Marquis Forest Grove Post Acute Rehab

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.

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.

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.

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OAR 411-085-0110 Nursing Services: Resident Care

Refer to F695

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OAR 411-086-0260 Pharmaceutical Services

Refer to F761

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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880

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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.

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

Refer to F689
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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 03/29/2021 and 04/04/2021, 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.