Clatsop Care Center

Based on observation and interview it was determined the facility failed to maintain a homelike environment with window cleanliness for 1 of 1 facility reviewed for a homelike environment. This placed residents at risk for an unclean homelike environment. Findings include:

On 9/9/24 at 3:38 PM Resident 22 stated her/his windows were all very dirty and she/he would like them cleaned. Observation of Resident 22's windows and windows throughout the facility determined the majority of windows were dirty and unhomelike.

On 9/13/24 at 9:06 AM Staff 8 (Maintenance Director) stated the outside windows in the facility had been cleaned only twice in the last eight years. Staff 8 confirmed the outside windows needed to be cleaned.

Based on interview and record review it was determined the facility failed to comprehensively assess 3 of 7 sampled residents (#s 8, 25 and 83) reviewed for medications, behavior and mood. This placed residents at risk for inaccurate or incomplete assessments and unmet care needs. Findings include:

1. Resident 83 was admitted to the facility in 8/2024 with diagnoses including recent stroke and delirium.

Resident 83's physician orders included the use of scheduled and PRN antipsychotic medication.

The 8/29/24 psychotropic CAA did not include a description of the specific behavior necessitating the use of the antipsychotic; causes and contributing factors; or risk factors related to the care area such as increased drowsiness, lethargy or increased risk for falls.

On 9/13/24 at approximately 9:50 AM Staff 2 (DNS) confirmed the CAAs lacked an analysis of findings.


, 2. Resident 8 was admitted to the facility on 2/2024 with diagnoses including dementia and depression.

A review of the 2/12/24 Cognitive Loss/Dementia CAA revealed Resident 8 had dementia. The family was aware and content with care and the plan moving forward. Communicate with Resident 8 and her/his family regarding capabilities and needs. The CAA failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident, or a rational for the care planning decision.

A review of the 2/15/24 Psychotropic Drug Use CAA revealed Resident 8 was on venlafaxine (an antidepressant) for major depressive disorder, which was effective with no adverse effects noted. The CAA failed to indicate specifically how depression was a problem for the resident, how the resident's depression impacted Resident 8, or a rationale for the care planning decision.

On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility.

On 9/12/24 at 4:19 PM Staff 3 (Social Service Director) stated she completed the Cognitive Loss/Dementia CAA for Resident 8. Staff 3 stated she was learning how to better complete the CAAs and acknowledged there was not sufficient information in the CAA section.

On 9/12/24 at 6:41 PM Staff 4 (LPN) stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 8's CAA but confirmed there was not enough "meat and potatoes" in Resident 8's Cognitive Loss/Dementia and Psychotropic CAA. Staff 4 stated The CAAs were important because they helped drive the care plan for each resident.

3. Resident 25 was admitted to the facility on 6/2024 with diagnoses including schizophrenia and cancer of the lung.

A review of the 7/2/24 Psychotropic Drug Use CAA revealed the resident received aripiprazole (an antipsychotic) for her/his schizophrenia which had been effective with no adverse effects noted. Medicate the resident per physician order and assess effectiveness of the medication for adverse effects. The CAA failed to include information regarding Resident 25's potential problems, manifested behaviors, precipitating factors, alleviating factors or non-pharmacological interventions.

On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility.

On 9/12/24 at 6:41 PM Staff 4 stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 25's CAA but confirmed there was not enough "meat and potatoes" in Resident 25's Psychotropic CAA. Staff 4 stated the CAAs were important because they helped drive the care plan for each resident.

Based on interview and record review it was determined the facility failed to follow physician orders for medication administration and implement bowel care timely for (1 of 5) sampled residents (# 17) reviewed for medications. This placed residents at risk for adverse side effects and constipation. Findings include:

Resident 17 was admitted to the facility in 10/2020 with diagnoses including hypothyroidism (deficiency of hormones used to regulate heart rate, body temperature and digestion) and constipation.

a. A physician order from 12/5/23 stated levothyroxine 50 mg was to be given once a day at 8:00 AM to Resident 17 for hypothyroidism.

On 9/6/24 the orders for levothyroxine were modified for the medication to be given at 5:00 AM.

Review of the 9/2023 MAR revealed Resident 17 did not receive levothyroxine from 9/6/24 through 9/11/24.

On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed Resident 17 did not receive levothyroxine on the dates listed and did not provide any additional information as to why the medication was not administered.

b. A physician order from 4/15/23 stated bisocodyl was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement

A physician order from 4/15/23 stated fleet enema was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement.

A physician order from 4/28/23 stated milk of magnesia was to be administered as needed for constipation to Resident 17 on the third day of no bowel movement.

Review of 8/2024 and 9/2024 bowel care records revealed the following:
- Resident 17 had no bowel movements from 8/29/24 through 9/1/24, a total of four days. Review of medication administration records revealed none of the medications listed above were attempted to be administered on day three or day four.
- Resident 17 had no bowel movements from 9/3/24 through 9/6/24, a total of four days. Review of medication administration records revealed none of the medications listed above were administered on day three or day four.
- Resident 17 had no bowel movements from 9/9/24 through 9/11/24, a total of three days. Review of medication administration records revealed milk of magnesia was not administered on day three.

On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed that based on the 8/2024 and 9/2024 bowel care records, medications used for constipation were not administered as ordered to Resident 17.

Based on observation and interview it was determined the facility failed to ensure medications were labeled with administration instructions for 1 of 5 residents (#11) for whom medication administration was observed. This placed residents at risk for decreased medication efficacy. Findings include:

On 9/11/24 at 8:43 AM Staff 6 (CMA) was observed to crush the medication pantoprazole 40 mg DR (delayed release) prior to administration to Resident 11.

According to the manufacturer's instruction, this medication is enteric coated to pass through the stomach and should not be crushed. The medication was labled as "pantoprazole 40 mg" without the DR. There were no instructions on the MAR or the medication bubble pack from the pharmacy to indicate the medication should not be crushed prior to administration.

On 9/12/24 at 10:48 AM Staff 7 (Consultant Pharmacist) confirmed pantoprazole 40 mg should not be crushed and was not labeled with instructions not to crush.

Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 1 of 5 residents (#8) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include:

Resident 8 was admitted to the facility in 2/2024 with diagnoses including dementia and depression.

A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/15/24, discontinued on 8/16/24, for mirtazapine (an appetite stimulant) 7.5 mg, one tablet for appetite stimulation for three days. The medication was administered on 8/15/24.

A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/16/24, for mirtazapine 7.5 mg, one tablet for appetite stimulation for 30 days.

A review of Resident 8's clinical record revealed no evidence the resident received her/his mirtazapine from 8/16/24 through 8/25/24.

In an interview on 9/12/24 at 1:42 PM, Staff 1 (Administrator) and Staff 5 (RNCM) stated both physician orders for the mirtazapine were incorrectly transcribed. Staff 1 stated facility staff clarified the mirtazapine order with the physician, and the physician clarified the mirtazapine with a new start date of 8/26/24. Staff 1 acknowledged the 8/2024 MARs were incorrectly transcribed.

Based on interview and record review it was determined the facility failed to meet the CNA to NA staffing ratio on 13 of 40 days reviewed for sufficient nurse staffing. This placed residents at risk for unmet needs. Findings include:

Review of Direct Care Staff Daily Reports from 8/1/24 through 9/9/24 revealed the facility failed to meet NA to CNA staffing ratios on the following dates and shifts:
- 8/4/24 Day shift: 2 CNAs, 3 NAs, and Evening shift: 2 CNAs, 2 NAs
- 8/5/24 Evening shift: 2 CNAs, 2 NAs
- 8/6/24 Evening shift: 2 CNAs, 2 NAs
- 8/7/24 Evening shift: 2 CNAs, 2 NAs
- 8/10/24 Day shift: 2 CNAs, 3 NAs
- 8/11/24 Day shift: 2 CNAs, 3 NAs
- 8/13/24 Evening shift: 2 CNAs, 3 NAs
- 8/20/24 Evening shift: 2 CNAs, 2 NAs
- 8/28/24 Evening shift: 2 CNAs, 2 NAs
- 9/1/24 Evening shift: 2 CNAs, 3 NAs
- 9/2/24 Evening shift: 2 CNAs, 3 NAs
- 9/3/24 Evening shift: 2 CNAs, 3 NAs
- 9/5/24 Evening shift: 2 CNAs, 2 NAs

On 9/12/24 at 2:04 PM Staff 2 (DNS) stated she had worked as the staffing coordinator for the last few months. Staff 2 acknowledged the CNA to NA ratio exceeded the maximum of 25% allowed on the dates listed above.

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OAR 411-087-0100 Physical Environment: Resident Rights

Refer to F584
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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OAR 411-086-0300 Clinical Records

Refer to F842
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Based on interview and record review it was determined the facility failed to properly administer anticoagulant medication to 1 of 2 sampled residents (#2) reviewed for medications. As a result, Resident 2 was hospitalized and required Vitamin K infusion (used as reverse the effects of blood thinning medications). Findings include:

Resident 2 was admitted to the facility in 5/2021, with diagnosis including paroxysmal atrial fibrillation (irregular heart beat caused by poor blood flow).

Resident 2's 5/20/22 Care Plan noted the resident received Coumadin (an anticoagulant medication) related to atrial fibrillation.

Resident 2's 5/2022 physician orders indicated Resident 2 was to be administered Coumadin 5 mg daily every Tuesday, Friday, and Sunday at 4:00 PM.

A review of Resident 2's 11/2023 MAR revealed the following dates and times the resident's Coumadin was administered:
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5 mg on 11/3/23 at 8:00 AM
-       
5 mg on 11/3/23 at 4:00 PM
-       
5 mg on 11/5/23 at 8:00 AM
-       
5 mg on 11/5/23 at 4:00 PM
-       
5 mg on 11/7/23 at 8:00 AM
-       
5 mg on 11/7/23 at 4:00 PM
-       
5 mg on 11/10/23 at 8:00 AM
-       
5 mg on 11/10/23 at 4:00 PM
-       
5 mg on 11/12/23 at 8:00 AM
-       
5 mg on 11/12/23 at 4:00 PM

An 11/14/23 facility investigation revealed Staff 4 (LPN) inputted a duplicate order of Coumadin, which resulted in Resident 2 receiving two doses of Coumadin for six days. The investigation noted Resident 2 was sent to the emergency department after lab test revealed critical lab results.

Resident 2's 11/15/23 Progress Note indicated the resident received a Vitamin K infusion while at the hospital.

On 7/15/24 at 11:58 AM, Staff 4 (LPN) stated he ordered a duplicate medication of Coumadin, which resulted in Resident 2 receiving extra Coumadin for six days.

On 7/11/24 at 12:56 PM, Staff 1 (Administrator) confirmed findings and indicated Resident 2 received a Vitamin K infusion while at the hospital as a result of the medication error.

On 11/20/23, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was medication error. The Plan of Correction included:

1. The effected resident was assessed and sent the emergency department for Vitamin K infusion.
2. An audit of all anticoagulant orders were reviewed for accuracy.
3. All nursing staff were provided education related to administration of Coumadin including warning systems to prevent duplicate orders.
4. Education was received by consultant pharmacist on avoiding medication errors.
5. Anticoagulation orders for residents continued to be monitored and triple checked for accuracy.

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OAR 411-086-0110 - Nursing Services: Resident Care

Refer to F760

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/18/2023 and 12/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/11/2023 and 12/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/13/2023 and 11/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/09/2023 and 10/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/25/2023 and 10/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/11/2023 and 09/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.