Avamere Rehabilitation of Clackamas

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions related to elopement for 1 of 1 sampled resident (#32) reviewed for elopement. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for an unsafe elopement and injury. Findings include:

The facility's revised 3/2019 Wandering and Elopement policy states the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

The facility's revised 7/18/24 Avamere Living-Code Pink Guidelines, an Elopement, Exit seeking, Wandering Assessment, stated the facility will complete the Code Pink Documentation tool when the resident is identified as at risk for elopement, exit seeking or wandering.

Resident 32 admitted to the facility in 3/2024, with diagnoses including dementia and congestive heart failure.

Resident 32's 6/19/24 Care Plan indicated Resident 32 may leave facility premises only if accompanied by a responsible party for therapeutic leave.

Resident 32's 8/15/24 AvaElopement Risk Evaluation indicated the resident was disoriented, cognitively impaired with poor decision-making skills, known history of elopement, able to self-propel wheelchair independently and a moderate risk for wandering.

On 8/19/24 at 12:41 PM, a complaint was received by the State Survey Agency (SSA), which alleged Resident 32 arrived on 8/16/24 via a medical transport bus to a brand-new appointment with a new practitioner, unattended and disoriented. Paperwork received from the nursing facility stated the resident had dementia and was an elopement risk. The receiving clinic recognized the residents' risk for elopement and assigned a staff member to monitor the resident.

On 9/16/24 at 10:59 AM Resident 32 stated she/he was unable to recall the recent clinic visit.

On 9/16/24 at 11:05 AM Staff 4 (CNA) stated she arranged for Resident 32's transportation to the new clinic and ordered Hand To Hand: Specific instructions when the resident arrived to the clinic she/he was not to be left alone. Staff 4 stated the facility did not send staff with the resident.

On 9/16/24 at 11:52 AM Staff 2 (DNS) stated medical transport takes residents to their appointments and then picks them back up. Staff 2 stated the facility did not send staff with Resident 32 for the clinic appointment and acknowledged Resident 32 was not able to communicate and was an elopement risk. Staff 2 stated the expectation was for Resident 32 to be accompanied by a responsible party.

On 9/17/24 at 12:05 PM Staff 3 (RNCM) stated she had received a phone call from the clinic stating Resident 32 was confused and could not give them any information. Staff 3 stated she knew Resident 32 was an elopement risk but assumed the driver from the medical transport would escort the resident in to the clinic.

On 9/18/24 at 10:27 AM Staff 5 (RN Charge Nurse) stated Resident 32 needed redirection due to being forgetful and acknowledged Resident 32 was an elopement risk. Staff 5 stated she did not know if the resident could leave the facility by her/himself.

On 9/18/24 at 10:52 AM Witness 2 (Medical Transport Driver) stated she did not know what the term Hand To Hand meant when transporting residents.

On 9/20/24 at 3:00 PM Staff 1 (Administrator) and Staff 2 were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to follow Resident 32's care plan to have a responsible party accompany the resident to an outside appointment.

On 9/20/24 at 4:51 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions:
1. The care plan for Resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks.
2. All staff on evening shift on 9/20/24, have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments.
3. All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift within the week will have been educated by 9/26/24.
4. All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary.
5. To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement for one week, weekly for three weeks, and then monthly until substantial compliance is achieved.
6. All findings to be reported to the Quality Assurance and Performance Improvement Committee.

On 9/23/24 at 2:20 PM, the IJ was removed as confirmed by onsite verification.

************************
411-086-0140: Nursing Services: Problem Resolution and Preventive Care

Refer to F689
************************

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for a lessened quality of life. Findings include:

The facility's 2021 Homelike Environment Policy revealed residents were provided with a safe, clean, comfortable and homelike environment. Comfortable and adequate lighting was provided in all areas of the facility.

Resident 24 admitted to the facility in 2019 with diagnoses including hypertension (high blood pressure) and depression.

Resident 24's 4/21/24 Annual MDS indication she/he was cognitively intact.

On 7/16/24 at 9:24 AM Resident 24 stated she/he was going to an activity in the dining room where the lighting was bad, and her/his vision was "not so great" so she/he sat by the window or the doors to see better.

On 7/16/24 at 3:40 PM Resident 24 stated the lights in the dining room could be brighter because when residents were in activities in the dining room, other residents would ask if the lights could be turned on, but the lights were already on.

During the Resident Council meeting on 7/16/24 at 1:00 PM the council members stated the lights in the dining room, where they had activity groups, had light bulbs out for a while and made it difficult to see.

On 7/16/24 at 1:53 PM the dining room was observed with three of the six ceiling lights to not produce light. The dining room floor had four large pieces of black tape on the light-colored floor and the flooring was buckled up near the soda machine.

On 7/17/24 at 11:10 AM the shared bathroom between room one and room three was observed with brown and yellow stained caulking around the base of the toilet. The floor was stained with brown markings and appeared dirty.

On 7/17/24 at 11:12 AM the shared bathroom between room two and room four was observed with brown and yellow stained caulking around the base of the toilet and appeared dirty.

On 7/17/24 at 11:13 AM room four's wall under the window was observed with the paneling peeling away from the wall in several spots.

On 7/19/24 at 9:58 AM Staff 11 (Maintenance Director) confirmed the lights in the dining room were not working properly and needed new bulbs. Staff 11 stated he found out about the lights on Tuesday (7/16/24) from the Resident Council meeting and was unaware prior to 7/16/24. Staff 11 confirmed the taped flooring in the dining room and the other identified areas were in disrepair. Staff 11 stated the facility did not have a plan in place to fix flooring repairs. Staff 11 acknowledged the stained caulking in the shared resident bathrooms between rooms one and three and rooms two and four. Staff 11 stated the caulking needed to be repaired. Staff 11 acknowledged the paneling pulled away from the wall in room four and stated the facility did not have a plan in place to fix the wall.

On 7/19/24 at 10:10 AM Staff 1 (Administrator) confirmed the needed repairs of lights in the dining room, flooring in the dining room, shared resident bathrooms between rooms one and three and rooms two and four, and the wall in room four. Staff 1 stated he expected a plan to be in place to make the repairs.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers for 1 of 2 licensed nurses (Staff #3) reviewed for infection control and medication administration. This placed residents at significant risk for bloodborne illness. Findings include:

Per OAR 851-045-0040 Scope of Practice Standards for All Licensed Nurses
(1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall:
(A) Adhere to professional practice and performance standards;
Per OAR 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined:
Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to:
(2) Conduct related to achieving and maintaining clinical competency:
(a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established;
(3) Conduct related to the client's safety and integrity:
(a) Developing, modifying or implementing policies that jeopardize client safety;

The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA registered wipes.

The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions.

On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a 3-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use.

On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls.

On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached.

Refer to F880.

Based on interview and record review it was determined the facility failed to implement resident-centered care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 1 of 1 sampled resident (#18) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors. Findings include:

The facility's revised 2018 Dementia - Clinical Protocol revealed for individuals with confirmed dementia, the IDT (Inter-Disciplinary Team) would identify a resident-centered care plan to maximize their remaining function and quality of life.

Resident 18 admitted to the facility in 2020 with diagnoses including dementia with agitation and depression.

Resident 18's 8/21/23 Annual MDS indicated behaviors including rejection of care, combative behavior and agitation.

Resident 18's 5/21/24 Quarterly MDS assessed her/him as severely cognitively impaired.

Review of Resident 18's 7/18/24 behavioral care plan identified her/him as confrontational, rude, demanding, suspicious, manipulative and anxious. The care plan identified behaviors of verbal aggression, physical aggression, yelling, hitting, interference with roommate's care, and history of false accusative statements. The care planned interventions were that sometimes she/he would calm down when chocolate was given, discharge planning, separate from other residents, approach calmly and unhurriedly, notify physician if behaviors interfered with medical needs, leave the room and leave her/him alone to give space.

Review of Resident 18's 7/18/24 ADL care plan revealed she/he refused ADLs and showers. The interventions were to document refusals and re-approach at a different time. No other interventions for ADLs and shower refusals were documented.

On 7/19/24 at 8:43 AM Staff 10 (CNA) stated she received her information to care for residents from the care plan and shift reports from other staff members. Staff 10 stated Resident 18 had behaviors often, ate meals in her/his room due to behaviors and the staff kept her/him away from people. No other interventions were provided to prevent negative behaviors.

On 5/19/24 at 9:13 AM Staff 2 (DNS) acknowledged Resident 18's care plan was not resident centered. Staff 2 acknowledged the interventions were for staff and were not specific to Resident 18 as an individual. Staff 2 reported some interventions were attempted but they were not documented or care planned in Resident 18's health record. No further information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use for 1 of 1 sampled resident (# 299) reviewed during CBG checks. This failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include:

The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes.

The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions.

On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a three-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use.

On 7/17/24 at 11:55 AM Staff 2 (DNS) provided a list of 15 residents who required CBG checks, which included Resident 15.

Resident 15's clinical record indicated she/he admitted to the facility on 6/13/24 with diagnoses including human immunodeficiency virus (HIV) and required CBG checks three times a day and used a shared glucometer.

Resident 15's Diabetic Administration Record indicated Staff 3 first completed Resident 15's CBG checks twice on 6/14/24.

On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls.

On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached.

On 7/17/24 at 2:15 PM the facility was informed that the facility's failure to improperly clean and sanitize the common use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested.

On 7/17/24 at 5:30 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions:
1. Glucometers in the facility have been immediately collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens prior to the next CBG checks.
2. Staff 3 was suspended, will receive 1:1 education/training on glucometer disinfection between uses, and dedicating CBG equipment for residents with diagnoses of bloodborne pathogens prior to return to work.
3. Licensed nurses, prior to start of shift, will be educated on the proper procedure for disinfecting blood glucose monitors and complete a Blood Glucose Monitoring Competency and will have dedicated CBG equipment for residents with bloodborne pathogens.
4. Resident 15 was provided with dedicated blood glucose monitoring equipment.
5. Residents in the facility will be audited for diagnoses of bloodborne pathogens and provided with dedicated blood glucose monitoring equipment if indicated.
6. The Medical Director was notified. Residents potentially exposed also notified. Testing will be offered as requested.
7. To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for routine blood glucose checks x 1 week, weekly x 3 weeks, monthly x 2 months to ensure proper disinfection.
8. All findings to be reported to the QAPI Committee.

On 7/18/24 at 2:30 PM it was determined the immediacy was removed after verification of completion of the IJ removal plan.

Based on interview and record review it was determined the facility failed to implement an active supervision program to monitor staff working on a preliminary basis for 2 of 5 staff (#s 7 and 8) reviewed for background checks. This placed residents at risk for abuse. Findings include:

On 5/16/24 at 10:32 AM Staff 9 (Human Resources/Staffing) stated Staff 7 (Dietary Aide) and Staff 8 (CNA) were working in the facility on a preliminary status while they waited for clearance of their background checks. Staff 9 was aware employees on preliminary status were required to be on active supervision. Staff 9 could not identify a facility system in place to provide active supervision to employees whose background checks were pending. Staff 9 stated she did not report employees who were on preliminary status to any other department manager.

According to records reviewed with Staff 9 on 5/16/24 at 10:32 AM, Staff 7 began working in the facility on 5/4/24 and was pending background clearance. Staff 8 began working on 5/4/24 and the background clearance was obtained on 5/9/24.

On 7/17/24 at 10:09 AM Staff 2 (DNS) stated she was aware employees on preliminary status were required to be on active supervision while background checks were pending. Staff 2 stated the facility required staff to have a red dot on their name tag until the background check was cleared.

On 7/17/24 at 10:10 AM Staff 7 was observed in the kitchen with no red dot on his name tag.

On 7/17/24 at 10:12 AM Staff 3 (RN) confirmed she was the charge nurse and was accountable for the CNAs. Staff 3 stated she did not know what a red dot would indicate on an employee's name tag.

On 7/19/24 at 8:38 AM Staff 1 (Administrator) acknowledged and confirmed the facility did not implement the active supervision program which required employees to be on active supervision while background checks were pending. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure state minimum staffing ratios were maintained for 10 of 30 days (14 of 90 shifts) reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 6/16/24 through 7/14/24 revealed the following days and shifts when the state minimum CNA staffing ratios were not met:

6/17/24 - evening shift.
6/23/24 - day and evening shifts.
6/27/24 - evening shift.
6/29/24 - day and evening shifts.
6/30/24 - day shift.
7/3/24 - evening shift.
7/5/24 - day and evening shifts.
7/6/24 - day and night shifts.
7/12/24 - evening shift.
7/14/24 - day shift.

On 9/9/24 at 9:27 AM Staff 9 (Human Resources/Staff) confirmed the dates and shifts the facility did not meet the state minimum CNA staffing ratios.

On 7/19/24 at 12:10 PM Staff 1 (Administrator) acknowledged the facility's failure to meet state minimum CNA staffing ratios. Staff 1 expected all shifts to be staffed to the minimum number of staff required. No additional information was provided.

Based on observation and interview it was determined the facility failed to ensure an audible and visual call signal at the nurse station and a visible signal in the corridor intersection for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet needs. Findings include:

Random observations from 7/15/24 through 7/17/24 revealed when residents utilized their call light, no visual signal was observed and no audible sound was heard at the nurse station. The West corridor intersection had a visual and audible system for rooms one through eleven, but there was no audio or visual signal in the other corridor intersections for rooms 12 thru 26 to alert staff a resident's call light activation.

On 7/19/24 at 8:48 AM Staff 10 (CNA) stated rooms 12 thru 26 did not have an audio signal to indicate an activated resident call light. Staff 10 stated in order to see if the call lights for rooms 12 through 26 were activated, she had to walk down the halls to look above the residents' doors.

On 7/19/24 at 12:10 PM Staff 1 (Administrator) acknowledged the observation that a resident's call light was activated in the hallway and the nurse station did not have an audible or visual alert to indicate a resident's call light was activated. Staff 1 confirmed there was no visual or audio signal in the hallway corridor for rooms 12 thru 26. No additional information was provided.

****************************
411-087-0100: Physical Environment: Generally

Refer to F584
****************************
411-086-0110: Nursing Services: Resident Care

Refer to F658
****************************
411-086-0240: Social Services

Refer to F744
****************************
411-086-0330: Infection Control and Universal Precautions

Refer to F880
****************************

Based on observation, interview, and record review it was determined the facility failed to re-evaluate elopement risks and revise care plan interventions to prevent repeated elopements for 1 of 1 sample residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include:

Resident 1 admitted to the facility in 3/2024, with diagnosis including dementia and Type 2 diabetes.

Resident 1's 3/16/24 Elopement Assessment identified she/he was a moderate risk for elopement.

Resident 1's 4/15/24 Care Plan indicated the resident presented as a high risk for wandering and elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was also revealed to be a significant fall risk due to cognitive impairment related to dementia. No additional interventions were identified.

A 4/24/24 Facility Incident Reported revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located according to the facility's investigation to have been found at the local market. Facility door alarms were in place but was revealed to have not alerted staff when resident exited the facility. Residents SLUMS score was revealed to be 12/30 indicating significant cognitive impairment.

On 4/24/24 Resident 1's care plan interventions included working with the resident to determine reasons for wanting to leave the facility. No additional interventions were identified.

A 5/31/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Facility indicated during internal review that staff were unaware of resident's whereabouts and unaware she/he could not leave the facility on her/his own. Facility investigation revealed care staff were not aware of Resident 1's elopement and prior interventions were determined to be unsuccessful. Resident 1 was located at the local market and returned to the facility by care staff.

On 5/31/24 Resident 1's care plan interventions included placing the resident on 15 minute checks.

A 6/10/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Resident was located at Clackamas Town Center by spouse. Resident 1 was picked up by the facility.

There was no documented evidence the facility re-evaluated Resident 1's elopement risk to identify her/his risk factors and to develop targeted interventions or to determine the need for increased supervision to prevent reoccurring elopements.

On 6/18/24 at 11:27 AM, Resident 1's room was observed to be located between two emergency exit doors.

On 6/18/24 at 11:34 AM, Staff 3 (CNA) stated Resident 1 "consistently wanted to elope from the facility" and continued to present as an elopement risk for the facility due to Resident 1's "elusiveness" and not having staff to monitor the resident every 15 minutes. Staff 3 was unaware of any additional interventions in place for Resident 1.

On 6/18/24 at 12:17 PM, Staff 7 (RNCM) stated Resident 1 was "not appropriate for a nursing facility due to residents consistent wandering behaviors and was more suitable for a memory care facility." Staff 7 indicated Resident 1 was capable of leaving the facility "without notifying anyone." Staff 7 stated no additional interventions other then fifteen minute checks were implemented in the resident's care plan.

On 6/18/24 at 3:06 PM, Staff 2 (DNS) stated no additional communication, assessments, or interventions were put into place for Resident 1 outside of the fifteen minute checks due to the facility's "belief in additional interventions or assessments to be unnecessary".

On 6/18/24 at 3:14 PM, (Staff 5) CNA stated Resident 1 was "smart enough" to elope from the building by waiting for care staff to "get busy then walk out through the front door or side door." Staff 5 stated only fifteen minute interventions were in place and was unaware of any additional interventions identified.

On 6/20/24 at 11:04 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility failed to implement additional interventions to prevent Resident 1's elopements. Staff 2 (DNS) acknowledged the facility failed to re-evaluate Resident 1's elopement risk and failed to revise care plan interventions to prevent Resident 1's elopements.

***************************
OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care

Refer to F689

***************************

Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms and linen supplies were maintained for 2 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include:

1. A 5/3/23 at 10:06 AM observation of Room 10 and bathroom revealed duct tape on the floor under the sink and across the toilet threshold. The grout around the toilet was uneven and patchy, there were tiles on the floor and wall in the shower stall that were cracked and broken. The dry wall leading toward the bathroom was cracked near the ceiling and the frame around the bathroom door was separated. There was a gap between the wall and ceiling along three of the bathroom walls (except the window wall). The exhaust vent did not turn on when tested. The resident in room 10 stated she/he used that bathroom.

A 5/1/23 at 11:49 AM observation of the bathroom between Rooms 24 and 26 revealed the linoleum around the toilet and across the width of the bathroom floor was separated which exposed subflooring. The bathroom was used daily.

A 5/1/23 at 12:24 PM observation of Room 23 and bathroom revealed the toilet riser was missing paint and visibly rusted in several spots. The linoleum was separated close to the toilet and a rust-colored ring was noted around the base of the toilet. The molding was separated from the wall under the sink, and the caulk and drywall was cracked above the sink. The floor was stained gray and brown in multiple locations, and there were several chips out of the bathroom door which exposed the wood underneath.

A 5/1/23 at 12:31 PM observation of Room 21 and bathroom revealed gray stains on the floor, a commode with non-cleanable tape, caulk missing at the base of the toilet, and the base of the toilet was stained brown. The commode was rusted, and the floor had several dark nicks and scratches.

A 5/1/23 at 12:43 PM observation of Room 17 and bathroom revealed a persistent urine odor, and the toilet seat did not fit the toilet (oversized). The caulk was missing from the base of the toilet and the floor surrounding the toilet was rusted and brown in color.

On 5/4/23 at 11:43 AM Staff 5 (Maintenance Director) stated the Facility had discussed two of the bathroom remodels however did not plan on all of them. Staff 5 confirmed all observed concerns and acknowledged the identified findings.

On 5/4/23 at 12:10 PM Staff 1 (Administrator) acknowledged the observed damage and confirmed repairs were needed.
,
2. On 5/1/23 at 9:52 AM Resident 40 stated her/his shower was delayed on Sunday, 4/30/23 due to the facility not having any clean towels or linen.

On 5/2/23 at 1:37 PM Staff 7 (Housekeeping Manager) stated the weekend staff did not show up to work on Saturday and Sunday. Staff 7 was not aware there was no housekeeping staff present in the facility until he was notified by the DNS on Sunday morning.

On 5/2/23 at 1:59 PM Staff 2 (DNS) stated Staff 8 (CNA) called her on Sunday morning stating there was no clean linen or towels in the facility and staff were cutting up bed sheets to use as washcloths. Staff 2 called Staff 7 immediately, who came in to provide laundry and housekeeping services.

On 5/5/23 at 8:48 AM Staff 8 (CNA) stated she was told by other CNA staff there was no clean towels or linen in the facility. Staff 8 called Staff 2 to inform her of the linen and towel shortage. Staff 8 stated she did not call Staff 7 because she did not have his number.

On 5/5/23 9:10 AM Staff 1 (Administrator) stated she was called on Sunday regarding the linen shortage.

Based on observation, interview and record review it was determined the facility failed to ensure oxygen filters were cleaned for 1 of 1 sampled resident (#4) reviewed for respiratory care. This placed residents at risk for lack of respiratory care. Findings include:

The facility's 2001 policy related to respiratory support indicated washable filters were to be rinsed under running water once a week to remove dust and debris.

Resident 4 admitted to the facility in 2020 with diagnoses including palliative care.

A physician order dated 2/10/23 indicated Resident 4 was to have 0-2 liters of supplemental oxygen PRN to maintain saturation of more than 88 percent.

A 4/24/23 hospice note indicated Resident 4 used 2 liters of oxygen continuously.

Review of the 4/2023 MAR indicate Resident 4 received 2 liters of oxygen routinely.

On 5/1/23 at 11:17 AM Resident 4 was observed to have oxygen in place. Resident 4 stated she/he used oxygen all the time. The oxygen filter was observed to have a thick layer of dust covering the entire filter.

On 5/2/23 at 12:47 PM Staff 2 (DNS) stated night shift staff was responsible for maintaining and cleaning resident oxygen equipment, including the filters. Staff 2 acknowledged Resident 4's oxygen filter was dirty and covered in dust.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include:

Resident 24 admitted to the facility in 2022 with diagnoses including depressive disorder.

The 3/3/23 pharmacy recommendation indicated the following:
-Resident 24 was taking Lexapro (antidepressant medication) 7.5 mg for depression and was due for a gradual dose reduction (GDR) assessment;
The pharmacy recommendation was not signed by the provider until 4/27/23 (55 days later) and indicated no change to Resident 24's Lexapro.

On 5/3/23 at 2:03 PM at Staff 2 (DNS) acknowledged the facility did not follow up with the pharmacy recommendation timely.

2. Resident 24 admitted to the facility in 2022 with diagnoses including heart failure.

The 3/29/23 physician orders indicated Resident 24 was to receive the following:
-polyethylene glycol powder (laxative medication) give 1 scoop in juice in the morning for bowel care;
-senna 8.6 mg (laxative medication) one tab in the evening for bowel care. Hold for loose stool or more than 2 bowel movements daily;
-senna-docusate sodium 8.6-50 mg (laxative medication) 2 tabs twice daily for stool softener.

A review of MARs from 4/4/23 through 5/3/23 indicated the following:
-Resident 24 received polyethylene glycol on 29 occasions and refused the medication four times;
-Resident 24 received all doses of senna 8.6 mg in the evening as ordered;
-Resident 24 received all doses of senna-docusate sodium 8.6-50 mg 2 tabs twice daily as ordered.

A review of Resident 24's bowel records from 4/4/23 through 5/3/23 indicated the resident had loose stools on 17 occasions.

On 5/3/23 at 1:05 PM Staff 2 (DNS) acknowledged Resident 24 had loose stools on 17 occasions between 4/4/23 and 5/3/23 and acknowledged the bowel medication was not held per the orders and not held per indication of use.

, Based on interview and record review it was determined the facility failed to withhold bowel medication as indicated for 2 of 5 sampled residents (#s 3 and 24) reviewed for medication. This placed residents at risk for adverse side effects of bowel medication. Findings include:

1. Resident 3 was admitted to the facility in 2019 with diagnoses including stroke.

Resident 3's 5/4/23 physician's orders included the following medications:
- Miralax (laxative) BID for bowel care.
- Senna (laxative) BID for bowel care.

Resident 3's Bowel elimination records from 4/4/23 through 4/30/23 revealed she/he had loose stools or diarrhea documented on 17 of 30 days for a total of 24 occurrences.

Resident 3's 4/2023 MAR indicated:
- The resident's scheduled Miralax was administered routinely every day from 4/1/23 through 4/30/23.
- The resident's scheduled senna was administered routinely every day from 4/1/23 through 4/30/23 except for the refusal of two doses.

Resident 3's 4/19/23 Care Plan indicated the resident had loose stools and diarrhea with a goal of reduced episodes of diarrhea.

On 5/4/23 at 11:05 AM Staff 10 (Agency RN) stated the CNAs reported loose stools to the CMA. The CMA then communicated this information to the nurse. Staff 10 reported she was not informed Resident 3 had loose stools or diarrhea.

On 5/4/23 at 12:58 PM Staff 2 (DNS) acknowledged Resident 3 had loose stools or diarrhea documented in April 2023 and the scheduled bowel care medications (Miralax and senna) were administered for all but two doses. She stated if a resident had a loose stool it should be communicated so this information could be passed on to the doctor to determine if the bowel care medication should be held or discontinued.

2. Resident 30 admitted to the facility in 2022 with diagnoses including anxiety.

The 10/10/22 Care Plan indicated Resident 30 was independent with eating.

A 3/28/23 progress note indicated Resident 30 was cognitively intact and was able to direct her/his own care.

On 5/1/23 at 10:50 AM Resident 30 stated the food was not always good and kitchen staff did not know how to cook the food.

On 5/4/23 at 12:15 PM surveyors sampled a regular diet meal consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked.

On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledeged the findings indentified.







, Based on observation, interview and record review it was determined the facility failed to provide palatable meals for 2 of 2 sampled residents (#s 12 and 30) reviewed for food quality. This placed residents at risk for impaired nutrition. Findings include:

1. Resident 12 was admitted to the facility in 2023 with diagnoses including pneumonia, dysphagia (difficulty swallowing) and malnutrition.

Resident 12's 4/24/23 Care Plan indicated the resident had altered nutrition related to diagnoses of malnutrition and dysphagia.

Resident 12's 4/26/23 ordered diet was a regular diet with minced and moist texture.

A Registered Dietitian Assessment dated 4/26/23 indicated the resident had an underweight BMI (body mass index).

On 5/1/23 at 1:06 PM Resident 12 reported the texture, preparation and appearance of the food was not good. The resident stated the meal served at lunch was "minced to death" and she/he was not able to identify what it was.

On 5/4/23 at 12:15 PM surveyors sampled two meals (regular and minced/moist) consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was observed to be overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked. The minced and moist food was not appetizing in appearance. The plate had two scoops of pale colored food (pork and orzo) and one scoop of green colored food. The food was lacking in flavor and the texture had a pureed (ground finely) consistency.

On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledged the findings identified.

Based on observation and interview it was determined the facility failed to ensure garbage storage areas were maintained in a sanitary manner to prevent the presence and feeding of pests, and to ensure garbage storage area dumpsters were covered condition for 1 of 1 facility storage areas reviewed for sanitary garbage storage. This placed residents at risk for presence of pests. Findings include:

On 5/1/23 at 9:09 AM during the initial kitchen tour including the outside garbage storage area Staff 9 (Cook) stated the trash compacter was broken for over a year and the facility brought in a large dumpster. A large, approximately 20 feet by 10 feet uncovered dumpster with two hinged doors at the front was observed at back side of the building.

On 5/2/23 at 12:58 PM one of the dumpster doors opened was observed open; trash bags and a pair of used gloves dangled off the edge of the dumpster.

On 5/3/23 at 10:12 AM one of the the dumpster doors was observed open and one garbage bag hung over the front edge; two black crows were observed by the dumpster opening.

On 5/3/23 at 10:25 AM Resident 29 stated she/he saw cats and birds in the dumpster at times.

On 5/4/23 at 1:55 PM Staff 6 (Dietary Manager) stated she was aware the dumpster required a cover to stop the risk of pests and rodents, but was not involved in the decision-making process for the dumpster.

On 5/4/23 at 2:09 PM Staff 5 (Maintenance Director) stated the trash compactor broke almost two years ago, and the two large uncovered dumpster was in use for almost a year. Staff 5 stated one of the dumpster doors was always left open because some staff were not able to throw trash bags into the dumpster from above.

On 5/5/23 at 9:07 AM Staff 1 (Administrator) acknowledged the dumpster was not covered and was not aware it had to be covered.

***************
OAR 411-085-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F757
***************
OAR 411-086-0360 Resident Furnishing, Equiptment

Refer to F584
***************
OAR 411-085-0110 Nursing Services: Resident Care

Refer to F695
***************
OAR 411-086-0260 Pharmaceutical Services

Refer to F756
***************
OAR 411-086-0250 Dietary Services

Refer to F804 and F814
***************

Based on observation, interview, and record review it was determined the facility failed to follow the plan of care for 1 of 3 sampled residents (#4) reviewed for falls. This failure resulted in Resident 4 experiencing a fall with a fracture. This placed residents at risk for increased falls. Findings include:

Resident 4 admitted to the facility on 5/2/21 with diagnoses including dementia.

Resident 4's Quarterly MDS dated 10/3/22 revealed she/he had a BIMS score of 5 (severely impaired).

Resident 4's care plan dated 7/21/22 included padded fall mats on both bedsides when in bed, wider bed for comfort and a scoop mattress to prevent rolling out of bed.

A 9/24/22 facility investigation revealed on 9/24/22 Resident 4 was found on the floor next to her/his bed and no fall mats were present. Staff 5 (LPN) checked Resident 4 for injuries. Staff 5 called for x-rays which revealed a broken left femur.

In an interview on 11/29/22 at 2:18 PM Staff 6 (CNA) stated she did not put the fall mats next to Resident 4's bed on 9/24/22. She didn't see the mats and thought the resident no longer needed them.

In an interview on 11/30/22 at 11:20 AM Staff 5 (LPN) stated he checked Resident 4 for injuries and pain on 9/24/22 after the fall. Resident 4 stated her/his knee hurt. The LN medicated the resident and call for x-rays.

In an interview on 11/29/22 at 2:04 PM Staff 3 (RNCM) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture.

In an interview on 11/29/22 at 2:06 PM Staff 2 (DNS) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture.

***********
OAR 411-086-0140

Refer to F689

***********

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 03/22/2021 and 03/28/2021, 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.