Marquis Vermont Hills

Based on observation, interview and record review the facility failed to revise the plan of care to reflect residents' needs for 1 of 1 sampled resident (#29) reviewed for hospice. This placed residents at risk for unmet care needs. Findings include:

Resident 29 was admitted to the facility in 9/2023 with diagnoses of dementia and hip fracture.

Resident 29's 10/15/24 Quarterly MDS indicated he/she required partial to moderate assistance with eating.

Resident 29's 10/15/24 Care Plan indicated he/she required one-on-one supervision, set up, and eating assistance for all meals.

Multiple random observations from 12/17/24 through 12/18/24 revealed:

-12/17/24 at 10:21 AM Resident 29 was observed sitting upright in bed with a cup of ice cream placed directly in front of him/her on an overbed table without supervision.
-12/17/24 at 12:28 PM Resident 29 was observed sitting upright in bed with a lunch tray placed directly in front of him/her on an overbed table without supervision during mealtimes.
-12/18/24 at 8:27 AM Resident 29 was observed sitting upright in bed with a breakfast tray placed directly in front of him/her on an overbed table without supervision during mealtimes.

On 12/18/24 at 8:41 AM Staff 12 (CNA) stated during mealtimes she provided frequent checks on Resident 29. Staff 12 stated she sat with him/her to assist with eating after meal tray pass had been completed and if the resident had not finished his/her meal.

On 12/18/24 at 12:05 PM Staff 2 (DNS) confirmed the expectation was to provide one-on-one supervision during all meals and for staff to be present in the resident's room to ensure assistance had been provided throughout the entire meal period.

On 12/19/24 at 8:55 AM Staff 11 (RCM) stated Resident 29 was care planned for one-on-one supervision at all mealtimes due to the resident's cognitive impairment and his/her pattern of sleeping through meals. Staff 11 stated it was appropriate to update Resident 29's care plan to reflect less supervision during meal times.

Based on interview and record review it was determined the facility failed to obtain a physician order for a respiratory device and ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#14) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include:

Resident 14 was admitted to the facility in 12/2024 with diagnoses including Alzheimer's disease and obstructive sleep apnea.

The Annual MDS dated 12/9/24 indicated Resident 14 did not utilize a CPAP (continuous positive airway pressure) machine .

A review of physician orders from 12/2024 revealed Resident 14 had no orders for use of a CPAP machine.

A review of Resident 14's Care Plan and TAR from 12/2024 revealed no instructions for maintenance of the CPAP machine.

On 12/17/24 at 10:41 AM Staff 5 (LPN) indicated Resident 14 used her/his CPAP machine at night. Staff 5 stated Resident 14 used her/his CPAP machine since her/his admission date and Staff 5 had cleaned it with distilled water at least two times but had no way to document the maintenance.

On 12/17/24 11:10 AM Staff 3 (RNCM) confirmed Resident 14 had a diagnosis of sleep apnea and did not have a physician's order for use of a CPAP machine nor was the CPAP machine care planned to be maintained weekly.

On 12/17/24 at 12:33 PM Staff 4 (NP) stated there should have been an order in place for Resident 14 prior to the CPAP machine being used.

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include:

The facility's undated "Storage of Frozen and Refrigerated Foods" policy specified the following:
-Food needs to be labeled with name of the product if removed from the original packaging.
-No food should be stored past the expiration date.

On 12/16/24 at 9:20 AM during the initial tour of the facility's kitchen, the following was observed in the walk-in refrigerator:

A rolling rack containing trays of multiple undated salad items under large sheets of plastic cling film:
-Partially-filled multi-use plastic bins of red beans, cottage cheese, diced hard-boiled eggs, carrots, shredded cheese;
-Multi-use plastic bins of full of chopped beets, chopped bacon, garbanzo beans;
-Two nearly empty multi-use plastic bins of salad dressings; and
-A large multi-use plastic bin of chopped greens.

On adjacent shelving, the following was observed:
-A tray of 25 individually covered juice glasses on top of another tray full of similar juice glasses; and
-Four trays with multiple covered disposable plastic condiment ramekins. There were no labels or dates on the items or on the trays.

On 12/16/24 at 9:39 AM Staff 7 (Dietary Manager) acknowledged the items which were not labeled or dated and stated they should be labeled and dated to know when they were prepared and when they should be discarded.

On 12/19/24 at 11:57 AM Staff 1 (Administrator) stated she was aware of the labeling issue and stated she expected items in the kitchen to be labeled and dated.

Based on observation, interview and record review it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 1 of 1 facility dumpster reviewed for sanitation. This placed residents at risk for exposure to used medical supplies. Findings include:

The facility's undated "Food/Waste Disposal" policy specified the following:
-Dumpster lids are to be closed at all times.
-Dumpster and dumpsite area is to be kept clean and free of debris.

On 12/16/24 at 9:39 AM the garbage dumpster located adjacent to the kitchen's side doorway (below the facility's E hall) was observed to be open with used examination gloves, sweetener packets, paper towels, and plastic spoons scattered on the ground at the base. A CNA stood on the railed walkway above the dumpster and threw a clear plastic bag over the railing into the dumpster. Staff 7 (Dietary Manager) stated the lid was always open to allow CNAs to throw waste into the dumpster from the end of the E hallway above. She stated this was the reason for the garbage on the ground and she cleaned it every morning. Staff 7 stated she would clean the area again and keep the dumpster closed to minimize the risk of attracting vermin to the kitchen door.

On 12/17/24 at 8:41 AM the same dumpster adjacent to the kitchen's side doorway was observed open with large plastic garbage bags visible inside the dumpster.

On 12/17/24 at 9:45 AM the garbage dumpster was observed from the railed walkway above to be open with plastic garbage bags inside.

On 12/17/24 at 2:29 PM Staff 9 (CNA) was observed with a bag of garbage in the E hallway. She opened the door at the end of the hallway, walked onto the railed walkway and threw the bag of garbage over the railing to the dumpster below. Staff 9 stated the garbage dumpster below was never closed as long as she worked in the facility. She stated she tied the bags because they contained garbage from residents' rooms including incontinence briefs.

On 12/17/24 02:37 PM Staff 10 (CNA) was observed to throw a bag of garbage over the railing into the open dumpster below. Staff 10 stated she and other CNAs always threw the garbage bags over the railing and the garbage dumpster was never closed.

On 12/18/24 11:26 AM Staff 7 stated she discussed the garbage dumpster situation with facility staff because they wanted to develop a way for the dumpster to be used by CNAs and kitchen staff while keeping it closed when it was not in use.

On 12/19/24 at 11:57 AM Staff 1 (Administrator) acknowledged the issue with the garbage dumpster being left open and stated she expected the garbage dumpster to be kept closed and the area around it to be clean to minimize the risk of vermin being attracted to the area.

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OAR 411-086-0060 Comprehensive Resident Centered Care Plans

Refer to F657
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OAR 411-086-0110 Quality Care: Nursing Services: Resident Care

Refer to F695
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OAR 411-086-0250 Food and Nutrition Services: Dietary Services

Refer to F812 and F814
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Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 1 of 3 sampled residents (#28) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include:

Resident 28 was admitted to the facility in 10/2023 with diagnoses including a fractured sacrum (back portion of the pelvis).

A 12/12/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 28's skilled days ended on 12/20/23.

Review of Resident 28's health record indicated the resident remained in the facility and paid for her/his care with private funds. There was no documentation indicating Advance Beneficiary Notification information was provided to the resident so she/he understood what her/his daily out-of-pocket costs were.

On 1/9/24 at 1:12 PM Staff 1 (Administrator) confirmed the facility failed to provide Advanced Beneficiary Notice information to Resident 28.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 4 sampled residents (#13) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include:

Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder).

Resident 13's 12/5/23 Bathing Care Plan indicated Resident 13 required assistance from one staff for bathing. Resident 13 preferred showers on scheduled bathing days.

The facility's 1/11/24 shower schedule revealed Resident 13 received showers twice a week on Sundays and Thursdays.

Resident 13's 12/14/23 through 1/7/24 bathing task logs indicated the resident received a bed bath or shower on the following days:
- 12/14, 12/17, 12/25 and 1/7.

A review of Resident 13's Progress Notes from 12/14/23 through 1/7/24 revealed no documentation Resident 13 was provided with additional bathing opportunities when bathing was not provided.

On 1/8/24 at 11:48 AM Witness 4 (Family) reported Resident 13 received only four showers since the resident was admitted to the facility and she had to request two of the showers.

On 1/11/24 at 10:25 AM Staff 8 (RN) stated residents were scheduled for two showers a week. Staff 8 stated if a resident refused or was unavailable for their shower, the resident typically had to wait until their next shower day because CNA staff were usually unable to make up missed showers. Staff 8 stated if time permitted, the evening shift was sometimes able to complete a missed shower.

On 1/11/24 at 1:29 PM Staff 6 (RNCM) stated residents were supposed to receive at least two showers a week. Staff 6 reported CNA staff were "extremely" busy and tried to fit in additional or missed showers "as they can."

On 1/12/24 at 8:49 AM Staff 2 (DNS) stated she expected Resident 13 would be showered or provided a bed bath more than four times from 12/14/23 to 1/7/24.

Based on observation, interview and record review it was determined the facility failed to provide appropriate and sufficient supervision and ensure interventions were followed to reduce the risk of accidents for 1 of 4 sampled residents (#14) reviewed for nutrition. This placed residents at risk for choking and aspiration. Findings include:

Resident 14 was admitted to the facility in 12/2023 with diagnoses including stroke.

Resident 14's 12/14/23 Physician Orders directed the following precautions related to the prevention of aspiration:
-Provide oral care before eating or drinking, clearing secretions from the oral cavity and moistening the mouth.
-Upright positioning as close as possible to a 90-degree angle.
-No straws.

Resident 14's 12/20/23 Admission MDS revealed the resident experienced short and long term memory loss, experienced some difficulty in decision making when faced with new tasks or situations and required partial/moderate assistance with eating. The MDS also indicated the resident held food in her/his mouth/cheeks or residual food was present in her/his mouth after meals and experienced coughing or choking during meals or when swallowing medications.

Resident 14's 12/21/23 Nutrition Impairment Care Plan revealed the following interventions:
-Full one-to-one support with all PO intake.
-Reinforce the resident should eat slowly.
-Supervision for all PO intake for safety. One-to-one for all meals.
-Aspiration precautions:
--Provide comprehensive oral care before eating or drinking, clearing secretions from the resident's oral cavity and moistening her/his mouth.
--Upright positioning at close to 90 degree angle.
--Straws okay.

Resident 14's 1/9/24 Dietitian Assessment indicated the resident received a regular diet with minced and moist texture (a diet requiring minimal chewing), the resident was not to use straws with thin liquids and she/he required full one-to-one support with all intake by mouth.

On 1/8/24 from 12:31 PM to 12:40 PM Resident 14 was observed alone in her/his room in bed. The resident was observed to eat her/his lunch which was placed on a tray table in front of her/him. No staff were observed to supervise or reinforce to eat slowly during this time period. No coughing or choking was observed.

On 1/9/24 at 8:02 AM Resident 14 was observed alone in her/his room in bed with her/his eyes closed. Resident 14's breakfast tray sat on her/his overbed table in front of the resident and her/his head of bed was elevated to approximately 30 degrees. At 8:13 AM Resident 14 opened her/his eyes and started to eat. From 8:04 AM to 8:24 AM no staff were observed to supervise or reinforce to eat slowly during this time period. No coughing or choking was observed.

On 1/9/24 at 8:27 AM Staff 16 (CNA) stated she obtained information on how to care for a resident, including any mealtime precautions, from the resident's care plan. Staff 16 stated Resident 14's bed was to be "all the way up" when she/he ate but otherwise was not aware of any other mealtime precautions for the resident. Staff 16 stated she assisted Resident 14 with oral care after mealtimes. Staff 16 viewed Resident 14's position in bed which was how she/he was positioned during breakfast, and stated the "bed was not high enough."

On 1/9/24 at 8:50 AM Staff 17 (CNA) stated she obtained information on how to care for a resident, including any mealtime precautions, from the resident's care plan. Staff 17 stated staff were supposed to "keep an eye on [Resident 14]" and the resident was to sit as close to a 90 degree angle during mealtimes. Staff 17 also indicated the resident was okay to use straws to drink fluids, and she provided oral care to Resident 14 after meals. Staff 17 viewed Resident 14's position in bed which was how she/he was positioned during breakfast, and stated "it was not adequate for mealtimes."

On 1/9/24 at 9:26 AM Staff 18 (SLP) stated Resident 14 was upgraded from thickened to thin liquids on 1/8/24 and the resident was not safe to use straws when drinking thin liquids. Staff 18 stated the resident previously needed one-to-one supervision during mealtimes but now required "peeking in when eating." Staff 18 further stated the resident was to be positioned upright for all meals, take small bites and eat slow.

On 1/10/24 at 9:52 AM Staff 6 (RNCM) stated Resident 14 required "not quite constant but intermittent supervision" at mealtimes, was to be sitting as close to 90 degrees as possible when eating and was to receive oral care before eating and drinking. Staff 6 stated the resident's care plan currently indicated the need for one-to-one supervision with oral intake but he wanted to check with Staff 18 before revising the care plan. Staff 6 further stated CNAs were to follow the care plan of providing the resident with one-to-one supervision until it was updated.

On 1/10/24 at 11:13 AM Staff 2 (DNS) acknowledged the findings of this investigation. Staff 2 stated she expected staff to follow the resident's care plan with regards to aspiration precautions and providing one-to-one supervision when eating and she needed to clarify the resident's use of straws.

Based on observation, interview and record review it was determined the facility failed to conduct timely post-dialysis assessments for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed residents at risk for unidentified complications of dialysis treatment. Findings include:

Resident 9 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease with dependence on dialysis (procedure to remove waste products from the blood).

Resident 9's 12/5/23 Dialysis Care Plan indicated the resident received dialysis three times per week, had an AV fistula (a procedure that connects an artery to a vein for dialysis) in her/his left upper extremity and post-dialysis assessments were completed in order to monitor the fistula for any bleeding or swelling.

On 1/10/24 at 11:54 AM Resident 9 was observed being escorted by a CNA to her/his room upon returning from dialysis.

Continuous observations on 1/10/24 between 11:54 AM and 12:58 PM revealed nursing staff did not complete a post-dialysis assessment of Resident 9 upon her/his return from dialysis.

On 1/10/24 at 12:58 PM Staff 8 (RN) stated she was aware Resident 9 returned from dialysis because the resident's red binder was on her desk. Staff 8 stated she typically completed a post-dialysis assessment right when a resident returned from dialysis but she did not do so this time. Staff 8 stated she should have completed the assessment within 30 minutes.

On 1/12/24 at 8:49 AM Staff 2 (DNS) stated she expected dialysis residents to have a post-dialysis assessment completed within 15 minutes of their return from dialysis.

Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician at least once every 60 days for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for unassessed and unmet needs. Findings include:

Resident 15 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease.

Review of Resident 15's 2023 health record revealed the resident's physician visits occurred on 5/6/23 and 10/10/23.

On 1/11/24 at 10:27 AM Staff 5 (RNCM) stated she was aware physician visits were required at least once every 60 days. Staff 5 reviewed Resident 15's health record and confirmed the physician visits occurred only twice in 2023.

On 1/11/24 at 1:08 PM Staff 2 (DNS) was notified of the findings of this investigation, acknowledged she was aware of the resident's situation and did not provide evidence to indicate Resident 15 was seen by the physician every 60 days. the facility proactively addressed the lack of physician visits.

Based on interview and record review it was determined the facility failed to provide physical therapy services as ordered for 1 of 1 sampled resident (#13) reviewed for rehabilitation services. This placed residents at risk for reduced mobility and quality of life. Findings include:

Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder).

Resident 13's 12/5/23 Physician Order indicated the resident was to be evaluated and treated by PT.

Resident 13's 12/5/23 Physical Therapy Evaluation and Plan of Care indicated the resident was to receive PT treatment five times a week from 12/6/23 through 3/13/24.

Resident 13's PT Service Log Matrix from 12/17/23 through 12/31/23 indicated the resident received six of ten treatment sessions.

On 1/8/24 at 12:24 PM Witness 4 (Family) stated the week before, during and after Christmas, Resident 13 did not receive physical therapy services at the frequency ordered because the rehabilitation department was short staffed. Witness 4 stated Resident 13 laid in her/his bed for several days in a row as a result.

On 1/10/24 at 11:36 AM Staff 3 (PT) stated he had time off around the holiday and there was minimal PT coverage during that time. Staff 3 stated when he returned from his time off several residents, including Resident 13, complained they did not receive consistent PT services.

On 1/10/24 at 11:56 AM Staff 4 (Physical Therapy Assistant/Rehab Director) stated she was responsible for scheduling therapy coverage. Staff 4 stated she attempted to find PT coverage for Staff 3's absence but was unable to schedule consistent PT services which resulted in reduced PT coverage during that period.

On 1/12/24 at 10:33 PM Staff 2 (DNS) stated Resident 13 should have received PT services five times a week as ordered.

Based on interview and record review it was determined the facility failed to ensure records were accurate for 4 of 4 sampled residents (#s 8, 18, 25 and 26) reviewed for Advance Directives. This placed residents at risk for inaccurate medical interventions. Findings include:

1. Resident 8 was admitted to the facility in 9/2023 with diagnoses including Parkinson's disease.

A 12/19/23 Multidisciplinary Care Conference report documented Resident 8 had an Advance Directive and a copy was in the clinical records.

On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 8 was documented as having a copy of an Advance Directive on file with the facility, but Resident 8 did not have an Advance Directive on file at the facility.

On 1/9/23 at 2:33 PM Resident 8 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility.

2. Resident 18 was admitted to the facility in 2/2020 with diagnoses including kidney failure.

A 12/29/23 Multidisciplinary Care Conference report documented Resident 18 had an Advance Directive and a copy was in the clinical records.

On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 18 was documented as having a copy of an Advance Directive on file with the facility, but Resident 18 did not have an Advance Directive on file at the facility.

On 1/9/23 at 2:45 PM Resident 18 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility.

3. Resident 25 was admitted to the facility in 12/2023 with diagnoses including congestive heart failure.

A 12/20/23 Multidisciplinary Care Conference report documented Resident 25 had an Advance Directive and a copy was in the clinical records.

On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 25 was documented as having a copy of an Advance Directive on file with the facility, but Resident 25 did not have an Advance Directive on file at the facility.

On 1/10/23 at 9:50 AM Resident 25 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility.

4. Resident 26 was admitted to the facility in 12/2023 with diagnoses including spinal cord compression.

A 12/8/23 Multidisciplinary Care Conference report documented Resident 26 had an Advance Directive and a copy was in the clinical records.

On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 26 was documented as having a copy of an Advance Directive on file with the facility, but Resident 26 did not have an Advance Directive on file at the facility.

On 1/9/23 at 2:21 PM Resident 26 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate disinfection of a shared glucometer (a device used to obtain blood sugar levels) for 3 of 5 sampled residents (#s 9, 25 and 196) observed for CBG monitoring. This placed residents at risk for the spread of bloodborne infection. Findings include:

The CDC website, section titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use.

The facility's 8/2016 Obtaining a Fingerstick Glucose Level Policy & Procedure specified the following steps in the procedure:
- place the equipment on the over-bed table upon a clean/protective surface;
- ensure the glucometer has been disinfected before use;
- obtain a blood sample;
- disinfect reusable equipment according to manufacturer's instructions.

Resident 9 was admitted to the facility in 12/2023 with diagnoses including type II diabetes.

Resident 25 was admitted to the facility in 12/2023 with diagnoses including type II diabetes.

Resident 196 was admitted to the facility in 1/2024 with diagnoses including type II diabetes.

On 1/10/24 at 11:36 AM Staff 13 (Nursing Student) gathered supplies from the medication cart, including a glucometer, entered Resident 25's room, used the glucometer and obtained Resident 25's blood sugar. Staff 13 returned to the medication cart in the hallway, placed the glucometer on the top surface of the cart and did not disinfect the glucometer. At 11:44 AM Staff 13 gathered supplies from the cart, including the used glucometer, and entered Resident 196's room. Staff 13 obtained Resident 196's blood sugar, returned to the medication cart in the hallway and placed the glucometer on the top surface of the cart. Staff 13 did not disinfect the glucometer before, during or after the process. At 1/10/24 at 11:51 AM Staff 13 gathered supplies from the medication cart, including the used glucometer and began to enter Resident 9's room. Staff 13 realized Resident 9 was out of the facility at an appointment and stated she was unable to obtain the resident's blood sugar.

Review of Resident 25's and Resident 196's health record revealed no diagnoses including viral bloodborne pathogens.

On 1/10/24 at 11:59 AM Staff 13 stated she performed tasks as a student nurse in the facility since 12/2023. When asked about the process and frequency for glucometer disinfection, Staff 13 responded she knew it needed to be cleaned with "this" and pointed to the container of Super Sani-Cloth Sanitizing wipes on the medication cart and she was unsure how often the glucometers were to be disinfected.

On 1/11/24 at 12:57 PM Staff 2 (DNS) stated the disinfection process for shared glucometers included the use of the Super Sani-Cloth Sanitizing wipes. Staff 2 stated the glucometer was to be wiped thoroughly and staff were to wait two minutes before using the glucometer on the next resident. Staff 2 was notified about the lack of glucometer disinfection between residents and stated her expectation was to disinfect between each resident use.

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OAR 411-085-0320 Residents' Rights: Charges and Rates

Refer to F582
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677 and F698
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OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F689
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OAR 411-086-0200 Physician Services

Refer to F712
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OAR 411-086-0220 Rehabilitative Services

Refer to F825
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OAR 411-086-0300 Clinical Records

Refer to F842
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
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Based on observation interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#10) reviewed for non-pressure skin conditions. This placed residents at risk for worsening skin conditions. Findings include:

Resident 10 admitted to the facility in 10/2022 with diagnoses including cholecystectomy (removal of gallbladder).

The 12/7/22 physician order indicated Resident 10 was to receive the following treatment:
*Cleanse drain site to abdomen, pat dry, apply skin protectant and replace split gauze and secure with paper tape every evening shift and PRN.

On 12/13/22 at 1:07 PM Resident 10 was observed to have a dressing on the right side of the lower abdomen covered by a dressing. The dressing was observed to have staff 10 (LPN) initials and was dated 12/11/22.

The 12/2022 TAR indicated Resident 10 received a dressing change from Staff 4 (LPN) on 12/12/22.

On 12/13/22 at 2:14 PM Staff 4 stated she thought the dressing was to be changed every two days and did not recall changing it on 12/12/22. Staff 4 confirmed the observed dressing was initialed by Staff 10 and dated 12/11/22. Staff 4 confirmed she documented a dressing change was completed on 12/12/22, did not complete the dressing change on 12/12/22 and acknowledged the physician orders were not followed.

On 12/13/22 at 2:24 PM Staff 2 (DNS) acknowledged the findings and stated the expectation was for staff to complete treatments before signing the TAR and follow physician orders for treatments.

Based on interview and record review it was determined the facility failed to ensure residents received pressure ulcer treatments for 1 of 1 sampled resident (#18) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

Resident 18 was admitted to the facility in 5/2022 with diagnoses including diabetes.

Resident 18 was hospitalized from 11/28/22 to 12/8/22.

The 12/8/22 hospital orders indicated Resident 18 had a pressure ulcer to the sacral area and to follow standard nursing protocols for wound care.

Wound Evaluations indicated Resident 18 had a Stage 2 pressure ulcer to the coccyx with the following measurements with no indication the wound worsened:
*11/28/22 3.51 cm x 2.17 cm x 0.0 cm.
*12/9/22 3.09 cm x 2.23 cm x 0.1 cm.
*12/16/22 1.11 cm x 2.64 cm x 0.0 cm.

The 12/2022 TARs indicated Resident 18 did not receive dressing changes from 12/8/22 through 12/19/22.

On 12/20/22 at 9:11 AM Resident 18 declined to allow staff to complete a dressing change or wound measurements.

On 12/20/22 at 10:23 AM Staff 2 (DNS) stated Resident 18 readmitted to the facility on 12/8/22 and acknowledged there was no indication treatment orders were received or implemented until 12/19/22. Staff 2 stated the expectation was for the charge nurse to implement wound care orders when Resident 18 readmitted to the facility on 12/8/22.

Based on observation, interview, and record review it was determined the facility failed to ensure interventions were implemented to prevent falls for 1 of 2 sampled residents (#8) reviewed for falls. This placed residents at risk for injury. Findings include:

Resident 8 admitted to the facility on 11/4/22 with diagnoses including dementia and a stroke with left sided weakness.

The 11/10/22 Admission MDS indicated Resident 8 was severely cognitively impaired and had a history of falls.

The Fall Care Plan, last revised 12/13/22, indicated Resident 8 had multiple falls related to her/his diagnoses. Interventions did not include the resident having two fall mats on both sides of her/his bed until 12/16/22.

Fall Investigations were reviewed for 12/8/22, 12/9/22, 12/10/22, and 12/14/22 and indicated fall mats were to be in place for Resident 8.

On 12/16/22 the following interviews were conducted with staff related to Resident 8's falls:
*11:11 AM Staff 7 (CNA) stated Resident 8 was impulsive and often tried to self-transfer out of bed. Staff 6 stated interventions included for the resident to have fall mats in place when she/he was in bed.
*11:27 AM Staff 8 (LPN) stated Resident 8 would "forget" she/he had left sided weakness and would "slide out" of bed. Staff 8 stated fall mats were to be on both sides of the resident's bed to prevent injury.
*12:43 PM Staff 9 (CNA) stated Resident 8 often self-transferred and interventions to prevent falls included fall mats on both sides of the resident's bed.

On 12/14/22 at 1:44 PM and 12/16/22 at 12:50 PM Resident 8 was observed in bed and there were no fall mats on the floor. The fall mats were observed rolled up against the wall.

On 12/16/22 at 12:51 PM Staff 9 (CNA) confirmed Resident 8's fall mats were not on the floor on either side of the resident's bed and were expected to be in place when the resident was in bed.

On 12/16/22 at 1:26 PM Staff 6 (RNCM) stated the resident was expected to have fall mats in place on both sides of the bed when the resident was in bed. Staff 6 stated the first fall mat was implemented shortly after the resident's admission and the second fall mat was added 12/14/22. Staff 6 acknowledged Resident 8's care plan did not include the interventions for fall mats.

Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The 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:
-Do not leave damp textiles or fabrics in machines overnight.

During an observation on 12/14/22 at 1:44 PM wet laundry including linens and towels was observed in both washing machines. Condensation was visible on the inside of door windows and the wash cycles were complete.

On 12/14/22 at 1:56 PM Staff 11 (HR/Staffing) stated Staff 12 (Laundry) worked from 4:00 AM until 12:30 or 1:00 PM. She confirmed laundry staff was gone for the day and would not return until the morning of 12/15/22.

In an interview on 12/15/22 at 9:20 AM Staff 12 (Laundry) stated she left the wet laundry in the washers overnight from 12/14/22 until the beginning of her shift on 12/15/22 at about 5:00 AM when she transferred the wet laundry to the dryers. She confirmed she normally left wet laundry in the large washing machine overnight. She stated she did not rewash the laundry before transferring it to the dryers.

In an interview on 12/15/22 at 2:16 PM Staff 1 (Director of Operations) was advised of these findings. He reported he did not know wet laundry could not be left in the washers overnight.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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OAR 411-086-1040 Nursing Services: Problem Resolution & Preventive Care

Refer to F686 & F689
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OAR 411-086-0230 Laundry Services

Refer to F880
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Based on interview and record review it was determined the facility failed to ensure wound treatment was provided and comprehensively assess pressure ulcers for 2 of 4 residents (#s 1 and 2) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

1. Resident 1 was admitted to the facility on 5/10/2021 with diagnoses including pressure ulcer.

A hospital Skilled/Intermediate Nursing Facility Transfer Orders dated 5/10/21 indicated Resident 1 discharged from the hospital with orders for "Wound Care - follow standard nursing protocols for wound care" and "Currently foam dressings to her SC (tailbone) and heels ...." The orders did not define "standard nursing protocols for wound care."

A facility Skin & Wound Evaluation dated 5/10/21 indicated Resident 1 admitted to the facility with an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by dead tissue) pressure ulcer to the sacrum (tailbone).

A review of Resident 1's TAR revealed from 5/10/21 through 5/31/21 "wound care: follow standard nursing protocol for wound care. keep skin moisturizes, wear long sleeves and long pants to help protect. Reposition every 2 hours every shift." The TAR indicated this treatment was provided every shift, however, did not define "standard nursing protocol for wound care." From 5/10/21 through 5/14/21 the TAR did not indicate the hospital orders for foam dressings, or any other specific wound care treatment was provided until 5/15/21 when new treatment orders were implemented.

A review of a subsequent Skin & Wound Evaluation dated 5/15/21 did not indicate worsening of the wound.

On 7/19/21 at 10:16 AM Staff 2 (DNS) confirmed the hospital order for a foam dressing was not in place on Resident 1's TAR and "wound care: follow standard nursing protocol for wound care" was not a complete order for wound treatment.

2. Resident 2 was admitted to the facility in 2021 with diagnoses including chronic pressure ulcer.

A physician's assistant Progress Note dated 2/18/21 indicated the resident admitted to the facility with a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) over the left ischial (hip) which appeared clean and uninfected. The note did not provide any additional assessment of the wound such as dimensions, wound bed or drainage.

A 3/3/21 Skin Event revealed Resident 2 developed a pressure ulcer on the coccyx (tailbone).

A review of the facility's Skin & Wound Evaluations (routine wound assessments) for Resident 2's left ischial pressure ulcer revealed the following:
- On 2/17/21 the assessment failed to indicate the condition of the wound bed, drainage and treatment.
- On 2/19/21 the assessment failed to indicate the condition of the wound bed, what type of drainage was present and treatment.
- On 3/5/21 the assessment failed to indicate the condition of the wound bed, drainage and treatment.

A review of the facility's Skin & Wound Evaluations (routine wound assessments) for Resident 2's coccyx pressure ulcer revealed the following:
- On 3/3/21 the assessment failed to indicate if drainage was present and treatment.
- On 3/5/21 the assessment failed to indicate the condition of the wound bed and treatment.

On 7/20/21 at 1:33 PM Staff 3 (RNCM) stated a comprehensive wound assessment should include descriptions of the wound bed, drainage, odor, surrounding tissue, the treatment in place and measurements. Staff 3 confirmed the missing data from Resident 2's wound assessments and stated the assessments did not meet her expectations.

Based on interview and record review it was determined the facility failed to assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 3 sampled residents (#8) reviewed for falls. This failure resulted in the resident having ten falls, two with serious injury including a head injury and fractured neck which required emergency medical services and treatment at the hospital. Findings include:

Resident 8 was admitted to the facility in 7/2019 with diagnoses including thoracic (mid-region of the spine) spinal compression fractures and rib fractures post fall, acute pain secondary to trauma and dementia.

Physician orders dated 7/25/19 indicated Resident 8 was prescribed Eliquis (anticoagulant medication which increases the risk of bleeding or delayed stopping of bleeding) twice daily.

The 7/2019, 8/2019 and 9/2019 MARs indicated Resident 8 received Eliquis as ordered.

A 7/25/19 Admission Nursing Assessment indicated Resident 8 had short and long-term memory problems and an inability to understand what was said. Resident 8 was a fall risk secondary to having previous falls prior to admission in the past two to six months resulting in fractures, taking three to four medications in the last seven days that increased fall risk and having dementia. Resident 8 was found climbing out of bed and had confusion and impulsivity.

The 8/1/19 Admission MDS revealed Resident 8 had a BIMS (Brief Interview of Mental Status) of five (severe cognitive impairment), required extensive assistance for most ADL care and required one to two-person assistance for walking and transferring.

The 8/1/19 Cognition, Fall and ADL CAAs indicated Resident 8 exhibited deficits in orientation and short term memory, had a history of falls with multiple fractures, was confused, incontinent, attempted to self-transfer to the commode and was at risk for falls.

Resident 8's Care Plan indicated the resident was at risk for falls related to weakness, impaired mobility, history of falls, dementia and decreased safety awareness. The following interventions were in place:
-Have commonly used items within easy reach: initiated on 7/25/19;
-Medication review with MD and Pharmacist: initiated on 7/25/19;
-Reinforce need to call for assistance: initiated on 7/25/19;
-Request therapy evaluation as appropriate: initiated 7/25/19;
-Wear non-skid shoes/slippers/socks: initiated 7/25/19;
-Commode next to bed: initiated 7/25/19;
-Leaving the room door open for increased visualization when not receiving care: initiated on 8/9/19;
-Seat in area of high visibility for supervision in wheelchair as allowed by resident: initiated 8/15/19;
-Provide visual prompts to ask for help: initiated 8/15/19.

From 8/7/19 through 9/9/19, Resident 8 experienced ten falls in the facility, two with serious injury requiring hospitalization.

-8/7/19 Fall Risk Assessment indicated Resident 8 was found lying on the floor in Resident 8's room resulting in an abrasion. Furniture was scattered around the room and in Resident 8's way if self-transferring. Resident 8 continously self-transferred and was found in her/his room without using the call light prior to this fall and Resident 8's call light was not activated when Resident 8 was found. Resident 8 was determined to have poor self-awareness. The recommended plan indicated the facility would try to have a visual sign in Resident 8's room and the plan indicated without wearing glasses (Resident 8 did not have glasses), it may not be effective. Resident 8 continued with PT and OT services.

The fall care plan was updated 8/9/19 to leave Resident 8's door open when not receiving care.

-8/11/19 Fall Risk Assessment indicated Resident 8 had an unwitnessed fall and was found on the floor in front of the bedside commode due to self-transferring to the commode resulting in a head injury requiring hospitalization. Resident 8 was known to have a history of falls and impulsive behaviors. Resident 8 was unable to remember to use the call light. The recommended plan indicated Resident 8's family was to spend more time in the facility to help supervise and family was to provide a private caregiver.

No new fall care plan interventions were put in place.

-The 8/14/19 Hospital Discharge Summary indicated Resident 8 was at risk for falls when unsupervised.

-8/15/19 Fall Risk Assessment indicated Resident 8 was found on the floor on the fall mat in Resident 8's room. Resident 8 was known to self transfer to the toilet with or without using the walker. The family provided effective supervsion when at the facility. Resident 8 was unable to use the call light, pulled off non-skid socks and visual prompts were not effective since Resident 8 did not see well enough or read them. The recommended plan indicated the family was to spend more time in the facility to help supervise and family was to provide a private caregiver.

The fall care plan was updated to seat Resident 8 in high visibility area and use visual prompts to ask for help.

-8/16/19 Fall Risk Assessment indicated Resident 8 was found on the floor in Resident 8's room due to ambulating without assistance. Resident 8's call light was not activated and Resident 8 was unable to remember to use the call light. The family provided effective supervision when at the facility. The recommended plan indicated the family was to spend more time in the facility to help supervise and family was to provide a private caregiver.

No new fall care plan interventions were put in place.

-8/17/19 Fall Risk Assessment indicated Resident 8 was found on the floor in Resident 8's room after the resident attempted to self-transfer; the resident got up often and had multiple falls the past three days. Resident 8's call light was not activated and the resident did not use the call light. The recommended plan indicated the family was to spend more time in the facility to help supervise and family was to provide a private caregiver.

No new fall care plan interventions were put in place.

-8/25/19 Fall Risk Assessment indicated Resident 8 was found on the floor in the hallway. Resident 8's call light was not activated. Resident 8 often got up, unassisted, and did not use the call light. Resident 8's family was not spending more time in the facility and did not hire a caregiver. The recommended plan indicated the family and staff would monitor Resident 8 as much as possible, interventions were slightly helpful and Resident 8 was expected to continue to get up unassisted due to decreased cognition and understanding.

No new fall care plan interventions were put in place.

-9/1/19 Fall Risk Assessment indicated Resident 8 was found on the floor in the hallway after falling from her/his wheelchair. The recommended plan indicated to continue with the care plan to avoid injury and falls as able. Interventions in place were somewhat effective. Resident 8 continued to self-transfer to the commode.

No new fall care plan interventions were put in place.

-9/6/19 Fall Risk Assessment indicated Resident 8 was found crawling on the floor in Resident 8's room. Resident 8 was on a toileting schedule with little to no improvement in preventing falls and the resident had increased behaviors over the past day. Resident 8 had multiple falls in the facility and was up within minutes of anyone leaving Resident 8's room or sight. The interventions in place were somewhat effective. Resident 8 often got up, unassisted, and did not use the call light. The recommended plan was to have the physician review medications on 9/9/19.

No new fall care plan interventions were put in place.

-9/8/19 Fall Risk Assessment indicated Resident 8 was found on the floor in the resident's room after falling from the wheelchair. Resident 8 did not use the call light and got up often, unassisted. The family visited daily for a few hours. While at the facility, Resident 8 was encouraged to be in her/his room with family or staff present or in the hallway or rotunda for high visibility. Resident 8 was expected to continue to have falls and the facility would attempt to reduce falls/injury as able.

No new fall care plan interventions were put in place.

-9/9/19 Fall Risk Assessment indicated Resident 8 was found on the floor in Resident 8's room after getting up from her/his wheelchair and ambulating, unassisted, resulting in hospitalization for a fractured neck. Resident 8 did not return to the facility.

The facility failed to implement new care plan interventions and re-assess current interventions to ensure Resident 8 was adequately supervised and her/his falls were unavoidable. Resident 8 experienced ten falls from 8/7/19 to 9/9/19, and on 8/11/19 and 9/9/19, Resident 8 fell sustaining a head injury and then a fractured neck.

On 7/15/21 at 5:49 PM, Witness 2 (Family) reported Resident 8 experienced multiple falls during her/his stay at the facility and felt the falls were preventable had staff watched Resident 8 more closely.

On 7/16/21 at 12:24 PM, Staff 4 (CNA) stated she recalled Resident 8 and Resident 8 had her/his bed in the lowest position, fall mats and a bedside commode. Staff 4 stated Resident 8 was unable to use her/his call light, the family visited frequently and, to her knowledge, no other fall interventions were in place. Staff 4 stated the facility did not provide one on one supervision to residents.

On 7/16/21 at 1:22 PM, Staff 5 (RN) reported the facility did not use any type of personal alarms and was not equipped to provide one on one supervision. Staff 5 recalled Resident 8 and stated she would have changed staffing to increase the number of CNAs on the hallway and moved Resident 8's room closer to the nursing station in order to increase supervision of Resident 8.

On 7/19/21 at 11:11 AM, Staff 25 (CNA) stated when residents were fall risks, the facility did not use personal alarms or provide one on one supervision but she would try to be with residents as much as possible because she had seen many falls and worried about the residents.

On 7/19/21 at 5:30 PM, Staff 9 (Former Licensed Nurse) reported Resident 8 often got up and ambulated, unassisted, and interventions were not working. Staff 9 stated Resident 8 would have benefitted from one to one supervision, it was a rigorous process to get approval and approval was rarely granted.

On 7/20/21 at 1:02 PM, Staff 2 (DNS) confirmed Resident 8 was prescribed an anticoagulant which increased the risk for head injury or bleeding with falls. Staff 2 confirmed new interventions were updated to the care plan on 8/9/19 and 8/15/19 and verified no other fall interventions were added. Staff 2 acknowledged the facility was required to provide the level of supervision a resident needed to keep them safe and stated the facility was unable to accommodate one on one supervision. Staff 2 stated if one on one supervision was needed the facility required the family to increase their time at the facility or hire a caregiver and if a resident did not have family the facility would attempt to get volunteers, engage the resident in more activities and look at placing the resident in a different setting or discharging the resident home with the family.

On 7/23/21 at 8:57 AM, Staff 1 (Administrator) reported the team attempted to monitor residents as much as possible. Staff 1 stated if residents required one on one supervision they would request the resident's family or friends provide the supervision or hire a caregiver and if the resident had no family or friends the facility would not be able to meet that resident's needs and would look at a different placement. Staff 1 stated in rare situations, if the behaviors posed enough of a risk, one on one supervision might be approved. Staff 1 reported the administrator approved all one on one supervision.

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

Refer to F686 and F689
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