Marquis Forest Grove Post Acute Rehab

Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes.-á Staff 3's employee file indicated on 10/13/25 education was provided regarding where to find crushed medication orders for Resident 49. The education was provided because Staff 3 gave whole medications to the resident and she/he choked on the whole medications. Resident 49's orders were reviewed with Staff 3. Resident 49's medications were to be crushed in applesauce as described in the special instructions. The 11/3/25 8:37 AM signed medication error report written by Staff 3 (LPN) indicated the following: ""This LN [licensed nurse] asked CNA in dining room who room [Resident 41] was and when she pointed with her head it was towards [Resident 49], so this LN gave methadone to [Resident 49] instead of [Resident 41], no side effects noted at this time. Unclear which patient was pointed at, seemed like this patient's direction was pointed at.""-á The 11/3/25 11:10 AM progress note by Staff 2 (DNS) indicated the following: ""Called [physician] to report change in condition. Resident somnolent and with slurred speech. Taken back to room and developed nausea/vomiting. Awake and talking during episode. Alert and oriented self and place with history of dementia, unchanged level of orientation from baseline. Blood pressure 180/64, pulse 52, respirations 14, oxygen saturation 96% on room air. New orders to administer Narcan nasal spray 4 mg x 1, and Zofran [antiemetic medication] 4 mg po x 1. Call physician back if no improvement after Narcan administration. Resident was assisted into bed and closely monitored."" The 11/3/25 11:40 AM progress note by Staff 2 indicated the following: ""Resident no longer with emesis, however, remains with GI upset and stating 'I don't feel good.' Heart rate 44 and irregular, pauses noted when listening to apical pulse. Heart rate 44, respirations 18, oxygen saturation 95% on room air. One liter oxygen per nasal canula placed and [the physician] called back ...and ordered to transfer the resident to the emergency room for monitoring and evaluation."" The 11/7/25 facility investigation indicated the following: -On 11/3/25 at approximately 8:30 AM a medication error occurred, Staff 3 administered Resident 41GÇÖs methadone 40 mg to Resident 49.-á -At 11:45 AM the provider was again contacted due to continued changes in condition and instructed staff to send to the emergency room for hospital evaluation. -At 11:53 AM, 911 was called and Resident 49 was transferred to the hospital for evaluation and was subsequently admitted for further monitoring. -The licensed nurse responsible for the medication error was educated by Staff 2 (DNS) on the five rights of medication administration, starting with their photo identification on record and verification of name. Staff 3 was subsequently placed on administrative leave pending investigation. -In conclusion, the investigation determined that the licensed nurse did not follow proper resident identification procedures and failed to confirm the resident's identity prior to medication administration. As a result, the incorrect medication was administered, leading to Resident 49 requiring hospital evaluation and continued monitoring. Staff 3 was terminated from employment.-á The 11/7/25 hospital records indicated Resident 49 was hospitalized for a primary diagnosis of accidental methadone overdose and bradycardia (slow heart rate).-á On 4/9/26 at 9:34 AM Staff 3 stated she remembered the incident when Resident 49 received Resident 41GÇÖs methadone medication. She stated the resident was not in her/his room and she went to the dining room and asked CNA staff who Resident 49 was and they pointed her to GÇ£the resident sitting up.GÇ¥ Staff 3 stated she asked the resident if she/he was Resident 41GÇÖs name and the resident stated ""Yes, yes, yes."" She was unaware Resident 49 had confusion. Staff 3 stated she gave Resident 49 the liquid methadone medication and the nurse that was in the dining room told her that was not the correct resident and she did not administer additional medications to the resident. Staff 3 stated she then reported the medication error to the resident care managers. She stated she GÇ£heard about the pulse being 44GÇ¥ and stated Staff 2 sent Resident 49 to the hospital. On 4/9/26 at 10:17 AM Staff 4 (LPN) stated on 11/3/25 she was in the dining room assisting a resident with a meal and heard Staff 3 say she could not crush medications, then observed Staff 3 next to Resident 49 with a medication cup with Resident 41GÇÖs room number on it and Staff 3 already administered Resident 41GÇÖs liquid medication to Resident 49. Staff 4 stated Staff 3 was going to give additional medications and she stopped her as she recognized that Resident 49 did not get liquid medication and the incorrect residentGÇÖs room number was on the medication cup. Staff 4 stated Staff 2 and Resident Care Managers were notified of the incident. On 4/8/26 at 12:09 PM, 4/8/26 at 12:45 PM and 4/10/26 at 10:20 AM Staff 2 stated Staff 3 refused to give a written statement regarding the medication error. Staff 2 stated Staff 3 worked with Resident 49 previously and a few weeks prior to the medication error she had a conversation with Staff 3 specifically because another staff reported they observed the resident having difficulty swallowing medication when Staff 3 administered medications to the resident. Staff 2 stated Staff 1 (Administrator) was present and they called Staff 3 in and reviewed Resident 49 in the electronic health record including her/his photo and specific orders to have medications crushed. Staff 2 stated on 11/3/25 Staff 3 administered Resident 41GÇÖs methadone 40 mg to Resident 49 due to Staff 3 not confirming who the resident was prior to administering medication. Staff 2 stated the physician was notified and Resident 49 was sent to the hospital due to Staff 3 administering Resident 41GÇÖs 40 mg of methadone to Resident 49 in error resulting in a change of condition. No evidence was found to indicate additional deficient practice occurred after 11/3/25. Due to the facility's identification of the deficient practice, and corrective measures put in place on 11/10/25, the deficient practice was determined to be past noncompliance. Refer to F760.

Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes.-á The 11/3/25 8:37 AM signed medication error report written by Staff 3 (LPN) indicated the following: ""This LN [licensed nurse] asked CNA in dining room who room [Resident 41] was and when she pointed with her head it was towards [Resident 49], so this LN gave methadone to [Resident 49] instead of [Resident 41], no side effects noted at this time. Unclear which patient was pointed at, seemed like this patient's direction was pointed at."" The note indicated the physician responded to monitor for somnolence for the rest of the day, and if noted, administer Narcan (opioid antagonist medication).-á The 11/3/25 11:10 AM progress note by Staff 2 (DNS) indicated the following: ""Called [physician] to report change in condition. Resident somnolent and with slurred speech. Taken back to room and developed nausea/vomiting. Awake and talking during episode. Alert and oriented self and place with history of dementia, unchanged level of orientation from baseline. Blood pressure 180/64, pulse 52, respirations 14, oxygen saturation 96% on room air. New orders to administer Narcan nasal spray 4 mg x 1, and Zofran [antiemetic medication] 4 mg po x 1. Call physician back if no improvement after Narcan administration. Resident was assisted into bed and closely monitored."" The 11/3/25 11:40 AM progress note by Staff 2 indicated the following: ""Resident no longer with emesis, however, remains with GI upset and stating 'I don't feel good.' Heart rate 44 and irregular, pauses noted when listening to apical pulse. Heart rate 44, respirations 18, oxygen saturation 95% on room air. One liter oxygen per nasal canula placed and [the physician] called back ...and ordered to transfer the resident to the emergency room for monitoring and evaluation."" The 11/7/25 facility investigation indicated the following: -On 11/3/25 at approximately 8:30 AM a medication error occurred. Staff 3 administered Resident 41GÇÖs methadone 40 mg to Resident 49. The provider was notified immediately, and Resident 49 was placed on close monitoring.-á-á -At approximately 11:00 AM Resident 49 exhibited a change in condition. Narcan and Zofran were administered per provider orders, and staff continued to monitor the resident closely. At 11:45 AM the provider was again contacted due to continued changes in condition and instructed staff to send the resident to the emergency room for hospital evaluation. -At 11:53 AM, 911 was called and Resident 49 was transferred to the hospital for evaluation and was subsequently admitted for further monitoring. -The licensed nurse responsible for the medication error was educated by Staff 2 on the five rights of medication administration, starting with their photo identification on record and verification of name. Staff 3 was subsequently placed on administrative leave pending investigation. -In conclusion, the investigation determined Staff 3 did not follow proper resident identification procedures and failed to confirm the resident's identity prior to medication administration. -Resident 49 readmitted to the facility on 11/7/25. The 11/7/25 hospital records indicated Resident 49 was hospitalized for a primary diagnosis of accidental methadone overdose and bradycardia (slow heart rate). The resident accidentally received 40 mg of liquid methadone that was meant for another resident. The emergency department called poison control who recommended 8-hour monitoring due to increases of arrhythmias, bradycardia, nausea and vomiting. After the eight hours, the resident continued to have intermittent bradycardia and atrial fibrillation and the resident was admitted for observation of unintentional methadone overdose.-á On 4/9/26 at 9:34 AM Staff 3 stated she remembered the incident when Resident 49 received Resident 41GÇÖs methadone medication. She stated the resident was not in her/his room and she went to the dining room and asked CNA staff who Resident 49 was and they pointed her to GÇ£the resident sitting up.GÇ¥ Staff 3 stated she asked the resident if she/he was Resident 41GÇÖs name and the resident stated ""Yes, yes, yes."" She was unaware Resident 49 had confusion. Staff 3 stated she gave Resident 49 the liquid methadone medication and the nurse that was in the dining room told her that was not the correct resident and she did not administer additional medications to the resident. Staff 3 stated she then reported the medication error to the resident care managers. She stated she GÇ£heard about the pulse being 44GÇ¥ and stated Staff 2 sent Resident 49 to the hospital. On 4/9/26 at 10:17 AM Staff 4 (LPN) stated on 11/3/25 she was in the dining room assisting a resident with a meal and heard Staff 3 say she could not crush medications, then observed Staff 3 next to Resident 49 with a medication cup with Resident 41GÇÖs room number on it and Staff 3 already administered Resident 41GÇÖs liquid medication to Resident 49. Staff 4 stated Staff 3 was going to give additional medications and she stopped her as she recognized that Resident 49 did not get liquid medication and the incorrect residentGÇÖs room number was on the medication cup. Staff 4 stated Staff 2 and Resident Care Managers were notified of the incident. On 4/8/26 at 12:09 PM and 12:45 PM Staff 2 stated on 11/3/25 Staff 3 administered Resident 41GÇÖs methadone 40 mg to Resident 49 due to the staff not confirming who the resident was prior to administering medication. Staff 2 stated Resident 49 was monitored and appeared to be sleepy and started throwing up so Staff 3 stayed in the room with the resident and CNAs. Staff 2 stated she obtained Narcan and Zofran, returned to the room and administered both medications to the resident. Staff 2 stated the physician was notified and Resident 49 was sent to the hospital due to Staff 3 administering Resident 41GÇÖs 40 mg of methadone to Resident 49 in error resulting in a change of condition. On 4/10/26 at 10:20 AM Staff 1 (Administrator) stated education was completed for all nursing staff after the 11/3/25 medication error and all staff were in serviced by 11/10/25. No evidence was found to indicate additional deficient practice occurred after 11/3/25. Due to the facility's identification of the deficient practice, and corrective measures put in place on 11/10/25, the deficient practice was determined to be past noncompliance.

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#12) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include: A 3/2015 Oxygen Administration facility policy indicated oxygen concentrator filters were to be cleaned weekly. Resident 12 was admitted to the facility in 10/2023 with diagnoses including Chronic Obstructive Pulmonary Disorder (a lung disease causing restricted airflow and breathing problems) and depression. The 10/19/24 Annual MDS indicated Resident 12 was cognitively intact. Resident 12's physician order dated 11/1/24 revealed she/he required oxygen nightly and as needed. The 11/2024 Task log to "Replace oxygen tubing and filter every seven days" indicated it was last completed on 11/17/24 by Staff 3 (RN). On 11/18/24 at 10:47 AM the oxygen concentrator was observed to have two foam external filters. The right-side foam filter appeared clean, and the left-side foam filter had a thick layer of dust. Resident 12 stated she/he used the oxygen concentrator nightly and as needed during the day. On 11/19/24 at 4:59 PM Staff 3 stated Resident 12's oxygen concentrator had one external foam filter that she cleaned every Sunday and last cleaned on 11/17/24. Staff 3 stated she was unaware the oxygen concentrator had two external foam filters. On 11/20/24 at 8:57 AM Staff 2 observed Resident 12's oxygen concentrator filters and acknowledged the left-side foam filter appeared dirty.

Resident #12’s identified concentrator was cleaned on 11/20/2024. All other concentrators for residents on Oxygen were inspected and cleaned as needed. All residents on Oxygen are potentially impacted by this citation.100% audit of all current residents on oxygen was completed on 11/20/2024. The DNS provided in-servicing on 11/20/2024 and 11/21/2024 to Nursing staff regarding different models of concentrators having more than one external filter and that all external filters should be cleaned every 7 days to prevent respiratory complications. DNS or designee will audit concentrators for appropriate cleaning weekly X 4 weeks, then monthly X 90 days to ensure ongoing compliance. All adverse events will be addressed immediately, and the results of the audits will be presented at the next QAPI meeting for review and recommendation. Date of Completion: January 11,2025

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained and failed to ensure proper labeling of biologicals for 1 of 1 medication storage refrigerator and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 11/21/24 at 11:18 AM one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 11/21/24 at 11:18 AM Staff 4 (LPN) acknowledged the vial of tuberculin was open and not labeled with the date opened. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for staff to label tuberculin with an open date. 2. On 11/21/24 at 11:32 AM one open insulin lispro pen was open with no open date in the East Hall treatment cart. The manufacturer's instructions indicated to discard the medication 28 days after opening. On 11/21/24 at 11:32 AM Staff 13 (LPN) acknowledged the insulin lispro pen was open with no open date. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for staff to label insulin with open dates. 3. On 11/21/24 at 11:54 AM the medication room refrigerator temperature logs were reviewed for 10/2024 and 11/2024 and revealed no temperatures were recorded for 10/6, 10/26, 10/28 and 11/16. On 11/21/24 at 12:38 PM Staff 2 (DNS) acknowledged the medication refrigerator logs had no temperatures recorded on the identified dates and the expectation was for staff to log temperatures twice daily. 4. On 11/21/24 at 11:54 AM the 10/2024 and 11/2024 medication room refrigerator temperature logs were reviewed and indicated the following: -Temperatures were to be kept within 36 F to 46 F. -On 10/2, 10/5, 10/8, and 10/9 the medication refrigerator was 48 F. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for the medication room refrigerator to be kept between 36 F and 46 F. Staff 2 acknowledged the medication room refrigerator temperature logs indicated temperatures exceeded 46 F on the identified dates and the refrigerator contained vaccines and insulin.

1.The identified vial of Tuberculin and the insulin pens were removed from use and discarded when identified. All resident’s receiving insulin are potentially impacted by this citation. Any person needing tuberculin skin test potentially impacted. 100% audit of all insulin currently in use was completed on 11/21/2024. The DNS provided in-servicing on 11/20/2024 and 11/21/2024 to Nursing staff regarding importance of labeling of insulin and Tuberculin with open and discard dates to comply with the currently accepted professional principles for cautionary instructions and expiration date. DNS or designee will audit all Insulin pens and Tuberculin weekly X 4 weeks, then monthly X 90 days to ensure ongoing compliance. All adverse events will be addressed immediately, and the results of the audits will be presented at the next QAPI meeting for review and recommendation. Date of Completion: January 11,2025 2.The medication refrigerator that registered the higher temps that were recorded in October was removed from use on 10/18/2024 and replaced. All residents receiving medications that must be refrigerated are potentially impacted by this citation. The DNS provided in-servicing on 11/21/2024 and 11/22/2024 to nursing staff regarding the importance of checking and recording temperatures for the medication refrigerator twice daily and what to do if they fall outside of the parameters to ensure safe medication storage. DNS or designee will audit medication fridge temperatures weekly X 4 weeks, then monthly X 90 days to ensure ongoing compliance. All adverse events will be addressed immediately, and the results of the audits will be presented at the next QAPI meeting for review and recommendation. Date of completion: January 11, 2025

Based on observation, interview, and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 11/21/24 at 1:48 PM Staff 11 (Housekeeping) stated her shift ended at 2:30 PM and she had the last shift of the day. Staff 11 stated when wet laundry was not completed in the washing machine at the end of her shift, she left the wet laundry in the washing machine overnight. Staff 11 stated the next morning she or other housekeeping staff transferred the wet laundry to the dryer and did not rewash the laundry. On 11/21/24 at 2:45 PM the washing machine was observed to contain damp clothing protectors after housekeeping staff left the facility for the day. On 11/21/24 at 2:46 PM 1 (Administrator) stated she was unaware of a laundry policy regarding damp laundry left in the washing machine overnight.

F880 The identified wet laundry found in the washing machine on 11/21/2024 was rewashed the morning of 11/22/2024. All residents are potentially impacted by this citation. The Housekeeping/Laundry supervisor provided in-servicing on 11/21/2024 and 11/22/2024 to all Laundry staff regarding processing laundry to produce hygienically clean laundry and prevent the spread of infection. Housekeeping Supervisor will audit for laundry being left in a washer overnight daily x1 week, weekly X 4 weeks, then monthly X 90 days to ensure ongoing compliance. All adverse events will be addressed immediately, and the results of the audits will be presented at the next QAPI meeting for review and recommendation. Date of Completion: January 11,2025

**************************************************** OAR 411-085-0110 Nursing Services: Resident Care Refer to F695 ****************************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ******************************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 *********************************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/01/2024 and 01/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/06/2023 and 02/12/2023, 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 provide the necessary care and services to prevent resident falls for 1 of 3 sampled residents (#2) reviewed for falls. This placed residents at risk for increased falls and injury. Findings include: Resident 2 admitted to the facility on 12/2/20 with diagnoses including traumatic brain injury, dementia and seizures. A review of Resident 2's medical record revealed Resident 2 fell on the following dates: *December 2020: 5, 8, 9, 11, 13 (twice), 15, 17, 22 and 23 *January 2021: 9 1. The 12/23/20 Post Fall Assessment revealed Resident 2 wore slippers without non-skid soles when she/he fell. The 12/2/20 Fall Care Plan revealed a revised intervention on 1/6/21 which indicated the resident was to wear non-skid shoes and slippers. [The care plan did not have the intervention to wear non-skid footwear in place upon admission which is considered a standard fall prevention practice.] On 1/31/23 at 12:35 PM Staff 2 (DNS) stated non-skid footwear was the standard of practice and generally put on care plans. Staff 2 verified Resident 2 wore shoes that did not have non-skid soles on 12/23/20. 2. A review of Resident 2's medical record revealed she/he had four prior unwitnessed falls between 12/2/20 through 12/12/20, was impulsive, had decreased cognition and experienced both hallucinations and delusions. The 12/13/20 Post Fall Assessment revealed Resident 2 fell when she/he attempted to self-transfer off the toilet. The resident was observed by staff one minute prior to the fall. The 12/2/20 Urinary Incontinence Care Plan revealed no supervision requirements prior to the resident's fall. A revised intervention dated 1/14/21 for the resident to have one person constant supervision and physical assist for safety. On 1/31/22 at 12:35 PM Staff 2 (DNS) stated Resident 2 should have been under constant supervision in the bathroom.

F689 Resident discharged from facility in Jan 2021. All residents with falls are potentially impacted by this citation. In order to establish compliance a 100% audit of all fall care plans has been completed to confirm inclusion of non-skid footwear as an intervention, as tolerated by resident. All Nursing staff have been re-inserviced on use of non-skid socks/shoes for residents, as they tolerate. All nursing staff have been re-inserviced on need for constant supervision with residents who have cognitive loss/impulse concerns during toileting. RCMS have been re-inserviced on Fall CP interventions based on admission risks, to include non-skid footwear. DNS, or designee, will audit all new admission for inclusion of nonskid footwear in the fall care plan x4 weeks then random monthly X 90 days to ensure ongoing compliance. DNS, or designee, will do random audits of residents being toileted to observe for constant supervision, as indicated by resident Care Plan. Audits will be done weekly X 4 and then random monthly X 90 days. to ensure ongoing compliance. Results will be reported at the monthly QAPI. Facility will be in compliance by 3/22/2023.

************************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 *************************