CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 596 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-05-25 | 309 | D | 1 | 0 | 14RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to administer medications per physician orders for 2 of 3 sampled residents (#s 1 and 3) reviewed for medications. This place residents at risk for adverse medication side affects. Findings include: 1. Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's physician orders did not include eye drops. The Medication Error Report indicated on 3/6/17 Staff 10 (RN) administered Resident 6's prescription eye drops to Resident 1. The note also indicated Resident 6's medications were left on Resident 1's bedside table. The physician was notified Resident 1 inadvertently received prescription eye drops. The Progress Notes for 3/6/17 through 3/10/17 did not have documentation to indicate the resident had pain, irritation or redness to the eyes. On 5/22/17 at 1:50 pm Staff 10 (RN) indicated on 3/6/17 the CMA called in sick and he came in the facility to assist. Staff 10 indicated another staff member prepared medications including an eye drop and handed the medications to Staff 10. Staff 10 indicated he was new at the facility and did not know the residents very well. Staff 10 entered the room and asked the two residents in the room who was Resident 6. Resident 1 responded. Staff 10 started to administer the eye drops to Resident 1 and Resident 1's family member indicated the resident did not have orders for eye drops. Staff 10 indicated he quickly left the room to verify which resident medications he brought into the room. Staff 10 indicated he was concerned about the medication error and when he left the room he left Resident 6's medications on Resident 1's table. He returned immediately and removed the medications. Resident 1 did not take Resident 6's oral medications. Staff 10 indicated he notified the physician and the physician indicated the resident was to be monitored for redness, pain and or irritation to the eyes. Staff 10 indicated the resident did not have any side affects from the eye drops. 2. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 4/30/17 Skilled Nursing Facility Transfer Orders revealed Resident 3 was to to be administered detemir (long acting insulin) twice a day and [MEDICATION NAME] (fast acting insulin) with meals. The Incident Investigation indicated on 5/1/17 Resident 3 was administered [MEDICATION NAME] (long acting insulin) and not detemir. The investigation indicated the readmission orders [REDACTED] On 5/22/17 Staff 1 (DNS) acknowledged Resident 3 was not administered the correct insulin on 5/1/17. Staff 1 indicated Resident 3 was previously prescribed [MEDICATION NAME], went to the hospital and returned with orders for detemir instead of [MEDICATION NAME]. | 2020-09-01 |
| 597 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2019-05-31 | 656 | D | 0 | 1 | SWDE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 5 sampled residents (#34) reviewed for medications. This place residents at risk for unmet care needs. Findings include: Resident 34 was admitted in 2019 with [DIAGNOSES REDACTED]. A hospital history and physical dated 1/23/19 indicated Resident 34 had current active [DIAGNOSES REDACTED]. A new [DIAGNOSES REDACTED]. A baseline care plan dated 1/22/19 included interventions related to use of blood thinner, pain, behaviors, fall risk, actual skin yeast, active infection, potential for weight loss and ADL care requirements. The current comprehensive care plan did not address issues related to weight loss surgery with chronic diarrhea and low potassium levels, lactose intolerance leading to bloating, abdominal pain and diarrhea, chronic leg [MEDICAL CONDITION] with skin changes and ulcerations, potential for skin breakdown related to immobility and diarrhea, nerve pain and pain management by pain clinic, recurrent urinary tract infections, history of bowel obstructions, history of blood clots in legs and lungs, potential for dehydration related to the use of two diuretics and chronic loose stools and restless leg syndrome. On 5/31/19 at 2:41 PM Staff 2 (DNS) acknowledged the comprehensive care plan did not include all care needs for Resident 34. | 2020-09-01 |
| 598 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2016-09-12 | 322 | D | 0 | 1 | QRTD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services for 1 of 1 sampled resident (#160) who was observed receiving medication through a gastrostomy tube (a surgically placed tube into the stomach for provision of nutrition, hydration and medication) during medication administration. This placed residents at risk for medical complications. Findings include: Resident 160 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility policy and procedure for Enteral Tube Medication Administration indicated prior to medication administration tube placement would be checked and medications would be administered one at a time by gravity. On 9/9/16 at 8:43 am Staff 4 (LPN) was observed to crush all of the following medications together in 1 pouch: aspirin, [MEDICATION NAME] sulfate and vitamin C. Staff 4 was observed to administer the crushed medications via Resident 160's [DEVICE]. Staff 4 did not check correct tube placement prior to medication administration. Staff 4 then used pressure to push the medications into the [DEVICE] with the syringe plunger rather than let the medication flow by gravity. On 9/9/16 at 10:41 am Staff 4 (LPN) confirmed she mixed the medications together, did not check tube placement prior to medication administration, and did not use gravity to administer the medications. | 2020-09-01 |
| 599 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2016-09-12 | 514 | D | 0 | 1 | QRTD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure documentation was accurate and complete for 1 of 6 sampled residents (#12) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 12 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A 5/10/16 Signed Physician order [REDACTED]. Special instructions: Document pre and post med scale. The (MONTH) (YEAR) PRN Medications Flowsheet indicated Resident 12 was not administered [MEDICATION NAME] on 5/8/16 and 5/14/16. The (MONTH) (YEAR) Narcotic Log indicated two 0.5 tabs (2 mg) of [MEDICATION NAME] were signed out on 5/8/16 and 5/14/16. On 9/9/16 at 9:00 am Staff 2 (RNCM) confirmed the discrepancy between the (MONTH) (YEAR) Narcotic Log and the (MONTH) (YEAR) PRN Medication Flowsheet for the dates 5/8/16 and 5/14/16 for Resident 12. b. The (MONTH) (YEAR) PRN Medication Flowsheet for [MEDICATION NAME] included areas to document the following: staff initials, time given, amount given, pain level pre-med and pain level post-med. The (MONTH) (YEAR) PRN Medication Flowsheet indicated Resident 12 received [MEDICATION NAME] on 17 occasions with the following documentation errors: amount given was not documented, the amount given column was used to document pre-pain levels and the pre-pain levels column was used to document post-pain level. On 9/8/16 at 10:36 pm Staff 3 (CMA) confirmed he did not document the amount of [MEDICATION NAME] administered to Resident 12 on the (MONTH) (YEAR) PRN Medication Flowsheet. Staff 3 further confirmed he used the incorrect lines to document both pre-med pain levels and post-med pain levels. On 9/9/16 at 9:00 am Staff 2 (RNCM) confirmed the (MONTH) (YEAR) PRN Medication Flowsheet did not reflect the amount of [MEDICATION NAME] administered to Resident 12 for 17 of 30 days. Staff 2 further confirmed the documentation was inaccurate. | 2020-09-01 |
| 600 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-09-18 | 309 | D | 1 | 0 | U3QG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to follow medication administration orders for an antibiotic and respond timely to a decline in condition for 1 of 3 sampled residents (#1) who's medications and records were reviewed. This placed the resident at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. On 6/6/17 a Physician ordered [MEDICATION NAME] (an antibiotic) 750 mg daily for seven days for pneumonia. The order was transcribed onto Resident 1's (MONTH) (YEAR) MAR and initiated on 6/7/17. On 6/13/17 Resident 1's (MONTH) (YEAR) MAR indicated the resident was not administered [MEDICATION NAME] on 6/13/17 nor on 6/14/17 because it wasn't available. The resident missed the last two doses of the physician ordered antibiotic course. There was no documented evidence the facility attempted to obtain the medication or notified the physician that the antibiotic wasn't available or administered as ordered. On 6/13/17 at 11:47 pm a nursing Progress Note indicated Resident 1 was lethargic and woke up a little when talked to but fell right back to sleep. In addition, the note indicated the resident was becoming more incontinent of bowel and bladder. On 6/15/17 at 9:02 pm a nursing Progress Note indicated the Physician called the facility and ordered Resident 1 sent out to the hospital for an evaluation for concerns related to dehydration. The hospital's History and Physical (H&P) indicated the resident had [DIAGNOSES REDACTED]. In interview on 9/12/17 Staff 4 (RNCM) confirmed Resident 1 did not receive [MEDICATION NAME] on 6/13/17 and 6/14/17 due to it not being available. She stated she could not find evidence the physician was contacted regarding the missed doses. In interview on 9/14/17 at 3:37 pm Staff 8 (LPN) reported Resident 1's last two doses were not available. Staff 8 stated he called the pharmacy but they didn't send more medication while he was working. In interview on 9/14/17 at 3:47 pm Staff 7 (LPN) reported Resident 1 had become more and more lethargic and went in and out of confusion. He stated he attempted to contact the physician. In interview on 9/15/17 at 12:39 pm Staff 2 (DNS) reported there was a lack of facility documentation showing what the facility attempted regarding pharmacy contact and physician notification. | 2020-09-01 |
| 601 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-09-18 | 327 | D | 1 | 0 | U3QG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assess a resident's risk for dehydration, attempt interventions to prevent dehydration, or identify signs and symptoms of dehydration timely for 1 of 1 sampled resident (#1) who drank poorly. This placed the resident at risk for unaddressed hydration needs. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. On 5/29/17 a Medical Nutrition Therapy Admission Assessment identified Resident 1's estimated fluid needs were 2400 milliliters (mls) per day, approximately 81 ounces. According to the resident's meal and fluid monitor, between 6/1/17 and 6/15/17 the resident averaged 253 mls of fluid per day, approximately 8 ounces. There was no evidence the facility assessed the resident's risk for dehydration or attempted interventions to address her/his hydration needs when the resident routinely drank less that her/his assessed fluid needs. On 6/12/17 at 10:01 pm a nursing Progress Note indicated the resident did not drink much for several days. On 6/13/17 at 11:47 pm a nursing Progress Note identified the resident refused liquids, was lethargic, and was becoming more incontinent. On 6/15/17 at 9:02 pm a nursing Progress Note identified the Physician ordered Resident 1 sent out to the hospital because lab results showed her/his kidney function was worse and she/he seemed dehydrated. On 6/15/17 an Emergency Department report indicated Resident 1's blood work showed elevated BUN and creatinine (a possible indication of dehydration) and the resident's mouth and face were dry and cracked which was consistent with a pretty severe dehydration. In interview on 9/14/17 at 3:37 pm Staff 8 (LPN) reported prior to Resident 1 being sent out on 6/15/17, the resident had appeared dehydrated for several days and stated he was trying to get the resident to drink and go to the hospital. Staff 8 confirmed that the resident's refusal to go to the hospital, his interventions, and his dehydration assessment was not documented in the resident's record. In interview on 9/15/17 at 12:39 pm Staff 2 (DNS) confirmed there was a lack of documentation related to Resident 1's fluid refusals and facility interventions. | 2020-09-01 |
| 602 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 641 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the MDS assessment was accurately coded for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for unassessed needs. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/5/17 Resident 24's physician ordered the use of an elopement alarm after the resident exited the facility without assistance and experienced a fall. The 10/4/17 comprehensive care plan indicated the Resident 24 had an elopement alarm in place to notify staff when resident was near exit doors. The 10/29/17 Annual MDS Section P - Restraints and Alarms did not indicate Resident 24's use of the elopement alarm. On 12/19/17 at 10:30 am Staff 17 (RNCM/MDS Coordinator) acknowledged she did not code the elopement alarm for Resident 24. | 2020-09-01 |
| 603 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 658 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined facility staff failed to meet professional standards for medication administration and skin assessments for 1 of 2 sampled residents (#7) reviewed for skin conditions. This placed residents at risk for adverse medication reactions and unmet needs. Per Division 45 Standards and Scope of Practice for the LPN and RN [PHONE NUMBER]; Conduct Derogatory to the Standards of Nursing Defined: - Failing to communicate information regarding the client's status to members of the health care team in an ongoing and timely manner as appropriate to the context of care; or - Failing to communicate information regarding the client's status to other individuals who are authorized to receive information and have a need to know. - Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 7 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. a. On 12/11/17 at 12:09 pm Resident 7 stated she/he had a rash on the left buttocks. On 12/15/17 at 10:45 am Staff 13 (RN) completed a skin check on Resident 7 which was observed by surveyor. Staff 13 stated there were red fungal spots on the resident's left groin fold, a fungal open area on the resident's right groin fold and a fungal area on the resident's buttocks. Staff 13 stated a CNA reported the skin conditions to him on 12/11/17 between day shift and evening shift. Staff 13 confirmed he did not observe the resident's skin until the morning of 12/15/17. Staff 13 stated he could not recall if he reported the skin condition to another charge nurse and did not know if another RN had assessed the change in the resident's skin condition. He did not remember which CNA reported the change in skin condition to him. He confirmed a skin grid was not completed. On 12/15/17 at 11:53 AM Staff 2 (DNS) and Staff 17 (RNCM/MDS Coordinator) confirmed Staff 13 (RN) should have reported Resident 7's change in skin condition to the next charge nurse. They confirmed the procedure was to assess and document when a change in skin condition was reported. On 12/18/17 at 9:06 AM Staff 2 (CNA) stated during incontinence care on 12/11/17 Resident 7 reported sore buttocks. Staff 2 stated she reported it to Staff 13 the same day. On 12/18/17 at 3:55 pm Staff 16 (RN) stated he was not informed of a change in Resident 7's skin condition and he did not complete a skin check during the week of 12/11/17. b. During the observed skin check on 12/15/17 at 10:45 am and after Staff 13 (RN) assessed Resident 7's skin, he took a tube of antifungal cream out of his pocket and applied it to the affected areas. He stated he did not have an order for [REDACTED]. On 12/18/17 at 11:10 AM Staff 3 (RNCM) confirmed there was no physician's order for the antifungal cream administered to Resident 7 and the order was received on 12/16/17, the day after it was applied. | 2020-09-01 |
| 604 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 684 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to follow physician's orders for 2 of 6 sampled residents (#s 7 and 33) reviewed for unnecessary medications and skin conditions. This placed residents at risk for adverse medication reactions and unmet needs. Findings include: 1. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 7's admission MDS dated [DATE] revealed the resident was at risk for skin breakdown related to urinary incontinency. Resident 7's comprehensive care plan dated 7/14/17 included an intervention for moisture barrier cream to the resident's skin. Resident 7's in-room care plan updated 11/26/17 directed staff to report any new skin issues to the nurse. On 12/11/17 at 12:09 pm Resident 7 stated she/he had a rash on her/his buttocks and a CNA had applied a barrier cream that morning. On 12/15/17 at 10:45 am Resident 7 gave permission for the surveyor to observe a skin check completed by Staff 13 (RN). Staff 13 described fungal areas in both of the resident's groin folds and on her/his buttock. Staff 13 applied an antifungal cream from a tube he kept in his pocket. He stated he did not have a physician's order for use of the cream for Resident 7 and would request one later. He stated he used the tube of antifungal cream on any residents with fungal skin conditions and afterward would request a physician order if there was not already an order. Resident 7's physician's orders did not include an antifungal cream until 12/16/17, a day after it was applied. On 12/15/17 at 11:53 am Staff 2 (DNS) and Staff 17 (RNCM/MDS Coordinator) confirmed Staff 13 (RN) should not have applied the antifungal cream to Resident 7 without a physician order. On 12/18/17 at 11:10 am Staff 3 (RNCM) confirmed an order for [REDACTED]. 2. Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 12/6/17 physician order indicated Resident 33 was to receive losartan (antihypertensive medication) daily and the medication was to be held if the systolic blood pressure was less than 90. The 11/2017 and 12/2017 MAR indicated [REDACTED] A review of the clinical record indicated Resident 33's blood pressure was not checked prior to losartan administration. On 12/18/17 at 2:01 pm Staff 16 (RN) stated Resident 33's blood pressure was not taken prior to losartan administration as ordered. | 2020-09-01 |
| 605 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 689 | E | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the environment was free of potential accident hazards for 3 of 33 resident rooms (#s 10, 12 and 19) and 1 of 2 dining (North) rooms reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Review of the 10/2012, Oregon Department of Human Services Administrator Alert, revealed the following for in-wall heater use for nursing facility regulatory compliance: -Residents and staff are at risk [MEDICAL CONDITION] unexpected fire due to existing in-wall heaters or replacement units; -The facility was responsible for the following: -Identify and evaluate hazards and risks, implement interventions to reduce hazards and risks, and monitor the effectiveness of the interventions; -Educate residents, resident representatives and staff about the risks of unsupervised access to in-wall heaters in rooms; -Determine the appropriateness, complete an accurate assessment and create a care plan reflecting the residents' ability for safe, unsupervised, independent access to in-wall heaters; -Ensure residents' records included documentation that the resident or representative received information and consents related to the risks associated with independent access and/ or use of the existing in-wall heaters. Observations on 12/15/17 at 9:02 am revealed the in-wall heater in room [ROOM NUMBER] was unable to be touched for momentary contact. The heater's precaution label stated: caution high temperature, at risk of fire, keep combustibles at least 3 feet away from the front of the heater. No combustibles were observed within three feet of the heater. Observation on 12/15/17 at 10:06 am revealed the in-wall heater vent surface read 199 degrees Fahrenheit (F) in the North dining area. During observation and interview on 12/15/17 at 10:08 am, room [ROOM NUMBER]'s in-wall heater vent surface temperature read 270F. Staff 1 (Administrator) verified the temperature. During observation and interview on 12/15/17 at approximately 10:10 am, room [ROOM NUMBER]'s in-wall heater vent surface temperature was 274.5F. Staff 1 verified the temperature. During an interview on 12/15/17 at 10:15 am, Staff 1 explained there was an Administrator Alert that came out about in-wall heaters and their appropriate usage but needed to look for it. The facility staff used to document the education and discussions the facility had with staff, family and residents regarding the heaters but did not currently do so. On 12/15/17 at 12:24 am, Staff 18 (LPN) stated she conducted safety assessments but had not done an assessment or education related to in-wall heaters for any resident. On 12/15/17 at 1:35 pm Staff 19 (LPN) stated she did assessments but had not done any assessments related to the heaters. She had not educated residents or their families related to the heaters that she could recall. During an observation on 12/15/17 at 1:53 pm, Staff 20 (Maintenance Director) tested room [ROOM NUMBER]'s heater surface. The temperature read 173F. On 12/15/17 at 1:57 pm, Resident 5 in room [ROOM NUMBER] stated do not touch the heater, it will burn you. | 2020-09-01 |
| 606 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 756 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for medication side effects. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 4/20/17 Note to Attending Physician/Prescriber indicated Resident 24 received [MEDICATION NAME] (stomach ulcer prevention) since 12/2016. The Consultant Pharmacist recommended reassessment to support continued use of the medication. On 4/21/17 the physician responded to the Consultant Pharmacist's recommendation: Is (resident) complaining of any symptoms? Resident 24's record revealed no documentation of facility follow-up or response to the physician's request. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 12/19/17 at 9:17 AM Staff 3 (RNCM) stated she would look for follow-up documentation related to the [MEDICATION NAME]. No additional information was provided. | 2020-09-01 |
| 607 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 757 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure adequate indication for the use of medications for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for inappropriate medication administration. Findings include: Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The resident's record did not include clinical rationales for the use of the [MEDICATION NAME] or the [MEDICATION NAME]es. On 12/19/17 at 9:17 am Staff 3 (RNCM) stated she would look for clinical rationales for the [MEDICATION NAME] and [MEDICATION NAME]es. No additional information was provided. | 2020-09-01 |
| 608 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 758 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to have an adequate indication for use of and complete gradual dose reductions for antipsychotic medications for 2 of 5 sampled residents (#s 20 and 26) reviewed for medications. This placed residents at risk for unnecessary antipsychotic medication. Findings include: 1. Resident 26 admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Signed physician orders [REDACTED]. Review of the 11/2017 MAR indicated [REDACTED]. On 12/15/17 at 1:59 pm Staff 5 (LPN/RCM) confirmed the [DIAGNOSES REDACTED]. 2. Resident 20 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. December (YEAR) physician's orders [REDACTED]. Consultant Pharmacist Medication Regimen Reviews from (MONTH) (YEAR) through (MONTH) (YEAR) documented no concerns. There was no documented attempts of gradual dose reductions for the [MEDICAL CONDITION] medications. A 11/9/17 physician telephone order requested a gradual dose reduction for the [MEDICATION NAME] and [MEDICATION NAME]. The signed physician order [REDACTED]. In an interview on 12/15/17 at 1:27 pm Staff 3 (RNCM) acknowledged the physician order [REDACTED]. In an interview on 12/15/17 at 1:45 pm Staff 11 (Medical Records) stated no gradual dose reduction requests could not be located prior to 11/9/17. In an interview on 12/15/17 2:00 pm Staff 2 (DNS) acknowledged there was no clinical rationale for why the medication reductions could not be attempted. Staff 2 stated she was working to educate each physician on the new [MEDICAL CONDITION] medication regulation pertaining to gradual dose reduction. | 2020-09-01 |
| 609 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 812 | F | 0 | 1 | PQSE11 | Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 kitchens reviewed. This placed residents at risk for potential food borne illness. Findings include: Observations in the facility walk-in refrigerator on 12/11/17 at 9:26 am revealed the following: -Closed container of salad dated 12/5/17. -Opened bag of spinach dated 12/4/17 and an opened bag of spinach with an incorrect open date of 12/25/17. -Two bunches of undated, uncovered and wilted celery. -Closed container of thawing pork with an unreadable opened date. -Undated raw chicken inside a plastic bag, partially uncovered. -Undated raw beef inside a plastic bag, partially uncovered. On 12/11/17 at 9:38 am Staff 27 (Kitchen Manager) stated the closed container of salad should have been tossed on 12/8/17 and the open bag of spinach dated 12/4/17 should have been tossed on 12/7/17. Staff 27 further stated the open date on the additional bag of spinach was unreadable, and was unable to confirm a date of delivery or the use by date for the celery. Staff 27 confirmed the date on the thawing pork was unreadable and both the thawing chicken and thawing beef were exposed to air and undated. | 2020-09-01 |
| 610 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 842 | E | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 4 of 10 sampled residents (#s 9, 24, 26 and 31) reviewed for unnecessary medications, accidents and pressure ulcers. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 31 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. An 8/15/17 progress note indicated Resident 31 had a large excoriation wound (abrasion type injury) on the coccyx/buttock with no open or bleeding areas. TARs from 8/15/17 through 9/14/17 revealed an order for [REDACTED]. A 9/3/17 progress note indicated Resident 31 had multiple open areas on the left and right buttocks. The 9/3/17 through 9/13/17 TARs revealed orders and instructions for treatment of [REDACTED]. On 12/18/17 at 4:18 pm Staff 16 (RN) stated Resident 31's skin issues were excoriation and not pressure in nature. During an interview on 12/19/17 at 12:15 pm Staff 2 (DNS) and Staff 3 (RNCM) confirmed Resident 31's wounds were not pressure related and the (MONTH) and (MONTH) (YEAR) TARs identified the skin issues inaccurately. 2. Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/5/17 Resident 24's physician ordered the use of an elopement alarm after the resident exited the facility without assistance and experienced a fall. Resident 24's 10/29/17 Annual MDS - Section [NAME] was not coded for wandering behaviors during the look back period (review time frame). The resident's record included no additional documentation of elopement incidents by Resident 24 as of the time of the survey on 12/11/17. From 12/11/17 through 12/19/17 Resident 24 was observed multiple times propelling her/his wheelchair in the hall near her/his room and adjacent dining room. The resident did not approach or attempt to open the nearby exit door. During an interview on 12/15/17 at 10:09 am Staff 14 (CNA) and Staff 26 (CNA) confirmed Resident 24 had an elopement alarm and stated she/he did not try to leave the building. Both staff indicated they were aware the resident had eloped one time. Staff 14 stated she had never heard Resident 24's elopement alarm sound. On 12/19/17 at 12:26 pm Staff 3 (DNS) and Staff 3 (RNCM) acknowledged there was a lack of documentation to show Resident 24 continued to require the use of an elopement alarm. 3. Resident 26 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2017 MAR indicated [REDACTED]. The 11/3/17 signed Psychotherapeutic Medications Disclosure and Consent document indicated Resident 26 received [MEDICATION NAME]. The document incorrectly identified [MEDICATION NAME] as an antidepressant medication. On 12/15/17 at 2:00 pm Staff 5 (LPN/RCM) confirmed the 11/3/17 signed Psychotherapeutic Medications Disclosure and Consent document incorrectly identified [MEDICATION NAME] as an antidepressant. 4. Resident 9 readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 9/18/17 Incident Investigation indicated Resident 9 sustained a fall with injury on 9/10/17. The Incident Investigation indicated witness interviews were attached to the document. Witness interviews were not attached to the document. On 12/18/17 at 1:24 pm Staff 1 (Administrator) stated she was unable to locate the signed witness interviews for the 9/18/17 Incident Investigation. | 2020-09-01 |
| 611 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-12-19 | 880 | D | 0 | 1 | PQSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene and infection control during random observations of nursing staff. This placed residents at risk for cross-contamination and infection. Findings include: 1. The facility's Policy and Procedure on Hand Hygiene dated 6/2017 included required hand hygiene before and after direct resident contact, upon and after contact with a resident's intact skin and after removing gloves. It indicated hand hygiene should be performed as soon as possible after hands become contaminated. Prior to entering Resident 7's room on 12/15/17 at 10:45 am, Staff 13 (RN) donned gloves in the hall prior to entering the resident's room. He did not change his gloves or wash his hands after entering the room and prior to touching Resident 7. Without changing gloves, he touched the resident's skin then took a tube of cream out of a plastic bag in his pocket which contained two other tubes. He applied the cream to the resident without changing gloves. He attempted to place the tube back in the plastic bag in his pocket with the other two tubes used for multiple residents. The surveyor stopped him and asked about cross-contamination. He stated he would disinfect the tube of cream but decided to dispose of it since it was almost empty. The two remaining tubes in his pocket were already cross-contaminated because he touched them with his contaminated gloved hands. Staff 13 stated the tubes were for any residents for whom he completed skin treatments. On 12/15/17 at 12:46 pm the three tubes of creams were observed in Staff 13's pocket. When asked about the administration of the cream for Resident 7 earlier in the morning, Staff 13 confirmed he should have put each cream in individual cups for each resident at the medication cart, changed gloves and washed his hands in between each procedure and resident. He said he didn't follow his normal routine because he was running behind and did a short-cut. He acknowledged the infection control break. On 12/15/17 at 11:53 am Staff 2 (DNS) and Staff 17 (RNCM/MDS Coordinator) acknowledged Staff 13 broke infection control policy when he donned the gloves in the hallway and not in Resident 7's room. They confirmed he should have taken off the gloves and washed his hands after probing the resident's skin and prior to touching the tubes of creams kept in his pocket. 2. An observation on 12/15/17 at 9:10 am Staff 13 (RN) entered resident room [ROOM NUMBER] carrying two glasses containing liquid in one hand with a finger inserted inside each glass. In an interview on 12/15/17 at 11:06 am Staff 13 acknowledged he should not have inserted his fingers inside the glasses and did not prevent potential infection. | 2020-09-01 |
| 2447 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2019-01-31 | 880 | D | 0 | 1 | JC1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to perform proper infection control techniques during a dressing change for 1 of 3 sampled residents (#40) reviewed for pressure ulcers. This placed residents at risk for cross contamination. Findings include: The facility's Hand Washing Policy and Procedure dated 1/1/98 directed staff to perform hand hygiene after contact with a wound dressing and to decontaminate hands after removing gloves. Resident 40 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. On 1/30/19 at 3:15 PM Staff 3 (LPN) performed hand hygiene before donning two pairs of gloves. Staff 3 removed the foam dressing and cleansed the wound area. Staff 3 discarded the first pair of gloves and applied a foam dressing with the remaining pair of gloves. On 1/30/19 at 3:55 PM Staff 3 (LPN) stated he should have removed the gloves to perform hand hygiene between the dressing removal and cleansing the wound instead of double gloving without performing hand hygiene. On 1/30/19 at 4:00 PM the wound dressing change was discussed with Staff 5 (DNS) and she acknowledged Staff 3 (LPN) did not perform proper hand hygiene during wound care for Resident 40. | 2020-09-01 |
| 2448 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 157 | D | 0 | 1 | YU2V11 | **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 timely of a severe weight loss for 1 of 3 sampled residents (# 133) reviewed for nutrition. This placed residents at risk for unmet nutritional needs. Findings include: Resident 133 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 133's Weight Tracking Report revealed the following weights: 2/6/16 172 pounds; 3/2/16 160 pounds; 4/2/16 162 pounds; and 5/2/16 152 pounds, a loss of ten pounds (6%) in one month and 20 pounds (11.6%) in three months. This constituted a severe weight loss for Resident 133. Resident 133's clinical record indicated the resident's physician was not notified of the severe weight loss identified on 5/2/16 until 10 days later on 5/12/16. On 6/17/16 at 1:00 pm the surveyor requested Staff 5 (RNCM) provide evidence Resident 133's physician was notified timely of the severe weight loss from (MONTH) (YEAR) to (MONTH) (YEAR), and the facility was unable to provide documentation of timely notification. | 2020-09-01 |
| 2449 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 225 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to conduct a comprehensive investigation of potential neglect for 1 of 3 sampled residents (# 68) reviewed for accidents. This placed residents at risk for neglect. Findings include: Resident 68 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 68's Interdisciplinary Notes indicated the following occurred: - On 5/26/16 the resident was started on a new antidepressant medication. - On 5/28/16 the resident was found on the bathroom floor with her/his brief off. The resident stated she/he tried to get to the bathroom. The call light was on but no one came to help so she/he decided to go on her/his own. The resident had a small abrasion to the left knee measuring 2.0 cm by 1.5 cm. Vital signs were taken and the resident's physician and family were notified. A facility fall investigation dated 5/28/16 failed to address Resident 68's allegation of potential neglect. The investigation indicated the resident was last assisted with toileting at 3:55 am on 5/28/16 and the resident was found on the floor at 5:30 am. The investigation did not indicate if the resident's call light was on at the time, how long it was on, or if the call light was checked for proper function. The investigation indicated the resident had a recent medication change, but did not indicate what the change was or how it may have pertained to the fall. On 6/16/16 at 10:35 am Staff 5 (RNCM) acknowledged the investigation did not indicate if Resident 68's call light was on at the time of the fall or if it was checked for proper function and did not indicate what the resident's medication change was. Staff 8 (RNCM) acknowledged the investigation did not rule out potential neglect. | 2020-09-01 |
| 2450 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 226 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to operationalize policy and procedure related to abuse for 1 of 3 sampled residents (#68) who were reviewed for accidents. This placed residents at risk for abuse. Findings include The Facility's Policy and Procedure for Resident Abuse dated 3/17/16 indicated the administrator or designee completed an investigation of suspected abuse or incident of unknown origin. The investigation was to begin promptly after the report of the problem. The investigation included a record of statements or interviews with the resident, suspect and witnesses. The administrator or designee were to immediately notify SPD or local Area Association on Aging. A physical injury of unknown cause was to be reported to SPD as suspected abuse unless the immediate facility investigation reasonably concluded the injury was not the result of abuse. The Facility's Policy and Procedure for Incident Reporting dated 8/21/16 indicated an incident form for falls was to document the time of the fall, where it occurred, how the resident was found, if the care plan was followed, last time the resident was toileted, type and location of assistive devices, medication review, alarm working and if the call light was used. Resident 68 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 68's Interdisciplinary Notes indicated the following occurred: - On 5/26/16 the resident was started on a new antidepressant medication. - On 5/28/16 the resident was found on the bathroom floor with her/his brief off. The resident stated she/he was trying to get to the bathroom and the call light was on but no one came to help so she/he decided to go on her/his own. The resident had a small abrasion to the left knee measuring 2.0 cm by 1.5 cm. Vital signs were taken and the resident's physician and family were notified. A facility fall investigation dated 5/28/16 did not include a record of statements or interviews with witnesses. The investigation did not rule out potential neglect. The investigation did not indicate if the resident's call light was on at the time, how long it was on or if the call light was checked for proper function. The investigation indicated the resident had a recent medication change but did not indicate what the change was or how it may have pertained to the resident's fall. On 6/16/16 at 10:35 am Staff 5 (RNCM) acknowledged the investigation did not indicate if Resident 68's call light was on at the time of the fall or if it was checked for proper function and did not indicate what the resident's medication change was. Staff 8 (RNCM) acknowledged the investigation did not rule out potential neglect. | 2020-09-01 |
| 2451 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 272 | D | 0 | 1 | YU2V11 | **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 psychoactive medications, risk for skin breakdown and urinary incontinence for 2 of 6 sampled residents (#s 18 and 81) reviewed for unnecessary medications and death. This placed residents at risk for unassessed needs. Findings include: 1. Resident 81 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 81's 5/29/16 [MEDICAL CONDITION] Drug Use CAA referred to the Fall CAA for information regarding antidepressant and antianxiety medication information. Resident 81's 5/29/16 Falls CAA failed to indicate how the resident's symptoms of depression and anxiety manifested. It also failed to indicate what made the symptoms worse or improved, and did not indicate non-pharmacological interventions. On 6/16/16 at 11:54 am Staff 7 (RNCM) acknowledged the assessment was not comprehensive. 2. Resident 18 was admitted from the hospital to the facility during (YEAR) with [DIAGNOSES REDACTED]. At admission, Resident 18 had a history of [REDACTED]. The 3/29/16 Hospital Health and Physical noted the resident had acute [MEDICAL CONDITION]ly related to recurrent pleural effusion. Resident 18 had additional contributing factors including chronic heart failure, [MEDICAL CONDITION] and flutter, obstructive sleep apnea and possible [MEDICAL CONDITION]. The resident was malnourished, had a poor prognosis and was in life threatening condition which needed aggressive therapy. The 3/24/16 facility Nursing Admission Report noted Resident 18 was not eating well and exhibited more confusion later in the day. Resident 18's 4/7/16 Admission MDS revealed the resident did not reject care and had a Brief Mental Status (BIMs) exam score indicative of intact cognition. The resident required extensive physical assistance of two or more staff for toileting, bed mobility and locomotion. Resident 18 was incontinent of bowel and bladder and at risk of pressure ulcers. Resident 18 needed the supervision of one staff person with eating and was dependent for bed mobility. The 4/7/16 Admission MDS triggered the areas of Pressure Ulcers and Urinary Incontinence for further assessment. The Urinary Incontinence CAA was not comprehensive and lacked a description of the type of incontinence (such as functional incontinence because the resident couldn't get to the bathroom in time or stress incontinence which occurs with coughing, sneezing laughing or lifting heavy objects), an analysis of why Resident 18 was incontinent and possible contributing factors that could be treated or corrected. The Pressure Ulcer CAA did not include an analysis of factors other than incontinence which could have impacted Resident 18's risk of pressure ulcers. The Pressure Ulcer CAA did not address the impact of resident specific issues such as poor nutrition, amount of time spent in bed, need for extensive assistance for bed mobility or dependence on staff for transfers. There was no analysis of potential contributing factors that could be treated or corrected. Resident 18's 4/13/16 CAAs did not include a comprehensive assessment of the resident's complex medical status and poor prognosis. On 6/15/16 at 1:03 pm Staff 2 (RNCM) verified Resident 18's Urinary Incontinence and Pressure Ulcer CAAs were not comprehensive. Staff 2 acknowledged Resident 18's complex medical status and poor prognosis should have been addressed in the CAAs but were not. | 2020-09-01 |
| 2452 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 278 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 2 of 5 sampled residents (#s 16 and 81) reviewed for unnecessary medications. This placed residents at risk for unidentified needs. Findings include: 1. Resident 81 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 81's 5/29/16 MDS indicated the resident did not receive antianxiety medication during the assessment reference period. Resident 81's (MONTH) (YEAR) MAR indicated [REDACTED]. On 6/16/16 at 11:54 am Staff 7 (RNCM) acknowledged the assessment was not accurate. 2. Resident 16 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A review of Resident 16's 4/12/16 MDS did not indicate the resident had dementia with agitation. On 6/17/16 at 11:13 am Staff 5 (RNCM) acknowledged the assessment was not accurate. | 2020-09-01 |
| 2453 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 279 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan regarding tube feeding for 1 of 1 sampled resident (#171) reviewed for tube feeding. This placed residents at risk for complications related to tube feeding. Findings include: Resident 171 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nurse's order dated 6/11/16 indicated the head of the resident's bed was to be elevated 30 degrees at all times. A review of the resident's current care plan, updated 6/11/16, did not indicate the rate of flow for the tube feeding formula, nor information regarding elevation of the head of the resident's bed. On 6/17/16 at 11:01 am Staff 7 (RNCM) acknowledged Resident 171's care plan did not indicate the rate of flow for the resident's feeding tube nor information about the elevation of the head of the resident's bed. | 2020-09-01 |
| 2454 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 280 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined facility failed to ensure a care plan was revised for 1 of 5 sampled residents (# 171) reviewed for nutrition and pressure ulcers. This placed residents at risk for unmet needs . Findings include: Resident 171 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. Facility weight records indicated the resident weighed 115 pounds on 5/14/16, and the resident's weight declined to a low of 100 pounds on 6/5/16. This represented a severe weight loss of 13% in less than 30 days. Resident 171's current care plan, dated 6/11/16, revealed no information regarding the severe weight loss. On 6/17/16 at 11:01 am Staff 7 (RNCM) acknowledged the resident's care plan did not indicate the resident experienced a severe weight loss. b. A 6/2/16 progress note indicated staff identified a pressure ulcer on Resident 171's coccyx . Resident 171's current care plan, dated 6/11/16, revealed no information regarding the presence of a pressure ulcer. On 6/16/16 at 1:35 pm Staff 7 (RNCM) acknowledged the resident's care plan was not updated regarding the presence of a pressure ulcer. | 2020-09-01 |
| 2455 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 309 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow physicians' orders for skin care and bowel care for 2 of 7 sampled residents (#s 45 and 169) reviewed for medications and non-pressure skin conditions. This placed residents at risk for delayed treatment. Findings include: 1. Resident 45 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Physician orders dated 6/6/16 directed staff to administer [MEDICATION NAME] (laxative) on day three if no bowel movement. The (MONTH) (YEAR) Daily Charting for Bowel movement indicated the resident did not have a bowel movement from 6/6/16 to 6/11/16. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 6/16/16 at 8:06 am Staff 5 (RNCM) confirmed that physician orders were not followed for the administration of [MEDICATION NAME]. 2. Resident 169 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. Physician's orders, dated 5/11/16, included an order for [REDACTED]. Protect periwound edges with no sting barrier film. Silver dressing to wound bed, cover with foam border dressing. Silicone if possible. On 5/29/16 Staff 4 (LPN) faxed an assessment to the resident's physician and requested order changes, . seems to be at a plateau for healing these wounds and each wound is in a different state of healing and appear to need more current orders . wounds to the bilateral ankles have moderate amounts of slough (tissue) present and the [MEDICATION NAME] (dressing which contains gel-forming agents in an adhesive compound) dressings may assist with autolytic debridement (the body's natural healing mechanisms of necrotic tissue). On 5/31/16 the physician approved the following treatment order to the bilateral ankle wounds: Cleanse with wound cleanser and apply [MEDICATION NAME] dressings every three days and PRN for soilage. The 5/31/16 order also had a note, documented by Staff 11 (LPN), which indicated the resident refused the use of the [MEDICATION NAME]. There was no documented evidence the physician was notified of the treatment refusal or new orders requested. The (MONTH) (YEAR) TAR documented the bilateral ankle wounds were treated per the 5/11/16 order. On 6/17/16 at 8:01 am Staff 7 (RNCM) stated [MEDICATION NAME] and Allevyn (wound dressing) were different mediums for wound care and the drainage from the resident's wounds prohibited the effective use of the [MEDICATION NAME]. On 6/17/16 at 10:16 am Staff 11 (LPN) acknowledged she was unable to locate notification to the physician regarding the treatment refusal, and stated the treatment for [REDACTED]. On 6/17/16 at 10:36 am, Staff 7 acknowledged the 5/31/16 order refusal was not processed and the physician should have been notified of the treatment change. b. Physician's orders, dated 5/11/16, included a Facility Skin Tear Protocol, Cleanse with Saf Cleanse (wound cleanser), steristrip if possible. [MEDICATION NAME]/[MEDICATION NAME] (non-adherent dressing) cover with dry dressing change daily til (sic) resolved or cleanse with Saf Cleanse, cover with Opsite (transparent adhesive film dressing), check daily for (signs/symptoms of infection). A 5/11/16 Skin Assessment Form identified Resident 169 admitted to the facility with a 1.5 cm by 1 cm skin tear to the left forearm. The 5/11/16 assessment further noted a Xeroform dressing (a sterile, mildly medicated gauze dressing) was applied at that time. Skin Assessment Forms, dated 5/18/16, 5/24/16 and 5/30/16 revealed Resident 169 also received wound care to an open area on the left shin. The assessments noted the areas were cleansed and Xeroform applied. Resident 169's physician's orders did not include a treatment protocol involving the use of a Xeroform dressing for the left forearm or left shin. On 6/16/16 at 8:01 am and 9:58 am the treatment orders were discussed with Staff 7, and she stated the left forearm treatment should have been the facility skin tear protocol. Staff 7 stated orders were processed and TARs updated by the licensed nurse who received the order. Staff 7 acknowledged the physician should have been contacted for orders. | 2020-09-01 |
| 2456 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 314 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to comprehensively assess a pressure ulcer, obtain and document treatment orders and develop and implement appropriate interventions for 1 of 2 sampled residents (# 171) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 171 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 6/2/16 progress note indicated staff identified an open pressure ulcer on Resident 171's coccyx. a. A 6/2/16 skin stamp sheet (Skin Assessment Form) indicated the pressure ulcer was 0.5 cm x 0.5 cm and unstageable (full tissue thickness loss in which the base of the ulcer is covered by tissue, slough (yellow, tan or gray tissue) or eschar (black or brown tissue) in the wound bed). The documentation lacked an assessment to indicate why the ulcer was considered unstageable. On 6/16/16 at 1:18 pm Staff 7 (RNCM) stated the pressure ulcer was unstageable due to being covered by slough. b. On 6/2/16 the following was faxed to the resident's physician, Resident has an open area to coccyx. We have been bridging (pressure reduction technique) resident to off load pressure. Will apply Allevyn (dressing) for extra protection. Any new orders? A 6/3/16 the physician responded, Sounds Good. The order did not indicate the frequency of treatment or if wound cleanser was to be used. Progress notes dated 6/4/16 and 6/7/16 indicated the dressing was changed and the wound was cleaned. A 6/11/16 physician's orders [REDACTED]. The order also directed staff to cleanse the wound with saline and apply Calcium Alginate to the wound bed and cover with Allevyn. The (MONTH) (YEAR) TAR indicated treatment for [REDACTED]. On 6/17/16 at 11:01 am Staff 7 acknowledged the 6/3/16 order for treatment of [REDACTED]. c. On 6/2/16 the following was faxed to the resident's physician, Resident has an open area to coccyx. We have been bridging (pressure reduction technique) resident to off load pressure . On 6/3/16 the physician responded, Sounds Good. Resident 171's current care plan, dated 6/11/16, revealed no information regarding the presence of a pressure ulcer or how the resident was to be positioned. On 6/15/16 at 2:07 pm Resident 171 was observed in bed on her/his back and pillows were underneath the resident's coccyx. On 6/16/16 at 11:18 am Staff 4 (LPN/Charge Nurse) stated the resident was to be kept off her/his coccyx as much as possible, and the resident should not be bridged (propped up with a pillow on each side). On 6/16/16 at 1:35 pm Staff 7 (RNCM) acknowledged the resident's care plan was not updated regarding the presence of a pressure ulcer. On 6/17/16 at 10:20 am Resident 171 was observed to lay in bed on her/his back with pillows underneath. A sign was observed near the resident's bed which indicated the resident was to be bridged (propped up on both sides with pillows underneath the resident's body). When asked how the resident was positioned, Staff 16 (CNA) stated the resident was propped up with pillows under her/his left side only and was not bridged. When asked why the resident was not bridged, Staff 16 stated the charge nurse instructed her to not bridge the resident. On 6/17/16 at 11:01 am Staff 7 acknowledged the resident's care plan was not updated regarding the coccyx pressure ulcer or proper positioning. | 2020-09-01 |
| 2457 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 322 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility used inappropriate technique to administer medications via [DEVICE] ([DEVICE]) and failed to provide appropriate positioning for 1 of 1 sampled residents (# 171) reviewed for tube feeding. This placed residents at risk for [DEVICE] complications. Findings include: Resident 171 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The facility's policy and procedure for Administration of Medications With Tube Feedings dated 2003 indicated to pour the liquefied medications into the syringe and allow it to flow by gravity into the tube. Never force fluid into the tube. Resident 171's (MONTH) (YEAR) MAR indicated [REDACTED]. On 6/16/16 at 7:05 am Staff 1 (CMA) stated she had already administered Resident 171's 8:00 am medications via [DEVICE]. She described the procedure she used including the use of a 60 ml syringe to push the medications into the [DEVICE]. Staff 1 stated she was taught the procedure by Staff 2 (RN). On 6/16/16 at 7:54 am Staff 2 stated she trained Staff 1 how to administer medications via [DEVICE]. Staff 1 acknowledged she instructed Staff 1 to use a syringe to push the medications into the [DEVICE]. Staff 2 stated she did not know what the facility's policy and procedure was for the administration of medications via [DEVICE]. On 6/16/16 at 11:18 am Staff 4 (LPN) stated she always administered Resident 171's medication by gravity into the [DEVICE]. She never forced the medications in because it could cause some reflux and last week the resident complained of burning in the throat. On 6/17/16 at 9:35 AM Staff 3 (DNS) acknowledged the facility's policy and procedure indicated medications were to be administered using gravity into the [DEVICE]. b. A physician's orders [REDACTED]. A nurse's order dated 6/11/16 indicated the head of the resident's bed was to be elevated 30 degrees at all times. A review of the resident's current care plan, updated 6/11/16, did not indicate the rate of flow for the tube feeding formula, nor information regarding elevation of the head of the bed. On 6/13/16 at 2:02 pm Resident 171 was observed to lay in bed with a feeding tube running. The head of the resident's bed was observed to be slightly elevated, approximately 20 degrees. On 6/16/16 at 9:35 am Resident 171 was observed to lay in bed with the head of the bed slightly elevated, approximately 20 degrees. On 6/16/16 at 9:40 am Staff 16 (CNA) stated she positioned the resident's bed to its current position and expressed belief that the head of the bed was elevated to approximately 45 degrees. On 6/16/16 at 11:18 am Staff 4 (LPN/Charge Nurse) accompanied surveyors to the resident's room and confirmed the head of the bed was elevated to approximately 20 degrees. Staff 4 stated the head of the bed needed to be elevated in order to avoid reflux of the tube feeding formula. Staff 4 adjusted the head of the bed to approximately 45 degrees and stated she preferred to position the bed to 45 degrees, but the minimum was 30 degrees. On 6/17/16 at 10:18 am Resident 171 was observed to lay in bed with the head of the bed elevated approximately 30 degrees. A sign was observed over the resident's bed which indicated the head of the bed was to be elevated to 45 degrees. On 6/17/16 at 11:01 am Staff 7 (RNCM) acknowledged Resident 171's care plan did not indicate the rate of flow for the resident's feeding tube nor have information about elevation of the head of the resident's bed. | 2020-09-01 |
| 2458 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 325 | G | 0 | 1 | YU2V11 | **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 care and services were provided to maintain acceptable nutritional parameters for 1 of 3 sampled residents (# 133) reviewed for nutrition. Resident 133 experienced a severe weight loss of ten pounds in one month. Resident 133's plan of care was not fully implemented, the effectiveness of the interventions were not evaluated timely and Resident 133 experienced a subsequent severe weight loss of 13.5 pounds in one month. Findings include: Resident 133 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 133's 2/9/16 Admission MDS and corresponding Nutritional Status and Dehydration/Fluid Maintenance CAAs indicated the resident ate independently with set-up and had no dental issues. The resident's weight during the assessment period was 173 pounds, with a recent weight gain and bilateral lower extremity [MEDICAL CONDITION]. The resident received a regular texture diet and had good intake. Compression stockings, lower extremity elevation and daily weights appeared to improve the [MEDICAL CONDITION]. Resident 133's 2/2/16 comprehensive care plan indicated the resident had potential for fluid volume imbalance related to [MEDICAL CONDITION]. The resident's vital signs and weight were to be obtained and recorded daily. A 4/1/16 progress note revealed Staff 23 (Registered Dietitian, RD) assessed Resident 133's weight was 163 pounds on 4/1/16. The resident was within her/his ideal body weight range, had recent bilateral [MEDICAL CONDITION] and good meal intake. It was noted 90 ml of house supplement (enhanced calorie drink) was ordered on [DATE] but had not been implemented, . may be just below kcal (caloric requirements) without the house supp(lement) . the house supp will be added to the MAR. Will proceed to care plan and monitor (her/his weight) at the NAR (Nutrition at Risk) meetings. Resident 133's Weight Tracking Report revealed the following weights: 2/6/16 172 pounds; 3/2/16 160 pounds; 4/2/16 162 pounds; and 5/2/16 152 pounds. This was a loss of ten pounds (6%) in one month and 20 pounds (11.6%) in three months, which constituted a severe weight loss. Resident 133's clinical record revealed the 5/2/16 weight of 152 pounds was the only weight documented in (MONTH) (YEAR). Resident 133's 5/11/16 Quarterly MDS indicated the resident's weight was 152 pounds, the resident had a weight loss of 5% or more in the last month and was not on a physician-prescribed weight-loss regimen. On 5/24/16 Staff 22 (Dietary Manager) completed a Quarterly Dietary Assessment, . has lost 7% wt (weight) in 30 days and 7% since admit . is weighed daily . related to [MEDICAL CONDITION] . has a history of fluctuating wts . RD evaluation done 4/1/16 and (she/he) is discussed at NAR. Supplements were increased to three times daily on 5/14/16 . is not a picky eater . does have a small appetite . Care plan wt goal was not met and was changed to maintain wt. at or near 150# . Continue to monitor at NAR. On 5/24/16 Staff 5 (RNCM) documented a Quarterly Assessment which noted the resident was independent in nature and chose to spend most of her/his days in recliner or bed. The assessment addressed recent changes in the resident's condition related to syncopal episodes ([MEDICAL CONDITION], at times with loss of consciousness) and hospitalization s, but it did not address the resident's nutrition, weight or weight loss. Resident 133's comprehensive care plan, updated 5/24/16, identified nutritional concerns related to potential for weight fluctuations due to [MEDICAL CONDITION] and weight loss. Interventions included daily weights, diet as ordered, offer menu choices, Dietitian consult PRN and house supplements as ordered. The resident required set-up assistance as needed, and fed her/himself. Resident 133's clinical record lacked documented evidence of daily weights between 5/2/16 and 5/20/16. A 6/1/16 progress note, documented by Staff 23 revealed, 5/2/16 wt reflects an overall 11# (pound) wt loss from the month before or 6.7% decrease . It further noted the resident readmitted to the facility after a hospitalization , had improved [MEDICAL CONDITION] and a new [MEDICAL CONDITION] medication which may help to explain wt loss . House supps were increased to TID (90 ml each) in response to wt loss . Will proceed to careplan and monitor (her/his) wt at the NAR meetings. Meal intake and acceptance of house supplements were noted to be good. Resident 133's Weight Tracking Report revealed the resident weighed 138.5 pounds on 6/4/16, this was an additional loss of 13.5 pounds (8.8%) in one month, and constituted a subsequent severe weight loss. There was no documented assessment or evaluation of Resident 133's continued weight loss. A 6/8/16 progress note, written by Staff 5 revealed, Wt loss increased health shake supplement from 90 ml to 120 ml, physician and (family) notified, will recheck wt (every two weeks). There was no documented assessment or evaluation of Resident 133's weight loss. On 6/14/16 at 2:32 pm Resident 133 was observed in bed. When asked about the food and if staff spoke to her/him about her/his weight, the resident said the food was ok, but she/he was not a big eater. The resident also said the head nurse spoke to her/him and said they thought she/he lost weight. On 6/16/16 at 7:33 am Staff 18 (CNA) stated the resident's appetite varied. The resident ate in her/his room and needed set-up. The resident liked breakfast and fresh fruit. Staff 18 also stated she weighed the resident on the scale in the west shower room. Staff 18 said all residents were weighed monthly and if a resident's care plan identified daily weights, it showed up on the computer as an assignment for the CNAs. On 6/16/16 at 7:38 am Staff 17 (CNA) stated she regularly worked with Resident 133 and thought the resident was weighed monthly. Staff 17 stated weights were documented on paper and in the electronic system. Staff 17 indicated she weighed the resident earlier in the month and used the wheelchair scale in the shower room. She stated she generally weighed the resident and her/his wheelchair separately. She stated the resident did not eat well and it was not a new issue. On 6/16/16 at 9:08 am Resident 133 was observed awake in bed. A covered breakfast tray was on the tray table in front of the resident and she/he was setting up straws. The resident uncovered the plate to reveal one large pancake with syrup, a cup of peaches, a glass of milk, cup of coffee and two glasses of ice water. At 9:35 am the resident stated she/he ate everything and the surveyor observed the empty plate and fruit cup. The glass of milk remained full. On 6/16/16 at 9:18 am Staff 5 said the resident did not eat like she/he should and sometimes said she/he was not hungry. Staff 5 stated the resident had weight loss and she thought it was related to depression and pain. The resident was started on an antidepressant. Staff 5 stated Staff 3 (DNS), Staff 22, Staff 23, and RNCMs met monthly and as needed for the NAR. She stated Staff 3 maintained meeting notes and RNCMs were responsible for implementing recommendations. On 6/16/16 at 10:09 am the RN surveyor observed staff weigh Resident 133 on the wheelchair scale. The total weight was 181 pounds and the wheelchair was reported to weigh 43 pounds. Resident 133's weight was 138 pounds. On 6/16/16 at 1:00 pm Staff 17 delivered and set up the resident's lunch tray. Fresh fruit, a hamburger with condiments and potato chips were served to the resident. At 1:47 pm the resident no longer had the tray and Staff 17 stated the resident ate 100%. On 6/16/16 at 1:04 pm Staff 23 said she was on-site weekly and NAR was held monthly. Staff 23 stated the resident lost 11 pounds from April, which she contributed to the hospitalization and supplements were increased. Staff 23 said in (MONTH) the resident's weight was stable. When asked about which residents were followed at NAR, Staff 23 said weights for the building were reviewed and residents with significant changes were discussed. Staff 23 stated NAR was done last Friday (6/10/16), and Resident 133 was weighed and assessed today (6/16/16). Staff 23 stated she recommended a fortified diet (caloric dense diet), stop the no-added salt diet, and evaluate the antidepressant medication, which she thought caused the weight loss. When asked if she reviewed the care plan and CNA charting as part of her review, Staff 23 stated, Yes. When asked if she was aware Resident 133's care plan had an intervention of daily weights, Staff 23 stated she deleted the intervention today (6/16/16). Staff 23 stated she wanted to review why Staff 22 indicated the resident was weighed daily. On 6/16/16 at 1:55 pm Staff 22 stated she obtained her information for dietary reviews from residents, interviews with staff and the residents' charts. Specific diet orders came from the nursing staff as did information such as skin issues, and changes in preferences or health status. Staff 22 stated she reviewed weights from the electronic record and wrote nutritional care plans. Staff 22 stated she was familiar with the resident and the last time she spoke with her/him the resident was focused on recent health changes and it was difficult to get the resident to talk about food. Staff 22 was not sure if the resident was weighed daily. On 6/16/16 at 2:13 pm and 3:10 pm Staff 23 stated Resident 133 was on the list of residents to be reviewed at the 5/9/16 NAR. She said she notified Staff 5 she was not able to assess the resident that week due to the number of other residents to review but they decided to increase the house supplement from 90 ml once daily to 90 ml TID. Staff 23 stated she did not assess Resident 133 until 6/1/16 and no recommendations were made because the supplement was increased. Staff 23 said the (MONTH) NAR was last week and the resident was assessed today (6/16/16). When asked if a more current weight should have been reviewed for the 6/1/16 assessment, Staff 23 stated she thought the resident's weight was on the up-swing, with an upward trend and a monthly weight was fine. The 6/16/16 RD Assessment revealed, Wt 6/16/16 138# reflects an overall 14# wt loss since RD eval(ulation on) 6/1/16 . or 9.2% decrease. RCM reports no [MEDICAL CONDITION]. Current wt is below (ideal body weight range) 139-169 and is low for (her/him) . From 4/2/16 to 5/2/16 Resident 133 experienced a severe weight loss of ten pounds (6%) in one month. Between 5/2/16 and 5/20/16 the resident was not weighed daily in accordance with her/his care plan. On 6/1/16 the ten pound weight loss from (MONTH) (YEAR) to (MONTH) (YEAR) was evaluated and the house supplement was increased from 90 ml TID to 120 ml TID. On 6/4/16 the resident's weight was 138.5 pounds, which was an additional loss of 13.5 pounds (8.8%) in one month, and constituted a severe weight loss. There was no documented assessment or evaluation of the resident, the care plan and effectiveness of the nutritional interventions regarding Resident 133's continued weight loss until 6/16/16. On 6/17/16 at 10:49 am Resident 133's continued weight loss, the failure to timely and accurately evaluate the resident's nutritional status and implement the care plan was discussed with Staff 3, Staff 5 and Staff 23. Staff 3 stated RNCMs were responsible for updating care plans and charge nurses were responsible for care planned daily weight monitoring. Staff 5 stated she thought the health shake increase would stabilize the weight and they followed the resident at NAR. | 2020-09-01 |
| 2459 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 329 | E | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to monitor the effectiveness of PRN medications and assess residents prior to the administration of PRN medications for 5 of 5 sampled residents (#s 16, 45, 53, 81, and 169) reviewed for unnecessary medications. This placed residents at risk for use of unnecessary medications. Findings include: 1. Resident 53 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A review of Resident 53's (MONTH) and (MONTH) (YEAR) MARs revealed the following: - The resident was administered PRN [MEDICATION NAME] (over the counter pain medication) five times and was not reassessed for the effectiveness of the medication four times. - The resident was administered PRN [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 14 times and was not reassessed for the effectiveness of the medication 11 times. On 6/16/16/ at 11:18 am Staff 5 (RNCM) verified the lack of effectiveness documentation on Resident 53's (MONTH) and (MONTH) (YEAR) MARs. b. The Oregon State Board of Nursing Standards and Authorized Duties for the Certified Nursing assistant and Certified Medication Aide indicated the following: (2) Administration of PRN Medications. A CMA may administer PRN medications (including controlled substances) to stable clients according to physician's or nurse practitioner's orders in the following circumstances: (a) In response to specific client requests: (A) Client request must be reported to licensed nurse; and (B) Client response must be reported to licensed nurse. (b) At the direction of the licensed nurse, when: (A) A licensed nurse assesses the patient prior to administration of the PRN medications; and (B) A licensed nurse assesses the patient following the administration of the PRN medication. A review of Resident 53's (MONTH) and (MONTH) (YEAR) MARs revealed the following: - The resident was administered PRN [MEDICATION NAME] (over the counter pain medication) by a CMA four times. The MAR indicated [REDACTED]. - The resident was administered PRN [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) by a CMA nine times. The MAR indicated [REDACTED]. On 6/15/16 at 12:00 pm Staff 10 (CMA) stated if a resident needed pain medication she asked the resident what the pain level was between one and ten, where the pain was and she charted that in the MAR. Then she administered the pain medication and signed it out if it was a narcotic. Then she would let the nurse know. On 6/15/16 at 12:05 pm Staff 9 (RN) stated it was okay for veteran CMAs to give PRN medications on their own initiative, including narcotics. On 6/15/16 at 12:45 pm and 6/17/16 at 9:35 am Staff 3 (DNS) stated sometimes it was okay for CMAs to administer PRN narcotics and [MEDICAL CONDITION] on their own initiative. Staff 3 verified the lack of licensed nurse assessment documentation on Resident 53's (MONTH) and (MONTH) (YEAR) MARs prior to the administration of PRN medications by CMAs. 2. Resident 81 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 81's (MONTH) and (MONTH) (YEAR) MARs revealed the following: - The resident was administered [MEDICATION NAME] (antianxiety medication) ten times and was not reassessed for the effectiveness of the medication nine times. - The resident was administered [MEDICATION NAME] (over the counter pain medication) five times and was not reassessed for the effectiveness of the medications on any of the five occasions it was administered. - The resident was administered [MEDICATION NAME] (narcotic pain medication) two times and was not reassessed for the effectiveness of the medication one time. On 6/16/16 at 11:54 am Staff 7 (RNCM) verified the lack of medication effectiveness charting on the MAR. 3. Resident 16 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. 3/2/16 Physician orders [REDACTED]. 3/31/16 Physician orders [REDACTED]. A review of Resident 16's (MONTH) and (MONTH) (YEAR) MARs revealed the following: - The resident was administered [MEDICATION NAME] (over the counter pain medication) seven times and was not reassessed for the effectiveness of the medication six times. - The resident was administered [MEDICATION NAME] four times and the need to void or defecate before giving the medication was not documented as assessed on the four occasions. On 6/17/16 at 11:13 am Staff 5 (RNCM) verified the lack of assessment and medication effectiveness charting on the MAR. 4. Resident 45 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. 5/2/16 Physician orders [REDACTED]. A review of Resident 45's (MONTH) (YEAR) MARs revealed the following: - The resident was administered PRN [MEDICATION NAME] one time and was not reassessed for the effectiveness of the medication. On 6/16/16 at 8:06 am Staff 5 (RNCM) verified the lack of medication effectiveness charting on the MAR. 5. Resident 169 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. 5/11/16 admission orders [REDACTED]. Review of Resident 169's (MONTH) and (MONTH) (YEAR) MARs revealed the following: - The resident was administered PRN [MEDICATION NAME] 26 times and the MARs lacked documentation regarding assessment of the efficacy of the medication 23 times. - The resident was administered 1000 mg [MEDICATION NAME] 30 times and the MARs lacked documentation regarding assessment of the efficacy of the medication 27 times. - The resident was administered 650 mg [MEDICATION NAME] 71 times and the MARs lacked documentation regarding assessment the efficacy of the medication 46 times. On 6/17/16 at 10:38 am the failure to ensure Resident 169 was assessed after the administration of PRN medications was discussed with Staff 3(DNS). Staff 2 acknowledged standards of practice require nursing staff to follow-up after PRN medications were administered. | 2020-09-01 |
| 2460 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 441 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined a nurse failed to use proper infection control technique while performing wound care for 1 of 2 sampled residents (# 154) who were reviewed for pressure ulcers. This placed residents at risk for infection and delayed wound healing. Findings include: Resident 154 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. During wound care observation for Resident 154 on 6/15/16 at 10:43 am Staff 11 (LPN) removed the resident's old dressing and without changing gloves or performing hand hygiene started to apply a clean dressing. Staff 11 touched the clean dressing pad with dirty gloves. The RN surveyor stopped Staff 11 from applying the new bandage and explained why. Staff 11 left the room to obtain a clean dressing. | 2020-09-01 |
| 2461 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 463 | D | 0 | 1 | YU2V11 | Based on observation, interview and record review it was determined the facility failed to have functioning call light system in 1 of 5 halls. This placed residents at risk for unmet needs. Findings include: Observation on 6/14/16 at 9:30 am revealed Resident 154 pushed her/his call light button and the call light did not function. On 6/14/16 at 9:31 am Resident 154 stated the call light was not functioning and did not function during the night of 6/13/16. Resident 154 stated she/he reported it to staff. On 6/14/16 at 9:35 am Staff 7 (RNCM) confirmed Resident 154's call light was not functioning. Review of Current Summary (investigation) dated 6/17/16 revealed Staff 12 (CNA) confirmed he was aware the call light was not working during the night of 6/13/16 and did not report the malfunction. | 2020-09-01 |
| 2462 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2016-06-17 | 514 | D | 0 | 1 | YU2V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to maintain complete and accurate treatment records for 1 of 3 sampled residents (# 169) reviewed for non-pressure skin issues. This placed residents at risk for inadequate treatment and monitoring. Findings include: Resident 169 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Skin Assessment Forms documented treatment and dressing changes were provided to a skin tear on Resident 169's left forearm on 5/11/16, 5/18/16, 5/24/16, 5/30/16 and 6/5/16. Skin Assessment Forms documented treatment and dressing changes were provided to a wound to Resident 169's left shin on 5/18/16, 5/24/16, 5/30/16, 6/5/16 and 6/13/16. On 6/13/16 at 3:48 pm dressings were observed on Resident 169's left arm and left shin. The resident stated the skin tears were from a fall and staff cared for them. TARs for 5/2016 and 6/2016 did not include entries for treatments to the resident's left forearm or left shin. On 6/17/16 at 10:36 am Staff 7 (RNCM) acknowledged the lack of treatment records for wound care provided to the resident's left forearm and left shin. | 2020-09-01 |
| 2463 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 157 | D | 0 | 1 | 8MOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to notify a resident's physician and responsible party after a change in condition for 1 of 3 sampled residents (#136) reviewed for pressure ulcers. This placed residents at risk for inappropriate medical care and not being informed of health status. Findings include: The facility's 7/20/16 Change of Condition Policy & Procedure indicated, Purpose: To assure that all change of conditions are reported to the RN Coordinator and the Director of Nursing. To assure that all change of conditions are adequately assessed by a RN and reported to the physician and significant other. To assure that appropriate interventions are implemented both to correct change and prevent further problems. The policy continued, The nurse on duty will evaluate the change of condition and determine the need for care and services. The physician will be notified immediately if the condition change warrants immediate medical attention . Family members/significant others will be notified of all condition changes. The policy continued, The RN coordinator will assess, investigate, and develop a plan of care for the resident regarding the condition change and future possible changes. The facility's 1/2013 Skin Stamp Protocol Policy & Procedure included notifications of family and physicians when new skin issues were identified. Resident 136 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/4/17 Staff 20 (LPN) documented a Skin Evaluation which indicated an unstageable pressure ulcer was found on Resident 136's outer right ankle. No evidence was found to indicate the resident's physician or responsible party was notified of the wound until 6/13/17 (nine days later). On 9/11/17 at 12:07 pm Staff 17 (RNCM) stated the pressure ulcer was found two days after Resident 136 admitted to the facility. Staff 17 acknowledged there was no evidence the physician or responsible party was notified until 6/13/17. | 2020-09-01 |
| 2464 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 253 | E | 0 | 1 | 8MOX11 | Based on observation and interview it was determined the facility failed to maintain clean equipment in occupied resident rooms on 3 of 4 halls observed. This placed residents at risk for unclean environment. Findings include: On 9/5/17 at 7:33 am Room 28-W was observed to have uncleanable foam taped to the side rails. On 9/5/17 at 7:39 am Room 27-W was observed to have uncleanable foam taped to the side rails. On 9/5/17 at 11:11 am the bathroom in Room 53 was observed to have uncleanable foam taped to the grab bars behind the toilet. On 9/5/17 at 1:06 pm Room 37-W was observed to have uncleanable taped and padded side rails. On 9/6/17 at 12:20 pm the bathroom in Room 54 was observed to have uncleanable foam taped to the grab bars next to the toilet. On 9/7/17 at 9:44 am Staff 1 (Maintenance Supervisor) acknowledged the side rails in rooms 28-W, 27-W, 37-W, and grab bars in bathrooms in rooms 53 and 54 were all uncleanable surfaces. | 2020-09-01 |
| 2465 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 272 | D | 0 | 1 | 8MOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to complete a comprehensive assessment of a resident's pressure ulcer for 1 of 3 sampled residents (#136) reviewed for pressure ulcers. This placed residents at risk for unassessed needs. Findings include: Resident 136 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/4/17 Staff 20 (LPN) documented a Skin Evaluation which indicated an unstageable pressure ulcer was found on Resident 136's outer right ankle. The evaluation described the wound as a raised vesicle with serosanguineous fluid (blister) to the right ankle. The 6/9/17 Pressure Ulcer CAA indicated the resident was at risk for pressure ulcers but did not indicate the presence of a pressure ulcer. On 9/11/17 at 12:07 pm Staff 17 (RNCM) stated the pressure ulcer was found two days after Resident 136 admitted to the facility. Staff 17 acknowledged the 6/9/17 Pressure Ulcer CAA was not comprehensive as it did not reflect the presence of a Stage II pressure ulcer. | 2020-09-01 |
| 2466 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 278 | D | 0 | 1 | 8MOX11 | **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 an MDS regarding the presence of pressure ulcers for 1 of 3 sampled residents (#136) reviewed for pressure ulcers. This placed residents at risk for unidentified needs. Findings include: 1. Resident 136 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. On 6/4/17 Staff 20 (LPN) documented a Skin Evaluation which indicated an unstageable pressure ulcer was found on Resident 136's outer right ankle. The evaluation described the wound as a raised vesicle with serosanguineous fluid (blister) to the right ankle. The 6/9/17 Admission MDS indicated the resident did not have a pressure ulcer. b. Resident 136 readmitted to the facility on [DATE]. A 7/19/17 Physician Fax indicated the resident had a pressure ulcer to her/his right heel and requested treatment orders. The 7/26/17 Admission MDS indicated the resident had a pressure ulcer that was not present on admission. On 9/11/17 at 12:07 pm Staff 17 (RNCM) stated the pressure ulcer was found two days after Resident 136 originally admitted to the facility. Staff 17 acknowledged the 6/9/17 Admission MDS and 7/26/17 Admission MDS were both coded inaccurately. | 2020-09-01 |
| 2467 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 281 | D | 0 | 1 | 8MOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility staff failed to follow professional standards of care for 1 of 3 sampled residents (#136) reviewed for pressure ulcers. This placed residents at increased risk for worsening pressure ulcers. Findings include: Division 45 Standards and Scope of Practice For The Licensed Practical Nurse and Registered Nurse 851-045-0040 . Scope of Practice Standards for All Licensed Nurses . (3) Standards related to the licensed nurse's responsibilities for ethics, including professional accountability and competence. The licensed nurse . (i) Demonstrates honesty and integrity in nursing practice . 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following . (3) Conduct related to communication . (c) Falsifying a client or agency record or records prepared for an accrediting or credentialing entity; including, but not limited to, filling in someone else's omissions, signing someone else's name, record care not given, and fabricating data/values. Resident 136 readmitted to the facility on [DATE]. A 7/19/17 Physician Fax indicated the resident had a pressure ulcer to her/his right heel and requested treatment orders. A 9/7/17 Skin Evaluation written by Staff 8 (LPN) described the wound as, slough (soft, moist, dead tissue on the wound bed) covered wound bed. Mascerated edges. Pink surrounding tissue. On 9/8/17 at 2:50 pm surveyors observed the wound with Staff 21 (LPN). The wound was observed to be resolved. Staff 21 acknowledged the wound was resolved as the wound was closed and the skin was blanchable. On 9/11/17 at 12:07 pm Staff 17 (RNCM) was asked about the description of the wound on the 9/7/17 Skin Evaluation which differed from observations of the wound the next day. Staff 17 stated she asked Staff 8 about the wound and he told her he did not remove the dressing to view the wound even though he documented the 9/7/17 assessment of the wound. Staff 17 acknowledged the 9/7/17 assessment of the wound was inaccurate and Staff 8 should have removed the dressing and viewed the wound in order to complete the assessment. Refer to F314, example 1. | 2020-09-01 |
| 2468 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 309 | D | 0 | 1 | 8MOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to administer bowel medications as ordered for 2 of 5 sampled residents (#s 50 and 56) reviewed for unnecessary medication. This placed residents at risk for complications from constipation. Findings include: The facility's 7/21/16 Bowel Care Protocol policy stated: 1. Every morning, administer: Two tablespoons power pudding with 8 oz. water. 2. If no BM (bowel movement) by day three - give [MEDICATION NAME] (laxative). 3. If no BM by dayshift of day 4 - give [MEDICATION NAME] suppository (laxative). 4. If no BM by dayshift of day 5 - give Fleet saline enema. 1. Resident 56 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. A 5/10/16 physician's orders [REDACTED]. A 5/10/16 physician's orders [REDACTED]. A 6/10/16 physician's orders [REDACTED]. A 10/19/16 physician's orders [REDACTED]. A 10/19/16 physician's orders [REDACTED]. if Step 1 ([MEDICATION NAME]) and Step 2 ([MEDICATION NAME] Suppository) of bowel care was not effective. A 7/5/17 physician's orders [REDACTED]. a. Resident 56's 8/2017 bowel records indicated she/he did not have a bowel movement from 8/3/17 through 8/6/17 (four days). Resident 56's 8/2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. b. Resident 56's 8/2017 bowel records indicated she/he did not have a bowel movement from 8/14/17 through 8/16/17 (three days). Resident 56's 8/2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. c. Resident 56's 8/2017 bowel records indicated she/he did not have a bowel movement from 8/19/17 through 8/21/17 (three days). Resident 56's 8/2017 MAR indicated [REDACTED]. On 9/8/17 at 11:29 am Staff 16 (LPN) stated each day the facility generated a list of residents who did not have a bowel movement for the past three days. Staff 16 stated she provided bowel medications as per the facility protocol and resident preferences. Staff 16 stated residents were to get [MEDICATION NAME] on the first day of being on the list and residents were to receive a suppository on the second day and an enema on the third day. On 9/8/17 at 11:43 am Staff 7 (RNCM) was asked about Resident 56 not receiving PRN bowel medication as ordered and as per the facility protocol for the above dates. Staff 7 stated she did not know what happened. Staff 7 acknowledged there was no information to indicate why the physician's orders [REDACTED]. 2. Resident 50 admitted to the facility in 2/2012 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident 50's 8/2017 bowel record reflected she/he had no bowel movements from: - 8/3/17 - 8/5/17 (three days) - 8/7/17 - 8/9/17 (three days) - 8/11/17 - 8/13/17 (three days) - 8/18/17 - 8/21/17 (four days) A review of Resident 50's 8/2017 MAR indicated [REDACTED]. On 9/8/17 at 1:51 pm Witness 1 (family member) explained during an interview she/he noticed Resident 50 had less bowel movements than usual. On 9/8/17 at 4:15 pm Staff 7 (RNCM) confirmed Resident 50 did not receive [MEDICATION NAME] per the facility's Bowel Care Protocol and physician's orders [REDACTED]. | 2020-09-01 |
| 2469 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 314 | D | 0 | 1 | 8MOX11 | **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 and/or ordered treatment for [REDACTED].#s 49 and 136) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The facility's 1/27/15 Ulcer, Stage II Guidelines Policy & Procedure stated, Definition: Stage II - Partial thickness skin loss of dermis presenting as shallow open ulcer with a red-pink wound bed, without slough. may also present as an intact or open/ruptured blister. The policy continued, The resident, physician and responsible party will be notified of the development of a Stage II pressure ulcer. Interventions are directed toward minimizing and/or eliminating the effects of the causal/contributing factors: pressure, moisture, friction/shear, hydration and nutrition. Observe skin at least daily . Continue to assess. Topical therapy for Stage II included cleansing the wound and applying a dressing. Documentation requirements included notification of resident/family and physician in the medical record, specific interventions such as dressing changes and assessments of the wound at least weekly. The facility's 1/2013 Skin Stamp Protocol Policy & Procedure stated, At initial skin problem, LNs (licensed nurses) will complete 'Skin Stamp'.1. Initiate skin stamp in (electronic health record) 2. Identify on weekly skin condition report. 3. If problem is an ulcer, LNs will stage. 4. Document treatment course. 5. Document cause and preventative measures. 6. If an ulcer, will update careplan. 7. Occurrence Report completed. 8. Family and MD notified. The facility's 12/29/14 Pressure Ulcer, Care and Prevention Policy & Procedure indicated procedures for pressure ulcers included, use elbow and heel protectors if needed. 1. Resident 136 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 136's care plan for pressure ulcer risk, initiated 6/2/17 indicated to reposition the resident frequently and use pressure relieving devices. The 6/2017 TAR indicated interventions to prevent pressure ulcers were put in place on 6/3/17 including turning the resident every two hours and floating the resident's heels. On 6/4/17 Staff 20 (LPN) documented a Skin Evaluation which indicated an unstageable pressure ulcer was found on Resident 136's outer right ankle. The evaluation described the wound as a raised vesicle with serosanguineous fluid (blister) to the right ankle. The Skin Stamp indicated the wound was closed and did not indicate why the wound was identified as unstageable and did not indicate the cause of the pressure ulcer. A Skin/Tissue Event document for the wound identified on 6/4/17 was initiated on 7/3/17 (29 days after the wound was noted), and completed on 8/8/17 (65 days after the wound was noted), indicated the wound was possibly caused by the resident rubbing her/his feet back and forth across the sheet while in bed. No new treatments were noted on the 6/2017 TAR until 6/13/17. No updates were found on the resident's care plan regarding the presence of the pressure ulcer until 7/20/17. The 6/9/17 Admission MDS indicated the resident did not have a pressure ulcer. The 6/9/17 Pressure Ulcer CAA indicated the resident was at risk for pressure ulcers but did not indicate the presence of a pressure ulcer. No evidence was found to indicate the resident's physician or responsible party was notified of the wound until 6/13/17. A 6/13/17 Skin Evaluation document indicated the wound burst open over night. The document did not include a description of the wound. New treatments were put in place including cleaning the wound and applying a dressing. The physician was notified and orders to treat the wound were received. On 9/7/17 at 1:36 pm Staff 16 (LPN) stated she was responsible to contact the doctor and inform the RNCM when new skin issues were identified. Staff 16 stated she also initiated skin reports, wrote incident reports and contacted residents' family members. Staff 16 stated wounds were evaluated by a RN in order to determine if the initial treatment was appropriate or not. A 9/7/17 Skin Evaluation written by Staff 8 (LPN) described the wound as, slough (soft, moist, dead tissue on the wound bed) covered wound bed. Mascerated edges. Pink surrounding tissue. On 9/8/17 at 2:50 pm surveyors observed the wound with Staff 21 (LPN). The wound was observed to be resolved. Staff 21 acknowledged the wound was resolved as the wound was closed and the skin was blanchable. On 9/11/17 at 11:21 am Staff 11 (LPN) stated her responsibilities were to measure and document any new wounds and complete an incident report, including notifying the doctor and family, before leaving. Staff 11 stated she did not stage pressure ulcers as she was unqualified. Staff 11 stated she contacted the RNCM in order to stage pressure ulcers. On 9/11/17 at 12:07 pm Staff 17 (RNCM) stated the pressure ulcer was found two days after Resident 136 admitted to the facility. Staff 17 stated it presented as a Stage II pressure ulcer and acknowledged the documentation describing the wound as an unstageable pressure ulcer was inaccurate. Staff 17 stated LPNs were to inform RNCMs of any identified wounds in order for the RNCMs to assess the wound. Staff 17 acknowledged there was no evidence that the wound was assessed by the RNCM or a RN. Staff 17 acknowledged the Skin/Tissue Event created one month after the wound was identified was not completed on time. Staff 17 acknowledged there was no description of the wound bed in the initial documentation and no new treatments put in place until 6/13/17, nine days after the wound was identified. Staff 17 acknowledged there was no evidence the physician or family was notified until 6/13/17. When asked about the description of the wound on the 9/7/17 Skin Evaluation which differed from observations of the wound the next day, Staff 17 stated Staff 8 told her he did not remove the dressing to view the wound even though he documented an assessment of the wound. Staff 17 acknowledged the 9/7/17 assessment of the wound was inaccurate and Staff 8 should have removed the dressing and viewed the wound. 2. Resident 49 admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. On 6/4/17 a progress note indicated Resident 49 had an open area to the back of her/his left heel with drainage and non-blanchable redness. The 6/4/17 Skin Stamp (weekly wound tracking sheet) indicated Resident 49 had a Stage 2 pressure ulcer on her/his left heel. The 6/7/17 Wound Care Consult indicated Resident 49 had an unstageable pressure injury to the heel and was to receive dressing changes twice weekly and PRN. The 6/25/17 Skin Stamp indicated Resident 49 had an unstageable pressure ulcer on her/his left heel. The 6/2017 TAR indicated Resident 49 received wound care on the following dates:6/7/17, 6/10/17, 6/13/17, 6/15/17, 6/17/17, 6/19/17, 6/21/17, 6/24/17. No wound care treatment was recorded on the TAR from 6/24/17 to 6/30/17. The 6/30/17 progress note indicated Resident 49 discharged from the facility. On 9/11/17 at 10:24 am Staff 5 (DNS) acknowledged the pressure ulcer treatments were not completed as ordered by the physician. | 2020-09-01 |
| 2470 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 356 | F | 0 | 1 | 8MOX11 | Based on observation, interview and record review the facility failed to ensure daily staffing reports were posted for 1 of 5 days reviewed for posted staffing reports. This placed visitors and residents at risk for lack of staffing information. Findings include: On 9/5/17 at 7:15 am the facility's Direct Care Staff Daily Report was posted in a central area near the entrance, but was noted to reflect the staffing for 9/3/17. No staffing information for 9/5/17 was observed. On 9/5/17 at 7:26 am Staff 18 (CEO) acknowledged the Direct Care Staff Daily Report was not updated since 9/3/17. On 9/6/17 at 3:15 pm Staff 19 (Administrator) acknowledged the Direct Care Staff Daily Report was not current when observed on 9/5/17. | 2020-09-01 |
| 2471 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 371 | F | 0 | 1 | 8MOX11 | Based on observation, interview and record review it was determined the facility failed to ensure food was stored in a safe and sanitary manner for 1 of 1 kitchen observed for safe food service. This placed residents at risk for potential foodborne illness. Findings include: The 1/2017 Food and Supply Storage Policy stated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Date and rotate items; first in, first out. Discard food past the use-by or expiration date. On 9/5/17 at 7:36 am one freezer, two walk-in coolers and one bread rack were observed to contain multiple expired food items, including meats, dairy products and bread with visible mold. The expired food included, but was not limited to; shrimp with a use by date of 8/18/17, Feta cheese which expired 8/24/17, molded sourdough bread with a use by date of 8/31/17 and ham which had expired on 9/2/17. In an interview on 9/5/17 at 7:51 am Staff 2 (Cook) acknowledged the items were expired and confirmed the items should have been discarded upon expiration. In an interview on 9/5/17 at 9:52 am Staff 3 (Executive Chef) confirmed he observed the expired items in the freezer and cooler and stated he felt the items were mislabeled. He stated the items were discarded and were not served to residents. In an interview on 9/8/17 at 2:12 pm Staff 4 (Nutrition Care Manager) confirmed expired food items were to be discarded when they reached their use-by date. | 2020-09-01 |
| 2472 | MENNONITE HOME | 385206 | 5353 COLUMBUS STREET SE | ALBANY | OR | 97321 | 2017-09-11 | 431 | D | 0 | 1 | 8MOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to record the date opened for a vial of Aplisol (used for testing to aid in the [DIAGNOSES REDACTED]. This placed residents at risk for decreased medication efficacy. Findings include: On 9/8/17 at 9:59 am the Doves Nest medication room refrigerator was observed to have an open vial of Aplisol without an open date indicated. The manufacturer's instructions indicated to discard the vial 30 days after opening. On 9/8/17 at 9:59 am Staff 6 (RN) acknowledged the Aplisol was open and did not have an open date label. | 2020-09-01 |
| 2620 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 253 | E | 0 | 1 | 14W711 | Based on observation and interview it was determined the facility failed to maintain a sanitary and orderly environment for 7 of 26 resident rooms (#s 103, 210, 214, 304, 305, 306, 307) and 1 of 3 halls (200 hall) reviewed for environment concerns. This placed residents at risk for an uncomfortable an odorous living environment. Findings include: a. On 3/7/17 at 9:26 am resident room 214 was observed with missing/scratched paint on the walls. On 3/7/17 at 11:14 am the shared bathroom between resident rooms 305 and 307 was observed unclean with damaged and missing floor tiling. The toilet was unclean with black grim on the floor around the toilet. The bathroom smelled of urine. On 3/7/17 11:43 am the shared bathroom between resident rooms 304 and 306 was observed with missing floor tiling and a hole in the wall near the floor The toilet was unclean with bits of yellow/brown dried substance around the front of the toilet. The bathroom smelled of urine. On 3/7/17 at 12:43 pm resident room 210 was observed with missing drywall near the entry to the bathroom as well as missing drywall in the corners. The wall behind the toilet had a smear of dried brown substance and the tile flooring was unclean with black grout. On 3/7/17 at 3:05 pm resident room 304 was observed with deep gouges in the floor, scratched/missing paint on the wall near the resident's bed and the heating/cooling unit had black marks across the front of the unit. On 3/7/17 at 3:36 pm resident [RM #] was observed with damaged/missing paint on the wall next to the head of the bed. On 3/10/17 at 2:04 pm Staff 14 (Maintenance Director) acknowledged resident rooms and bathrooms #s 103, 210, 214, 304, 305, 306 and 307 were in disrepair and unclean. Staff 14 stated he did not have enough time to complete the long list of maintenance projects. Staff 14 further stated he did not have an assistant and had asked management for help. Staff 14 acknowledged the bathrooms were unclean and stated it was difficult to find regular housekeeping staff to complete housekeeping duties. Staff 14 stated the bathroom toilet and floor areas were cleanable and could be scrubbed with a chemical cleaning agent. On 3/10/17 at 3:08 pm Staff 16 (Administrator) was informed resident rooms and bathrooms #s 103, 210, 214, 304, 305, 306 and 307 were observed in disrepair and unclean. O2100 b. On 3/7/17 at 9:37 am an over toilet commode in room 103ls resident bathroom was observed to have dry brown caked substance present. Staff 8 (CNA) acknowledged the commode was dirty with a brown substance. Staff 8 stated housekeeping usually cleaned the commode when CNAs notify them. On 3/10/17 at 9:44 am Staff 9 (housekeeper) stated resident room commodes were cleaned by CNA staff. Staff 9 stated housekeeping cleans toilets but not commodes. On 3/10/17 at 12:32 pm Staff 10 (CNA) stated CNAs are responsible to clean bowel residue from commodes following resident use and routine general cleaning of commodes are conducted by housekeeping staff. On 3/10/17 at 12:36 pm Staff 4 (interim DNS) stated CNAs are responsible to clean commodes with bowel residue in the dirty utility room. On 3/10/17 at 12:41 pm Staff 11 (CNA) stated housekeeping are responsible to clean dirty commodes. On 3/10/17 at 12:45 pm Staff 12 (Housekeeping) stated CNAs are responsible to clean commodes. Staff 12 stated the CNAs notified housekeeping who followed-up to disinfect the commode. c. On 3/9/17 at 3:47 pm equipment stored in hall 200 was observed to be unclean. A Hoyer elevate lift had black greasy particles on multiple top surfaces, and an Invacare reliant RPS 350 lift had dust to multiple surfaces. On 3/9/17 at 3:57 pm Staff 6 (LPN pt care coordinator) believed central supply staff clean the lift equipment. Staff 6 observed the lift equipment in hall 200 and acknowledged it was unclean. On 3/10/17 at 9:05 am Staff 14 (Maintenance Director) stated he was responsible to perform equipment maintenance but he did not clean the equipment. Staff 14 stated he was not aware who was responsible to clean the equipment. On 3/10/17 at 9:44 am Staff 9 (Housekeeper) stated she did not know who was responsible to clean resident equipment. On 3/10/17 at 9:51 am Staff 15 (CNA) stated she did not know who was responsible to clean resident equipment. | 2020-09-01 |
| 2621 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 257 | D | 0 | 1 | 14W711 | Based on observation and interview it was determined the facility failed to provide a comfortable temperature for 1 of 26 (#201) resident rooms reviewed for comfortable temperatures. This placed residents at risk for an uncomfortable environment. Findings include: On 3/6/17 at 1:55 pm Resident 47 stated her/his room (#201) was cold at night and the heater only blew cold air. Resident 47 stated her/she used blankets to keep warm. On 3/10/17 at 1:41 pm Staff 14 (Maintenance Director) stated each room was equipped with a heat and cooling unit which allowed each room to be adjusted for individual resident preference. Staff 14 stated he did not have a system to check resident room temperatures. Staff 14 further stated the heating and cooling units were not inspected to ensure proper functioning. On 3/10/17 at 2:47 pm Staff 16 (Administrator) was informed the heating and cooling unit for Resident 47 was not working properly. Staff 16 acknowledged the facility did not have a process to check resident room temperatures and ensure the heating and cooling units worked properly. | 2020-09-01 |
| 2622 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 272 | D | 0 | 1 | 14W711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to comprehensively assess 3 of 8 sampled residents (#s 26, 48 & 54) reviewed for medications, range of motion and pressure ulcers. This placed residents at risk for unmet needs. Findings include: 1. Resident 54 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The annual MDS ADL CAA dated 12/23/16 indicated Resident 54 continued to require assistance with mostly transfers and dressing. The CAA also indicated the resident directed her/his own care. The ADL CAA failed to indicate Resident 54's level of assistance she/he required, her/his decreased ROM and how the resident's pain issues contributed to her/his ADL care needs. On 3/9/17 at 11:19 am Staff 1 (MDS Coordinator) confirmed Resident 54's ADL CAA was not comprehensive. 2. Resident 48 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Signed physician orders [REDACTED]. The [MEDICAL CONDITION] Drug CAA dated 2/27/17 did not include any information regarding [MEDICATION NAME] and [MEDICATION NAME] use, side effects and non-pharmacological interventions. On 3/10/17 at 2:36 pm Staff 1 (MDS Coordinator) acknowledged the CAA did not include information for [MEDICATION NAME] and [MEDICATION NAME] use, side effects or non-pharmacological interventions. 3. Resident 26 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/9/17 at 9:13 am Staff 5 (RN) provided wound care to Resident 26's feet. Three wounds were observed on the left foot, and one on the right foot. Review of the 12/14/16 Pressure Ulcer CAA Summary identified four open areas on her/his feet, two on each. Interventions included BID dressing changes, non-weight-bearing status and (pressure ulcer) prevention interventions in place upon admit and continue. No evidence was found that described the resident's foot wounds, or identified risk factors having an impact on the development, treatment and healing for each wound. On 3/9/17 at 11:34 am and 12:15 pm Staff 6 (LPN Patient Care Coordinator) was asked to provide the current comprehensive assessment for Resident 26's foot wounds. No other assessment was provided. | 2020-09-01 |
| 2623 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 314 | D | 0 | 1 | 14W711 | **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 necessary treatment and services to promote healing for 1 of 2 sampled residents reviewed for pressure ulcers. This placed residents at risk for unmet wound care needs. Findings include: Resident 47 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On 3/10/17 at 9:11 am Resident 47 was observed to have a white piece of felt covering the wound on the left ankle. On 3/10/17 at 9:11 am Staff 2 (LPN) stated the wound should be covered with a dressing instead of the felt. She cleansed the area and covered it with [MEDICATION NAME] ointment and foam dressing. On 3/10/17 at 10:00 am Staff 2 (LPN) acknowledged she removed a piece of felt from Resident 47's ankle wound which was not the physician ordered dressing. | 2020-09-01 |
| 2624 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 332 | D | 0 | 1 | 14W711 | **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 2 errors in 26 opportunities which resulted in an error rate of 7%. This placed residents at risk for medication side effects and ineffective medication management. Findings include: 1) Resident 55 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident 55's (MONTH) (YEAR) MAR indicated [REDACTED]. On 3/6/17 at 12:06 pm Staff 3 (RN) stated the resident requested not to get the insulin that morning. On 3/6/17 at 12:08 pm Staff 3 was observed to go to Resident 55's room to administer the 8:00 am [MEDICATION NAME] insulin. Staff 3 stated she was going to give the insulin and then notify the physician. This surveyor asked Staff 3 to stop before administering the resident's insulin. Staff 3 stated she would notify the physician before giving the [MEDICATION NAME]and took the insulin back to the treatment cart. 2) Resident 54 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On 3/7/17 at 7:39 am Staff 3 (RN) was observed to pour 40 ml (1600 mg) of [MEDICATION NAME] 40 mg/ml into a cup to be administered to Resident 54. The correct dose was 5 ml of [MEDICATION NAME] (200 mg). This surveyor asked for clarification regarding the dosage poured. Staff 3 acknowledged she poured 40 ml (1600 mg) for Resident 54 instead of the 5 ml (200 mg) that was ordered. She acknowledged she made a mistake, disposed of the 40 ml (1600 mg) and poured the correct amount of 5 ml (200 mg) to be administered to the resident. | 2020-09-01 |
| 2625 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 334 | D | 0 | 1 | 14W711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** O2100 Based on interview and record review it was determined the facility failed to offer an influenza immunization for 1 of 5 sampled residents (#5) and a pneumococcal immunization for 1 of 5 sampled residents (#39) reviewed for immunizations. These placed residents at risk for communicable infections. Findings include: 1) Resident 5 was admitted to the facility (YEAR) with [DIAGNOSES REDACTED]. Resident 5's current record revealed the resident was neither offered nor received the influenza vaccine. On 3/9/17 at 4:14 pm Staff 4 (Interim DNS) acknowledged Resident 5 was not offered nor received the influenza immunization. 2) Resident 39 was admitted in 7/2016 with [DIAGNOSES REDACTED]. Resident 39's current record showed no information regarding a pneumococcal immunization. On 3/10/17 at 2:58 pm Staff 7 (RN Consultant) stated no record of pneumococcal immunization for Resident 39 was located. No further information was provided. | 2020-09-01 |
| 2626 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 431 | D | 0 | 1 | 14W711 | Based on observation and interview it was determined the facility failed to label insulin with date opened in 2 of 3 medication carts and 1 of 2 treatment carts. This placed residents at risk for receiving medications with decreased efficacy. Findings include: 1. On 3/6/17 at 11:59 am the 100 hall treatment cart was observed to contain a Levemir insulin pen without an open date. On 3/6/17 at 12:02 pm Staff 3 (RN) acknowledged the Levemir insulin pen was not labeled with an open date. 2. On 3/6/17 at 12:36 pm the 100 hall treatment cart was observed to contain a Novolog insulin flex pen without an open date. On 3/6/17 at 12:36 pm Staff 17 (RNCM) acknowledged the Novolog insulin flex pen was not labeled with an open date. 3. On 3/6/17 at 12:30 pm the 300 hall medication cart was observed to contain a Novolog vial without an open date. On 3/6/17 at 12:30 pm Staff 18 (LPN) acknowledged the Novolog insulin vial was not labeled with an open date. 4. On 3/6/17 at 12:34 pm the 200 hall medication cart was observed to contain a Lantus insulin pen not labeled with an open date. On 3/6/17 at 12:34 pm Staff 19 (LPN) acknowledged the Lantus insulin pen was not labeled with an open date. | 2020-09-01 |
| 2627 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-10 | 441 | E | 0 | 1 | 14W711 | **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 appropriate hand washing, glove and gown use and infection control practices for 2 of 2 sampled residents (#s 26 & 47) during pressure ulcer care (1 of 2 residents who required contact isolation precautions). The facility also failed to keep reusable resident equipment clean for 5 of 5 reusable resident equipment. This placed residents at risk for cross contamination. Findings include: 1. Resident 47 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. On 3/8/17 at 10:40 am Staff 3 (RN) stated Resident 47 was on contact precautions for MRSA (antibiotic resistant infection). On 3/10/17 at 9:11 am Staff 2 (LPN) was observed to complete wound dressing changes for Resident 47 while wearing a gown and gloves. At 9:41 am Staff 2 stepped outside of Resident 47's room into the hallway while wearing the gown and gloves that were worn inside Resident 47's room. On 3/10/17 at 10:00 am Staff 2 acknowledged she stepped outside of the resident's room without removing gown and gloves or washing her hands. b. On 3/10/17 at 9:11 am Staff 2 (LPN) was observed to complete wound dressing changes for Resident 47 while wearing a gown and gloves. On 3/10/17 at 10:00 am Staff 2 was observed to remove her gloves and wash her hands. She then removed her gown. Staff 2 then exited Resident 47's room without washing her hands after removing her gown. On 3/10/17 at 10:00 am Staff 2 acknowledged she did not wash her hands after removing her gown in Resident 47's room. 2. Resident 26 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/9/17 at 9:13 am Staff 5 (RN) was observed providing wound care to Resident 26's bilateral foot wounds. Staff 5 washed her hands, donned blue exam gloves, prepared supplies, handled the bed control, and then left the room to gather additional supplies and touched the room door handle while still wearing gloves. Staff 5 returned to the room without gloves on, continued preparations and put on new gloves without sanitizing her hands. Staff 5 then removed the old dressings from Resident 26's left foot including wound packing, and then placed new wound packing and applied new dressings. Staff 5 did not change her gloves or sanitize her hands after removing the old dressings and wound packing before applying new wound packing and dressings. Staff 5 then reached into her pocket with the same pair of gloves on her hands to retrieve the dressing scissors, changed the dressing to the resident's right foot, and afterward touched room furnishings such as drawers and cabinet doors while searching for socks. During the dressing change procedure Staff 5 tossed all waste materials directly onto the floor. Staff 5 was not observed to change her gloves or sanitize her hands during the dressing change procedure. A review of the current facility wound care protocol revealed the instruction to place a disposal bag nearby to collect soiled dressings .remove old dressings, one layer at a time, and place them in a disposable bag during dressing changes. On 3/9/17 at 11:13 am Staff 5 stated she was distracted during wound care and was not sure if changed gloves and sanitized her hands at each stage of the wound care process. She further stated she she should not have placed waste materials on the floor. On 3/9/17 at 4:23 pm Staff 4 (Interim DNS) acknowledged Staff 5's infection control practices during the wound care observation were incorrect. | 2020-09-01 |
| 2628 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-03-14 | 689 | D | 1 | 0 | GV5111 | **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 equipment and measures were in place for 2 of 3 sampled residents (#s 1 and 2) who were reviewed for falls. As a result the residents fell and sustained minor injuries. Findings include: 1. Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 9/13/17 a MDS assessment identified the resident was totally dependent for transfers and locomotion. Resident 1 had range of motion impairment, both upper and lower, on both sides of the body. The assessment indicated the resident used a wheelchair for mobility and had no falls since the prior assessment. Resident 1's care plan identified the resident was totally dependent on two staff and a mechanical lift for transfers and one staff for locomotion using a tilt-in-space wheelchair (a reclining wheelchair). The plan indicated the resident was at risk for falls due to her/his chronic medication condition and directed staff to adjust the wheelchair's tilt to ensure Resident 1's safety. On 11/15/17 at 9:00 am an Incident Note identified the resident yelled for help before falling to the floor. The resident was found face first on the floor and with a hematoma (blood-filled swelling) to the left upper forehead. The resident was sent out to the hospital. A Fall incident report indicated when staff found the resident in the dining room after the fall, the wheelchair was missing the left side. After interviewing staff, the facility concluded the CNAs forgot to place the left armrest on the wheelchair after transferring Resident 1 into it. The resident was in the dining room eating when she/he fell out of the chair. The facility educated the CNAs on appropriated safety measures and the need to ensure the resident's wheelchair equipment was in place. The Emergency Department report indicated Resident 1 had a ground level fall and sustained a contusion (bruise) to the forehead but the rest of her/his exam was nonremarkable and neurologically the resident seemed at baseline. Resident 1's (MONTH) (YEAR) MAR indicated [REDACTED]. There was no additional pain medication administered after the fall on 11/15/17. November (YEAR) nursing notes were reviewed and there was no indication the resident complained of pain after 11/15/17. In interview on 3/7/18 at 9.47 am Staff 4 (LPN) reported Resident 1 was totally dependent for care and used a tilt-in-space wheelchair. She reported CNAs take one of the sides with the arm rest off during transfers then put the side back in place once the resident is positioned in the chair. On 11/15/18 Resident 1 rolled out of the wheelchair because the side was not put back on. In interview on 3/7/18 at 11:10 am Staff 5 (CNA) reported he and another CNA transferred Resident 1 into the wheelchair on 11/15/17 and brought the resident to the dining room for a meal. He stated they forgot to re-attach the left arm rail after transfer and the resident rolled to the left and fell out of the wheelchair. Staff 5 reported he went through transferring procedures with the DNS after the incident. In interview on 3/7/18 at 11:25 am Staff 6 (CNA) reported she was a float on 11/15/17 and assisted Staff 5 with transferring Resident 1 into the wheelchair. She reported they took the arm rest off the wheelchair to protect the resident from hitting the side and being injured. Staff 6 stated she heard the food carts were out over the loud speaker and was in a hurry to get residents to the dinging room and forgot to replace Resident 1's arm rest before taking the resident to the dining room. She reported the resident had a black eye but didn't complain of pain after the fall. Staff 6 reported she went through a safe transfer training session with the DNS after the incident. In interview on 3/14/18 at 10:41 am Staff 2 (DNS) reported CNAs forgot to replace Resident 1's wheelchair arm rest and the resident fell out of the chair and sustained a bump and bruise on the head. She stated the resident had no change in status related to the fall. 2. Resident 2 was admitted to the facility in 2008 and had [DIAGNOSES REDACTED]. On 1/10/18 a Fall Risk Evaluation indicated the resident was at moderate risk for falls. The residents's care plan identified the resident required one-person extensive assistance for transfers. On 1/16/18 a Fall incident report indicated during a transfer with the CNA, a bad step was taken and Resident 2 fell to the floor hitting her/his head on the right side. The resident was sent to the hospital because the resident was a [MEDICATION NAME] (blood thinner) and was at risk for bleeding. The investigation indicated the CNA transferred the resident without a gait belt and the resident was not strong enough to transfer with one person and no gait belt. The CNA was re-educated by the DNS on the facility gait belt policy. On 1/16/18 a hospital Provider Note indicated they evaluated the resident for a head injury and the imaging results were unremarkable. The resident was treated for [REDACTED]. In interview on 3/7/18 at 11:35 am Staff 9 (CNA) reported every resident had a gait belt in their room and CNAs are supposed to have one on them at all times. He stated if a resident required extensive assistance, a gait belt was used during the transfer. In interview on 3/8/18 at 10:37 am Staff 8 (CNA) reported on 1/16/18 she transferred Resident 2 from the wheelchair to the bed when the resident lost her/his balance and fell . She reported she forgot to put on the gait belt prior to the transfer and stated she usually did and felt horrible after the resident fell . In interview on 3/14/18 at 10:36 am Staff 2 (DNS) reported Resident 2 re-admitted to the facility on [DATE] after a hospitalization . The resident was weak and fell during a transfer and sustained a bruise to the head. Staff 2 confirmed the CNA did not use a gait belt during the transfer and reported it was a standard of care that CNAs use gait belts when transferring residents who require assistance. | 2020-09-01 |
| 2629 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 550 | E | 1 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on observation and interview the facility failed to ensure residents were treated with dignity related to dining needs for 2 of 3 sampled dining areas reviewed for dining and 2 of 2 sampled residents (#s 37 and 44) reviewed for dignity in the dining area. This placed residents at risk for lack of dignity. Finding include: a. On 4/23/18 at 12:19 PM Staff 32 (CNA) was observed feeding residents in the 200 hall dining area. Staff 32 stood in front of or beside residents as she fed them bites of food. On 4/23/18 at 1:00 PM Staff 32 stated she was not able to sit down while feeding residents because she was the only CNA in the dining room and other residents needed assistance. On 4/25/18 at 12:10 PM Staff 33 (CNA) was observed standing over a resident in the 300 hall dining area while she provided feeding assistance to a resident. Staff 33 was observed walking back and forth between residents as she provided feeding assistance while standing over the residents. When interviewed, Staff 33 stated she was supposed to sit down while feeding residents. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated it was important for staff to sit with residents during feeding assistance as this was a dignity issue. b. Resident 37 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/24/18 at 12:22 PM Resident 37 was observed sitting in the 200 hall dining room. Resident 37 was wearing a hospital gown that was not connected in the back and was sagging down leaving the resident's upper back and right shoulder exposed. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated it was important for staff to ensure that residents were covered appropriately as this was a dignity issue. Staff 2 acknowledged Resident 37 was dependent on staff assistance for dressing. c. Resident 44 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. On 4/24/18 at 12:24 PM Resident 44 was observed sitting in the 200 hall dining room. Resident 44 was wearing a hospital gown that was sagging down leaving the resident's upper back and shoulders exposed. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated it was important for staff to ensure that residents were covered appropriately as this was a dignity issue. Staff 2 acknowledged Resident 44 was dependent on staff assistance for dressing. 2. Based on interview and record review the facility failed to ensure residents receivied appropriate sized incontinent supplies for 3 of 5 sampled residents (#s 27, 10 and 18) reviewed for dignity. This placed residents at risk for lack of dignity. Finding include: a. Resident 27's 3/5/18 Quarterly MDS revealed the resident was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. A 3/29/18 Grievance Form revealed the following: -On 3/24/18 and 3/25/18 the resident stated the facility was out of her/his correct sized briefs all weekend and it had happened before; -The facility investigated the concern and verified size 2XL briefs were not available 3/25/18 and 3/26/18; -On 3/23/18 size 2XL brief inventory was low and staff went to a local stores to purchase additional inventory but the largest brief size available at stores was XL; -On 3/23/18 the facility ran out of size 2XL briefs and an order was placed 3/26/18; -Staff 1 (Administrator) signed the Grievance Form on 4/10/18. In an interview on 4/23/18 at 10:04 AM Resident 27 stated she/he went without the correct size briefs and did not like the plumbers butt so she/he taped the briefs instead of them falling off. In an interview on 4/26/18 at 2:34 PM Staff 36 (CNA) stated the facility ran out of supplies a couple of times. Staff went to local stores to buy briefs and wipes. There were not enough size 2XL briefs in stock at local stores so residents (including Resident 27) were placed in smaller briefs. In an interview on 4/26/18 at 3:02 PM Staff 1 stated there was a new person in central supply and there was a time when she did not order enough briefs so he instructed staff to go to the stores and buy more. He was not aware anyone was placed in a smaller sized brief. If there was an issue there was a grievance process to track all the complaints. In an interview on 4/27/18 at 8:54 AM Staff 13 (Central Supply) stated the facility ran out of bariatric briefs one time that she was aware of. b. Resident 10's 2/3/18 Quarterly MDS revealed the resident was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. In an interview on 4/23/18 at 1:21 PM Resident 10 stated she/he experienced problems getting the correct size briefs in the last week and there were times the facility was completely out. Staff placed her/him in a smaller brief. If she/he lay in bed it worked fine as long as staff did not try to fasten the brief, but if she/he was up for an appointment then it created a mess (urine and/or feces). When the facility was out of the briefs the resident stayed in the facility until they got new ones. The resident told everyone including the ombudsman that the facility ran out of briefs. The facility told the resident new central supply staff did not order enough size 2XL briefs, but the facility ran out time and time again. It was not just one time the facility ran out of briefs. In an interview on 4/26/18 at 2:34 PM Staff 36 (CNA) stated the facility ran out of supplies a couple of times. Staff went to local stores to buy briefs and wipes. There were not enough size 2XL briefs in stock at local stores so residents (including Resident 10) were placed in smaller briefs. In an interview on 4/26/18 at 3:02 PM Staff 1 stated there was a new person in central supply and there was a time when she did not order enough briefs so he instructed staff to go to local stores and buy more. He was not aware anyone was placed in a smaller sized brief. In an interview on 4/27/18 at 8:54 AM Staff 13 (Central Supply) stated the facility ran out of bariatric briefs one time that she was aware of. c. Resident 18 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The care plan, revised 2/9/18, indicated Resident 18 was at risk for skin breakdown related to limited mobility, dependent on others for care and incontinent of bowel and bladder. Staff were to provide additional peri-care as needed and provide lotions or barrier creams to promote comfort and protect the skin. In an interview on 4/24/18 at 1:03 PM the resident stated the facility ran out of larger briefs. The resident stated staff put a small brief on her/him which was tight and made her/his bottom sore. The resident stated staff were constantly running out of supplies and sent a staff member to the store to get more briefs and peri wipes. The resident stated staff put a small brief on her/him at least four times within the last two weeks. The resident stated she/he was humiliated and embarrassed. In an interview on 4/26/18 at 3:02 PM Staff 1 (Administrator) stated there was new central supply staff and there was a time when she did not order enough briefs so he instructed staff to go to the stores and buy more. He was not aware anyone was placed in a smaller sized brief. | 2020-09-01 |
| 2630 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 558 | D | 1 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents received reasonable accommodation of needs for 2 of 3 sampled residents (#s 27 and 10) reviewed for accommodation of needs. This placed the residents at risk for not meeting residents' individualized needs. Findings include: 1. Resident 27's 3/5/18 Quarterly MDS revealed the resident was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. In an interview on 4/23/18 at 10:04 AM Resident 27 stated she/he went without the correct size briefs and did not like the plumbers butt so she/he taped the briefs instead of them falling off. In an interview on 4/26/18 at 2:34 PM Staff 36 (CNA) stated the facility ran out of briefs and there were not enough size 2XL briefs available at local stores so residents were placed in smaller briefs. In an interview on 4/26/18 at 3:02 PM Staff 1 (Administrator) stated there was a new person in central supply and there was a time when she did not order enough briefs so he instructed staff to go to the stores and buy more. He was not aware anyone was placed in a smaller sized brief. In an interview on 4/27/18 at 8:54 AM Staff 13 (Central Supply) stated the facility ran out of bariatric briefs one time that she was aware of. 2. Resident 10's 2/3/18 Quarterly MDS revealed the resident was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. In an interview on 4/23/18 at 1:21 PM Resident 10 stated she/he experienced problems getting the correct size briefs in the last week and there were times the facility was completely out. Staff placed her/him in a smaller brief. If she/he lay in bed it worked fine as long as staff did not try to fasten the brief, but if she/he was up for an appointment then it created a mess (urine and/or feces). When the facility was out of the briefs the resident stayed in the facility until they got new ones. The resident told everyone including the ombudsman that the facility ran out of briefs. The facility told the resident new central supply staff did not order enough, but the facility ran out time and time again. It was not just one time the facility ran out of briefs. In an interview on 4/26/18 at 2:34 PM Staff 36 (CNA) stated the facility ran out of briefs and there were not enough size 2XL briefs from outside stores so the residents were placed in smaller briefs. In an interview on 4/26/18 at 3:02 PM Staff 1 (Administrator) stated there was a new person in central supply and there was a time when she did not order enough briefs so he instructed staff to go to the stores and buy more. He was not aware anyone was placed in a smaller sized brief. In an interview on 4/27/18 at 8:54 AM Staff 13 (Central Supply) stated the facility ran out of bariatric briefs one time that she was aware of. | 2020-09-01 |
| 2631 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 582 | E | 0 | 1 | VJE211 | Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of advance beneficiary information for 2 of 2 sampled residents (#s 146 and 147) reviewed for required advanced beneficiary notices. This placed residents at risk for not being informed of financial liabilities. Finding include: 1. Resident 146 admitted to the facility with Medicare Part A services on 10/18/17. On 12/8/17 a Notice of Medicare Non-coverage (NOMNC) was provided for Medicare A discharge on 12/12/17. According to the Skilled Nursing Facility (SNF) Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 12/12/17 as a private pay resident. No evidence of written notification of financial responsibility was provided upon surveyor request. On 5/1/18 at 9:39 AM Staff 10 (Social Services Director) stated changes in coverage were discussed with residents and family members when Medicare coverage ended, but the facility did not put financial liability information in writing for residents. 2. Resident 147 admitted to the facility with Medicare Part A services on 2/14/18. On 3/30/18 a Notice of Medicare Non-coverage (NOMNC) was provided for Medicare A discharge on 4/3/18. According to the Skilled Nursing Facility (SNF) Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 4/3/18 as a private pay resident. No evidence of written notification of financial responsibility was provided upon surveyor request. On 5/1/18 at 9:39 AM Staff 10 (Social Services Director) stated changes in coverage were discussed with residents and family members when Medicare coverage ended, but the facility did not put financial liability information in writing for residents. | 2020-09-01 |
| 2632 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 584 | E | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on interview and record review it was determined the facility failed to ensure a system for returning or replacing residents' personal items for 3 of 4 sampled residents (#s 34, 13 and 37) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: a. Resident 34's 3/22/18 Admission MDS revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 4/24/18 at 9:17 AM Resident 34 stated most of her/his clothes were missing. The resident further stated she/he told most everyone on staff about the missing clothes, and they said they could not find them yet. The resident thought the clothes were in the laundry because laundry was a month behind. In an interview on 4/25/18 at 9:35 AM Staff 7 (Laundry), stated there was a new laundry person that was not as fast at getting clothes back to the residents. It took as long as five days to get clothes back. She thought most clothes missing from residents were not lost but were in laundry. In an interview on 4/25/18 at 9:40 AM Staff 8 (Nurse Aid) stated she was aware of missing items and felt the items were in laundry because laundry was short staffed and it took awhile before clothes came back. In an interview on 4/25/18 at 11:54 AM Staff 9 (CNA) stated she was aware of missing items and it took about two days for items to come back from laundry. The facility started a new protocol where they had a missing items sheet staff filled out and turned into the social services director and she handled it. In an interview on 4/25/18 at 12:06 PM Staff 10 (Social Services Director) stated she was aware of concerns about Resident 34 missing pants and had relayed the concern to laundry, but would need to follow up to see if the pants were found. In an interview on 4/26/18 at 3:02 PM Staff 1 (Administrator) stated there was a new grievance process related to missing items with social services. Staff checked the laundry and if items were not located then he authorized reimbursement to the resident. There was no specific time line when reimbursement would occur, but approximately a week after staff tried to find the items. In an interview on 4/25/18 at 1:59 PM and 4/27/18 at 10:12 AM and 11:03 AM Staff 42 (Laundry Account Manager), stated missing items were part of the profession. When a resident reported missing items she tried to find them and 99% of the time she found the missing items. If they were not in laundry she would let social services know they did not have the items and social services took care of it. b. Resident 13's 2/15/18 Admission MDS revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 4/23/18 at 9:34 AM and 4/26/18 at 2:00 PM, Resident 13 stated she had problems with missing clothes and had to buy new pants. The social services director spoke with her about missing clothes but she was still missing pants and a shirt. In an interview on 4/25/18 at 9:35 AM Staff 7 (Laundry) stated there was a new laundry person that was not as fast at getting clothes back to the residents. It took as long as five days to get clothes back. She thought most clothes missing from residents were not lost but were in laundry. In an interview on 4/25/18 at 9:40 AM Staff 8 (Nurse Aid) stated she was aware of missing items and felt the items were in laundry because laundry was short staffed and it took awhile before clothes came back. In an interview on 4/25/18 at 11:54 AM Staff 9 (CNA) stated she was aware of missing items and it took about two days for items to come back from laundry. The facility started a new protocol where they had a missing items sheet staff filled out and turned into the social services director and she handled it. In an interview on 4/25/18 at 12:06 PM Staff 10 (Social Services Director) stated she was aware of concerns about Resident 13's missing pants, and was under the impression they had been returned. In an interview on 4/26/18 at 3:02 PM Staff 1 (Administrator) stated there was a new grievance process related to missing items with social services. Staff checked the laundry and if items were not located then he authorized reimbursement to the resident. There was no specific time line when reimbursement would occur, but approximately a week after staff tried to find the items. In an interview on 4/25/18 at 1:59 PM and 4/27/18 at 10:12 AM and 11:03 AM Staff 42 (Laundry Account Manager), stated missing items were part of the profession. When a resident reported missing items she tried to find them and 99% of the time she found the missing items. If they were not in laundry she would let social services know they did not have the items and social services took care of it. c. Resident 37 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/24/18 at 10:44 AM Witness 5 (Family Member) stated some of Resident 37's clothes were stolen and were not replaced. On 4/25/18 at 2:51 PM Staff 15 (CNA) stated residents complained about missing items. Staff 15 stated if the item was not found she left a note for other staff to look for it. On 4/25/18 at 4:03 PM Staff 34 (CNA) stated a lot of residents complained about missing items. Staff 34 stated when residents reported missing items she looked for the items and reported it to the laundry manager. Staff 34 stated she did not know of the Social Services department being involved with missing personal property. On 4/26/18 at 7:53 AM Staff 18 (CNA) stated Resident 37 and other residents were missing clothes. Staff 18 stated when a resident's clothes went missing she looked for the items, talked to laundry and reported the information to Staff 2 (DNS). On 4/26/18 at 9:30 AM Staff 3 (LPN/Resident Care Manager) stated the facility recently put a new system in place for marking clothes due to residents missing clothes. On 4/26/18 at 10:24 AM Staff 10 (Social Services) acknowledged Resident 37 was missing some personal items. Staff 10 stated some of the items were found but others were not. Staff 10 stated the items went missing over a month ago and were not replaced yet because staff were still looking for the items. Staff 10 stated CNAs were trained to report missing items to Social Services. When provided with information that none of the CNAs interviewed indicated Social Services was involved with missing items, Staff 10 acknowledged additional training was needed. On 4/26/18 at 3:02 PM Staff 1 (Administrator) stated the facility received grievances from residents regarding missing items. Staff 1 stated missing personal items were to be replaced in a reasonable amount of time. When asked what a reasonable amount of time would be, Staff 1 stated, A week or so. 2. Based on observation and interview it was determined the facility failed to ensure rooms were free of unpleasant odors and were adequately maintained for 1 of 1 family room and 3 of 15 bathrooms reviewed for environment. This placed residents at risk for an unclean or unhomelike environment. Findings include: a. Multiple observations 4/23/18 through 5/1/18 revealed an unpleasant odor in the facility family room. On 4/26/18 at 5:23 AM Staff 27 (Agency CNA) acknowledged an odor of urine was present in the family room. On 4/26/18 at 6:51 AM Staff 27 (Dietary Manager) acknowledged there was a history of an unpleasant odor in the family room and further acknowledged a current odor of urine was present. On 4/26/18 at 7:43 AM Staff 2 (DNS) acknowledged a history of strong unpleasant odor in the family room and stated she believed the carpet in the family room needed to be replaced. On 4/26/18 at 7:48 AM Staff 1 (Administrator) confirmed an odor of urine was present in the family room carpet. b. On 4/23/18 at 1:49 PM observations revealed room [ROOM NUMBER]'s bathroom to have a toilet with a cracked base. On the morning of 4/30/18 additional observation revealed the toilet seat had a piece of peeled plastic leaving a rough edge. On 4/30/18 at 8:04 AM Staff 41 (Maintenance Director) verified the cracked toilet and peeled plastic on the toilet seat in room [ROOM NUMBER]. He was aware the toilet needed replaced. c. Multiple observations 4/23/18 through 4/30/18 revealed the shared bathrooms in rooms 102/103, 105/107 and 109/111 had multiple holes on the wall beside the paper towel holders. In an interview on 4/24/18 at 8:36 AM Resident 36 stated the holes in the bathroom wall were there for two months and it bothered her/him. In an interview on 4/26/18 at 2:00 PM Resident 13 stated the holes in the bathroom wall bothered her/him at times. In an interview on 4/27/18 at 8:58 AM Staff 40 (Housekeeper) stated the holes in the bathroom walls were there since the paper towel holders were replaced with new ones approximately two months ago. In an interview on 4/30/18 at 8:04 AM Staff 41 (Maintenance Director) stated he was aware of the holes in the bathrooms in the 100 hall and they were there since he started working at the facility in 2/2018. | 2020-09-01 |
| 2633 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 636 | D | 0 | 1 | VJE211 | **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 a resident's use of [MEDICAL CONDITION] medication for 1 of 5 sampled residents (#17) reviewed for unnecessary medication. This placed residents at risk for unassessed needs. Findings include: Resident 17 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2017 MAR indicated [REDACTED]. The [MEDICAL CONDITION] Drug Use CAA associated with Resident 17's 11/16/17 Annual MDS indicated the resident received antidepressant medication and antipsychotic medication but did not indicate the resident received antianxiety medication. The CAA also did not indicate how the resident's symptoms of depression, [MEDICAL CONDITION] and anxiety manifested and if the medications were effective. On 4/30/18 at 2:22 PM Staff 2 (DNS) acknowledged the [MEDICAL CONDITION] Drug Use CAA was not comprehensive as it lacked information regarding the resident's use of antianxiety medication and lacked information regarding the resident's symptoms and the effectiveness of the [MEDICAL CONDITION] medication. | 2020-09-01 |
| 2634 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 641 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to medication, pressure ulcer risk, presence of pressure ulcers, activities and weight gain for 3 of 11 sampled residents (#s 17, 30 and 44) reviewed for pressure ulcers, activities and unnecessary medication. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 17 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The 11/16/17 Annual MDS Section N: Medications indicated Resident 17 did not receive antianxiety medication. The 11/2017 MAR indicated [REDACTED]. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated Resident 17 did receive antianxiety medication and acknowledged the 11/16/17 Annual MDS was coded in error. b. The 11/16/17 Annual MDS Section K: Swallowing and Nutrition indicated Resident 17 weighed 287 pounds and was on a physician-prescribed weight-gain regimen. On 4/30/18 at 2:22 PM Staff 2 stated Resident 17 was not on a physician-prescribed weight-gain regimen and the 11/16/17 Annual MDS was coded in error. c. The 11/16/17 Annual MDS Section G: ADLs indicated Resident 17 required extensive assistance with bed mobility. Section M: Skin Conditions of the same MDS indicated Resident 17 was not at risk for developing pressure ulcers. On 4/30/18 at 2:22 PM Staff 2 stated Resident 17 was at risk for pressure ulcers due to low mobility and the 11/16/17 Annual MDS was coded in error. 2. Resident 44 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. The 4/12/18 Admission MDS indicated Resident 44 did not receive antidepressant medication. The 4/2018 MAR indicated [REDACTED]. On 4/30/18 at 2:22 PM Staff 2 stated Resident 44 received antidepressant medication and the 4/12/18 Admission MDS was coded in error. 3. Resident 30 readmitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. The 2/28/18 Admission Profile indicated Resident 30 had a Stage 2 pressure ulcer (open skin appearing as a scrape, blister or shallow crater in the skin). The 3/15/18 Significant Change MDS, Section M: Skin Conditions, indicated Resident 30 had a Stage 2 pressure ulcer. The 3/16/18 Pressure Ulcer CAA indicated Resident 30 had a Stage 3 pressure ulcer (extending into the tissue beneath the skin and forming a small crater) on the coccyx (small triagnular bone at the base of the spinal column) that measured 0.8 cm x 2.5 cm. On 4/30/18 at 3:45 PM Staff 2 (DNS) acknowledged the 3/15/18 Significant Change MDS, section M and 3/16/18 Pressure Ulcer CAA were not consistant with one another, indicating an error in data. | 2020-09-01 |
| 2635 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 655 | D | 0 | 1 | VJE211 | **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 a baseline person-centered care plan for 1 of 5 sampled residents (#96) reviewed for [MEDICAL TREATMENT], nutrition and pain. This placed residents at risk for unassessed needs. Findings include: Resident 96 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A physician order [REDACTED]. There was no documentation the resident's dressing was being checked or removed. The resident's admission baseline care plan dated 4/23/18 did not indicate the resident had a new [MEDICAL TREATMENT] catheter placed to the right chest and a new port to the left chest on 4/17/18 or which type of [MEDICAL TREATMENT] the resident received. On 4/30/18 at 11:52 AM Resident 96 stated the staff had not checked on either of the access sites on her/his chest since admission. On 4/30/18 at 3:36 PM Staff 3 (LPN Resident Care Manager (RCM)) acknowledged the resident's baseline care plan did not indicate the type of [MEDICAL TREATMENT] the resident was receiving, [MEDICAL TREATMENT] or how to properly care for the site. b. A dietary assessment dated [DATE] indicated Resident 96 had poor food intake and a BMI of 15.5 (severely underweight). The resident lost 3.8 pounds since admission and the Dietician indicated the resident would start to receive enhanced meals to maximize calories. Resident 96's 4/23/18 baseline care plan indicated the resident was to be observed for aspiration. The care plan did not indicate the resident was underweight or her/his personal preferences of food. Snack records from 4/20/18 through 4/28/18 indicated the resident was not available for day and evening shifts to receive a snack. An observation on 4/24/18 at 1:47 PM revealed the resident was thin and pale. On 4/30/18 at 3:36 PM Staff 3 (LPN Resident Care Manager) acknowledged the resident's baseline care plan did not reflect Resident 96's needs. c. Resident 96's 4/23/18 baseline care plan indicated the resident's goal for pain relief was two out of ten pain level, six hours of sleep and assist with ADLs. The care plan did not indicate the nature and location of the resident's pain or non-pharmacological interventions to decrease pain. The resident's 4/2018 MAR indicated [REDACTED]. An observation on 4/24/18 at 1:47 PM revealed the resident was grimacing with movement. In an interview on 4/24/18 at 2:37 PM Staff 14 (LPN) stated she had not tried any of the non-pharmacological pain interventions and did not know exactly where the resident had pain. An observation on 4/25/18 at 2:48 PM revealed the resident was in bed with her/his spouse at bedside. The spouse indicated the resident was painful that day. An observation on 4/30/18 at 12:25 PM revealed the resident lay in bed grimacing and groaning with movement. In an interview 4/30/18 at 11:52 AM The resident stated the only pain medication she/he received was Tylenol which didn't help. The resident stated sometimes she/he just needed to rest or apply ice. On 4/30/18 at 3:36 PM Staff 3 (LPN Resident Care Manager) acknowledged the resident's baseline care plan did not reflect Resident 96's needs. | 2020-09-01 |
| 2636 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 656 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to create a comprehensive care plan related to pressure ulcers and activities and failed to implement a care plan for activities for 2 of 6 sampled residents (#s 30 and 44) reviewed for pressure ulcers and activities. This placed residents at risk for unmet needs. Findings include: 1. Resident 44 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Hospital records dated 3/23/18 indicated Resident 44 was to wear Prevalon boots (padded boots) to offload pressure. During observations of Resident 44 from 4/24/18 through 5/1/18 the resident was observed to wear Prevalon boots. No information regarding the Prevalon boots was found in the resident's care plan. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated Resident 44's use of Prevalon boots should have been included on the resident's care plan. 2. Resident 30 readmitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. Review of the 3/15/18 Activities CAA indicated Resident 30 enjoyed TV, movies and music. Review of the 3/17/18 Activities Care Plan indicated Resident 30 was to be provided with 1 to 1 activities that included television and music. On the morning of 4/23/18 Resident 30 was observed to be asleep and laying in her/his bed. There was no television observed in the resident's room. On 4/23/18 at 2:27 PM Witness 3 (Family) stated there was never a television on in her/his room. On 4/25/18 at 8:06 AM and 9:46 AM Resident 30 was observed to be in bed. There was no television in her/his room and no music playing. On 4/25/18 at 10:02 AM Staff 20 (Activity Director) confirmed Resident 30's care plan for activities indicated she/he would have 1 to 1 activities that included television or music. Staff 20 acknowledged Resident 30's care plan for activities was not being implemented. | 2020-09-01 |
| 2637 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 657 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to review and revise the care plan related to diet and [MEDICAL CONDITION] medications for 2 of 5 sampled residents (#s 9 and 30) reviewed for nutrition and medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 30 readmitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. a. A 3/30/18 signed physician order [REDACTED]. Review of Resident 30's current comprehensive care plan revealed the most recent revision related to the resident's diet to be 3/1/18. The revision indicated Resident 30 was to receive a puree texture diet. Review of Resident 30's Kardex (CNA care plan) indicated Resident 30 was to receive a puree texture diet. On 4/25/18 at 12:00 PM Resident 30 was observed to be assisted to eat a mechanical soft texture meal. The resident's meal card indicated a nutritionally enhanced meal with mechanical soft texture. On 4/25/18 at 1:10 PM Staff 2 (DNS) confirmed Resident 30's care plan was not updated to accurately reflect her/his current mechanical soft texture diet. b. Review of Resident 30's of medical record revealed no comprehensive plan of care related to dental. The ADL care plan, last revised on 2/28/18 indicated Resident 30 required total assist by one staff for oral care. The 3/15/18 Significant Change MDS, section L indicated there were no coded dental concerns for the resident during the resident assessment lookback period of 3/1/18 through 3/7/18. Observation of Resident 30 on 4/24/18 at 9:46 AM revealed the resident was missing multiple upper teeth. On 4/25/18 at 1:02 PM Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) both indicated during the resident assessment lookback period of 3/1/18 through 3/7/18, Resident 30 had partial dentures which included an upper plate. Following a trip out to the hospital after this period, the resident did not return with her/his upper plate. Staff 2 and Staff 3 acknowledged Resident 30's care plan should have been updated to reflect the resident's change in dental status and care needs. 2. Resident 9 admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Resident 9's 1/2017 care plan revealed the following information: -Focus: medication/[MEDICAL CONDITION] medication therapy; -At risk for complications related to the use of [MEDICATION NAME] (antianxiety medication); -Goal: the resident will be free from discomfort or adverse reactions related to the use of [MEDICATION NAME] through the next review date; -Interventions: evaluate [MEDICATION NAME] medication usage for a gradual dose reduction, monitor side effects of [MEDICATION NAME] therapy. A physician order [REDACTED]. Review of the resident's record revealed the care plan was not updated since 1/2017 related to the resident's use of [MEDICATION NAME]. On 4/30/18 at 1:30 PM Staff 2 (DNS) verified the care plan was inaccurate and the care plan was not updated to remove [MEDICATION NAME]. | 2020-09-01 |
| 2638 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 658 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined facility staff failed to meet professional standards for medication administration for 3 of 3 sampled residents (#s 9,16 and 28) observed during medication administration. This placed residents at risk for adverse medication reactions. Findings include: Per Division 45 Standards and Scope of Practice for the LPN and RN [PHONE NUMBER]; Conduct Derogatory to the Standards of Nursing Defined: - Failing to dispense or administer medications in a manner consistent with state and federal law. According to the Nursing Drug Handbook (YEAR) edition, food should be consumed within 15 minutes of the administration of [MEDICATION NAME] (a fast-acting insulin used to treat diabetes). 1. Resident 16 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The 4/2018 Licensed Nurse Administration Record indicated the resident was to receive sliding scale (predefined blood glucose range) and a scheduled dose of 12 units of [MEDICATION NAME] insulin. On 4/25/18 at 11:20 AM Staff 29 (LPN) was observed to administer [MEDICATION NAME] to Resident 16. The resident received a lunch tray at 12:05 PM 50 minutes after insulin administration. On 4/28/18 at 11:10 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 16. The resident received a lunch tray at 11:55 AM 45 minutes after insulin administration. 2. Resident 9 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The resident's 4/2018 Licensed Nurse Administration Record indicated the resident was to receive [MEDICATION NAME] insulin. On 4/28/18 at 11:20 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 9. The resident received a lunch tray at 12:00 PM 40 minutes after insulin administration. 3. Resident 28 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. The resident's 4/2018 Licensed Nurse Administration Record indicated the resident was to receive a sliding scale and scheduled dose of 16 units of [MEDICATION NAME] insulin. On 4/28/18 at 11:15 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 28. The resident received a lunch tray at 11:50 AM 35 minutes after insulin administration. On 4/25/18 at 11:20 AM Staff 2 (DNS) acknowledged Residents 9, 16 and 28 were not provided food within 15 minutes of [MEDICATION NAME] fast acting insulin administration. | 2020-09-01 |
| 2639 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 684 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure residents received treatment for [REDACTED].#37) reviewed for non-pressure skin conditions. This placed residents at risk for worsening skin conditions. Findings include: Resident 37 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/24/18 at 10:13 AM Resident 37 was observed to have an approximate one inch bruise on her/his left hand near the base of the thumb. Resident 37 was also observed to have an approximate half inch scab under her/his right eye. No assessments, treatment or monitoring of the skin issues were found in the resident's clinical record. On 4/24/18 at 10:44 AM Witness 5 (Family Member) stated Resident 37 sometimes received injuries to her/his hands if she/he was not transferred correctly by staff. On 4/26/18 at 7:53 AM Staff 18 (CNA) stated she assisted Resident 37 with dressing that day and was not aware of Resident 37 having any bruises or skin impairment. Staff 18 stated when she observed any skin issues she reported them to the nurse. On 4/26/18 at 9:18 AM Staff 12 (RN) acknowledged the skin impairment under Resident 37's right eye and the bruise on Resident 37's left hand. Staff 12 stated the charge nurse was responsible for assessing and monitoring any skin issues until they resolved, including skin impairment and bruises. Staff 12 stated she was not aware of any assessment, treatment or monitoring of Resident 37's skin impairment or bruise. On 4/26/18 at 9:30 AM Staff 3 (LPN Resident Care Manager) stated any bruises on Resident 37 were to be fully assessed and documented. | 2020-09-01 |
| 2640 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 686 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to accurately assess and monitor pressure ulcers for 1 of 3 sampled residents (#30) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 30 readmitted to the facility 2/5/2018 following hospitalization with [DIAGNOSES REDACTED]. A 2/5/18 hospital History and Physical revealed the following for Resident 30: - Sacral (coccyx/sacrum - small triangular bone at the base of the spinal column) pressure wound. The 2/5/18 Admission Profile for Resident 30 revealed the following: -Three Stage 2 pressure wounds (broken skin which forms an ulcer and can look like a scrape, blister or shallow abrasion in the skin) present, close together on buttocks 1) 2.5 cm x 2 cm 2) 2 cm x 2 cm 3) 3 cm x 3 cm Resident 30's 2/23/18 Significant Change MDS had an assessment reference date of 2/9/18 and revealed the following: - One Stage 2 pressure ulcer present on admission and discovered on 2/5/18. - Most severe tissue type was granulation tissue (granular tissue/healing surface of a wound). Review of Resident 30's medical record indicated the resident discharged to the hospital on [DATE] with an anticipated return to the facility. Review of Resident 30's medical record revealed no evidence weekly skin assessments were completed for the Stage 2 pressure ulcer to the coccyx between her/his 2/5/18 admission and a 2/20/18 discharge to the hospital. A 2/22/18 hospital wound consult document indicated Resident 30 had a Stage 2 pressure ulcer to the coccyx measuring 1.5 cm x 3 cm with a scant amount of draining and no signs or symptoms of infection. Resident 30's medical record revealed she/he was re-admitted to the facility on [DATE]. The 2/28/18 Admission Profile for Resident 30 revealed the following: - Stage 2 pressure ulcer to the coccyx/sacrum measuring 1.5 cm by 3 cm. The 3/15/18 Significant Change MDS had an assessment reference date of 3/1/18 through 3/7/18 revealed the following: - One Stage 2 pressure ulcer, present on admission and discovered 2/28/18. - Most severe tissue type was granulation tissue. Resident 30's 3/16/18 Pressure Ulcer CAA revealed the following: - Stage three pressure ulcer (pressure sore that extends to tissue beneath the skin which may show fat, but not muscle, tendon or bone) to the coccyx. Resident 30's Weekly Skin Ulcer Measurement Wound Evaluations for the coccyx/sacrum wound from 2/28/18 through 4/17/18 did not indicate current wound stage. On 4/30/18 at 12:51 PM Staff 29 (LPN) was observed to perform a dressing change on Resident 30. Three separate wounds were observed on Resident 30's sacrum/coccyx. Two of the wounds were noted to likely be unstagable, and one of the wounds was noted to likely be a Stage 2. Because Staff 29 was not an RN, she was unable to say for sure what the stage of the resident's wounds were. On 4/30/18 at 3:30 PM Staff 2 (DNS) confirmed there were no assessments of the documented pressure ulcers to the coccyx/sacrum between 2/5/18 and 2/20/18. Staff 2 further confirmed the wounds were not staged between the dates of 2/28/18 and 4/17/18, acknowledged this made it difficult to determine the actual stage and number of pressure ulcers to the sacrum/coccyx, and confirmed there was no indication of whether or not the pressure ulcers were progressing towards healing. | 2020-09-01 |
| 2641 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 692 | G | 1 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to provide timely treatment for [REDACTED].#297) reviewed for hydration and nutrition. Resident 297 experienced a delay in dehydration treatment which resulted in the resident being hospitalized for [REDACTED]. Resident 297 admitted to the facility in 3/2018 post heart-surgery. A care plan dated 3/15/18 indicated the resident was at risk for skin impairment related to immobility, fragile skin and actual skin impairment of multiple surgical incisions. Staff were to encourage good nutrition and hydration in order to promote healthier skin. A Hydration assessment dated [DATE] indicated Resident 297 was not at risk for dehydration. The assessment did not indicate a rationale for why the resident was not at risk for dehydration despite her/his post-heart surgery status. The assessment indicated staff were to offer fluids as requested. According to the Mayo Clinic (https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art- 256), the average adult requires 2700-3700 cc of fluid per day to maintain adequate hydration. A Fluid Monitor document dated 3/15/18 through 3/27/18 revealed: -3/15/18 at 6:27 PM the resident drank 175 CCs of fluid. -3/16/18 850 cc for all shifts. -3/17/18 690 cc for all shifts. -3/18/18 900 cc for all shifts. -3/19/18 600 cc for all shifts. -3/20/18 680 cc for all shifts. -3/21/18 1320 cc for all shifts. -3/22/18 650 cc for all shifts. -3/23/18 660 cc for all shifts. -3/24/18 390 cc for all shifts. -3/25/18 780 cc for all shifts. -3/26/18 530 cc for all shifts. -3/27/18 day and evening shift 110 cc. A physician order [REDACTED]. A 3/17/18 Alert note indicated the resident was up most the night. The resident had conversations that did not make sense. The resident was alert to self only, was non-compliant with sternal precautions and kept attempting to self-transfer. The resident was very confused and staff would continue to monitor the resident. A 3/18/18 Skilled nursing note indicated the resident was alert and oriented but did seem to have some confusion during the night. A 3/19/18 Skilled nursing note indicated the resident had [MEDICAL CONDITION]. A 3/19/18 Alert note indicated the resident complained of dry mouth and the cardiovascular physician was notified. The 3/22/18 Nutrition CAA indicated Resident 297 had difficulty with swallowing and was cognitively intact upon admission. The 3/22/18 Medication CAA indicated Resident 297 received diuretic medication. An IDT (interdisciplinary team) meeting dated 3/22/18 indicated the resident and family stated there were some issues with CNA attentiveness. Both the resident and her/his family stated the resident was not often checked on. A Dietary Profile dated 3/22/18, indicated the resident received regular food, had dry mouth, received 715 cc daily of fluid and foods did not taste right since surgery. A 3/22/18 physician order [REDACTED]. Lab results from the 3/22/18 BMP included a high BUN (test to check for kidney damage due to dehydration) result of 37 (normal range is 7 to 20). The facility received the results on 3/23/18 and the results were faxed to the physician on 3/23/18. No new orders or reply from the physician was found in the resident's medical record. Documentation of PT notes dated 3/23/18 indicated the resident was having diarrhea and worried about her/his nutrition due to no appetite. PT indicated they worked with the resident in her/his room to be close to the toilet. PT notes indicated nursing staff were made aware of the resident's status. A 3/24/18 skilled nursing note indicated the resident stayed in bed that day and had mild to moderate diarrhea since surgery about an hour after every meal. A 3/25/18 MAR indicated [REDACTED]. A 3/25/18 skilled nursing note indicated the resident worked with OT. Witness 1 (Complainant) stated to staff the resident was continuing to have diarrhea. Staff told the Witness 1 that Immodium had been ordered. Witness 1 also stated the resident was not eating due to very dry mouth and no appetite. A nurse stated she told Witness 1 it could be possible adverse side effects from medication. A 3/26/18 NAR Review indicated the resident had a 9.6 lb weight loss since admission. The resident stated food did not not taste right since surgery and her/his appetite was poor. The resident did have some swelling of the feet on admit that resolved, and that could account for some of the weight loss. The resident's medical record indicated the resident's intake was variable with several refusals. A 3/26/18 skilled nursing note indicated an order for [REDACTED]. A 3/27/18 MAR indicated [REDACTED]. A 3/27/18 Alert note indicated the resident went to a doctor's appointment, then returned to the facility. The resident's [MEDICATION NAME] surgeon called and ordered the resident be hospitalized due to abnormal lab results attained during the appointment. A hospital note dated 3/27/18 indicated the resident was readmitted to the hospital due to weakness, dehydration, diarrhea and acute kidney injury indicative of dehydration with decreased oral intake and increased gastrointestinal losses. In addition, the resident tested positive for [MEDICAL CONDITION] (inflammation of the colon caused by bacteria [MEDICAL CONDITION]). On 4/29/18 at 7:19 PM Witness 1 stated after the resident's surgery the resident was not eating or drinking. The resident drank some fluids brought in by family members, but did not drink much. Witness 1 stated Resident 297 had diarrhea continuously since surgery. Witness 1 stated staff did not check on the resident in order to bring drinks to the resident. Witness 1 asked Staff 45 (RN) if the resident was able to see a doctor and Staff 45 stated the physician had up to 30 days to see a resident after admission to the facility. Witness 1 asked Staff 45 if an IV could be started and Staff 45 stated she would have get a physician order. Witness 1 stated Staff 45 did not call to get the order. Witness 1 stated the resident was constantly complaining of dry mouth and dark colored urine to the nurses when she/he was residing in the facility but the physician was not called. On 4/30/18 at 11:33 AM Staff 2 (DNS) acknowledged progress notes indicated the resident experienced loose stools while in the facility. Staff 2 acknowledged the medical records indicated an inadequate amount of fluids consumed by Resident 297. Staff 2 acknowledged the abnormal lab results from 3/22/18 and indicated the results were faxed to the physician. During an interview on 4/30/18 at 5:30 PM Witness 3 (Complainant) stated the following: Witness 3 told the nurses daily since admission the resident was continuing to have diarrhea and not eating or drinking. Witness 3 tried to get the resident to eat and drink by going to all her/his favorite restaurants to get food. Witness 3 brought in milkshakes for the resident but the resident stated there was a funny taste and got nauseated. Witness 3 stated there was no water or anything for the resident to drink on the bedside table in the mornings and staff did not come in to offer fluids. Witness 3 stated Resident 297 had loose stools and the resident appeared lethargic and pale on 3/18/18. Witness 3 stated the physician was not notified of the resident's condition. Witness 3 stated Resident 297 had loose stools 4-5 times per day. On 5/1/18 at 8:33 AM Staff 18 (CNA) stated she knew the resident was not eating or drinking well and let the nurses know. Staff 18 stated the nurses would have staff get the resident healthshakes but the resident would refuse those too. Staff 18 stated the resident was not good at drinking fluids. Staff 18 stated she reported the resident's loose stools to the nurses. On 5/1/18 at 9:21 AM Staff 17 (OT) stated she remembered the resident complaining of food not tasting right since surgery. On 5/1/18 at 11:01 AM Staff 2 stated it was her expectation when a nurse received an abnormal lab the physician would be called. Staff 2 stated she would expect a response within an hour of a phone call or the nurse should wait on the phone to talk with the physician until the issue was resolved. Staff 2 stated nurses were to keep calling the physician until they got the answers they needed. Staff 2 acknowledged there was no documentation in the medical record to indicate the physician responded regarding abnormal lab results. | 2020-09-01 |
| 2642 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 695 | E | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure residents respiratory equipment was maintained and cleaned for 8 of 8 sampled residents (#s 3, 10, 21, 33, 38, 43, and 97) reviewed for respiratory care. This placed residents at risk for infections. Findings include: 1a. Resident 10 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 4/27/18 at 9:00 AM Resident 10 utilized a [MEDICAL CONDITION] (continuous positive airway pressure) machine with a nasal mask (device that fits into the nostrils for delivery of oxygen) while in bed. A review of Resident 10's 4/2018 TAR revealed the resident was to have oxygen tubing and distilled water for the [MEDICAL CONDITION] changed every week, labeled with the date changed and documented on the TAR. The resident's TAR on 4/25/18 indicated the task was completed however on 4/27/18 at 9:00 AM revealed the oxygen tubing and distilled water were not dated. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the oxygen tubing and distilled water for Resident 10 was not marked with the date tubing and distilled water was changed. b. Resident 21 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed Resident 21 utilized oxygen at night and as needed via an oxygen concentrator and wore a nasal cannula (a device that fits into the nostrils for delivery of oxygen therapy). A review of Resident 21's 4/2018 TAR revealed the resident was to have oxygen tubing and distilled water for the oxygen concentrator changed every week, labeled with the date changed and documented on the TAR. The resident's TAR indicated the task was completed, however multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed oxygen tubing and distilled water were not dated. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the oxygen tubing and distilled water for Resident 21 was not marked with the date changed. c. Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 33's 4/2018 TAR revealed the resident was to have oxygen tubing and distilled water for the oxygen concentrator changed every week, labeled with the date changed and documented on the TAR. The resident's TAR indicated the task was completed on 4/10/18, however observation on 4/27/18 at 9:00 AM revealed oxygen tubing and distilled water were not dated and the concentrator filter was dirty. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the oxygen tubing and distilled water for Resident 33 was not marked with the date the tubing, and distilled water was changed and the concentrator filter was dirty. d. Resident 43 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed Resident 43 utilized a [MEDICAL CONDITION] (continuous positive airway pressure) machine with a nasal mask while in bed and as needed. A review of Resident 43's 4/2018 TAR indicated the resident was to have oxygen tubing and distilled water for the [MEDICAL CONDITION] changed every week, labeled with the date changed and documented on the TAR. The resident's TAR indicated the task was completed, however multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed the oxygen tubing and distilled water were not dated. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the oxygen tubing and distilled water for Resident 43 were not marked with the date tubing and distilled water were changed. e. Resident 97 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed Resident 97 utilized oxygen at all times. A review of Resident 97's 4/2018 TAR revealed the resident was to have oxygen tubing and distilled water changed every week, labeled with the date changed and documented on the TAR. The resident's TAR indicated the task was completed, however multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 indicated the oxygen tubing and distilled water were not dated. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the oxygen tubing and distilled water for Resident 97 was not marked with the date the tubing and distilled water were changed. 2a. Resident 43 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 indicated Resident 43 utilized an oxygen concentrator. A review of Resident 43's 4/2018 TAR revealed the resident was to have the oxygen concentrator filters cleaned every week and the task documented on the TAR. The resident's TAR indicated the task was completed, however multiple daily observations on day and evening shifts from 4/23/18 through 4/28/18 revealed the concentrator filters were covered in dust and brown debris. On 4/27/18 at 9:06 AM Staff 3 (LPN Resident Care Manager) acknowledged the concentrator filters were dirty and needed to be changed. b. Resident 3 readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 3's 4/2018 TAR revealed an order to receive oxygen daily. The treatment record further revealed an order to clean the oxygen concentrator filter weekly. On 4/27/18 at 8:51 AM the filter on Resident 30's oxygen concentrator was observed to be covered with dust. On 4/27/18 at 8:52 AM Staff 2 (DNS) confirmed Resident 30's oxygen concentrator filter was unclean. c. Resident 38 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 38's 4/2018 TAR revealed an order to receive oxygen daily. The treatment record further revealed an order to clean the oxygen filter concentrator weekly. On the morning of 4/23/18 Resident 38's oxygen concentrator filter was observed to be covered with dust. Resident 38 confirmed the oxygen concentrator was unclean and stated facility staff did not clean it. | 2020-09-01 |
| 2643 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 697 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure residents received appropriate pain management for 1 of 4 sampled residents (#96) reviewed for pain. This placed residents at risk for pain. Findings include: Resident 96 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 4/23/18 baseline care plan indicated the resident's goal for pain relief was 2 out of 10 pain level, six hours of sleep and assist with ADLs. The care plan did not indicate what and where the resident's pain was or non-pharmacological interventions to be used to decrease pain. The resident's 4/2018 MAR indicated [REDACTED]. Staff were to perform non-pharmacological interventions. No documentation on the MAR indicated [REDACTED]. An observation on 4/24/18 at 1:47 PM revealed Resident 96 was grimacing with movement. In an interview on 4/24/18 at 2:37 PM Staff 14 (LPN) stated she had not tried any of the non-pharmacological pain interventions and did not know exactly where the resident had pain. An observation on 4/25/18 at 2:48 PM revealed the resident was in bed with her/his spouse at bedside. The spouse indicated the resident was painful today. An observation on 4/30/18 at 12:25 PM revealed the resident lay in bed grimacing and groaning with movement. In an interview on 4/30/18 at 11:52 AM the resident stated the only pain medication she/he received was Tylenol which did not help. The resident stated sometimes she/he just needed to rest or use ice. The resident stated staff never offered any pain interventions and stated she/he told the staff Tylenol did not work for the pain but it was all they brought. The resident stated she/he asked the staff to call the physician to have different pain medication but nothing was done. The resident stated she/he was happy to be going home soon. On 4/30/18 at 3:36 PM Staff 3 (LPN Resident Care Manager) acknowledged the facility did not have a plan of care in place to reflect Resident 96's pain needs. | 2020-09-01 |
| 2644 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 698 | D | 0 | 1 | VJE211 | **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 the resident received proper [MEDICAL TREATMENT] care and services after [MEDICAL TREATMENT] for 1 of 1 sampled resident (#96) reviewed for [MEDICAL TREATMENT]. This placed resident at risk for unmet [MEDICAL TREATMENT] needs. Findings include: Resident 96 admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. On 4/24/18 at 12:37 PM Resident 96 was observed to have a [MEDICAL TREATMENT] catheter on the right side of her/his chest and an infusion port (small appliance installed beneath the skin) on the left side of the chest. Resident 96 stated the catheter and the port were new and the catheter was used as the access site for [MEDICAL TREATMENT]. Resident 96's current care plan for [MEDICAL TREATMENT] dated 4/20/18 indicated the resident had [MEDICAL TREATMENT] three times a week and for staff to monitor the site for infection. A physician order [REDACTED]. No evidence was found in the resident's clinical record to indicate monitoring of the resident's access site or monitoring and assessment of the resident upon return from [MEDICAL TREATMENT]. In an interview on 4/27/18 at 4:22 PM Staff 3 (LPN Resident Care Manager) acknowledged there was nothing on the resident's care plan to indicate the type of [MEDICAL TREATMENT] the resident had or care needs for the site. In an interview on 4/30/18 at 11:52 AM the resident stated staff did not checked the dressings to the [MEDICAL TREATMENT] catheter site or the port since admission or taken vital signs upon return from [MEDICAL TREATMENT]. | 2020-09-01 |
| 2645 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 725 | E | 1 | 1 | VJE211 | **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 sufficient nursing staff to ensure residents attained their highest practicable physical, mental and psychosocial well-being for 7 out of 7 sampled residents (#s 10, 13, 18, 21, 29, 34, 38, 43 and 45) reviewed for staffing and 1 of 1 sampled resident (#24) during random observation and dining observations. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's 2/3/18 Quarterly MDS revealed the following: -BIMS score of 15 (cognitively intact). -Total assist with one-person physical assist for transfers. -Extensive assistance with two-person physical assist for bed mobility, toilet use and personal hygiene. -Extensive assistance with one-person physical assist for dressing. On 4/23/18 at 3:18 PM Resident 10 stated she/he waited up to an hour for staff assistance, and would only turn on her/his call light when in pain. 2. Resident 13 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13's 2/15/18 Admission MDS revealed the following: -BIMS score of 15 (cognitively intact). -Extensive assist with one-person physical assist for transfers, dressing, toilet use and personal hygiene. -Extensive assist with two-person physical assist for bed mobility. On 4/23/18 at 9:45 AM Resident 13 stated it could take 30-45 minutes for assistance from nursing staff when there was only one nurse on night shift who passed medications, the nurse was on another wing or had too many patients. 3. Resident 18 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18's 2/18/18 Quarterly MDS revealed the following: -BIMS score of 15 (cognitively intact). -Extensive assist with one-person physical assist for dressing and eating. -Extensive assist with two-person physical assist for bed mobility. -Total dependence with one-person physical assist for toilet use, personal hygiene and locomotion on and off the unit. On 4/24/18 at 2:15 PM Resident 18 stated she/he did not believe there was enough staff to care for the residents. Resident 18 further stated she/he waited hours for staff assistance to the bathroom and frequently ended up having accidents. Resident 18 further stated staff told her they did not have the time to shower her/him, and had missed a shower because of this. 4. Resident 21 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's 2/28/18 Admission MDS revealed the following: -BIMS score of 15 (cognitively intact). -Limited assist with one-person physical assist for bed mobility, toileting and personal hygiene. -Extensive assist with one-person physical assist for dressing. On 4/23/18 at 9:41 AM Resident 21 stated night shift was bad in terms of staffing. Resident 21 further stated she/he previously had a toileting accident in the hall and there were no staff present to help. 5. Resident 24 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's 2/27/18 Quarterly MDS revealed the following: -BIMS score of 15 (cognitively intact). -Extensive assist with one-person physical assist for personal hygiene. -Extensive two-person physical assist for bed mobility, transfer, dressing and toilet use. Random observation on 4/30/18 at 8:42 AM revealed Resident 24's room had the call light activated. The resident was observed in her/his power chair to leave the room and approach a CNA to ask for assistance with toileting. The CNA was observed to indicate to the resident that she would assist her/him when she had time. On 4/30/18 at 8:42 AM Resident 24 stated she/he was waiting up to 25 minutes for staff assistance. On 4/30/18 at 8:44 AM observation of the call light system at the nurses station revealed Resident 24's call light was activated at 8:21 AM and was not deactivated until 8:46 AM. 6. Resident 29 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 29's 2/19/18 Admission MDS revealed the following: -BIMS score of 15 (cognitively intact). -Limited assist with one-person physical assist for bed mobility, locomotion on and off the unit and personal hygiene. -Extensive assist with one-person physical assist for transfers, dressing and toileting. On 4/24/18 at 8:38 AM Resident 29 stated she/he had wet her/his bed a couple of times when waiting for staff assistance. Resident 29 further stated she/he believed change of shift to be the most difficult time for staff assistance. 7. Resident 34 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 34's 3/22/18 Admission MDS revealed the following: -BIMS score of 14 (cognitively intact). -Extensive assist with one-person physical assist for locomotion on and off the unit. -Extensive assist with two-person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. On 4/24/18 at 9:07 AM Resident 34 states she/he believes night shift to be the time when she/he had to wait the longest for toileting assistance. The resident further stated she/he would have accidents in bed due to this, and the brief change in bed would cause extreme pain to her/his hip and back. Resident 34 further stated staff would come into her/his room when the call light was activated, turn the call light off and then leave without providing assistance. Resident 34 further stated she/he had waited up to an hour on the commode for staff assistance when her/his call light was activated. 8. Resident 43 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 43's 4/10/18 Quarterly MDS revealed the following: -BIMS score of 15 (cognitively intact). -Two-person physical assist with transfers. -Extensive assist with two-person physical assist for bed mobility, dressing, toilet use and personal hygiene. On 4/23/18 at 12:44 PM Resident 43 stated she/he believed there was not enough staff at shift change. Resident 43 further stated she/he had waited up to an hour to have her/his brief changed, and further stated it was difficult to have to sit in a soiled brief. 9. On 4/24/18 at 1:45 PM the resident council group interview which included Residents 29, 21, 38 and 45 identified the following: -Resident 21 stated staff would come in her/his room, turn off the call light and state they would return to assist the resident, leave the room and then not return. -Resident 38 stated she/he believed staff were overworked on evening shift and there were not enough staff working on night shift. The resident further stated it could be most difficult when a resident needed a two-person transfer and waited up to an hour for assistance. -Resident 45 stated she/he believed it was difficult to get timely staff assistance when she/he needed a two-person assist to transfer. -Resident 29 stated staff were so busy at times they would turn off her/his call light and not even have enough time to really hear what she/he needed. On 4/25/18 at 7:21 AM Staff 31 (LPN) stated that when direct care staff need a second person to assist with a hoyer (mechanical lift) transfer there were times when LPNs had to be pulled away from licensed nurse duties to assist. Staff 31 stated she believed this issue could be improved by having more staff. On 4/25/18 at 7:30 AM Staff 30 (CNA) stated it could get very busy when two-person hoyer transfers were needed, and further stated he had waited up to 90 minutes on evening shifts to get assistance from staff for a two-person hoyer transfer. Staff 30 further stated residents became very agitated when waiting to be transferred because often they needed to be transferred due to an incontinence accident and needed to be cleaned up. Staff 30 stated he had to rely on licensed nursing staff to assist with transfers and even physical therapy staff. Staff 30 further stated he heard of residents waiting 30-45 minutes for someone to come answer their call light, but then self-transferred and had accidents getting to the restroom because of the lack of staff response. Staff 30 stated the most recent time he recalled a resident self transferring and had an accident was about two weeks ago. He stated a resident told him her/his call light was on 15-20 minutes and when nobody answered the call light she/he had an accident in her/his briefs. Staff 30 said the staff person who was assigned to assist her hall was busy giving another resident a shower, and further stated evening was a tough time for staff and residents because for evening shift whoever has to take over a section while another CNA is giving a shower had 20 rooms assigned to them compared to their nine or ten rooms in their own section. Staff 30 stated due to the acuity of residents' needs an additional staff for each shift would be beneficial to the residents. On 4/25/18 at 8:21 AM Staff 29 (LPN) stated there were times where licensed nursing staff needed to step in and assist CNAs with two-person hoyer transfers. On 4/25/18 at 8:27 AM Staff 9 (CNA) stated she believed there were not enough staff to assist residents in a timely manner due to the acuity of residents. On 4/25/18 at 1:25 PM Staff 28 (CNA) stated she saw Resident 45 wait up to 30 minutes for staff assistance with a brief change. Staff 28 further stated she had seen Resident 43 wait up to an hour for assistance to have a brief change. Staff 28 further stated the facility met the state minimum requirements for CNA to resident ratios, but because of the acuity of residents she did not believe there were always enough CNAs to provide timely assistance to residents. On 4/26/18 at 4:55 AM Staff 27 (Agency CNA) stated on both day and swing shifts she waited up to 35 minutes for another staff to assist her with a two-person hoyer transfer for a resident. On 4/26/18 at 6:11 AM Staff 25 (nursing assistant) stated she sometimes struggled to find staff to assist her with two-person transfers for residents. On 4/26/18 at 12:21 PM Staff 23 (CNA) stated on 4/25/18 she waited 30-45 minutes for another staff to have time to assist her to transfer a resident and this happened frequently. Staff 23 further stated she had to stay late to provide resident showers when there were not enough staff to assist residents with their care needs. On 4/26/18 at 2:34 PM Staff 36 (CNA) stated administrative staff placed most residents with hoyer lifts in the back hall, which made it more complicated for staff in that area to get assistance with a two-person hoyer transfer. Staff 36 stated staff could wait up to 30 minutes for assistance from a second staff person for a two-person hoyer transfer. Staff 36 stated the facility was not making it work for staff or residents in terms of CNA to resident ratios based on acuity of residents. Staff 36 further stated just because state minimum ratios for staffing were met, they were not meeting the needs of residents on a regular basis. On 4/26/18 at 3:01 PM Staff 1 (Administrator) stated they met the state minimum ratio for direct care staff to residents, and often have a float staff position on duty to help on day shift. Staff 1 stated the center hall had a lot of hoyer residents, and the facility policy was that two persons assist whenever a resident was transferred via a hoyer. Staff 1 stated when he became aware of a complaint about a call light situation the process was to look at the call light tracking system to see if the resident was right or not. Staff 1 stated he did not believe residents should have to wait longer than 10 minutes to have a call light answered. Staff 1 was made aware by survey staff of multiple resident and staff concerns regarding call lights times and resident needs not being met due to staffing concerns. Staff 1 acknowledged these concerns. 10. On 4/23/18 at 12:19 PM Staff 32 (CNA) was observed feeding residents in the 200 hall dining area. Staff 32 stood in front of or beside residents as she fed them bites of food. On 4/23/18 at 1:00 PM Staff 32 stated she was not able to sit down while feeding residents because she was the only CNA in the dining room and other residents needed assistance. Staff 32 stated there were not enough CNAs to have more than one CNA per dining room. On 4/25/18 at 12:10 PM Staff 33 (CNA) was observed standing over a resident in the 300 hall dining area while she provided feeding assistance to a resident. Staff 33 was observed walking back and forth between residents as she provided feeding assistance while standing over the residents. On 4/25/18 at 5:28 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (LPN Resident Care Manager) and other administrative staff were all observed assisting with passing meal trays to residents and setting residents up for eating. During interviews on 4/25/18 and 4/26/18 Staff 15 (CNA), Staff 16 (CNA), Staff 34 (CNA) and Staff 36 (CNA) all stated the administrative staff did not typically assist with meals. On 4/26/18 at 8:06 AM Staff 19 (CNA) was observed providing feeding assistance to two residents at two different tables in the 300 hall dining room. Staff 19 was the only staff in the dining area. Both residents sat in front of their food and waited for their next bite as Staff 19 went back and forth between the two residents. On 4/26/18 at 3:02 PM Staff 1 (Administrator) acknowledged the administrative staff did not typically assist with meals. | 2020-09-01 |
| 2646 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 758 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record record review it was determined the facility failed to ensure an order for [REDACTED]. Findings include: Resident 4 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of the 3/2018 Consultation Report indicated a pharmacist recommendation to discontinue the use of PRN [MEDICATION NAME] (antipsychotic) unless a physician rationale indicated a new PRN order was necessary. The document further indicated the physician accepted the recommendation to discontinue PRN [MEDICATION NAME], with a signature date of 3/22/18. Review of the 3/2018 MAR indicated [REDACTED]. On 4/27/18 at 3:22 PM Staff 2 (DNS) confirmed Resident 4 had an order for [REDACTED]. | 2020-09-01 |
| 2647 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 759 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** According to the Nursing Drug Handbook (YEAR) edition, food should be consumed within 15 minutes of the administration of [MEDICATION NAME] (a fast-acting insulin used to treat diabetes). 1. Resident 16 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The 4/2018 Licensed Nurse Administration Record indicated the resident was to receive sliding scale (predefined blood glucose range) and a scheduled dose of 12 units of [MEDICATION NAME] insulin. On 4/25/18 at 11:20 AM Staff 29 (LPN) was observed to administer [MEDICATION NAME] to Resident 16. The resident received a lunch tray at 12:05 PM 50 minutes after insulin administration. On 4/28/18 at 11:10 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 16. The resident received a lunch tray at 11:55 AM 45 minutes after insulin administration. 2. Resident 9 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The resident's 4/2018 Licensed Nurse Administration Record indicated the resident was to receive [MEDICATION NAME] insulin. On 4/28/18 at 11:20 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 9. The resident received a lunch tray at 12:00 PM 40 minutes after insulin administration. 3. Resident 28 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. The resident's 4/2018 Licensed Nurse Administration Record indicated the resident was to receive a sliding scale and scheduled dose of 16 units of [MEDICATION NAME] insulin. On 4/28/18 at 11:15 AM Staff 12 (RN) was observed to administer [MEDICATION NAME] to Resident 28. The resident received a lunch tray at 11:50 AM 35 minutes after insulin administration. On 4/25/18 at 11:20 AM Staff 2 (DNS) acknowledged Residents 9, 16 and 28 were not provided food within 15 minutes of [MEDICATION NAME] fast acting insulin administration. | 2020-09-01 |
| 2648 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 761 | E | 0 | 1 | VJE211 | Based on observation and interview it was determined the facility failed to secure treatment supplies and medications in a locked storage area and to limit access to authorized personnel consistent with state or federal requirements and professional standards of practice for 1 of 2 treatment carts and 1 of 3 medication carts. This placed residents at risk for unsafe access to stored biologicals. Finding include: On 4/25/18 at 9:10 AM a treatment cart was observed to be unlocked and unattended in the 300 hall. Staff 38 (LPN) acknowledged the treatment cart was unlocked. On 4/27/18 at 9:27 AM a treatment cart was observed to be unlocked and unattended in the 300 hall. Staff 16 (CNA) acknowledged the treatment cart was unlocked. On 4/27/18 at 2:55 PM a medication cart was observed to be unlocked and unattended on the 300 hall. Staff 3 (LPN Resident Care Manager) acknowledged the medication cart was unlocked. | 2020-09-01 |
| 2649 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 812 | F | 0 | 1 | VJE211 | Based on observation and interview it was determined the facility failed to ensure food was stored appropriately and was discarded in a timely manner for 1 of 1 facility kitchens and 1 of 3 facility medication carts reviewed for food storage and handling. This placed residents at risk for food-borne illness and cross contamination. Findings include: 1. During a tour of the kitchen on 4/23/18 at 8:20 AM the following was observed: - Low calorie syrup with a best by date of 1/19/18 located in the dry storage room. - Undated, open and unopened packages of bread products located in the dry storage room. - Open and unsealed container of chicken salad located in the refrigerator. - Open and unsealed container of tuna salad located in the refrigerator. - Open container of green beans, dated 4/18/18, located in the refrigerator. - Open container of peaches, dated 4/19/18, located in the refrigerator. - Open package of yellow cheese, undated, located in the refrigerator. - Undated and open package of white cheese located in the refrigerator. - Undated and open package of deli meat located in the refrigerator. - Sealed milkshake packages, which indicated keep frozen, located in the refrigerator - Sealed packages of tortillas with expiration date of 2/14/18, located in the refrigerator. Staff 37 (Dietary Manager) acknowledged the above observations during the kitchen tour. Staff 37 stated the bread was previously frozen and was still good for two months after it was thawed. Staff 37 stated he was not sure how long the green beans and peaches were good after they were opened. Staff 37 acknowledged the milkshake packages were thawed even though the directions indicated they were to be kept frozen. Staff 37 stated all the food in the kitchen was to be used for residents of the facility. 2. On 4/26/18 at 6:57 AM a package of pudding was observed on a medication cart in the 200 hall. The pudding was dated 4/22/18. Staff 44 (LPN) stated the pudding was used for medication administration. Staff 44 (LPN) acknowledged the pudding was dated 4/22/18 and stated the pudding was supposed to be discarded after 72 hours. Staff 44 stated the pudding should have been discarded on 4/25/18. Staff 44 was observed to discard the pudding. On 4/30/18 at 11:14 AM Staff 37 stated the pudding was to be discarded after 72 hours. | 2020-09-01 |
| 2650 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 835 | F | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the lack of effective systems for ensuring adequate staffing levels, adequate supplies, treating residents with dignity, safeguarding of personal property, storing food, providing personal beneficiary information and maintaining accurate and complete medical records the facility failed to utilize its resources effectively and efficiently to assure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. This placed residents at risk for lack of timely assistance, lack of accommodation of needs, lack of dignity, loss of personal property, food-borne illness, lack of information about personal liability and inappropriate treatment. Findings include: 1. The facility did not have a system in place to ensure adequate staffing levels were maintained. Residents and staff indicated residents were not assisted in a timely manner due to a lack of available staff. On [DATE] at 3:02 PM Staff 1 (Administrator) stated facility staffing levels were based on state minimum staffing levels, with one added staff working as a float during the day. Refer to F-725. 2. The facility did not have an effective system in place to ensure needed supplies were readily available for residents at all times. Residents and staff indicated the facility ran out of supplies for residents. Refer to F-550 and F-558. 3. The facility did not have an effective system in place to ensure residents were treated with dignity. Residents and staff reported residents at times had to wear briefs that were too small for them and staff in the dining areas were observed to not maintain residents' dignity. Refer to F-550. 4. The facility did not have an effective system in place to safeguard residents' personal property. Residents and staff expressed awareness of residents missing their personal belongings and residents did not receive replacement items in a timely manner. Refer to F-584 5. The facility did not have an effective system in place to ensure food was stored and discarded appropriately. Expired and improperly stored food was observed in the kitchen and on a medication cart. Refer to F-812 6. The facility did not have an effective system in place to ensure residents were informed of personal financial liability. Staff indicated residents were not informed in writing of personal financial liability information when remaining in the facility post-Medicare coverage. Refer to F-582 7. The facility did not have an effective system in place to ensure resident medical records were complete and accurate. Facility administration acknowledged resident records were inaccurate or incomplete. Refer to F-842 | 2020-09-01 |
| 2651 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 842 | D | 0 | 1 | VJE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to maintain accurate medical records related to meal intake, pressure ulcers and physician notification for 3 of 4 sampled residents (#s 41, 44 and 297) reviewed for pressure ulcers, nutrition and infection control.This placed residents at risk for unmet needs. Findings include: 1. Resident 297 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. A Meal Monitoring document dated 3/15/18 through 3/27/18 indicated: -3/15/18 the resident ate 25% of breakfast and refused lunch and dinner. -3/16/18 the resident ate 75% of breakfast, 75% of lunch and 75% of dinner. 3/17/18 the resident ate 75% of breakfast, 99% of lunch and refused dinner. -3/18/19 the resident ate 99% of breakfast, refused lunch and dinner. -3/19/18 the resident ate 75% of breakfast, 75% of lunch and 99% of dinner. -3/20/18 the resident ate 75% of breakfast, refused lunch and dinner. -3/21/18 the resident ate 99% of breakfast, 99% of lunch and 99% of dinner. -3/22/18 the resident ate 75% of breakfast, 75% of lunch and 99% of dinner. -3/23/18 the resident ate 75% of breakfast, 75% of lunch and refused dinner. -3/24/18 the resident ate 25% of breakfast, 25% of lunch and 50% of dinner. -3/25/18 the resident ate 50% of breakfast, 75% of lunch and 50% of dinner. -3/26/18 the resident ate 75% of breakfast, 25% of lunch and 50% of dinner. -3/27/18 the resident ate 25% of breakfast, refused lunch and was out of the facility for dinner. An IDT assessment dated [DATE] indicated the resident's weight was stable at 180 lbs, the resident's intake was approximately 70%, though family reported that percentage was inaccurate and the resident was eating significantly less. During an interview on 4/29/18 at 7:19 PM Witness 1 (Complainant) stated the resident was not eating much so the family brought in the resident's favorite foods but the resident would not eat. Witness 1 stated the resident was not eating but staff were documenting 80% to 85% had been eaten by the resident. Witness 1 stated Staff 45 (RN) indicated staff were putting in the wrong documentation for meal monitoring because the staff assumed the resident was eating the food the family brought in. Witness 1 stated staff never asked if the resident was eating the food family brought in. Witness 1 was not sure how they could document the amount eaten when they had no idea. On 4/30/18 at 11:33 AM Staff 2 (DNS) acknowledged the CNAs were not documenting the meal monitoring correctly. 2. Resident 44 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Hospital records dated 3/23/18 indicated Resident 44 had nine pressure ulcers including three Stage 3 pressure ulcers (full thickness loss of skin), two unstageable pressure ulcers (ulcer covered by dead or devitalized tissue) and five pressure ulcers of unspecified stage. Initial Skin Ulcer Assessments dated 3/26/18 indicated Resident 44 had eight Stage 3 pressure ulcers and one Stage 4 pressure ulcer (visible muscle or bone). The assessments did not indicate depth of the pressure ulcers. The assessments also did not indicate a description of how the stage was determined. Hospital records dated 4/5/18 indicated Resident 44 had six unstageable pressure ulcers. On 4/30/18 at 2:22 PM Staff 2 (DNS) stated Resident 44 had unstageable pressure ulcers when she/he was admitted to the facility and acknowledged the 3/26/18 assessments were inaccurate. 3. Resident 41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A nurse's note on 4/2/18 at 5:09 AM revealed the resident had bright orange urine with a strong odor. A nurse's note on 4/2/18 at 9:15 PM revealed the resident complained of dysuria (pain or difficulty urinating) and a dip stick test for UTI was positive. The documentation indicated a plan to call the physician for an order for [REDACTED].>No documentation was found in the resident's clinical record to indicate the physician was notified. In an interview on 4/27/18 at 10:38 AM Staff 43 (Physician) stated he did not recall if staff called him related to Resident 41 and did not document every time the facility called about residents. In an interview on 4/26/18 at 11:17 AM and 4/30/18 at 1:30 PM Staff 2 (DNS) stated she expected staff to document the follow-up staff had with the physician. She verified there was no documentation related to contacting the physician between 4/2/18 and 4/8/18 related to the urinary symptoms. | 2020-09-01 |
| 2652 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2018-05-01 | 880 | F | 1 | 1 | VJE211 | > Based on observation and interview it was determined the facility failed to ensure staff used appropriate procedures to prevent infections related to sanitizing hands during dining service, cleaning oxygen filters, testing water for contamination and using gloves while administering medication for 1 of 3 facility dining rooms reviewed for dining service, 1 of 1 facility water system, 5 of 7 oxygen filters reviewed for infection control and 1 of 3 nurses observed during insulin administration. This placed residents at risk for infection. Findings include: 1. On 4/23/18 at 12:03 PM Staff 32 (CNA) was observed providing assistance to residents in the 200 hall dining area during the lunch meal. Staff 32 provided clothing protectors to residents, touched residents, touched silverware and other items in the residents' peripheral area. Staff 32 was not observed to sanitize her hands at any time. On 4/23/18 at 12:09 PM a surveyor interrupted Staff 32 as she went to the meal tray cart and prepared to deliver a tray to a resident. Staff 32 acknowledged she did not sanitize her hands between assisting residents and said she probably should have sanitized her hands after touching objects before providing assistance to residents in the dining room. On 4/23/18 at 12:19 PM Staff 32 was observed providing feeding assistance to a resident. Staff 32 held the resident's food in her bare hand as she fed the resident. Staff 32 wiped her hands with a napkin, then touched the resident's cheek and touched her own shirt with her hand before picking up the food in her bare hand again in order to feed it to the resident. On 4/23/18 at 1:00 PM Staff 32 acknowledged she fed the resident by hand and said some residents would not eat unless they were fed by hand. Staff 32 stated staff were not allowed to wear gloves while assisting residents in the dining room. On 4/23/18 1:14 PM Staff 2 (DNS) stated staff were to use hand sanitizer between residents and after touching objects when providing dining assistance. Staff 2 stated staff providing feeding assistance were to feed residents with silverware. Staff 2 stated staff were to use gloves if they had to touch the resident's food. 2. On 4/26/18 at 12:34 PM Staff 12 (RN) was observed to perform a CBG check on Resident 9 while wearing gloves. Staff 12 then proceeded to place her gloved hands on the computer and touched items in the treatment while wearing contaminated gloves. On 4/26/18 at 12:36 PM Staff 12 acknowledged she should have removed her gloves and sanitized her hands before proceeding to type on her computer and get into the cart. 3. On 4/30/18 at 8:04 AM Staff 41 (Maintenance Director) stated he received the legionella (water-borne bacteria) paperwork for implementing a plan the previous week. Staff 41 stated he started work on it but the facility did not have water test kits, had not tested the water and had not made changes to the water system to reduce the risk of legionella. | 2020-09-01 |
| 2653 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-06-06 | 637 | D | 1 | 0 | B5GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to complete significant change assessments within the required 14 day timeframe for 2 of 3 sampled residents (#s 5 and 9 ) reviewed for significant change. This placed residents at risk for unmet need. Findings include: 1. Resident 5 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. A progress note dated 4/9/19 indicated Resident 5 was discharged from hospice services. Resident 5's care plan was revised on 4/9/19 to remove the resident from hospice services. Resident 5's Significant Change in Status MDS was completed on 5/3/19, 11 days late. On 6/6/19 at 6:12 PM Staff 17 (Regional RN) confirmed the significant change MDS was late. 2. Resident 9 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A progress noted dated 12/2/18 indicated Resident 9 had a feeding tube placed on 11/30/18. Resident 9's Significant Change in Status MDS was completed on 12/28/18, 14 days late. On 5/23/19 at 5:04 PM Staff 18 (MDS Coordinator) confirmed Resident 9's feeding tube was placed on 11/30/18 and the Significant Change in Status MDS was late. | 2020-09-01 |
| 2654 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-06-06 | 658 | D | 1 | 0 | B5GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility staff failed to meet professional standards for medication administration for 2 of 2 sampled residents (#s 8 and 10) reviewed for medication administration. This placed residents at risk for adverse side effects. Findings include: Per Division 45 Standards and Scope of Practice for the LPN and RN [PHONE NUMBER]; Conduct Derogatory to the Standards of Nursing Defined: - Failing to communicate information regarding the client's status to members of the health care team in an ongoing and timely manner as appropriate to the context of care; or - Failing to communicate information regarding the client's status to other individuals who are authorized to receive information and have a need to know. - Failing to dispense or administer medications in a manner consistent with state and federal law. OAR Conduct Derogatory to the Standards of Nursing Defined indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (2) Conduct related to other federal or state statute/rule violations: (3) Conduct related to communication: (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner; and (i) Failing to communicate information regarding the client's status to other individuals who need to know; for example, family, and facility administrator. 1. Resident 8 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/18/19 physician order [REDACTED]. A 4/24/19 Medication Error incident report written by Staff 2 (Regional Director of Nursing) revealed the resident was alert and oriented and was able to make her/his needs known. The resident admitted post abdominal surgery. The resident had two JP ([NAME] Pratt) drains (a closed suction medical device commonly used as a post-operative drain for collecting bodily fluids) as well as an order for [REDACTED]. The resident was not ambulatory except with PT for a short distance. On 4/24/19 Witness 2 (Complainant) informed Staff 2 the resident did not have any vials of [MEDICATION NAME] in stock and there were 18 doses documented as administered but only 15 doses were delivered from the pharmacy. In total the resident missed four doses out of 21. The physician was notified and the resident was put on alert. The 4/2019 MAR indicated nursing staff where to administer [MEDICATION NAME] 1 ml injection at midnight, 8:00 AM and 4:00 PM. The MAR further indicated on 4/23/19 at 4:00 PM an agency nurse who no longer worked in the facility documented the medication was administered. On 4/24/19 at midnight Staff 10 (LPN) documented on the MAR [MEDICATION NAME] was administered. On 4/24/19 at 8:00 AM Staff 9 (LPN) documented on the MAR [MEDICATION NAME] was administered. There was no [MEDICATION NAME] in the building on the dates listed above. The facility's Medication Error investigation dated 4/24/19 revealed the following: - 18 doses of medication were documented as administered when only 15 doses were delivered. - The first three doses were documented as administered when the medication was not in the facility. - the fourth dose was documented as unavailable on 4/24/19 when the errors were discovered. - The medication was not delivered from the pharmacy before the scheduled administration. - witness statements revealed the pharmacy delivery schedule was problematic, there was only one delivery a day and the ekit (emergency kit) was limited. - Nurses were educated to NEVER document medications were administered when the medications were unavailable and/or not given. On 6/6/19 at 2:07 PM Staff 16 (LPN/RCM) stated the pharmacy can send the facility medication within four hours from the time the medication was ordered. Staff 16 further stated if the pharmacy was not able to get the medication they called a pharmacy near the facility to get the medication. Staff 16 stated there was no reason the residents' medications should be unavailable. On 6/17/19 at 8:45 AM Staff 4 (Pharmacy Technician) stated the facility received 15 vials of [MEDICATION NAME] on 4/18/19 and another 15 vials on 4/25/19. On 6/18/18 at 12:43 PM Staff 13 (LPN) and Staff 14 (LPN) stated when there was seven days left of a medication, the electronic health record would give notification to reorder. Staff 13 and Staff 14 stated there was no reason the medications should be unavailable. On 6/18/19 at 12:48 PM Staff 4 (DNS) acknowledged the nurses documented they administered [MEDICATION NAME] to Resident 8 when the medication was not in the facility and should not have documented a medication as given when it was not. 2. Resident 10 was admitted to the facility in 4/20/19 with [DIAGNOSES REDACTED]. A 4/15/19 physician order [REDACTED]. The 5/2019 MAR indicated staff were to administer [MEDICATION NAME] 15 mg at bedtime. The MAR further indicated on 5/4/19 the medication was unavailable but was documented as administered on 5/5/19, 5/6/19 and 5/7/19. A 5/9/19 Medication Error incident report revealed the resident was alert and oriented and able to make their needs known. Resident 10 was taking [MEDICATION NAME] 15 mg every night since admission and had no behaviors since admission. On 5/4/19 Staff 13 (LPN) documented the medication was not given because it was unavailable. On 5/5/19 the medication was still unavailable. Staff 13 then borrowed the same medication and dosage from another resident, administered it to the resident and documented it as administered. This same process occurred on 5/6/19 and 5/7/19. Staff 13 stated she was unsure what to do when the medication did not arrive and the other nurse told her to borrow the medication from another resident. Staff 13 was a new nurse and was not aware that it was against company policy to borrow medication from one resident to another. The physician was notified. and ordered the dose be reduced to 5 mg every night. On 6/6/19 at 1:49 PM Staff 8 (LPN) and Staff 12 (RN) stated If a resident is out of medication all you have to do is get on the phone, call pharmacy and they can deliver the medication to the facility in two hours. Staff 8 and Staff 12 stated staff should never borrow medication from another resident, especially when the medication could be ordered through the electronic health record or by calling the pharmacy. On 6/6/19 at 2:04 PM Staff 17 (Corporate Registered Nurse) stated it was not proper nursing standard of practice for a nurse to give a resident another resident's medication. On 6/6/19 at 5:58 PM Staff 13 (LPN) acknowledged she documented she gave the resident [MEDICATION NAME] when the medication was not in the building and gave [MEDICATION NAME] from another resident's medication. On 6/19/19 at 8:51 PM Witness 4 (Complainant) stated she went to the medication cart to administer the [MEDICATION NAME] to Resident 10 on 5/9/19 but it was not available. Witness 4 stated the medication was documented as given for the last four days but the medication was not in the facility. Witness 4 stated she called the pharmacy to find out when the order was last filled and the pharmacist stated the medication was last filled on 4/21/19 and was not reordered. | 2020-09-01 |
| 2655 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-06-06 | 684 | D | 1 | 0 | B5GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to follow physician's orders for 3 of 3 sampled residents (#s 6, 8 and 10) reviewed for medication. This placed residents at risk for adverse side effects. Findings include: 1. Resident 6 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 8/27/18 physician order indicated Resident 6 was to receive [MEDICATION NAME] (narcotic pain medication) 5-325 mg one to two tablets by mouth every four hours for severe pain of seven to 10 out of 10. A review of Resident 6's 8/2018 MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED] - On 8/28/18 for pain of five out of 10 at 12:43 PM and 7:43 PM - On 8/29/18 for pain six out of 10 at 7:06 AM and 12:41 PM. The 8/2018 MAR further indicated to give two tablets of [MEDICATION NAME] 5-325mg by mouth every four hours PRN for severe pain. Documentation on the MAR indicated [REDACTED] - on 8/28/18 for pain of seven out of 10 at 5:16 AM - 8/29/18 for pain of six out of 10 at 1:46 PM for pain nine out of 10 at 5:15 PM. On 5/21/19 at 10:17 AM Resident 6 stated she/he had orders to receive [MEDICATION NAME] one to two tablets every four hours. Resident 6 stated she/he would start with one tablet to see if it would work for the pain. If the one tablet did not work Resident 6 stated she/he would ask for another pain pill and staff would tell her/him to wait another four hours to get another one. Resident 6 stated I could not take it anymore and left. On 6/17/19 at 8:28 AM Staff 19 (Medical Records) stated she was the person who inputted the physician orders onto the MAR. Staff 19 further stated after she was done two nurses and then the the RCM reviewed to verify the orders were correct on the MAR. On 6/17/19 at 9:30 AM Staff 15 (RNCM) stated the orders on the MAR indicated [REDACTED]. Staff 15 further stated the nurses should have called the physician right away when they saw the order on the MAR indicated [REDACTED]. On 6/17/19 at 9:50 AM Staff 4 (DNS) acknowledged the order was not written correctly and staff were not following the physician order. 2. Resident 8 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/18/19 physician order revealed the resident had an order for [REDACTED]. A 4/25/19 Medication Error incident form revealed 15 vials of [MEDICATION NAME] was delivered from the pharmacy to the facility and 18 doses were administered. On 6/18/19 at 12:48 PM Staff 4 (DNS) acknowledged the nurses did not follow the physician order to administer [MEDICATION NAME]. 3. Resident 10 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/15/19 physician order revealed the resident had an order for [REDACTED]. The 5/2019 MAR indicated [REDACTED]. The MAR further indicated on 5/4/19 the medication was unavailable but was documented as administered on 5/5/19, 5/6/19 and 5/7/19. On 6/18/19 at 1:32 PM Staff 4 (DNS) acknowledged staff did not follow the physician order to administer [MEDICATION NAME]. | 2020-09-01 |
| 2656 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-06-06 | 760 | D | 1 | 0 | B5GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 2 of 2 sampled residents (#s 8 and 10) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 8 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/18/19 physician order [REDACTED]. A review of Resident 8's 4/2019 MAR indicated [REDACTED]. On 6/18/19 at 12:48 PM Staff 4 (DNS) acknowledged the nurses did not administer [MEDICATION NAME] as ordered by the physician. 2. Resident 10 was admitted to the facility in 4/15/19 with [DIAGNOSES REDACTED]. A 4/15/19 physician order [REDACTED]. The 5/2019 MAR indicated [REDACTED]. The MAR further indicated on 5/4/19 the medication was unavailable but was documented as administered on 5/5/19, 5/6/19 and 5/7/19. On 6/18/19 at 1:32 PM Staff 4 (DNS) acknowledged staff did not administer [MEDICATION NAME] as ordered by the physician. | 2020-09-01 |
| 2657 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-06-06 | 842 | D | 1 | 0 | B5GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure accurate resident records were maintained for 2 of 2 sampled residents (#s 8 and 10) reviewed for medications. This placed resident at risk of inaccurate information. Findings include: 1. Resident 8 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/18/19 physician order [REDACTED]. The 4/2019 MAR indicated nursing staff where to administer [MEDICATION NAME] 1 ml injection at midnight, 8:00 AM and 4:00 PM. The 4/2019 MAR revealed [MEDICATION NAME] was given 4/23/19 at 4:00 PM, 4/24/19 at midnight and 8:00 AM. but the medication for the resident was not available in the building. On 6/17/19 at 9:16 AM Staff 4 (DNS) acknowledged staff documented on the MAR [MEDICATION NAME] was administered when it was not. 2. Resident 10 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 4/15/19 physician order [REDACTED]. The 5/2019 MAR indicated on 5/5/19, 5/6/19 and 5/7/19 the medication was documented as administered. On 6/18/19 at 12:43 PM Witness 4 (Complainant) indicated the resident did not have [MEDICATION NAME] in the medication cart since 4/21/19 but the documentation on the MAR indicated the medication was given. On 6/18/19 at 1:38 PM Staff 4 (DNS) acknowledged staff documented on the MAR [MEDICATION NAME] was administered when it was not. | 2020-09-01 |
| 2658 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 550 | D | 0 | 1 | TQOE11 | Based on observation and interview it was determined the facility failed to ensure residents were provided a dignified dining experience for 1 of 3 dining rooms reviewed. This placed residents at risk for a lack of personal choices and a dignified dining experience. Findings include: On 12/9/19 from 11:46 AM to 12:48 PM observations of the facility dining room designated for residents requiring assistance revealed the following: - 11:46 AM: A resident was asked by Staff 21 (CNA) if she/he wanted a clothing protector and the resident declined. Staff 20 (CNA) came into the dining room and said to the resident of course you want it. Staff 16 (CNA) placed a clothing protector on the resident without her/his consent. - 11:55 AM: A resident was wheeled into the dining room and was observed to be loudly yelling, having vocalizations of laughing, calling out and being disruptive. Staff 16 and three other residents were present in the dining room and there was no attempt to calm the loud resident. - 12:00 PM: Staff 16 entered the dining room and placed clothing protectors on the three other residents in the dining room without asking permission. - 12:16 PM: Staff 16 assisted the resident with the loud verbal behaviors, providing bites of food with minimal interaction or discussion between her and the resident. - 12:22 PM: A resident seated in the corner was not close enough to the table to access the food easily. Each time she/he took a bite she/he had to grab the side of the table and pull herself/himself up to a more appropriate position to reach the food. No staff attempted to reposition the resident. On 12/13/19 at 1:26 PM Staff 2 (DNS) and Staff 19 (Regional RN) acknowledged the observations of the assisted dining room were not dignified for the residents. | 2020-09-01 |
| 2659 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 580 | D | 1 | 1 | TQOE11 | **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 family member of a fall for 1 of 2 sampled residents (#292) reviewed for accidents. This placed residents and their families at risk for not being fully informed. Findings include: Resident 292 was admitted to the facility in 11/2019 for hospice respite care with [DIAGNOSES REDACTED]. An Admission Profile completed 11/1/19 indicated Resident 292 was confused and at risk for falls. Resident 292's Admission Record form listed Witness 2 (Complainant) under Contacts as Emergency Contact #1. A progress note dated 11/4/19 at 9:58 PM indicated Resident 292 had an unwitnessed fall with injury in her/his room and hospice was notified. There were no progress notes indicating the resident's contact was notified by the facility. There was no documentation anywhere in Resident 292's clinical record the emergency contact (Witness 2) was notified by the facility of the resident's 11/4/19 fall. On 12/11/19 at 11:50 AM Staff 3 (Resident Care Manager - LPN) stated Witness 2 told her she was upset the facility did not call her about the resident's 11/4/19 fall. On 12/11/19 at 12:20 PM Witness 2 stated during the resident's admission process to the facility, she requested staff to notify her of any incidents involving Resident 292. Witness 2 stated Resident 292 sustained a fall with injury at the facility on 11/4/19 and the staff did not notify her. Witness 2 believed hospice notified her two to three days after the fall. On 12/11/19 at 1:07 PM Staff 2 (DNS) confirmed the facility did not notify the resident's emergency contact about the 11/4/19 fall but did notify hospice. On 12/11/19 at 1:30 PM Staff 7 (LPN) stated during the admission process Witness 2 requested to be notified by the facility for everything. Staff 7 stated the information was communicated on the Admission Record form. On 12/13/19 at 7:15 AM Staff 5 (LPN) stated she could not recall notifying Witness 2 when the resident fell . | 2020-09-01 |
| 2660 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 677 | D | 0 | 1 | TQOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide services to maintain adequate personal hygiene for 1 of 5 sampled residents (#9) reviewed for ADLs. This placed residents at risk for food borne illnesses and inadequate personal hygiene. Findings include: Resident 9 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 9/11/19 Quarterly MDS assessment revealed Resident 9's BIMS score was 6 indicating severe cognitive impairment. Resident 9 required one person extensive assistance for personal hygiene. On 12/9/19 at 12:09 PM Resident 9 was observed lying in bed on her/his right side while reaching back with her/his left hand to scratch inside her/his brief. Resident 9 resumed eating the meal placed on her/his tray table with her/his left hand. On 12/9/19 at 12:30 PM Resident 9 confirmed staff did not wash her/his hands before eating. Resident 9's hands were sticky although the meal tray was no longer present. On 12/11/19 at 11:43 AM Staff 9 (CNA) was observed setting up Resident 9's meal. No handwashing was offered to Resident 9 before Staff 9 left the room. The current comprehensive care plan revealed Resident 9 was able to eat independently after set-up. On 12/11/19 at 12:27 PM Staff 10 (CNA) indicated he and other CNAs were aware Resident 9 often had feces on her/his hands. On 12/11/19 at 12:32 PM Staff 9 (CNA) confirmed she did not wash Resident 9's hands before she/he ate. On 12/13/19 at 12:08 PM Staff 3 (Resident Care Manager - LPN) confirmed handwashing should be offered especially before meals begin. | 2020-09-01 |
| 2661 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 759 | D | 1 | 1 | TQOE11 | **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 pass error rate of less than 5%. There were three errors in 26 opportunities resulting in an 11.54% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: 1. Resident 8 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The Oregon Patient Safety Commission guidelines revealed the beyond-use date after initially opening multi-dose containers was 28 days. Resident 8's medical record revealed physician orders [REDACTED]. On 12/12/19 at 12:30 PM Staff 14 (RN) removed the eye drops from the medication cart. The eye drops were dated 8/29/19 (105 days after first opened) and Staff 14 confirmed the vial was initially opened and used on that date. Staff 14 administered the eye drops to Resident 8. On 12/13/19 at 1:49 PM Staff 2 (DNS) and Staff 19 (Regional RN) acknowledged eye drops should be disposed of 28 days after initially opened. 2. Resident 33 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. Resident 33's medical record revealed a physician order [REDACTED]. On 12/13/19 at 8:44 AM Staff 15 (RN) administered Resident 33 the carvedilol in her/his room. On 12/13/19 at 11:41 AM Staff 17 (LPN) stated she was Resident 33's nurse and the resident had breakfast earlier around 7:30 AM or 7:45 AM On 12/13/19 at 1:49 PM Staff 2 (DNS) and Staff 19 (Regional RN) acknowledged Resident 33's carvedilol was not administered with a meal as ordered. b. Resident 33's medical record included a physician order [REDACTED]. On 12/13/19 at 8:44 AM Staff 15 (RN) administered the medication mixed in a cup of water to Resident 33. The resident drank half of the cup of water with the medication and Staff 15 took the cup and tossed it into the trash. The resident was not observed to refuse the remainder of the medication. Outside the resident's room when asked by the surveyor, Staff 15 stated Resident 33 did not always drink all of the cup of medication. Resident 33's 12/2019 MAR indicated [REDACTED]. On 12/13/19 at 1:49 PM Staff 2 (DNS) and Staff 19 (Regional RN) acknowledged Staff 15 failed to administer the entire dose of [MEDICATION NAME] and documented it incorrectly on the 12/2019 MAR. | 2020-09-01 |
| 2662 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 761 | E | 1 | 1 | TQOE11 | **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 medications were properly discarded when expired for 2 of 2 medication carts reviewed during medication storage. This placed residents at risk for receiving medications with decreased efficacy. Findings include: The Oregon Patient Safety Commission guidelines revealed the beyond-use date after initially opening multi-dose containers was 28 days. Review of medication cart 2 with Staff 14 (RN) on [DATE] at 12:45 PM revealed the following: - Refresh Tears (lubricating eye drops), no date when opened. - Blink Drops (provides moisture to eyes), dated as opened [DATE] (121 days after opened). - Refresh Tears, dated as opened [DATE] (91 days after opened). - Refresh Tears, dated as opened [DATE] (94 days after opened). Review of medication cart 4 on [DATE] at 8:50 AM with Staff 17 (LPN) revealed the following: - [MEDICATION NAME] Tears (provides lubrication to eyes), dated as opened [DATE] (237 days after opened). - Lubricating eye drops, dated as opened on [DATE] (161 days after opened). On [DATE] at 1:49 PM Staff 2 (DNS) and Staff 19 (Regional RN) acknowledged the multiple eye drops in medication carts 2 and 4 were not discarded when expired. | 2020-09-01 |
| 2663 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2019-12-13 | 880 | D | 0 | 1 | TQOE11 | Based on interview and record review it was determined the facility failed to include an outdoor water feature in their water management plan for 1 of 1 water feature reviewed for Legionella bacteria. This placed residents at risk for infection through inhalation of water contaminated with legionella bacteria. Findings include: A review of the facility's Legionella Water Management Plan revealed the facility failed to include a resident accessible outside water feature in the plan. On 12/12/19 at 10:19 AM Staff 8 (Maintenance Director) confirmed the water feature was not in the Legionella Water Management Plan and residents do sit near it. On 12/13/19 at 10:03 AM Staff 1 (Administrator) acknowledged the water feature was not included in the Legionella Water Management Plan. | 2020-09-01 |
| 4540 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 309 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to follow physician's orders related to fluid restriction for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for complications related to [MEDICAL CONDITION] and low sodium levels. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Hospital Orders at discharge date d 11/26/16 indicated to restrict Resident 1's fluid intake to 1200 ml per day and weigh the resident daily. Resident 1's Diet Order & Communication dated 11/26/16 indicated the resident was on a 1200 ml per day fluid restriction. Resident 1's 12/2016 physician's orders included a fluid intake goal of 1200 ml per day. The night shift nurse was to record the 24 hour total. Resident 1's fluid intake record charted under the resident's vital signs in the computerized medical record revealed on 17 of the 25 days from 11/26/16 through 12/21/16 the resident went over her/his 1200 ml per day fluid restriction by as little as 70 ml to as much as 3080 ml per day. The resident's average intake from 11/26/16 through 12/14/16 was 1964 ml per day. Resident 1's 11/2016 and 12/2016 TARs revealed the facility also documented the resident's per shift fluid intake on the TAR. According to the TAR the resident's average intake from 11/26/16 through 12/14/16 was 1353 ml per day. On 3/15/17 at 1:53 am Staff 1 (DNS) acknowledged there were times Resident 1 went over her/his daily fluid restriction. | 2020-03-01 |
| 4541 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 325 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to reassess the risk for poor food intake after a change in mental status for 1 of 3 sampled residents (#1) reviewed for food intake. This placed residents at risk for unintended weight loss. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 12/1/16 Registered Dietitian (RD) assessment indicated Resident 1's intake was enough to promote weight gain and the resident agreed to start nutritionally enhanced meals. The resident's average breakfast, lunch and dinner intake was 76-100%. A fax sent to the physician on 12/5/16 indicated the facility requested a new order for nutritionally enhanced meals for planned weight gain. The order was approved by the physician. A 12/8/16 Nutritional Risk Review indicated the resident's seven day breakfast, lunch and dinner average intake was 76-100%. Resident 1's meal intake record from 11/26/16 through 12/21/16 indicated the amount of meals consumed using ranges of: 1-25%, 26-50%, 51-75% and 76-100%. On other times it was recorded as None, Not taken or it was not recorded at all. From 11/26/16 through 12/15/16 the record revealed the following average meal intakes using the highest number in the ranges recorded and using zero where it was not recorded or indicated the resident did not eat: - Breakfast 74% - Lunch 66% - Dinner 59% Resident 1's meal intake record from 12/14/16 through 12/21/16 revealed the following average meal intakes: - Breakfast 32% - Lunch 38% - Dinner 21% Resident 1's 11/2017 and 12/2016 TARs revealed the resident was supposed to be weighed daily at 6:30 am. On 11/27/16 the resident weighed 133.6 pounds and on 12/18/16 weighed 130 pounds (an insignificant loss of 3.6 pounds). On 12/21/16, the day the resident was discharged from the facility, the resident weighed 123.4 pounds, an overall loss of 10.2 pounds or 7.6% body weight over 24 days. (As the resident was discharged from the facility that day the facility was unable to verify the weight the next day or implement interventions if needed.) Hospital ED Provider Notes dated 12/18/16 indicated the resident appeared well developed and well-nourished with no distress. The resident was pleasantly confused. Extensive testing in the emergency department did not reveal an obvious cause to warrant emergent consultation, admission or transfer. The resident's sodium level was within normal range. A review of Resident 1's Progress Notes revealed the following: - On 12/15/16 at 10:31 am the night shift nurse (unnamed) reported the resident had some hallucinations. - On 12/15/16 at 11:16 pm a report was received from PT (physical therapy) the resident appeared more confused and lethargic. - On 12/16/16 the resident was noted with some confusion. - On 12/17/16 the resident was confused and did not know where she/he was. - On 12/18/16 at 2:31 am the resident remained confused. - On 12/18/16 at 2:19 pm the resident was confused and combative, refused food and fluids. The physician was notified and gave an order to send the resident to the emergency department for evaluation of altered mental status. - On 12/18/16 at 6:30 pm the resident was found on the floor by the bathroom. - On 12/20/16 the resident was confused and agitated, resistive to cares and would not communicate with staff. Fluids were encouraged within the resident's fluid restriction. The resident was to discharge home on hospice. - On 12/21/16 the resident was discharged from the facility and was signing on with hospice the same day. Physician Discharge Orders signed 12/19/16 indicated Resident 1 was discharged to an adult foster home on hospice. A review of Resident 1's clinical record revealed no indication the facility reassessed the resident's risk for decreased food intake after the resident was sent to the hospital on [DATE] for a change in mental status. On 3/15/17 at 1:53 am and 3/16/17 at 10:45 am Staff 1 (DNS) acknowledged Resident 1 had a significant decline in food intake after 12/14/16. When Staff 1 was asked about any new interventions related to the resident's decline in intake she stated they could not force the resident to eat or drink and they continued with the same interventions. She acknowledged the RD was not consulted regarding the decline in intake after 12/14/16. She stated no care plan changes were needed for something they would normally do. Staff 1 acknowledged Resident 1's weight on 12/21/16 was 123.4 pounds. | 2020-03-01 |
| 4542 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 327 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to assess the risk factors for dehydration, assess actual fluid intake and reassess the risk for dehydration after a change in mental status for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for fluid imbalance. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Hospital Orders at discharge date d 11/26/16 indicated to restrict Resident 1's fluid intake to 1200 ml per day and weigh the resident daily. Resident 1's Diet Order & Communication dated 11/26/16 indicated the resident was on a 1200 ml per day fluid restriction. Resident 1's 12/2016 physician's orders [REDACTED]. The night shift nurse was to record the 24 hour total. The resident also had a physician's orders [REDACTED]. Resident 1's Care Plan dated 12/5/16 indicated the facility was to maintain the resident's fluid and sodium restrictions as indicated and monitor for clinical evidence of fluid imbalance including skin turgor, level of consciousness changes, vital sign changes, laboratory values and mucous membranes. The Care Plan did not indicate the resident was on a 1200 ml per day fluid restriction. Resident 1's In Room Care Plan (IRCP) last updated on 12/6/16 (a copy of which was made by this surveyor on 2/23/17 from the resident's chart) did not indicate the resident was on a fluid restriction. On 3/3/17 at 3:15 pm Staff 1 (DNS) provided a copy of Resident 1's IRCP which indicated 1200ml fluid restriction but was otherwise identical and was also last updated 12/6/16. A 12/1/16 Registered Dietitian (RD) assessment indicated Resident 1 was on a 1200 ml per day fluid restriction and the assessment calculated the resident's fluid needs as 1800 ml per day. The resident received a diuretic with no signs or symptoms of dehydration. The assessment failed to address the resident's actual fluid intake in relation to the ordered fluid restriction. A 12/8/16 Nutritional Risk Review indicated the resident had [MEDICAL CONDITION] and was on [MEDICATION NAME] (diuretic) therapy. The resident had no signs or symptoms of dehydration and the plan was to reassess the resident in four weeks. The assessment failed to indicate the resident was on an ordered 1200 ml per day fluid restriction, address the resident's actual fluid intake in relation to the ordered fluid restriction or the facility's failure to maintain Resident 1's physician ordered fluid restriction. Resident 1's fluid intake record from 11/26/16 through 12/21/16 charted under the resident's vital signs in the computerized medical record revealed that on 17 of the 25 days from 11/26/16 through 12/21/16 the resident went over her/his 1200 ml per day fluid restriction by as little as 70 ml to as much as 3080 ml per day. The resident's average intake from 11/26/16 through 12/14/16 was 1964 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 763 ml per day which was a 61% decrease. Resident 1's 11/2016 and 12/2016 TARs revealed the facility also documented the resident's per shift fluid intake on the TAR. According to the TAR the resident's average intake from 11/26/16 through 12/14/16 was 1353 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 596 ml per day which was a 56% decrease. Resident 1's Resident Behavior Report Sheets dated 12/15/16 through 12/20/16 revealed the resident hallucinated, was confused, physically and verbally aggressive, frustrated and upset. The Mayo Clinic indicated symptoms related to [MEDICAL CONDITION] (low blood sodium level) included: nausea, vomiting, headache, confusion, loss of energy, fatigue, restlessness, irritability and muscle weakness. Hospital ED Provider Notes dated 12/18/16 indicated the resident appeared well developed and well-nourished with no distress. The resident was pleasantly confused. Extensive testing in the emergency department did not reveal an obvious cause to warrant emergent consultation, admission or transfer. The resident's sodium level was within normal range. A review of Resident 1's Progress Notes revealed the following: - On 11/26/16 the resident was admitted to the facility after exacerbation of [MEDICAL CONDITION] and the resident was on a fluid restriction. - On 11/28/16 the physician indicated it was alright to administer [MEDICATION NAME] and [MEDICATION NAME] to the resident related to questions about allergies [REDACTED].> - On 12/4/16 the resident was alert and oriented, able to make her/his needs known, compliant with cares from staff and had no noted behaviors. The resident was compliant with the fluid restriction. - On 12/15/16 at 10:31 am the night shift nurse (unnamed) reported the resident had some hallucinations. - On 12/15/16 at 11:16 pm a report was received from PT (physical therapy) the resident appeared more confused and lethargic. - On 12/16/16 the resident was noted with some confusion. - On 12/17/16 the resident was confused and did not know where she/he was. - On 12/18/16 at 2:31 am the resident remained confused. - On 12/18/16 at 2:19 pm the resident was confused and combative, refused food and fluids. The physician was notified and gave an order to send the resident to the emergency department for evaluation of altered mental status. - On 12/18/16 at 6:30 pm the resident was found on the floor by the bathroom. - On 12/20/16 the resident was confused and agitated, resistive to cares and would not communicate with staff. Fluids were encouraged within the resident's fluid restriction. The resident was to discharge home on hospice. - On 12/21/16 the resident was discharged from the facility and was signing on with hospice the same day. Physician Discharge Orders signed 12/19/16 indicated Resident 1 was discharged to an adult foster home on hospice. A review of Resident 1's clinical record revealed no indication the facility assessed the resident's risk for fluid imbalance on admission to the facility related to fluid restriction, low sodium level, diuretic therapy and [DIAGNOSES REDACTED]. There was no indication the facility reassessed the resident's risk for fluid imbalance after the resident was sent to the hospital on [DATE] for a change in mental status. There was no documented evidence to indicate the facility reviewed the resident's actual fluid intake. On 3/15/17 at 1:53 am and 3/16/17 at 10:45 am Staff 1 (DNS) acknowledged there were times Resident 1 went over her/his daily fluid restriction and the fluid intake documentation was not accurate. She stated the resident was on Nutritional Risk Review for skin issues not for fluids. When Staff 1 was asked if the 12/1/16 RD assessment addressed the residents fluid restriction versus her/his actual intake she stated the RD did not indicate any concerns. Staff 1 acknowledged the resident was not assessed related to her/his fluid restriction and actual fluid intakes. Staff 1 acknowledged the resident had a significant decline in fluid intake after 12/14/16. When Staff 1 was asked about any new interventions related to the resident's decline in intake she stated they could not force the resident to eat or drink and they continued with the same interventions. She acknowledged the RD was not consulted regarding the decline in intake after 12/14/16. She stated no care plan changes were needed for something they would normally do. | 2020-03-01 |
| 4543 | TIMBERVIEW CARE CENTER | 385107 | 1023 6TH AVE SW | ALBANY | OR | 97321 | 2017-03-16 | 514 | D | 1 | 0 | IMNU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to maintain accurate fluid intake records for a resident on a physician ordered fluid restriction for 1 of 3 sampled residents (#1) reviewed for fluid intake. This placed residents at risk for inaccurate fluid intake data needed for accurately monitoring and assessing residents on fluid restrictions. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Hospital Discharge Summaries dated 11/26/16 indicated Resident 1 was on a 1200 ml per day fluid restriction related to low sodium in the blood. The resident would benefit from having palliative care on-board. Resident 1's fluid intake record from 11/26/16 through 12/21/16 charted under the resident's vital signs in the computerized medical record revealed that on 17 of the 25 days from 11/26/16 through 12/21/16 the resident went over her/his 1200 ml per day fluid restriction by as little as 70 ml to as much as 3080 ml per day. The resident's average intake from 11/26/16 through 12/14/16 was 1964 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 763 ml per day which was a 61% decrease. Resident 1's 11/2016 and 12/2016 TARs revealed the facility also documented the resident's per shift fluid intake on the TAR. According to the TAR the resident's average intake from 11/26/16 through 12/14/16 was 1353 ml per day. The resident's average intake from 12/15/16 through 12/21/16 dropped to 596 ml per day which was a 56% decrease. On 3/15/17 at 1:53 am and 3/16/17 at 10:45 am Staff 1 (DNS) acknowledged the fluid intake documentation was not accurate. | 2020-03-01 |
| 4563 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 157 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to notify interested family members for 1 of 3 sampled residents (#4) reviewed for falls. This placed the resident at risk for unmet needs. Findings include: Resident 4 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 11/16/16 progress notes and incident investigation report documented the resident fell on the floor. The documentation indicated the resident's left ear was bleeding and she/he was transported to the local hospital emergency department. There was no documentation the resident's family members were notified of the incident. The 12/30/16 progress notes and incident investigation report documented the resident was found lying on the floor on her/his right side. The resident was noted to have a laceration above her/his left eye and was transported to the local hospital emergency department. There was no documentation the resident's family members were notified of the incident. On 2/9/17 at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide documentation of notification of the resident's interested family members. No additional information was provided. | 2020-03-01 |
| 4564 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 225 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to thoroughly investigate incidents of falls for 3 of 4 sampled residents (#s 3, 4 and 10) reviewed for falls. This placed the resident at risk for risk for unmet needs. Finding include: 1. Resident 3 was readmitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 1/9/17 progress note written at 7:17 pm documented a summary of an incident. The progress notes documented a CNA reported Resident 3 fell in her/his room. The staff indicated neurological checks were implemented and the resident refused to be transported to the local hospital emergency department. On 1/31/17 at 2:35 pm Staff 2 (Interim DNS) was asked to provide an investigation of the resident's fall. On 2/2/17 at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. 2. Resident 4 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 11/16/16 progress notes and incident investigation report documented the resident was found on the floor laying down with her/his head on the floor by the foot of the bed with her/his feet pointing door. The resident's left ear was bleeding and she/he was transported to the local hospital emergency department. Resident 4 stated she/he tried to get up from the bed and fell on the floor. The investigation contained no documentation to determine where and when the resident was last seen, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall. The 12/30/16 progress notes and incident investigation report documented the resident was found lying on the floor on her/his right side. The resident was noted to have lacerations around her/his left eye and was transported to the local hospital emergency department. The information indicated the resident stated she/he was sitting on the bed and reached for the table and fell . The investigation contained no documentation to determine where and when the resident was last seen, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall. On 2/9/17 at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide documentation of thorough investigations for the 11/16/16 and 12/30/16 falls. No additional information was provided. 3. Resident 10 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 10/28/16 progress notes written at 1:53 pm documented the resident rolled out of bed in the morning. The resident sustained [REDACTED]. There was a 10/28/16 Incident Investigation which documented the resident was found beside her/his bed. The fall was unwitnessed. There was no documentation to determine where and when the resident was last seen, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall. There was a 10/30/16 Incident Investigation which documented the resident was found on the floor in dining room. The investigation indicated the resident slipped out of the wheelchair in the dining room. The resident's care plan was going to be changed to reflect to stay in common areas as possible. There was no documentation of the incident in the resident's progress notes. The 11/21/16 progress notes documented the resident was sitting on the floor in front of her/his wheelchair. The resident sustained [REDACTED]. The 11/21/16 Incident Investigation indicated the resident was found on the floor in front of wheelchair. The resident had a 4 cm skin abrasion found on her/his left upper thigh. The investigation indicated the resident was found siting on the floor in room in front of wheelchair. The fall was unwitnessed and there was no documentation neuro checks were started. There were no witness statements. The investigation contained no documentation to determine where and when the resident was last seen, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall. The 11/26/16 progress notes documented the resident slid out of her/his bed onto foam bed next to her/his bed. No injuries were sustained in this incident. The 11/26/16 Incident Investigation indicated there were no witness statements or neuro checks conducted. The investigation contained no documentation to determine where and when the resident was last seen, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall. On 3/16/17 at 2:00 pm Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 24 (RN Corporate Consultant) were asked to provide any additional information regarding investigations of the falls. On 3/20/17 Staff 2 and Staff 24 provided a statement to indicate there was no additional documentation to provide. | 2020-03-01 |
| 4565 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 279 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to include the provision of the use of insulin and lowered bed for 3 of 7 sampled residents (#s 4, 10 and 11) reviewed for care plans. This placed the resident at risk for for unmet needs. Findings include: 1. Resident 4 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident 4's 12/2/16 comprehensive care plan did not identify the use of insulin. The care plan did not have measurable objectives and interventions developed to ensure the resident did not have side effects from the insulin. On 1/18/17 at 11:00 am Staff 13 (RNCM) reviewed the comprehensive care plan and verified the resident's care plan was not updated to include diabetes and insulin usage. On 1/18/17 at 4:33 pm Staff 1 (Administrator) and Staff 2 (Interim DNS) were informed the insulin usage was not included on the resident's comprehensive plan of care. 2. Resident 10 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 10/1/16 Progress notes written at 9:47 am indicated the resident was observed to roll off of her/his bed onto the floor. The resident was assessed not to be injured. The 10/1/16 Incident Investigation indicated the resident had rolled out of bed and the bed was in the lowest position. There was no inclusion of the bed in the lowest position on the resident's care plan initiated on 7/28/15 and revised on 1/28/16 and 7/14/16. The 10/28/16 Progress notes written at 1:53 pm documented the resident rolled out of bed in the morning. The resident sustained [REDACTED]. The 11/1/16 local Hospice RN notes indicated Resident 10's bed was in the high position. The RN wrote the bed was lowered to the lowest level and a crash mat was next to the resident's bed. The care plan was not updated to include the resident's bed in the lowest position. The use of a fall mat was not included on the resident's care plan until 11/2/16. On 3/16/17 at 2:00 pm Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 24 (Corporate RN Consultant) were asked to provide additional information about the low bed on the care plan. There was no additional information provided. 3. Resident 11 was readmitted to the facility in 12/27/16. The resident was admitted to the local hospice service when she/he was a patient at the local hospital. The resident's care plan did not include the provision of hospice services until 1/16/17. On 3/20/17 at 3:07 pm Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 24 (Corporate RN Consultant) confirmed the resident's care plan did not include the provision of hospice services until 1/16/17. | 2020-03-01 |
| 4566 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 281 | G | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined Staff 14 (LPN) failed to provide resident care according to standards of practice for nurses. Resident 4 had a low blood sugar and the licensed nurse failed to monitor the resident and recheck the resident's CBGs. Resident 4 died at the facility. Findings include: Scope of Practice Standards for All Licensed Nurses: [PHONE NUMBER]-(1) (b) Intervenes on behalf of the client to identify changes in health status to protect, promote and optimize health and alleviate suffering .(5) Standards related to the licensed nurse's responsibility to assign and supervise care. (c) Ensures documentation of the activity .(e) Provides follow-up on problems and intervenes when needed. Resident 4 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] physician's orders [REDACTED]. The facility staff were to follow the [DIAGNOSES REDACTED] protocol. The (MONTH) (YEAR) Licensed Nurse Administration Record contained no documentation on [DATE] at 5:00 pm of the CBG reading or the sliding scale insulin provided. The record also documented the scheduled dose of insulin at 8:00 pm was not provided. The record documented the information was documented in the progress notes. The resident's progress notes for [DATE] contained no documentation of the resident's blood sugar level at 5:00 pm and sliding scale insulin provided. There was also no documentation regarding the scheduled insulin. The [DATE] progress note written at 8:20 pm by Staff 12 (RN) documented the CNA found the resident unresponsive during rounds. The progress note determined the CNA last checked the resident around 7:30 pm and she/he appeared to be resting quietly. Staff 12 documented when the resident was assessed at (8:20 pm) resident was found with no respirations, no apical heart tones, no blood pressure, sallow skin color and cold. On [DATE] Staff 14 (LPN) documented a handwritten progress note as a late entry for [DATE]. Staff 14 documented the resident was lying in bed on the evening of [DATE] and indicated it was unusual for her/him to be in bed. Staff 14 stated she administered Resident 4's medications at 4:45 pm and checked her/his CBG at 5:30 pm and the CBG registered at 61. Staff 14 stated she asked the CNAs to provide the resident with orange juice as she wasn't sure the resident would eat dinner. Staff 14 stated she did not check the resident's CBG at 8:00 pm and did not provide the resident with 5 units of insulin. Staff 14 stated at 8:20 pm it was reported Resident 4 was dead. The facility provided documentation on [DATE] Staff 14 (LPN) was provided with a verbal warning and education. The [DATE] performance documentation indicated Staff 14 failed to recheck the resident's CBG and did not document in a timely manner the nursing interventions implemented. The performance documentation indicated education was provided to improve on documentation and insulin/CBG management. On [DATE] at 1:40 pm Staff 2 (Interim DNS) stated Staff 14 (LPN) did not document the resident's CBG and did not monitor the resident's condition on [DATE]. Staff 2 stated she educated Staff 14 and provided her with a verbal warning. Staff 2 stated she also provided inservice education to all of the licensed nurses about the facility's [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 1:50 pm Staff 12 (RNCM) stated she was was working as a charge nurse on the other end of the building on the night of [DATE]. Staff 12 stated the CNA reported Resident 4 was unresponsive and Staff 12 assessed the resident and determined the resident had been dead for quite awhile. On [DATE] at 2:25 pm Staff 14 (LPN) stated she took the resident's CBG at 5:00 pm and it was 61. She stated she asked the CNAs to provide the resident with orange juice as she was not certain if the resident was to eat her/his meal. Staff 14 stated she did not recheck the resident's CBG after 5:00 pm. Staff 14 stated a CNA reported the resident was unresponsive. Staff 14 stated she assessed the resident to be dead. Staff 14 stated she did not document the CBG at the time it was taken and did not recheck the CB[NAME] On [DATE] at 12:10 pm Witness 2 (Complainant) stated the facility failed to monitor the resident's condition on [DATE]. Witness 2 stated the resident had a new order for insulin on her/his readmission to the facility and questioned if the facility managed the resident's diabetes. On [DATE] at 10:16 am Witness 3 (physician) stated the facility was to follow hypoglycemic protocol. Witness 3 stated the facility staff needed to document the findings of the resident's CBG when taken. Witness 3 stated it was difficult to determine the accuracy of the CBG reading without documentation at the time it was taken. Witness 3 stated if Staff 14 (LPN) was concerned about the resident's condition and low CBG reading she needed to recheck the resident's CB[NAME] Refer to F-309. | 2020-03-01 |
| 4567 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 309 | G | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on interviews and record review it was determined the facility failed to follow physician's orders, provide interventions, monitor and contact the physician for episodes of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) for 4 of 7 sampled residents (#s 2, 3, 4 and 6) reviewed for diabetes management. Resident 4 had a low blood sugar reading, the facility did not recheck the resident's blood sugar and monitor her/his condition. Resident 4 died at the facility. Findings include: The facility's undated hypoglycemic protocol contained instructions to the facility staff to monitor blood glucose (sugar) for resident with diabetes. The record indicated the facility was to document the results of the blood glucose monitoring and if the glucose reading was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The protocol indicated if the resident was able to swallow the facility was to provide four ounces of juice, without extra sugar added or provide five packets of sugar in four to six ounces of water, or administer one tube of glucose paste/gel sublingually. The staff were to recheck CBG (Capillary Blood Glucose) in ten to fifteen minutes. If still below 60, repeat the measures. Recheck CBG again in ,[DATE] minutes. If the CBG was still below 60, the facility was to notify MD and call 911 per LN discretion. The facility staff were to document steps taken, resident response, physician notification in a note. There was a [DIAGNOSES REDACTED] protocol if the resident was not able to swallow: the facility was to provide [MEDICATION NAME] 1.0 mg IM (intramuscular). If the resident was in bed the staff were to turn the resident onto their side to prevent aspiration. The facility staff were to recheck the CBG in ten to fifteen minutes. If the CBG was still below 60, the staff were to repeat IM [MEDICATION NAME] and recheck CBG again in ten to fifteen minutes. If the CBG was still below 60 the staff were to notify MD and call 911 per nurse's discretion. The staff were to document steps taken, resident response and MD notification in the record. a. Resident 4 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] physician's orders directed the facility to document the results of the blood glucose monitoring and if the resident's CBG was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The [DATE] physician's order was for a scheduled dose of five units of Insulin [MEDICATION NAME] Solution Pen-injection 100 unit ML at 8:00 pm. The physician ordered a sliding scale dose of insulin to be provided according to the CBG reading and was to be administered five to ten minutes prior to the meal. i. The (MONTH) (YEAR) Licensed Nurse Administration Record contained no documentation on [DATE] at 5:00 pm of the CBG reading or the sliding scale insulin provided. The record also documented the scheduled dose of insulin at 8:00 pm was not provided. The record documented the information was documented in the progress notes. The resident's progress notes for [DATE] contained no documentation of the resident's blood sugar level at 5:00 pm and sliding scale insulin provided. There was also no documentation regarding the scheduled insulin. The resident's [DATE] meal monitor and fluid monitor documented the resident did not consume a meal for the entire day. The documentation indicated the resident consumed 100 cc of fluids at 11:26 am. The documentation indicated the resident was provided fluids at 6:00 pm and there was no documentation of fluids consumed at 6:00 pm. The [DATE] progress note written at 8:20 pm by Staff 12 (RN) documented the CNA found the resident unresponsive during rounds. The progress note determined the CNA last checked the resident around 7:30 pm and she/he appeared to be resting quietly. Staff 12 documented when the resident was assessed at (8:20 pm) resident was found with no respirations, no apical heart tones, no blood pressure, sallow skin color and cold. On [DATE] Staff 14 (LPN) documented a handwritten progress note as a late entry for [DATE]. Staff 14 documented the resident was lying in bed on the evening of [DATE] and indicated it was unusual for her/him to be in bed. Staff 14 stated she administered Resident 4's medications at 4:45 pm and checked her/his CBG at 5:30 pm and the CBG registered at 61. Staff 14 stated she asked the CNAs to provide the resident with orange juice as she wasn't sure the resident would eat dinner. Staff 14 stated she did not check the resident's CBG at 8:00 pm and did not provide the resident with 5 units of insulin. Staff 14 stated at 8:20 pm it was reported Resident 4 was dead. The undated Event and Occurrence Conclusion Sheet documented Staff 15 (CNA) stated the resident didn't have dinner on [DATE] and recalled the resident received fluids though was not able to remember how much the resident consumed. An interview with Staff 16 (CNA) revealed he picked up the meal tray at 6:20 pm and recalled a cup of orange juice with 100 cc left in the cup. The documentation indicated the resident would have consumed 200 cc of orange juice. The documentation indicated on [DATE] at 6:30 pm Staff 16 (CNA) picked up the resident's meal tray, saw the resident lying in bed mumbling in her/his sleep and moving her/his hands towards her/his mouth in motion. At 8:20 pm Staff 16 (CNA) went into the room and shook the resident's shoulder. Staff 16 noticed the resident was very cold and her/his lips were blue. The facility provided documentation on [DATE] Staff 14 (LPN) was provided with a verbal warning and education. The [DATE] performance documentation indicated Staff 14 failed to recheck the resident's CBG and did not document in a timely manner the nursing interventions implemented. The performance documentation indicated education was provided to improve on documentation and insulin/CBG management. On [DATE] at 1:40 pm Staff 2 (Interim DNS) stated Resident 14 (LPN) did not document the resident's CBG and did not monitor the resident's condition on [DATE]. Staff 2 stated she educated the resident and provided her with a verbal warning. Staff 2 stated she also provided inservice education to all of the licensed nurses about the facility's [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 1:50 pm Staff 12 (RNCM) stated she was was working as a charge nurse on the other end of the building on the evening of [DATE]. Staff 12 stated the CNA reported Resident 4 was unresponsive. Staff 12 assessed the resident and determined she/he had been dead for quite awhile. On [DATE] at 2:25 pm Staff 14 (LPN) stated she took the resident's CBG at 5:00 pm and it was 61. She stated she asked the CNAs to provide the resident with orange juice as she was not certain if the resident would eat her/his meal. Staff 14 stated she did not recheck the resident's CBG after 5:00 pm. She stated the CNA reported the resident was unresponsive and Staff 14 stated the resident was dead when she assessed her/him. Staff 14 stated she did not document the CBG at the time it was taken and did not recheck the resident's CB[NAME] On [DATE] at 2:45 pm Staff 15 (CNA) stated she was not assigned to care for Resident 4 and worked on the front part of the hallway. Staff 15 stated it was strange to see Resident 4 lying in bed as she/he usually refused to lie in bed and preferred to sit up in her/his wheelchair. Staff 15 stated she observed the resident from the hallway and she/he appeared to be be sleeping. Staff 15 stated she/he appeared to be as comfortable as she had seen the resident. Staff 15 stated she could not remember if the resident ate the dinner meal or drank orange juice or water. On [DATE] at 3:20 pm Staff 16 (CNA) stated he was assigned to care for Resident 4 on the evening of [DATE]. Staff 16 stated it was abnormal for the resident to be sleeping in bed. Staff 16 stated usually the resident preferred to sit up in her/his wheelchair. Staff 16 stated the resident woke up around 4:30 pm and wanted to go outside to smoke and then complained she/he was too tired and then laid back down in bed to sleep. Staff 16 stated he delivered the resident's meal tray and removed the meal tray from the room. Staff 16 stated he was not able to remember if the resident ate or drank. Staff 16 stated he checked on the resident and she/he appeared to be sleeping. On [DATE] at 12:10 pm Witness 2 (Complainant) stated the facility failed to monitor the resident's condition on [DATE]. Witness 2 stated the resident had a new order for insulin on her/his readmission to the facility and questioned if the facility managed the resident's diabetes. On [DATE] Witness 4 (Pharmacist) provided documentation there was no record the facility returned Resident 4's insulin to the pharmacy. Staff 2 (Interim DNS) provided documentation the facility no longer had the resident's insulin to determine if the resident received a dose of insulin on the evening of [DATE]. On [DATE] at 10:16 am Witness 3 (Physician) stated the facility was to follow hypoglycemic protocol. Witness 3 stated the facility staff needed to document the findings of the resident's CBG when taken. Witness 3 stated it was difficult to determine the accuracy of the CBG reading without documentation at the time it was taken. Witness 3 stated if Staff 14 (LPN) was concerned about the resident's condition and low CBG reading she needed to recheck the resident's CB[NAME] ii. The [DATE] physician's orders directed the facility to document the results of the blood glucose monitoring and if the resident's CBG was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The [DATE] physician's order for a scheduled dose of five units of Insulin [MEDICATION NAME] Solution Pen-injection 100 unit ML at 8:00 pm. The physician ordered a sliding scale dose of insulin to be provided according to the CBG reading and was to be administered five to ten minutes prior to the meal. The (MONTH) (YEAR) Licensed Nurse Administration Record had an area on the form where the staff were to document food, blood sugars, time of day and the sliding scale insulin provided. The record indicated the resident needed sliding scale insulin on 23 occasions and there were three occasions when there was no documentation food was provided for the resident on [DATE] at 7:00 am, 11:00 am and 5:00 pm. The (MONTH) (YEAR) and (MONTH) (YEAR) Licensed Nurse Administration Record and progress notes contained no documentation the resident's CBG was checked prior to the scheduled dose of insulin at bedtime on 27 out of 32 occasions. There were 19 occasions Staff 14 (LPN) documented the scheduled insulin was provided and there was no documentation Staff 14 obtained a CBG prior to the scheduled insulin at 8:00 pm. On [DATE] at 2:27 pm Staff 2 (Interim DNS) was asked to provide the facility's policy and procedure regarding CBGs obtained for schedule insulin at bedtime. Staff 2 stated she would expect the facility to follow the [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. b. Resident 3 was readmitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] physician's order was for 6 units of Humalog insulin and 28 units of [MEDICATION NAME] at 7:00 am and 11:00 am. The physician ordered 12 units of Humalog insulin at 5:00 pm. All of the insulin was to be provided within five to ten minutes of a meal. The (MONTH) (YEAR) Licensed Nurse Administration Record had an area where the resident's CBG was to be recorded when the insulin was administered. There was no documentation of the resident's CBG recorded at 5:00 pm on [DATE] through [DATE]. There was no documentation of the resident's CBG in the resident's progress notes or in the vitals summary for CBGs. The (MONTH) (YEAR) Licensed Nurse Administration Record for [DATE] documented Resident 3's CBG as 57 at 7:00 am. The documentation indicated the resident received 6 units of Humalog and 28 units of [MEDICATION NAME] at 7:00 am. There was a progress notes written at 7:48 am to indicate the resident was provided with eight ounces of orange juice and three sugar packets. The Licensed Nurse Administration Record contained documentation the [DIAGNOSES REDACTED] protocol was effective. The vital summary for blood sugars documented the resident's CBG as 57 at 7:47 am and 7:48 am. There was no documentation the resident's CBG was rechecked until 12:14 pm when the resident's CBG was recorded as 145. The next documentation of a CBG was at 12:20 pm and the CBG was recorded as 119. At 5:00 pm there was no documentation of a CBG recorded on the Licensed Nurse Administration Record, Vitals Summary or progress notes. The documentation on the Licensed Nurse Administration Record indicated the resident received 12 units of Humalog insulin. The (MONTH) (YEAR) Meal Monitor contained no documentation the resident received a meal at noon. The documentation at 9:08 pm documented the resident at 50 percent of meal and offered a supplement and refused the supplement. The [DATE] progress notes documented at 7:00 pm Resident 3 was found unresponsive and her/his CBG was 37. The facility staff provided three quarters of a tube of glucose and the CBG registered 189. The documentation indicated five minutes later the resident was unconscious with a CBG of 43. IM [MEDICATION NAME] was provided and the CBG was 44. 911 was called and the resident was transported to the local hospital emergency department. The [DATE] Licensed Nurse Administration Record documented the resident's CBG was 103 at 7:00 am and the resident was provided with 8 units of insulin. The [DATE] progress notes written at 1:16 pm documented the resident was confused and sedated in the morning. Her/his fasting CBG was 52 and glucose was given and following CBG was 51. The progress notes documented the CBG after breakfast was 92. The notes documented the resident ate very little today The [DATE] progress notes written from 5:18 pm through 9:50 pm documented the resident was unresponsive. The [DATE] progress notes written at 11:20 pm indicated the resident's CBG was 49 and was unable to administer medications, food or fluids. The evening insulin was held. There was no documentation the IM [MEDICATION NAME] was provided. The [DATE] progress notes written at 12:22 am documented the resident died at 11:50 pm. On [DATE] at 11:25 am Staff 12 (RNCM) was asked about the resident's CBG recorded at 49 on [DATE] with no documentation IM [MEDICATION NAME] was provided. Staff 12 stated she discussed the incident with Staff 2 (Interim DNS) as there was no documentation written by Staff 7 (LPN). On [DATE] at 3:01 pm Staff 7 (LPN) stated she was the evening shift charge nurse on [DATE] and stated the resident was unresponsive and was unable to swallow. Staff 7 stated she was aware of the [DIAGNOSES REDACTED] protocol and did not provide the resident with the IM [MEDICATION NAME]. Staff 7 stated she thought the resident's low CBG was part of the dying process. On [DATE] at 4:00 pm Staff 2 (Interim DNS) stated she was in the process of conducting an investigation into the incident. The facility's [DATE] Investigation Summary documented the resident was actively dying on the evening shift of [DATE]. The resident had a CBG of 43 and the nurse attempted to administer glucose paste. The nurse did not follow the hypoglycemic protocol to give IM [MEDICATION NAME] and recheck the resident's CB[NAME] The investigation indicated the resident's condition was declining with comfort care measures in place. On [DATE] at 12:20 pm Witness 7 (physician) stated he would expect the facility staff to follow the hypoglycemic protocols when the resident's CBG was 49 and unresponsive even though the resident was on comfort care measures. Witness 7 stated he determined the cause of the resident's death to be due to [MEDICAL CONDITION]. Witness 7 stated it would be difficult to stated the resident's death was due to low CB[NAME] Witness 7 stated Witness 6 (Family member) was concerned the facility provided insulin to the resident when the resident had a low CB[NAME] On [DATE] at 9:30 am Witness 6 (Family member) stated there were occasions when the facility staff gave the resident insulin even though she/he had a low CB[NAME] Witness 6 stated the facility provided the resident with insulin when they did not know how much the resident ate. Witness 6 stated on one occasion the resident's CBG was 32 and the facility gave the resident sugar and the CBG went to 181 through there was nothing in the resident's stomach so the CBG went down again. Witness 6 stated the nurse was scared and sent the resident to the local hospital emergency department. On [DATE] at 2:35 pm Staff 2 (Interim DNS) verified the documentation revealed the resident was provided with insulin on [DATE] at 6:00 am when the resident's CBG was below 60. Staff 2 verified there was no record of the resident's CBG at 5:00 pm. Staff 2 verified on [DATE] Staff 7 (LPN) did not follow the [DIAGNOSES REDACTED] protocol. On [DATE] at 5:08 pm Staff 17 (LPN) stated she was the night shift charge nurse on [DATE]. Staff 17 stated Staff 7 (evening shift charge nurse/LPN) informed her the resident had a low CB[NAME] Staff 17 asked Staff 7 if she followed the [DIAGNOSES REDACTED] protocol and Staff 7 stated she attempted to administer the glucose paste. Staff 17 went to assess the resident and found the resident to be in the active dying process. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. c. Resident 2 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The facility's undated hyperglycemic protocol contained instructions to the facility staff to monitor blood glucose (sugar) for residents with diabetes. The protocol indicated if the resident's blood glucose was over 400 mg the facility staff were to notify the physician and administer insulin per order. The staff were to recheck the CBG in one hour. Notify the MD if the CBG was still above 400. The [DATE] physician's orders indicated if the resident's CBG was over 400 the facility staff was to contact the physician, administer insulin, recheck CBG in ,[DATE] minutes and notify the physician if CBG remained over 400. The (MONTH) and (MONTH) (YEAR) Licensed Nursing Administration Records, progress notes and vital sign summary of Resident 2's CBGs were reviewed from [DATE] through [DATE]. On [DATE] at 12:00 pm there was no documentation of the resident's CB[NAME] There were thirteen occasions when the resident's CBG was over 400 and the resident's CBG was not rechecked and the physician was not contacted. On [DATE] Resident 2's physician appointment notes indicated the resident did not like how her/his blood sugars were handled at the facility. The resident was discharged to the local hospital on [DATE] and was not readmitted to the facility. On [DATE] at 4:26 pm Witness 1 (Complainant) stated Resident 2 did not want to be readmitted to the facility because the physician's orders were not followed regarding management of her/his insulin. Witness 1 stated the resident was discharged to another local care facility. On [DATE] at 2:00 pm Staff 2 (Interim DNS) stated facility staff were to follow the facility's [MEDICAL CONDITION] protocol. On [DATE] Staff 2 provided documentation to indicate on thirteen occasions when the resident's CBG was over 400 there was no evidence the resident's CBG was rechecked and the physician was contacted. d. Resident 6 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. There was a [DATE] physician's order for the resident to receive 45 units of [MEDICATION NAME] two times a day at 8:00 am and 8:00 pm. The [DATE] progress note written as a late entry at 8:30 pm documented the resident's CBG at HS (hour of sleep or 8:00 pm) was 97. Staff 18 (RN) documented the resident had a history of [REDACTED]. Staff 18 indicated she made a decision to administer Resident 6 half of the insulin dose ordered by the physician and did not inform the resident's physician. The [DATE] progress note written at 7:31 am documented the resident's CBG was 439. The resident required 8 units of sliding scale insulin along with the scheduled dose of 45 units of [MEDICATION NAME]. The notes indicated the resident had no signs or symptoms of [MEDICAL CONDITION]. The resident's physician was contacted. The [DATE] progress note written at 2:23 pm documented on [DATE] at HS it was noted the resident's CBG was 97 and the nurse on duty gave only half of the ordered dose of insulin. The physician was notified of the medication error and the physician changed the order to decrease the dose of insulin by 5 units if the resident's CBG was under 90. The [DATE] Performance Documentation indicated Resident 6's CBG was 97 on the evening of [DATE]. Staff 18 knew the resident had a history of [REDACTED]. Staff 18 received a verbal warning to follow physician's orders and to contact the physician about the resident's condition and obtain new physician's orders as necessary. On [DATE] at 2:35 pm Staff 2 (Interim DNS) verified Staff 18 did not contact the physician about the resident's CBG and obtain new orders to change the amount of insulin provided. Staff 2 stated Staff 18 did not follow physician's orders and did not inform the resident's physician of her decision to provide half of the prescribed insulin. 2. Based on interviews and record review it was determined the facility failed to provide wound care treatments as ordered for 4 of 5 sampled residents (#s 3, 4, 7 and 11) reviewed for non-pressure ulcers. This placed the residents at risk for worsening wounds. Findings include: a. Resident 3 was readmitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. i. The [DATE] initial skin ulcer assessment documented the presence of a vascular ulcer on the top of her/his left foot to measure 1 cm by 0.5 cm. The physician ordered skin prep to be applied daily. The (MONTH) (YEAR) TAR contained no documentation of a treatment for [REDACTED]. The (MONTH) (YEAR) TAR contained the [DATE] physician's order for the ulcer to be cleaned with wound cleanser, pat dry gauze, cover over with non-stick pads and kerlix every day and PRN. There was no documentation the resident received a treatment on [DATE] and [DATE]. The weekly skin ulcer measurement wound evaluation completed on [DATE] documented the ulcer measured 1.4 cm by 1.1 cm with non-measurable depth. The (MONTH) (YEAR) TAR contained a [DATE] physician's order for the ulcer to be cleaned daily with wound cleanser, was to be patted dry, calcium alginate applied and covered with boarder gauze. There was no documentation the resident received a treatment on [DATE] and [DATE]. The weekly skin ulcer measurement wound evaluation completed on [DATE] documented the ulcer measured 1.2 cm by 0.9 cm with non-measurable depth. The resident died in the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. ii. The Weekly Non-Pressure Skin Condition Assessment conducted [DATE] indicated the resident had an stasis ulcer on the left lower leg (front) shin and the ulcer was first observed on [DATE]. The measurements were 0.7 cm by 0.9 cm with non-measurable depth. The treatment was described as cleanse with wound cleanser, calcium alginate to wound bed, skin prep periwound, cover with boarder gauze daily. The (MONTH) (YEAR) TAR contained no documentation of treatments provided to the resident from [DATE] through [DATE]. The Weekly Non-Pressure Skin Condition Assessment conducted on [DATE] assessed the ulcer to measure 1 cm by 0.8 cm with non-measurable depth. The assessment indicated the facility was to continue with current treatment. The (MONTH) (YEAR) TAR contained documentation the resident was provided with one treatment for [REDACTED]. The resident died in the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. b. Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The local hospital discharge summary documented the resident complained of a draining ulcer on her/his left leg. The documentation indicated the resident's left lower extremity ulceration was healing well with granulation tissue. The resident was to have a follow-up appointment for a wound recheck on [DATE]. The local hospital physician's orders were for the resident to have weekly skin checks. The facility's [DATE] Admission Profile documented the resident had a right lower leg dressing in place for stasis ulcer and left knee incision wrapped with ace bandage. There was a [DATE] physician's order for the resident's left lower leg to be cleansed with wound cleanser, xeroform gauze, cover with ABD pad and secure gauze wrap and surginet. The (MONTH) (YEAR) TAR contained the physician's order for treatment for [REDACTED]. The documentation indicated treatments were not provided on seven occasions because the resident refused the treatment, two occasions because the resident was sleeping, three occasions the TAR was blank, three occasions the nurse documented the dressing was clean dry and intact and did not indicate the dressing change was completed. The [DATE] progress notes indicated the resident's wound care was not provided as there was a change in the physician's order. There was no documentation of the new physician's order. There was a [DATE] physician's order for unna boots applied to both extremities with kerlix and coban to change every 5 days and PRN every day shift every 5 days for [MEDICAL CONDITION]. The (MONTH) (YEAR) TAR contained no documentation the unna boots were changed from [DATE] through [DATE], a period of fourteen days. The (MONTH) (YEAR) TAR did not contain the [DATE] physician's order for treatment of [REDACTED]. The TAR documented the resident refused the use of unna boots on [DATE]. There was no documented assessment of the resident's lower extremities from her/his readmission on [DATE] through [DATE]. There was no documentation the resident had a follow-up appointment for a wound recheck on [DATE]. The resident died at the facility on [DATE]. On [DATE] Staff 2 (Interim DNS) provided written documentation there were no skin assessments conducted for Resident 4 from [DATE] through [DATE]. Staff 2 confirmed there was no follow-up appointment for a wound recheck on [DATE]. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information regarding the treatments provided for the resident. No additional information was provided. c. Resident 7 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] progress notes documented the resident was at risk for pressure ulcers due to incontinence, dependent on staff for care and required repositioning schedule to prevent future skin issues. The note indicated the resident had a skin issue which appeared to be due to extended exposure to moisture. Left 1 cm x 1 cm with 2 cm by 2 cm periwound redness. Right 1 cm x 1 cm with 3 cm x 2 cm periwound redness. MD notified via fax with request for [MEDICATION NAME] application. Pending approval The [DATE] incident report documented the resident had skin abrasions of both upper buttocks. There was no documentation the physician was notified of the resident's skin condition. There was no documentation of the treatment of [REDACTED]. The [DATE] Weekly non-pressure skin condition assessment documented the moisture related skin issue for bilateral upper buttocks resolved. On [DATE] Staff 2 (Interim DNS) provided documentation the physician was not notified of the resident's skin condition and [MEDICATION NAME] treatments provided. Staff 2 confirmed the open area on the resident's buttocks resolved. d. Resident 11 readmitted to the facility on [DATE]. The [DATE] progress notes written at 8:45 pm documented the CNA reported new open areas to the resident's buttocks. Barrier cream was applied. There was no documentation of skin assessments or treatments provided to the resident's open areas. The [DATE] progress notes documented the resident had redness to bilateral gluteal fold. The resident also had a shearing wound on her/his left buttock and measured 1.4 cm length by 0.4 cm wide and caused her/him discomfort. The progress notes indicated the wound was cleansed and barrier cream was applied. The progress notes indicated a fax was sent to physician for further wound care orders. There was no documentation of skin assessments or treatments provided to the resident's open areas. Resident 11 died on [DATE]. On [DATE] at 2:00 pm Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 24 (RN Corporate Consultant) were asked to provide documentation of skin assessment and treatments provided to the resident. On [DATE] Staff 2 (Interim DNS) and Staff 24 (RN Corporate Consultant) indicated there was no follow up for the resident's skin issues. 3. Based on interviews and record review it was determined the facility failed to conduct neurological checks for 3 of 4 sampled residents (#s 3, 4 and 10) reviewed for unwitnessed falls or falls when the residents hit their heads. This placed the residents at risk for unmet needs. Findings include: The facility's (MONTH) (YEAR) neurological (neuro) check form indicated neuro checks were to be completed following an unwitnessed fall, witnessed fall with head injury or as needed. The neuro check form indicated the neuro checks were to be done every 15 minutes for four occasions, every hour for four occasions, every four hours for four occasions and every eight hours for six occasions. The facility staff were to document level of consciousness, temperature, heart rate, respiration rate, blood pressure, oxygen saturation rate, pupil size, pupil reactivity, hand grip and additional comments. a. Resident 4 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] progress notes documented the resident fell on her/his face. There was no documentation neurological checks were conducted. The progress notes written on [DATE] at 10:40 pm documented Resident 4 had a fall and was found face down on the floor and the resident was assisted off of the floor by the local Emergency Medical Transport Services (EMTs). The documentation indicated neuro checks were started on 10:40 pm. There was no neu | 2020-03-01 |
| 4568 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 312 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews it was determined the facility failed to provide showers as care planned for 3 of 5 sampled residents (#s 1, 3 and 7) reviewed for showers. This placed the residents at risk for unmet needs. Findings include: 1. Resident 3 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) care plan directed the facility to provide a shower twice a week. The shower record revealed the following: There was no shower provided from 11/1/16 through 11/9/16, a period of eight days. There was no shower provided from 11/12/16 through 11/22/16, a period of 10 days. There was no shower provided from 12/2/16 through 12/16/16, a period of 14 days. There was no shower provided from 12/20/16 through 12/27/16, a period of seven days. There was no shower provided from 12/27/16 through 1/13/17, a period of seventeen days. The failure to provide showers was verified through interview on 1/31/17 at 2:35 pm with Staff 2 (Interim DNS). 2. Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) care plan directed the facility staff to provide showers twice a week. The shower record revealed the resident did not receive a shower from 12/14/16 through 12/26/16, a period of twelve days. The record also revealed the resident did not receive a shower from 12/28/16 through 1/9/17, a period of 11 days. The failure to provide showers was verified through interview on 1/31/17 at 2:35 pm with Staff 2 (Interim DNS). 3. Resident 7 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) care plan directed the facility staff to provide showers twice a week. The shower record revealed the resident did not receive a shower form 12/27/16 through 1/5/17, a period of 9 days. The failure to provide showers was verified through interview on 1/31/17 at 2:35 pm with Staff 2 (Interim DNS). | 2020-03-01 |
| 4569 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 314 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to conduct skin assessments and provide treatments for 3 of 5 sampled residents (#s 3, 4 and 8) reviewed for pressure ulcers. This placed the residents at risk for worsening ulcers. Findings include: 1. Resident 3 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. a. The [DATE] Initial Skin Ulcer assessment indicated the resident developed a facility acquired pressure ulcer of her/his left outer ankle. The ulcer measured 0.8 cm by 0.5 cm with no depth and was determined to be unstageable. The physician ordered skin prep to be applied daily until resolved. The (MONTH) (YEAR) TAR contained documentation the resident received skin prep treatment daily from [DATE] through [DATE]. The [DATE] weekly skin ulcer measurement wound evaluation described the resident's pressure ulcer as unstageable and now measured 1.2 cm by 0.9 cm. The (MONTH) (YEAR) TAR and progress notes contained no documentation the resident received a treatment for [REDACTED]. There was a [DATE] physician's orders [REDACTED]. The (MONTH) (YEAR) TAR and progress notes contained no documentation the resident received a treatment for [REDACTED]. The weekly skin ulcer measurement wound evaluation completed on [DATE] measured the left ankle ulcer as 1 cm by 0.9 cm with 100 percent slough in wound bed. The physician changed the treatment orders on [DATE] to cleanse the wound with wound cleanser, apply calcium alginate to wound bed, skin prep wound edges, cover with boarder gauze, change daily until resolved. The (MONTH) (YEAR) TAR and progress notes contained no documentation treatments were provided on [DATE] and [DATE]. The weekly skin ulcer measurement wound evaluation completed on [DATE] measured the left ankle ulcer as 1.2 cm by 1.4 cm with 80 percent slough and 20 percent eschar in wound bed. The resident died at the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. b. The [DATE] Initial Skin Ulcer Assessment documented on [DATE] the resident had an unstageable pressure ulcer on her/his left hip which measured 0.8 cm by 0.8 cm. There was a [DATE] physician's orders [REDACTED]. The [DATE] Weekly Skin Ulcer Measurement Wound Evaluation documented the ulcer measured 0.7 by 0.7 with 100 percent slough in wound bed. The [DATE] physician's orders [REDACTED]. The (MONTH) (YEAR) TAR and progress notes contained no documentation the resident received a treatment for [REDACTED]. The weekly skin ulcer measurement wound evaluation completed on [DATE] documented the left hip ulcer resolved. The resident died at the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. 2. Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a [DATE] physician's orders [REDACTED]. The orders indicated the wound was to be cleansed with wound cleanser, xeroform gauze applied, covered with [MEDICATION NAME] and wound care was to be provided every evening shift. The (MONTH) (YEAR) TAR included the physician's orders [REDACTED]. The TAR contained documentation the left buttock treatment was not provided on eight occasions when the resident refused the treatments. There were six occasions the TAR was blank when the treatments were to be documented. There were two occasions when the resident was sleeping and the treatment was not provided. There was no additional documentation in the resident's progress notes to indicate the treatments were provided or the resident was reapproached for wound care. The (MONTH) (YEAR) TAR on [DATE] indicated the treatment was not provided for the resident and there was additional documentation in the progress notes to state why the treatment was not provided. There was no documentation in the progress notes to indicate why the the resident's ulcer treatment was not treated. There was no documentation of an assessment of the resident's left buttock ulcer from [DATE] through [DATE] to determine if the resident's ulcer improved or worsened. Resident 4 died at the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] Staff 2 (Interim DNS) provided written documentation there were no skin assessments conducted for Resident 4 from [DATE] through [DATE]. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. 3. Resident 8 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The [DATE] progress note documented a new pressure ulcer was observed on the resident's right heel. The documentation determined the pressure ulcer developed from the resident's ankle foot orthosis (AFO brace). The physician ordered skin prep to be administered every shift. The [DATE] Initial Skin Ulcer Assessment documented the resident had a blister on her/his right heel which measured 5.0 cm by 3.8 cm with unknown depth. The ulcer was identified as unstageable. The (MONTH) (YEAR) TAR and progress notes contained no documentation skin prep was provided to the resident on the night shift of [DATE], [DATE] and [DATE]. On [DATE] at 6:16 pm Staff 2 (Interim DNS) provided documentation to verify the skin prep was not provided as ordered. There was documentation the facility assessed the resident's skin on a weekly basis. The [DATE] weekly skin assessment documented the ulcer improved and measured 4.3 cm by 3.9 cm and had a dry/hard blister cap on the heel. The (MONTH) (YEAR) TAR and progress notes contained no documentation skin prep was provided to the resident on the night shift of [DATE] and [DATE] and the day shift of [DATE]. The facility continued to monitor the resident's pressure ulcer on a weekly basis and the ulcer continued to improve. The [DATE] and [DATE] weekly skin assessments documented the resident's pressure ulcer measured 4.1 cm by 3.1 cm. On [DATE] at 1:05 pm Staff 1 (Administrator) and Staff 2 (Interim DNS) verified skin prep was not provided on three occasions in (MONTH) (YEAR). | 2020-03-01 |
| 4570 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2017-03-20 | 514 | D | 1 | 0 | 2Y0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility failed to accurately document information in 1 of 9 sampled resident (#4) records reviewed. This placed the resident's record at risk for misinformation. Findings include: Resident 4 was readmitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident 4's comprehensive care on the date of admission on [DATE] did not identify the use of insulin, did not have measurable objectives and interventions developed to ensure the resident did not have side effects from the insulin. Resident 4 died at the facility on [DATE]. The documentation on the comprehensive care plan indicated the care plan was closed on [DATE] because the resident was discharged . On [DATE] at 11:00 am Staff 13 (RNCM) reviewed the comprehensive care plan and verified the resident's care plan was not updated to include diabetes and insulin usage. On [DATE] at 11:30 am Staff 13 (RNCM) provided a comprehensive care plan with a revision date of [DATE]. On [DATE] at 3:25 pm Staff 19 (Medical Records Supervisor) stated on [DATE] she printed the copy of the resident's care plan in the computer system. On [DATE] at 4:33 pm Staff 1 (Administrator) and Staff 2 (Interim DNS) were informed of the change to the resident's comprehensive plan of care. Staff 2 (Interim DNS) was shown the resident's entire comprehensive care plan was changed to [DATE]. | 2020-03-01 |
| 4665 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2016-02-02 | 275 | D | 0 | 1 | B8ES11 | **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 within 366 days of the previous annual assessment for 2 of 8 sampled residents (#s 9 and 18) reviewed for participation in care planning and medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 18 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. A review of Resident 18's medical records on 1/26/16 indicated the resident's annual comprehensive MDS assessment was incomplete and 41 days overdue as the previous comprehensive assessment was completed on 12/15/14. On 1/28/16 at 10:51 am Staff 19 (MDS Coordinator) acknowledged Resident 18's MDS assessment was late. 2. Resident 9 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of the resident's clinical record on 1/27/16 revealed an admission MDS was completed on 12/1/14 and there was no documentation the resident's annual MDS assessment was completed within 366 days. The resident's next annual assessment was due 12/2/15. In an interview on 1/26/16 at 2:28 pm Staff 19 (MDS Coordinator) acknowledged the resident's annual MDS was due on 12/2/15 and was not completed within 366 days. In an interview on 1/27/16 at 8:54 am Staff 1 (Regional Nursing Consultant) said the facility was aware of several MDS assessments not completed within 366 days and the facility was in the process of correcting the issue. | 2020-01-01 |
| 4666 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2016-02-02 | 278 | D | 0 | 1 | B8ES11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to accurately identify a resident's status for 3 of 11 sampled residents (#s 30, 18 and 49) reviewed for pressure ulcers, medications, dental status and hospice. This placed residents at risk for unassessed needs. Findings include: 1. Resident 30 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a weekly pressure ulcer wound evaluation dated 11/19/15 revealed the resident had a pressure ulcer on the right heel. Review of a quarterly MDS assessment dated [DATE] revealed the resident had no pressure ulcers. In an interview on 1/27/2016 at 1:06 pm Staff 3 (RNCM) acknowledged the 11/19/15 MDS was inaccurate and should have indicated the resident had a pressure ulcer on the right heel at the time of the assessment. 2. Resident 49 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. In (MONTH) (YEAR) Resident 49 began hospice care. Resident 49's (MONTH) (YEAR) comprehensive MDS assessment indicated the resident received hospice care. The resident's quarterly MDS assessment, dated 12/16/15, did not indicate the resident received hospice care. On 1/28/16 at 10:51 am Staff 19 (MDS Coordinator) indicated the resident still received hospice care and the lack of indication of hospice care on the quarterly MDS was a mistake. On 1/28/16 at 11:28 am Staff 19 stated the assessment was corrected and resubmitted. 3. Resident 18 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. On 1/26/16 at 9:57 am Resident 18 was observed to be edentulous. Resident 18 stated she/he did not have teeth and did not use dentures. Resident 18's 1/27/16 comprehensive MDS assessment indicated the resident had no dental issues and did not identify the resident as edentulous. On 1/28/16 at 10:51 am Staff 19 (MDS Coordinator) stated Resident 18's MDS assessment should have indicated the resident was edentulous. | 2020-01-01 |
| 4667 | REGENCY ALBANY | 385220 | 805 19TH AVENUE SE | ALBANY | OR | 97321 | 2016-02-02 | 280 | D | 0 | 1 | B8ES11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] Based on interview and record review it was determined the facility failed to honor the right to participate in planning care and treatment for 1 of 3 sampled residents (#9) reviewed for participation in care planning. This placed residents at risk for a lack of individualized care. Findings include: Resident 9 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of care conference notes dated 5/20/15, 7/14/15 and 12/23/15 revealed no documentation the resident was invited or present at the meetings. On 1/26/16 at 2:32 pm Staff 20 (Social Services) stated resident care conferences were completed quarterly to discuss resident and family concerns. Staff 20 acknowledged there was no documentation the resident was invited to the last three meetings. On 1/27/16 at 9:18 am Resident 9 stated she/he could not remember the last time she/he attended a care conference and wanted to participate in the meetings. B. Based on interview and record review it was determined the facility failed to update and revise a care plans for 2 of 8 sampled resident (#s 3 and 36) reviewed for medications and pressure ulcers. This placed residents at risk for unmet needs. Findings include: 1. Resident 36 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of a care plan updated 1/16/16 revealed no focus, established goals or staff interventions regarding the resident's use of [MEDICATION NAME] and [MEDICATION NAME]. In an interview on 1/27/16 at 9:43 am Staff 3 (RNCM) acknowledged the resident's care plan was not revised regarding the use of [MEDICATION NAME] and [MEDICATION NAME]. 2. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The most recent Initial Ulcer assessment dated [DATE] indicated Resident 3 had an unstageable pressure ulcer on the coccyx. Review of the care plan on 1/28/16 revealed Resident 3 had a current stage 1 pressure ulcer but did not identify the location of the pressure ulcer. On 1/28/16 at 2:04 pm Staff 3 (RNCM) acknowledged Resident 3's care plan was not updated or revised. | 2020-01-01 |