Creekside Health and Rehab of Cascadia

Based on interview and record review, the facility failed to report allegations of abuse to the state survey agency within the required time frame for 1 of 2 sampled residents (R16) whose abuse incidents were reviewed. This failure placed residents at risk for abuse.

Findings include:

Facility's policy, Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, revision date 8/1/23, documented "If any form of abuse is alleged (e.g., physical, verbal, etc.) ....is identified related to any other reported incident (e.g., Injury of Unknown Source or allegation of Neglect involving serious bodily injury), the CEO/designee will notify the State Agency immediately, but not later than 2 hours after the allegation is made or serious bodily injury is identified."

Review of R16's record indicated the facility admitted the resident on 3/27/25, readmitted on 5/12/25 and 6/24/25 with diagnoses including history of encephalopathy (disease or dysfunction of the brain, affecting its normal function), chronic obstructive pulmonary disease (lung disease making it difficult to breathe), acute respiratory distress syndrome, depression and anxiety. R16's Minimum Data Set (MDS-assessment tool), dated 5/18/25, documented R16's brief interview for mental status was 15. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 13 to 15 is an indication of intact cognitive status) and had adequate hearing described as no difficulty in normal conversations.

During an interview on 7/8/25 at 8:03 AM R16 stated there was an incident with a Certified Nursing Assistant (CNA) several months ago at night. I had to go to the bathroom and CNA was mad because I couldn't stand on my own. It was horrible, he threw my walker across the room, and it hit two chairs that were against the wall, but I don't think the walker hit the wall. He was really rough, he picked me up and threw me on the bed and told me, he used the f word, he told me that he was f**cking sick of me for not trying, but I was trying. I was scared to death. This happened the first time I was here (admitted to the facility). He also dropped something at the end of my bed and it fell to the floor, he got right in my face, like this close (resident placed her hand about 5 inches from her face) and said through his clenched teeth, why do you put things at the end of the bed, what is wrong with you f**cking people. I was crying. When he picked up the item and realized it was his stuff and not mines, he was like ooops and then said you are going to be ok and was trying to appease me. But I can't ever forget what happened earlier, it was nightmarish. He was angry, his teeth were clenched, he raised his voice and it was growly, I was scared. The next day, I talked to staff and filed a grievance.

Review of Grievance Form, dated 3/29/25, written by R16 stated incident occurred on 3/28/25 about 9pm. "He says he's a monk. He was angry with me because I had to go potty, and he refused to "deal" with me. He got me to the bed, made me sit up high on the bed, actually threw the walker, went and got a urinal and said that he was "fucking tired of this." Then he told me to get my legs up on the bed. I was too slow, so he grabbed my legs and roughly tossed them on the bed. Then I used the urinal, and he kept ranting. Then when I was done, he was having me move to my side and gave me a rough shove then something dropped behind the bed. Then he got scary. He clenched his teeth together got right in my face and said, "what's wrong with you fucking people." You put personal shit all over your bed, then he pulled the bed out while I was in it and found the call light. By then I was crying, then he said I didn't need to cry, he patted my hand, I am scared of him. I worry that he may hurt me or someone small and elderly. When I asked for a woman CNA and he said not to worry I'm not his type. I'd be concerned about his temper."

Review of Grievance Form, dated 3/29/25, completed by Rehabilitation staff (RS)1, documented that on 3/28/25 on the evening shift "[R16] reported to [RS1] during therapy session an incident that happened on night shift the previous night with CNA5. Pt stated "when I asked for a female shower aide, he said "You're not my type". [CNA5] was helping pt in bed and the call light fell off the bed. Pt reported [CNA5] stated with clenched teeth and in my face "I don't understand you fu***ing people leaving your sh** on the bed." Pt also stated "he folded the walker and threw it in the corner of the room." Pt reported at the end of session I'm "afraid" I have him again tonight. Reported to nursing."

Review of Oregon Department of Human Services (State Survey Agency) Nursing Facility Reported Incident (FRI) Form, dated 3/31/25 at 10:00 am, documented:
"*Purpose of form: A nursing facility must ensure all alleged violations are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency (SSA), in accordance with §483.12(c)(1). A nursing facility should use this form to report FRIs that meet §483.12(c)(1) to Oregon's SSA, Safety, Oversight and Quality (SOQ), Nursing Facility (NF)Complaint Intake Unit.
*Reporting time frames: Immediately but no later than 2 HOURS after the allegation is made - If the alleged violation involves abuse (refer to Federal abuse definitions) or results in serious bodily injury (refer to Federal definition) or reasonable suspicion of a crime if the events that cause the suspicion result in serious bodily injury."
*The FRI form documented the form was completed on 3/31/25 at 10:00 am with "mistreatment" box checked as the alleged violation being reported. The checkbox for "abuse" was not checked. The incident date and when staff first became aware of the incident was documented as 3/29/25 at 10:46 pm when "Two residents reported that CNA was verbally aggressive with them, impatient and thew a walker in the room (not at the resident)." R16 was documented as one of the involved residents and CNA5 was documented as the reported perpetrator.

During an interview on 7/8/25 at 1:08 PM Director of Rehabilitation (DOR) stated that RS1 was not on the schedule today. DOR stated that RS1 was their Saturday therapist and provided services to R16 and R17 who both relayed concerns about CNA5 who cared for them the previous night. RS1 called him after completing grievance forms. DOR stated he then called the Administrator who stated she was already aware of the concerns. DOR stated he didn't have details about the residents' concerns. During joint review of grievance forms completed by RS1, DOR stated that the grievance forms were concerning because R16 stated that CNA5 used curse words, threw walker, R16 stated she was afraid and it sounded like CNA5 was intimidating to the resident. DOR stated that if he knew the details of the resident's concerns he would have changed his tone and communicated greater urgency when speaking with the Administrator. DOR stated that after the incident, the facility provided education about abuse reporting; what should be reported and when it should be reported.

During an interview on 7/8/25 at 2:24 PM with Clinical Resource Nurse (CRN) and Director of Nursing (DON) DON stated that Administrator told her there were grievances and two residents were not happy with CNA5 and did not want to work with him anymore, but they did not have the details. We checked and knew CNA5 was not scheduled to work that weekend. On Monday [3/31/25], when we saw the grievance forms, we talked to R16 and reported it to the State as a FRI on 3/31/25. DON stated that CNA5 was no longer working at the facility and stated that all staff, including RS1 and DOR, were provided with in-person education on grievances, how grievances are different than abuse and grievances can rise to abuse/neglect allegations, and provided training logs and training materials showing staff completed training on complaints and grievances policy and procedure and abuse (preventing, recognizing, and reporting).

During an interview on 7/8/25 at 3:56 PM with Administrator, CRN and DON, Administrator stated that DOR called her and said two residents stated they did not like CNA5 and DOR stated he would forward the grievance form, but the forms were never received. Administrator stated that on Monday, 3/31/25, when the grievance forms were reviewed, it raised concerns about abuse, therefore, it was immediately reported to the State. The Administrator stated that based on the allegations and concerns received RS1 should have called since they were abuse allegations and the grievance forms did not need to be completed. The Administrator stated that education was provided to all staff that grievances were different from abuse allegations and abuse allegations needed to be reported immediately.

Past noncompliance was determined as the noncompliance occurred after the exit date of the last standard (recertification) survey and before this current survey and facility provided sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey.

Based on interview and record review, it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 sampled residents (#16) reviewed for abuse. This placed residents at risk for lack of dignity and respect. Findings include:

Resident 16 was admitted to the facility in 3/2025, with diagnoses including anxiety.

An Admission MDS dated 4/2/25 indicated Resident 16 was cognitively intact.

The Baseline Care Plan dated 3/28/25, indicated Resident 16 used anti-anxiety medications, with interventions including she/he could become overwhelmed. Staff could assist with one-on-one support. Resident 16 required moderate assistance of one staff member for stand pivot transfers and toileting.

A 3/29/25 facility investigation was initiated after two residents complained about Staff 5 (Former CNA). Multiple grievances against Staff 5 led to him being placed on administrative leave. Resident 16 filed a grievance on 3/29/25, which detailed an incident on 3/28/25 during the evening or night shift. Resident 16 reported she/he had requested a female CNA to assist with her/his shower, to which Staff 5 responded one was not available and "you're not my type." During assistance with toileting and assisting Resident 16 into bed a call light fell off the bed. Resident 16 reported Staff 5, with clenched teeth and after getting close to her/his face stated, "I don't understand you fucking people leaving your shit on the bed." Resident 16 also stated Staff 5 folded her/his walker and threw it in the corner of the room. Resident 16 reported Staff 5 was angry about her/him needing to use the "potty," and Staff 5 refused to "deal" with her/him. Staff 5 got a urinal and stated, "fucking tired of this," then told Resident 16 to put her/his legs on the bed. Resident 16 was too slow; Staff 5 reportedly grabbed her/his legs and roughly tossed them on the bed. While Resident 16 used the urinal, Staff 5 kept "ranting." An item dropped behind the bed, and Staff 5 became "scary," clenching his teeth and getting into Resident 16's face saying, "what's wrong with you fucking people. You put your personal shit all over your bed." Staff 5 then pulled the bed out and found the call light. Resident 16 was crying, and Staff 5 stated she/he did not need to cry and patted her/his hand. The investigation indicated Staff 5 reported he was in a hurry on 3/28/25 and felt he may have been "short" but never intended to be.

On 6/12/25 at 9:19 AM, Staff 5 (Former CNA) stated he did not remember Resident 16. Staff 5 denied throwing the walker, though he conceded he might have "inadvertently" moved a walker quickly, causing it to hit a wall. Staff 5 also admitted he might have "inadvertently" used profanity in a resident's room and "not intentionally" moved a resident's legs roughly. Staff 5 mentioned numerous complaints from multiple residents at the facility and stated he resigned as there was no resolution.

On 6/12/25 at 10:12 AM, Staff 6 stated she heard residents complain about Staff 5, describing him as "gruff" with the residents and was "rough around the edges."

On 6/12/25 at 10:38 AM, Resident 16 stated on the night of 3/28/25 a male CNA came into her/his room to assist her/him with toileting. Resident 16 stated she/he asked for a female caregiver and Staff 5 informed her/him there was no female CNA available and stated, "you are not my type." Resident 16 stated Staff 5 assisted her/him with toileting and getting into bed. Staff 5 folded up the walker and he threw it, and it hit hard. Resident 16 stated she/he was frightened. Staff 5 stated he "did not have time for this bull shit" and picked Resident 16 up and "plopped" her/him on the bed. Resident 16 stated he picked her/him up from underneath the arm pits and he was very strong. During the time he put her/him into the bed an object fell behind the bed. Staff 5 was very close to her/his faced and stated, "I am so fucking sick of you guys putting stuff on the end of the bed." Resident 16 stated it scared her/him. Staff 5 picked up the items behind the bed, patted Resident 16 on the back and told her/him everything was okay.

On 6/12/25 at 11:53 AM, Staff 2 (DNS) and Staff 3 (Regional RN Consultant) stated the facility ruled out abuse and neglect as Resident 16's story would go "back and forth" with her/his statement. Staff 2 stated she felt everything was resolved with Resident 16.

The deficient practice was identified as Past Noncompliance based on the following:

On 3/31/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures in the identification of potential abuse and neglect. The Plan of Correction included:

*On 3/31/25, Staff 7 (RN) was educated on abuse and neglect policies, along with grievances which could potentially rise to the level of an allegation of abuse or neglect which should be reported to the Administrator immediately.

*Ten additional residents were interviewed. All indicated they felt safe at the facility and vocalized no concerns regarding staff care and services.

*Staff 5 was provided education regarding communication and perception of communication by others. Staff 5 was provided a work plan which included access to counseling services and offered additional time off. Staff 5 was assigned training, which included Stress Management and Building up Emotional Intelligence. This training must be completed prior to returning to the facility along with abuse and neglect training.

*All staff educated on grievances and understanding that grievances could potentially rise to the level of alleged abuse or neglect along with the facility's reporting abuse and neglect policy.

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OAR 411-85-310 Resident Rights Generally
        
        
        

Refer to F550
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Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 residents(#50)reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include:

Resident 50 was admitted to the facility in 11/2024 with diagnoses including congestive heart failure.

A 12/20/24 physician order for Enestro (a heart and blood pressure medication) indicated to hold the medication if Resident 50's systolic blood pressure(SBP)was less than 120.

A review of the 1/2025 MAR revealed on 1/2/25 the PM dose of Enestro was given with a SBP of 118 and on 1/4/25 the PM dose of Enestro was given with a SBP of 110.

A review of the 2/2025 MAR revealed on 2/1/25 the PM dose of Enestro was given with a SBP of 104.

On 2/14/25 at 11:58 AM Staff 2(DNS)acknowledged Resident 50 received Enestro on 1/2/25, 1/4/25, and 2/1/25 when the medication should have been held per orders.

On 2/14/25 at 2:19 PM Staff 10(LPN)stated he gave Enestro on 2/1/25 when it should have been held based on the blood pressure parameter order.

On 2/14/25 at 2:30 PM Staff 16(RN)stated she gave Enestro on 1/4/25 when it should have been held based on the blood pressure parameter order.

On 2/14/25 at 2:47 PM Staff 17(CMA)stated she gave Enestro on 1/2/25 when it should have been held based on the blood pressure parameter order.

Based on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 5 sampled residents (#313) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include:

Resident 313 was admitted to the facility in 1/2025 with diagnoses including anxiety.

A 1/23/25 Nutrition Evaluation indicated Resident 313 had difficulty grasping a fork related to hand tremors and the RD recommended adaptive ware (flatware in foam tubes to make it easier to grip) for all meals.

A 1/23/24 order indicated Resident 313 was to have adaptive flatware for all meals.

On 2/10/25 at 12:52 PM Resident 313 was observed eating in the dining room, no adaptive ware was observed.

On 2/11/25 at 1:38 PM Resident 313's tray was observed without adaptive ware.

On 2/12/25 at 12:25 PM Resident 313's tray was observed without adaptive ware.

On 2/12/25 at 12:25 PM Staff 18 (Dietary Aide) stated adaptive ware are added to the trays during the tray line in the kitchen based on what the tray tickets indicated.

On 2/13/25 at 2:52 PM Staff 13 (RD) stated she met with Resident 313 on 1/23/25 and she/he had a hard time holding her/his fork so, with Resident 313's agreement, she put in orders to use adaptive ware with meals.

On 2/13/25 at 3:16 PM Staff 14 (Culinary Manager) stated the order for adaptive ware for Resident 313 was in the orders but was not on the tray tickets.

OAR-411-086-0110: Nursing Services

Refer to F684
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OAR-411-086-0250: Dietary Services

Refer to F810
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Based on observation, interview and record review it was determined the facility failed to update resident care plans for 2 of 2 sampled residents (#s 6 and 36) reviewed for accidents. This placed residents at risk for lack of ADL care needs and safety. Findings include:

1. Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness.

Review of Resident 36's Care Plan initiated 9/29/23, revealed the resident had an ADL self-care performance deficit related to blindness, decreased mobility and wounds. The resident required one or two-person extensive assist with toileting, substantial/maximum assistance for repositioning, personal hygiene and dressing. The resident was encouraged to use her/his pressure sensitive call device to ring for assistance.

The Admission MDS, dated 10/5/23, revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment.

Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and whistled until staff entered her/his room and her/his call light was not activated.

On 10/18/23 at 6:24 AM Staff 4 (CNA) and 6:45 AM Staff 3 (RN) stated Resident 36 was legally blind and had a touch pad alarm but whistled for assistance. Staff 4 and Staff 3 stated Resident 36 did not use the touch pad alarm.

On 10/18/23 at 6:43 AM Resident 36 stated she/he did not use the call device but "whistled" for help.

On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 never used her/his touch pad alarm and whistled when she/he needed assistance with her/his ADL care needs.

On 10/18/23 at 7:41 PM Staff 13 (CNA) stated Resident 36 was dependent for all ADL care needs and had a difficult time using her/his touch pad alarm and whistled to get staff attention.

On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a touch pad alarm but whistled to alert staff when she/he needed assistance. Staff 12 acknowledged this was not on the care plan and needed to be updated to reflect Resident 36's ADL care needs.

, 2. Resident 6 was admitted to the facility in 8/2019 with diagnoses including severe protein calorie malnutrition and osteoporosis.

An 8/28/23 Quarterly MDS indicated Resident 6 was cognitively intact.

On 10/16/23 and 10/17/23 between 2:30 PM and 4:15 PM Resident 6 was observed driving her/his power wheelchair in the facility parking lot towards the street.

A Care Plan last updated on 10/16/23 revealed Resident 6 had "unsafe community behaviors." The care plan did not include any interventions regarding her/his unsafe community behaviors.

On 10/17/23 at 2:10 PM Staff 18 (RN) stated Resident 6's typical behavior was to get into her/his power wheelchair around 2:00 PM or 3:00 PM, leave the facility, and return around 3:30 AM. Staff 18 stated she was unsure of where Resident 6 went, but per other staff Resident 6 was either in the facility parking lot, at stores, or the two nearby parks. Staff 18 further stated Resident 6 did not tell staff where she/he went.

On 10/17/23 at 11:47 PM Staff 17 (CNA) stated Resident 6 was out of the facility in her/his power wheelchair and did not expect her/him to return until 3:00 AM or 3:30 AM when she/he was ready to go to bed.

On 10/20/23 at 9:00 AM Staff 2 (DNS) acknowledged Resident 6's care plan was not updated to reflect the resident's preference for being in the community all day and there were no interventions in place for safety.

Based on observation, interview and record review it was determined the facility failed to implement care planned interventions related to fall safety for 1 of 2 sampled residents (#36) reviewed for accidents. This placed residents at risk for injury. Findings include:

Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness.

A review of an incident report, dated 10/1/23, indicated Resident 36 had an unwitnessed fall and was found next to her/his bed on 10/1/23. The resident indicated she/he attempted to reposition herself/himself in bed, slid off the bed and onto the floor. The resident was assessed and not injured from the fall.

Review of Resident 36's Care Plan, initiated 9/29/23, revealed the resident was at risk for falls related to visual impairment and impaired functional mobility. A revision on 10/6/23 revealed the resident had a non-injury fall out of bed on 10/1/23 and interventions included a fall mat at bedside, bed in a low position and the resident was placed on the falling star program (more frequent checks).

The Admission MDS dated 10/5/23, revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment.

Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and the bed was approximately two feet from the floor with a fall mat next to her/his bed.

On 10/18/23 at 6:24 AM Staff 4 (CNA) stated Resident 36 had a non-injury and stated Resident 36's bed was to be in the lowest position. Staff 4 acknowledged Resident 36's bed was not in the lowest position.

On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 was a fall risk and her/his bed was to be in the lowest position. Staff 14 acknowledged the bed was approximately two feet from the floor and was not in the lowest position.

On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a non-injury fall out of bed and staff were expected to follow the care plan and ensure her/his bed was in the lowest position while the resident was in bed.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include:

Resident 18 was admitted to the facility in 2023 with diagnoses including diabetes.

Resident 18's current physician orders indicated the resident had an order for MiraLAX (a laxative) once daily for constipation. The medication was to be held for loose stools.

Bowel elimination records from 9/20/23 through 10/17/23 revealed Resident 18 had loose stools or diarrhea documented on the following dates:

- 9/20/23, 9/28/23, 9/29/23, 10/4/23, 10/6/23, 10/13/23, and 10/17/23.

Resident 18's MARs from 9/20/23 through 10/17/23 indicated the scheduled MiraLAX was not held for the loose stools.

On 10/18/23 at 2:20 PM Staff 5 (LPN) stated Resident 18's MiraLAX should have been held on the days the resident had loose stools.

On 10/19/23 at 12:09 PM Staff 2 (DNS) verified Resident 18 was administered MiraLAX with documented loose stools and stated her expectation was for medications to be administered according to the physician's orders.

OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F657
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OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care

Refer to F689 and F757

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 06/05/2023 and 06/11/2023, 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 interview and record review it was determined the facility failed to obtain informed consent prior to initiating psychotropic medication for 1 of 5 sampled residents (#6) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include:

Resident 6 admitted to the facility in 2018 with diagnoses including stroke and depression.

The 7/1/22 Quarterly MDS revealed Resident 6 had a BIMS score of 13, indicating she/he was cognitively intact.

Resident 6's physician orders revealed an 8/16/22 order for trazodone (an antidepressant) for insomnia.

A review of Resident 6's 8/2022 and 9/2022 MAR revealed she/he received trazodone each night after 8/16/22.

A review of the medical record revealed no documentation of Resident 6's consent to receive trazodone.

On 9/9/22 at 9:40 AM Resident 6 stated she/he did not know what medications she/he received.

On 9/9/22 at 11:11 AM Staff 2 (Interim DNS) stated there was no consent in the medical record for Resident 6 to receive trazodone.

Based on interview and record review it was determined the facility failed to follow up regarding Advance Directives for 2 of 4 sampled residents (#s 4 and 5) reviewed for Advance Directives. This placed residents at risk for not having their healthcare wishes honored. Findings include:

1. Resident 4 was admitted to the facility in 2019 with diagnoses including stroke.

On 9/7/22 at 8:13 AM Resident 4 was asked about Advance Directives. Resident 4 stated she/he did not have an Advance Directive and the facility did not ask about Advance Directives.

Care Conference Notes from 9/2021 to current were reviewed. There was no information related to Advance Directives documented in the notes.

Review of the medical record revealed no information related to Resident 4's desire to execute Advance Directives.

On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and they were reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered.

2. Resident 5 was admitted to the facility in 2019 with diagnoses including diabetes.

Care Conference Notes from 5/2021 to current were reviewed. There was no information to indicate advance directives were discussed with Resident 5.

Review of the medical record revealed no information related to Resident 5 having an advance directive or her/his desire to execute an Advance Directive.

On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered.

Based on interview and record review it was determined the facility failed to assess and care plan a restraint for 1 of 1 sampled resident (#9) reviewed for accidents. This placed residents at risk for restraint use. Findings include:

Resident 9 was admitted to the facility in 2020 with diagnoses including Parkinson's Disease.

An investigation note for a fall on 8/7/22 recommended the use of a seatbelt in Resident 9's wheelchair.

A review of the medical record indicated there was no information related to the addition of a seatbelt or who applied the seatbelt to Resident 9's wheelchair. There was no information related to seatbelt use for Resident 9 until 9/6/22.

A Health Status note dated 9/6/22 indicated Resident 9 had a seatbelt.

A Care Plan Change note dated 9/7/2022 indicated due to multiple falls Resident 9 would benefit from the use of a seatbelt.

On 9/9/22 at 11:15 AM Staff 13 (CNA) was asked about the use of the seatbelt for Resident 9 and Staff 13 indicated Resident 9 used the seatbelt for approximately one month.

On 9/9/22 at 11:42 AM Resident 9's seatbelt was reviewed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated they just found out Resident 9 used a seatbelt. Staff 1 added upon review of the medical record they identified there was no information or assessment for the use of the seatbelt for Resident 9.

Based on observation, interview and record review it was determined the facility failed to provide services related to ROM and splints for 2 of 3 sampled residents (#s 1 and 8) reviewed for positioning and mobility. This place residents at risk for ROM decline. Findings include:

1. Resident 1 admitted to the facility in 8/2019 with diagnoses including muscular dystrophy (disease of progressive loss of muscle mass and increased weakness) and chronic pain.

An 8/16/21 signed physician order revealed OT was to evaluate and treat Resident 1 for hand/wrist splints for contracture prevention.

An 8/17/21 OT Plan of Care Evaluation revealed Resident 1 would benefit from bilateral resting hand splints for the prevention of contractures of the wrist/hand and without therapy Resident 1 was at risk for bilateral hand contractures.

The 10/17/21 Annual MDS revealed Resident 1 had upper and lower extremity impairments to both sides and there was no indication splints or ROM services were provided.

Resident 1's 8/23/22 revised care plan did not include information regarding her/his hand/wrist contractures, provision of restorative ROM or use of splints on either hand.

On 9/6/22 at 5:29 PM Witness 1 (Family) stated hand/wrist splints were ordered for Resident 1 but the use of the splints were not mentioned during recent care plan meetings.

On 9/7/22 at 12:12 PM and 9/8/22 at 12:39 AM Resident 1 was observed in her/his wheelchair with her/his hands resting on a pillow on her/his lap. All of Resident 1's fingers were curled into a fist and no splints were observed on either hand.

On 9/7/22 at 1:29 PM Staff 4 (CNA) stated she worked with Resident 1 since 10/2021 provided ROM by stretching Resident 1's hands during bathing but did not document the information into Resident 1's medical record. Staff 4 acknowledged she did not see ROM services listed for Resident 1 in her/his care plan and had no knowledge of any hand/wrist splints for Resident 1.

On 9/7/22 at 1:44 PM Staff 5 (Therapy Director) stated he believed the hand/wrist splints for Resident 1 were ordered but was unsure if they ever arrived.

On 9/9/22 at 1:00 PM Staff 2 (Interim DNS) acknowledged there was no evidience the hand/wrist splints for Resident 1 were ordered or implemented.
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2. Resident 8 admitted to the facility in 2018 with diagnoses including multiple sclerosis (a neurological disease.)

A 7/15/22 Annual MDS revealed Resident 8 had limited ROM in her/his upper and lower extremities.

An 8/3/22 physician order indicated physical therapy was to evaluate and treat Resident 8 as indicated. There were no orders for ROM for Resident 8.

An 8/12/22 Physical Therapy Daily Treatment Note revealed Resident 8 had a physical therapy evaluation and it recommended Resident 8 receive ROM from CNA staff three to five days a week on her/his hips, knees and ankles.

A review of Resident 8's current care plan revealed no documentation related to ROM.

The 8/2022 and 9/2022 Documentation Survey Reports revealed no documentation ROM exercises were completed with Resident 8.

On 9/7/22 at 1:52 PM Staff 4 (CNA) stated she did ROM with Resident 8 by extending Resident 8's arms when getting dressed and in the showers. Staff 4 stated Resident 8's care plan did not indicate if ROM was to be completed.

On 9/8/22 at 11:03 AM Staff 14 (CNA) stated she was unaware of ROM exercises for Resident 8.

On 9/8/22 at 12:12 PM Staff 5 (Therapy Director) stated Resident 8 was evaluated for ROM and the CNAs were to complete ROM exercises. Staff 5 stated Resident 8 needed ROM to prevent contractures and it was best if ROM was completed daily.

On 9/8/22 at 3:08 PM Staff 3 (RNCM) stated Resident 8's medical record did not have charting or orders to direct facility staff to do ROM, did not include what exercises were to be completed and did not include when the exercises were to be completed. Staff 3 further stated it was dependent on the CNAs or nurses to remember to do the ROM exercises and to know the residents and what they needed.

Based on interview and record review it was determined the facility failed to ensure adequate RN charge nurse staffing for 15 of 28 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

A review of the facility's Direct Care Staff Daily Reports from 10/24/22 through 11/20/22 revealed 15 days with no RN coverage for eight hours each day.

On 11/21/22 at 10:56 AM Staff 1 (Administrator) confirmed the lack of RN staffing.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate and complete for 12 of 36 sampled days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include:

Review of the Direct Care Staff Daily Report postings from 8/1/22 through 9/5/22 revealed the following:

*Nine days (8/5/22, 8/8/22, 8/26/22, 8/27/22, 8/30/22, 8/31/22, 9/1/22, 9/2/22 and 9/4/22) the actual hours worked by the RN, LPN or CNAs were not documented as required for one or more of the shifts each day.
*Four days (8/31/22, 9/1/22, 9/2/22 and 9/4/22) the resident census was not documented as required for one or more of the shifts each day.
*Two days (8/28/22 and 8/29/22) the nursing staff signature and resident census were missing for one or more of the shifts each day.
*One day (9/3/22) the night shift information was incomplete and the total number and the actual hours worked by the RN, LPN and CNAs and the total resident census were not documented as required.

On 9/9/22 at 12:18 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) acknowledged the Direct Care Staff Daily Reports reviewed were inaccurate or incomplete.

Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include.

Resident 9 was admitted to the facility in 2020 with diagnoses including Parkinson's Disease.

A Pharmacy Review conducted 6/2022 indicated the need to clarify an antibiotic order based on Resident 9's noted allergy to the antibiotic.

A Pharmacy Review conducted 8/2022 repeated the recommendation to clarify the antibiotic allergy and review the need for continued use of a proton pump inhibitor (used to decrease stomach acid).

A review of the medical record revealed there was no follow up to the pharmacy recommendations for Resident 9.

On 9/9/22 at 11:42 AM Pharmacy Reviews were discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated she was not aware pharmacy reviews were conducted. Staff 1 provided no additional information.

Based on observation, interview and record review it was determined the facility failed to provide routine dental services to meet resident needs for 1 of 2 sampled residents (#6) reviewed for dental care. This placed residents at risk for unmet dental needs. Findings include:

Resident 6 admitted to the facility in 2018 with diagnoses including stroke.

Resident 6 was observed on 9/6/22 at 1:16 PM with many upper teeth missing.

A 3/30/22 Oral Dental Assessment revealed Resident 6's last dental appointment was unknown and a dental appointment was to be scheduled the week of 4/4/22 through 4/8/22.

At the time of this survey a review of the medical records revealed no documentation of a dental appointment after the 3/30/22 assessment.

On 9/8/22 at 9:36 AM Staff 3 (RNCM) stated dental appointments were scheduled as needed and she did not know if Resident 6 saw the dentist.

On 9/8/22 at 11:08 AM Staff 1 (Administrator) stated there was nothing in the chart indicating Resident 6 was seen by the dentist after the 3/30/22 Oral Dental Assessment.

Based on observation, interview and record review it was determined the facility failed to ensure AGP (aerosol generating procedure) precautions were used according to CDC guidelines for 1 of 1 sampled resident (#10) reviewed for respiratory care. This placed staff and residents at increased risk for infections and contracting COVID-19. Findings include:

A review of Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) policy and procedure dated 6/1/22 revealed the following:
- AGP to reduce the risk of transmission during bronchoscopy, sputum induction, intubation and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways.
-Procedure should be performed in an airborne isolation room if available (negative pressure) and door must be closed.
-Limit the number of healthcare workers present.
-Staff must wear a fit tested N95 or PAPR (powered air purifying respirator).
-Eye protection (goggles or face shield) should be worn if not using a PAPR.
-Gown and gloves.
-A patient who underwent AGP must have the door closed two hours in a standard room.

Resident 10 admitted to the facility in 11/2020 with diagnoses including sleep apnea and chronic heart failure.

A comprehensive care plan dated 2/22/22 revealed Resident 10 had difficulty breathing related to obstructive sleep apnea and a CPAP (continuous positive airway pressure) machine was used each night when she/he slept. Staff were to assist Resident 10 at bedtime and remove the CPAP as she/he desired.

Random observations from 9/6/22 through 9/9/22 revealed Resident 10 had a CPAP machine on her/his night stand. Resident 10 did not have any AGP or PPE precautions posted or supplies available outside her/his door identifying when the CPAP was in use.

On 9/7/22 at 1:10 PM Resident 10 stated she/he used a CPAP machine at night because she/he had better quality of sleep.

On 9/7/22 at 4:59 PM Staff 13 (CNA) stated Resident 10 utilized her/his CPAP machine at night and was not aware of any AGP or PPE precautions needed.

On 9/8/22 at 11:03 AM Staff 3 (RNCM) stated Resident 10 used a CPAP machine at night. Staff 3 stated she was not aware AGPs were required for Resident 10's CPAP machine use.

On 9/9/22 at 1:34 PM Staff 1 (Administrator) and Staff 2 (DNS) stated staff were expected to implement and follow AGP precautions for Resident 10.

Based on interview and record review it was determined the facility failed to ensure adequate RN charge nurse staffing for 15 of 28 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

A review of the facility's Direct Care Staff Daily Reports from 10/24/22 through 11/20/22 revealed 15 days with no RN coverage from the start of day shift through the end of evening shift.

On 11/21/22 at 10:56 AM Staff 1 (Administrator) confirmed the lack of RN staffing.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 33 of 36 sampled days reviewed for CNA staffing. This placed residents at risk for unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 8/1/22 through 9/5/22 revealed the facility did not have sufficient CNA staff to meet the minimum CNA staffing ratios for 33 of 36 days.

On 9/9/22 at 12:18 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were present during the review of the findings. Staff 1 acknowledged the facility did not meet the required minimum CNA staffing ratios.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F 552
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OAR 411-086-0040 Admission of Residents (Advance Directive)

Refer to F 578
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OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F 604 and F 688
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F 732
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OAR 411-086-0260 Pharmaceutical Services

Refer to F 756
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OAR 411-086-0210 Dental Services

Refer to F 791
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OAR 411-086-0330 Infection control and Universal Precautions

Refer to F 880




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411-086-0100 Nursing Services: Staffing

Refer to F-727

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Based on interview and record review it was determined the facility failed to address a resident's change in condition, failed to ensure provision of care and services for wounds and failed to follow physicians' orders for 4 of 6 sampled residents (#s 1, 4, 5 and 11) reviewed for wounds and medications. Resident 11 required acute care intervention due to sepsis (infection that causes life-threatening injury to the body's own tissues and organs) and amputation. Findings include:

1. Resident 11 admitted to the facility on 9/2021 with diagnoses including diabetes and osteomyelitis (infection of the bone).

A 12/13/21 orthopedic clinic note revealed amputations of Resident 11's right third toe, and left fourth and fifth toes were completed.

The 1/2022 TAR revealed wound care orders for Resident 11 were as follows:
-Pack right toe with strips moistened with Dakin's (an antiseptic solution containing bleach) solution and if the wound vac (a device used to conduct negative pressure to promote wound healing) on the left toe dislodged the procedures for the right toe should be followed for the left toe.

A 1/5/22 orthopedic clinic note revealed Resident 11 was to receive wound care two times each week.

A 1/24/22 Wound Care Provider Note revealed Resident 11's wound vac fell off during her/his sleep over the weekend and her/his wounds were dressed by the facility using iodosorb (an antiseptic containing iodine) packing on the left foot and hydrafera (a blue colored antiseptic) packing on the right foot.

A 1/28/22 orthopedic clinic note revealed Resident 11 had no signs of infection and the surgical wound was healing.

A 1/28/22 facility Wound RN Assessment revealed Resident 11 had a non-pressure related wound to her/his left toes. No other information was documented.

A 1/31/22 FAX Communication to Physician revealed Staff 12 (Nurse Practioner) was informed Resident 11 had decreased mobility and there were no changes at that time.

A 2/1/22 progress note revealed Staff 2 (DNS) reported Staff 3 (RN Care Manager) observed Resident 11 had increased weakness and Witness 7 (clinic physician) was informed. The progress note revealed additional orders for Resident 11 would only be sent if orders for Resident 11 needed to occur before her/his upcoming appointment.

A 2/4/22 facility Wound RN Assessment revealed Resident 11 had a surgical wound on her/his left toes with partial thickness loss and the depth of the wound had increased.

On 3/26/22 at 3:05 PM Staff 3 stated Resident 11 slept more according to an unidentified CNA and staff reported this information to her since they knew Staff 3 was aware of Resident 11's history with infection. Staff 3 stated because of Resident 11's weak condition and infection history she intended for Staff 12 to assess Resident 11 but was unsure if the request was completed.

Review of Resident 11's medical record revealed no ongoing assessment and monitoring after increased weakness was noted on 2/1/22.

A 2/4/22 progress note revealed Resident 11 was scheduled for an appointment with the wound clinic on 2/7/22.

A 2/7/22 progress note revealed transportation did not arrive for Resident 11's appointment.

The 2/2022 facility appointment calendar revealed an appointment for Resident 11 with the orthopedic clinic on 2/10/22 was canceled since no transportation was scheduled.

On 3/25/22 at 3:24 PM Witness 4 (Clinic LPN) stated Resident 11 often arrived to appointments with wound care not completed or done incorrectly. Witness 4 also stated on 2/11/22 Resident 11 was not seen but was sent directly to the hospital because she/he had a fever and was unable to communicate.

On 3/29/22 at 2:05 PM Staff 11 (receptionist) stated there was a period of time when Witness 6 (former Social Services Director) was gone and resident transportation was "a little chaotic". Staff 11 stated she helped facilitate resident transportation during the week of 2/7/22 through 2/11/22 when Witness 6 was out of the facility.

On 3/29/22 at 11:23 AM Witness 5 (wound clinic receptionist) stated Resident 11 was scheduled routinely for wound care appointments, had a wound care appointment on 2/4/22, was scheduled for appointments on 2/7/22 and 2/9/22 and those appointments were canceled (one week without wound care). On 2/11/22 Resident 11 arrived for wound care and was immediately sent to the hospital.

A 2/11/22 History and Physical revealed Resident 11 was positive for MRSA (a bacteria resistant to antibiotics) and presented with a wound infection complicated by septic shock which required a central line access for blood pressure management.

A 2/16/22 hospital Consultation revealed Resident 11 had a new streptococcal bacteremia (bacteria in the blood stream) infection of the right foot fourth digit after amputation of the third digit (in 12/2021) and septic shock which required admission to intensive care.

A 2/23/22 Operative Note revealed Resident 11 was admitted to the hospital with sepsis and additional amputation occurred to her/his right and left toes due to infection.

On 3/18/22 at 4:57 PM Staff 2 (DNS) stated she should have advocated more for a physician visit based on the observation and infection history of Resident 11 provided by Staff 3. Staff 2 confirmed there was no additional charting related to Resident 11's increased weakness and monitoring did not occur. Staff 2 also stated she recently provided wound care for Resident 11 and she/he informed Staff 2 she/he wanted the alternative wound dressing other nurses provided and not what was ordered. Staff 2 confirmed wound dressing should be provided as ordered.

On 3/29/22 at 5:00 PM and 3/30/22 at 1:15 PM Staff 1 (Administrator) confirmed there was no evidence rides for the missed appointments for Resident 11 were scheduled and it was an ongoing issue that needed to be addressed.

2. Resident 1 admitted to the facility on 9/2022 with diagnoses including Parkinson's disease and anxiety disorder.

A 12/31/21 physician order indicated Resident 1 was to receive lorazepam (antianxiety medication) in the morning and at bedtime every day.

The 2/2022 MAR revealed lorazepam was administered to Resident 1 by Witness 3 (former Agency LPN) each morning on 2/15/22, 2/16/22, 2/17/22, 2/18/22, 2/22/22, 2/23/22 and 2/24/22.

The 2/2022 Facility Narcotic Book revealed no morning lorazepam was dispensed on 2/15/22, 2/16/22, 2/17/22, 2/18/22, 2/22/22, 2/23/22 and 2/24/22.

On 3/17/22 at 4:01 PM Staff 7 (RN) stated Staff 6 (LPN) informed her that Resident 1's lorazepam was not administered based on her observation of the narcotic book. Staff 2 (DNS) was informed.

On 3/22/22 at 5:52 PM Staff 2 stated an investigation was initiated and confirmed Witness 3 did not administer Resident 11's medication as ordered.

3. Resident 4 admitted to the facility in 2/2019 with diagnoses including chronic pain syndrome and heart disease.

A Physician Order dated 2/14/19 revealed metoprolol (medication used for heart problems) was to be administered twice daily and held if systolic blood pressure (SBP, pressure on the artery during heart contraction) was less than 100 and/or the pulse was less than 50 beats per minute.

The 2/2022 MAR revealed on 2/15/22 and 2/23/22 the evening metoprolol was not administered and no pulse or blood pressure was monitored.

Review of the Resident 4's clinical record revealed no indication why the metoprolol was held or that the physician was notified.

On 3/28/22 at 5:28 PM Staff 2 (DNS) confirmed there was no indication in the clinical record why Resident 4's metoprolol was not administered, the physician should have been notified and physician orders followed.

4. Resident 5 admitted to the facility in 2/2022 with diagnoses including cutaneous abscess (pus under the skin) and chronic pain.

A 2/24/22 Order Audit Report for physician orders revealed Resident 5's wounds on both legs were to be cleansed every other day with saline, covered with a highly absorbent dressing, secured with kerlix (a type of gauze) and an elastic wrap applied.

A 3/1/22 Order Audit Report of physician orders revealed Resident 5's left hip wound was to be daily cleansed and flushed with Dakin's (an antiseptic solution containing bleach) solution until clear, packed with packing strips and covered with a waterproof foam.

The 3/2022 TAR revealed Resident 5's wound treatment for both legs was not provided as scheduled on 3/7/22 and left hip wound treatment was not provided as scheduled on 3/15/22.

Review of Resident 5's clinical record revealed no indication why wound treatment was not provided on 3/7/22 or 3/15/22 or physician was notified.

On 3/23/22 at 3:52 PM and 3/24/22 at 1:15 PM Staff 4 (LPN) stated nurses were not able to view tasks of the previous shift that were not provided. Staff 2 (DNS) was informed any time care for a resident was not provided but the reason for any lapse in treatment might not be documented. Staff 4 also stated she informed Staff 7 (RN) Resident 5's wound care was not done.

On 3/24/22 at 3:11 PM Staff 5 (CNA) stated Resident 5 sometimes refused treatment on shower days but nurses were to document and address any refusals.

On 3/28/22 at 5:28 PM Staff 2 stated no entry for a scheduled treatment indicated the order was not provided. Staff 2 confirmed physician orders should be followed and any refusals documented and addressed.

Based on interview and record review it was determined the facility failed to follow physician orders and provide monitoring regarding a feeding tube for 1 of 4 sampled residents (#2) reviewed for medications. This placed residents at risk for inadequate nutritional intake. Findings include:

Resident 2 admitted to the facility in 10/2019 with diagnoses including dysphasia (difficulty swallowing) and protein-calorie malnutrition.

The 1/2022 Quarterly MDS revealed Resident 2 had a PEG tube (a tube inserted through the abdomen wall into the stomach for enternal nutrition).

The 1/24/22 updated care plan revealed Resident 2 received nothing by mouth and all nutrition and hydration was to be given by a licensed nurse via the PEG tube.

The 9/4/21 physician orders revealed Resident 2 was to receive 240 ml of free water flushes via a PEG tube five times daily and 100 ml per hour of nutritional formula for 15 hours each day. The PEG tube was to be off between 7:00 AM and 4:00 PM and run continuously at other times.

The 2/2022 TAR revealed the following:
-No nutritional formula was administered on 2/16/22 and 2/18/22.
-The nutritional formula was not turned off on 2/6/22, 2/8/22, 2/11/22, 2/15/22 and 2/17/22.
-No water was administered on 2/1/22 and 2/6/22.
-Two water flushes of 240 ml each were administered on 2/5/22, 2/9/22, 2/16/22, 2/18/22 and 2/22/22.
-Three water flushes of 240 ml each were administered on 2/2/22, 2/10/22. 2/11/22 and 2/15/22.
-Four water flushes of 240 ml each were administered on 2/4/22, 2/7/22, 2/17/22 and 2/19/22.

The 3/2022 TAR revealed no nutritional formula was administered on 3/1/22 and 3/12/22 and no water flushes administered on 3/1/22.

The clinical record did not reveal the physician or family were aware or notified when physician orders were not followed 2/1/22 through 2/10/22 or 3/12/22 for the administration of Resident 2's nutritional formula or water flushes.

On 3/22/22 at 11:34 AM Staff 6 (LPN) stated she observed a time when the feeding tube and water flush equipment in Resident 2's room was not used and reported it to Staff 7 (RN).

On 3/23/22 at 3:52 PM Staff 4 (LPN) stated she came back on 3/2/22 after leaving on 2/28/22 and observed the nutritional formula bag from 2/28/22 was not changed on 3/1/22. Staff 4 stated she was unable to view if water flushes were administered for the previous shift and reported her concerns to Staff 2 (DNS). Staff 4 indicated concerns were to be brought to Staff 2 and then wait for further instructions. Staff 4 stated no instructions were given to monitor Resident 2 after the 3/1/22 incident.

On 3/24/22 Staff 2 stated there was no monitoring of nursing staff to ensure nursing tasks were completed.

On 3/25/22 Staff 15 (Registered Dietitian) stated she monitored Resident 2's condition by review of her/his weights and any progress notes and did not see any documentation of nursing concerns or that Resident 2's orders for nutritional formula and water flushes were not administered.

On 3/28/22 at 5:28 PM Staff 2 stated computer tools were not utilized that would direct nursing staff to notify and monitor residents after an incident. Staff 2 confirmed without progress notes she assumed any blank TAR revealed the orders for Resident 2's nutritional formula and water flushes were not followed

Based on interview and record review it was determined the facility failed to follow physician orders related to pain for 1 of 4 sampled residents (#4) reviewed for medications. This placed residents at risk for unmanaged pain. Findings include:

Resident 4 was admitted to the facility in 2/2019 with diagnoses including chronic pain and diabetes.

The 3/5/22 Quarterly MDS revealed Resident 4 received scheduled pain medication and had frequent pain.

A 7/24/21 initiated care plan intervention revealed staff were to observe and report vocalization of pain or changes to mood or behavior to the nurse.

A 12/19/20 physician order revealed Resident 4 was to receive Voltaren gel (a topical pain medication) two times a day.

The 3/21/22 Order Recap Report revealed physician orders were in place for Resident 4 to receive a lidocaine (a nerve pain block medication) patch to both knees one time a day and acetaminophen-codeine (opioid pain medication) twice daily in 2/2022 and 3/2022.

The 2/2022 and 3/2022 MAR revealed acetaminophen-codeine was administered by Witness 3 (former Agency LPN) each morning on 2/15/22, 2/16/22, 2/18/22, 2/22/22, 2/24/22 and 3/1/22.

The 2/2022 and 3/2022 Facility Narcotic Book revealed no morning acetaminophen-codeine was dispensed on 2/15/22, 2/16/22, 2/18/22, 2/22/22, 2/24/22 and 3/1/22.

The 2/2022 MAR revealed Resident 4's pain level was rated one to six out of 10 on 2/1/22 through 2/18/22 and three to seven out of 10 on 2/19/22 through 2/28/22.

The 3/2022 TAR revealed no lidocaine patch was administered on 3/1/22 and 3/10/22 and no Voltaren gel was administered on 3/1/22 and 3/8/22.

On 3/22/22 at 5:52 PM Staff 2 (DNS) stated an investigation was initiated and confirmed Witness 3 did not administer Resident 4's medication as ordered.

On 3/24/22 at 3:02 PM Staff 9 (CNA) stated it was very unusual for Resident 4 to complain of pain but during morning care on 3/1/22 she/he complained of pain and Staff 9 forgot to inform the nurse. Staff 9 indicated she observed Resident 4 with no lidocaine patch on her/his knees.

On 3/28/22 at 5:36 PM Staff 2 stated nurses were expected to complete resident rounds during the shift to ensure pain was managed and it did not happen for Resident 4. Staff 2 also indicated she was not aware pain treatments were not provided as ordered.

Based on observation, interview and record review it was determined the facility failed to establish and maintain infection control practices for 1 of 1 COVID-19 testing station of unvaccinated staff reviewed for staff vaccinations. This placed residents at risk for potential exposure of the COVID-19 virus. Findings include:

The facility's 2/16/22 COVID-19 Immunization, Employee-Enterprise document indicated "Any person who is exempt from the COVID-19 vaccination for a medical or religious exemption shall be required to wear source control covering the nose and mouth at all times" and "submit to mandatory surveillance testing."

An undated vaccination log provided on 3/22/22 revealed five staff were "exempt" from vaccination.

On 3/22/22 at 12:47 PM Staff 3 (Infection Preventionist) stated a change to self-testing took place during the last few months and she informed Staff 1 (Administrator) there were issues with the COVID-19 testing station. Staff 3 also stated she did not monitor the COVID-19 testing process and was not involved in any plans to resolve the COVID-19 self-testing infection control concerns.

On 3/22/22 at 2:27 PM a completed COVID-19 test result with a used nasal swab was observed on a small table in a room near the facility entrance with no gloves, hand sanitizer or disinfection wipes on or near the table.

On 3/22/22 at 2:37 PM Staff 16 (Ancillary Staff) stated he placed his completed COVID-19 nasal test on the table for nurses to review because he watched other staff complete that same procedure and no information was provided related to infection control before performing the COVID-19 nasal test or the cleaning and disinfection of the area after the test was completed.

On 3/24/22 at 2:47 PM Staff 10 (Cook) stated he left his COVID-19 test on the table because "that's what others do", there were no written directions for the testing procedure except what he read in the COVID-19 test kit. Staff 10 also stated he performed hand hygiene when he entered the building but not at the COVID-19 testing station and there were no instructions for cleaning or disinfection of the areas after the COVID-19 test was completed.

On 3/28/22 at 2:49 PM Staff 1 (Administrator) confirmed no direction or written procedures were provided to ensure staff followed infection control practices related to COVID-19 self testing and the sanitization of the COVID-19 self-testing station. Staff 1 also stated there was a team working on a solution for the COVID-19 self-testing station and confirmed Staff 3 was not currently involved.

Based on interview and record review it was determined the facility failed to develop policies and follow procedures intended to mitigate the transmission and spread of COVID-19 for 1 of 2 unvaccinated staff (#10) reviewed for COVID-19 staff vaccinations. This placed residents at risk for potential exposure to the COVID-19 virus. Findings include:

The facility's 2/16/22 COVID-19 Immunication, Employee-Enterprise document indicated "Any person who is exempt from the COVID-19 vaccination for a medical or religious exemption shall be required to wear source control covering the nose and mouth at all times" and "submit to mandatory surveillance testing."

On 3/22/22 at 12:47 PM Staff 3 (Infection Preventionist) stated unvaccinated staff were to test twice weekly for COVID-19.

The 3/2022 test results log of all unvaccinated staff revealed Staff 10 (Cook) only tested weekly.

On 3/22/22 at 2:00 PM Staff 14 (Health Information Coordinator) stated the vaccination log was recently updated and did not include intermittent staff.

On 3/24/22 at 2:47 PM Staff 10 (Cook) stated management provided reminders if COVID-19 testing was forgotten.

On 3/28/22 at 4:00 PM Staff 1 (Administrator) stated the honor system was in place for twice weekly staff testing of unvaccinated staff and acknowledged the testing system was not monitored. Staff 1 also stated the procedure to obtain vaccination and/or exemption information of intermittent staff was not in place and corporate headquarters indicated it was up to the facility to establish those policies which were not completed.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684, F693 and F697
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880 and F888
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