED]. On 10/5/17 at 12:39 pm Staff 3 (RNCM) stated when Resident 74 was admitted to the facility she believed the surgical dressing to be new and the facility practice was to not remove a surgical dressing until a follow up with the surgeon occurred. Staff 3 confirmed t… | 2020-09-01 |
| 1663 | 1663 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2017-10-06 | 371 | D | 1 | 1 | 8NPJ11 | > Based on observation and interview it was determined the facility failed to ensure proper hand hygiene on 1 of 4 patient halls during lunch delivery. This placed residents at risk for cross-contamination and infection. Findings include: On 10/2/17 at 12:30 pm Staff 5 (CNA) delivered a lunch tray to resident [RM #] and touched several items in the resident's room. Staff 5 did not wash or sanitize her hands before leaving the room. She proceeded to the meal cart to pick up another tray without sanitizing her hands. The surveyor stopped her from touching the tray. Staff 5 stated she should have sanitized her hands between trays. She confirmed she touched items in resident [RM #] and did not sanitized her hands before she went to get another tray. On 10/6/17 at 11:35 am Staff 6 (Dietary Manager) confirmed Staff 5 should have sanitized her hands after touching items in resident [RM #] and before touching another tray. | 2020-09-01 |
| 1664 | 1664 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2017-10-06 | 441 | E | 1 | 1 | 8NPJ11 | > 1. Based on interview and record review it was determined the facility failed to maintain a comprehensive infection control program. This placed residents at increased risk for acquiring an infection. Findings include: On 10/5/17 at 2:45 pm a review of the facility Infection Control Book revealed no antibiotic use tracking or monitoring information for (MONTH) and (MONTH) (YEAR). On 10/5/17 at 2:25 pm Staff 2 (DNS) acknowledged there was no one currently designated for the infection control program and there had been no official tracking or monitoring of antibiotic use for (MONTH) and (MONTH) (YEAR). 2. Based on interview and record review it was determined the facility failed to follow infection control policy and procedures for the cleaning of a reusable medication device (glucometer). This placed residents at risk for cross-contamination. Findings include: On 10/5/17 at 11:47 am Staff 7 (RN) stated he cleaned the multi-use glucometer with alcohol and a Q-tip once a day at the beginning of his shift. A review of the facility's Policy & Procedures for Blood Glucose Monitoring, Disinfecting and Cleaning indicated cleaning and disinfecting a glucose meter should be done after each use and to refer to the user manual for specific instructions for each meter. A review of the Manufacturer User's Manual indicated the Cleaning & Disinfecting Guidelines recommended the use of commercially available EPA-registered disinfectant detergent or germicide wipes for cleaning and disinfecting of the meter and the meter should be cleaned after every use whether assigned to a single resident or for multiple resident use. On 10/5/17 at 2:30 pm Staff 2 (DNS) confirmed the glucometer was not cleaned and disinfected appropriately. | 2020-09-01 |
| 4885 | 4885 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2016-10-13 | 333 | D | 1 | 0 | 85KT11 | **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 1 sampled residents (#1) who had liver disease. This placed residents at risk of ineffective therapeutic results from medications. Findings include: Resident 1 had four facility admissions and discharges between (MONTH) (YEAR) and (MONTH) (YEAR) due to complications related to chronic pleural infusion (buildup of fluid between the tissues which line the lungs and the chest). Other [DIAGNOSES REDACTED]. Physician orders [REDACTED]. [MEDICATION NAME] is a laxative, but with liver disease also draws ammonia from the blood stream to the colon where the ammonia can be excreted. Resident 1's 8/17/16 admission assessment indicated the resident required extensive assistance of two staff with all ADLs. Changes in the resident's cognition could occur in part due to a change in ammonia level due to liver failure. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The LNs initialing the MAR for the missed doses included Staff 5 (RN), Staff 6(LPN) and Staff 7(LPN). On 10/12/16 at 8:28 am Staff 5 (RN) confirmed he passed medications on the resident's hall on 8/22/16 and the [MEDICATION NAME] was not given because it was not available. Staff 5 stated he was not able to recall if he ordered [MEDICATION NAME] from the pharmacy. He stated normally he would call or fax the pharmacy to communicate the facility needed a medication. Staff 5 worked only one shift that week on the resident's hall and did not follow up. Staff 5 stated [MEDICATION NAME] was a bowel medication and at the time he had not been aware of the use to lower ammonia levels related to liver disease. On 10/12/16 at 9:08 am Staff 7 (LPN) stated on 8/25/16 he could not find the [MEDICATION NAME] for Resident 1 and reported to Staff 4 (RNCM). Staff 7 stated later in the day the medication was found and given, but Staff 7 stated he forgot to do… | 2019-10-01 |
| 5416 | 5416 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 176 | D | 0 | 1 | ONPL11 | **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 2 of 2 sampled residents (#s 70 and 15) for safety with self administration of medications. This placed residents at risk for unsafe medication administration. Findings include: 1. Resident 70 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. The resident's admission MDS dated [DATE] indicated the resident was alert and oriented. On 7/7/15 at 7:55 am two bottles of medication were observed sitting on the resident's bedside table, Stopain (a topical [MEDICATION NAME]) and a bottle of Enzymes (used for digestive function.) The resident had not been assessed for self administration of medications, there was no physician order and no care plan interventions for the resident to have medications at her/his bedside. On 7/9/15 at 1:08 pm Staff 3 (RNCM) was unaware Resident 70 had medications at her/his bedside. Staff 3 verified the resident had not been assessed for self administration of medications or to have medications at the bedside. 2. Resident 15 was admitted to the facility in 12/2010 with [DIAGNOSES REDACTED]. Record review revealed the resident was not assessed for self administration of medications, there was no physician order and no care plan interventions for the resident to self medicate in the dining room. On 7/7/15 at 12:25 pm the resident was observed in the dining room, reclined in a wheelchair. Resident 15 had a glass of water in front of her/him, and there were pills sitting on the resident's napkin. Resident 15 indicated the nurse left the pills, they were mostly vitamins and the resident stated she/he was fully capable of taking the pills a little at a time. On 7/9/14 at 10:45 am Staff 3 (RNCM) was asked about the medications left on the table in the dining room. Staff 3 indicated she saw the nurse leave the medications, and Staff 3 stood by Resident 15 until she/he took all the medications. Staff 3 indicated she wa… | 2019-03-01 |
| 5417 | 5417 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 253 | E | 0 | 1 | ONPL11 | Based on observation and interview, it was determined the facility failed to maintain cleanliness of kitchen flooring, carpets in resident rooms and common areas of the facility, the residents' bathroom ceiling fans or maintain door frames and drapes in good repair for 4 of 33 resident rooms. This placed residents at risk for an unkept environment. Findings include: Observations from 7/6/15 through 7/9/15 revealed the following: Carpets in the common areas throughout the facility had dark, visible stains. Room 205: There was a large carpet stain in the resident's room by the door and in the hall outside the resident's room. Room 301: The lower half of the bathroom door jam was missing paint. Room 303: The drapes were hanging off the tracks, and the bathroom fan was dusty. Room 305: The lower half of the bathroom door jam was missing paint, and the bathroom fan was dusty. On 7/9/15 at 2:20 pm, Staff 8 (Maintenance Director) was informed of, and acknowledged the areas in disrepair. 2. On 7/6/15 at 10:38 am the floor throughout the kitchen, under food prep tables, dishwashing counters, stove, oven, steam table and in the dry food storage area was observed to be dirty with food particles and crumbs. The cleaning log for (MONTH) (YEAR) was posted in the kitchen and revealed only one day was signed that the floor had been swept/cleaned in (MONTH) (YEAR). There was no cleaning log posted for (MONTH) (YEAR). On 7/7/15 at 9:00 am the kitchen floor was observed to still be dirty and un-swept. On 7/8/15 at 8:20 am the dirty floor in the kitchen and dry food storage areas was verified as dirty and in need of cleaning by Staff 9 (Dietary Manager) and Staff 10 (Cook). | 2019-03-01 |
| 5418 | 5418 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 272 | B | 0 | 1 | ONPL11 | **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 comprehensive assessment regarding cognitive loss/dementia for 3 of 5 sampled residents (#s 6, 13 and 29) reviewed for death and hydration. This placed residents at risk for unmet needs. Findings include: 1. Resident 29 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a Cognitive Loss/Dementia CAA dated 3/3/15 revealed the resident was at risk for cognitive loss due to the resident's heart condition. The CAA had no analysis of the resident's cognitive function and the impact on care. On 7/9/15 at 11:21 am Staff 2 (Social Services) acknowledged the cognitive loss CAA was not comprehensive and did not include an analysis of the resident's cognitive function. 2. Resident 13 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a Cognitive Loss/Dementia CAA dated 1/20/15 revealed the resident was at risk for cognitive loss due to dementia. The CAA had no analysis of the resident's cognitive function and the impact on care. On 7/9/15 at 12:12 pm Staff 2 (Social Services) acknowledged the cognitive loss CAA was not comprehensive and did not include an analysis of the resident's cognitive function. 3. Resident 6 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a Cognitive Loss/Dementia CAA dated 4/9/15 revealed the resident was at risk for cognitive loss due to [MEDICAL CONDITION]. The CAA had no analysis of the resident's cognitive function and the impact on care. On 7/9/15 at 12:09 pm Staff 2 (Social Services) acknowledged the cognitive loss CAA was not comprehensive and did not include an analysis of the resident's cognitive function. | 2019-03-01 |
| 5419 | 5419 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 309 | D | 0 | 1 | ONPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to follow the care plan related to pressure ulcer prevention and keeping the resident's call light within reach for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for unmet needs. Findings include: Resident 6 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a 4/9/15 Pressure Ulcer CAA revealed the resident was at risk for pressure ulcer development due to immobility and the need for staff assistance with repositioning. The CAA indicated there were multiple interventions in place to decrease the potential for pressure ulcers including moon boots (padded heel protectors) to be worn while the resident was in bed and chair. Resident 6's comprehensive care plan updated 4/29/15 revealed the resident was at risk for pressure ulcers and interventions included the use of moon boots on the resident's feet while the resident was in bed and in a Broda chair (specialized wheelchair). The care plan also indicated the resident had impaired mobility due to [MEDICAL CONDITION] and required total assistance from staff for mobility. The care plan indicated staff were to place the resident's call light near the resident's right hand for resident use. On 7/8/15 at 8:19 am the resident was observed sitting in a Broda chair in the resident's room. The resident's moon boots were observed on the resident's bed and not on the resident's feet. The resident's call light was on the floor on the right side of the resident's Broda chair. On 7/8/15 at 8:38 am Staff 1 (RNCM) acknowledged the resident's care plan was not followed regarding the resident's moon boots and having the resident's call light within reach. | 2019-03-01 |
| 5420 | 5420 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 323 | D | 0 | 1 | ONPL11 | **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 accidents and identify causative factors to prevent further accidents for one of three sampled residents (#7) reviewed for falls. This placed residents at risk for further falls. Findings include: Resident 7 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. The resident's annual MDS dated [DATE] indicated the resident required one person extensive assist with bed mobility and transfers. The resident's care plan, updated 6/3/15, identified the resident was at risk for falls and included interventions for call light use, frequent staff visual checks, use of alarms in the resident's bed and chair, staff assist to toilet, and for review and modification of environmental hazards that could cause or contribute to falls. On 5/24/15 at 2:35 pm the resident fell in the bathroom. The Fall Risk Data Collection form identified the resident had a history of [REDACTED]. Progress notes dated 5/24/15 at 2:35 pm did not indicate the resident fell or include a description of a fall. The facility's investigation of the resident's fall on 5/24/15 indicated the resident toileted independently, reached over to place an item in the trash can and fell over onto the floor. There was no resident interview, no witnesses or caregiver staff identified, witness or staff statements, description of the resident's position when found. There were no identifiers of how the resident got to the toilet, how long the resident was on the toilet, or if staff was with the resident. There was no identification of antecedents such as when the resident last received care or what the resident was doing the last time she/he was seen by staff. On 6/30/15 at 11:30 am the resident was found on the floor. Progress notes dated 6/30/15 at 11:30 am did not indicate the resident fell or include a description of a fall. An incident report dated 6/30/15 at 11:30 am indicated the reside… | 2019-03-01 |
| 5421 | 5421 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 371 | F | 0 | 1 | ONPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to prepare, store, and serve food under sanitary conditions. This placed resident's at risk for food-borne illness. Findings include: 1. On 7/8/15 at 7:25 am the dishwasher temperature log indicated the temperature was monitored once a day during (MONTH) and (MONTH) (YEAR). The dishwasher was a hot water machine and the manufacturer recommendation was for 150 degree wash cycle and 180 degree rinse cycles. The facility's Dishwashing Policy and Procedure indicated the cycle temperatures were to be checked at each meal service for those parameters. 2. On 7/8/15 from 7:25 am through 9:00 am the kitchen breakfast tray line and meal service the following was observed: -Staff 10 (Cook) repeatedly wiped her gloved and bare hands on her apron. Staff 10 did not wash her hands after contact with the apron and continued the meal service. - Staff 10 also wiped the food thermometer on her apron and with a cleaning rag while testing food temperatures. -The food prep sink contained dirty dishes. 3. On 7/8/15 at 9:00 am the the kitchen had a three compartment sink for cleaning pots, pans, and large items. The left compartment sink was observed filled with water that had visible suds. Staff 10 (Cook) stated it contained the cleaning chemical solution and that she had prepared the solution that morning. Staff 10 stated the same solution would be used all day and the facility routinely used the same solution three times a day daily. The sanitizing log was posted next to this sink and signed to designate the solution strength was tested on [DATE] and 7/6/15 only. The log contained no directions to staff for the desired solution concentration. Staff 10 used quaternary test strips and tested the concentration. Staff 10 added an undetermined amount of solution to the sink and rechecked the concentration. The process was repeated until the test strips indicated the correct solutio… | 2019-03-01 |
| 5422 | 5422 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 431 | E | 0 | 1 | ONPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store medications in a secured area, ensure there were no expired items in the medication storage room or treatment cart and the integrity of sterile supplies were maintained in 1 of 1 central supply room. This placed residents at risk for decreased efficacy of medication and compromised integrity of sterile supplies. Findings include: Observations on [DATE] at 9:15 am of the storage room which included supplies and the treatment cart, revealed the following: -There was a sterile gravity drainage bag (for urinary catheters)opened to air; -Four expired dressing change trays were dated ,[DATE]; - There was Icy Hot Balm dated [DATE], which was expired; and -The treatment cart had a piece of sterile foam dressing opened to air for the [DEVICE] machine, and another piece of sterile foam dressing in a bag taped shut. The package indicated for single use only, do not use if the package was open. Observations on [DATE] at 10:07 am of the medication room revealed there was an Ensure Immune Health Therapeutic Nutrition drink which expired (MONTH) (YEAR). The need to store items in a sanitary manner and to dispose of outdated items was discussed with Staff 1 (RNCM) on [DATE] at 10:45 am. She acknowledged the items should be thrown away. Observation of the medication cart on [DATE] at 9:15 am revealed there was an insulin bottle sitting on top of the medication cart unattended. On [DATE] at 9:20 am Staff 11 (RN) acknowledged the insulin was left unattended. | 2019-03-01 |
| 5423 | 5423 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 441 | D | 0 | 1 | ONPL11 | Based on observation, interview and record review it was determined the facility failed to perform hand hygiene between soiled and clean tasks during a dressing change for 1 of 3 residents (#6) for whom pressure ulcers were reviewed. This placed residents at risk for contamination of open wounds. Findings include: The facility's written procedure for wound dressing change revised (MONTH) (YEAR) directed staff to put on gloves then remove and discard the soiled dressing. Staff were directed to remove and discard their gloves, perform hand hygiene, prepare supplies and then put on clean gloves prior to cleaning the wound and surrounding skin. On 7/8/15 at 4:24 pm Staff 1 (RNCM) provided wound care for Resident 6. Staff 1 washed her hands, prepared supplies, washed hands again and put on a pair of gloves. She helped reposition the resident's bed, touching the footboard of the bed and bed linen. Staff 1 helped turn the resident to the side and removed the resident's clothing and an incontinence garment with the assistance of a CNA. With the same gloves she removed the soiled dressing and then cleaned the wound with gauze and wound cleanser without first removing the soiled gloves and performing hand hygiene. On 7/8/15 at 4:37 pm this observation was discussed with Staff 1 who confirmed she did not perform hand hygiene and did not put on clean gloves after removing the soiled dressing. | 2019-03-01 |
| 5424 | 5424 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2015-07-10 | 514 | D | 0 | 1 | ONPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately document the appearance of a pressure ulcer for one of three sampled residents (#70) who were reviewed for pressure ulcers. This placed residents at risk for unmet needs. Findings include: The facility's Procedure for Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements indicated pressure ulcers should be assessed/evaluated at least weekly and documented. The observations of the ulcers's characteristics should include at least the following: measurements, characteristics of the ulcer wound bed, exudate and surrounding skin, presence of pain, and current treatment. Resident 70 was admitted to the facility in 6/2015 with an unstageable pressure ulcer on her/his right heel. A Wound RN assessment dated [DATE] indicated Resident 70 had an Unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (devitalized tissue) in the wound bed) on her/his right heel. The assessment included no measurements, wound bed or surrounding tissue characteristics, or description of the eschar. A Wound RN assessment dated [DATE] inaccurately indicated Resident 70 had a Healing Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister) on her/his right heel. The assessment included no measurements, wound bed or surrounding tissue characteristics, or description of the eschar. A Wound RN assessment dated [DATE] again inaccurately indicated the resident had a Healing Stage 2 pressure ulcer on her/his right heel. The assessment included no measurements, wound bed or surrounding tissue characteristics, or description of the eschar. On 7/8/15 at 1:45 pm Staff 3 (RNCM) verified the residents right heel was an unstageable pressure ulcer with an eschar covering. Staff 3 veri… | 2019-03-01 |
| 6580 | 6580 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-06-05 | 279 | D | 0 | 1 | IQUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to care plan for the use of an antidepressant, hypnotic and anticoagulant medication and diabetic management for 3 of 5 sampled residents (#s 20, 68 and 76) for whom a medication regimen was reviewed. This placed residents at risk for adverse medication side effects and impaired blood glucose control. Findings include: 1. Resident 20 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A current care plan updated 4/11/14 revealed no documented problem statement, goals or interventions for the use of a [MEDICATION NAME] and [MEDICATION NAME]. The care plan also did not include the potential side effects of the medications and what non pharmacological interventions were to be attempted prior to the administration of the [MEDICATION NAME]. In an interview on 6/5/14 at 7:53 am Staff 4 (RNCM) acknowledged the resident care plan did not include the resident's use of an antidepressant and hypnotic medication and did not include goals, potential side effects and non pharmacological interventions. 2. Resident 76 was admitted to the facility in March 2014 and readmitted in early April, 2014 with [DIAGNOSES REDACTED]. Resident 76 was prescribed [MEDICATION NAME] (an anticoagulant) daily for prevention of blood clots related to the [DIAGNOSES REDACTED]. The Comprehensive Care Plan updated in April and May, 2014, did not include a problem statement related to the use of the anticoagulant and it was not mentioned in other pertinent areas of the care plan such as fall risk or nutrition. On 6/5/14 at 8:40 am Staff 3 (RNCM) confirmed the care plan did not include a problem statement related to the use of the anticoagulant. 3. Resident 68 was admitted to the facility in February 2014. The MDS dated [DATE] identified a [DIAGNOSES REDACTED]. The May and June 2013 MARs indicated the resident received long-acting insulin… | 2017-11-01 |
| 6581 | 6581 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-06-05 | 280 | D | 0 | 1 | IQUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to review and revise the comprehensive plan of care for nutritional status for 1 of 3 sampled residents (#17) reviewed for nutrition. This placed residents at risk for unmet needs associated with nutrition. Findings include: Resident 17 was admitted to the facility in February 2014 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 2/13/14 was updated on 4/30/14 and indicated Resident 17 had a potential nutritional problem of decreased intake related to a cast on right arm and intake less than 75% of meals. The stated goal was for the resident to consume an average greater than 75% of meals through the review date. Interventions included meals in resident's room according to the resident's preference, invite to food-related activities, custard with caramel sauce at lunch and dinner, Mighty Shake at lunch and dinner, and all weights with the chair scale. Review of Resident 17's weight records indicated the resident lost eight pounds between admission and 4/6/14. The facility identified the trending weight loss and a Registered Dietician completed comprehensive assessments on 2/27/14, 4/9/14 and 5/14/14. The resident was reviewed in the interdisciplinary Nutrition Risk meeting monthly. The Comprehensive Care Plan was updated on 4/30/14. The Nutrition Care Plan was not changed or updated at that time to reflect the actual weight loss and additional interventions implemented to prevent further weight loss. A Mini Nutrition Assessment Short Form dated 5/5/14 identified Resident 17 as malnourished. Physician orders [REDACTED]. On 6/4/14 at 9:59 am Staff 10 (CNA) stated Resident 17 received a supplement beverage with meals. She was unable to find documented evidence the resident received the supplement and stated the resident did not always drink it. On 6/4/14 at 3:00 pm Staff 8 (Registered Dietician, RN) stated she could see where the supplement for Resident 17 sho… | 2017-11-01 |
| 6582 | 6582 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-06-05 | 354 | C | 0 | 1 | IQUZ11 | Based on interview and record review it was determined that the facility failed to have Registered Nurse coverage seven days per week. This placed residents at risk for of lack of RN assessment and supervision. Findings included: On 6/2/14 the licensed nurse staff work schedule provided by the facility on survey entrance indicated the facility had one RN Charge who worked three nights per week. The two RNCM's were scheduled to work five days per week. There was no RN scheduled in the building on Sundays or on the Memorial Day Holiday. On 6/4/14 at 8:45 am the daily staffing report was reviewed with Staff 6 (Business Office). The report indicated no RN coverage on 6/1, 6/2, or 6/3/14. The lack of RN coverage was verified by Staff 6. The Licensed Nurse working schedule for May 2014 indicated no RN was in the facility on 5/4/14, 5/11/14, 5/18/14, 5/25/14, or 5/26/14. On 6/4/14 at 9:30 am Staff 1 (Administrator) stated the facility was without a RN since April 2014 and verified the lack of seven day RN coverage from 5/1/14 through 6/4/14. Staff 1 indicated the facility did not change the RNCM assignments to cover the required seven days. | 2017-11-01 |
| 6583 | 6583 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-06-05 | 356 | C | 0 | 1 | IQUZ11 | Based on observation, interview and record review it was determined the facility failed to prominently post accurate daily nursing staff information. This placed residents and the public at risk for not being fully informed regarding nurse staffing levels. Findings include: On 6/3/14 at 2:00 pm an outdated version of the mandatory Care Staff Daily Report for the day shift was observed posted on a bulletin board on a wall at the back of the facility near the dining room. The form was not completed and was empty for the day shift. The mandatory Nursing Assistant Staff Ratio Chart was not posted. At 6:30 pm the nursing staff hours and numbers for both the day or evening shifts were empty. On 6/4/14 at 8:30 am Staff 6 (Business Office) provided copies of the June 2014 Direct Care Staff Daily Reports. Staff 6 verified the forms for 6/3/14 were empty when she received them that morning and that she wrote the day and evening shift hours on the form when she arrived to work on 6/4/14. Staff 6 stated she routinely completed the forms the following day and verified she was unaware of the outdated forms. Staff 1 (Administrator) verified the Direct Care Staff Daily Reports were to be completed at the start of every shift, Staff 1 also verified the reports were not posted prominently for public view in a public area, and were not readily accessible to residents, family, direct care staff and general public. Staff 1 was unaware the facility's Direct Care Staff Daily Reports and staffing ratios were outdated versions. | 2017-11-01 |
| 6584 | 6584 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-06-05 | 441 | D | 0 | 1 | IQUZ11 | Based on observation and interview it was determined the facility failed to ensure the use of an Environmental Protection Agency (EPA) approved germicide when cleaning a multiuse glucometer (machine to test blood sugar levels on multiple residents) for residents on 2 of 4 halls (Halls 300 and 400) who shared a glucometer. This placed residents at risk for potential cross-contamination. Findings include: On 6/4/14 at 8:10 am Staff 5 (LPN) obtained a CBG level from a resident on the 300 Hall. After she left the room Staff 5 cleaned the glucometer with an alcohol wipe rather than an approved EPA germicide. Staff 5 said she was instructed to use alcohol wipes and had done so for years. On 6/4/13 at 12:30 pm Staff 2 (DNS) stated she recently purchased the EPA approved product for all the medication carts. Staff 2 did not know why the product was taken from the medication cart or why Staff 5 did not know to use it. | 2017-11-01 |
| 6683 | 6683 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-09-23 | 323 | G | 1 | 0 | JZXF11 | Deficiency Text Not Available | 2017-09-01 |
| 6684 | 6684 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2014-09-23 | 514 | D | 1 | 0 | JZXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to document notification of interested family members for 1 of 3 sampled residents (#2) reviewed for falls. This placed the resident at risk for unmet needs. Findings include: The facility's February 2005 Notification of Change in Resident Status indicated the facility will immediately inform the resident, if appropriate (except in a medical emergency or when resident is incompetent), and consult with the resident's physician and if known, notify the resident's family or legal representative in the following cases: 1. Resident accident which results in injury with a potential for requiring physician intervention Resident 2 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The 7/24/14 Progress Note documented Resident 2 fell backwards in her/his wheelchair, and hit her/his head when attempting to wheel back into the building. The progress notes indicated the resident complained of a headache and had a 4.0 cm abrasion on the back of her/his head with a 1.0 cm superficial open area. The resident also had a 5.0 cm reddened area on the top of her/his back between the shoulder blades. Documentation revealed neurological checks were conducted. There was no documentation the resident's family member/responsible party was informed of the incident. On 9/16/14 at 10:00 am (DNS) and Staff 4 (RNCM) stated Resident 2 stated the resident did not want family notified of the incident. Staff 2 and 4 were asked if there was documentation of the resident's request not to inform family members. Staff 2 acknowledged there was no documentation of the resident's request not to inform the family member. | 2017-09-01 |
| 7548 | 7548 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2013-01-10 | 241 | D | 0 | 1 | OE1511 | **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 dignified dining environment and timely staff assistance for 2 of 8 non-sampled residents (#s 27 and 29) who required staff assistance with meals. These failures created an undignified environment and placed residents at potential risk of increased dependence on staff with decreased self esteem and self worth. Findings include: 1. Resident 27 was admitted to the facility during 2012 with [DIAGNOSES REDACTED]. The 11/30/12 Speech Therapy evaluation indicated staff were to let the resident eat independently, then assist when Resident 27 fatigued. The 12/12/12 MDS revealed the resident had BIMS (Brief Interview for Mental Status) score indicative of severe cognitive impairment. Resident 27 was assessed to need limited physical assistance of one person with meals. The resident's chart care plan, last updated on 1/4/13, listed interventions including staff assistance with meals. On 1/7/13 at 12:30 pm Resident 83, seated next to Resident 27, was served lunch. Residents at other tables were being served but the remaining three residents at Resident 83's table were not served until 12:37 pm and 12:38 pm. Resident 27's wheelchair was positioned back from the table and was not repositioned closer to the table until 19 minutes after the resident's meal was served. During the 1/7/13 lunch observation, the tables in the dining room had tablecloths and residents' meals were removed from trays then the plates placed in front of the residents. During the 1/8/13 dinner observation the tables were without tablecloths and residents' plates were left on dinner trays which were then placed in front of residents. On 1/8/13 at 5:40 pm Resident 27 received her/his dinner. The tray did not have the resident's built up utensils. The resident's wheelchair was positioned approximately seven inches away from the edge of the table. After being served, Resident 27 tried uns… | 2016-09-01 |
| 7549 | 7549 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2013-01-10 | 371 | E | 0 | 1 | OE1511 | Based on observation, interview and record review, it was determined the facility failed to ensure food was stored in a sanitary manner and dishwasher temperatures reached the manufacturer's specified temperatures for sanitization. These failures placed residents at risk of food borne illnesses. Findings include: 1. During observations on 1/7/13 at 4:40 pm and 1/8/13 at 12:35 pm, a large beige food bin containing bags of thickener was observed with the clear lid on backwards. The incorrectly placed food bin lid left both front corners of the bin open to contamination and pests. The top bag of thickener in the bin was unsealed. On 1/7/13 at 4:40 pm the freezer had four boxes of food (chicken breasts and seeded rye bread) stored on the floor. On 1/8/13 at 12:35 pm, three of the same four boxes of food (chicken breasts and seeded rye bread) remained on the freezer floor. On 1/8/13 at 1:31 pm Staff 9 (Dietary Manager) said she was aware the boxes of food were stored on the freezer floor and planned to put those supplies away soon. Staff 9 also looked at the thickener bin then correctly positioned the lid which sealed thickener bin. 2. During the initial kitchen tour on 1/7/13 at 10:40 pm Staff 9 (Dietary Manager) stated the dishwasher used heat for sanitization. Observation of the the manufacturers' specifications posted on the dishwasher listed a wash temperature of 150 degrees and rinse temperature of 180 degrees. The dishwasher temperature log revealed a wash temperature of 146 degrees and rinse temperature of 154 degrees on 1/3/13. On 1/4/13 the wash temperature was 144 degrees and the rinse temperature was 155 degrees. During observation on 1/8/13 at 12:44 pm the dishwasher reached 167 degrees during the rinse. At that time Staff 9 stated the first batch through the dishwasher tended to run low for the rinse so staff always ran the first batch through twice to get the temperatures up. The low temperatures documented for 1/3/13 and 1/4/13 were reviewed with Staff 9. Staff 9 said when the temperatures were low sta… | 2016-09-01 |
| 8317 | 8317 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-08-12 | 279 | D | 0 | 1 | BLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviewit was determined that the facility failed to develop plans of care with problem statements and goals that accurately reflected resident condition for 1 of 14 residents (#2) whose care plans were reviewed. Findings include: 1. Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. Annual MDS assessments from 2009 and 8/18/10 indicated Resident 2 had a history of [REDACTED]. A RAP from 2010 identified severe weakness to his lower extremities and contractures to his feet. The assessments revealed that contractures to his toes had been present since 2009 and he refused physical therapy. An Annual MDS dated [DATE] indicated Resident 2 required extensive assist from two persons for bed mobility and was dependent for transfer. He was non-ambulatory, totally dependent for locomotion and required extensive assistance for dressing. The CAA dated 5/10/11 addressed Resident 2's need for ADL assistance and use of narcotics to treat his chronic pain. Treatment records for May 2011 indicated that the resident had an area of skin breakdown on his coccyx. In an interview on 8/9/11 at 8:36 am Staff 2, RNCM, stated that the resident currently had contractures of his toes on both feet and used soft booties to protect them. He refused therapy or splints. Resident 2's comprehensive care plan dated 5/19/11 identified that the resident had a mobility impairment. The stated goals for "the next 90 days" were to strengthen muscle tone and joint ROM in both upper and lower extremities, regain ability to mobilize with minimal assistance, regain maximum ambulatory function and to demonstrate safe and appropriate use of "assistive" devices. Interventions listed on the care plan included providing the assistance of one to two persons for repositioning and turning every two hours. Resident 2 was to be transferred with a lift and the assistance of two persons. He was to be transported to areas of destination using … | 2015-08-01 |
| 8318 | 8318 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-08-12 | 319 | D | 0 | 1 | BLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to comprehensively assess and/or provide appropriate services to 1 of 1 sampled residents (#7) who displayed verbally and physically aggressive behaviors. Findings include: Resident 7 was readmitted to the facility in September 2010 with a medical history that included [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION]. An annual MDS completed in April 2011 identified that Resident 7 was alert and oriented to person and place, was dependent on staff for all care needs, but was able to make needs known. The MDS further identified that the resident had expressed to staff symptoms of depression to include feeling down, depressed or hopeless nearly everyday, had difficulty falling asleep and felt tired or had little energy. A Psychosocial CAA dated 04/26/11 identified that the resident displayed both verbally and physically aggressive behaviors toward staff and at times was sexually inappropriate with some staff. The CAA read,"...has constant verbal bx (behavior) of calling out loudly and cussing loudly which intrude on other resident's living environment ...". It was also identified that no further evaluation was needed and the behavior would be addressed on Resident 7's behavior care plan. A [MEDICAL CONDITION] Drug Use CAA dated 04/26/11 indicated that Resident 7 had received both a daily anti-depressant, and a daily anti-psychotic medication in an attempt to manage the resident's agitation and verbal outbursts to include profanities directed at both staff and other residents. According to this CAA, medication dosage adjustments had been made and a prn anti-psychotic trialed; however these interventions were described as ineffective. The CAA read, "Resident at present continues calling out and hollering...Resident has been calling out in the dining room and the activity room...". The CAA further indicated that no referral was ne… | 2015-08-01 |
| 8319 | 8319 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-08-12 | 325 | D | 0 | 1 | BLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to provide timely assessment and intervention to prevent further weight loss for 1 of 3 residents (# 2) who had a history of [REDACTED]. Findings include: Resident 2 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. A quarterly Interdisciplinary assessment dated [DATE] identified that Resident 2 had lost weight and was no longer snacking all day although snacks were still available. He was placed back on Nutrition Risk monitoring. His diet was described as "regular, level 2" (dysphagia diet). The note indicated that the resident was refusing Ensure with meals but would accept whole milk fortified with extra protein and calories. He was re-assessed on 4/13/11, was noted to be regaining weight and by 5/4/11 had regained 20 pounds. According to facility weight monitoring records, Resident 2 lost 22 pounds (lbs) between 5/4/11 when he weighed 200.6 and 6/6/11, when his weight was 178.7. A Nutrition Risk assessment note dated 5/24/11 identified that the resident was frequently refusing breakfast and lunch and would remain on nutrition monitoring. The note indicated the resident's ordered diet had not changed. Review of the Dining Records for May, 2011 and June, 2011, revealed intakes of 88% - 75% between 5/1 and 5/4/11. His intake then declined significantly to as low as 13% on 5/16/11. According to the Dining Record for May, 2011 the resident accepted evening nourishments 11 times when offered. The resident's intake improved somewhat in June, 2011. There was no written assessment in June, 2011 in the Interdisciplinary Progress Notes or the Interdisciplinary Assessments and Summary Reviews about the resident's weight loss. A dietary assessment dated [DATE] indicated Resident 2 had experienced a significant weight loss. His weight was down to 179, a 10 % loss in 90 days or a 13% loss in 180 days. The assessment also identified that the residen… | 2015-08-01 |
| 8320 | 8320 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-08-12 | 329 | D | 0 | 1 | BLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to monitor the efficacy of a PRN pain medication administered for routine pain management for 1 of 10 residents (325) for whom medications were reviewed. Findings include: Resident 25 was admitted to the facility in early 2011 with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident 25 had indicators of [MEDICAL CONDITION] with behaviors of calling out, hitting and yelling. This resident was totally dependent for ADLs, had communication difficulties and was coded as able to understand but only sometimes able to be understood. The resident was prescribed scheduled and PRN pain medications for chronic pain of a moderate to severe level. The July 2011 MAR indicated Resident 25 was receiving a [MEDICATION NAME] 75 mcg changed every 72 hrs, [MEDICATION NAME] 2mg BID and [MEDICATION NAME] 10/325 every 3-4 hours PRN for pain control. The July 2011 MAR showed that the [MEDICATION NAME] was not given from 7/9/11 through 7/19/11. During this time period [MEDICATION NAME] 10/325mg was given BID. No documentation as to effectiveness of the BID [MEDICATION NAME] for pain relief was documented on the MAR or in the interdisciplinary notes during this time frame. On 7/19/11 [MEDICATION NAME] was re-initiated BID for pain control. The July 2011 Mood and Behavior Report indicated no behaviors were reported during the month of July. On 8/11/11 at 2:30 pm, Staff 3, RNCM reviewed the psychoactive team meeting notes from June and July 2011. Staff 3 stated the team was working to identify the pain medications offering the best relief for Resident 25 as they identified some behaviors may have been related to pain. The [MEDICAL CONDITION] Drug Review Committee meeting notes indicated Resident 25 continued to call out for help at times. Staff 3 was unable to locate any documentation of behaviors or pain monitoring for Resident 25 during July or August 2011. On 8/12/11 at 10:00 am… | 2015-08-01 |
| 8321 | 8321 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-08-12 | 441 | E | 0 | 1 | BLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to consistently implement accepted standards of infection control related to medication administration and management of potentially infectious waste to include disposal of soiled dressing material, used CBG equipment and storage of urine specimens. Findings include: 1. On 08/10/11 at the conclusion of a gangrenous wound cleansing and dressing change, Staff 4, LPN secured the discarded soiled dressing and gauze used to cleanse the wound in a grey plastic bag, initially tossed the bag onto the floor adjacent to Resident 67's bed and then placed it onto the resident's overbed table. When asked by the Surveyor regarding appropriate disposal of soiled dressing materials, Staff 4 responded that she didn't know what to do with it because the resident's room did not have a trash can available. During a review of the facility's infection control program on 08/11/11 at 11:00 am, Staff 7 confirmed that all soiled items were to be immediately disposed of in the trash, neither linens nor trash was to be discarded on the floor. Staff 7 further explained that every resident's room had access to a bathroom that contained a covered trash can and a supply of grey trash bags. 2. On 08/11/11 at 8:00 am during medication administration, Staff 5, LPN was observed to don gloves and used a wrist cuff to check a non-sampled resident #37 blood pressure. Without removing the gloves, Staff 5 returned to and used a touch pad key to unlock the medication cart, pulled Resident 37's medication cards, and began checking and popping the medications from the cards into a medication cup. Staff 5 recognized that Resident 37 stock medication located in the medication room. Still wearing the same gloves, Staff 5 used a touch pad key to enter the medication room, retrieved the medication from the storage cupboard and returned to the medication cart where she re-opened the cart using the to… | 2015-08-01 |
| 9293 | 9293 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-01-26 | 221 | D | LE1K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review it was determined the facility failed to keep a resident free from physical restraints for 1 of 3 residents (# 2). Findings include: Resident 2 was admitted to the facility September 2010 with [DIAGNOSES REDACTED]. Review of the resident's 9/27/10 MDS revealed the resident did not have restraints. Review of the 12/24/10 Interdisciplinary Progress Notes revealed at 3:00 am the resident was awake most of the night shift and repeatedly tried to climb out of bed. The resident was a fall risk and was assisted to the geri-chair in front of the nurses station to be watched continuously. The resident was "content" in the geri-chair. Review of the resident's 12/24/10 and 12/28/10 Incident Details revealed the resident had [DIAGNOSES REDACTED]. The resident transferred out of bed and chairs multiple times during the night and was allegedly tied to the geri-chair with a sheet. The staff were educated on appropriate restraint use. Review of the "Conclusion of Investigation of the improper use of restraint/abuse investigation dtd (dated) 12/24/10" revealed on 12/24/10 Staff 12 (RN/charge nurse) tried many interventions to prevent Resident 1 from falling including offering food and other distractions. The resident was assessed by Staff 12 to be very restless and was at risk for falling. Staff 12 placed a loose sheet around the resident, tied a loose knot and continued to perform the medication pass. Staff 12 did not complete an assessment on the use of the bed sheet. On 1/19/11 at 11:33 am Staff 12 (RN/charge nurse) verified a bed sheet was tied in a loose "slip knot" over the resident's lap. The intent of the sheet over the resident's lap was to give the facility staff time to reach the resident if the resident attempted to get up without assistance. The sheet was loose and the resident would have been able to slip under the sheet. Staff 12 did not realize an assessment had to be completed before using a… | 2014-04-01 | ||
| 9294 | 9294 | GOOD SAMARITAN SOCIETY - CURRY VILLAGE | 385165 | 1 PARK AVENUE | BROOKINGS | OR | 97415 | 2011-01-26 | 323 | G | LE1K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review it was determined the facility failed to ensure the resident had adequate devices as identified on the care plan to prevent accidents for 1 of 3 sampled residents with falls (# 1). The resident fell from the wheelchair and suffered lacerations requiring sutures. Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Review of the 10/19/10 quarterly MDS revealed the resident was totally dependent with the assistance of one facility staff for locomotion on and off the unit. Review of the resident's 10/28/10 Falls Data Collection Tool revealed the resident was a high risk for falls. Review of the Resident's 10/28/10 Quarterly Nursing Assessment revealed the resident did not attempt to self transfer. The assessment also referred to the resident's annual RAP for information regarding falls. Review of the 10/28/10 Comprehensive Care Plan provided by the facility on 2/17/11 revealed the resident had impaired mobility related to left hip fracture and polio. The interventions included " Encourage to propel own w/c (wheelchair) with leg rests to build LE (lower extremity) strength " , transport resident to areas of destination PRN and the resident used the wheelchair for mobility. Review of the resident's 12/28/10 Comprehensive Care Plan revealed the resident had impaired mobility and care planned interventions included leg-rests on the wheelchair and to transport the resident PRN. The care plan also revealed the resident was at risk for falls and care planned interventions included alarms to be used when in the wheelchair. Review of the resident's 4/27/10 Resident RAP Key Guideline Report-Online revealed the resident triggered for falls secondary to receiving an antidepressant. The resident had a history of [REDACTED]. Precautions in place included having an alarm on at all times, a fall mat was to be next to the resident's bed and visual checks were to be done as facility staff w… | 2014-04-01 | ||
| 315 | 315 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2017-01-27 | 334 | D | 0 | 1 | 62RI11 | **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 and procedures for 2 of 5 sampled residents (#s 14 & 51) reviewed for infection control. This placed resident at risk for unmet immunization needs. Findings include: Resident 51 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 14 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 1/27/17 at 12:11 pm, Staff 1 (Infection control nurse) confirmed the facility had no information Resident 51 or Resident 14 had received or was offered the pneumococcal vaccine. | 2020-09-01 |
| 316 | 316 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2017-01-27 | 371 | F | 0 | 1 | 62RI11 | Based on observation and interview it was determined the facility failed to ensure 1 of 1 ice machine was plumbed appropriately for sanitation. This placed residents at risk for food borne illness. Findings include: The Federal Food Sanitation Rules code 5-402.11 Backflow Prevention directed facilities to ensure a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 1/27/17 at 11:29 am the facility ice machine drain was observed to be directly plumbed into a pipe that connected to an outside pipe which touched the exterior wall. There was no air gap observed between the wall and the pipe which would prevent pests or possible waste water from invading the ice machine. On 1/27/17 at 8:40 am Staff 2 (Maintenance Director) confirmed the ice machine did not have the required air gap to prevent pests or outside waste water from invading the ice machine. | 2020-09-01 |
| 317 | 317 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 550 | E | 0 | 1 | OB4611 | Based on observation and interview it was determined residents requiring assistance with dining were not afforded choice related to use of clothing protectors. During 2 of 3 assisted dining room observations, 5 sample residents (#s 12, 14, 18, 20 & 52) and 11 non-sampled residents had clothing protectors applied without their consent. This resulted in residents not being afforded personal choice and a dignified dining experience. Findings include: On 2/26/18 at 12:05 PM, in the first floor assisted dining room, clothing protectors were placed on tables at each place setting prior to the meal. Staff 5, 6 and 13 (CNAs), systematically applied clothing protectors on Residents 12, 14, 18, 20 & 52 and 11 other non-sampled residents without asking their preference or affording them a choice of a napkin. Staff 13 was heard saying to residents, I'm going to put your clothing protector on you. On 2/27/18 at 8:32 AM, in the first floor assisted dining room, clothing protectors were again placed on Residents 12, 14, 18, 20 & 52 as well as 11 other non-sampled residents without asking residents their preference for use of the clothing protectors or offering a napkin alternative. During an interview on 2/27/18 at 3:02 PM, Staff 3 (RNCM) stated it was his expectation that aides would wash each resident's hands and put a clothing protector on each resident in preparation for a meal. Staff 2 (LPN/Resident Care Manager) indicated aides should put clothing protectors on unless the resident specifically did not want one. On 2/28/18 at 8:12 AM, when asked about the use of clothing protectors for those eating in the assisted dining room, Staff 6 (CNA), stated everyone in this room gets a clothing protector, those eating in the independent dining room are offered one. When asked if residents in the assisted dining room were offered a choice, she stated, if they don't want it they can tell us. During an interview on 2/28/18 at 4:23 PM, Staff 1 (DNS) stated all staff were trained to ask residents what they preferred and to offer the cho… | 2020-09-01 |
| 318 | 318 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 565 | E | 0 | 1 | OB4611 | Based on interview and record review it was determined the facility failed to promptly respond to grievances and recommendations from the resident council for 3 of 3 months reviewed. This placed residents at risk for unresolved quality of life and care issues. Findings include: During a resident group meeting on 2/28/18 at 10:12 AM, residents stated facility staff did not consistently respond to suggestions and concerns offered by the resident council. Residents indicated they did not feel staff communicated with them effectively and did not feel fully informed of the actions taken in response to their concerns. Resident Council Minutes on 11/21/17, 12/20/17 and 1/24/18 revealed the following resident issues with staff responses documented: - water pitcher with ice and water not filled enough during the day. - no response provided - request for salt and pepper shakers on the tables (both 11/2017 and 1/2018) - We will continue to improve the kitchen performance, then staff responded salt & pepper shakers are to be on tables starting 2/1/18. However, no salt & pepper shakers were observed in the independent dining room on 2/28/18 at 12:32 PM. - request to look into heated meal carts - We will continue to do our best to bring you quality food. - multiple residents not receiving washcloths or towels in the morning to clean up, one resident with complaints regarding toileting assistance - Will bring up at next CNA (meeting.) The responses to these concerns did not explain how the facility intended to address them, what the outcome was, or what the rationale was if the facility did not address the concern. In a 2/28/18 interview at 12:32 PM, Staff 4 (Social Services Director) stated she took the minutes at resident council and voiced concerns to staff, but was not the decision maker and simply brought the facility responses back to the group. When the resident council concern responses were reviewed with Staff 8 (Executive Director) on 3/1/18 at 10:03 AM, she stated staff did address issues individually, but did not al… | 2020-09-01 |
| 319 | 319 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 578 | F | 0 | 1 | OB4611 | **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 received written information regarding their right to execute an advanced directive and to obtain existing copies of advance directives for residents when available for 7 of 11 sample residents (#s 8, 25, 27, 51, 52, 53 and 165) reviewed for advanced directives. This placed residents at risk of receiving care in conflict with their wishes. Findings include: The facility's Admission Paperwork, provided to the resident or responsible party upon admission, stated: The facility recognizes Resident's right to make health care decisions and to consent to or refuse treatment. We will honor Advance Directives and other healthcare decision documents as recognized by law. The Resident hereby consents to all treatment or services rendered and facility will not be liable for any physician payment. In a 2/27/18 interview at 10:39 AM, Staff 4 Social Services Director (SSD) stated the Admission Paperwork and Resident Handbook were provided to the resident or responsible party upon admission. The current admission paperwork did not include Advanced Directive forms to fill out or further information regarding formulating Advanced Directives. Staff 4 mentioned the need to bring copies of existing Advanced Directives for the medical chart during the admission process. Staff 4 printed forms, for the resident or responsible party, from the Internet if interest was shown in formulating an Advanced Directive. No further follow up was provided and it was the responsibility of the family to bring in the copies of those forms. The following residents were found to have inaccurate information regarding Advanced Directives in their medical record or no evidence they received information regarding execution of an Advanced Directive: - Resident 51 was admitted in 1/2018 and identified to have a Power of Attorney for Healthcare (POA/HC) on her/his Face Sheet. The medical record d… | 2020-09-01 |
| 320 | 320 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 584 | D | 0 | 1 | OB4611 | Based on observation, interview and record review it was determined the facility failed to provide a homelike dining environment in 1 of 3 resident dining rooms (the Independent dining room). This placed residents at risk for an institutional dining experience and lack of autonomy. Findings include: Resident Council Minutes from 11/21/17 and 1/24/18 reflected the residents request for salt and pepper shakers to be placed on the dining room tables for resident use. The dietary response on 1/24/18 identified, salt & pepper shakers are to be on tables starting 2/1/18. On 2/28/18 at 10:12 AM, the following issues with the Independent Dining Room were identified by the resident group: - Salt and pepper shakers were removed from the Independent dining room and residents were told it was a contamination issue. Although residents had voiced the desire to have the salt and pepper shakers back on the table, there was no resolution of the issue. - No table cloths or placemats were available although they had previously been used. The residents felt the use of those items would make them feel more human. - They felt the environment was sterile. On 2/28/18 at 11:40 AM, the cabinets in the assisted dining room on the main floor were found with a sign that directed staff to place salt and pepper caddies on independent dining tables, however no caddies were found in the cabinets. On 2/28/18 at 12:32 PM, the Independent dining room was observed with tables which had no linens, decorations or condiments (including salt or pepper shakers) on them. The walls were bare, except for advertising pictures on one wall and bright lighting overhead. Residents were eating lunch with approximately half of the meals served on trays on top of the table. There was no music or TV available and sound reverberated in the room. There were no staff in the room. In a 3/3/18 interview at 8:23 AM, Staff 8 (Executive Director) stated the room was painted about two weeks previously and decorations had been ordered. Seasonal placemats and decorations were … | 2020-09-01 |
| 321 | 321 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 655 | D | 0 | 1 | OB4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to develop a baseline care plan within 48 hours of admission and to provide a summary of that plan to 1 of 4 newly admitted sample residents (#116), whose baseline care plans were reviewed. This placed residents at risk of not being involved and informed of the planned delivery of care and services. Findings include: Resident 116 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/27/18 (10 days after admission), there was no evidence of a baseline care plan found in the resident's clinical record. A bed side care plan dated 2/16/18 was posted in a closet of the resident's room and outlined primarily the resident's need for ADL assistance. This document did not identify treatment goals or interventions for treatment of [REDACTED]. During an interview on 2/28/18 at 1:31 PM, with Staff 2 (LPN/Resident Care Manager) and Staff 3 (RNCM) they acknowledged the care plan developed within 48 hours of the resident's admission was the bed side care plan, used by aide staff to identify ADL assistance needed. During an interview with the resident on 2/28/18 at 12:14 PM, the resident stated she had no memory of seeing a copy of her care plan. She stated the only document she was aware of was a handbook, which she showed the surveyor, that had been provided the day she admitted to the facility. | 2020-09-01 |
| 322 | 322 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2018-03-02 | 757 | D | 0 | 1 | OB4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure an adequate indication for use of insulin for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for adverse side effects. Findings include: Resident 1 admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Resident 1's 1/2018 Diabetic MAR indicated [REDACTED]. - On 1/16/18 at 7:23 AM Resident 1's CBG level was 93 and the scheduled doses of [MEDICATION NAME] and [MEDICATION NAME] were not held. - On 1/26/18 at 8:30 AM Resident 1's CBG level was 95 and the scheduled doses of [MEDICATION NAME] and [MEDICATION NAME] were not held. Resident 1's 2/2018 Diabetic MAR, there were three instances when Resident 1's CBG level was less than 100 and scheduled insulin was not held. - On 2/5/18 at 5:14 PM Resident 1's CBG level was 98 and the scheduled doses of [MEDICATION NAME] and [MEDICATION NAME] were not held. - On 2/15/18 at 7:25 AM Resident 1's CBG level was 92 and the scheduled doses of [MEDICATION NAME] and [MEDICATION NAME] were not held. - On 2/25/18 at 7:41 AM Resident 1's CBG level was 95 and the scheduled doses of [MEDICATION NAME] and [MEDICATION NAME] were not held. Resident 1's CBG levels taken at the next scheduled time were greater than 100 for all instances and there was no documentation to indicate Resident 1 experienced symptoms of low blood sugar as a result of the insulin administration. On 3/1/18 at 4:54 PM, Staff 10 (LPN) reported Resident 1's insulin should be held for a CBG of less than 100. The order was not included in each insulin order in the electronic MAR indicated [REDACTED]. On 3/2/18 at 8:55 AM Staff 11 (RN) verified all of Resident 1's insulins should be held for a CBG of less than 100. The order was included in the electronic MAR, but not under each insulin order, and was not easily visible. She confirmed she administered [M… | 2020-09-01 |
| 4721 | 4721 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2015-10-19 | 247 | D | 0 | 1 | D2C411 | Based on interview and record review it was determined the facility failed to provide documented notification of a room or roommate change for 2 of 3 (#24 and 40) sampled residents reviewed for a roommate change. This placed residents at risk of not being informed. Findings include: In interview on 10/12/15 at 2:30 pm, Resident 40 stated she/he went to a medical appointment and upon returning found her/his possessions were packed up and moved to another room with no notice or consent. Resident 40 stated she/he would have preferred to have been present when her/his things were packed into boxes and moved. In interview on 10/12/15 at 3:00 pm, Resident 24 stated she/he had several roommate changes, and had not been given notice before they happened. On 10/14/15 at 2:54 pm there was no documentation in either residents' medical record of the room changes. In Interview on 10/14/15 at 3:24 pm, Staff 14, (Social Services Director) confirmed there was no documentation either resident was notified of the room change, no documentation of follow up to check for adjustment to the room change and confirmed Resident 40's room change was done while the resident was out of the facility. | 2019-11-01 |
| 4722 | 4722 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2015-10-19 | 274 | D | 0 | 1 | D2C411 | **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 MDS within 14 days of the initiation of hospice services for 1 of 1 (#23) sampled residents reviewed for hospice. This placed the resident at risk for unmet needs related to comfort care. Findings include: Resident 23 was readmitted in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. A 9/19/15 telephone order directed staff to place the resident on hospice services. On 10/13/15, the electronic medical record identified the significant change MDS was in process. In a 10/16/15 interview at 9:41 am, Staff 4, RNCM, stated the start date of hospice was 9/19/15 when the telephone order was written for services. Staff 4 stated the resident's significant change MDS was still in process (27 days after the start of hospice). When interviewed on 10/16/15 at 1:43 pm, Staff 2, DNS, confirmed the significant change MDS was late for Resident 23. | 2019-11-01 |
| 4723 | 4723 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2015-10-19 | 314 | D | 0 | 1 | D2C411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to prevent pressure ulcer development for 1 of 1 sampled residents (# 92) reviewed with a removable brace. As a result, the resident developed pressure ulcers. Findings include: Resident 92 was admitted to the facility in 7/2015 with a fractured tibia. A hospital history and physical examination [REDACTED]. There was no information related to the resident's skin. Hospital Physical Therapy notes indicated the resident utilized a right knee immobilizer in the hospital. The resident had admission physician orders [REDACTED]. The Admission Clinical Admission Documentation, dated 7/20/15, indicated the resident had pressure ulcer risks factors which included predisposing diseases such as diabetes and arthritis and immobility. The resident had no skin impairment, no skin issues, no foot problems, or amputations when admitted . A Skin at Risk Assessment, dated 7/20/15, indicated the resident had no pressure ulcers and had a brace in place. The resident's 7/20/15 bedside care plan identified the use of a right lower leg immobilizer, and no weight bearing status on the right lower extremity. There were directions to staff related to removal of the brace. On 7/21/15 the Progress Notes indicated at 3:43 am the resident had right lower extremity [MEDICAL CONDITION] and the immobilizer in place on her/his right lower extremity. Two days later, on 7/23/15 at 2:54 am, the progress notes indicated Staff 9 (LPN) removed the immobilizer 'briefly for skin check and assessed no irritation or open areas. A fax dated 7/23/15 at 1:42 pm indicated Staff 10 (LPN) notified the physician of two open areas on the resident's posterior thigh, requested orders to remove the brace while in bed, and orders for treatment. On 7/23/15 at 2:42 pm the physician replied and agreed to the brace removal in bed and open area treatment requests. On 7/24/15 a Skin/Wound Care progress note indicated the resident … | 2019-11-01 |
| 4724 | 4724 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2015-10-19 | 318 | D | 0 | 1 | D2C411 | **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 services to prevent decreased range of motion (ROM) for 1 of 3 sampled residents (#15) reviewed for contractures. This placed residents at risk for unmet needs. Findings include: Resident 15 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. The resident's 12/8/14 Annual MDS indicated the resident had functional limitation in bilateral lower extremity range of motion. The functional CAA reflected the resident had limited left knee ROM, and needed assistance but did not include information about the resident's RA program. The resident's 6/4/15 Contractures Clinical Observation indicated the resident's general state of health was poor/declining, she/he had very limited mobility, moderate risk for contractures risk, and the plan was to continue the current plan of care. There was no description of the plan of care. The resident's care plan updated 9/2015 identified the resident had decreased mobility, had a goal to maintain or increase current mobility, and included the approaches of PT/OT/ST as ordered prn with decline, and RA (Restorative Services) if (resident) agrees. The care plan did not address specific RA components such as measurable goals, frequency of program or approaches. On 10/13/15 at 11:12 am the resident was observed sitting in her/his wheelchair with both knees bent and legs positioned to the right side. The resident kept her/his knees bent to the right when she/he attempted to turn the wheelchair around. On 10/13/15 at 2:20 pm Staff 3 (RNCM) stated the resident had contractures of her/his left knee and did not receive range of motion (ROM) or have a splint device in place. Staff 3 stated ROM and splints were too painful for the resident. On 10/15/15 at 12:23 pm Staff 12 (CNA/CMA ) stated she led an RA exercise group class Monday through Friday that Resident 15 attended. On 10/15/15 at 1:18 pm Staff 3 (RNCM) stated St… | 2019-11-01 |
| 4725 | 4725 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2015-10-19 | 325 | D | 0 | 1 | D2C411 | **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 acceptable parameters of nutritional status were maintained for 2 of 3 sampled residents(#s 20 and 25)reviewed for nutrition. This placed residents at risk for potential weight loss. Findings include: The facility's Nutrition(Impaired)/Unplanned Weight Loss - Clinical Protocol identified the criteria threshold for significant and severe weight loss. The protocol indicated staff would closely monitor residents who have been identified as having impaired nutrition. The monitoring approaches included: evaluating the resident's response to interventions based on defined criteria for improvement/worsening of nutritional status such as stabilization of weight. The facility's Policy and Procedure for Weighing and Measuring the Resident indicated the purpose of the procedure was to provide an ongoing record of the resident's body weight as an indicator of the nutritional status. The preparation to weigh a resident included to be sure the weight scale was calibrated(balanced to zero). The policy also included thresholds for significant and severe weight loss, and directions to report significant weight loss to the nurse supervisor. 1. Resident 25 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. The resident's 5/11/15 annual RAI/MDS indicated the resident weighed 153 lbs, had no severe weight loss or gain in the previous month or six months, and received a mechanically altered therapeutic diet. The nutritional CAA reflected the resident had a downward weight trend and a weight goal of 150-160 lbs. A Nutritional Assessment completed by the Registered Dietician(RD)on 5/19/15 indicated the resident was on a regular pureed diet and received healthshake supplement with medications three times a day. The assessment revealed the resident weighed 165 lbs in 12/2014, 157 lbs in 2/2015, 152.8 lbs in 2/2015, and 149 lbs in 5/2015 which was a weight los… | 2019-11-01 |
| 4850 | 4850 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-10-11 | 166 | D | 1 | 0 | YVPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to make prompt efforts to resolve the grievance of missing personal items for 1 of 2 sampled residents (#1) reviewed for missing personal items. This placed the resident at risk for undue anxiety. Findings include: The facility's undated Item Replacement policy indicated any missing, lost, stolen or damaged items reported will be investigated to determine the nature of the incident Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. On 9/14/16 at 9:00 am Resident 1 stated she/he was missing a wallet, $35.00, a driver's license and Social Security Card. Resident 1 stated she/he told everyone about the loss and it took seven months for the facility to provide her/him with a new wallet and to replace the money. On 9/14/16 at 11:45 am Staff 13 (Social Services Director) was asked if she was aware of the resident's grievance. Staff 13 stated she was aware of the resident's complaint. Staff 13 provided a completed Resident Concern of Lost Items Report dated 1/6/16 with documentation of her/his missing brown wallet with $30.00. The form had an area to document the result of the investigation to include a copy of the report was given to Witness 1 (Former DNS). There was a statement to indicate on 1/6/16 the staff searched the resident's room and no wallet was found. The documentation indicated the resident was to arrange and make an appointment with the Department of Motor Vehicles to get a replacement driver's License. There was no documentation to indicate the Social Security Card was missing. There was no documentation of a further investigation and follow up with the resident until 7/1/16 to indicate a new wallet was purchased by the facility and the resident was given $30.00 in cash. At 1:00 pm Staff 13 stated she thought the resident obtained a replacement driver's License and Social Security Card. At 1:10 pm the resident was approache… | 2019-10-01 |
| 4851 | 4851 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-10-11 | 225 | D | 1 | 0 | YVPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to thoroughly investigate incidents involving the use of an electric wheelchair, Hoyer and standing lift transfers for 2 of 6 sampled residents (#s 1 and 3) reviewed for lift transfers and use of electric wheelchair. This placed the residents at risk for injury. Findings include: The facility's (MONTH) (YEAR) Accident/Incident Policy and Procedure directed the staff to complete an incident investigation for allegations of abuse, neglect, negligent treatment by staff and falls with or without injury. A plan to prevent re-occurrence must be initiated at the time of the incident. Assess for the reason the incident occurred and then take steps to prevent it. 1. Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. a. The 12/30/15 In room care plan directed the staff to provide one person assist with standing lift and the staff were to use 500 pound lift. The care plan indicated Must use leg straps while in standing lift .place (resident's) right arm through the black strap on lift sling to support (her/his) limp arm The 1/5/16 progress notes documented Resident 1 had a witnessed fall when being transferred with her/his care planned lift. The progress notes indicated the lift tipped over and the resident landed on the floor. The resident denied hitting her/his head or any injury. The 1/5/16 event report documented two CNAs transferred the resident to her/his wheelchair from the bed using a standing lift as care planned. The lift tipped over and one of the CNAs made an unsuccessful attempt to shift the resident's position in the lift to prevent the lift from tipping over. The second CNA attempted to lower the lift to the floor as gently as possible. The lift tipped over and the resident fell on the floor. Resident 1 denied injury. The action plan indicated the lift was removed from use and assessed by Staff 9 (Maintenance Director). It was n… | 2019-10-01 |
| 5339 | 5339 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-04-18 | 157 | D | 1 | 0 | GKLP11 | **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 and residents' responsible parties were notified of incidents and changes in condition for 3 of 4 sampled residents (#s 1, 2 and 4) reviewed for notifications. This put residents at risk for unmet needs. Findings include: 1. Resident 1 was admitted to the facility in (MONTH) (YEAR). Review of the resident's signed Physician order [REDACTED]. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. The medication was documented as drug unavailable. Nurse's Notes for (MONTH) (YEAR) showed no documentation the resident was informed her/his medication was unavailable and doses were not administered. Interview on 4/5/16 at 2:30 pm Resident 1 indicated her/his infectious disease doctor prescribed [MEDICATION NAME] for long term use related to a history of flesh eating bacteria. The resident stated she/he was on the antibiotic for many years. The resident further stated she/he was unaware the antibiotic had run out or that she/he missed any doses until Staff 22 (CMA) mentioned the medication was not at the facility yet. Resident 1 stated she/he would have obtained the medication herself/himself if she/he was informed the medication was running low. Interview on 4/11/16 at 4:58 pm Staff 22 (CMA) stated when the resident's supply and the e-kit supply were out she let the resident know. She did not tell the resident the medication was low or out prior to both supplies being exhausted. Interview on 4/11/16 at 11:00 am Staff 26 (LPN) indicated the medication aide told her the resident was out of [MEDICATION NAME]. Staff 26 attempted to get the antibiotic from the pharmacy but they wanted a new order so there was a delay. A few doses were pulled from the emergency kit and administered to the resident but the resident did miss a few doses. Staff 26 did not speak to the resident regarding the medication. Interview on 4/11/16 at 8:15 pm Staff 19 (LPN) indicated s… | 2019-04-01 |
| 5340 | 5340 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-04-18 | 309 | D | 1 | 0 | GKLP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to provide medications as ordered by physician and the assessed fall interventions for 3 of 8 sampled residents (#s 1, 5 and 11) reviewed for medication administration and falls. This placed the residents at risk for unmet needs. Findings include: 1. Resident 11 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. a. The 3/10/16 physician's orders [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The 3/14/16 Progress Notes documented the medication error was found by CMA to indicate the resident received the incorrect dose of [MEDICATION NAME]. The 3/14/16 medication error report completed by the facility indicated the physician's orders [REDACTED]. On 4/6/16 at 10:10 am Staff 1 (DNS) stated the resident was provided with the wrong dose of [MEDICATION NAME] for three days and there was inservice training provided to the facility staff on 3/16/16. b. The 3/8/16 physician's orders [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The 3/16/16 Progress Notes documented the facility was out of the medication and the pharmacy was called and stated they did not have a current physician's orders [REDACTED]. The documentation indicated the physician was notified and an order requested. The 3/21/16 Progress Notes documented a fax was sent to the physician about the Klonopin. The documentation indicated the resident continues to miss nightly dose On 4/6/16 at 10:10 am Staff 1 (DNS) stated the facility staff should have faxed the physician again on 3/17/16 and if there was no response the facility staff should have called the physician or on-call physician. Staff 1 stated the resident received hospice services and the facility staff would have been able to contact hospice for physician's orders [REDACTED]. 2. Resident 5 was admitted to the facility in (MONTH) (YEAR). The resident's care plan dated 3/9/16 indicated the resident had fall interventions including… | 2019-04-01 |
| 5341 | 5341 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-04-18 | 329 | D | 1 | 0 | GKLP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews it was determined the facility failed provide non-pharmacological interventions prior to the use of an anti-anxiety medication for 1 of 5 sampled residents (#4) reviewed for anti-psychotic medications. This placed the resident at risk for unnecessary medications. Findings include: Resident 4 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. There was a 10/2/15 physician's orders [REDACTED]. The (MONTH) (YEAR), January, (MONTH) and (MONTH) (YEAR) MARs were reviewed and they contained direction to Be sure to chart interventions prior to medication use. The MAR indicated [REDACTED]. The direction indicated This resident needs to be documented for mood/behavior sx (symptoms) per shift. (+) behavior occurred, (-) behavior did not occur. It is mandatory to document in progress notes if behavior/mood sx occurred and which interventions were used to alter behavior/mood sx The (MONTH) (YEAR) MAR indicated [REDACTED]. On 4/12/16 at 4:14 pm Staff 5 (LPN) stated she was to document the interventions used prior to the use of PRN [MEDICATION NAME] in the progress notes. Staff 5 stated she didn't document as thoroughly as she should. On 4/13/16 at 4:09 pm Staff 1 (DNS) stated there was no consistent documentation of interventions used prior to the administration of PRN [MEDICATION NAME]. | 2019-04-01 |
| 5342 | 5342 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2016-04-18 | 514 | E | 1 | 0 | GKLP11 | **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 medical records were complete and accurately documented for 5 of 12 sampled residents (#s 2, 3, 4, 6 and 7) whose records were reviewed. This put residents at risk for unmet needs. Findings include: 1. Resident 2 was admitted to the facility in (MONTH) (YEAR). A hospital History and Physical dated 2/24/16 indicated the resident was admitted to the hospital for a [MEDICAL CONDITION]. The resident was noted to have multiple [DIAGNOSES REDACTED]. An event report dated 3/9/16 indicated the resident had a witnessed non-injury fall from her/his recliner. Under the section labeled Event Details it was written Is resident Diabetic? The corresponding box was marked no. The form noted if a resident was diabetic then blood sugars were to be taken as soon as possible, if they were not taken then an explanation of why was to be documented. Interview on 4/7/16 at 10:30 am Staff 6 (RN) indicated she completed the initial event report. She was unsure why she indicated the resident was not diabetic. 2. Resident 7 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the resident's Skin/Wound Care Progress Record showed no documentation of a wound assessment on 3/11/16. The assessments completed on 3/4/16 and 3/18/16 showed no change in the status of the wound. Additional review of the Skin/Wound Care Progress Record showed an undated wound assessment located on the same page as a wound assessment completed on 2/19/16. There was no wound assessment dated between 2/5/16 and 2/19/16. Interview on 4/7/16 at 7:40 am Staff 1 (DNS) indicated the resident's pressure ulcers were present from her/his admission years ago. Staff 1 was unable to locate the missing wound assessment from 3/11/16. She believed the staff completed the assessment but for some reason it was not documented. Staff 1 believed the undated wound assessment was completed on 2/12/16 … | 2019-04-01 |
| 6345 | 6345 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-08-01 | 166 | D | 0 | 1 | 70O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to promptly resolve grievances for 2 of 3 sampled residents (#s 40 and 108) reviewed for personal property. This put residents at risk for unresolved grievances. Findings include: The facility's policy for Personal Items dated 1/9/13 indicated, Facility shall not be responsible for any personal items brought into the facility .Personal items damaged during staff handling or in laundry will be replaced with reasonably-like item. We will investigate all items reported missing and attempt to locate or determine what happened . The facility's Resident Handbook dated 1/11/13 indicated a resident or family member could fill out a concern form for missing items. The SSD (Social Services Director) would initiate an investigation and inform the person of the results of the investigation and corrective action via verbal and written response within seven working days. 1. Resident 40 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. On 7/29/14 at 10:26 am Witness 1 stated Resident 40 was missing a personal pillow. Social Services had been notified and the pillow had not been found. On 7/31/14 at 11:55 am Staff 12, Social Services Supervisor, stated a white down feather pillow was reported missing 11/1/13. It was still an open case, which meant the item had not been found. She stated the facility did not replace missing items unless they could be replaced with donated clothing. She stated the pillow would not be replaced because the facility had pillows available for resident use. She confirmed grievances could go unresolved because the facility didn't replace missing items. On 7/31/14 at 12:45 pm, Staff 2, Administrator, stated the facility had occasionally replaced missing items at their discretion. If the facility's action or inaction caused something to be broken or lost it was replaced. He said Witness 1 needed to be contacted for the facility to resolve the grie… | 2018-03-01 |
| 6346 | 6346 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-08-01 | 309 | D | 0 | 1 | 70O411 | **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, monitor and re-evaluate for effective treatment for 1 of 3 sampled residents (#108) reviewed for non-pressure related skin conditions. This placed residents at risk for untreated skin conditions. Findings include: The Facility Admission Check Off List updated 11/12/13 instructed staff to initiate a weekly Skin/Wound Progress Report if a resident was admitted with impaired skin integrity. Resident 108 was admitted to the facility 4/29/14 with [DIAGNOSES REDACTED]. Nurses' notes dated 4/29/14 at 9:35 am revealed Resident 108 was admitted to the facility with multiple scattered small pinkish purple colored bruises on right arm. Res also has psoriasis, (she/he) has a couple patches on (her/his) right arm. On 7/30/14 at 1:23 pm Resident 108 was observed to have dark red, purple and black, irregularly-shaped spots on her/his hands and arms. They ranged in size from dots to larger than a silver dollar. Resident 108 stated some of the spots were psoriasis and some were bruises. Her/his arms were very sensitive and hurt and she/he stated staff needed to be very gentle with her/him. Resident 108 pointed to a round flaky spot the size of a dime on her/his arm and scratched the flaky skin off. She/he stated it was psoriasis and would be a dark spot in a couple of days. On 7/31/14 at 4:08 pm Staff 6, RNCM, stated she wasn't aware Resident 108 had psoriasis. She observed the resident's hands and arms and stated the resident's Nurse Practitioner would need to see them and the care plan needed to be updated. On 7/31/14 at 4:39 pm Staff 9, RN, stated he was aware of the skin condition on Resident 108's hands and arms. He stated he used [MEDICATION NAME] cream as ordered PRN rash on them periodically and the resident liked it. According to the July 2014 MAR indicated [REDACTED]. There was no evidence in the medical record the flaky skin and dark discolorations on… | 2018-03-01 |
| 6347 | 6347 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-08-01 | 314 | D | 0 | 1 | 70O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to prevent the development of pressure ulcers for 2 of 3 sampled residents (#s 48 and 71) for whom pressure ulcers were reviewed. This placed residents at increased risk for worsening pressure ulcers, pain and infection. Findings include: 1. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing progress note dated 2/10/14 indicated the resident was painful and the admitting nurse was unable to fully assess the resident's skin due to pain with movement. An admission care plan form dated 2/10/14 indicated the nurse was to check (X) all that apply and included lists of interventions. The form indicated Resident 48 required complete assistance for positioning and a hand-written note on the form instructed staff to place a pillow under the resident's left leg. The intervention to float heels (prop the resident's feet so that the heels did not touch the mattress) was not checked as applicable to the resident. According to nursing progress notes dated 2/11/14, 2/12/14, 2/13/14 and 2/14/14 the resident experienced periods of altered mental status and limited independent mobility. A progress note dated 2/18/14 indicated the resident was alert and oriented and a bruise on bottom of left foot was reported to the nurse. An Event Report completed on 2/18/14 by Staff 3 (RNCM) described the discovery of a 2.0 x 4.3 cm irregular blue/dark red blister-like area on the resident's left heel, described as a possible deep pressure wound. The Occurrence Investigation Final Summary indicated the resident was found to have a blister-like lesion on her/his left heel. Factors for skin breakdown were listed and included diabetes, advanced age, decreased mobility related to hip pinning/pain, and at the time of the injury, extreme confusion. The note concluded this lesion definitely looks to be pressure related. According to the investigation the reside… | 2018-03-01 |
| 6348 | 6348 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-08-01 | 425 | D | 0 | 1 | 70O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide over-the-counter (OTC) physician-ordered medications to 1 of 5 sampled residents (#108) reviewed for unnecessary medications. This put residents at risk for not having their health needs met. Findings include: Resident 108 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Hospital Discharge Instructions for Resident 108 included: -Calcium & Magnesium Chelate 180 mg - 90 mg: take one orally once a day -Ocean for Kids Premium Saline 0.65% Nasal Spray: 1 spray nasal once a day. Review of MARs from 4/2014, 5/2014, 6/2014 and 7/2014 revealed Resident 108 was not given Calcium & Magnesium Chelate nor the Saline Nasal Spray because they were unavailable. NN dated 6/3/14 revealed Resident 108's family was informed they needed to bring in Calcium & Magnesium Chelate and Saline Nasal Spray for the resident. On 7/31/14 at 4:08 pm Staff 6, RNCM, stated certain OTC medications were not covered by insurance so the facility did not provide them. Since the family hadn't brought them in yet, she needed to call the doctor to get the orders discontinued. On 7/31/14 at 4:42 pm Staff 1, DNS, provided a list of the facility's house supply stock medications. It included, Residents/Families who wish to have .other OTCs provided to the Residents will be required to pay for the medications. Staff 1 stated if a physician ordered an OTC medication not on the list and the family didn't bring it in, then the facility would call the physician to see if the medication was necessary. If it was deemed medically necessary then the facility would pay for it. If it was not necessary, then the facility would have the physician discontinue it. She stated Resident 108's medications should have been clarified with the physician. On 8/1/14 at 10:00 am Staff 7, CMA, stated whenever a medication was unavailable she would notify the nurses and the RNCMs. If she knew the family she would… | 2018-03-01 |
| 7114 | 7114 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-03-12 | 242 | D | 1 | 0 | SNCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide bathing services consistent with 1 of 2 sampled residents' (# 1) preferences who were reviewed for bathing. This placed the resident at risk for a lack of choice in bathing. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's electronic bathing history, she/he was not bathed from the date of admission on 11/1/13 until 11/12/13 at 9:41 pm, eleven days later. On 11/8/13 the facility conducted a Preferences for Customary Routine and Activities assessment. The resident indicated to the assessor (Staff 7, Activity Director) that the choice between a tub bath, shower, bed bath, or sponge bath was very important and identified she/he preferred a shower three or four times a week in the morning. The resident's care plan indicated under Bathing, Dressing & Grooming, the resident was to be showered There were no schedule or time preferences identified on the plan. The resident's electronic bathing history and Shower Schedule sheets indicated the resident was scheduled for twice a week showers and received, on average, 1.6 showers per week from 11/1/13 through 2/27/14. In the 17 week period, the resident refused 5 showers, all of which were offered in the evenings. Resident 1 was observed on 2/26/14 at 11:15 am and appeared to be adequately groomed. The resident was not interviewable due to [MEDICAL CONDITION] diagnosis. In interview on 2/26/14 at 12:33 pm Staff 3, DNS, confirmed the resident wasn't bathed from the time of admission until 11/12/13 and reported the resident had been put on one floor's bathing schedule but moved to another floor and was not placed on that floor's schedule so showers were missed. In interview on 2/27/14 at 11:36 am Witness 3, Complainant, reported the resident was not bathed on a consistent basis at the facility and was observed on occasion with greasy hair. Witness 3 … | 2017-03-01 |
| 7115 | 7115 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-03-12 | 309 | D | 1 | 0 | SNCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to offer pain medication prior to a medical procedure for 1 of 3 sampled residents (#2) reviewed for pain. This placed the resident at risk for greater pain than was necessary during the procedure. Findings include: Resident 2 was admitted to the facility on [DATE] after a hospitalization with a [DIAGNOSES REDACTED]. On 11/7/13 a Clinical Admission Documentation assessment identified the resident was moderately impaired in her/his decision making, understood, and usually was understood by others. The form identified the resident had no pain at the time of the assessment and a family member stated the resident's pain was well controlled and only experienced pain during transfers. On 11/7/13 the resident had physician's orders [REDACTED]. There was no other pain medication ordered. The resident's November 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 11/14/13 at 3:06 pm a nursing note identified the resident denied pain at rest. The note indicated the resident's surgical stables were removed and steri-strips placed. On 11/14/13 at 6:47 pm a nursing note identified the resident denied having any current pain. The resident was discharged from the facility on 11/26/13. In interview on 2/26/14 at 12:00 pm Witness 1, Complainant, reported on 11/14/13 the facility removed the resident's wound staples without premedicating her/him for pain. Witness 1 stated the facility reported the resident screamed during the procedure. In interview on 3/4/14 at 1:37 pm Witness 2, Complainant, reported the resident experienced pain when her/his staples were removed and the facility failed to premedicate the resident prior to the procedure. In interview on 3/7/13 at 5:00 pm Staff 4, RNCM, reported the resident didn't complain of pain other than at times with movement. Staff 4 stated the resident had an order for [REDACTED]. Staff 4 stated she positioned the resident on her/hi… | 2017-03-01 |
| 7116 | 7116 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2014-03-12 | 323 | D | 1 | 0 | SNCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to implement a care planned safety intervention for 1 of 3 sampled resident (#2) who were reviewed for falls. This placed the resident at risk for continued falls. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/13 a Fall Risk assessment identified the resident was at risk for falls. The resident's care plan identified safety interventions which included motion alarm at bedside & recliner. A Safety Event document indicated the resident was found on the floor on 11/7/13. The fall investigation identified the resident had been placed on the bedpan and when Staff 13, CNA returned she found her/him on the floor. The resident reported she/he was just trying to get up and the resident sustained [REDACTED]. The investigation indicated the resident's motion alarm was off so all care planned interventions were not followed at the time of the fall. The resident was discharged from the facility on 11/26/13. In interview on 2/26/14 at 12:00 pm Witness 1, Complainant, reported the facility could have prevented the resident's fall on 11/7/13 by not leaving her/him on the bedpan. In interview on 3/4/14 at 1:37 pm Witness 2, Complainant, reported the facility left the resident on a bedpan and the resident fell out of bed. In interview on 3/4/14 at 4:56 pm Staff 13, CNA, reported on 11/7/13 she thought she had turned the motion alarm on prior to leaving the resident on the bedpan. She stated she returned in approximately five minutes and found the resident on the floor and the alarm on off. Staff 13 stated she must have forgotten to turn in on. In interview on 3/4/14 at 5:11 pm Staff 14, LPN, reported she was informed on 11/7/13 the resident had fallen and was found sitting on the floor. She stated she assessed the resident and didn't recall the fall resulting in any injury. In interview on 3/12/13 at 1:45 pm Staff 3, DNS, reported… | 2017-03-01 |
| 7155 | 7155 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2012-11-30 | 329 | D | 0 | 1 | 4WZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to monitor medication effectiveness for 1 of 10 sampled residents (#13) whose medication regimens were reviewed. This placed the resident at risk for adverse medication side effects and unnecessary medication use. Findings include: Resident 13 was admitted in 05/2011, with [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. The last documented potassium level was completed in 04/2011, prior to the resident's admission to the facility. In interview on 11/28/12 at 11:45 am, Staff 2, RNCM, was unable to locate any potassium levels in the resident's clinical record since the resident's admission (a total of approximately 19 months). Staff 2 stated there should have been monitoring of the use of [MEDICATION NAME] with the potassium. Staff 2 stated she would expect to have monitoring done every six months and at least once yearly. In interview on 11/28/12 at 3:06 pm, Witness 1, Pharmacist, stated he would expect a basic metabolic panel to be completed within the first 30 days the medication was first administered, then at least every six months afterwards for the use of any kind of diuretic. | 2017-02-01 |
| 7156 | 7156 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2012-11-30 | 387 | D | 0 | 1 | 4WZI11 | **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 seen by a physician as required for 1 of 1 sampled resident (#13) reviewed for physician visits. This placed the resident at risk of having medical needs not met. Findings include: Resident 13 was admitted in 05/2011 with [DIAGNOSES REDACTED]. Review of the resident's record indicated the resident was seen by a physician on 11/7/12. Prior to this, the last documented date the resident was seen by a physician was on 3/1/12. There was no documentation of any physician visits between 3/1/12 and 11/7/12 (a total of 8 months). On 11/29/12 at 9:57 am, Staff 2, RNCM, was unable to find documentation of any physician visits between 3/1/12 and 11/7/12 to verify the resident was seen by a physician within the 60-day timeframe. On 11/29/12 at 12:05 pm, Staff 1, DNS, stated she was the resident's RNCM until October 2012. Staff 1 stated the physician visits must have been overlooked or a letter was sent from medical records to notify the physician. Staff 1 was not sure which one had occurred or if any had been done. On 11/29/12 at 2:08 pm, Staff 3, Medical Records, stated that she did not have any documentation of any physician visits for the resident between 3/1/12 and 11/7/12. She further stated she did not have any documentation in regards to resident's physician being notified of the required 60-day visits not being done. | 2017-02-01 |
| 7157 | 7157 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2012-11-30 | 388 | E | 0 | 1 | 4WZI11 | Based on interview and record review, it was determined the facility failed to assure the initial physician visits were formed by a medical doctor for 4 of 4 sampled residents (#s 26, 58, 69 and 114) who were Medicare recipients upon admission. This placed the resident at risk of having medical needs not assessed due to not being seen by a physician. Findings include: Resident 114 was admitted in 10/2012 and had Medicare A as the primary payment source. The resident's primary physician was identified as Witness 2, General Nurse Practitioner (GNP). The first documented physician visit was on 10/30/12 by Witness 2 and not by a medical doctor. Resident 58 was admitted in 6/2012 and had Medicare A as the primary payment source. The resident's primary physician was identified as Witness 2, GNP. The first documented physician visit was 7/3/12 by Witness 2 and not by a medical doctor. Resident 26 was admitted in 6/2012 and had Medicare A as the primary payment source. The resident's primary physician was identified as Witness 3, Advanced Nurse Practitioner (ANP). The first documented physician visit was 6/4/12 by Witness 3 and not a by a medical doctor. Resident 69 was admitted in 6/2012 and had Medicare A as the primary payment source. The resident's primary physician was identified as Witness 2, GNP. The first documented physician visit was 7/3/12 by Witness 2 and not by a medical doctor. In an interview on 11/30/12 at 10:00 am, Staff 1, DNS, confirmed that the residents were seen by Nurse Practitioners for their initial physician visits and not by a medical doctor. | 2017-02-01 |
| 7158 | 7158 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2012-11-30 | 428 | D | 0 | 1 | 4WZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility's pharmacist failed to identify the need for monitoring effectiveness or adverse side effects for 1 of 10 sampled residents (#13) whose medications were reviewed. This placed the resident at risk for adverse medication side effects. Findings include: Resident 13 was admitted to the facility in 05/2011, with [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. The last documented potassium level was completed in 04/2011, prior to the resident's admission to the facility. The monthly pharmacy review failed to identify the lack of monitoring effectiveness or adverse side effects of the Lasix and potassium administration. In interview on 11/28/12 at 3:06 pm, Witness 1, Pharmacist, stated he would expect a basic metabolic panel to be completed within the first 30 days the medication was administered, then at least every six months afterwards for the use of any kind of diuretic. Witness 1 acknowledged this had not been done. | 2017-02-01 |
| 7435 | 7435 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2013-10-01 | 224 | D | 1 | 0 | K6MO11 | **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 1 of 4 sampled residents (# 1) was free from neglectful care related to call lights. This placed residents at risk for unmet needs. Resident 1 did not receive timely care and services and sustained a fall. Findings include: Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. According to Resident 1's call light response report, from 8/19/13 to 9/22/13, there were 77 incidents of the resident's call light response time exceeding more than 15 minutes. For example, an 8/20/13 Progress Note indicated Resident 1 fell during the previous evening (8/19/13). The facility's investigation noted the call light was on for a prolonged period of time when the fall occurred. The resident reported she/he needed to use the bathroom at the time of the fall. According to the correlating call light response report, the resident's call light response time was 41 minutes 43 seconds. Additional examples of extended call light wait times include: 8/23/13 at 7:27 am: 47 minutes 22 seconds 8/23/13 at 9:00 am: 55 minutes 54 seconds 9/14/13 at 9:19 am: 44 minutes 43 seconds 9/16/13 at 4:30 pm: 37 minutes 16 seconds On 9/23/13 at 9:50 am, Resident 1 was observed sitting in a recliner, with the call light in reach. The resident stated staff never come, but was not able to give any specific details of incidents or timeframes. In interview on 9/23/13 at 5:00 pm, Staff 2, DNS, stated staff were expected to respond to call lights in five to seven minutes. However, it could take as long as 15 minutes if it was a busy time such as lunchtime. In interview on 9/25/13 at 8:33 am, Staff 4, RNCM, stated she was not aware of Resident 1's call light response times, but if it is 40 minutes it is a concern. Staff 4 stated she only reviewed the call light report if it was related to a fall or if she received a complaint regarding call light response. In interview on 9/… | 2016-10-01 |
| 7436 | 7436 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2013-10-01 | 323 | D | 1 | 0 | K6MO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to answer a call light in a timely manner and/or follow fall care plan interventions for 2 of 4 sampled residents (#s 1 & 4) reviewed for falls. This placed residents at risk for accidents. Residents 1 and 4 experienced falls. Findings include: 1. Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. An 8/15/13 facility fall investigation noted on 8/19/13 the resident's care plan was updated for the resident to receive one person assistance with a four wheeled walker. An 8/20/13 Progress Note indicated Resident 1 fell during the previous evening (8/19/13). The facility's investigation described Resident 1 was forgetful, did not follow through with weight bearing status, had poor safety awareness and over estimated physical abilities. There was no injury sustained in the fall. The call light was on for a prolonged period of time when the fall occurred. The resident reported she/he needed to use the bathroom at the time of the fall. According to the correlating call light response report, the resident's call light response time was 41 minutes 43 seconds. Staff education was provided on answering call lights in a timely manner to prevent self transfers. In interview on 9/25/13 at 8:33 am, Staff 4, RNCM, stated the resident's assigned CNA no longer worked in the facility. The CNA was on lunch break and would have seen the resident's call light upon return to the floor, however, the CNA provided care to a different resident. When Staff 12, CNA, returned from taking other residents outside for a smoke break, she saw that Resident 1's call light had been on for 45 minutes, went in the room and found the resident on the floor. In interview on 10/1/13 at 2:30 pm, Staff 4, CNA, stated she did not recall how long Resident 1's call light had been on, however, it had been on a couple of minutes before she took other residents outside for smoking. Staff 4 stated… | 2016-10-01 |
| 8045 | 8045 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2011-09-22 | 371 | F | 0 | 1 | 5TIK11 | Based on observation, interview and record review, it was determined that the facility failed to maintain the kitchen in a sanitary manner. Findings include: On 9/21/11 at 11:30 am, the following areas were observed in the kitchen: - Food debris and food splashes on both of the standup and table top mixers, the two waffles makers on the counter, the back of the bread toaster, and the side of the stove/oven. - The handles of the spice and cereal cupboards had sticky food debris on them and the cupboard fronts and shelves inside were visibly dirty. A partially used bottle of liquid maple flavoring was found uncovered in the spice cupboard. - The food tray transport carts had a greasy film layer and build up of dirt on the bottom shelves, tops and around the wheels. The steel and plastic storage racks located in the kitchen and dry storage areas were greasy to the touch. - The tile floors and baseboards through out the kitchen and in the dish machine area had a greasy slick film and food debris. - The garbage container in the kitchen work area was overflowing with the top open during the meal service. - Hand scoops were observed left in the bulk flour and salt bins. On 9/21/11 at 11:58 am, Staff 5, Dietary Aide, was observed to hold a partially emptied salt shaker in her ungloved hands over the open bulk salt container. She poured salt from the scoop over her ungloved hand into the salt shaker and the bin. The salt touched her hand as it went back into the bulk bin. The uncleaned areas in the kitchen were discussed and shown to Staff 4, Dietary Manager, on 9/21/11 at 3:17 pm. Staff 4 acknowledged the findings. | 2015-11-01 |
| 8272 | 8272 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2012-07-18 | 323 | D | 1 | 0 | WBBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow care planned interventions related to falls for 1 of 3 sampled residents (#1) reviewed for falls. Due to that failure, the resident fell and sustained an injury. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Hospital Discharge Summary noted [DIAGNOSES REDACTED]. The [DATE] Care Plan disclosed the resident was at risk for falls and staff were to be on alert for hypotension and syncope. "Safety Measures" included the use of an alarming fall mat and transferring the resident with one person, gait belt and front wheel walker assistance. [DATE] and [DATE] Progress Notes indicated the resident had attempted self transfers and had poor safety awareness. A [DATE] 1:15 am Progress Note, recorded as a late entry on [DATE], disclosed from 10:30 pm to 1:00 am, the resident made consistent attempts to self transfer, increasing the resident's risk of fall. Multiple interventions had been attempted by staff, which had failed. A [DATE] Progress Note revealed at 2:55 am, Staff 4, RN, heard a "crash" and went running in the direction of the noise. Staff 4 found Resident 1 lying on the floor in the hallway, lying on her/his left side, holding her/his head. The resident was described as "confused, restless, disoriented and unable to sleep all night" with multiple attempts to get out of bed and ambulate without assistance. The resident got out of bed and was ambulating independently down a dark hallway without the use of the walker. The bedside alarm was in the "off" position. The resident had ambulated out of her/his room and approximately 30 feet down the hallway when she/he fell . The fall was unwitnessed and the resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation and treatment. The [DATE] Emergency Department Report indicated Resident 1 sustained a contusion with soft tissue hema… | 2015-08-01 |
| 9335 | 9335 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2010-10-22 | 323 | D | 801P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review it was determined the facility failed to implement care planned interventions to prevent falls for 2 of 3 residents (#s 2 and 3) who were at risk for falls. Resident 2 fell without injury. Findings include: 1. Resident 2 was admitted to the facility in 5/2010 with [DIAGNOSES REDACTED]. According to nursing notes the resident had fallen in his room on 8/23/10 and 9/11/10. To prevent falls the resident was care planned to wear non-skid socks and use a pressure alarm in bed at night. According to a Fall Report, on 10/18/10 at 2:00 pm, the resident was found on the bathroom floor in his room; his walker was next to him. The resident was unable to say how he fell and he was not injured. The Fall Report indicated the resident was not wearing shoes or non-skid socks when he fell . On 10/21/10 at 11:00 am, the resident was observed in bed without non-skid socks on. In an interview the resident stated he had fallen in the past while going to the bathroom. The resident stated he could get to bathroom by himself but staff didn't want him to go alone. In an interview on 10/21/10 at 11:10 am, Staff 3, CNA, stated she had forgot to put non-skid socks on the resident. 2. Resident 3 was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. To prevent falls the resident was care planned to wear non-skid socks and use a pressure alarm when in her wheelchair. On 10/21/10 at 11:15 am the resident was observed in bed without non-skid socks. In an interview on 10/21/10 at 12:45 pm, Staff 4, RNCM, stated the resident should have been wearing non-skid socks when in bed. In an interview on 10/22/10 at 10:20 am, Staff 4, DNS, stated she expected the resident to have non-skid socks on while in bed. | 2014-02-01 | ||
| 9365 | 9365 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2010-09-13 | 157 | D | PBMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to immediately inform the resident's legal representative when there had been an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention for 1 of 3 residents ( #1) who sustained an injury. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of Attorney and she was the first person to be contacted regarding changes to the resident's medical status. According to an 8/18/10 Event Investigation, on 8/18/10 the resident was transferred by one CNA from her wheelchair to the toilet. During the transfer the CNA heard a "popping" sound. The resident complained of left knee pain. According to nursing notes, between 8/19 and 8/25/10 the resident periodically complained of pain in her left knee. On 8/25/10 the physician ordered an x-ray of the resident's left knee. According to an 8/26/10 x-ray the resident's left knee was "suspicious for possible lateral tibial plateau fracture." On 9/1/10 a follow-up x-ray showed a "Nondisplaced acute/subacute fracture from the anterior aspect of the lateral tibial plateau ..." The resident's medical record did not contain evidence that the resident's daughter had been contacted after the 8/18/10 incident. In an interview on 9/10/10 at 9:45 am Staff 1, DNS, stated that after an incident involving resident the facility's policy was for the charge nurse to complete an incident report and notify the physician and family of the incident. Staff 1 acknowledged that the resident's daughter had not been notified after the incident and that nursing staff had not followed facility policy for family notification. | 2014-01-01 | ||
| 9366 | 9366 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2010-09-13 | 225 | D | PBMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure that incidents resulting from staff not following the resident's care plan were immediately reported to adult protective services (APS) for 1 of 3 sampled residents (# 1) who had an incident resulting in injury. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to an 8/18/10 Event Investigation, on 8/18/10 the resident was transferred by one CNA from her wheelchair to the toilet. During the transfer the CNA heard a "popping" sound. The resident complained of left knee pain. According to nursing notes, between 8/19/10 and 8/25/10 the resident periodically complained of pain in her left knee. On 8/25/10 the physician ordered an x-ray of the resident's left knee. According to an 8/26/10 x-ray the resident's left knee was "suspicious for possible lateral tibial plateau fracture." On 9/1/10 a follow-up x-ray showed a "Nondisplaced acute/subacute fracture from the anterior aspect of the lateral tibial plateau ..." An Investigation Summary dated 9/7/10 concluded that the CNA had not followed the resident's care plan for a two-person transfer and was terminated from employment. In addition, the investigation indicated that APS had not been notified until 9/7/10. In an interview on 9/10/10 at 9:45 am Staff 1, DNS, acknowledged that the CNA had not followed the resident's care plan for a two-person transfer and that APS had not been notified of the incident until 9/7/10. | 2014-01-01 | ||
| 9367 | 9367 | COLUMBIA BASIN CARE FACILITY | 385049 | 1015 WEBBER ROAD | THE DALLES | OR | 97058 | 2010-09-13 | 323 | G | PBMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to implement care planned interventions to prevent injury for 1 of 3 residents (# 1) who were at risk for injury during transfers. Resident 1 sustained a left knee fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was care planned to require two-person assistance with transfers and the use of a gait belt. According to an 8/18/10 Event Investigation, on 8/18/10 the resident was transferred by one CNA from her wheelchair to the toilet. During the transfer the CNA heard a "popping" sound. The resident complained of left knee pain. The resident's physician was notified of the incident and orders were received to treat the resident's knee with ice, compression wrap and Naproxen for pain. According to nursing notes, between 8/19/10 and 8/25/10 the resident periodically complained of pain in her left knee. On 8/25/10 the physician ordered an x-ray of the resident's left knee. According to an 8/26/10 x-ray the resident's left knee was "suspicious for possible lateral tibial plateau fracture." On 9/1/10 a follow-up x-ray showed a "Nondisplaced acute/subacute fracture from the anterior aspect of the lateral tibial plateau ..." The Investigation Summary dated 9/7/10 concluded that the CNA had not followed the resident's care plan for a two-person transfer and was terminated from employment. In an interview on 9/10/10 at 9:45 am Staff 1, DNS, acknowledged that the CNA had not followed the resident's care plan for a two-person transfer. . | 2014-01-01 | ||
| 596 | 596 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-05-25 | 309 | D | 1 | 0 | 14RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to administer medications per physician orders for 2 of 3 sampled residents (#s 1 and 3) reviewed for medications. This place residents at risk for adverse medication side affects. Findings include: 1. Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's physician orders did not include eye drops. The Medication Error Report indicated on 3/6/17 Staff 10 (RN) administered Resident 6's prescription eye drops to Resident 1. The note also indicated Resident 6's medications were left on Resident 1's bedside table. The physician was notified Resident 1 inadvertently received prescription eye drops. The Progress Notes for 3/6/17 through 3/10/17 did not have documentation to indicate the resident had pain, irritation or redness to the eyes. On 5/22/17 at 1:50 pm Staff 10 (RN) indicated on 3/6/17 the CMA called in sick and he came in the facility to assist. Staff 10 indicated another staff member prepared medications including an eye drop and handed the medications to Staff 10. Staff 10 indicated he was new at the facility and did not know the residents very well. Staff 10 entered the room and asked the two residents in the room who was Resident 6. Resident 1 responded. Staff 10 started to administer the eye drops to Resident 1 and Resident 1's family member indicated the resident did not have orders for eye drops. Staff 10 indicated he quickly left the room to verify which resident medications he brought into the room. Staff 10 indicated he was concerned about the medication error and when he left the room he left Resident 6's medications on Resident 1's table. He returned immediately and removed the medications. Resident 1 did not take Resident 6's oral medications. Staff 10 indicated he notified the physician and the physician indicated the resident was to be monitored for redness, pain and or irritation to the eyes. Staff 10 indicate… | 2020-09-01 |
| 597 | 597 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2019-05-31 | 656 | D | 0 | 1 | SWDE11 | **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 for 1 of 5 sampled residents (#34) reviewed for medications. This place residents at risk for unmet care needs. Findings include: Resident 34 was admitted in 2019 with [DIAGNOSES REDACTED]. A hospital history and physical dated 1/23/19 indicated Resident 34 had current active [DIAGNOSES REDACTED]. A new [DIAGNOSES REDACTED]. A baseline care plan dated 1/22/19 included interventions related to use of blood thinner, pain, behaviors, fall risk, actual skin yeast, active infection, potential for weight loss and ADL care requirements. The current comprehensive care plan did not address issues related to weight loss surgery with chronic diarrhea and low potassium levels, lactose intolerance leading to bloating, abdominal pain and diarrhea, chronic leg [MEDICAL CONDITION] with skin changes and ulcerations, potential for skin breakdown related to immobility and diarrhea, nerve pain and pain management by pain clinic, recurrent urinary tract infections, history of bowel obstructions, history of blood clots in legs and lungs, potential for dehydration related to the use of two diuretics and chronic loose stools and restless leg syndrome. On 5/31/19 at 2:41 PM Staff 2 (DNS) acknowledged the comprehensive care plan did not include all care needs for Resident 34. | 2020-09-01 |
| 598 | 598 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2016-09-12 | 322 | D | 0 | 1 | QRTD11 | **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 appropriate treatment and services for 1 of 1 sampled resident (#160) who was observed receiving medication through a gastrostomy tube (a surgically placed tube into the stomach for provision of nutrition, hydration and medication) during medication administration. This placed residents at risk for medical complications. Findings include: Resident 160 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility policy and procedure for Enteral Tube Medication Administration indicated prior to medication administration tube placement would be checked and medications would be administered one at a time by gravity. On 9/9/16 at 8:43 am Staff 4 (LPN) was observed to crush all of the following medications together in 1 pouch: aspirin, [MEDICATION NAME] sulfate and vitamin C. Staff 4 was observed to administer the crushed medications via Resident 160's [DEVICE]. Staff 4 did not check correct tube placement prior to medication administration. Staff 4 then used pressure to push the medications into the [DEVICE] with the syringe plunger rather than let the medication flow by gravity. On 9/9/16 at 10:41 am Staff 4 (LPN) confirmed she mixed the medications together, did not check tube placement prior to medication administration, and did not use gravity to administer the medications. | 2020-09-01 |
| 599 | 599 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2016-09-12 | 514 | D | 0 | 1 | QRTD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure documentation was accurate and complete for 1 of 6 sampled residents (#12) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 12 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A 5/10/16 Signed Physician order [REDACTED]. Special instructions: Document pre and post med scale. The (MONTH) (YEAR) PRN Medications Flowsheet indicated Resident 12 was not administered [MEDICATION NAME] on 5/8/16 and 5/14/16. The (MONTH) (YEAR) Narcotic Log indicated two 0.5 tabs (2 mg) of [MEDICATION NAME] were signed out on 5/8/16 and 5/14/16. On 9/9/16 at 9:00 am Staff 2 (RNCM) confirmed the discrepancy between the (MONTH) (YEAR) Narcotic Log and the (MONTH) (YEAR) PRN Medication Flowsheet for the dates 5/8/16 and 5/14/16 for Resident 12. b. The (MONTH) (YEAR) PRN Medication Flowsheet for [MEDICATION NAME] included areas to document the following: staff initials, time given, amount given, pain level pre-med and pain level post-med. The (MONTH) (YEAR) PRN Medication Flowsheet indicated Resident 12 received [MEDICATION NAME] on 17 occasions with the following documentation errors: amount given was not documented, the amount given column was used to document pre-pain levels and the pre-pain levels column was used to document post-pain level. On 9/8/16 at 10:36 pm Staff 3 (CMA) confirmed he did not document the amount of [MEDICATION NAME] administered to Resident 12 on the (MONTH) (YEAR) PRN Medication Flowsheet. Staff 3 further confirmed he used the incorrect lines to document both pre-med pain levels and post-med pain levels. On 9/9/16 at 9:00 am Staff 2 (RNCM) confirmed the (MONTH) (YEAR) PRN Medication Flowsheet did not reflect the amount of [MEDICATION NAME] administered to Resident 12 for 17 of 30 days. Staff 2 further confirmed the documentation was inaccurate. | 2020-09-01 |
| 600 | 600 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-09-18 | 309 | D | 1 | 0 | U3QG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to follow medication administration orders for an antibiotic and respond timely to a decline in condition for 1 of 3 sampled residents (#1) who's medications and records were reviewed. This placed the resident at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. On 6/6/17 a Physician ordered [MEDICATION NAME] (an antibiotic) 750 mg daily for seven days for pneumonia. The order was transcribed onto Resident 1's (MONTH) (YEAR) MAR and initiated on 6/7/17. On 6/13/17 Resident 1's (MONTH) (YEAR) MAR indicated the resident was not administered [MEDICATION NAME] on 6/13/17 nor on 6/14/17 because it wasn't available. The resident missed the last two doses of the physician ordered antibiotic course. There was no documented evidence the facility attempted to obtain the medication or notified the physician that the antibiotic wasn't available or administered as ordered. On 6/13/17 at 11:47 pm a nursing Progress Note indicated Resident 1 was lethargic and woke up a little when talked to but fell right back to sleep. In addition, the note indicated the resident was becoming more incontinent of bowel and bladder. On 6/15/17 at 9:02 pm a nursing Progress Note indicated the Physician called the facility and ordered Resident 1 sent out to the hospital for an evaluation for concerns related to dehydration. The hospital's History and Physical (H&P) indicated the resident had [DIAGNOSES REDACTED]. In interview on 9/12/17 Staff 4 (RNCM) confirmed Resident 1 did not receive [MEDICATION NAME] on 6/13/17 and 6/14/17 due to it not being available. She stated she could not find evidence the physician was contacted regarding the missed doses. In interview on 9/14/17 at 3:37 pm Staff 8 (LPN) reported Resident 1's last two doses were not available. Staff 8 stated he called the pharmacy but they didn't send more medica… | 2020-09-01 |
| 601 | 601 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-09-18 | 327 | D | 1 | 0 | U3QG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assess a resident's risk for dehydration, attempt interventions to prevent dehydration, or identify signs and symptoms of dehydration timely for 1 of 1 sampled resident (#1) who drank poorly. This placed the resident at risk for unaddressed hydration needs. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. On 5/29/17 a Medical Nutrition Therapy Admission Assessment identified Resident 1's estimated fluid needs were 2400 milliliters (mls) per day, approximately 81 ounces. According to the resident's meal and fluid monitor, between 6/1/17 and 6/15/17 the resident averaged 253 mls of fluid per day, approximately 8 ounces. There was no evidence the facility assessed the resident's risk for dehydration or attempted interventions to address her/his hydration needs when the resident routinely drank less that her/his assessed fluid needs. On 6/12/17 at 10:01 pm a nursing Progress Note indicated the resident did not drink much for several days. On 6/13/17 at 11:47 pm a nursing Progress Note identified the resident refused liquids, was lethargic, and was becoming more incontinent. On 6/15/17 at 9:02 pm a nursing Progress Note identified the Physician ordered Resident 1 sent out to the hospital because lab results showed her/his kidney function was worse and she/he seemed dehydrated. On 6/15/17 an Emergency Department report indicated Resident 1's blood work showed elevated BUN and creatinine (a possible indication of dehydration) and the resident's mouth and face were dry and cracked which was consistent with a pretty severe dehydration. In interview on 9/14/17 at 3:37 pm Staff 8 (LPN) reported prior to Resident 1 being sent out on 6/15/17, the resident had appeared dehydrated for several days and stated he was trying to get the resident to drink and go to the hospital. Staff 8 confirmed that the resident's refusal to go … | 2020-09-01 |
| 602 | 602 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 641 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the MDS assessment was accurately coded for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for unassessed needs. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/5/17 Resident 24's physician ordered the use of an elopement alarm after the resident exited the facility without assistance and experienced a fall. The 10/4/17 comprehensive care plan indicated the Resident 24 had an elopement alarm in place to notify staff when resident was near exit doors. The 10/29/17 Annual MDS Section P - Restraints and Alarms did not indicate Resident 24's use of the elopement alarm. On 12/19/17 at 10:30 am Staff 17 (RNCM/MDS Coordinator) acknowledged she did not code the elopement alarm for Resident 24. | 2020-09-01 |
| 603 | 603 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 658 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined facility staff failed to meet professional standards for medication administration and skin assessments for 1 of 2 sampled residents (#7) reviewed for skin conditions. This placed residents at risk for adverse medication reactions and unmet needs. Per Division 45 Standards and Scope of Practice for the LPN and RN [PHONE NUMBER]; Conduct Derogatory to the Standards of Nursing Defined: - Failing to communicate information regarding the client's status to members of the health care team in an ongoing and timely manner as appropriate to the context of care; or - Failing to communicate information regarding the client's status to other individuals who are authorized to receive information and have a need to know. - Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 7 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. a. On 12/11/17 at 12:09 pm Resident 7 stated she/he had a rash on the left buttocks. On 12/15/17 at 10:45 am Staff 13 (RN) completed a skin check on Resident 7 which was observed by surveyor. Staff 13 stated there were red fungal spots on the resident's left groin fold, a fungal open area on the resident's right groin fold and a fungal area on the resident's buttocks. Staff 13 stated a CNA reported the skin conditions to him on 12/11/17 between day shift and evening shift. Staff 13 confirmed he did not observe the resident's skin until the morning of 12/15/17. Staff 13 stated he could not recall if he reported the skin condition to another charge nurse and did not know if another RN had assessed the change in the resident's skin condition. He did not remember which CNA reported the change in skin condition to him. He confirmed a skin grid was not completed. On 12/15/17 at 11:53 AM Staff 2 (DNS) and Staff 17 (RNCM/MDS Coordinator) confirmed Staff 13 (RN) should have reported Resident 7's change in sk… | 2020-09-01 |
| 604 | 604 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 684 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to follow physician's orders for 2 of 6 sampled residents (#s 7 and 33) reviewed for unnecessary medications and skin conditions. This placed residents at risk for adverse medication reactions and unmet needs. Findings include: 1. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 7's admission MDS dated [DATE] revealed the resident was at risk for skin breakdown related to urinary incontinency. Resident 7's comprehensive care plan dated 7/14/17 included an intervention for moisture barrier cream to the resident's skin. Resident 7's in-room care plan updated 11/26/17 directed staff to report any new skin issues to the nurse. On 12/11/17 at 12:09 pm Resident 7 stated she/he had a rash on her/his buttocks and a CNA had applied a barrier cream that morning. On 12/15/17 at 10:45 am Resident 7 gave permission for the surveyor to observe a skin check completed by Staff 13 (RN). Staff 13 described fungal areas in both of the resident's groin folds and on her/his buttock. Staff 13 applied an antifungal cream from a tube he kept in his pocket. He stated he did not have a physician's order for use of the cream for Resident 7 and would request one later. He stated he used the tube of antifungal cream on any residents with fungal skin conditions and afterward would request a physician order if there was not already an order. Resident 7's physician's orders did not include an antifungal cream until 12/16/17, a day after it was applied. On 12/15/17 at 11:53 am Staff 2 (DNS) and Staff 17 (RNCM/MDS Coordinator) confirmed Staff 13 (RN) should not have applied the antifungal cream to Resident 7 without a physician order. On 12/18/17 at 11:10 am Staff 3 (RNCM) confirmed an order for [REDACTED]. 2. Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 12/6/17 physician order indicated Resident 33 was to receive lo… | 2020-09-01 |
| 605 | 605 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 689 | E | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the environment was free of potential accident hazards for 3 of 33 resident rooms (#s 10, 12 and 19) and 1 of 2 dining (North) rooms reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Review of the 10/2012, Oregon Department of Human Services Administrator Alert, revealed the following for in-wall heater use for nursing facility regulatory compliance: -Residents and staff are at risk [MEDICAL CONDITION] unexpected fire due to existing in-wall heaters or replacement units; -The facility was responsible for the following: -Identify and evaluate hazards and risks, implement interventions to reduce hazards and risks, and monitor the effectiveness of the interventions; -Educate residents, resident representatives and staff about the risks of unsupervised access to in-wall heaters in rooms; -Determine the appropriateness, complete an accurate assessment and create a care plan reflecting the residents' ability for safe, unsupervised, independent access to in-wall heaters; -Ensure residents' records included documentation that the resident or representative received information and consents related to the risks associated with independent access and/ or use of the existing in-wall heaters. Observations on 12/15/17 at 9:02 am revealed the in-wall heater in room [ROOM NUMBER] was unable to be touched for momentary contact. The heater's precaution label stated: caution high temperature, at risk of fire, keep combustibles at least 3 feet away from the front of the heater. No combustibles were observed within three feet of the heater. Observation on 12/15/17 at 10:06 am revealed the in-wall heater vent surface read 199 degrees Fahrenheit (F) in the North dining area. During observation and interview on 12/15/17 at 10:08 am, room [ROOM NUMBER]'s in-wall heater vent surface temperature read 270F. Staff 1 (Administrator) verified … | 2020-09-01 |
| 606 | 606 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 756 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for medication side effects. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 4/20/17 Note to Attending Physician/Prescriber indicated Resident 24 received [MEDICATION NAME] (stomach ulcer prevention) since 12/2016. The Consultant Pharmacist recommended reassessment to support continued use of the medication. On 4/21/17 the physician responded to the Consultant Pharmacist's recommendation: Is (resident) complaining of any symptoms? Resident 24's record revealed no documentation of facility follow-up or response to the physician's request. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 12/19/17 at 9:17 AM Staff 3 (RNCM) stated she would look for follow-up documentation related to the [MEDICATION NAME]. No additional information was provided. | 2020-09-01 |
| 607 | 607 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 757 | D | 0 | 1 | PQSE11 | **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 indication for the use of medications for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for inappropriate medication administration. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The resident's record did not include clinical rationales for the use of the [MEDICATION NAME] or the [MEDICATION NAME]es. On 12/19/17 at 9:17 am Staff 3 (RNCM) stated she would look for clinical rationales for the [MEDICATION NAME] and [MEDICATION NAME]es. No additional information was provided. | 2020-09-01 |
| 608 | 608 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 758 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to have an adequate indication for use of and complete gradual dose reductions for antipsychotic medications for 2 of 5 sampled residents (#s 20 and 26) reviewed for medications. This placed residents at risk for unnecessary antipsychotic medication. Findings include: 1. Resident 26 admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Signed physician orders [REDACTED]. Review of the 11/2017 MAR indicated [REDACTED]. On 12/15/17 at 1:59 pm Staff 5 (LPN/RCM) confirmed the [DIAGNOSES REDACTED]. 2. Resident 20 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. December (YEAR) physician's orders [REDACTED]. Consultant Pharmacist Medication Regimen Reviews from (MONTH) (YEAR) through (MONTH) (YEAR) documented no concerns. There was no documented attempts of gradual dose reductions for the [MEDICAL CONDITION] medications. A 11/9/17 physician telephone order requested a gradual dose reduction for the [MEDICATION NAME] and [MEDICATION NAME]. The signed physician order [REDACTED]. In an interview on 12/15/17 at 1:27 pm Staff 3 (RNCM) acknowledged the physician order [REDACTED]. In an interview on 12/15/17 at 1:45 pm Staff 11 (Medical Records) stated no gradual dose reduction requests could not be located prior to 11/9/17. In an interview on 12/15/17 2:00 pm Staff 2 (DNS) acknowledged there was no clinical rationale for why the medication reductions could not be attempted. Staff 2 stated she was working to educate each physician on the new [MEDICAL CONDITION] medication regulation pertaining to gradual dose reduction. | 2020-09-01 |
| 609 | 609 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 812 | F | 0 | 1 | PQSE11 | Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 kitchens reviewed. This placed residents at risk for potential food borne illness. Findings include: Observations in the facility walk-in refrigerator on 12/11/17 at 9:26 am revealed the following: -Closed container of salad dated 12/5/17. -Opened bag of spinach dated 12/4/17 and an opened bag of spinach with an incorrect open date of 12/25/17. -Two bunches of undated, uncovered and wilted celery. -Closed container of thawing pork with an unreadable opened date. -Undated raw chicken inside a plastic bag, partially uncovered. -Undated raw beef inside a plastic bag, partially uncovered. On 12/11/17 at 9:38 am Staff 27 (Kitchen Manager) stated the closed container of salad should have been tossed on 12/8/17 and the open bag of spinach dated 12/4/17 should have been tossed on 12/7/17. Staff 27 further stated the open date on the additional bag of spinach was unreadable, and was unable to confirm a date of delivery or the use by date for the celery. Staff 27 confirmed the date on the thawing pork was unreadable and both the thawing chicken and thawing beef were exposed to air and undated. | 2020-09-01 |
| 610 | 610 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 842 | E | 0 | 1 | PQSE11 | **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 records were complete and accurate for 4 of 10 sampled residents (#s 9, 24, 26 and 31) reviewed for unnecessary medications, accidents and pressure ulcers. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 31 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. An 8/15/17 progress note indicated Resident 31 had a large excoriation wound (abrasion type injury) on the coccyx/buttock with no open or bleeding areas. TARs from 8/15/17 through 9/14/17 revealed an order for [REDACTED]. A 9/3/17 progress note indicated Resident 31 had multiple open areas on the left and right buttocks. The 9/3/17 through 9/13/17 TARs revealed orders and instructions for treatment of [REDACTED]. On 12/18/17 at 4:18 pm Staff 16 (RN) stated Resident 31's skin issues were excoriation and not pressure in nature. During an interview on 12/19/17 at 12:15 pm Staff 2 (DNS) and Staff 3 (RNCM) confirmed Resident 31's wounds were not pressure related and the (MONTH) and (MONTH) (YEAR) TARs identified the skin issues inaccurately. 2. Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/5/17 Resident 24's physician ordered the use of an elopement alarm after the resident exited the facility without assistance and experienced a fall. Resident 24's 10/29/17 Annual MDS - Section [NAME] was not coded for wandering behaviors during the look back period (review time frame). The resident's record included no additional documentation of elopement incidents by Resident 24 as of the time of the survey on 12/11/17. From 12/11/17 through 12/19/17 Resident 24 was observed multiple times propelling her/his wheelchair in the hall near her/his room and adjacent dining room. The resident did not approach or attempt to open the nearby exit door. During an interview on 12/15/17 at 10:09 am Staff 14 (CNA) and St… | 2020-09-01 |
| 611 | 611 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 880 | D | 0 | 1 | PQSE11 | **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 proper hand hygiene and infection control during random observations of nursing staff. This placed residents at risk for cross-contamination and infection. Findings include: 1. The facility's Policy and Procedure on Hand Hygiene dated 6/2017 included required hand hygiene before and after direct resident contact, upon and after contact with a resident's intact skin and after removing gloves. It indicated hand hygiene should be performed as soon as possible after hands become contaminated. Prior to entering Resident 7's room on 12/15/17 at 10:45 am, Staff 13 (RN) donned gloves in the hall prior to entering the resident's room. He did not change his gloves or wash his hands after entering the room and prior to touching Resident 7. Without changing gloves, he touched the resident's skin then took a tube of cream out of a plastic bag in his pocket which contained two other tubes. He applied the cream to the resident without changing gloves. He attempted to place the tube back in the plastic bag in his pocket with the other two tubes used for multiple residents. The surveyor stopped him and asked about cross-contamination. He stated he would disinfect the tube of cream but decided to dispose of it since it was almost empty. The two remaining tubes in his pocket were already cross-contaminated because he touched them with his contaminated gloved hands. Staff 13 stated the tubes were for any residents for whom he completed skin treatments. On 12/15/17 at 12:46 pm the three tubes of creams were observed in Staff 13's pocket. When asked about the administration of the cream for Resident 7 earlier in the morning, Staff 13 confirmed he should have put each cream in individual cups for each resident at the medication cart, changed gloves and washed his hands in between each procedure and resident. He said he didn't follow his normal routine because he was ru… | 2020-09-01 |
| 4540 | 4540 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 309 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to follow physician's orders related to fluid restriction for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for complications related to [MEDICAL CONDITION] and low sodium levels. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Hospital Orders at discharge date d 11/26/16 indicated to restrict Resident 1's fluid intake to 1200 ml per day and weigh the resident daily. Resident 1's Diet Order & Communication dated 11/26/16 indicated the resident was on a 1200 ml per day fluid restriction. Resident 1's 12/2016 physician's orders included a fluid intake goal of 1200 ml per day. The night shift nurse was to record the 24 hour total. Resident 1's fluid intake record charted under the resident's vital signs in the computerized medical record revealed on 17 of the 25 days from 11/26/16 through 12/21/16 the resident went over her/his 1200 ml per day fluid restriction by as little as 70 ml to as much as 3080 ml per day. The resident's average intake from 11/26/16 through 12/14/16 was 1964 ml per day. Resident 1's 11/2016 and 12/2016 TARs revealed the facility also documented the resident's per shift fluid intake on the TAR. According to the TAR the resident's average intake from 11/26/16 through 12/14/16 was 1353 ml per day. On 3/15/17 at 1:53 am Staff 1 (DNS) acknowledged there were times Resident 1 went over her/his daily fluid restriction. | 2020-03-01 |
| 4541 | 4541 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 325 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to reassess the risk for poor food intake after a change in mental status for 1 of 3 sampled residents (#1) reviewed for food intake. This placed residents at risk for unintended weight loss. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 12/1/16 Registered Dietitian (RD) assessment indicated Resident 1's intake was enough to promote weight gain and the resident agreed to start nutritionally enhanced meals. The resident's average breakfast, lunch and dinner intake was 76-100%. A fax sent to the physician on 12/5/16 indicated the facility requested a new order for nutritionally enhanced meals for planned weight gain. The order was approved by the physician. A 12/8/16 Nutritional Risk Review indicated the resident's seven day breakfast, lunch and dinner average intake was 76-100%. Resident 1's meal intake record from 11/26/16 through 12/21/16 indicated the amount of meals consumed using ranges of: 1-25%, 26-50%, 51-75% and 76-100%. On other times it was recorded as None, Not taken or it was not recorded at all. From 11/26/16 through 12/15/16 the record revealed the following average meal intakes using the highest number in the ranges recorded and using zero where it was not recorded or indicated the resident did not eat: - Breakfast 74% - Lunch 66% - Dinner 59% Resident 1's meal intake record from 12/14/16 through 12/21/16 revealed the following average meal intakes: - Breakfast 32% - Lunch 38% - Dinner 21% Resident 1's 11/2017 and 12/2016 TARs revealed the resident was supposed to be weighed daily at 6:30 am. On 11/27/16 the resident weighed 133.6 pounds and on 12/18/16 weighed 130 pounds (an insignificant loss of 3.6 pounds). On 12/21/16, the day the resident was discharged from the facility, the resident weighed 123.4 pounds, an overall loss of 10.2 pounds or 7.6% body weight over 24 days. (As the resident was discha… | 2020-03-01 |
| 4542 | 4542 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 327 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assess the risk factors for dehydration, assess actual fluid intake and reassess the risk for dehydration after a change in mental status for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for fluid imbalance. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Hospital Orders at discharge date d 11/26/16 indicated to restrict Resident 1's fluid intake to 1200 ml per day and weigh the resident daily. Resident 1's Diet Order & Communication dated 11/26/16 indicated the resident was on a 1200 ml per day fluid restriction. Resident 1's 12/2016 physician's orders [REDACTED]. The night shift nurse was to record the 24 hour total. The resident also had a physician's orders [REDACTED]. Resident 1's Care Plan dated 12/5/16 indicated the facility was to maintain the resident's fluid and sodium restrictions as indicated and monitor for clinical evidence of fluid imbalance including skin turgor, level of consciousness changes, vital sign changes, laboratory values and mucous membranes. The Care Plan did not indicate the resident was on a 1200 ml per day fluid restriction. Resident 1's In Room Care Plan (IRCP) last updated on 12/6/16 (a copy of which was made by this surveyor on 2/23/17 from the resident's chart) did not indicate the resident was on a fluid restriction. On 3/3/17 at 3:15 pm Staff 1 (DNS) provided a copy of Resident 1's IRCP which indicated 1200ml fluid restriction but was otherwise identical and was also last updated 12/6/16. A 12/1/16 Registered Dietitian (RD) assessment indicated Resident 1 was on a 1200 ml per day fluid restriction and the assessment calculated the resi… | 2020-03-01 |
| 4543 | 4543 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 514 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to maintain accurate fluid intake records for a resident on a physician ordered fluid restriction for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for inaccurate fluid intake data needed for accurately monitoring and assessing residents on fluid restrictions. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Resident 1's fluid intake record from 11/26/16 through 12/21/16 charted under the resident's vital signs in the computerized medical record revealed that on 17 of the 25 days from 11/26/16 through 12/21/16 the resident went over her/his 1200 ml per day fluid restriction by as little as 70 ml to as much as 3080 ml per day. The resident's average intake from 11/26/16 through 12/14/16 was 1964 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 763 ml per day which was a 61% decrease. Resident 1's 11/2016 and 12/2016 TARs revealed the facility also documented the resident's per shift fluid intake on the TAR. According to the TAR the resident's average intake from 11/26/16 through 12/14/16 was 1353 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 596 ml per day which was a 56% decrease. On 3/15/17 at 1:53 am and 3/16/17 at 10:45 am Staff 1 (DNS) acknowledged the fluid intake documentation was not accurate. | 2020-03-01 |
| 5169 | 5169 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 225 | D | 0 | 1 | EZTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to ensure a thorough investigation was completed for 1 of 1 sampled resident (#78) reviewed for Nasogastric (NG) tube. This put a resident at risk for unmet needs. Findings include: Resident 48 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. NNs dated 4/10/15 at 3:13 am indicated during a staff assisted transfer the resident's NG feeding tube came all the way out. The resident denied any pain and was transported to the emergency room to have the tube reinserted. An incident investigation dated 4/10/15 indicated during a transfer to the bathroom the resident's NG feeding tube came all the way out. The resident was monitored until morning, the physician was notified and the resident was sent to the ER for replacement in the morning. Staff were educated on being aware of the tube location during transfers and to ensure proper placement to prevent the tube from coming out. There was no additional information in the investigation regarding details of the incident such as: care plan interventions, how the resident was being transferred, at what point in the transfer the incident occurred, the number of staff involved, where the staff were in relation to the resident or how to prevent future occurrences. In an interview on 7/23/15 at 12:50 pm Staff 4 (LPN) and Staff 5 (RNCM) indicated from what they could recall there was not a concern with how the staff completed the transfer. They believed the care plan was followed at the time. Staff 4 stated there was no wrong doing; staff were reminded to be extra aware of the placement of the tubing during transfers. Staff 4 could not say why she did not document more information during the investigation. b. NNs dated 3/25/15 through 4/15/15 contained no documentation or information of bruising to the resident's forearm. NNs dated 4/16/15 indicated Staff 4 (LPN) went to the resident's room and family stated th… | 2019-06-01 |
| 5170 | 5170 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 272 | D | 0 | 1 | EZTS11 | **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 and document the use of a blood thinning medication and a resident's ability to leave the facility for community travel for 2 of 8 sampled residents (#s 33 and 48). This put residents at risk for unmet needs. Findings include: 1. Resident 48 was admitted to the facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. NNs dated 1/1/15 through 7/24/15 indicated the resident traveled out of the facility both alone and accompanied by a friend 1-3 times per week. The resident was noted to verbally check out or sign out in the notebook at the nurses station on most occasions. The resident had intermittent increases in paranoia and delusions which corresponded to UTIs. The resident was treated with antibiotics and some of the behaviors decreased. The resident additionally had two mental health evaluations completed and adjustments to medications to address the resident's behaviors. Elopement risk assessments completed on 1/22/15 and 3/31/15 indicated the resident was not considered an elopement risk. No additional assessment information could be located regarding the resident's independent travel into the community. The resident's quarterly MDS dated [DATE] showed no behaviors occurred during the assessment period. The resident did not display any unsafe wandering attempts but the resident continued to have ongoing delusions. The resident's brief interview for mental status exam score was 11 which indicated the resident was cognitively intact. The resident's care plan dated 6/10/15 indicated extensive assistance of one person was needed for transfers, two person assistance for bed mobility. The resident was noted to have an electric wheelchair. The resident was alert, oriented and could direct her/his own care. Staff were to monitor the resident for behaviors, delusions and paranoia. No other information regarding the resident's independent t… | 2019-06-01 |
| 5171 | 5171 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 280 | D | 0 | 1 | EZTS11 | **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 with participation of the resident, resident family or the responsible party for 2 of 3 sampled residents (#s 52 and 55) reviewed for participation in care planning. This placed residents at increased risk for lack being informed. Findings include: 1. Resident 52 was admitted to the facility 6/9/15 with [DIAGNOSES REDACTED]. The resident's MDS Assessment Summary indicated the assessment was completed on 6/13/15 and indicated the resident was cognitively intact. On 7/20/15 at 2:26 pm Resident 52 indicated the staff did not discuss her/his plan of care and treatment options with her/him. On 7/21/15 at 9:30 am Staff 3 (Social Services Director) acknowledged the initial care conference with the participation of the resident or responsible party was not done after the comprehensive assessment was completed. On 7/23/15 at 1:50 pm Staff 2 (Administrator) acknowledged within seven days after the admission assessment was completed the interdisciplinary team was to meet with the resident, family or responsible party to discuss the resident's goals and treatment plan. 2. Resident 55 was admitted to the facility 6/29/15 with [DIAGNOSES REDACTED]. The resident's Admission MDS Summary indicated the admission assessment was completed on 7/7/15 and identified the resident to be cognitively intact On 7/20/15 at 3:09 pm Resident 55 stated the staff did not discuss her/his plan of care and treatment options with her/him. On 7/21/15 at 9:30 am Staff 3 (Social Services Director) acknowledged the initial care conference with the participation of the resident or responsible party was not done after the comprehensive assessment was completed. On 7/23/15 at 1:50 pm Staff 2 (Administrator) acknowledged within seven days after the admission assessment was completed the interdisciplinary team was to meet with the resident, family or responsible party to discus… | 2019-06-01 |
| 5172 | 5172 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 309 | D | 0 | 1 | EZTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to identify a resident's steroid induced bruises, failed to report a resident's change of condition to licensed staff and follow physician's orders [REDACTED].#s 78, 152 and 156) reviewed for skin conditions, medications and change in condition. This place residents at increased risk for unmet needs and delayed treatment. Findings include: 1. Resident 156 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's Vitals Report from 6/23/15 through 7/23/15 indicated on the evening and night shift on 7/21/15 Resident 156 was documented to have tarry/black bowel movements. The day shift indicated the resident did not have a bowel movement. The 7/21/15 at 1:32 pm Progress Note indicated the resident had a poor appetite. The 7/21/15 at 10:08 pm note indicated the resident denied pain. The 7/22/15 at 1:34 am note indicated the CNA reported the resident had multiple black bowel movements in less than one hour. The resident's physician was notified and the resident was sent to the local emergency room for possible gastro-intestinal bleeding. On 7/23/15 at 5:23 am Staff 23 (Night Shift LPN) stated on 7/21/15 at approximately 11:30 pm she assessed the resident. The resident reported an upset stomach and reported she/he did not feel well. Staff 23 stated at 11:30 pm Staff 20 (Night Shift CNA) reported the resident had a loose bowel movement but the CNA did not report the stool was black and tarry. At approximately 12:30 am on 7/22/15 Staff 20 reported to Staff 23 the resident had another loose bowel movement and reported it was tarry and black. Staff 23 stated she observed the bowel movement, knew the tarry black bowel movement was indicative of a possible gastro-intestinal bleed, called the physician and the resident was sent to the hospital emergency room for evaluation. Staff 23 indicated the nurse on the evening shift staff did not report th… | 2019-06-01 |
| 5173 | 5173 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 314 | G | 0 | 1 | EZTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to thoroughly evaluate equipment to determine if there was pressure to the resident's feet and assess and treat a toe ulcer for 1 of 4 sampled residents (# 90) reviewed for skin conditions. Resident 90 was diagnosed with [REDACTED]. Findings include: The facility's (MONTH) (YEAR) Skin at Risk/Skin Breakdown Policy and Procedures indicated Upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, rash, skin tear, surgical wound, etc.) the Licensed Nurse will: Document skin impairment that includes measurements of size, color, presence of odor and exudates .Notify the Physician and obtain a Treatment Order if needed, document on the TAR after implemented .Document findings on the Skin Grid for Pressure, Venous, Arterial and Diabetic Ulcers or the Skin Grid for Non-Pressure Related Skin Impairment .Evaluate environment, mobility equipment, functional and cognitive ability, medications and labs to identify interventions to promote healing/resolution of skin impairment. Implement interventions and document on the resident's care plan and In Room Care Plan. Document all of the previous actions and resident's response in the Progress Notes .If the new skin impairment is noted after admission .the Licensed Nurse/RCM will: Initiate Alert Charting through the Managing Acute Condition Change (MACC) process. Review Skin Risk and evaluate current interventions for effectiveness. Complete Braden Skin Risk Assessment if new skin impairment is a Pressure Sore,and evaluate current interventions for effectiveness. Implement new interventions as needed .Notify Director of Nursing Services (DNS) of Skin Impairments that indicate a potential Significant Change in Condition .The Resident Care Manager and or designee will complete a comprehensive review of resident's medical record to assess if the pressure ulcer was avoidable or unavoidable. This … | 2019-06-01 |
| 5174 | 5174 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 329 | D | 0 | 1 | EZTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure blood pressure medications were monitored and an anti-anxiety medication was assessed prior to use for 2 of 5 sampled residents (#43 and 152) reviewed for unnecessary medications. This placed residents at increased risk for adverse medication reactions. Findings include 1. Resident 152 was admitted to the facility 7/17/15 with [DIAGNOSES REDACTED]. The resident's 7/17/15 Discharge Summary and Orders included the resident was to be administered [MEDICATION NAME] (medication used for anxiety) four times a day as needed. The 7/20/15 physician Fax included the supporting [DIAGNOSES REDACTED]. The resident's chart did not include an assessment for the [MEDICATION NAME] to indicate what behaviors the resident exhibited when anxious. The chart also did not include if there were non-pharmacological interventions to assist with the resident's muscle spasms, anxiety or sleeplessness prior to the administration of the [MEDICATION NAME]. The resident's 7/17/15 In Room Care Plan indicated staff were to notify the licensed nurse of any behaviors and to refer to the resident's behavior monitor for interventions. The care plan did not identify resident specific behaviors to monitor. The resident's undated Resident Behavior Report Sheet did not identify specific resident behaviors. Interventions listed were to re-approach the resident, switch staff if the resident was angry with the original staff and to provide risk versus benefits when the resident made poor choices. The interventions did not address interventions to provide for the resident's muscle spasms, anxiety or inability to sleep. On 7/22/15 at 10:51 am Staff 5 (RNCM) acknowledged the resident did not have an assessment to include the resident's potential behaviors exhibited when anxious. Staff 5 also acknowledged there were no resident specific non-pharmacological interventions listed for the staff to use for the r… | 2019-06-01 |
| 5175 | 5175 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2015-07-29 | 428 | D | 0 | 1 | EZTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to act upon a pharmacy recommendation in a timely manner for 1 of 5 sampled residents (#33) reviewed for medications. This placed residents at increased risk for unmet needs. Findings include: Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. The resident's Consultant Pharmacist Medication Regimen Review Summary for 6/18/15 indicated the resident was on Valium (medication used for anxiety). The note included the resident's physician was to identify the risk versus benefits for the continued use of the Valium. The 7/16/15 pharmacy review indicated the resident's physician did not address the risk and benefits of the continued use of Valium. The resident's chart indicated a Note to Attending Physician/Prescriber was sent to the resident's physician on 7/16/15. The note was signed by the physician and returned on 7/16/15 to indicate the resident was to continue the use of the Valium. On 7/23/14 at 11:15 am Staff 1 (DNS) indicated the pharmacy recommendations were to be addressed as soon as possible. Staff 1 indicated the RNCMs were responsible to ensure the recommendations were addressed and a response was to be returned prior to the next pharmacy review. On 7/23/15 at 11:30 am Staff 5 (RNCM) indicated within 24 to 48 hours after a pharmacy recommendation was submitted to the resident's physician, a response was expected. Staff 5 indicated she was not sure why the 6/18/15 pharmacist recommendation was not addressed by the resident's physician until 7/16/15. | 2019-06-01 |
| 6119 | 6119 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2014-05-09 | 441 | E | 0 | 1 | V46T11 | Based on observation and interview it was determined the facility failed to use an EPA (Environmental Protective Agency) approved sanitizer effective on blood borne pathogens to clean the laundry equipment for 1 of 2 laundry staff and failed to protect resident use paper products from potential contamination in 1 of 1 Barrel Room (soiled linens stored in this area prior to washing). This placed residents at increased risk for cross contamination. Findings include: Observation on 5/6/14 at 11:00 am with Staff 3 (Laundry Staff) present revealed the Barrel Room had open shelves with paper products including resident use toilet paper and paper towels in close proximity to the dirty linen barrels. The open shelves also contained Lysol disinfectant wipes. Staff 3 stated the paper products were stored in the soiled linen area for approximately six months. Staff 3 stated the Lysol disinfectant wipes were used to clean the laundry equipment. On 5/6/14 at 2:51 pm Witness 1 (Housekeeping Director) stated the paper products were stored in the Barrel Room for the last six months and acknowledged the paper products were not stored in a manner to prevent potential contamination from the soiled linens. Witness 1 stated the laundry staff were not to use the Lysol wipes to clean the laundry equipment. On 5/8/14 at 2:00 pm Staff 2 (Corporate RN Consultant) stated the Lysol wipes were not effective against blood borne pathogens. . | 2018-05-01 |
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CREATE TABLE [cms_OR] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );