Willamette View Health Center

Resident 12 was admitted to the facility in 4/2026 with diagnoses including heart failure and dependence on renal dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly). The 4/26/26 Admission MDS revealed Resident 12 had a BIMS score of 8 indicating the resident had moderate cognitive impairment. The 6/1/26 hospital re-admission physician orders revealed an order to call the covering provider if Resident 12GÇÖs HR (heart rate) was greater than 100 bpm (beats per minute) or less than 55 bpm. -á A review of Resident 12GÇÖs vital signs from 6/1/26 through 6/17/26 revealed her/his HR was out of range on the following dates: -6/5/26, HR 47 bpm -6/11/26, HR 53 bpm A review of Resident 12GÇÖs progress notes and full medical record revealed no indication the provider was notified on 6/5/26 and 6/11/26 of the low HR reading. On 6/15/26 at 12:11 PM Staff 5 (CNA) stated she obtained Resident 12GÇÖs vital signs on her shift and if the vital signs were out of range, she told the charge nurse who then rechecked the vital signs. -á On 6/16/26 at 1:38 PM Staff 6 (RN) stated the CNA or sometimes the nurse obtained vital signs and the nurse reviewed the vital signs to verify they were within normal range. Staff 6 stated the CNAs communicated with the nurse if there was an abnormal reading, and the nurse rechecked to verify the accuracy of the reading, then contacted the provider and documented in a progress note.-á On 6/16/26 at 2:24 PM Staff 7 (RN) stated the CNA or the nurse obtained vital signs and she, as the nurse, always reviewed to ensure vital signs were within normal range. Staff 7 stated she contacted the provider if there were any abnormal readings and then documented in a progress note. Staff 7 stated she was unsure what happened on the identified dates and stated if she called a provider, it was documented in the progress notes. On 6/17/26 at 10:14 AM Staff 3 (DNS) stated the charge nurse oversaw all vital signs and was to contact the provider of any abnormal readings, and then document in a progress note that the provider was contacted. Staff 3 acknowledged the physician order was not followed as Resident 12GÇÖs provider was not notified of the low HR on 6/5/26 and 6/11/26.

For the resident identified during the survey, the physician was notified, and physician orders were reviewed and implemented as appropriate on 6/18/26. All licensed nursing staff received re-education on physician notification requirements by 6/19/26. The Director of Nursing, or designee, will audit all SNF residents weekly for 8 weeks to ensure physician orders are followed. Thereafter, 5 residents will be audited monthly for 3 months to verify continued compliance. Audit results will be reviewed by the Quality Assurance Committee.

A review of the 11/11/24 facility Background Checks with Prospective Candidates or Employees Reviewable by DHS (Department of Human Services) policy revealed all staff would have a criminal background check conducted prior to employment and as required. On 6/16/26 at 1:06 PM during a review of background checks for the facility's staff employed two or more years and eligible for a recheck, Staff 8 (Human Resources) stated Staff 4 (SSD/Admissions) had a completed background check on 11/13/23 and the most recent background check was completed on 3/4/26. Staff 8 acknowledged the time between background checks exceeded the required timeframe for completion. On 6/17/26 at 10:27 AM Staff 2 (Assistant Administrator) acknowledged Staff 4GÇÖs criminal background recheck was not completed every two years as required.

Criminal History recheck audit was completed by 7/2/2026 by HR Department to assure compliance. HR Department to utilize HRIS system to track when CRIM rechecks are due. Reviewed policy with HR staff on the CRIM recheck requirements. HR Dept will audit monthly for 6 months to ensure on-going compliance. Audits to be submitted quarterly for review by Administrator and Quality Assurance Committee.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self administration of medications for 1 of 1 sampled resident (#1) reviewed for medication administration. This placed residents at risk for adverse medication related consequences. Findings include: The facility's 8/2024 Self-Medication policy outlined the following criteria for a resident to self-administer medications: -The resident must successfully pass the Medication Self-administration Safety Screen; -Their primary care physician must approve their request to self-administer medications; and -They must consistently secure their medications out of the reach of others. Resident 1 was admitted to the facility in 2/2025 with diagnoses including left leg fracture and amnesia. A review of Resident 1's 2/18/25 Admission MDS revealed she/he had moderately impaired vision and required cueing for recall. On 3/11/25 at 10:36 AM, Resident 1 was observed to have the following medications on her/his bedside table: -Two tubes of Benadryl itch stopping cream. -One tube of Benadryl extra strength itch stopping gel. -One tube of GC dry mouth gel. -Three tubes of Systane night time eye lubricant gel. -Two bottles of TheraTears lubricant eye drops. On 3/11/25 at 10:36 AM, Resident 1 stated the medications on the bedside table were her/his and she/he applied the Benadryl and TheraTears herself/himself several times each day. Resident 1 also stated she/he did not remember the last time she/he used the Systane. On 3/11/25 at 11:16 AM, Staff 4 (RN) stated residents were allowed to self administer medications with a physician's order and successful completion of an evaluation. Staff 4 stated the resident needed to name the medication, its use, and when it was given. Staff 4 acknowledged Resident 1 did not complete the evaluation and did not have an order from her/his physician for medication self administration. On 3/11/25 at 11:30 AM, Staff 3 (DNS) stated she expected residents to have a physician order and complete an assessment to self administer medications.

Immediate Corrective Actions: • An immediate review of resident rooms was conducted to ensure no medications were left at the bedside unless the self-administration policy/procedures were in place. • All staff were educated on the requirements of F554; specifically, the nursing staff on the importance of completing the self-administration assessment if applicable before any resident self-administers medication, this includes leaving OTC medications at bedside. • On-going monitoring of items in resident rooms by all staff to make sure items are secured in resident locked cabinet if applicable or in the medication cart. Ongoing Monitoring: • The Director of Nursing will monitor new admissions to ensure self-administration assessments are completed if appropriate. • An environmental rounding tool was implemented, it includes checking the residents’ rooms for any medications that should be secured. • The Resident Care Manager will conduct this audit at random weekly x 4, then bi-weekly x 2, and then monthly x 1. • Audits show compliance • Results of Audits to be reviewed by the Quality Assurance Committee

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 35 of 39 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: The facility's Nursing Staffing Plan policy, dated 1/9/24, indicated that staffing information on the Daily Staff Public Posting form must be an accurate reflection of the actual staff working each shift. A review of the facility's DCSDRs revealed the following: From 2/1/25 through 3/10/25, 39 days were reviewed and revealed 35 days when licensed nursing staff hours were inaccurate on 2/2/25, 2/3/24, 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, 2/11/25, 2/12/25, 2/13/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/21/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 2/28/25, 3/1/25, 3/2/25, 3/3/25, 3/4/25, 3/5/25, 3/6/25, 3/7/25, 3/8/25, 3/9/25 and 3/10/25. On 3/11/25 at 11:18 AM, Staff 2 (Assistant Administrator) reviewed the 2/1/25 through 3/10/25 DCSDRs and verified the reports were inaccurate on the days identified. Staff 2 stated she was currently responsible for ensuring the accuracy of the reports and expected the DCSDRs to accurately reflect the correct hours licensed nursing staff worked each shift.

Immediate Corrective Actions: " Nursing staff received training on how to record hours between shifts to account for overlap. " The Resident Care Manager will complete daily audits to verify that the posted nurse staffing information is accurate, formatted correctly, and up to date. " Assistant Administrator or designee will complete weekly audits to assure compliance. "Audit results to be reviewed by Quality Assurance Committee

Based on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely and not accessible to unauthorized individuals for 1 of 1 sampled medication room reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals. Findings include: The facility's 8/2024 Medication Management Policy & Procedure specified refrigerated medications were kept in a locked, secure refrigerator and all medications were stored in rooms accessible to authorized personnel. On 3/11/25 from 9:05 AM through 10:02 AM the unit's skilled nursing office door was propped open. During this time, various staff members went in and out of the room, and non-staff construction workers walked by the room. A white refrigerator and a silver refrigerator were observed inside the office. On 3/11/25 at 10:02 AM, Staff 4 (RN) reviewed the contents of the refrigerators. The silver refrigerator was empty and the white refrigerator contained an Aplisol vial (used for tuberculosis testing). Staff 4 stated the white refrigerator was used to store drugs and biologicals. On 3/11/25 at 10:18 AM, Staff 4 stated the refrigerator was not routinely locked. Staff 4 confirmed the office door was open and unlocked since 9:00 AM and the contents of the unlocked refrigerator were accessible to unauthorized staff and personnel. Staff 4 stated the office door should be locked at all times since the refrigerator remained unlocked. On 3/11/25 at 3:53 PM, the office door was observed open and no staff were in the office. On 3/12/25 at 8:22 AM, the office door was observed open and no staff were in the office. On 3/12/25 at 9:29 AM, Staff 3 (DNS) stated the office refrigerator was used to store drugs and biologicals. Staff 3 was notified the office door was unlocked and accessible to unauthorized personnel on 3/11/25 and 3/12/25 and the refrigerator was left unlocked. At 9:37 AM, Staff 3 observed the unlocked refrigerator and stated the door to the office and the refrigerator were to be locked at all times.

Immediate Action: " Secure the Fridge: Immediately lock the fridge containing medications and ensure that only authorized personnel have access to the keys or security codes. A second lock that is visually identified as being locked was added. " Provide training to all relevant staff on the importance of securing medication storage areas, including fridges. Emphasize the regulatory requirements and potential risks associated with unsecured medications. " Per change of shift audit performed by Charge nurses on securable items. " Weekly audits to be performed by Director of Nursing x 3 weeks, then monthly x 4 on-going. Results of audit to be reviewed by the Quality Assurance Committee.

Based on interview and record review it was determined the facility failed to ensure criminal background rechecks were completed for staff employed two or more years for 1 of 3 sampled staff (# 5) reviewed for background checks. This placed residents at risk for abuse. Findings include: The facility's Background Checks with Prospective Candidates or Employees Reviewable by DHS policy, dated 11/11/24, indicated the following: -All persons offered a position at the facility will have a criminal background check conducted. On 3/11/25 at 1:10 PM, during a review of background checks for three randomly selected staff employed two years or more, Staff 6 (Human Resources Business Partner) stated the following: -Staff 5 (CNA), hire date 11/8/16, required a criminal background recheck on 11/9/24 which had not been completed, and Staff 5 was working with residents without a current criminal background check in place. On 3/12/25 at 9:48 AM, Staff 1 (Administrator) and Staff 2 (Assistant Administrator) acknowledged Staff 5's criminal background recheck was not completed on 11/9/24 as required. Staff 1 and Staff 2 stated they expected all staff to have current criminal background checks in place.

The criminal background re-check was completed for the one employee immediately. An Audit was performed to verify all employees have background re-checks completed timely, any areas out of compliance were corrected immediately. Monthly audits were put into place on-going to verify background re-checks are completed timely. Audits to be performed by the Human Resources Department staff and verified by HR Director and Facility Administrator. Audit results will be reviewed by the Quality Assurance Committee.

******************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 and F761 ******************** OAR 411-086-0100 Nursing Services: Staffing Refer to F732 ********************

Based on interview and record review it was determined the facility failed to have a system in place to monitor and document food temperatures for 1 of 1 kitchen reviewed for safe food preparation. This placed residents at risk for food borne illness. Findings include: Review of the facility census indicated two residents resided in the facility. Resident 1 and Resident 2 indicated no concerns regarding food. Review of the residents' medical records revealed no indication of food related illnesses. On 1/3/24 at 10:42 AM during a kitchen observation, Staff 4 (Dining Manager) and Staff 5 (Executive Sous Chef) were asked to provide documentation of the food temperature logs. Staff 4 stated once food was prepared in the kitchen it was placed into the "hot box" (temperature controlled food cart). Food temperatures were taken and documented by the staff in the skilled unit when the food was removed from the hot box. Staff 4 and Staff 5 stated food temperatures were not taken in the kitchen and there was no documentation of food temperatures. On 1/3/24 at 11:20 AM Staff 3 (RN) stated there was no documentation kept of food temperatures in the skilled unit. On 1/3/24 11:20 AM Staff 2 (DNS) stated nursing staff took food temperatures only when food was reheated. On 1/3/24 at 1:10 PM Staff 1 (Administrator) acknowledged the facility did not have a system in place for monitoring food temperatures and did not have documentation of food temperatures.

A system was put into place to document the monitored food temperatures per guidelines. Temperatures are to be taken when the food is finished cooking, prior to dividing between service pans and the hot wells. Cooks completed in-service training regarding the proper way to document food temperatures. Additional training was reviewed on obtaining a proper food temperature and times during meal service to monitor. On-going education on food temperature documentation will be provided annually and as needed. Executive Sous Chef or designee will audit the temperature logs weekly to ensure compliance. The Register Dietician or designee will review audits monthly. Audit results will be reviewed by the Quality Assurance Committee.

************ OAR 411-086-0250 Dietary Services Refer to F812 ************

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 07/17/2023 and 07/23/2023, 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.