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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4579 | 4579 | MYRTLE POINT CARE CENTER | 385254 | 637 ASH STREET | MYRTLE POINT | OR | 97458 | 2017-03-07 | 225 | D | 1 | 0 | 01GS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to complete an investigation regarding falls for 1 of 3 sampled residents (#2) reviewed for accidents. This placed residents at risk for additional falls. Findings include: Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of nurse's notes from 10/4/16 through 1/17/17 revealed the resident fell on [DATE], 11/27/16, 12/2/16, 12/5/16, 12/16/16, 12/19/16 and 1/9/17. Review of facility's fall investigations on 2/22/17 revealed no documentation an investigation was completed for Resident 2's falls on 12/2/16, 12/5/16, 12/16/16, 12/19/16 and 1/9/17. In an interview on 2/27/17 at 2:15 pm Staff 1 (Administrator) acknowledged no investigation was completed for Resident 2's falls on 12/2/16, 12/5/16, 12/16/16, 12/19/16 and 1/9/17. | 2020-03-01 |
| 7218 | 7218 | AVAMERE REHABILITATION OF EUGENE | 385053 | 2360 CHAMBERS STREET | EUGENE | OR | 97405 | 2014-01-10 | 309 | D | 1 | 0 | 01YS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to follow physician's orders regarding laboratory testing for PT/INR (PT-[MEDICATION NAME] time-measures the time it takes blood to clot and INR-international normalized ratio-INR is a formula that adjusts for chemicals used in different laboratories so that test results can be comparable) and the administration of [MEDICATION NAME] (anti-coagulation medication) and [MEDICATION NAME] (a muscle relaxer) as ordered for 1 of 3 sampled residents (#1) reviewed for anti-coagulation and medications . This placed the resident at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in August 2013 with [DIAGNOSES REDACTED]. a. The local hospital's Care Transfer form contained physician's orders for a PT/INR to be done on 8/28/13. The physician determined the resident's INR goal was between 2-3. The physician's orders indicated Resident 1 was to receive 1 to 2 tablets of 1 mg [MEDICATION NAME] daily- check INR and dose accordingly. Dose to be determined by MD depending on [MEDICATION NAME]. The August 2013 MAR indicated [REDACTED]. There was no documentation the resident's PT/INR was tested until 8/30/13. The PT/INR indicated the resident's INR was 1.4 and identified the reading as H for high. The reference for the laboratory test was 0.9 to 1.1 and the [MEDICATION NAME] was 14.6 the documentation identified the reading as H for high. The reference for the [MEDICATION NAME] was 9.0-11.0 seconds. There was no documentation the resident's physician was informed of the resident's PT/INR results on 8/30/13. The 9/2/13 fax to the physician included the 8/30/13 PT/INR results. On 9/3/13 the Family Nurse Practitioner (FNP) responded to the 9/2/13 fax to indicate the PT/INR was dated 8/30/13 and asked the facility if the PT/INR was addressed and if the PT/INR was not addressed the facility was to put the PT/INR in the FNP's box. There was a handwritten note by… | 2017-01-01 |
| 7219 | 7219 | AVAMERE REHABILITATION OF EUGENE | 385053 | 2360 CHAMBERS STREET | EUGENE | OR | 97405 | 2014-01-10 | 315 | D | 1 | 0 | 01YS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to obtain physician's orders for a Foley catheter and provide documentation of catheter care for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed the resident at risk for infection. Findings include: Resident 1 was admitted to the facility in August 2013 with [DIAGNOSES REDACTED]. The local hospital's 8/27/13 transfer form contained physician's orders for no urinary catheter for the resident. The nursing portion of the form indicated the resident had a Foley catheter in place. The facility's 8/28/13 admission nursing data base indicated the resident did not have an indwelling or external catheter in place. The documentation indicated the resident was able to void without difficulty and was always continent. The 8/30/13 Progress Notes written at 11:40 pm indicated the resident had a Foley catheter in place and the resident's urine was clear and yellow. The 9/4/13 five day MDS assessed the resident to have an indwelling catheter. The CAAS (Care Area Assessment) for Urinary Incontinence and Indwelling Catheter indicated the resident had a Foley catheter due to pain and environmental factors of restricted mobility; [MEDICAL CONDITION] ([MEDICAL CONDITION]-enlarged prostate) and the use of [MEDICATION NAME] including [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (narcotic pain medication). The CAA indicated the resident's use of a catheter was to be addressed in the resident's care plan to avoid complication. The rationale for the care plan decision indicated Resident 1 has a Foley catheter. She/he has dx (diagnosis) of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. She/he has c/o (complaints of) back pain and had recent back surgeries. Staff provides catheter care. She/he is at risk for UTIs due to catheter The facility's 9/4/13 care plan indicated the resident had Foley catheter in place related to [MEDICAL CONDITION] and pain. The intervent… | 2017-01-01 |
| 9253 | 9253 | REGENCY HERMISTON NURSING & REHAB CENTER | 385263 | 970 W JUNIPER AVENUE | HERMISTON | OR | 97838 | 2011-02-08 | 323 | D | 1 | 0 | 039M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure safety devices were in place to prevent a fall for 1 of 3 sampled residents (#1) who had falls. Findings include: Resident 1 was admitted to the facility in December 2004 and had [DIAGNOSES REDACTED]. On 3/19/10 a Physical Restraint Device Assessment identified the resident needed safety devices which included a pressure alarm in bed, and a tab alarm on while in the wheelchair or recliner. The assessment indicated the devices allowed "staff response time in the event of a self-transfer to prevent falls." The assessment was updated on 6/22/10 and on 9/28/10 and the devices were identified as still appropriate to prevent falls. On 9/28/10 a Fall Assessment identified the resident was at high risk for falls. On 9/28/10 Resident 1's Plan of Care indicated the resident had a history of [REDACTED]. The plan identified multiple safety interventions and included a fall mat at bedside, body pillow on outside edge of the bed, a pressure alarm in the bed, and a tab alarm in the recliner and wheelchair. The plan directed staff to "check placement and functioning at beginning of each shift." On the December 2010 CNA Flowsheet staff were directed to "check placement and functioning of tabs/pressure alarms at the beginning of each shift (pressure alarm in bed/recliner tab alarm in w/c)." On 12/30/10 all three shift's staff initialed that this intervention had been followed. On 12/30/10 a nursing note identified the nurse was called into Resident 1's room and found the resident face down on the floor. The note indicated the resident's lower body was on the fall mat and upper body on the floor beside the fall mat. The note identified the resident had a large hematoma to the right side of the head, an ambulance was called, and the resident sent out for evaluation in the hospital. December and January MARs were reviewed and revealed the resident complained of headache pain one … | 2014-06-01 |
| 7614 | 7614 | CASCADE TERRACE | 385187 | 5601 SE 122ND AVENUE | PORTLAND | OR | 97236 | 2013-07-02 | 323 | G | 1 | 0 | 03XI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to prevent injury while being transported in a wheelchair for 1 of 3 sampled residents (#1) reviewed for injuries. As a result, Resident 1 sustained ankle and knee injuries. Findings include: Resident 1 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Resident 1 was admitted with physician orders [REDACTED]. A 1/21/13 Progress Note indicated Resident 1 returned from the physician's office with the immobilizer removed and a pre existing right leg wound. A 3/6/13 Progress Note indicated Resident 1's right leg wound required a muscle flap and a skin graft, which was scheduled for 3/11/13. A 3/11/13 Progress Note revealed Resident 1 had the planned leg wound surgery. A 4/4/13 Progress Note disclosed Resident 1 had an incident in therapy where her/his right leg was caught under the wheelchair when wheeling down the hall. The resident reported I heard a pop and had a lot of pain. The correlating facility's investigation noted at 3:00 pm, Staff 6, OTA (occupational therapy assistant), was bringing Resident 1 back to the room after a session. The resident's leg/foot dropped and caught on the carpet, under the wheelchair. A 4/19/13 Care Plan noted the resident was to use leg rests on the wheelchair for long distances only. Staff may use the wheelchair without leg rests for short distances. At the time of the survey, there was no documented evidence in the clinical record of how staff were going to prevent a repeated incident if the leg rests were not in use. A 4/25/13 10:04 pm Progress Note revealed Resident 1 was being assisted in the wheelchair without leg rests and the resident's right foot boot caught on the floor, causing the resident to complain of pain. The correlating facility's investigation disclosed Staff 4, CNA, was pushing the resident in the wheelchair to the shower room without foot rests in place, when the resident's shoe caught on the carpet. T… | 2016-07-01 |
| 7885 | 7885 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2013-02-14 | 309 | D | 1 | 0 | 043P11 | **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 orders [REDACTED].#1) reviewed for medications. This failure placed the resident at risk for adverse side effects from the continued medication use. Findings include: Resident 1 was readmitted to the facility with [DIAGNOSES REDACTED]. The 1/15/13 hospital physician discharge orders included Bactrim (an antibiotic) twice daily, 14 tablets. Per the physician's orders [REDACTED]. Staff 7, Agency RN, documented in a 1/24/13 Nurse's Note the Bactrim was to be discontinued after a seven day course, however, the stop date had not registered in the computer. Staff 7 noted the antibiotic was stopped and the computer was updated. The physician order [REDACTED]. It was documented the resident received the medication from the evening on 1/15/13 to the morning on 1/26/13, two days after Staff 7 had documented stopping the medication in the computer. The 1/26/13 Occurrence Report revealed that while the Bactrim was ordered for 14 tablets, it was entered into the computer as 14 days. The medication stop date was not correctly identified on admission order verification and should have been stopped on 1/22/13. The resident received an additional eight doses of antibiotics. Staff 7 was in-serviced on the discontinuation of orders in the computer system. On 2/13/13 at 9:02 am Resident 1 was observed to be lying in bed, awake, with a tracheotomy in place. In interview on 2/13/13 at 11:35 am, Staff 8, Medical Records, stated she reviewed the hospital discharge orders with Staff 1, RNCM. Staff 8 stated she was told by Staff 1 the orders were for 14 days and the error was not identified. In interview on 2/13/13 at 11:42 am, Staff 1, RNCM, stated the medication had been scheduled for seven days, however, medical records put it in as 14 days rather than 14 doses. Staff 1 stated she missed the error when she rechecked the orders. Staff 7, Agency RN, was not ava… | 2016-02-01 |
| 1701 | 1701 | MARYVILLE | 385166 | 14645 SW FARMINGTON ROAD | BEAVERTON | OR | 97007 | 2017-11-07 | 281 | D | 1 | 0 | 04PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined Staff 19 (Agency CMA) and Staff 20 (Agency CMA) failed to ensure professional standards were provided to 2 of 6 sampled residents (#s 1 & 5) reviewed for medication administration. This placed the residents at risk of adverse side effects. Findings include: Division 63 STANDARDS AND AUTHORIZED DUTIES FOR THE CERTIFIED NURSING ASSISTANT AND CERTIFIED MEDICATION AIDE 851-063-0100 Conduct Unbecoming a Certified Medication Aide A certified medication aide is subject to discipline as a CNA as described in these rules. In addition, a CMA is subject to discipline for conduct unbecoming a medication aide. Such conduct includes but is not limited to: (1) Failing to administer medications as ordered by a LIP; (2) Failing to document medications as administered, medications withheld or refused and the reason a medication was withheld or refused. 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 9/2017 Physician order [REDACTED]. The 9/2017 MAR indicated [REDACTED]. The 10/1/17 at 10:25 am Progress Note documented a CMA alerted the charge nurse the resident's [MEDICATION NAME] was not the correct dose. The charge nurse verified the resident had a 25 mcg patch in place not a 12 mcg patch. The charge nurse immediately removed the patch and contacted the on-call physician who directed staff to not place another patch until the next scheduled date (10/2/17). The facility's correlating investigation noted there was only one supply of patches in the medication cart which was for a different resident and there were no patches available for Resident 1. Staff 19 signed out a patch from a different resident's narcotic count page. There was a difference in the appearance of both patches as the 12 mcg patch was transparent and the 25 mcg patch was beige in color and bigger in size. In interview on 11/1/17 at 12:30 pm Staff 19 (Agency CMA) stated she was a CMA for six years and p… | 2020-09-01 |
| 1702 | 1702 | MARYVILLE | 385166 | 14645 SW FARMINGTON ROAD | BEAVERTON | OR | 97007 | 2017-11-07 | 333 | D | 1 | 0 | 04PP11 | **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 orders [REDACTED].#s 1 & 5) reviewed for medication administration. This placed residents at risk for adverse side effects. Findings include: 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 9/2017 Physician order [REDACTED]. Staff were directed to check the patch placement every shift. The 9/2017 MAR indicated [REDACTED]. The 10/1/17 at 10:25 am Progress Note documented a CMA alerted the charge nurse the resident's [MEDICATION NAME] was not the correct dose. The charge nurse verified the resident had a 25 mcg patch in place not a 12 mcg patch. The charge nurse immediately removed the patch and contacted the on-call physician who directed staff to not place another patch until the next scheduled date (10/2/17). The facility's correlating investigation noted there was only one supply of patches in the medication cart which was for a different resident and there were no patches available for Resident 1. There was a difference in the appearance of both patches as the 12 mcg patch was transparent and the 25 mcg patch was beige in color and bigger in size. In interview on 11/1/17 at 12:30 pm Staff 19 (Agency CMA) stated she was a CMA for six years and previously administered [MEDICATION NAME]es. On 9/29/17 while attempting to administer Resident 1's medications at around 10:30 am to 11:00 am she reviewed the resident's medications, was interrupted, then resumed gathering the resident's medications. Staff 19 stated she noted the resident had orders for the [MEDICATION NAME] and grabbed the box of [MEDICATION NAME]es from the medication cart. Staff 19 stated she did not remember checking the box for Resident 1's name. She removed the old patch and applied the new patch and could not remember if the patches looked different. Staff 19 stated prior to the error she did not know there were differences in how patches looked fo… | 2020-09-01 |
| 1703 | 1703 | MARYVILLE | 385166 | 14645 SW FARMINGTON ROAD | BEAVERTON | OR | 97007 | 2017-11-07 | 425 | D | 1 | 0 | 04PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure medications were available for 2 of 6 sampled residents (#s 1 and 3) reviewed for medication administration. This placed the residents at risk for adverse side effects. Findings include: 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 9/2017 Physician order [REDACTED]. The 9/2017 MAR indicated [REDACTED]. The 10/1/17 at 10:25 am Progress Note documented a CMA alerted the charge nurse the resident's Fentanyl patch was not the correct dose. The charge nurse verified the resident had a 25 mcg patch in place not a 12 mcg patch. The charge nurse immediately removed the patch and contacted the on-call physician who directed staff to not place another patch until the next scheduled date (10/2/17). The facility's correlating investigation noted there was only one supply of Fentanyl patches in the medication cart which was for a different resident. The last of Resident 1's patches were used on 9/26/17 and there were no patches available for the resident on 9/29/17. In interview on 10/27/17 at 11:20 am Staff 2 (DNS) stated either two or three days or two or three administrations before running out of Fentanyl patches staff were to fax the pharmacy for re-ordering the medication. Staff 2 stated staff had re-ordered the Fentanyl patches but they had not yet arrived from the pharmacy. Staff 2 stated if medications were not provided by the pharmacy timely the CMA should inform the nurse the medications were not available and the nurse should call the pharmacy for follow up. In interview on 11/1/17 at 12:30 pm Staff 19 (Agency CMA) stated on 9/29/17 while attempting to administer Resident 1's medications she reviewed the resident's medications, was interrupted, then resumed gathering the resident's medications. Staff 19 stated she noted the resident had orders for the Fentanyl patch and grabbed the box of Fentanyl patches from the medicat… | 2020-09-01 |
| 7717 | 7717 | CARE CENTER EAST HLTH | 385219 | 11325 NE WEIDLER | PORTLAND | OR | 97220 | 2012-06-05 | 312 | D | 0 | 1 | 05DX11 | **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 toenail care for 1 of 3 sampled residents (#108) of 6 residents who were observed to have potential grooming needs. This failure put residents at risk for potential poor cleanliness and hygiene. Findings include: Resident 108 was admitted to the facility in April 2012 with [DIAGNOSES REDACTED]. Review of a nursing admission data collection and assessment form dated 4/3/12 revealed the resident's toenails were WNL (within normal limits). Review of a care plan dated 4/6/12 revealed the resident was to receive diabetic nail care by a licensed professional as needed. Review of a TAR for April and May 2012 revealed no documentation of the care planned intervention to have nail care completed by a licensed professional and that the resident had received toenail care. Observations on 5/30/12 at 9:30 am revealed the resident was not wearing socks or shoes and the resident's toenails were long, discolored and untrimmed. In an interview on 5/30/12 at 9:30 am Resident 108 indicated staff had not done toenail care since the resident was admitted to the facility. The resident had asked nursing staff three weeks ago for toenail care but staff had not done it yet. In an interview on 5/30/12 at 12:47 pm Staff 1 (RNCM) indicated the resident's diabetic nail care was documented on the TAR. The facility's policy was for nursing to provide diabetic nail care for residents when staff complete a weekly skin assessment. Staff 1 did not know when the last time the resident received diabetic nail care and acknowledged she forgot to add diabetic nail care to the resident's TAR. In an interview on 5/30/12 at 1:21 pm Staff 2 (RN) indicated she had not trimmed the resident's toenails since the resident was admitted . Staff 2 said nursing staff were to provide diabetic nail care for the resident during the weekly skin assessment and would document nail care on the TAR. | 2016-06-01 |
| 7718 | 7718 | CARE CENTER EAST HLTH | 385219 | 11325 NE WEIDLER | PORTLAND | OR | 97220 | 2012-06-05 | 315 | D | 0 | 1 | 05DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to routinely change and obtain a physician's order for removal of an indwelling urinary catheter for 1 of 3 sampled residents (#30) of the 18 residents identified with urinary catheter use. This failure placed residents at risk for potential urinary tract infections. Findings include: Resident 30 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed the resident was alert and oriented, and was cognitively intact without memory impairment. NN dated 4/23/12 at 4:00 pm indicated Pt (patient) requesting for Foley (urinary catheter) to be pulled and left out for a couple of days d/t (due to) irritation and urethral pain. Foley pulled and resident put in brief. Will replace cath. on Wednesday. WCTM (will continue to monitor). There were no NN regarding urinary function, catheter replacement or care until NN dated 5/1/12 at 6:00 am foley patent & draining clear yellow urine. Review of the clinical record revealed no communication with the physician regarding the resident's complaint of urethral irritation or pain, no physician's order to remove the catheter, no assessment of the resident's urinary function without the catheter and no physician's order to reinsert the catheter. The April 2012 TAR revealed an undated order to change foley catheter once a month (and PRN for patency). There was no evidence the resident's catheter had been changed, discontinued or reinserted. Review of the facility's infection control tracking revealed the resident had urinary tract infections [MEDICAL CONDITION] on 10/29/11, 11/29/11, 12/29/11 and 3/1/12. On 5/31/12 at 1:39 pm Resident 30 stated staff did not change the urinary catheter each month. The resident stated the catheter was changed around Thanksgiving time and not again for about five or six months, adding, If they keep honest records you'll find it. When asked about the remov… | 2016-06-01 |
| 7719 | 7719 | CARE CENTER EAST HLTH | 385219 | 11325 NE WEIDLER | PORTLAND | OR | 97220 | 2012-06-05 | 441 | D | 0 | 1 | 05DX11 | Based on observation and interview it was determined the facility failed to properly clean a multi-resident use glucose meter during a random observation of a CBG check for a resident. This put the residents at risk for cross contamination. Findings include: During a random observation on 6/4/12 at 12:00 pm Staff 5 (RN) was standing at the treatment cart and cleaned a multi-resident use glucose meter with an alcohol swab. When asked if an alcohol swab was what she usually used to clean the glucose meter she stated that it was and she didn't know that wasn't what she should use to clean the meter. Staff 3 (DNS) joined the conversation and stated that the purple top cleaner was the proper cleaner to use. (The purple top wipes eliminate blood borne pathogens). Staff 5 got the purple top wipes and cleaned the glucose meter. | 2016-06-01 |
| 7026 | 7026 | AVAMERE REHABILITATION OF EUGENE | 385053 | 2360 CHAMBERS STREET | EUGENE | OR | 97405 | 2014-04-16 | 279 | D | 1 | 0 | 05PW11 | **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 plan of care including potential risks and facility interventions regarding the use of [MEDICATION NAME] (anticoagulant medication) for 1 of 3 sampled residents (#2). This placed residents at risk for complications related to the use of anticoagulant medications. Findings include: Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of a Care Transfer Form from a local hospital dated 1/14/14 revealed the resident the resident was to receive [MEDICATION NAME] for [MEDICAL CONDITION] (irregular heartbeat) and the resident's goal INR (lab value to determine anticoagulant dosage) was 2-3. The form also indicated the resident's INR was to be tested daily. Review of a Re-Entry Nursing Data Base dated 1/14/14 revealed no documentation of the resident's use of [MEDICATION NAME] and indication for use. Review of a care plan dated 1/15/14 revealed no documentation of the resident's [MEDICATION NAME] use, measurable goals or facility interventions which included monitoring the resident's INR and risks and potential side effects of the medication. In an interview on 4/16/14 at 3:00 pm Staff 1 (DNS) acknowledged the resident was not care planned for the use of [MEDICATION NAME]. | 2017-04-01 |
| 7027 | 7027 | AVAMERE REHABILITATION OF EUGENE | 385053 | 2360 CHAMBERS STREET | EUGENE | OR | 97405 | 2014-04-16 | 281 | D | 1 | 0 | 05PW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined Staff 5 (LPN failed to verify the resident's hospital transfer orders for the use of oxygen and Staff 8 (LPN), Staff 9 (LPN) and Staff 4 (RN) administered oxygen to 1 of 3 sampled residents (#2) without obtaining a physician's order. This placed residents at risk for unnecessary treatment and services. Findings include: Oregon State Board of Nursing Division 45: Standards and Scope of Practice of the Licensed Practical Nurse and Registered Nurse: 851-045-0040 Scope of Practice Standards for All Licensed Nurses (6) Standards related to the licensed nurse ' s responsibility to accept and implement orders for client care and treatment. The licensed nurse: (e) Prior to implementation of the order or recommendation, must have knowledge that the order or recommendation is within the health care professional's scope of practice and determine that the order or recommendation is consistent with the overall plan for the client's care. 851-045-0050 Scope of Practice Standards for Licensed Practical Nurses: (2) (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; (C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed; (E) Validating data by utilizing available resources, including interactions with the client and health team members. 851-045-0060 Scope of Practice Standards for Registered Nurses (2) (C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed; Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of a Care Transfer Form from a local hospital dated 1/14/14 revealed the resident was transferred to the facility for… | 2017-04-01 |
| 7028 | 7028 | AVAMERE REHABILITATION OF EUGENE | 385053 | 2360 CHAMBERS STREET | EUGENE | OR | 97405 | 2014-04-16 | 309 | D | 1 | 0 | 05PW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain a physician's order for the administration of oxygen for 1 of 3 sampled residents (#2). This placed residents at risk for receiving unnecessary treatments and services. Findings include: Resident 2 was admitted to the facility in 2013 and readmitted in 2014 with [DIAGNOSES REDACTED]. Review of the facility's standing physician's orders (services that do not need prior physician approval) dated 5/28/13 did not include the use of oxygen. Review of a Care Transfer Form from a local hospital dated 12/28/13 revealed the resident was sent to the facility for skilled care with a [DIAGNOSES REDACTED]. Review of an Admission Nursing Data Base form dated 12/28/13 revealed the resident's respirations were within normal limits and the resident used oxygen therapy. Review of a physician's order dated 12/28/13 revealed the resident was to receive oxygen to maintain oxygen blood saturation between 92-94%. The order was discontinued on 1/10/14. Review of a nurse's note dated 1/10/14 at 12:48 pm revealed the resident was in no distress and was discharged home from the facility. Review of a Care Transfer Form from a local hospital dated 1/14/14 revealed the resident was transferred to the facility for skilled care with a [DIAGNOSES REDACTED]. Review of an Re-Entry Nursing Data Base (admission) form dated 1/14/14 revealed the respiratory status was within normal limits. The assessment did not indicate the resident used oxygen. Review of a nurse's note dated 1/15/14 at 4:09 pm revealed the resident was doing well and had oxygen on from night shift. The note indicated the resident blood oxygen saturation was 96%. The note also indicated the resident and the resident's family requested the oxygen be removed and the resident's family told staff there was no physician order for [REDACTED].>Review of a nurse's note dated 1/16/14 at 3:29 am revealed the resident's vital signs were sta… | 2017-04-01 |
| 9156 | 9156 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 156 | D | 0 | 1 | 06JI11 | Based on interview and record review, the facility failed to provide the liability information for 1 of 4 sampled residents (#113) reviewed for discontinuation of Medicare services. Failure to disclose liability information prevented the resident and their family from making fully informed financial decisions. Findings include: Resident 113 received a Notice of Medicare Provider Non-Coverage on 3/28/12 stating Medicare services would end on 3/31/12. The resident signed this notice on 3/28/12. The resident remained in the facility until 4/4/12, however no documentation could be provided showing the resident had been notified of their potential financial liability. In interview on 7/18/12 at 2:40 pm, Staff 9, Social Service Director, stated "I'm sure it was discussed ...Nothing else was given at that time." In interview on 7/18/12 at 2:55 pm, Staff 12, Business Office Manager, stated "I believe it was discussed with the resident", but could not locate any documentation in the resident's file that the resident was provided appropriate liability notice. | 2014-07-01 |
| 9157 | 9157 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 279 | D | 0 | 1 | 06JI11 | Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan in relation to hospice services for 1 of 2 sampled residents (#88) who were reviewed for hospice care. This practice placed the hospice resident at risk for not having the necessary care and services identified in collaboration with the resident's hospice provider. Findings include: Resident 88 was admitted to the facility in 2/2012. The resident's comprehensive MDS completed in 5/2012, coded the resident as having a prognosis/life expectancy of six months or less. The resident's 5/2012 Psychosocial CAA noted "...resident has been admitted to Hospice secondary to medical factors..." The resident's care plan did not outline those services that would be provided by the hospice provider. The care plan only noted "...hospice care will be provided..." The resident's closet care plan, which CNAs accessed, did not identify the resident as being on hospice care. In a 7/17/12 interview at 1:25 pm, Staff 3, RNCM, confirmed that there was no hospice care plan. | 2014-07-01 |
| 9158 | 9158 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 280 | D | 0 | 1 | 06JI11 | Based on interview and record review, it was determined that the facility failed to revise a care plan for 1 of 3 residents (#159) who were reviewed for urinary incontinence. Failure to revise the care plan placed the resident at risk for unmet care needs. Findings include: A nursing note dated 3/30/12, documented, " resident has a pessary (a device used to support the bladder or uterus) - it was falling out, but went "back in place on its own", in contact w/OBGYN, who stated it could be removed and a new one can be placed at next (appointment) in April." The care plan for Resident 159 was reviewed and did not include information regarding pessary use or care. In interview on 7/16/12 at 11:44 am, Staff 3, RNCM, was unsure if the resident had a pessary. On 7/16/12 at 4:40 pm, Staff 3, RNCM, reported that the pessary was in place and the nurses were aware. She further stated she was not sure if it was care planned, "Don't really do anything with it, unless something goes wrong and notify the physician." In interview on 7/17/12 at 9:30 am, Staff 5, LPN Charge Nurse, stated she was not sure if the resident had a pessary and could not locate information in care plan. In interview on 7/17/12 at 10:52 am, Staff 14, CNA, days, stated she didn't know what a pessary was. After it was explained, she stated she did not think the resident had one. In interview on 7/18/12 at 3:10 pm, Staff 17, day/evening CNA, stated she did not know what a pessary was. After it was explained, she stated she did not think the resident had one. | 2014-07-01 |
| 9159 | 9159 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 325 | D | 0 | 1 | 06JI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to assess and implement interventions for 1 of 3 sampled residents (#98) reviewed for nutrition. The failure to assess and monitor the nutritional needs of the resident resulted in an unintended weight loss. Findings include: Resident 98 was a long term resident with [DIAGNOSES REDACTED]. The 4/27/12 Dietary Quarterly Review identified that the resident was now eating small meals with the speech therapist. Her tube feeding continued to provide 1621 calories, 81 grams of protein and 1200 cc water per day. The resident was at risk for weight gain with nutritional needs easily met. No [MEDICAL CONDITION] was noted. It was recommended that the tube feedings be decreased. On 5/22/12, the night time tube feeding was discontinued. Weight records for 6/10/12 noted the resident's weight to be 189 pounds. A gain of five pounds in approximately one month. A 6/14/12 interdisciplinary team meeting reviewed the resident's weight gain and the recent transition from tube feedings to oral intake. A gain of 18.2 pounds was identified during the transition. A plan to recheck her weight in two weeks was made to determine if weight gain would persist. There was no evidence in the medical record that the resident's weight was rechecked as planned. The July 2012 electronic MAR indicated [REDACTED]. No further quantity was defined. The dietary slip used in July reflected a 6/20/12 order for "pureed/thin liquids." Weight records for 7/3/12 identified a 10 pound weight loss at 179 pounds and on 7/11/12 noted the resident's weight to be 175 pounds, a loss of 14 pounds in one month. There was no acknowledgement or assessment of the loss in the medical record. The current nutrition care plan noted the resident was at risk of dehydration and weight loss due to a swallow deficit and head injury. A goal to stabilize weight was identified. Approaches reflected a 4/26/12 diet order for 2 s… | 2014-07-01 |
| 9160 | 9160 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 329 | D | 0 | 1 | 06JI11 | **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 identify adequate indicators of use for 1 of 3 sampled residents (#21) who received anti-anxiety medication. The failure to identify why the medication was needed placed the resident at risk of receiving medication for symptoms outside of their intended clinical use. Findings include: Resident 21 was a long time resident with [DIAGNOSES REDACTED]. The 5/10/12 Annual MDS coded the use of an antidepressant only with the behavior committee following up as needed. A 5/22/12 fax from the physician gave orders for "[MEDICATION NAME] (an anti-anxiety medication) 0.5 mg once daily IF needed for extreme anxiety." There was no documentation to identify why [MEDICATION NAME] had been prescribed or the symptoms displayed by the resident when extremely anxious. No evidence was found in the medical record that staff clarified the reason/s for the order or an assessment had been completed to identify the resident's symptoms of extreme anxiety. The current mood/behavior care plan identified approaches including: Provision of 1:1 attention, maintain familiar routines and caregivers, rule out medical causes for anxious behavior, and to give her PRN (as needed) [MEDICATION NAME] if redirection was not successful. The July 2012 electronic MAR indicated [REDACTED]. The corresponding behavior monitors identified one episode of anxiety with crying out on the evening shift of 7/6/12 and two episodes of anxiety on the 7/9/12 night shift. No other documentation was found that supported the use of the medication. When observed on 7/12/12 at 3:02 pm and 7/13/12 at 8:51 am, 10:56 am and 2:01 pm, the resident appeared relaxed and interacted appropriately with staff and other residents. In interviews on 7/17/12 at 1:43 pm and 7/18/12 at 2:55 pm, Staff 20 and Staff 13, CNAs, reported that the resident did not display anxious behaviors to their knowledge. On 7/17/12 at 2:01 pm, St… | 2014-07-01 |
| 9161 | 9161 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 428 | D | 0 | 1 | 06JI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to act upon pharmacist recommendations for medication changes for 2 of 2 sampled residents (#'s 101 and 119) who were reviewed for pharmacy consultation. Failure to respond to pharmacy recommendations placed residents at risk for not receiving the fullest efficacy of their medications and/or at risk for unnecessary use. Findings include: 1. Resident 119 was admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. Resident's current 7/2012 MAR indicated [REDACTED]." The resident's Consultant Pharmacist's Medication Regimen Review for 3/13/12 noted "...current does of Razadyne is 8 mg/day since 11/9/2011, which is not an optimum dose to slow the progression of dementia...please consider increasing the does to 8 mg twice daily x 4 weeks, then 12 mg twice daily thereafter if tolerated." In a 7/18/12 interview at 2:43 pm, Staff 3, RNCM, when asked if the resident's pharmacy recommendations had been followed up, stated "I don't recall the recommendations for March..." Staff 3 was unable to provide any documentation to show the pharmacy recommendations had been acted upon. 2. Resident 101 was admitted to the facility in 10/2010 with a [DIAGNOSES REDACTED]. The resident's Consultant Pharmacist's Medication Regimen Review for 4/16/12 noted "This resident has been on Fluoxetine (a medication used to treat depression) 40 mg/day since 8/12/11. Please evaluate current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose..." In a 7/18/12 interview at 3:10 pm, Staff 3, stated that she had faxed the resident's doctor twice on 4/20/12 and 4/27/12. When asked if there had been any response and/or additional follow up after this time, Staff 3 stated "I don't recall..." In a 7/19/12 interview at 11:52 am, Staff 9, Social Service Director, stated that she had not been aware of the resident's gradual dose reduction recommen… | 2014-07-01 |
| 9162 | 9162 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 514 | E | 0 | 1 | 06JI11 | **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 accurately transcribe physician orders [REDACTED].#s 20, 21, 62, 84, and 124) whose medication records were reviewed. Failure to have clear physician orders [REDACTED]. Findings include: 1. During the medication pass observation on 7/13/12 at 12:39 pm, Staff 21, CMA, administered two and a half tablets of Calcium [MEDICATION NAME] 500 mg, which equaled 1250 mg, to Resident 124. According to the physician order, Calcium [MEDICATION NAME] 500 mg was to be given. In an interview on 7/17/12 at 11:00 am, Staff 21 showed the order as it had been transcribed into the resident's electronic medication administration record. The order read "Calcium [MEDICATION NAME] 500 mg calcium (1250 mg) (500 mg chew tab) by mouth three times daily." Staff 21 confirmed two and one half tablets to equal 1250 mg had been given to the resident. On 7/17/12 at 11:10 am Staff 3, RNCM, said in interview that the 1250 mg was possibly the elemental calcium and the computer program library only has the selection that includes the (1250 mg) in the order. Staff 3 confirmed the amount administered was an error. 2. Resident 20 had physician orders [REDACTED]. It was not clear how much medication to administer. In interview on 7/17/12 at 2:30 pm Staff 2, DNS, said the parenthesis around the 1250 mg may be the elemental calcium supplied in the capsule. Staff 2 confirmed the order could be confusing and needed to be clarified. 3. Resident 62 had two medication orders transcribed into the resident's electronic record that read "Tums E-X 300 mg (750 mg) (2 tabs) by mouth three times a day" and "[MEDICATION NAME] 100 mg (75 mg) by mouth one time daily". It was not clear what strength of the medication dose was to be administered. The resident's electronic MAR indicated [REDACTED]. Staff 22 said the orders had been confusing and she had clarified the order with the charge nurse. With regard t… | 2014-07-01 |
| 9163 | 9163 | WEST HILLS HEALTH & REHABILITATION CENTER | 385112 | 5701 SW MULTNOMAH BLVD | PORTLAND | OR | 97219 | 2012-07-19 | 314 | G | 0 | 1 | 06JI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined that the facility failed to conduct a comprehensive assessment, obtain treatment orders, adequately monitor and revise the care plan for 1 of 1 sampled resident (#101) who was reviewed for a facility acquired pressure ulcer. As a result of this deficient practice, the resident's wound worsened and required debridement. Findings include: Resident 101 was admitted to the facility in 10/2010, with [DIAGNOSES REDACTED]. A nursing note on 3/2/12 documented "...the (wheelchair) cushion in the power chair is custom fit, but because of prolonged use a lot of the pressure reducing properties are no longer effective....After some discussion back and forth it was decided to use the power chair with frequent monitoring of the skin area..." The resident's current 5/2012 quarterly MDS, Section M - Skin Conditions, identified the resident as "at risk for developing pressure ulcers." The resident's current care plan identified "...alteration in skin integrity related to decreased mobility and need for assistance, history of skin breakdown." And included interventions such as, "cushion in wheelchair; observe skin for s/s (signs/symptoms) of redness, drainage, blisters or evidence of skin breakdown...notify MD if noted...weekly skin assessments...treatment to skin impairment per MD order..." A nursing note on 5/11/12, documented "...notified by CNAs of reddened area on resident's left upper thigh/lower buttock. Area is approx. (approximately) 7 cm x 8 cm, firm and warm to touch. Two smaller darker red areas in middle. No open areas or drainage noted. Resident denies pain to site. MD notified." A 5/11/12 Skin Issue Details Report concluded "...based on the warmth it is likely that this area is either an area of [MEDICAL CONDITION] or a boil that has not yet come to head..." A nursing note on 5/31/12, documented "...resident has skin issues...lower buttock and upper left thigh there is a 9 cm… | 2014-07-01 |
| 4580 | 4580 | ROSE VILLA SENIOR LIVING COMMUNITY | 38A031 | 13505 SE RIVER ROAD | PORTLAND | OR | 97222 | 2017-03-01 | 323 | D | 1 | 0 | 071Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to follow the fall prevention care plan for 1 of 3 sampled residents (#1) reviewed for accidents. This put residents at risk for falls. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The fall prevention care plan for Resident 1, most recently revised 1/8/17, contained an intervention added 12/7/16 which directed the bed to be in lowest position when the resident was in bed unattended, and another intervention dated 12/28/16 which directed to not leave walker or wheelchair at bedside as the resident may attempt to self transfer. The Accident Investigation/Incident Report dated 1/8/17, prepared by Staff 1 (RN), indicated on 1/8/17 at 2:00 pm Resident 1 was found lying on her/his right side with her/his head lying between the back of the wheelchair wheels and that the bed was not in the lowest position. A progress note dated 1/8/17 at 4:07 pm indicated approximately 10 minutes prior to the incident a nurse assisted Resident 1 from her/his wheelchair to bed per the resident's request. In an interview on 3/1/17 at 11:30 am via telephone Staff 1 (RN) indicated the resident had gotten out of bed in an attempt to self transfer and had fallen on the fall mat with her/his head under the wheelchair that was next to the bed. Staff 1 also indicated the bed was low, but not in the lowest position. In an interview on 3/1/17 at 1:05 pm Staff 3 (RNCM) acknowledged Resident 1's bed had not been in the lowest position as was directed on the care plan. | 2020-03-01 |
| 6199 | 6199 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 241 | E | 0 | 1 | 076Z11 | Based on observation, interview and record review, it was determined the facility failed to promote residents dignity and respect during 4 of 4 meal observations in the Ponderosa Unit. This placed the residents at risk for an undignified dining experience. Findings include: The Ponderosa Unit dining area consisted of three areas where residents were observed to be dining. There were two separate dining rooms, one with four tables and one with one table and an alcove area with one table in the hallway that lead to both dining rooms. The facility's posting for meal times indicated breakfast was scheduled to be served from 8:00 am to 8:20 am and lunch was scheduled to be served from 12:00 pm and 12:20 pm. During four meal observations from 12/15/14 to 12/18/14, the following was observed: meals were served past the posted scheduled times; residents had to wait to be assisted with eating; residents at the same table were not served at the same time; staff were standing up when assisting residents with eating; and staff going back and forth between multiple residents when assisting residents with eating. Observations on 12/15/14 in the Ponderosa Unit dining area from 12:20 pm to 2:15 pm revealed the following: -At 12:20 pm, multiple residents (including Residents 17, 35, 36, 47, 57, 71, 76, 79, 82 and 92) were observed in the dining areas to be drinking liquids, moving around the area by walking or in wheelchairs. Staff 14, 18 and 19, CNAs and Staff 16, LPN, who was passing medications, were observed in the dining areas. Staff 15, CNA, arrived towards the end of the meal service. -Between 12:51 pm and 1:23 pm, Staff 14, 18 and 19 were observed carrying resident meal trays (one at a time) to the residents in the three separate dining areas. Resident meals were served from a small kitchenette room about 20 to 30 feet away from the dining areas. Staff 14, 18 and 19 had to go back and forth in order to deliver each meal tray to each resident. Staff were observed to assist residents to eat for a few minutes then left alone… | 2018-05-01 |
| 6200 | 6200 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 253 | E | 0 | 1 | 076Z11 | Based on observation and interview, it was determined the facility failed to provide a clean and comfortable environment for 11 of 24 residents' windows in the Ponderosa Unit. This placed residents at risk for poor quality of life related to not being able to see out towards the windows in the room. Findings include: During tour of the Ponderosa Unit on 12/19/14 from 1:42 pm to 2:32 pm, the following rooms were noted to have windows with water spots, smears and were difficult to see through: 101, 102, 103, 106, 107, 109, 111, 112, 115, 123, and 124. On 12/19/14 at 3:29 pm, Staff 12, Maintenance Director and Environmental Services, acknowledged the water spots. He stated the windows had not been cleaned in the three and a half months he had worked at the facility. He stated the windows were stained with calcium and lime deposits from sprinklers. He confirmed there was no formal schedule to clean the inside of the windows. On 12/19/14 at 3:53 pm, Staff 11, RNCM, confirmed the inside of the windows in resident rooms were dirty. She stated when the weather is stormy the windows were often dirty on the outside. On 12/19/14 at 4:19 pm, Staff 13, CNA, confirmed the window was foggy in room 109, as well as others, and thought it was between the panes of glass. She was not sure how long the windows had been dirty and foggy. Staff 13 confirmed it was difficulty to see out the windows. | 2018-05-01 |
| 6201 | 6201 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 309 | D | 0 | 1 | 076Z11 | **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 physician's order for lab work related to [MEDICATION NAME] (a medication used to prevent blood clots) was followed for 1 of 5 sampled residents (#72) reviewed for unnecessary medications use. The failure to follow a physician's order placed residents at risk for excessive or subtherapeutic dosing of the medication. Findings include: Resident 72 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. A 11/25/14 physician order indicated [MEDICATION NAME] 5 mg qd and to check the INR (International normalized ratio, a test used to monitor [MEDICATION NAME] effectiveness) on 12/1/14. There was no documentation in Resident 72's record the INR was completed. Resident 72's 11/2014 and 12/2014 MARs indicated the resident continued to receive [MEDICATION NAME] 5 mg from 11/25/14 to 12/17/14. On 12/18/14 at 12:30 pm, Staff 6, LPN, confirmed Resident 72's physician ordered INR was not completed. | 2018-05-01 |
| 6202 | 6202 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 353 | E | 0 | 1 | 076Z11 | Based on observation and interview, it was determined the facility failed to provide sufficient staffing to meet residents needs during 4 of 4 meal observations in the Ponderosa Unit. This placed residents at risk for unmet dietary needs. Findings include: The Ponderosa Unit dining area consisted of three areas where residents were observed to be dining. There were two separate dining rooms, one with four tables and one with one table and an alcove area with one table in the hallway that lead to both dining rooms. During four meal observations from 12/15/14 to 12/18/14, residents who required some assistance with eating were observed to wait extensive periods of time for staff assistance or not receive any staff assistance. Observations on 12/15/14 in the Ponderosa Unit dining area from 12:20 pm to 2:15 pm revealed the following: -At 12:20 pm, multiple residents (including Residents 17, 35, 36, 47, 57, 71, 76, 79, 82 and 92) were observed in the dining areas to be drinking liquids, moving around the area by walking or in wheelchairs, entering and leaving the dining areas. Staff 14, 18 and 19, CNAs and Staff 16, LPN, who was passing medications, were observed in the dining areas. Staff 15, CNA, arrived towards the end of the meal service. -Between 12:51 pm and 1:23 pm, Staff 14, 18 and 19 were observed carrying resident meal trays (one at a time) to the residents in the three separate dining areas. Resident meals were served from a small kitchenette room about 20 to 30 feet away from the dining areas. Staff 14, 18 and 19 had to go back and forth in order to deliver each meal tray to each resident. Staff were observed to assist residents to eat for a few minutes then left alone, unassisted, for periods ranging 10-25 minutes. -At 12:51 pm, 30 minutes after residents were first observed in the dining room, the first lunch meal was delivered and left uncovered in front of Resident 79. From 12:51 pm to 1:17 pm, (a total of 26 minutes), Resident 79 sat in her/his chair looking out towards the window in the room and did … | 2018-05-01 |
| 6203 | 6203 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 431 | E | 0 | 1 | 076Z11 | Based on observation and interview it was determined the facility failed to maintain 6 of 13 medication storage areas free of expired medications and/or supplies. This placed residents at risk for receiving medications with decreased efficacy and/or supplies with compromised integrity and sterility. Findings include: On 12/19/14 at 1:38 pm, Santiam Unit med-room was observed with Staff 2, RNCM, to contain the following expired medications: [REDACTED] - Lantanoprost eye drop. Open date of 10/31/14 with label on top of medication, indicating medication should be used by or pulled by 12/11/14 - artificial tears, eye drops. Open date of 2/9/14. According to Medication Reference Guide provided by pharmacy, eye drops should be discarded 6 months after opening. On 12/19/14 at 1:38 pm, Santiam Unit treatment cart was observed with Staff 2, RNCM, to contain the following expired supply: -True Test for calibrating Glucometer, expired on 11/30/14 On 12/19/14 at 2:29 pm, Santiam Unit central supply room was observed with Staff 5, Staffing/Central Supply, to contain the following expired medications and supplies: - one suction catheter tray, expired on 7/2014 - one glucose control solution, expired on 1/31/14 - two urine specimen containers, expired on 11/2009 - two IV catheters, expired on 3/2014 On 12/19/14 at 1:38 pm, the Ponderosa Unit medication cart was observed with Staff 10, LPN, to contain the following expired supply: - one glucose control solution, expired 8/31/2013 On 12/19/14 at 1:50 pm, the Ponderosa Unit treatment cart was observed with Staff 10, LPN, to contain the following expired medication: - one zinc oxide ointment, expired 11/2014 On 12/19/14 at 2:05 pm, the Ponderosa Unit Central Supply room was observed with Staff 10, LPN, to contain the following expired supplies: - three Povidone-iodine swab sticks, expired 1/2013 - 51 alcohol prep pads, expired 11/2013 - two bottles of Jevity (feeding tube formula), a label indicated use before 8/1/14 - one bottle of 0.9 % sodium chloride irrigation, expired 10/2014… | 2018-05-01 |
| 6204 | 6204 | MARIAN ESTATES | 385240 | 390 SE CHURCH STREET | SUBLIMITY | OR | 97385 | 2014-12-22 | 441 | D | 0 | 1 | 076Z11 | **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 posted isolation precautions for 1 of 7 residents (#69) for whom isolation precautions were in place, and failed to use proper hand hygiene for 1 of 3 sampled residents (#98) for whom wound dressing changes were observed. This placed residents at risk for cross-contamination and infection. Findings include: 1. Resident 69 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. On 12/15/14 at 10:15 am, a sign was observed outside Resident 69's room which indicated droplet precautions were in place and a mask with goggles or faceshield were required. A small cabinet was located outside of the resident's room which contained disposable gowns, gloves, face masks and reusable goggles. Staff 2, RNCM, stated all staff and visitors were to wear a gown, gloves, mask and goggles before entering the room. On 12/15/14 at 1:02 pm, Staff 3, CNA, was observed as she prepared to enter Resident 69's room. Staff 3 donned a disposable gown and gloves. She then put on a mask, situated just below her nose, which failed to meet accepted professional standards. Staff 3 did not put on goggles and entered Resident 69's room. After delivering the resident's food, Staff 3 walked outside the resident's room to remove her gown, gloves and mask. She disposed of them in a small trash can located just outside the door. Staff 3 then walked down the hall to the locked utility room, punched in the code to open the door, and entered the room. On 12/15/14 at 1:09 pm and 12/16/14 at 1:21 pm, Staff 3 stated she thought she didn't have to wear goggles and she wore the mask right below her nose because her nose itched. She stated there was always a trash can inside and outside of Resident 69's room used for soiled gowns, gloves and mask. She stated for residents not on isolation precaution, she washed her hands inside their room, and for residents in isolation, she walked down t… | 2018-05-01 |
| 7997 | 7997 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 241 | E | 0 | 1 | 07QH11 | Based on observation and interview, it was determined the facility failed to ensure an environment that promoted and enhanced residents' dignity for 11 of 11 sampled residents (#s 17, 35, 49, 52, 57, 60 ,66, 83, 89, 94 and 103) eating in the Assisted Dining Room (ADR). The resulting environment was not conducive to social dining. The impact to residents included loss of independence and potential decreased feelings of self worth. Findings include: 1. On 2/1/12 at 8:08 am, observations revealed the independent dining room and the main dining room, adjacent to the ADR, had tablecloths which the ADR tables lacked. None of the ADR residents' (#s 17, 35, 49, 52, 60, 66, 83, 89, 94 and 103) wheelchair (w/c) arms fit under the tables except for Resident #57. At 8:10 am, staff were observed to place clothing protectors on the residents in the ADR without asking or acknowledging the residents. At 8:26 am, Staff 18 (CNA) was feeding Resident 17 with a plastic spoon although a regular spoon was lying on the resident's divided plate. At 8:28 am, observations revealed Resident 94's wheelchair (w/c) was positioned four inches from the table and the resident was observed to have to lean forward to get spoonfuls of food from the plate, which she occasionally dropped onto the clothing protector. The w/c brakes were not locked and the w/c moved while the resident was trying to eat. 2. On 2/6/12 during lunch, continuous observation of the ADR from 12:30 pm until 12:50 pm revealed Staff 17 (CNA) standing to assist Residents 57 and 66. 3. On 2/7/12 during the evening meal, Staff 10 (CNA) was observed to stand while assisting residents (#s 17, 35, 57, 66 and 94) to eat. 4. During observations on 2/1/12 at breakfast, 2/7/12 at lunch and 2/7/12 at dinner, the CNAs' walkies (talkies) were noted to be loud and disruptive during the meals. The volume and frequency of use of the walkies introduced a lot of stimuli into the dining area and created a dining experience that was not home-like or pleasant. 5. On 2/9/12 during breakfast observati… | 2016-01-01 |
| 7998 | 7998 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 246 | D | 0 | 1 | 07QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined the facility failed to ensure call lights were accessible for 2 of 19 sampled residents (#s 56 and 60) who were able to use call lights. This placed the residents at risk for not getting their needs met in a timely manner. Findings include: 1. Resident 60 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. On 1/31/12 at 2:36 pm Resident 60 was observed lying in bed crying and calling out in a distressed manner. No call light was within reach of the resident. The call light was located by Staff 11 (CNA) and placed within the resident's reach. Staff 11 talked with the resident identifying that the resident was in pain. Staff 19 (LPN) came within 5 minutes to evaluate Resident 60's pain and administered pain medication. On 2/1/12 at 9:25 am Staff 19 confirmed that Resident 60 was able use the call light. 2. Resident 56 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. On 2/2/2012 at 1:23 pm it was observed that the resident was in bed with no call light within reach. Staff 6 (CNA) stated that the resident was able to use the call light and attached the call light to the bed. | 2016-01-01 |
| 7999 | 7999 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 247 | D | 0 | 1 | 07QH11 | Based on interviews, it was determined 1 of 4 Residents (#8) who were reviewed for admission, transfer and discharge review was not given notification prior to the arrival of a new roommate: Failure to give timely notification did not respect the resident's right to have input regarding having a roommate change. Findings include: On 2/1/12 at 11:14 am Resident 8 was asked if she had a roommate change in the last nine months and responded that a resident had been moved into her room without receiving notification that she was getting a new room mate. During an interview on 2/7/12 at 12:25 pm Staff 8 (Admission Coordinator) confirmed that Resident 8 was not informed she was getting a new roommate prior to the new resident moving in. | 2016-01-01 |
| 8000 | 8000 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 253 | E | 0 | 1 | 07QH11 | Based on observations and interview, it was determined the facility failed to maintain furniture, doors, hand rails and walls in resident use areas in good repair for 9 of 37 resident rooms and 4 of 10 common use resident areas. The failure created a living environment for the residents that was not home-like or well maintained. Findings include: Observations between 2/1/12 at 7:30 am and 2/7/12 at 9:10 am revealed the following areas were not in good repair: -In resident room 101, the top surface of the bedside table for bed-B had cracks and the finish was worn off in some areas. The laminate windowsill had a 1 half moon shaped missing section. -In resident room 102, the top surface of two bedside tables had areas where the finish was worn off. The overbed tray for 102-A had areas along the edges where the veneer was scratched or missing. -In resident room 105, the wall behind the headboard of bed-B had a 4 by 3 hole and three areas that had been patched but not repainted to match the rest of the wall. There was a 12 by 1 gap with exposed insulation on the left side of the wall heater. -In resident room 106, the wall at the end of bed-B had multiple linear scuffs and dark marks along a three foot section. -In resident room 107, the room sink was located in an alcove. The corners of the wall on both sides of the sink were gouged and scraped, leaving the metal undersurface exposed for 9 above the floor coving. The top surface of the bedside table for bed-B had cracked areas where the finish was worn off. -The bottom edge of the entry door to resident room 111 had a one inch section with gouges that were rough and splintered. -The finish on the hand rail between resident rooms 112 and 114 was worn off. -The finish on the hand rail between resident room 114 and the clean linen closet had been worn off. -In resident room 115, the bathroom door was missing sections of the top surface from the lower part of the door beneath the inner hinge. -In the alcove between resident rooms 115 and 117, the lower wooden rail had mu… | 2016-01-01 |
| 8001 | 8001 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 279 | D | 0 | 1 | 07QH11 | **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 meeting the nutritional needs for 1 of 1 sampled resident (#96) who received [MEDICAL TREATMENT]. Lack of an individualized care plan placed the resident at risk for nutritional services not being provided. Findings include: Resident 96 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a Nutritional CAA dated 1/5/12 revealed the resident was on a no added salt, regular thin liquid (NAS/REG/THIN) diet. The assessment indicated the resident had pressure ulcers and would be followed weekly in the nutrition at risk (NAR) meetings. The resident was inconsistent with intake and sack lunches were to be sent on days the resident was scheduled to go to the [MEDICAL TREATMENT] center. Review of an Registered Dietician (RD) assessment dated [DATE] revealed the resident had increased nutritional needs related to wound healing and [MEDICAL TREATMENT]. The resident's current intake was 54-89% of meals which was not adequate to meet the resident's estimated nutritional needs. The assessment indicated the resident's current weight was above ideal body weight (IBW) but had lost 5.1 lbs since admitting to the facility. The resident's goal was for the resident's weight to remain stable with no significant weight changes. Recommendations included a level two meal enhancement, two scoops of [MEDICATION NAME] (protein supplement) three times a day and add controlled carbohydrates (CCHO) and Renal (diet) to the resident's diet order. Review of the current nutritional care plan dated 1/17/12 revealed the resident had a nutritional problem related to a decreased appetite and unstable health conditions. The goal was for the resident's weight to remain stable through 3/29/12. Interventions included an RD assessment to make diet changes and recommendations as needed and for the facility to weigh the resident. The care plan did not i… | 2016-01-01 |
| 8002 | 8002 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 309 | D | 0 | 1 | 07QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to ensure a resident who had requested pain medication received pain medication in a timely manner for 1 of 5 sampled residents (#162) reviewed for pain management. Resident 162 did not receive pain medication for 94 minutes after the resident requested the medication and experienced avoidable severe pain. Findings include: Resident 162 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of a hospital transfer physician's orders [REDACTED]. Review of a NN dated 1/26/12 at 4:30 pm revealed the resident was admitted to the facility at 3:15 pm and was alert and oriented to person, place and time. The note indicated the resident denied pain or shortness of breath. Review of an Admission Nursing Evaluation dated 1/26/12 at 4:37 pm revealed the resident was admitted from a local hospital for rehabilitation after left total knee replacement surgery. The evaluation indicated the resident was alert, awake, oriented to place, had clear speech and was able to follow instructions. The resident had indicated experiencing frequent pain over the last five days. Review of a Pain Evaluation dated 1/26/12 at 5:13 pm revealed the resident had occasional pain, which limited day to day activities, in the last five days and indicated the resident's pain was a 4 on a scale of 1 to 10 (1 being minimal pain and 10 being severe pain). Review of a pain monitoring form for January 2012 revealed the resident was having pain on 1/26/12 at 11:10 pm. Review of a MAR for January 2012 revealed the resident received one tablet of [MEDICATION NAME] on 1/26/12 at 6:08 pm for pain. The MAR also indicated the resident's next dose of [MEDICATION NAME] was given at 11:19 pm. In an interview on 2/2/12 at 10:42 am Resident 162 indicated that on 1/26/12 at 9:30 pm Resident 162 was having pain and had asked Staff 11 (CNA) to call the nurse for pain medication. The resident said that the nurse b… | 2016-01-01 |
| 8003 | 8003 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 312 | E | 0 | 1 | 07QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility failed to provide timely and consistent dining assistance to 9 of 41 sampled residents (#s 17, 35, 49, 52, 57, 60, 66, 94 and 103) of the 42 residents identified as needing assistance to eat. The lack of adequate and timely dining assistance placed the residents at risk for decreased interest in eating, decline in independent eating ability and weight loss. Findings include: 1. Resident 17 was admitted to the facility during 2010 with [DIAGNOSES REDACTED]. The resident's Kardex (CNA plan of care informational sheet) indicated the resident required prompting and assistance to eat and encouragement to complete the meal. On 2/1/12 during breakfast observations in the assisted dining room (ADR), the resident was holding a utensil, moving it around the plate but not feeding herself. The resident received no staff cueing or assistance from 8:16 am until 8:26 am. On 2/7/12 during the dinner observations in the ADR, the resident was served at 5:10 pm and received no prompting or assistance until 5:19 pm when staff encouraged the resident to eat. The resident received no assistance from staff from 5:19 pm until 5:24 pm. At 5:35 pm, Staff 10 (CNA) sat down and fed the resident until the resident said she was done. On 2/9/12 at 11:11 am, Staff 18 (CNA) stated that Resident 17 needed a lot of cueing. Staff 18 said the resident would start to eat on her own and when she became tired, staff would assist her. Staff 17 indicated the resident needed some hands on help due to the resident's hands jerking but that some days were worse than others. 2. Resident 49 was admitted to the facility during 2011 with [DIAGNOSES REDACTED]. The resident's Kardex reflected that the resident needed prompts to drink fluids and assistance to eat. On 2/7/12 during lunch observations in the ADR, the resident sat at the table with eyes closed and made no attempt to feed herself from 12:30 pm until 12:44 pm. Staff … | 2016-01-01 |
| 8004 | 8004 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 353 | E | 0 | 1 | 07QH11 | Based on observations, record reviews, and interviews, it was determined the facility failed to provide sufficient staffing to meet the dining needs as described in their care plans for 9 of 10 sampled residents (#s 17, 35, 49, 52, 57, 60, 66, 94 and 103) in the assisted dining room. The lack of sufficient staff at meals placed the residents at risk for decreased interest in eating, decline in independent eating ability and weight loss. Findings include: The residents' (#s 17, 35, 49, 52, 57, 60, 66, 94 and 103) Kardexes (CNA plan of care informational sheet) indicated two residents (#s 35 and 57) required extensive assistance (were dependent) with eating. One resident (# 66) needed extensive assistance with lots of cueing. Two residents (#s 52 and 89) needed limited assistance and two residents (#s 17 and 49) were to receive prompting and assistance to eat. One resident (# 103) needed constant encouragement and staff were to remain with the resident during meals, reinforce that the resident should eat slowly and assist the resident with eating when resident became fatigued. One resident (# 94) was only to eat with supervision and needed occasional cueing and assistance with eating. One resident (# 60) required cueing assistance to eat and complete meals. On 2/7/12, observation revealed the meal cart arrived at 5:02 pm. Multiple staff delivered covered meals to the tables in the assisted dining room (ADR) and the main dining room. The first resident was served in the ADR at 5:05 pm and the last resident in the ADR was served at 5:21 pm. One resident (#83), who was totally dependent, was being fed by their spouse. At 5:10 pm, Resident 89 was observed to be the only resident in the ADR eating and the other seven residents (#s 17, 35, 49, 52, 60, 66 and 94) who needed assistance were waiting to be helped. At 5:13 pm, Residents 57 and 103 were escorted to the ADR, bringing the total number of residents needing staff assistance with eating to 10 residents. Direct, uninterrupted observations from 5:01 pm until 6:25 pm … | 2016-01-01 |
| 8005 | 8005 | AVAMERE COURT AT KEIZER | 385233 | 5210 RIVER ROAD N. | KEIZER | OR | 97303 | 2012-02-10 | 371 | F | 0 | 1 | 07QH11 | Based on observations and interview it was determined the facility failed to store, prepare, and serve food under sanitary conditions and ensure serving staff practiced appropriate hand hygiene. This placed residents at risk for food bourne illness. Findings include: 1. Observations of the facility's kitchen on 1/31/12 at 10:45 am revealed three plastic food storage bins labeled flour, sugar and thickener had dried food debris on the lids and sides of the containers. A refrigerator in food preparation area had a dried liquid on the handle and exterior door. Two food transport carts had multiple areas of dried food debris, dirt and grime. Two ovens had dried food debris, dirt and grime on the handles, exterior sides and knobs. Findings were reviewed on 2/6/12 at 3:04 PM with Staff 7 (Dietary Manager) who acknowledge the unclean equipment, indicated the equipment was wiped down daily and said she would have staff clean the equipment. 2. On 1/31/12 at 12:05 PM, a CNA was observed to wipe her nose with the back of her hand, then pour milk into a glass for a resident from a milt-use dispenser without washing her hands. On 2/2/12 from 8:10 am to 8:45 am, continuous observation of breakfast meal, Cans moved from clean to dirty to clean surfaces while assisting residents with their meal without washing their hands. 3. During observations of breakfast on 2/1/12, Staff 17 (CNA) was observed at 8:16 going from touching potentially dirty surfaces (tray cart, trays and plate covers) with his hands and then handling the clean surfaces of residents' plates without washing his hands. After pulling plates from the tray cart at 8:16 am and 8:19 am, Staff 17 was observed carrying residents' plates. Staff 17 had his thumb overlapping the rim of the plate onto the clean eating surface. During observations of dinner on 2/7/12, at 5:11 PM Staff 17 served Resident 94's meal. While transporting the plate, Staff 17 had his thumb on the rim of the divided plate. On 2/9/12 at 12:03 PM, these issues of CNAs going from clean to dirty to clean… | 2016-01-01 |
| 9149 | 9149 | HILLSIDE HEIGHTS REHAB CT | 385046 | 1201 MCLEAN BLVD. | EUGENE | OR | 97405 | 2011-03-21 | 309 | D | 1 | 0 | 07R211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to administer a resident's medication for 1 of 3 sampled residents (# 2). Findings include: Resident 2 was readmitted to the facility 2/26/11 with [DIAGNOSES REDACTED]. Review of the 2/26/11 Nursing Home Care Transfer Form revealed the resident was to have one multivitamin with minerals QD. Review of the March 2011 MAR indicated [REDACTED]. Review of a hand written note transcribed across the multivitamin administration times revealed "cannot find order." On 3/3/11 at 1:20 pm Staff 3 (RNCM) verified the multivitamin was not administered to the resident per physician orders. Staff 3 stated she reviewed the March 2011 MAR for accuracy and facility staff discontinued the medication after the March 2011 MAR indicated [REDACTED] | 2014-07-01 |
| 2592 | 2592 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 272 | E | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to comprehensively assess 4 out of 10 sampled residents (#s 1, 12, 32 and 40) reviewed for accidents, medications and dental status. This placed residents at risk for unmet needs. Findings include: 1. Resident 40 was admitted to the facility in (YEAR) with a [DIAGNOSES REDACTED]. Review of Resident 40's record revealed no comprehensive assessment could be located. On 4/7/17 at 2:54 pm, Staff 1 (Administrator) confirmed a comprehensive assessment was not completed for Resident 40. 2. Resident 1 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. The 9/29/16 [MEDICAL CONDITION] Medication CAA indicated Resident 1 received [MEDICATION NAME] once daily for depression and had no adverse signs or symptoms. The CAA did not include risk factors, causes or contributing factors regarding the use of [MEDICATION NAME]. On 4/6/17 at 2:06 Staff 2 (DNS) acknowledged Resident 1's 9/29/16 [MEDICAL CONDITION] Medication CAA did not include risk factors, causes or contributing factors regarding the rationale for the use of [MEDICATION NAME]. 3. Resident 12 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 12's last comprehensive MDS had an ARD (assessment reference date) of 12/31/15. On 4/6/17 at 2:12 pm Staff 2 (DNS) acknowledged the last comprehensive MDS had an ARD date of 12/31/15 and an additional comprehensive MDS was not completed. 4. Resident 32 was admitted to the facility 2009 with [DIAGNOSES REDACTED]. The 10/19/16 [MEDICAL CONDITION] Medication CAA indicated Resident 32 received an antipsychotic. The CAA did not include risk factors, causes or contributing factors regarding the use of the antipsychotic. On 4/7/17 at 9:36 am Staff 2 (DNS) confirmed the 10/19/16 [MEDICAL CONDITION] Medication CAA was not comprehensive. | 2020-09-01 |
| 2593 | 2593 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 273 | D | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to complete an admission MDS within 14 days of admission for 3 of 9 sampled residents (#s 1, 77 and 83) reviewed for medications, participation in care planning and PASRR. This placed residents at risk for unmet needs. Findings include: 1. Resident 77 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 77's record revealed the resident's admission MDS was due on 9/29/16. The admission MDS was signed as completed on 11/9/16, 41 days after it's required due date. On 4/10/17 at 10:29 am, Staff 2 (DNS) acknowledged the resident's admission MDS was not completed within 14 days of admission. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Cognitive Loss CAA, Visual Function CAA and Communication CAA, was not completed until 9/16/16. Resident 1's ADL CAA, Urinary Incontinence CAA, Fall CAA, Nutrition CAA, Pressure Ulcer CAA, and [MEDICAL CONDITION] Drug CAAs were not completed until 9/29/16. On 4/6/17 at 2:06 pm Staff 2 (DNS) acknowledged Resident 1's CAAs were not completed within 14 calendar days after admission. 3. Resident 83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review revealed the Admission MDS Assessment was due on 9/7/16 and was not completed by Staff 2, (DNS) until 9/19/16. During an interview on 4/6/17 at 3:46 pm, Staff 2 acknowledged the admission assessment was due 9/7/16. Staff 2 confirmed she completed the admission assessment on 9/19/16. | 2020-09-01 |
| 2594 | 2594 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 274 | D | 0 | 1 | 08ND11 | **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 MDS within the required time frame for 1 of 1 sampled residents (#103) reviewed for urinary incontinence. This placed residents at risk for unmet needs. Findings include: Resident 103 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 103's record revealed the resident required a significant change MDS due 1/2/17. The significant change MDS was completed by the facility on 1/29/17. On 4/7/17 at 4:40 pm, Staff 2 (DNS) acknowledged the significant change MDS was completed on 1/29/17. | 2020-09-01 |
| 2595 | 2595 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 275 | E | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to complete an annual MDS assessment within 366 days of the previous assessment for 5 of 9 sampled residents (#s 7, 12, 32, 64 and 66) reviewed for PASRR, medications and dental status. This placed residents at risk for unmet needs. Findings include: 1. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 7's annual MDS revealed it was due 3/20/17. The Annual MDS was signed as completed on 3/31/17. On 4/10/17 an 10:29 am Staff 2 (DNS) acknowledged the Annual MDS for Resident 7 was completed late. 2. Resident 64 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 64's previous annual MDS ARD (assessment reference date) was 4/16/15. Resident 64's annual MDS was due for completion on 4/17/16 (366 days from the ARD date of 4/16/15). It was completed over two months late on 6/18/16. On 4/7/17 at 11:24 am Staff 2 (DNS) and Staff 8 (RN consultant) confirmed Resident 64's annual MDS was not completed on time. 3. Resident 66 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 66's previous annual MDS ARD (assessment reference date) was 7/10/15. Resident 66's annual MDS was due for completion on 7/11/16 (366 days from the ARD date of 7/10/15). It was completed over two months late on 10/4/16. On 4/7/17 at 11:44 am Staff 2 (DNS) and Staff 8 (RN consultant) confirmed Resident 66's annual MDS was not completed on time. 4. Resident 12 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 12 previous comprehensive MDS ARD (assessment reference date) was 12/31/15. On 4/6/17 at 2:12 pm Staff 2 (DNS) acknowledged the last comprehensive MDS was dated 12/31/15 and an additional comprehensive MDS was not completed. 5. Resident 32 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. A review on 4/6/17, of the Annual MDS Comprehensive Assessment revealed it was due on 7/10/16 … | 2020-09-01 |
| 2596 | 2596 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 276 | D | 0 | 1 | 08ND11 | **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 quarterly MDS for 3 of 6 sampled residents (#s 64, 66 and 83) reviewed for participation in care planning and dental status. This placed residents at risk for unmet needs. Findings include: 1. Resident 64 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of Resident 64's Quarterly MDS revealed it was due on 9/20/16 and was not completed until 10/5/16, 15 days late. No other Quarterly MDS assessments were completed prior to the next annual assessment completed on 3/27/17. On 4/7/17 at 11:24 am Staff 2 (DNS) and Staff 8 (RN consultant) acknowledged the facility failed to completed the Quarterly MDSs within the 92 days from the previous assessment for the 10/5/16 MDSs. 2. Resident 66 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of Resident 66's Quarterly MDS revealed it was due on 1/4/17 and was not completed until 3/21/17, over 2 months late. On 4/7/17 at 11:44 am Staff 2 (DNS) and Staff 8 (RN consultant) acknowledged the facility failed to complete the Quarterly MDS within the 92 days from the previous assessment for the 3/21/17 assessment. 3. Resident 83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review on 4/6/17, revealed the facility did not complete a Quarterly MDS Assessment between 9/19/16 and 3/17/17. A quarterly assessment was due on 12/18/16. The assessment was not completed by Staff 2 until 3/17/17. During an interview on 4/6/17 at 3:46 pm, Staff 2 confirmed a quarterly assessment was not completed between 9/19/16 and 3/17/17. | 2020-09-01 |
| 2597 | 2597 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 278 | D | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately code the MDS for 1 of 1 sampled residents (#103) reviewed for urinary incontinence. This placed residents at risk for unmet needs. Findings include: Resident 103 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 103's Significant Change MDS dated [DATE] revealed the resident was coded as being always incontinent of urine. Review of Resident 103's Resident Functional Performance Record for bladder function for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident was both incontinent and continent of bladder. On 4/7/17 at 1:40 pm Staff 2 (DNS) confirmed the coding for urinary incontinence on the Significant Change MDS was inaccurate. | 2020-09-01 |
| 2598 | 2598 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 332 | D | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review it was determined the facility failed to ensure a medication error rate of less than 5%. There were three errors in 29 opportunities which resulted in an error rate of 10%. This placed residents at risk for medication side effects and ineffective medication management. Findings include: 1. Resident 29 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The 4/3/17 physician orders [REDACTED]. According to the facility (YEAR) Nursing Drug Handbook, Humalog is a fast-acting insulin and should be given within 15 minutes before a meal or immediately after a meal. On 4/6/17 at 11:45 am, Staff 3 (LPN) was observed administering Humalog fast acting insulin to Resident 29. Resident 29 did not receive her/his meal until 12:17 pm, 32 minutes after the insulin was administered. On 4/6/17 at 12:25 pm, Staff 3 (LPN) stated Humalog was a fast acting insulin and the resident should have received her/his meal within 15 minutes. 2. Resident 55 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/26/17 physician orders [REDACTED]. According to the facility (YEAR) Nursing Drug Handbook, [MEDICATION NAME] is a fast-acting insulin and should be given within 15 minutes before a meal or immediately after a meal. On 4/6/17 at 11:39 am, Staff 3 (LPN) was observed administering Humalog fast acting insulin to Resident 55. Resident 55 did not receive her/his meal until 12:24 pm, 45 minutes after the insulin was administered. On 4/6/17 at 12:25 pm, Staff 3 (LPN) stated [MEDICATION NAME] was a fast acting insulin and the resident should have received her/his meal within 15 minutes. 3. Resident 59 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/26/17 physician orders [REDACTED]. According to the facility (YEAR) Nursing Drug Handbook, Humalog is a fast-acting insulin and should be given within 15 minutes before a meal or immediately after a meal. On 4/6/17 at 11:32 am, Sta… | 2020-09-01 |
| 2599 | 2599 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 334 | D | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to offer and provide information for the pneumococcal immunization for 1 of 5 sampled residents (#1) reviewed for immunizations. This placed residents at increased risk for illness. Findings include: Resident 1 admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. The 7/26/16 Admission MDS, Section O - Special Treatments & Programs, did not include a response to the question, Is the resident's Pneumococcal vaccination up to date? A review of Resident 1's medical record contained no indication the resident was offered or provided with information about the pneumococcal vaccine. On 4/6/17 at 10:15 am Staff 2 (DNS) acknowledged there was no evidence the resident was offered or provided with information about the pneumococcal vaccine. | 2020-09-01 |
| 2600 | 2600 | EMPRES HILLSBORO HEALTH AND REHABILITATION CENTER | 385217 | 1778 NE CORNELL ROAD | HILLSBORO | OR | 97124 | 2017-04-10 | 431 | D | 0 | 1 | 08ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to label insulin with date opened in 1 of 3 treatment carts and failed to discard expired medication in 1 of 2 medication refrigerators. This placed residents at risk for receiving medications with decreased efficacy. Findings include: 1. On 4/7/17 at 7:27 am Aplisol ([DIAGNOSES REDACTED] testing solution) had an open date of 2/25/17. Staff 5 (LPN) and Staff 6 (RNCM) were unsure if the solution was expired. Manufacturer guidelines indicated vials in use for more than 30 days should be discarded. On 4/7/17 at 7:38 am Staff 5 acknowledged the Aplisol was expired. 2. On 4/7/17 at 9:11 am a Humalog insulin vial had an open date of 3/7/17. The vial also had an orange tag that indicated the medication expired on 4/5/17. On 4/7/17 at 9:51 am Staff 4 (LPN) acknowledged the Humalog was expired. | 2020-09-01 |
| 111 | 111 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 176 | D | 1 | 1 | 09S111 | **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 for safe self-administration of medication for 1 of 1 sampled resident (#11) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include: Resident 11 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. On 8/9/17 at 10:22 am Resident 11 was observed laying in bed. The resident opened the bedside table drawer and revealing over-the-counter medications. The medications included the following: - [MEDICATION NAME] (allergy) - Eye Drops - mouth spray (for dry mouth) The resident did not have a current self-administration assessment and there were no physician orders for the resident to self-administer the [MEDICATION NAME] and the mouth spray. On 8/9/17 at 10:31 am Staff 19 (LPN) indicated Resident 11 had dementia and she was unaware the resident had over-the-counter medications in her/his drawer but had a physician order to self-administer eye drops. She indicated she would take the over-the-counter medications, put them in the medication cart and talk to the family about not bringing in medications for the resident. On 8/10/17 at 7:38 am Resident 11 was observed in bed. The resident's bedside table drawer was open and there were [MEDICATION NAME] and other over-the-counter medications in the drawer. On 8/10/17 at 9:09 am Staff 2 (DNS) was made aware of the over-the-counter medications in the drawer. Staff 2 and the surveyor entered the resident's room. Staff 2 saw the medications in the resident's drawer and took them out of the drawer and indicated they already took the medications out of her/his drawer yesterday and would look into why there were more medications in her/his drawer. She also indicated the self-administration assessment was over a year old and did not include the [MEDICATION NAME]. On 8/10/17 at 11:08 am Staff 18 (RCM LPN) indicated the family brought in m… | 2020-09-01 |
| 112 | 112 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 244 | D | 1 | 1 | 09S111 | > Based on interview and record review it was determined the facility failed to effectively respond to resident concerns expressed at Resident Council meetings. This placed residents at risk for unmet needs. Findings include: On 8/9/17 at 11:13 am Resident 88 stated staff frequently did not respond to the Resident Council members' concerns and did not give explanations when no response was provided. The Resident Council meeting minutes were reviewed on 8/9/17 at 1:10 pm with Staff 13 (Activity Director) and there was no documentation for April, May, (MONTH) or (MONTH) (YEAR) Resident Council minutes. The 2/23/17 and 3/28/17 Resident Council/Family Council Department Response Forms were reviewed. One of the (MONTH) forms for nursing issues was labeled as Not Resolved and was unsigned. The forms for (MONTH) were not complete. There were no department responses to concerns of the Council and no signatures on the forms. On 8/10/17 at 11:42 am Staff 1 (Administrator) acknowledged there was lack of documentation and follow-up for the Resident Council concerns. | 2020-09-01 |
| 113 | 113 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 248 | D | 1 | 1 | 09S111 | **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 an ongoing program of activities to meet resident interests for 1 of 1 sampled resident (#22) reviewed for activities. This placed residents at risk for social isolation. Findings include: Resident 22 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 22's Admissions MDS dated [DATE] revealed Resident 22 was not assessed for activity preferences. Resident 22's activities care plan dated 6/12/17 revealed Resident 22 was dependent on staff for activities, cognitive stimulation and social interaction. The care plan instructed staff to provide one to one bedside/in-room visits and activities if Resident 22 was unable to attend out of room activities. The care plan did not include information regarding Resident 22's activity preferences. Review of Resident 22's medical record found no evidence Resident 22's activity preferences were obtained. On 8/7/17 at 4:50 pm Resident 22 stated she/he used to read her/his bible every day but was not able to as it was out of her/his reach and no staff had offered assistance to obtain it for her/him. Resident 22 also stated staff did not offer to turn on her/his radio. On 8/8/17 at 7:58 am Resident 22 was observed in her/his bed. Her/his bible and radio were located on a dresser by Resident 22's bed but out of her/his reach and both were noted to have a thin layer of dust on them. Random observations between 8/7/17 and 8/10/17 revealed Resident 22 did not attend any out of room activities and was not provided with one to one visits or in room activities. On 8/10/17 at 11:03 am Staff 13 (Activities Director) confirmed activity preferences were not obtained for Resident 22, the resident had not participated in out of room activities and was not provided one to one visits. | 2020-09-01 |
| 114 | 114 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 272 | E | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to comprehensively assess 7 of 11 sampled residents (#s 11, 68, 88, 106, 115, 130 and 214) reviewed for medications, urinary incontinence, pressure ulcers and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 130 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 130 had a physician order [REDACTED]. Resident 130's Admission MDS dated [DATE] indicated the resident received [MEDICAL TREATMENT] services and did not indicate the resident was on a renal diet. As a result, a nutrition CAA related to [MEDICAL TREATMENT] was not completed. On 8/10/17 at 11:21 am Staff 2 (DNS) confirmed a renal diet was not coded on the resident's annual MDS and a nutritional CAA should have been completed. 2. Resident 106 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Resident 106's 4/27/17 Admission MDS Section M identified the resident was a high risk for pressure ulcers and had a Stage 4 pressure ulcer The resident was admitted with a Stage 4 pressure injury of her/his left lower ischial tuberosity (two bony swellings found on the lower back part of the hip bone). A Stage 4 pressure injury was defined in the RAI manual as Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The pressure Ulcer CAA was not comprehensive and contained no assessment of the resident's risk factors, relationship of the resident's medications or [DIAGNOSES REDACTED]. On 8/11/17 at 12:39 pm Staff 2 (DNS) and Staff 18 (Resident Care Manager LPN) verified Resident 106's Pressure Ulcer CAA was not comprehensive and did not assess the resident's risk factors or [DIAGNOSES REDACTED]. 3. Resident 88 was a long term facility resident with [DIAGNOSES REDACTED]. The resident's 5/16/17 Annual MDS Section M indicated the re… | 2020-09-01 |
| 115 | 115 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 273 | D | 1 | 1 | 09S111 | **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 admission assessment within 14 days of admission for 2 of 3 sampled residents (#s 130 and 218) reviewed for [MEDICAL TREATMENT] and pain. This placed residents at risk for unassessed needs. Findings include: Per the RAI Manual the admission MDS should be completed no later than the 14th calendar day of the resident's admitted 1. Resident 130 was admitted to the facility in (MONTH) (YEAR) and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment reference date (ARD) was 11/17/16. The MDS was completed on 12/29/16 which was 43 days from the date of admission. On 8/10/17 at 2:20 pm Staff 2 (DNS) acknowledged Resident 130's admission MDS was not completed timely. 2. Resident 218 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/11/17, 23 days after admission, there was no documentation a 14-day MDS Admission assessment was completed. On 8/11/17 at 9:11 am Staff 2 (DNS) confirmed Resident 218's Admission MDS was not completed within the required 14-day timeframe. | 2020-09-01 |
| 116 | 116 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 278 | E | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to accurately code for cognition, behavior and diet on the MDSs for 6 of 13 sampled residents (#s 3, 22, 115, 124, 130 and 214) reviewed for nutrition, activities, ADLs and falls. This placed residents at risk for unmet needs. Findings include: 1. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The RAI Manual instructed to code for cognition as no(,) resident is rarely/never understood and to complete Staff Assessment for Mental Status. This was not coded on Resident 3's annual MDS. Resident 3's annual MDS dated [DATE] was coded as not assessed for cognition. On 8/10/17 at 12:02 pm Staff 9 (Social Services Director) stated she attempted to assess Resident 3 for cognition but the resident was not able to participate. Staff 9 stated she coded cognition as not assessed. On 8/10/17 at 12:14 pm Staff 6 (Regional RN), Staff 8 (Social Services Director) and Staff 9 (Social Services Director) confirmed the MDS was incorrectly coded. 2. Resident 130 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The RAI Manual instructed to code for cognition as no(,) resident is rarely/never understood and to complete Staff Assessment for Mental Status. This was not coded on Resident 130's admission MDS. Resident 130's admission MDS dated [DATE] was coded as not assessed for cognition. On 8/10/17 at 12:02 pm Staff 9 (Social Services Director) stated she attempted to assess Resident 3 for cognition but the resident was not able to participate. Staff 9 stated she coded cognition as not assessed. On 8/10/17 at 12:14 pm Staff 6 (Regional RN), Staff 8 (Social Services Director) and Staff 9 (Social Services Director) confirmed the MDS was incorrectly coded. 3. Resident 115 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. Resident 115's 6/30/17 Admission Nursing Data Base indicated no signs or symptoms of dehydration. A physician's v… | 2020-09-01 |
| 117 | 117 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 279 | D | 1 | 1 | 09S111 | **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 (#115) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 115 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The resident's 7/21/17 Admission MDS Section M identified the resident received two antidepressant and two anticoagulant medications. The 7/2017 and 8/2017 MARs indicated the resident received trazadone (antidepressant) 100 mg every evening for [MEDICAL CONDITION]. The care plan dated 7/20/17 inaccurately indicated the resident used sedative/hypnotic medication related to [MEDICAL CONDITION] but the care plan did not include non-drug interventions to promote sleep. The 7/2017 and 8/2017 MARs indicated the resident received Trintellix (antidepressant) 10 mg every morning for treatment of [REDACTED]. signs and symptoms of depression. The 7/2017 and 8/2017 MARs indicated the resident received [MEDICATION NAME] and Xarelto (anticoagulant medications) since her/his admission to the facility. The resident's care plan updated on 7/20/17 did not reflect the resident's use of either medication for treatment of [REDACTED]. On 8/11/17 at 1:28 pm Staff 18 (Resident Care Manager LPN) was unaware of the effectiveness of the trazadone for [MEDICAL CONDITION] and verified there was no resident specific signs and symptoms of depression listed on the care plan. Staff 18 verified the anticoagulant medications were not addressed on the care plan. | 2020-09-01 |
| 118 | 118 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 309 | D | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation interview and record review it was determined the facility failed to obtain physician orders [REDACTED].#s 11, 147, 213) reviewed for medications. This placed residents at risk for unmet medication needs. Findings include: 1. Resident 147 was admitted to facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 147 was discharged from the hospital with 30-day physician orders [REDACTED]. The resident's 6/2017 and 7/2017 MARs revealed the following: - [MEDICATION NAME] was started on 6/2/17 and ended on 7/1/17. A new order did not start until 7/6/17. There were four days when resident did not receive [MEDICATION NAME] medication. - [MEDICATION NAME] was started on 6/1/17 and ended 6/30/17. A new order did not start until 7/5/17. There were four days when resident did not receive the trazadone medication. - [MEDICATION NAME] was started on 6/1/17 and ended on 6/30/17. One of two daily ordered doses was not administered on 7/1/17. A new order did not start until 7/6/17. There were four and a half days when the resident did not receive the [MEDICATION NAME] medication. - [MEDICATION NAME] was started on 6/1/17 and ended 6/30/17. One of two daily ordered doses was not administered on 7/1/17. A new order did not start until 7/6/17. There were four and a half days when the resident did not receive the [MEDICATION NAME] medication. A Physician's Progress Note dated 7/5/17 revealed This is my first time seeing this patient. I was asked to review and refill all of the patient's medications. Upon arrival, the patient's meds were ordered for 30 days and were not written for refill at admission. On 8/11/17 at 2:13 pm Staff 2 (DNS) acknowledged Resident 147 did not receive [MEDICATION NAME] and [MEDICATION NAME] medications between the dates the hospital orders ended and the new physician orders [REDACTED]. 2. Resident 213 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. a. The 12/2012 Bowel Care Protocol for the facili… | 2020-09-01 |
| 119 | 119 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 312 | D | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assist residents with incontinence care and grooming for 1 of 3 sampled residents (#213) reviewed for incontinence care and ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 213 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. The 4/11/17 Bowel and Bladder Assessment revealed the resident did not always void appropriately without incontinence, was incontinent of stool one to three times per week and required a one person assist with toileting. The 4/11/17 care plan revealed the resident had an ADL Self Care Performance Deficit or limited mobility. The resident required little or no help for hygiene and required set up assistance for grooming. The resident required one person assistance with toileting, was incontinent of bladder and bowel and required toileting upon rising, before and after meals and at night. The resident required staff participation to use the toilet and the resident wore briefs. The 4/2017 ADL Survey Report for bowel, bladder, toilet use and grooming revealed on 4/19/17, Resident 213 wore briefs and was incontinent of bladder requiring extensive assistance at 9:42 am and 7:11 pm. The resident was continent of bowel at 12:54 pm and 7:11 pm. The resident required supervision with a one person assist for grooming at 12:54 pm and 7:11 pm. The 4/2017 Bowel Report revealed the resident did not have a bowel movement for seven days and the 4/2017 MAR indicated [REDACTED]. A progress note dated 4/19/17 at 9:15 pm revealed the resident was alert and able to make her/his needs known throughout the day. The residents family approached the LN stating (Resident 213 was) shaking. The family then stated (Resident 213) has a blood clot somewhere, we want her/(him) to go to ER and get checked out. The facility notified the physician and received an order to transport the resident to the hospital. According to the 4/… | 2020-09-01 |
| 120 | 120 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 323 | D | 1 | 1 | 09S111 | **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 for 1 of 3 sampled residents (#147) reviewed for accidents. This placed residents at risk for additional accidents. Findings include: Resident 147 was admitted to facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's Admission MDS dated [DATE] indicated the resident was at risk for falls related to general weakness and medical condition. The Kardex (a condensed Care Plan for CNA's) dated 6/2/17 had directions for Resident 147's care including two staff participation for toileting and transfers. Resident 147's Care Plan dated 6/2/17 indicated the resident was a two-person assist to reposition, turn in bed, toilet use and transfers. An Incident Report dated 8/7/17 indicated the resident had a fall from her/his bed on 8/7/17 while staff were changing her/him which left the resident with red and swollen knees. On 8/11/17 at 2:19 pm Staff 18 (Resident Care Manager LPN) stated the fall precautions in place prior to resident's fall included having the bed in the low position and the assist of two persons with bed mobility, toileting and transfers. On 8/11/17 at 3:14 pm Staff 27 (LPN) stated Staff 28 (CNA) rolled the resident to bring her/him towards her but the resident kept going and she couldn't stop her/him from falling. There were two aides in the room to assist the resident to be changed but Staff 28 said she rolled the resident by herself. On 8/10/17 at 1:50 pm Staff 29 (CNA) stated she was in the room to assist Staff 28 (CNA) with changing resident. Staff 29 said she had wipes in one hand and was standing there getting ready to help turn and change the resident but Staff 28 (CNA) went ahead and rolled the resident on her own. Staff 28 was so fast Staff 29 did not have time to respond. The resident was not trying to get out of the bed during this time. Staff 28 rolled the resident by herself and did not wait for Staff 29 to … | 2020-09-01 |
| 121 | 121 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 325 | D | 1 | 1 | 09S111 | **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 the necessary assistance to allow a resident to eat adequately for 1 of 2 sampled residents (#22) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 22 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 22's admission MDS dated [DATE] did not assessed for nutrition due to a coding error. Resident 22's comprehensive care plan last revised 5/25/17 revealed Resident 22 was at risk for nutritional problems related to unstable health and had swallowing problems. Care planned interventions included providing supervision to Resident 22 when eating and for Resident 22 to eat in the assisted dinning room. On 8/7/17 at 6:00 pm Resident 22 was observed to have staff deliver a meal tray, assist with repositioning and then leave the room. Resident 22 was not offered assistance with eating or provided supervision. Resident 22 attempted to eat the dinner meal which included a wrap. Resident 22 was not able to open her/his hands wide enough to effectively hold the wrap and as she/he tried to lift it to her/his mouth the wrap fell apart. On 8/7/17 at 6:09 pm Resident 22 stated she/he needed assistance to be fed and was not being provided with assistance. Resident 22 stated she/he attempted to eat without assistance however would often get tired and was not able to complete the task. On 8/7/17 at 6:12 pm Resident 22 stated she/he was not able to eat the wrap and placed it back on her/his plate. On 8/7/17 at 6:15 pm Staff 15 (CNA) stated Resident 22 was no longer able to eat without staff assistance due to her/his inability to hold food, she planned on assisting Resident 22 however she was not able to make it back into Resident 22's room. On 8/8/17 at 7:58 am Resident 22 attempted to eat cereal with her/his hands and spilled the cereal on her/his shirt. Resident 22 asked if the surveyor could… | 2020-09-01 |
| 122 | 122 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 329 | D | 1 | 1 | 09S111 | **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 use of a neurological medication and failed to ensure monitoring of the medication for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for side effects from unnecessary medications. Findings include: Resident 3 was admitted to the facility in (YEAR) for [DIAGNOSES REDACTED]. Resident 3's comprehensive care plan updated 5/31/17 indicated the resident had visual and auditory hallucinations and delusions related to cognitive impairment. The care plan interventions included to monitor behaviors and report confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideation, withdrawal and decline in cognitive function. Resident 3 had a physician order [REDACTED]. Resident 3's (MONTH) (YEAR) and (MONTH) (YEAR) MARs indicated the resident received [MEDICATION NAME] 20 mg/10 mg every 12 hours. A review of Resident 3's progress notes dated back to (MONTH) (YEAR) did not document any behaviors of uncontrollable and inappropriate laughing and/or crying. A 9/13/16 physician progress notes [REDACTED]. The note indicated the resident was calmer, not calling out. and to continue the resident on [MEDICATION NAME]. Behavior Monitoring Records dated back to (MONTH) (YEAR) revealed no episodes of uncontrollable and inappropriate laughing/crying and indicated some hallucinations, paranoia, delusions and confusion as follows: - 12/24/16 there was one episode of behavior documented - (MONTH) (YEAR) there were three episodes of behaviors documented - February, March, April, (MONTH) (YEAR) there were no behaviors documented - (MONTH) (YEAR) there was one episode of behaviors documented - (MONTH) (YEAR) there were no documented episodes of behaviors CNA behavior monitoring in the electronic health record revealed no documented behavior monitoring from 7/11/17 to 8/11/17. On 8/… | 2020-09-01 |
| 123 | 123 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 332 | D | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to administer medications with less than a 5% medication error rate for 3 of 5 sampled residents (#s 80, 210, and 217) observed during medication administration. The facility had an 14% medication error rate with 4 errors in 27 opportunities. This placed residents at risk for inaccurate medications. Findings include: 1. Resident 210 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. On 8/10/17 between 7:10 am and 7:35 am Staff 22 (LPN) was observed to prepare Resident 210's medications. At 7:35 am Staff 22 was observed to administer [MEDICATION NAME] 50 mg orally without [MEDICATION NAME] to Resident 210. On 8/10/17 at 9:20 am Staff 22 verified she did not give Resident 210 the [MEDICATION NAME] and stated she asked the resident before the administration of the medication if she wanted the [MEDICATION NAME]. Staff 22 was not observed to ask the resident and did not document the resident's refusal of the [MEDICATION NAME]. 2. Resident 217 was admitted to the facility 7/2017 with [DIAGNOSES REDACTED]. On 8/10/17 at 8:00 am Staff 23 (CMA) was observed to administer [MEDICATION NAME] (antianxiety medication) 1 mg to Resident 217. The resident had physician orders [REDACTED]. On 8/10/17 9:20 am Staff 23 and Staff 24 (LPN) verified the [MEDICATION NAME] was administered at the incorrect time to Resident 217. 3. Resident 80 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. On 8/10/17 at 11:40 am Staff 21 (LPN) was observed to administer [MEDICATION NAME] 20 units subcutaneous to Resident 80. The resident had physician orders [REDACTED]. According to the facility's drug reference book [MEDICATION NAME] is classified as a rapid acting insulin and was to be administered immediately (5-10 minutes) before a meal. On 8/10/17 at 12:06 pm the resident's meal had not been served 26 minutes afte… | 2020-09-01 |
| 124 | 124 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 371 | F | 1 | 1 | 09S111 | > Based on observation and interview it was determined the facility failed to maintain a clean environment for 1 of 1 kitchens, ensure an ice machine was plumbed appropriately for sanitation for 1 of 1 ice machines, maintain proper temperatures for 1 of 3 snack refrigerators and ensure snack refrigerators did not contain expired items for 2 of 3 snack refrigerators. This placed residents at risk for food-borne illness. Findings include: 1. On 8/7/17 at 11:50 am and on 8/9/17 at 12:37 pm the ceiling in the facility kitchen was observed to have dust on it which accumulated by the vents located above the dishwashing area and above a food preparation area. On 8/9/17 at 3:47 pm Staff 12 (Dietary Manager) acknowledged the kitchen ceiling had built up dust especially around the vents and there was potential for dust to get into the residents' food. 2. The Federal Food Sanitization Rules code 5-402.11 Back flow 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 8/9/17 at 3:44 pm the ice machine in the kitchen was observed with an air gap between the ice machine drain and the outside piping. On 8/10/17 at 8:50 am Staff 5 (Maintenance) confirmed the ice machine did not have the required air gap to prevent back flow. 3. On 8/11/17 at approximately 1:50 pm the snack refrigerator on hall three was observed. The refrigerator temperature was between 42 and 43 degrees. The refrigerator contained the following undated or expired items: - an undated bowl of cut up fresh fruit - an undated container of yogurt - an undated small glass of thickened liquid - three undated cheese and cracker snacks - a container of soy milk dated 1/11 with no year documented - a small bowl of jello with a use by date of 8/8/17 - a small bowl of pudding with a use by date of 8/7/17 - three pitchers of beverages with use by dates to include 8/4/17, 7/29/17 and one which had a (MONTH) date but no day or year… | 2020-09-01 |
| 125 | 125 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 441 | D | 1 | 1 | 09S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to use the appropriate Personal Protective Equipment (PPE) prior to entering 2 of 2 rooms with contact precautions. This placed the facility at risk for cross-contamination. Findings include: The facilities policy for PPE for contact precautions included the following: -Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with residents or indirect contact with environmental surfaces or resident-care items in the the resident's environment. -Examples of infections requiring contact precautions included diarrhea associated with clostridium difficile (CDIFF a bacterial infection in the colon). -Place the individual in a private room -In addition to wearing gloves as outlines in standard precautions, wear gloves (clean, non-sterile) when entering the room. -Wear a disposable gown upon entering the Contact Precautions room. 1. On 8/7/17 at 12:10 pm during initial tour room [ROOM NUMBER] had a sign on the door that directed staff and visitors to the nurses station prior to entering the room. There was also a cart with PPE next to the room. Staff 25 (CNA) indicated the resident had CDIFF. On 8/8/17 at 10:18 am Staff 24 (Physical Therapy Assistant) knocked on room [ROOM NUMBER] and entered the room wearing gloves but did not wear a gown. Staff 24 indicated she did not gown up prior to entering the room until she knew she was going to treat the resident. On 8/11/17 at 10:25 am Staff 6 (Regional RN) indicated the resident in room [ROOM NUMBER] still had active diarrhea on 8/8/17 and acknowledged Staff 24 should have gowned up prior to entering the room. 2. Resident 111 readmitted to the facility during 7/2017 with [DIAGNOSES REDACTED]. On 8/10/17 at 12:51 pm Resident 111's door was observed to have a sign which instructed individuals to check with the nurse before entering the room. Personal pro… | 2020-09-01 |
| 126 | 126 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2017-08-11 | 516 | E | 1 | 1 | 09S111 | > Based on observation and interview it was determined the facility failed to safeguard resident medical records in 1 of 1 medical records office. This placed resident at risk for loss and/or unauthorized use of their medical records. Findings include: On 8/9/17 at 9:37 am through 9:59 am the medical records office/storage room was observed open and unlocked. There was no facility staff in the office and multiple resident medical records were within easy view and reach. The office door opened directly into the delivery hall which had supply delivery boxes, wheelchairs and three additional office doors to a beauty shop, dietician and maintenance offices. The medical records office window had open vertical blinds with stacks of resident specific information on a table directly in front of the window. On 8/9/17 at 9:50 am the resident records were noted to be visible from the back parking lot through the window. On 8/9/17 at 9:59 Staff 3 (Medical Records) verified the boxes in the hall were deliveries from outside vendors. At 10:47 am on 8/9/17 Staff 3 left the medical records office and left the door open. While Staff 3 was out of the office Staff 4 (Housekeeping-Laundry Manager) was observed to walk in and out of the medical records office and also left the door open. On 8/9/17 at 11:28 am Staff 3 was observed to walk away from the office and left the door open and unlocked again. On 8/9/17 at 10:05 am Staff 5 (Maintenance) stated he unlocked the hall entrance/exit doors when he came to work in the morning but otherwise the doors were locked. Staff 5 stated deliveries for central supply and kitchen came through the back hall doors and passed directly in front of the medical records office. On 8/9/17 at 12:17 pm Staff 1 (Administrator) verified residents had access to the beauty shop next to the medical records office and supply and kitchen deliveries came through the hall. Staff 1 verified the resident medical records were easily accessible and visible through the window. Staff 1 stated the medical records office … | 2020-09-01 |
| 4918 | 4918 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 157 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to notify a physician of weight loss for 1 of 3 sampled residents (#92) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 92 was admitted in (YEAR) with [DIAGNOSES REDACTED]. Resident 92's 11/10/15 MDS indicated the resident had experienced weight loss in the previous 30 days and was on a diuretic (a medication to reduce the amount of fluid the body) for [MEDICAL CONDITION]. A 11/17/15 Nutritional/Dietary note indicated Resident 92 had significant weight loss related to decreased [MEDICAL CONDITION] and the use of diuretics Resident 92's physician orders [REDACTED]. Resident 92's (MONTH) (YEAR) TAR revealed the resident lost 7.8 pounds between 11/13/15 and 11/14/15. There was no progress note or evidence the facility notified the MD of the 7.8 pound weight loss. On 11/18/15 at 2:39 pm Staff 4 (RN) confirmed the MD wasn't notified of the 7.8 pound weight loss between 11/13/15 and 11/14/15 and acknowledged there was no documentation to indicate the MD had been notified. | 2019-09-01 |
| 4919 | 4919 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 246 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to keep call lights within reach of 1 of 2 sampled residents (#22) reviewed for accommodation of needs. This placed residents at risk for not being able to call for assistance. Findings include: Resident 22 was admitted in (YEAR) with [DIAGNOSES REDACTED]. Resident 22's care plan dated 11/8/15 indicated the resident was able to make her/his needs known. On 11/16/2015 at 10:53 am Resident 22 was observed in bed and the call light was not within reach. On 11/17/15 at 10:24 am, Resident 22 was observed in bed and the call light was, again, not within reach. The resident demonstrated she/he could not reach the call light. Staff 8 (CNA) acknowledged the call light was not within reach and stated a stuffed animal was usually on the end of the call light string in order for the resident to be able to reach and use the call light. | 2019-09-01 |
| 4920 | 4920 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 274 | D | 0 | 1 | 0BOO11 | **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 in condition assessment for 1 of 1 sampled residents (# 56) identified with a change in functional status between the previous comprehensive assessment and most recent quarterly MDS. This placed residents at risk for unmet needs. Findings include: 1. Resident 56 was admitted to the facility in Nov. 2012 with [DIAGNOSES REDACTED]. A review of the Annual MDS dated [DATE] indicated the resident was independent and only needed staff set up for ADL's. The resident was also identified as being continent of bowel and bladder. A review of the most recent quarterly MDS dated [DATE] indicated Resident 56's functional ability declined and required extensive assistance with bed mobility, transfers, locomotion on and off of the unit, and toilet use. Personal hygiene and dressing were changed from supervision to 1 person physical assist. The resident was also identified as occasionally being incontinent. On 11/18/15 at 3:04 pm, Staff 12 (NA) stated the resident was an extensive assist with 1-2 people. On 11/19/15 at 7:50 am, Staff 9 (CNA) stated the resident required 2 person transfer with extensive assistance and needed quite a bit of help with ADLs and dressing. On 11/18/15 at 9:56 am Staff 3 (RNCM) confirmed she had not completed a Significant Change MDS for Resident 56. | 2019-09-01 |
| 4921 | 4921 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 279 | E | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to develop comprehensive care plans related to diabetic management, skin conditions, behaviors and medication management for 4 of 16 sampled residents (# 20, 38, 62 and 70) for whom care plans were reviewed. This placed residents at risk for unmet needs. Findings include: 1. Resident 62 was admitted in early (YEAR) with [DIAGNOSES REDACTED]. The Comprehensive MDS dated (MONTH) (YEAR) indicated the use of insulin daily. The (MONTH) MAR indicated [REDACTED]. The Comprehensive Care Plan dated (MONTH) (YEAR) noted a [DIAGNOSES REDACTED]. On 11/19/15 at 5:30 pm the lack of care planning was reviewed with Staff 3 (RNCM). Staff 3 verified she had not care planned Resident 62's diabetic management. 2. Resident 70 was admitted in late 2014 with [DIAGNOSES REDACTED]. The Annual MDS dated (MONTH) (YEAR) indicated the use of insulin daily. The (MONTH) MAR indicated [REDACTED]. The Comprehensive Care Plan dated (MONTH) (YEAR) noted a [DIAGNOSES REDACTED]. On 11/19/15 at 5:30 pm the lack of care planning was reviewed with Staff 3 (RNCM). Staff 3 verified she had not care planned Resident 62's diabetic management. 3. Resident 20 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. On 6/24/15 the resident had physician orders [REDACTED]. On 8/28/15 the physician ordered Carvediol 3/125 mg twice daily (anti-hypertensive) and on 9/29/15 [MEDICATION NAME] 80 mg daily (a diuretic used to treat hypertension). There were physician directions to hold the [MEDICATION NAME] medication if the resident's systolic blood pressure was less than 90. The resident also had physician orders [REDACTED]. Both medications have the potential side effect of bleeding or hemorrhage. The resident's care plan dated 7/24/15 contained no interventions related to the resident's cardiac or hypertension status, or monitoring the resident for potential complications of bleeding related to t… | 2019-09-01 |
| 4922 | 4922 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 280 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to revise care plans for 3 of 8 sampled residents (#s 38, 56, and 107) who were reviewed for unnecessary medications and ADL needs. This placed residents at risk for unmet needs. Findings include: 1. Resident 38 was admitted in (YEAR) with [DIAGNOSES REDACTED]. Resident 38's Admission MDS dated [DATE] indicated the resident had behaviors of lashing out, hitting and striking out during care. Resident 38's care plan dated 11/8/15 referred staff to a behavior care plan and gave instructions to follow the behavior care plan. On 11/19/15 at 2:24 pm Staff 2 (DNS) confirmed Resident 38's care plan referred to a behavior care plan which no longer existed. On 11/20/15 at 10:13 am Staff 3 (RNCM) confirmed there should have been a behavior care plan as mentioned within Resident 38's care plan. 2. Resident 107 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. The resident's Admission Nursing Transfer summary, signed by the physician, dated 11/11/15, included no transfers, no ambulation, 2 person assist for bed mobility, 1 person assist with eating, and total assist with toileting and dressing. The resident's bedside care plan, dated 11/12/15, indicated the resident was alert, oriented, forgetful, non-ambulatory, and at risk for falls. The resident needed 2 person assist with hoyer lift transfers, bed mobility, dressing, and bathing. The resident's bedside care plan did not identify the resident's pelvic fracture or restrictions related to her/his pelvic fracture. On 11/16/15 at 12:13 pm the resident was observed uncovered and wearing only a gown top in bed with her/his legs exposed. The resident had a facial rash, dry leg skin, long hair and long fingernails. The resident was able to move her/his feet and ankles but unable to move her/his hips. On 11/19/15 at 10:20 am Staff 5 (CNA) stated the resident did not get out of bed. Staff 5 verified the care … | 2019-09-01 |
| 4923 | 4923 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 309 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to coordinate care to meet the needs of a resident receiving [MEDICAL TREATMENT] for 1 of 1 sampled residents (#65) for whom [MEDICAL TREATMENT] services were reviewed. This placed residents at risk for unmet [MEDICAL TREATMENT] needs. Findings include: 1. Resident 65 was admitted in late 2013 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated the resident was receiving [MEDICAL TREATMENT] services. The Comprehensive Care Plan dated 9/28/15 noted a problem statement for [MEDICAL TREATMENT] with interventions for fistula management and dressing changes. The Bedside Care Plan dated 11/16/15 indicated the resident was receiving [MEDICAL TREATMENT] three days a week, a specialized diet and fluid restrictions, monitoring of fistula site and restrictions for blood pressures on right arm. Review of the medical record found no information pertaining to emergency contact for the [MEDICAL TREATMENT] unit, location, phone number, transport company and it's number or the times for [MEDICAL TREATMENT]. On 11/20/15 at 11:00 am the lack of information in the medical record related to coordination of care and emergency contact information was reviewed with Staff 3 (RNCM). Staff 3 confirmed the information could not be located. | 2019-09-01 |
| 4924 | 4924 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 314 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to prevent skin breakdown for 1 of 3 sampled residents (#89) reviewed for pressure ulcers. As a result the resident developed a pressure ulcer. This placed residents at risk for skin breakdown. Findings include: Resident 89 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. The Nursing Admission Screening/History dated 7/16/15 indicated the resident was admitted with surgical wounds and had no other wounds or pressure ulcers. The resident's 7/16/15 bedside care plan indicated the resident had surgical wounds, transferred with one person assist, used a walker for ambulation, and had bilateral bed side rails. The comprehensive assessment dated [DATE] identified the resident's was at a low risk for skin breakdown with no pressure wounds or skin breakdown, and with functional limitation in range of motion. The facility's interventions included weekly skin audits, place a pressure relieving bed mattress, and a pressure relieving chair cushion. On 7/23/15 the bedside care plan was updated to indicate the resident was non-ambulatory, directed staff to use a gait belt for transfers but did not identify the resident's use of a wedge cushion. On 7/29/15 the bedside care plan was updated to include the resident's use of a single point cane and to be non-weight bearing on her/his left shoulder but did not identify the resident's use of a wedge cushion. On 8/5/15 at 9:47 am Wound-weekly Observation Tool indicated the resident had acquired a 13 mm x 10 mm (1.3 cm x 1.0 cm ) Stage 1 ( intact skin with non-blanchable redness) coccyx pressure ulcer on 8/4/15. The tool indicated the resident had a pressure relieving mattress and chair cushion but did not identify the use of a wedge cushion. On 8/5/15 at 10:41 am a Nursing wound progress note written by Staff 4 (RN) indicated the resident had an open area to her/his coccyx/buttock. The resident was admitted with a wedge in… | 2019-09-01 |
| 4925 | 4925 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 322 | D | 0 | 1 | 0BOO11 | **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 care and treatment of [REDACTED].#51) reviewed for feeding tube management. This placed the resident at risk for aspiration. Finding include: Resident 51 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. The resident's admission tube feeding orders were for [MEDICATION NAME] 1.5 at 110 mls twelve hours a day and 240 ml additional water flushes every four hours. On 10/6/15 Staff 10 Registered Dietician (RD) identified the resident was receiving more water than needed and recommended to reduce the water flushes to 120 ml every fours hours for a total of 1800 ml per day. Staff 10 planned to continue to monitor tube feeding tolerance. Review of the resident's progress notes and physician orders [REDACTED]. The 10/9/15 Hydration CAA indicated the resident was working with Speech Therapy for PEG ( a tube passed into a person's stomach through the abdominal wall) tube feedings at a slow rate due [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) and the resident's risk for bottom-up aspiration. The resident's head of the bed was to be upright at 30 degrees at all times. On 11/18/15 a sign was noted in the resident's room that indicted the resident was at risk for aspiration of secretions and bolus feeding and directed the resident to be upright at least 30 degrees at all times of rest and upright at 70-90 degrees with a slow rate for PE[DEVICE] continuous feeding due to history of GERD. On 11/19/15 at 8:30 am the resident was observed in bed. The head of the bed was elevated but the resident had slid down in the bed so that her/his head was the only body part elevated and not her/his torso or chest. Staff 11 (LPN) was observed to administer the resident's medications and a total of 790 mls of water (more than three times the amount ordered) without repositioning the resident. On 11/19/15 at 2:10 pm Staff 14 (Speech The… | 2019-09-01 |
| 4926 | 4926 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 325 | D | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to prevent and treat weight loss for 1 of 4 sampled residents (#89) reviewed for nutrition. As a result the resident sustained [REDACTED]. This placed residents at risk for weight loss. Findings include: Resident 89 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. On admission the resident weighed 193 pounds, had a left arm cast in place, and received a regular diet. On 7/21/15 a Registered Dietician (RD) assessment indicated the resident weighed 192 pounds and the plan was to continue with the current diet plan and no changes were recommended. On 7/23/15 the resident's Admission MDS indicated the resident weighed 193 pounds and was not at risk for weight loss. The Nutritional CAA indicated the facility would weigh the resident every week and the RD was to evaluate the resident and make recommendations. On 7/26/15 weekly weights were initiated when the resident weighed 181.6 pounds for a 5.0% weight loss. The nursing progress notes for 7/28/15 indicated the resident's left upper extremity cast was still in place after the resident's 5% weight loss. There was no evidence the facility identified the 5% weight loss occurred before the removal of the left upper extremity cast. On 11/19/15 at 4:30 pm Staff 3 (RNCM) verified the resident's weight loss started before the removal of the cast. She verified there were no diet changes or new nutritional interventions initiated when the 5% weight loss occurred. | 2019-09-01 |
| 4927 | 4927 | BAYCREST HEALTH CENTER | 385039 | 3959 SHERIDAN AVENUE | NORTH BEND | OR | 97459 | 2015-11-20 | 332 | E | 0 | 1 | 0BOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review it was determined the facility failed to ensure a medication error rate of less than 5%. This placed residents at risk for subtherapeutic medication levels and side effects. Findings include: 1. On 11/19/15 at 8:28 am Staff 11 (LPN) was observed to pour Resident 51's liquid [MEDICATION NAME] (an [MEDICAL CONDITION] medication) into a medication cup that was not marked to indicate the exact ordered dose. The resident's physician order [REDACTED]. 2. On 11/19/15 at 8:28 am Staff 11 was also observed to crush one [MEDICATION NAME] 324mg [MEDICATION NAME] coated tablet for Resident 51. The [MEDICATION NAME] container was labeled do not crush. The resident's physician order [REDACTED]. On 11/19/15 at 9:30 am Staff 11 verified she poured an approximate amount of [MEDICATION NAME] and not the exact dose. Staff 11 verified the [MEDICATION NAME] was labeled to not crush and that she did not follow medication directions. | 2019-09-01 |
| 8928 | 8928 | AVAMERE REHABILITATION OF KING CITY | 385132 | 16485 SW PACIFIC HIGHWAY | TIGARD | OR | 97224 | 2011-08-29 | 323 | G | 1 | 0 | 0CYX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to notify nursing timely when a resident experienced falls or follow care planned interventions for 2 of 3 sampled residents (#s 2 & 3) reviewed for falls. Resident 2 sustained a fracture as a result of the falls. Findings include: 1. Resident 2 was admitted to the facility in 2/2007 and had [DIAGNOSES REDACTED]. The resident was care planned for one person, extensive assistance with transfers. An 8/7/11 incident report revealed Staff 12, CNA, reported toileting the resident after lunch. When Staff 12 transferred the resident off the toilet, the resident reported "my knee popped." Staff 12 guided the resident to the floor with the gaitbelt. Staff 12 reported Staff 10, CMA, came in to help lift the resident back on the toilet and then to the wheelchair, followed by Staff 11, CNA, assisted the resident back to bed. Staff 5, LPN, was notified of the incident and found the resident in bed. The resident's knee was assessed, there was no swelling, redness or bruising. The resident had no complaints of pain at that time, however, when Staff 5, asked the resident what had happened, the resident stated "I felt my knee pop when she was transferring me and its sore". The 8/7/11 6:45 pm Interdisciplinary Progress Note disclosed the resident complained of 10 out of 10 level pain in the left knee, and swelling and purple bruising were noted to the inside aspect of the knee. The physician was contacted and the resident was sent to the hospital. The 8/7/11 hospital records revealed the resident was accidentally dropped during a transfer during toileting, landing directly on the left knee. The resident had severe pain with the left knee. The resident was found to have a fracture of the tibia and fibula. Per the facility's 8/16/11 summary of the fall investigation, after reviewing the hospital records, the investigation was re-opened. The facility determined that two separa… | 2014-12-01 |
| 8929 | 8929 | AVAMERE REHABILITATION OF KING CITY | 385132 | 16485 SW PACIFIC HIGHWAY | TIGARD | OR | 97224 | 2011-08-29 | 281 | G | 1 | 0 | 0CYX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to notify nursing timely when a resident experienced falls for 1 of 3 sampled residents (# 2) reviewed for falls. Resident 2 sustained a fracture as a result of the falls. Findings include: Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides Conduct Unbecoming a Nursing Assistant 851-063-0090 A CNA, regardless of job location, responsibilities, or use of the title "CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (2) Conduct related to other federal or state statutes/rule violations: (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (3) Conduct related to communication: (a) Inaccurate recordkeeping in client or agency records; (c) Falsifying a client or agency record; including but not limited to filling in someone else's omissions, signing someone else's name, recording care not given, fabricating data/values; (g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner. Resident 2 was admitted to the facility in 2/2007 and had [DIAGNOSES REDACTED]. The resident was care planned for one person, extensive assistance with transfers. An 8/7/11 incident report revealed Staff 12, CNA, reported toileting the resident after lunch. When Staff 12 transferred the resident off the toilet, the resident reported "my knee popped." Staff 12 guided the resident to the floor with the gaitbelt. Staff 12 reported Staff 10, CMA, came in to help lift the resident back on the toilet and then to the wheelchair, followed by Staff 11, CN… | 2014-12-01 |
| 8930 | 8930 | AVAMERE REHABILITATION OF KING CITY | 385132 | 16485 SW PACIFIC HIGHWAY | TIGARD | OR | 97224 | 2011-08-29 | 309 | D | 1 | 0 | 0CYX11 | **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 orders [REDACTED].#3) reviewed for medication administration. Findings include: Resident 3 was admitted to the facility in 8/2011 with [DIAGNOSES REDACTED]. The 8/3/11 hospital discharge orders included [MEDICATION NAME] 150 mg, one tablet at bedtime. The 8/8/11 signed recapped physician's orders [REDACTED]. The 8/2011 Medication Administration Record [REDACTED]. In interviews on 8/22/11 at 12:47 pm, Staff 8, RNCM, checked the medication cart and stated the resident received 150 mg. Staff 8 stated she would clarify the dosage with the physician. On 8/23/2011 at 8:30 am, Staff 8 stated the resident had been given the wrong dosage of [MEDICATION NAME]. The physician currently ordered for the resident to receive 50 mg of [MEDICATION NAME]. | 2014-12-01 |
| 5818 | 5818 | PRESTIGE CARE AND REHABILITATION - MENLO PARK | 385044 | 745 NE 122ND AVENUE | PORTLAND | OR | 97230 | 2015-10-01 | 309 | G | 1 | 0 | 0DEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to respond to a change in condition and inform/follow up with physicians in a timely manner, complete alert charting, follow physician orders, review/revise an ineffective pain management program and assess and track wounds for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 & 6) reviewed for changes in condition and skin breakdown. Residents 1, 2, 3, 4, 5 and 6 were at risk for continued decline in conditions and worsening skin breakdown. Resident 2 experienced prolonged, unaddressed pain. Findings include: The facility's Policy and Procedure for Skin At Risk/Skin Breakdown included: Upon discovery of newly identified skin impairment .the Licensed Nurse will document skin impairment that includes measurements of size, color, presence of odor and exudates (fluid). Document presence of pain associated with the skin impairment. 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 Skim Impairment .Weekly Wound Rounds are to be completed by a team consisting of the Director of Nursing Services (DNS)/Designee and Resident Care Manager's (RCM's). Arterial, Pressure, Status, Venous Ulcers and Surgical Wounds are to be assessed, measured and documented on the Skin Grid . 1. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. a. The 4/2015 and 5/2015 physician orders [REDACTED]. [MEDICATION NAME] was to be applied to the left heel wound at dressing changes. Staff were directed to administer pain medication 20-30 minutes prior to changing dressings, once daily. The 4/1/15 at 11:35 pm Progress Note disclosed Resident 2 reported being in a lot of pain as a result of dressing changes done that day. The 4/2/15 Wound physician progress notes [REDACTED]. The physician noted the res… | 2018-10-01 |
| 5819 | 5819 | PRESTIGE CARE AND REHABILITATION - MENLO PARK | 385044 | 745 NE 122ND AVENUE | PORTLAND | OR | 97230 | 2015-10-01 | 314 | D | 1 | 0 | 0DEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to investigate causative factors for the development of pressure ulcers, contact the physician for treatment orders, follow physician orders [REDACTED].#s 5 & 6) reviewed for pressure ulcers. This placed Residents 5 & 6 at risk of worsening wounds and developing additional wounds. Findings include: The facility's Policy and Procedure for Skin At Risk/Skin Breakdown included: Upon discovery of newly identified skin impairment .the Licensed Nurse will: document skin impairment that includes measurements of size, color, presence of odor and exudates (fluid) 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 Skim Impairment .If the new skin impairment is noted after admission . the Licensed Nurse/RCM will: Review Skin Risk and evaluate current interventions for effectiveness .The Resident Care Manager and or designee will complete a comprehensive review of the resident's medical record to asses if the Pressure ulcer was avoidable or unavoidable .Weekly Wound Rounds are to be completed by a team consisting of the Director of Nursing Services (DNS)/Designee and Resident Care Manager's (RCM's). Arterial, Pressure, Status, Venous Ulcers and Surgical Wounds are to be assessed, measured and documented on the Skin Grid . 1. Resident 5 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 8/2015 Care Plan noted keep bony prominences from direct contact with one another with pillows and staff were directed to place a cushion/pillow between Resident 5's legs. The 8/3/15 at 12:40 am Progress Note revealed Resident 5 was found to have 3 dime size sores and 1 smaller sore on right tibia and 1 on left leg where the legs cross each other. The correlating Skin Grid For Pressure, Venous, … | 2018-10-01 |
| 5820 | 5820 | PRESTIGE CARE AND REHABILITATION - MENLO PARK | 385044 | 745 NE 122ND AVENUE | PORTLAND | OR | 97230 | 2015-10-01 | 319 | D | 1 | 0 | 0DEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain mental health services, assess refusals of care, monitor behaviors and follow identified mental health interventions for 1 of 3 sampled residents (#2) reviewed for depression. Resident 2 did not receive mental health services when she/he exhibited an increase in depression and refused care that jeopardized her/his health. Findings include: Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 3/26/15 at 12:16 pm Social Services Progress Note indicated Resident 2 discussed her/his new plan and stated Things are getting better and was seen in the hallway chatting with others. The 4/2015 and 5/2015 Physician order [REDACTED]. The 4/2015 and 5/2015 MARs documented Resident 2 received the three antidepressant medications. The 4/2/15 Wound physician progress notes [REDACTED]. The physician noted the resident had improved compliance with dressing changes and offloading and the nutritional status seemed to be steadily improving given healing at that time. The 4/9/15 Wound physician progress notes [REDACTED]. Wounds were described as mostly showing slow steady improvement. The physician noted should work on getting a better handle on the resident's pain control. The 4/23/15 Wound physician progress notes [REDACTED]. The resident felt a little more upbeat, though still lapsed between frustration and joking regarding the infection leading to death. The wounds continued to mostly show some mild improvement and the resident's nutritional status had improved significantly, allowing a referral to plastic surgery. The 5/7/15 at 4:06 pm Progress Note disclosed Resident 2 was noted to have maggots in the right lateral leg wound. Wounds appear to be getting worse because pt (patient) has denied wound care so many times the past month. PT refusing to be repositioned .refusing supplemental nutrition . Resident 2 stated she/he no longer wanted to be treate… | 2018-10-01 |
| 6771 | 6771 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2014-08-05 | 323 | D | 1 | 0 | 0DT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews it was determined the facility failed to provide an environment to prevent accidents for 1 of 3 sampled residents (#1). This placed the resident at risk for injury. Findings include: Resident 1 was admitted to the facility in May 2014 with [DIAGNOSES REDACTED]. The 6/11/14 Occupational Therapy initial assessment indicated the resident needed 25 percent hands on assist Stand pivot from chair to commode. CNA reports the resident needs stabilization assist occasionally when short of breath and when getting out of swivel recliner The 6/23/14 Occupational Therapy note indicated it was difficult (for the resident) to get out of recliner chair until OT stabilized it On 7/16/14 at 2:30 pm Staff 6 (CNA) stated he was assigned to care for Resident 1 on a consistent basis. Staff 6 stated the resident needed to have the assistance of one CNA for transfers. Staff 6 stated the resident would not use the call light and would transfer by herself/himself at least one to two times a shift. Staff 6 was not able to remember the recliner the resident had in her/his room. On 7/16/14 at 2:55 Staff 4 (RN) stated the resident required the assistance of one CNA for transfers though the resident would transfer independently from her/his recliner to the commode. On 7/16/14 at 3:30 pm Staff 5 (Maintenance Director) stated he was not aware of swivel recliners used in the facility. On 7/17/14 at 12:28 pm Staff 13 (Occupational Therapist/OT) was asked about the 6/11/14 assessment of Resident 1's swivel recliner. Staff 13 stated she remembered seeing the swivel recliner in the facility. Staff 13 indicated the swivel recliner was in the facility on the 100 hallway. The recliner was observed to be a rocking, swivel recliner. Staff 13 stated a swivel recliner was probably not a good choice for a resident who required the assistance of one to transfer and when the resident transferred independently. On 7/17/14 at 12:40 pm Staf… | 2017-08-01 |
| 6772 | 6772 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2014-08-05 | 325 | D | 1 | 0 | 0DT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews it was determined the facility failed to consistently assess unplanned weight gain and [MEDICAL CONDITION] for 1 of 1 sampled residents (#1). This placed the resident at risk for unmet needs. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was in the local hospital from 5/1/14 through 5/5/14 and the resident's weight on 5/5/14 was 236 pounds. The resident returned to the local hospital on [DATE] with a weight of 242 pounds. On 5/12/14 the local hospital documented the resident's weight on discharge was 219 pounds. There was no documentation the resident had bilateral lower extremity [MEDICAL CONDITION]. The physician ordered 80 mg of [MEDICATION NAME] (medication for fluid retention) daily. The local hospital transfer form indicated the resident was on a no added salt diet. The facility's undated weight policy and procedures indicated the facility was to utilize weights as one significant component of data collection needed to assess residents nutritional status, fluid retention or diuresis. New admits were weighed the day of admission then weekly for one month. Any weight with a 5 pound variance or a significant weight gain or loss in a 30 day period .If variance is actual after reweigh, the nurse documents in the medical records, revises the care plan as needed, refers to Nutrition Committee and notifies the physician, resident or responsible party The 5/12/14 facility's weight record documented Resident 1 weighed 218 pounds. The 5/12/14 Interdisciplinary Progress Notes (IPN) did not document the resident had [MEDICAL CONDITION] of her/his bilateral lower extremities. There was a 5/13/14 physician's orders [REDACTED]. The 5/15/14 Registered Dietitian (RD) initial assessment indicated the facility obtained a clarification of the physician's orders. The physician indicated the resident's current diet was correct. The 5/20/14 weight record indica… | 2017-08-01 |
| 6517 | 6517 | THE DALLES HEALTH AND REHABILITATION CENTER | 385172 | 1023 W. 25TH STREET | THE DALLES | OR | 97058 | 2014-12-19 | 157 | D | 1 | 0 | 0EO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to notify an interested family member in a timely manner for 2 of 5 sampled residents (#s 2 & 3) reviewed for notification of changes. This placed Resident 2's and Resident 3's family members at risk for lack of involvement in care. Findings include: 1. Resident 2 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. An 8/14/14 Fax to the physician noted Resident 2 reported she/he may have had a [MEDICAL CONDITION]. An 8/17/14 Nurse's Note disclosed Resident 2 reported another possible [MEDICAL CONDITION]. At the time of the 12/19/14 survey, there was no documented evidence in the clinical record the resident's family was notified after the resident reported possible [MEDICAL CONDITION]. In interview on 12/18/14 at 3:14 pm Staff 2, DNS stated Resident's 2's family should have been notified regarding the possible [MEDICAL CONDITION]. 2. Resident 3 was admitted to the facility in 2001 with [DIAGNOSES REDACTED]. 11/26/14 Nurse's Notes indicated Resident 3 was diagnosed with [REDACTED]. At the time of the 12/19/14 survey, there was no documented evidence in the clinical record the resident's family was notified of the [DIAGNOSES REDACTED]. In interview on 12/17/14 Staff 2, DNS stated Resident 3's family should have been notified of the resident's [DIAGNOSES REDACTED]. | 2017-12-01 |
| 6142 | 6142 | AIDAN SENIOR LIVING AT REEDSPORT | 385164 | 600 RANCH ROAD | REEDSPORT | OR | 97467 | 2014-11-21 | 253 | E | 0 | 1 | 0FBU11 | Based on observation and interview it was determined the facility failed to ensure a sanitary environment was maintained for 8 of 16 current residents. This placed residents at risk for complications in health status. Findings include: 1. On 11/19/14 at 12:05 pm there was a uncovered dusty suction canister observed in the facility's clean utility room. Staff 1 (DNS) stated it would not take long to clean it if a resident needed suctioning and she assigned a staff member to clean it. 2. A tour of the facility on 11/19/14 at 2:15 pm revealed: Resident rooms 118, 126, 129 and 130; uncleanable foam padding on the bed rails. Room 126: an uncovered uncleanable foam pad on a chair and on the chair arm. Room 127: toilet seat riser with exposed uncleanable foam on the arm rests in the restroom. Room 128: torn piece of exposed uncleanable foam on the grab bar in the restroom. On 11/19/14 at 2:25 pm Staff 4 (Administrator) stated he was unaware the foam padding was considered an uncleanable surface and he would follow-up on the issue. | 2018-05-01 |
| 6143 | 6143 | AIDAN SENIOR LIVING AT REEDSPORT | 385164 | 600 RANCH ROAD | REEDSPORT | OR | 97467 | 2014-11-21 | 309 | D | 0 | 1 | 0FBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to administer medication per physician orders [REDACTED]. Findings include: 1. Resident 21 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of the resident's November 2014 MAR indicated [REDACTED]. Resident 21's 11/3/14 Laboratory Patient Results Report revealed the resident's TSH ([MEDICAL CONDITION] stimulating hormone) was elavated indicating the resident did not have enough [MEDICAL CONDITION] hormone in the resident's body. A fax dated 11/11/14 to the resident's physician indicated the resident's TSH was elevated and the resident was currently administered 75 mcg of [MEDICATION NAME]. The note requested orders to increase the [MEDICATION NAME] dose or to keep the medication dose the same and recheck the TSH level in 12 weeks. The physician responded to Increase [MEDICATION NAME] to 75 mcg daily. Recheck TSH in 3 months. The resident was already prescribed 75 mcg of [MEDICATION NAME]. On 11/18/14 at 3:11 pm and 4:21 pm Staff 1 (DNS/RNCM) acknowledged Resident 21's physician fax response did not increase the resident's [MEDICATION NAME] dose to 75 mcg because the resident was already administered 75 mcg each day. Staff 1 stated the fax should have be clarified upon receipt before it was filed in the chart. 2. Resident 95 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The resident's 7/25/14 Physician order [REDACTED]. Review of the 7/25/14 Admission Nursing Assessment, the 7/28/14 Medical Nutrition Therapy Assessment and the 8/20/14 physician progress notes [REDACTED]. Review of the resident's July and August 2014 MAR indicated [REDACTED]. On 11/19/14 at 11:36 am Staff 2 (LPN) stated Resident 95 had [MEDICAL CONDITION] to the legs, wore support hose and elevated the legs to decrease the [MEDICAL CONDITION]. On 11/18/14 at 4:24 pm Staff 1 (DNS/RNCM) acknowledged the resident was to be administered PRN [MEDICATION NAME] and potass… | 2018-05-01 |
| 6144 | 6144 | AIDAN SENIOR LIVING AT REEDSPORT | 385164 | 600 RANCH ROAD | REEDSPORT | OR | 97467 | 2014-11-21 | 323 | D | 0 | 1 | 0FBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure bed rails were securely placed for 2 of of 3 sampled residents (#s 16 and 21) reviewed for accidents. This placed residents at increased risk for injury. Findings include: 1. Resident 21 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Observation on 11/19/14 at 8:13 am revealed bilateral mobility bars on the resident's bed were loose and moved approximately three inches away from the bed when pressure was applied. On 11/19/14 at 11:29 am Staff 3 (Plant Operations Manager) acknowledged Resident 21's bed rails were loose. Staff 3 stated if resident rails were loose, staff were to call him and he would tighten the rails. Staff 3 stated he was not informed Resident 21's bed rails were loose and would secure the mobility bars. 2. Resident 16 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Observations on 11/19/14 at 2:25 pm revealed the bilateral mobility bars on the resident's bed were loose and moved approximately two inches away from the bed when pressure was applied. On 11/19/14 at 3:00 pm Staff 3 (Plant Operations Manager) indicated he was unaware Resident 16's bed rails were loose, staff were to contact him if there were loose rails and he would secure the mobility bars as soon as possible. | 2018-05-01 |
| 6145 | 6145 | AIDAN SENIOR LIVING AT REEDSPORT | 385164 | 600 RANCH ROAD | REEDSPORT | OR | 97467 | 2014-11-21 | 465 | E | 0 | 1 | 0FBU11 | Based on observation and interview it was determined the facility failed to ensure door surfaces, wall surfaces, flooring and furnishings were maintained in 8 of 18 resident rooms. This placed residents at risk for injury from rough surfaces. Findings include: On 11/19/14 at 2:15 pm a tour of the facility revealed: Room 119: yellow insulation material on a bathroom wall was exposed. Resident rooms 121, 125, 127, 128, 129 and 130: rough door surfaces. Dining room: rough surface on hallway doors; two chairs with cracked vinyl and exposed foam. Room 130: bent window blinds and a broken slat. Room 123: cracked vinyl chair seat covered with duct tape. Room 128: no floor tile near the threshold of the restroom. On 11/19/14 at 2:55 pm Staff 3 (Plant Operation Manager) acknowledged several resident room doors, walls, flooring and furniture needed to be repaired. Staff were to let him know of maintenance problems and staff 3 was not informed of the problems. | 2018-05-01 |
| 8959 | 8959 | HOOD RIVER CARE CENTER | 385104 | 729 HENDERSON ROAD | HOOD RIVER | OR | 97031 | 2011-07-27 | 281 | G | 1 | 0 | 0FG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to follow professional standards for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a left [MEDICAL CONDITION]. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] (6) (d) Follow the care plan as directed by the licensed nurse; (f) Tasks associated with safety; (B) Apply preventive/supportive/protective strategies or devices when working with a person with dementia. Conduct Unbecoming a Nursing Assistant [PHONE NUMBER] (2) (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant. Resident 1 was admitted to the facility in late January 2011 with [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-[MEDICAL CONDITION] agents) for polymyalgia rheumatica and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in lowest position and mats on both sides of the bed. Review of the resident's clinical record revealed a history of falls from her/his wheelchair. The care plan was updated on 6/24/11 and included, "Do not leave the resident alone when in the W/C (wheelchair)." An IR (Incident Report) on 7/15/11 revealed the resident was placed in a shower chair and taken to the shower area in the ba… | 2014-11-01 |
| 8960 | 8960 | HOOD RIVER CARE CENTER | 385104 | 729 HENDERSON ROAD | HOOD RIVER | OR | 97031 | 2011-07-27 | 323 | G | 1 | 0 | 0FG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to proved the necessary supervision for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a left hip fracture. Findings include: Resident 1 was admitted to the facility in late January 2011. Admitting [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-inflammatory agents) for polymyalgia rheumatica and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in lowest position and floor mats on both sides of the bed. Review of the resident's clinical record revealed a history of a fall from her/his wheelchair. The care plan was revised on 6/24/11 and included, "Do not leave the resident alone when up in the W/C (wheelchair)." An IR (Incident Report) on 7/15/11 revealed the resident was placed in a shower chair and taken to the shower area in the bathroom in her/his room by Staff 2, CNA. Staff 2 noticed a puddle of urine just outside the bathroom door. The IR revealed Staff 2 reached for paper towels and placed them on the urine outside of the bathroom and wiped the floor with her foot. Staff 2 reported she heard a thump and found the resident on the floor against the shower wall and on her/his left side. The documented conclusion of the facility investigation related to the incident revealed, "Aide made an error in judgment by turning away to wipe up fluid on the floor when with high risk patient." The IR revealed Staff 4, RN, assessed the resident and the resident was transported to a local hospital ER. Hospit… | 2014-11-01 |
| 3380 | 3380 | AVAMERE REHABILITATION OF HILLSBORO | 385251 | 650 SE OAK STREET | HILLSBORO | OR | 97123 | 2019-07-15 | 550 | D | 1 | 1 | 0FNT11 | > Based on observation and interview it was determined the facility failed to provide a dignified dining experience for the dinner meal for 1 of 1 dining halls observed for dining. This placed residents at risk for a decrease in their quality of life. Findings include: On 7/12/19 at 5:32 PM to 6:25 PM, while in the 200 hall dining room, the following dinner meal observations were made: -The medication cart was stationed outside of the dining room. A staff member's personal cell phone was playing music (70's rock) and at the same time the dining room television was on at a medium volume level. While standing in the dining room, the music and TV station could be heard and the combination of both sounds interfered with each other and created an unpleasant and loud environment. - At 6:02 PM, Staff 15 (CNA) began to assist Resident's 17 and 32 with their meal. Staff 15 stood over Resident 17 and 32 and went from one resident to the other resident assisting them with their meal. Staff 15 continued to stand over each resident until the completion of their meal at approximately 6:25 PM. - From 6:07 PM to 6:19 PM, while Staff 15 (CNA) was in the dining room and another staff member periodically entering and leaving the dining room, left Resident 25 sitting at a table with food dribbling down her/his chin without assisting the resident with cleaning Resident 25's chin. In interviews on 7/11/19 at 6:39 PM and 6:48 PM, Staff 16 (CNA) and Staff 17 (CNA) stated it was very difficult to assist all residents with only one staff in the 200 hall dining room. Staff 16 stated she had to go from one resident to another resident to assist with their meal and this was very difficult. Staff 16 stated there was supposed to be a staff member from other halls to help but this did not happen. Staff 17 stated you can not have one staff in the dining room, you have to hurry residents and this was criminal. In an interview on 7/12/19 at 6:30 PM, Staff 15 (CNA), when asked why she stood to assist Resident 17 and 32 with their meal, stated it is… | 2020-09-01 |
| 3381 | 3381 | AVAMERE REHABILITATION OF HILLSBORO | 385251 | 650 SE OAK STREET | HILLSBORO | OR | 97123 | 2019-07-15 | 582 | D | 1 | 1 | 0FNT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to inform residents of the charges for services not covered under Medicare for 1 of 1 sampled residents (#52) who used transportation services. Resident 52 was not able to make an informed financial decision as a result, and all medicare residents were placed at risk for incurring undue costs. Findings include: The facility's admission packet directed residents to the Resident Handbook for information on services not covered under Medicare. The facility's Resident Handbook contained examples of services that may not be covered under Medicare, but did not include information what the associated charges were. Resident 52 admitted to the facility in 6/2019 with a [MEDICAL CONDITION] (the diversion of the colon through the abdomen) and pressure ulcers. On 6/17/19, Resident 52 was transported to the emergency department to have the [MEDICAL CONDITION] evaluated. On 7/9/19 at 10:01 AM, Resident 52 reported she/he went to the emergency department because of concern there was a complication developing with the [MEDICAL CONDITION]. Resident 52 stated different options were provided for transportation, but not the associated costs. Resident 52 chose to transport via stretcher in an ambulance because of the pressure ulcers and later received a bill for over $1000. Resident 52 then learned the other modes of transportation were approximately $80 or $5 and stated she/he would have chosen one of those if the information was available. On 7/12/19 at 10:43 AM, Staff 19 (LPN) reported she would talk to residents or family about transportation options, depending on the situation. When asked about the costs, Staff 19 stated she was not personally responsible for that information, but would go to the business office. On 7/12/19 at 11:00 AM, Staff 9 (RNCM) reported the receptionist made the appointments and talked with the resident or family about transportation options. On 7/12/19 at 1… | 2020-09-01 |
| 3382 | 3382 | AVAMERE REHABILITATION OF HILLSBORO | 385251 | 650 SE OAK STREET | HILLSBORO | OR | 97123 | 2019-07-15 | 679 | D | 1 | 1 | 0FNT11 | **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 person-centered activity program for 3 of 5 sampled residents (#s 30, 36 and 54) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: The 7/2019 Activity Calendar revealed the following: Monday through Fridays revealed five to six planned activities per day; Saturday 7/6/19 first come first serve computer access. At 1:30 PM and 7:00 PM family games. Saturday 7/13/19 at 10:00 AM Native American flute and guitar. The activities director was on vacation. Sundays: 7/7/19 and 7/14/19 revealed 2:00 PM church service and computer access. At 1:30 PM and 7:00 PM family games. 1. Resident 30 was readmitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. The 5/2019 MDS revealed the resident had moderate cognitive impairments and required cues and supervision. The revised 5/2019 Care Plan revealed the following: -Non-contributory in group activities; -Invite to activities of interest with a daily flyer; -Was an avid reader, enjoyed history, books, movies and puzzles. The resident disliked group activities and wished to be independent in her/his room with activities of choice; -Offer and arrange in room activities of choice, provide an activity calendar and provide in room materials, as indicated. On 7/8/19 2:04 PM and 7/10/19 at 8:09 AM, Resident 30 was observed in bed with her/his eyes open with no stimulation or activities. In an interview on 7/12/19 at 1:11 PM, Staff 3 (CNA) stated there was no set person on weekends. If the residents were bored on weekend staff could take the resident outside but that was only if staff had time. In an interview on 7/12/19 at 1:42 PM, Staff 4 (LPN) stated during the weekends staff did not plan activities because families often visited. In an interview on 7/12/19 at 1:45 PM, Staff 5 (LPN) stated staff tried to keep residents occupied when time allowed but there … | 2020-09-01 |
| 3383 | 3383 | AVAMERE REHABILITATION OF HILLSBORO | 385251 | 650 SE OAK STREET | HILLSBORO | OR | 97123 | 2019-07-15 | 868 | C | 1 | 1 | 0FNT11 | > Based on interview and record review it was determined the facility failed to ensure the medical director and/or designee attended the facility's quarterly Quality Assurance Performance Improvement (QAPI) committee meetings. This placed residents at risk for an ineffective QAPI program to address and resolve identified quality of life and quality of care issues. Findings include: The facility's QAPI policy and procedures noted This facility shall develop, implement and maintain an ongoing program designed to monitor, evaluate the quality of resident care, pursue methods to improve quality care and to resolve identified problems. The committee membership will include the following individuals to serve on the committee: Administrator, Director of Nursing Services, Medical Director .and the committee will meet quarterly . In interviews on 7/15/19 at 3:30 PM and 4:32 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the facility meets quarterly and invited the medical director to the facility's QAPI meetings. Staff 1 stated the facility's medical director does not have the best attendance. When asked when was the last time the facility's medical director attended, Staff 2 stated the last time the medical director and/or designee attended was in 12/2018. Staff 1 confirmed the medical director's designee has not been at the facility's QAPI meetings for awhile and stated we need to do better in having the medical director and/or designee attend. | 2020-09-01 |
| 3384 | 3384 | AVAMERE REHABILITATION OF HILLSBORO | 385251 | 650 SE OAK STREET | HILLSBORO | OR | 97123 | 2019-07-15 | 880 | D | 1 | 1 | 0FNT11 | > Based on observation, interview and record review, it was determined the facility failed to ensure staff disinfected common use glucometers (a device used to obtain blood glucose levels) for 2 of 3 staff (#s 18 and 19) observed performing CBG tests. This placed residents at risk for infection. Findings include: The facility's current Blood Sampling - Capillary (Finger Sticks) policy directed staff to use an approved EPA registered disinfectant for cleaning the glucometer after each use and before returning it to the treatment cart. The operator's manual for the glucometer emphasized the importance of disinfecting it after use with an approved disinfected wipe. On 7/12/19 at 7:46 AM, Staff 18 (LPN) was observed using a common use glucometer to perform a CBG test for Resident 163. Upon completion, Staff 18 proceeded to clean the glucometer with an alcohol wipe. Staff 18 reported either an alcohol wipe or the approved wipes provided on the cart could be used to disinfect the glucometer. On 7/12/19 at 11:43 AM, Staff 19 (LPN) was observed using a common use glucometer to perform a CBG test for Resident 164. Staff 19 proceeded to put the glucometer back into the treatment cart drawer without disinfecting it. When asked, Staff 19 reported she was instructed to use the approved wipes located on the cart to disinfect the glucometer. On 7/12/19 at 12:18 PM, Staff 20 (Regional Nurse Consultant) reported staff were directed to use the approved wipes provided on the treatment carts to clean the glucometers after use. Staff 20 confirmed Staff 18 and Staff 19 did not clean the glucometers according to facility policy and manufacturer's instructions. | 2020-09-01 |
| 1498 | 1498 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 584 | D | 0 | 1 | 0GGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to keep a resident room in good repair for 1 of 1 sampled resident (#27) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: Resident 27 was admitted to the facility in (YEAR) with a [DIAGNOSES REDACTED]. The 5/1/19 Quarterly Nursing Assessment indicated Resident 27 was able to ambulate independently. On 7/8/19 at 11:02 AM the resident was observed to walk independently throughout her/his room. An observation of the resident's room revealed the following environmental repair issues: -A hole in the wall by the resident's bed measuring 4 x 2.75 inches. The hole contained a broken outlet cover inside. -A gouge on the wall with exposed sheetrock above the resident's bed measuring 3 x 1.5 inches. -A section of missing baseboard by the resident's heater measuring 22.75 x 6.25 inches. -Missing flooring by the resident's heater measuring 34 x 4 inches. On 7/12/19 at 11:20 AM Staff 15 (Maintenance) confirmed the missing baseboard and flooring in Resident 27's room. Staff 15 further acknowledged the wall hole and the gouge needed repair. | 2020-09-01 |
| 1499 | 1499 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 658 | G | 0 | 1 | 0GGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Staff 9 (RN), Staff 10 (LPN), Staff 17 (LPN), Staff 19 (RN) Staff 29 (LPN) and Staff 30 (RN) adhered to professional standards related to provision and documentation of treatments for 2 of 7 sampled residents (#s 23 and 225) reviewed for pressure ulcers and skin conditions. This failure resulted in Resident 23 experiencing a worsening pressure ulcer and placed other residents at risk for worsening skin conditions. Findings include: Oregon Administrative Rule [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined includes: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (1) Conduct related to general fitness to practice nursing: (b) Demonstrated incidents of dishonesty, misrepresentation, or fraud. (3) Conduct related to the client's safety and integrity: (c) Failing to develop, implement or modify the plan of care; (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; (B) Documenting the provision of services that were not provided; 1. Resident 23 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A current order initiated 6/14/19, indicated Resident 23 had a Stage 3 (full thickness skin damage) pressure ulcer to the right lateral calf and staff were to complete the following treatment: -Cleanse the area, pat dry, apply [MEDICATION NAME] treatment, skin prep the surrounding tissue, cover with border or foam gauze… | 2020-09-01 |
| 1500 | 1500 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 677 | D | 0 | 1 | 0GGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure a resident who was unable to carry out necessary ADLs received bathing to maintain personal hygiene for 1 of 1 sampled resident (#268) reviewed for ADL care. This placed residents at risk for a lack of hygiene. Findings include: Resident 268 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 268's Admission Nursing Database indicated the resident was alert and oriented to person, place and time. Resident 268 was dependent upon staff for bathing. Resident 268's 7/6/19 baseline In Room Care Plan revealed the resident required one person assistance with bathing, by bed bath, on Monday and Thursday evenings. On 7/10/19 at 10:00 AM Resident 268 was observed in bed resting on her/his back. Resident 268's hair was uncombed and her/his beard was unkempt. On 7/10/19 at 10:00 AM Resident 268 stated she/he had not received a bath since admission to the facility on [DATE]. Resident 268's Point of Care History from 7/6/19 through 7/9/19 revealed no indication the resident was bathed. On 7/12/19 at 12:28 PM Staff 23 (CNA) stated if a resident did not get a bath for any reason it was to be reported to the charge nurse. On 7/10/19 at 11:20 AM Staff 14 (LPN Resident Care Manager) confirmed Resident 268 had not received a bath since admission to the facility. The resident's bath was scheduled for Sundays and Thursdays. Staff 14 further stated the resident required incontinent care and Staff 14 could not explain why the resident was not bathed as there was no documentation with any detail, and no nursing notes about why the activity did not occur. | 2020-09-01 |
| 1501 | 1501 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 684 | E | 0 | 1 | 0GGS11 | **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 orders were in place to treat and monitor surgical sites and to provide bowel medication and treatment when indicated for 4 of 8 sampled residents (#s 28, 35, 53, and 225) reviewed for non-pressure skin conditions, constipation and unnecessary medication. This placed residents at risk for infection, worsening skin conditions and impacted bowels. Findings include: 1. Resident 225 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/19 at 2:19 PM Resident 225 was observed to have an ACE bandage wrapped around her/his lower left leg, with only the resident's toes exposed. The resident was observed to have several surgically implanted pins, which extended out from the resident's skin and attached to an external stabilizing cage on her/his lower left leg. The tops of the pins were visible, but the bottom of the pins, where the pins entered the skin, were not visible due to the bandage. On 7/9/19 at 11:33 AM the same bandage was observed covering the resident's left lower leg. Resident 225 stated the bandage was present since her/his surgery prior to admission to the facility. Resident 225 stated staff did not monitor her/his skin under the bandage where the pin sites and additional incisions were located. A review of the resident's 7/2019 TAR indicated the pin sites were to be monitored for signs of infection on each shift. Documentation on the TAR indicated various staff, including Staff 19 (RN) and Staff 17 (LPN), monitored the pin sites on each shift since the resident's admission. No evidence was found in the resident's clinical record to indicate any treatment for [REDACTED]. On 7/10/19 at 2:05 PM Staff 19 (RN) stated Resident 225's left lower leg was to be assessed on each shift. Staff 19 stated he had not yet seen Resident 225's leg on his shift, but he was on his way to look at it. On 7/10/19 at 2:15 PM Staff 19 was observed to… | 2020-09-01 |
| 1502 | 1502 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 686 | G | 0 | 1 | 0GGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to implement interventions to prevent and treat pressure ulcers for 2 of 4 sampled residents (#s 23 and 268) reviewed for pressure ulcers. This resulted in Resident 23 experiencing a worsened pressure ulcer and placed residents at risk for the development of pressure ulcers. Findings include: 1. Resident 23 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A 1/4/19 admission nursing assessment indicated Resident 23 readmitted to the facility from the hospital and had a fluid filled blister on the back of her/his right heel. The 1/2019 TAR indicated weekly skin checks were to be completed on Tuesdays. On 1/8/19 there was no indication of new skin changes for Resident 23. A 1/10/19 Skin Incident Investigation indicated a CNA reported a new skin issue on Resident 23's right posterior lower leg. The wound was noted to have non-blanchable redness discoloration and measured 6 cm x 2 cm. Resident 23 preferred to lay in bed with legs elevated on pillows and was unable to move her/his legs independently. The investigation indicated Resident 23 was rehosptalized on [DATE] so the investigation was unable to be completed. A 1/10/19 physician order [REDACTED]. A 1/14/19 Hospital Wound, Ostomy and Skin Department Progress Note indicated Resident 23 had a 3 cm x 1 cm non-blanchable red area to the right posterior leg, source unknown. A 1/14/19 admission nursing assessment indicated Resident 23 readmitted to the facility with an abrasion to the right lower leg. No measurements were indicated. No indication of non-blanchable redness was noted. The 1/2019 TAR indicated no treatment was completed for Resident 23's right leg wound until 1/20/19, seven days after the resident readmitted . A 1/20/19 Skin Incident Investigation indicated new skin impairment on Resident 23's right lower calf. The wound measured 5 cm x 1 cm. The investigation noted the wound was pr… | 2020-09-01 |
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CREATE TABLE [cms_OR] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );