Marquis Autumn Hills Memory Care

Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 admitted to the facility in 3/2025 with diagnoses including Alzheimer's disease. Resident 2's 3/17/25 Admission MDS revealed she/he had a BIMS of 9, which indicated moderate cognitive impairment.Resident 3 admitted to the facility in 8/2023 with diagnoses including dementia.Resident 3's 2/24/25 Quarterly MDS revealed she/he had a BIMS of 12, which indicated moderate cognitive impairment.An 4/19/25 facility Investigation Summary and Conclusion revealed on the morning of 4/19/25 Resident 2 and Resident 3 were in their shared room asleep when Resident 2 woke up and turned on the overhead light. Resident 3 woke up and became angry, swore at Resident 2, and pushed her/him back onto her/his bed. Resident 3 then went to the common television room to complain about the overhead light being on. The facility moved the residents to different rooms. Neither resident was injured during the incident.Resident 2's 4/19/25 Resident to Resident Event Assessment revealed Resident 2 was interviewed after the incident and stated Resident 3 cursed at her/him when the bedroom light was turned on. Resident 2 stated Resident 3 then shoved her/him hard onto the bed and attacked her/him because she/he turned on the light. Resident 2 stated the incident scared her/him and she/he complained of left shoulder pain later in the day.Resident 3's 4/19/25 Resident to Resident Event Assessment revealed Resident 3 was interviewed after the incident and stated Resident 2 stood over her/his bed yelling and Resident 3 then pushed Resident 2 onto her/his bed. On 5/15/25 at 7:51 AM Staff 6 (CNA) stated she worked on 4/19/25 and recalled the incident between Resident 2 and Resident 3. Staff 6 stated she found Resident 3 screaming about pushing Resident 2 because she/he turned the light on. Resident 2 was very scared and wanted to be out of the shared room. The two residents were then separated. On 5/15/25 at 1:25 PM Resident 3 stated she/he and Resident 2 had many issues because they shared a room and Resident 2 turned the light on every night. Resident 3 stated on 4/19/25 Resident 2 woke her/him up when she/he turned the light on. Resident 3 stated the two residents then went back and forth turning the light on and off until she/he shoved Resident 2 onto the bed. On 5/15/25 at 1:32 PM Resident 2 stated Resident 3 was upset because she/he said the light was in her/his face and then Resident 3 shoved Resident 2 down on the bed. Resident 2 stated she/he was afraid at the time but felt safe now because the facility moved her/him out of the shared room. Resident 2 stated she/he felt abused by Resident 3 and no longer interacted with her/him. On 5/15/25 at 4:51 PM Staff 11 (LPN) stated on 4/19/25 she was called to the room Resident 2 and Resident 3 shared. Staff 11 stated Resident 3 was upset and stated she/he pushed Resident 2 because Resident 2 turned on the light. Staff 11 stated Resident 2 was upset and reported being scared.On 5/15/25 at 2:50 PM Staff 2 (DNS) stated she investigated the 4/19/25 event and concluded the incident met the definition of abuse. The deficient practice was identified as Past Noncompliance based on the following:On 4/19/25, the deficient practice was identified by the facility and was corrected when the facility implemented the following to prevent further incidents of resident to resident abuse: 1. Resident 2 and Resident 3 were separated, 2. The facility implemented auditing through alert charting, 3. The facility reviewed and updated Resident 2 and Resident 3's care plans.

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OAR 411-086-0360 Abuse

Refer to F600
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Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include:

Resident 9 was admitted to the facility in 8/2024 with the diagnoses including vascular dementia.

The 10/22/24 Physician Orders revealed an order for Duloxetine (antidepressant)to be administered daily.

The medical record revealed no evidence risk and benefit information for Duloxetine was reviewed with Resident 9.

On 10/24/24 at 11:05 AM Staff 6 (LPN Resident Care Manager Support) acknowledged risk and benefit information related to the use of Duloxetine was not provided to Resident 9.

Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk for additional weight loss. Findings include:

Resident 11 admitted to the facility in 5/2023 with diagnoses of vascular dementia and malnutrition.

A 5/2/23 Nutrition Care Plan revealed Resident 11 was at risk for impaired nutrition due to severe malnutrition and vascular dementia with a goal of Resident 11 maintaining or increasing her/his weight to above 167 pounds. The interventions for Resident 11 included a referral to a dietitian for evaluation and recommendations as needed.

A 5/12/24 Dietitian Assessment revealed Resident 11 weighed 157.4 pounds and weight gain was beneficial.

A 7/23/24 Provider Progress Note revealed Resident 11 weighed 164.9 pounds, her/his weight was stable for the last six months, no additional interventions were put in place.

An 8/21/24 Provider Progress Note revealed Resident 11 weighed 164.8 pounds, her/his weight was stable for the last six months, no additional interventions were put in place.

A 9/24/24 Provider Progress Note revealed Resident 11 weighed 156.4 pounds, her/his weight was down 10 pounds over the last month and seven pounds over the last six months. No additional interventions were put in place.

A review of the 7/2024 through 10/2024 Progress Notes revealed no additional assessments of Resident 11's weight loss.

An 10/11/24 Quarterly MDS indicated Resident 11 did not have weight loss and weighed 159 lbs.

An 10/11/24 Summary Dietary revealed Resident 11 currently weighed 158.6 pounds, and over the last 180 days Resident 11 had significant weight loss.

An 10/17/24 Summary Nursing assessment did not address Resident 11's weight loss.

Resident 11's Weights and Vitals Summary revealed the following weights:
- 4/12/24: 178.3 pounds
- 7/12/24: 164.4 pounds
- 9/13/24: 157 pounds
- 10/11/24: 158 pounds
- 10/14/24: 157.4 pounds
- 10/18/24: 152.4 pounds
- 10/23/24: 150 pounds

On 10/22/24 at 2:48 PM Staff 6 (Resident Care Manager Support) reviewed Resident 11 and stated she did not identify weight loss on the 10/11/24 MDS but confirmed Resident 11 did have over a 10 percent weight loss in the last six months. Staff 6 stated when weight loss was identified she was to notify the provider, the family, make a registered dietitian referral, and add the resident to the Nutrition at Risk list.

On 10/23/24 at 9:52 AM Staff 10 (Registered Dietitian) stated she was last at the facility on 10/18/24 and did not see Resident 11. Staff 10 stated she expected to be notified of any significant weight loss. Staff 10 confirmed she did not assess Resident 11 since 5/2024, but her/his goal was to maintain or increase her/his weight. Staff 10 stated the facility should have notified her of Resident 11's weight loss. Staff 10 stated when notified of a resident with significant weight loss she assessed her/him to see what else was going on. Staff 10 stated Resident 11 had a diagnosis of congestive heart failure so the facility needed to ensure the weight loss was not fluid related.

On 10/24/24 at 11:23 AM Staff 3 (Regional RN) stated when weight loss was identified the staff were to make a referral to the registered dietitian, add the resident to nutrition at risk, and do a nutrition and weight assessment; Staff 3 confirmed these interventions were not in place for Resident 11.

Based on observation, interview, and record review it was determined the facility failed to ensure medication storage areas were secured and free of expired medication for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for safe medication storage. This placed residents at risk for misappropriation of medications, adverse medication consequences and diminished treatment efficacy. Findings include:

The facility's Storage of Medication Policy, revised 5/2010, stated, "The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner."

1. On 10/21/24 at 1:49 PM the Intemediate Care medication cart outside of Room 17 was unlocked and unattended.

On 10/21/24 at 1:53 PM Staff 4 (CMA) confirmed the cart was unlocked and unattended.

On 10/24/24 at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided.

2. On 10/24/24 at 7:44 AM a multidose bottle of Lorazepam (a controlled antianxiety medication) was found in the locked medication refrigerator with an expiration date of 7/21/24.

On 10/24/24 at 7:44 AM Staff 5 (LPN) confirmed the Lorazepam was expired.

On 10/24/24 at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided.

Based on observation, interview, and record review it was determined the facility failed to implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections. Findings include:

The facility's undated "Isolation - Categories of Transmission-Based Precautions" policy indicated Enhanced Barrier Precautions were to be used for residents with catheters and complex wounds.

On 10/21/24 Staff 1 (Administrator) provided a list of residents with catheters which included Residents 2, 8, and 14.

On 10/22/24 at 12:38 PM Resident 2 and Resident 14's rooms were observed with no signage to indicate they were on Enhanced Barrier Precautions. At this time Staff 8 (CNA) stated there were no residents with precautions on the hall.

On 10/22/24 at 2:10 PM Resident 8's room was observed with no signage to indicate she/he was on Enhanced Barrier Precautions.

On 10/22/24 at 2:16 PM Staff 2 (DNS) stated the facility implemented Enhanced Barrier Precautions for Resident 2, Resident 8, and Resident 14 due to catheter use. Staff 2 stated there were no signs or indicators about Enhanced Barrier Precautions on the resident rooms at this time because the facility was waiting for blue sticker dots be delivered. Staff 2 further stated the facility did not store PPE in the hallways, but it was available to staff in the "spa". Staff 2 went to the "spa" on the ICF hall to show the PPE storage and discovered the hospital gowns were not stored there. Staff 7 (CNA) offered assistance to Staff 2 and stated none of the residents on the ICF hall had precautions of any kind. Staff 2 told Staff 7 the facility were to follow Enhanced Barrier Precautions for all residents with an indwelling catheter. Staff 7 stated she was not aware and the facility staff were not doing that. Staff 2 then confirmed the facility did not implement Enhanced Barrier Precautions.

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at risk for lack of vaccination. Findings Include:

Resident 27 admitted to the facility in 2/2024 with diagnoses including chronic pain.

Resident 27's immunization records did not indicate if she/he was assessed for, offered, or declined a pneumococcal vaccination following admission to the facility.

On 10/24/24 at 12:06 PM Staff 3 (Regional RN) stated the medical record showed no documentation the facility offered a pneumococcal vaccination to Resident 27.

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OAR 411-085-0310 Resident Rights: Generally

Refer to F552

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

Refer to F692 and F883

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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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The findings of the state licensure and memory care unit health survey conducted from 10/21/24 through 10/24/24 are documented in this report. The survey was conducted to determine compliance with OAR 411 Division 57. For additional information, refer to Form CMS 2567 dated 10/24/24.


Abbreviations possibly used in this document:
ADL:    
activities of daily living
bid:    
        
twice a day
BIMS:   
Brief Interview for Mental Status
CAA:    
Care Area Assessment
CBG:    
capillary blood glucose or blood sugar
cm:     
        
centimeter
CMA:    
Certified Medication Aide
CNA:    
Certified Nursing Assistant
CPR:    
Cardiopulmonary Resuscitation
DNS:    
Director of Nursing Services
F:      
        
Fahrenheit
FRI:    
        
Facility Reported Incident
HS or hs:       
hour of sleep
LPN:    
        
Licensed Practical Nurse
MAR:    
Medication Administration Record
mcg:    
        
microgram
MDS:    
Minimum Data Set
mg:     
        
milligram
ml:     
        
milliliters
O2 sats:        
oxygen saturation in the blood
OT:     
        
Occupational Therapist
PCP:    
Primary Care Physician
PO:     
        
by mouth, orally
PRN:    
as needed
PT:     
        
Physical Therapist
RA:     
        
Restorative Aide
RAI:    
        
Resident Assessment Instrument
RD:     
        
Registered Dietitian
ROM:    
range of motion
RN:     
        
Registered Nurse
RNCM:   
Registered Nurse Care Manager
SA:     
        
State Agency
SLP:    
        
Speech Language Pathologist
TAR:    
Treatment Administration Record
tid:    
        
three times a day
UA:     
        
Urinary Analysis
UTI:    
        
Urinary Tract Infection









A follow-up survey was conducted on 12/18/24 to verify correction of the deficiencies noted from the memory care community health survey dated 10/24/24. These deficiencies are corrected as of 12/13/24.

Based on interview and record review it was determined the facility failed to ensure the administrator completed 10 hours of dementia training. This placed residents at risk for lack of dementia specific care. Findings include:

Review of the current Course Completion records revealed Staff 1 (Administrator) did not complete ten hours of dementia training.

On 10/24/24 at 10:46 AM Staff 1 stated he did not have 10 hours of dementia training.

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 3 sampled residents (#9) had individually identifiable rooms. This placed residents at risk for not being able to locate their rooms. Findings include:

Resident 9 was admitted to the facility in 8/2024 with diagnoses including vascular dementia.

On 10/21/24 at 10:45 AM Resident 9's room was observed to have an empty shadow box at her/his room entrance. No other individualized identification was visible to assist Resident 9 in locating her/his room.

On 10/24/24 at 9:41 AM Staff 11 (Activity Director) acknowledged Resident 9 did not have an individually identified resident room.

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 04/08/2024 and 04/14/2024, 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 interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 15 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 2 was admitted to the facility in 1/2024 with diagnoses including dementia.

Resident 2's most recent MDS assessment dated 1/29/24 revealed no BIMS score, which indicated she/he had severe cognitive impairment. Resident 2 had no behavioral issues documented.

Resident 1 was admitted to the facility in 3/2022 with diagnoses including dementia and delusional disorder.

Resident 1's most recent MDS assessment dated 3/1/24 revealed a BIMS score of 9, which indicated she/he had moderate cognitive impairment. Behaviors documented were physical and verbal symptoms directed toward others which placed other residents at significant risk of physical injury. Interventions were to remove her/him from the area and provide low stimulus diversional activities.

On 2/23/24 the facility submitted a report which revealed on 2/23/24, Resident 1 was observed by staff standing over Resident 2 holding Resident 2's wrist. Resident 2 was lying on the couch in the living room. The residents were separated and Resident 2 was observed to have scratches on her/his face.

On 4/8/24 at 1:20 PM Staff 7 (CNA) confirmed he was working the day of the incident. He stated Resident 1 needed close supervision due to her/his behaviors which included physical aggression toward other residents. Staff 7 stated he was on break when the incident occurred.

On 4/10/24 at 11:57 AM Staff 6 (CNA) confirmed she was working the day of the incident. She stated she was in the living room with the residents and walked across the hall to wash her hands, then heard Resident 2 yelling. She ran into the living room and observed Resident 1 standing over Resident 2, who was lying on the couch. She observed Resident 1's hands to be on Resident 2's face. Staff 6 separated the residents and reported the incident to the charge nurse. Staff 6 stated she observed two skin tears on Resident 2's face as a result of Resident 1 grabbing Resident 2's face.

On 4/8/24 and 4/9/24 both residents were observed and had no recall of the incident.

On 4/10/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no further information.

Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) reviewed for falls. As a result, Resident 3 experienced prolonged pain over a period of four weeks, and a delay in diagnosis of hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 8/5/23, 31 days after her/his fall on 7/4/23. Findings include:

Resident 3 was admitted to the facility in 3/2023, with diagnoses including stroke and dementia.

Resident 3's care plan dated 2/28/23 noted she/he was was a fall risk due to impaired mobility, gait unsteadiness and decreased safety awareness due to her/his cognitive impairment. The care plan indicated Resident 3 had experienced falls in 3/2023 and 6/2023.

Resident 3's Progress Notes revealed she/he experienced three falls on 7/4/23, 7/8/23 and 7/9/23.

The 7/4/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and hit her/his head and hip and reported pain in her/his back, left side of her/his head, left hip and right shoulder.

The 7/8/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and complained of pain in her/his left hip. The facility provider was notified and ordered a hip and spine x-ray.

The 7/9/23 Post Fall Assessment revealed Resident 3 attempted to self transfer, fell from the chair she/he was seated in and was observed to slide to the floor by staff. Resident 3 complained of pain "everywhere."

On 7/11/23, a progress noted written by Staff 3 (RCM) stated the x-ray was canceled by the service provider.

Resident 3's 7/2023 and 8/2023 Progress Notes documented the following dates she/he experienced pain:

- 7/4/23 at 6:31 PM: "Resident complained of pain"
- 7/4/23 at 8:59 PM: Resident had a non witnessed fall this evening. Resident stated she/he hit her/his head and hip...Resident also complained of pain to lower lateral left back and right shoulder.
- 7/5/23 at 2:34 AM: "Resident complained of pain all over."
- 7/5/23 at 12:46 PM: "Resident this morning complained of discomfort from fall, resident just had scheduled medication."
- 7/6/23 at 2:10 PM: "Post fall, no injuries noted, complained of leg pain."
- 7/7/23 at 1:15 AM: Resident complained of pain in her/his legs.
- 7/7/23 at 10:54 AM: Resident states only pain is related to her/his legs especially during wound care.
- 7/8/23 at 10:38 AM: "Medication given for leg pain per LN (licensed nurse). 6/10 pain scale."
- 7/8/23 at 1:05 PM: "Resident took a shower today, complained of legs burning after shower...There is some increased generalized weakness, accompanied by general aches/pains after shower."
- 7/8/23 at 3:12 PM: Resident had a fall this afternoon during shift change. Resident was following another resident and lost her/his balance and fell in the common area. She/he did not hit her/his head, but does complain of pain in her/his left hip where she/he fell.
- 7/9/23 at 4:42 AM: Resident was sleeping in the living room tonight...she/he tried to stand on her/his own and slid off the chair...Pain pill given for complaints of generalized pain.
- 7/10/23 at 7:45 AM: "Resident complained of 6/10 pain."
- 7/11/23 at 7:46 AM: "Resident complained of pain."
- 7/12/23 at 12:23 PM: "Post multiple falls, resident per baseline, noted pain in legs."
- 7/14/23 at 4:18 PM: "Resident complained of back pain."
- 7/15/23 at 9:41 AM: "Resident complained of pain per LN 7/10."
- 7/16/23 at 8:24 AM: "Resident complained of leg pain 6/10 per LN."
- 7/16/23 at 12:51 PM: "Resident was pulling at Unna boots, complained of burning on the right leg."
- 7/17/23 at 8:30 AM: "Resident complained of leg pain."
- 7/18/23 at 1:51 AM: "Resident complained of pain in her/his legs.
- 7/19/23 at 1:51 AM: Resident complained of pain in her/his legs."
- 7/19/23 at 4:57 AM: Resident appeared to be restless, she/he complained of pain in her/his legs.
- 7/20/23 at 1:34 AM: Resident complained of pain in her/his legs.
- 7/20/23 at 5:20 AM: Resident refused to sleep in her/his bed. She/he stated that she/he was uncomfortable in bed..she/he complained of pain in her/his legs.
- 7/21/23 at 2:15 AM: Resident complained of pain in her/his legs.
- 7/21/23 at 4:44 AM: Resident appeared to be restless/anxious all NOC. She/he was given a snack, complained of pain in her/his legs.
- 7/22/23 at 5:40 AM: "Please rule out pain as contributing factor; complaint of pain when Unna boots had to be reapplied."
- 7/22/24 at 10:28 AM: "Resident complained of burning leg pain once during shift."
- 7/22/23 at 11:11 AM: "Resident complained of pain in both legs."
- 7/24/23 at 1:03 AM: Resident complained of pain in her/his legs.
- 7/24/23 at 9:31 AM: "Resident complained of pain in both legs."
- 7/24/23 at 12:42 PM: "Resident up this morning, calling out for help constant, pain medications have been offered for legs pain."
- 7/25/23 at 9:07 AM: "Complained of leg pain."
- 7/26/23 at 7:40 AM: "Resident complained of pain 6/10 per LN."
- 7/27/23 at 1:30 AM: Resident complained of pain in her/his legs.
- 7/27/23 at 9:55 AM: "PRN Administration was ineffective. Continue complaints of back pain."
- 7/27/23 at 10:02 AM: "Resident complained of leg pain per LN."
- 7/28/23 at 1:30 AM: Resident complained of pain in her/his legs.
- 7/28/23 at 4:21 PM: "Resident complained of lower back pain."
- 7/28/23 at 8:11 PM: "Resident was observed restless this evening, frequently standing, grimacing, complained of leg pain."
- 7/29/23 at 11:24 AM: "Complained of leg pain."
- 7/29/23 at 4:50 PM: "Resident had complaint of back pain."
- 7/29/23 at 7:35 PM: "Resident expressed pain when staff raised legs to install new dressings."
- 7/30/23 at 3:14 AM: Resident is complaining of her/his legs are burning and her/his back hurts. Medicated with PRN Norco at 11:30 PM, appears to have no effect...at this time she/he appears anxious, continuously asking us to not hurt her/him or why we hate her/him.
- 7/30/23 at 12:57 PM: "Resident awake all morning, constant asking for assist, crying out, trying to walk without assist in dining."
- 7/31/23 at 1:43 AM: Resident complained of pain in her/his legs.
- 7/31/23 at 12:19 PM: "Complained of back pain."
- 7/31/23 at 11:58 PM: Resident complained of pain in her/his legs.
- 8/1/23 at 7:39 AM: "Resident complained of pain 8/10 per LN."
- 8/2/23 at 5:51 AM: Increase complained of pain noted,..resident slept on and off throughout the NOC complaining of pain in her/his legs.
- 8/2/23 at 8:24 AM: "Report stated that patient didn't sleep well last night due to pain. Made multiple changes to RX for pain on 8/1/23, but she/he no longer has any PRN pain RX. Messaged nurse practitioner to request possible PRN."
- 8/2/23 at 8:29 PM: Resident has been uncomfortable, grimacing, calling out in pain in her/his left hip and leg off and on for several hours. Occasionally re-directable but she/he returns to complaints of pain after a few minutes. She/he does not want to lay down, she/he will not keep her/his legs elevated. Family is very worried that the current dose/frequency of medication is not effective, they note she/he is rarely vocal about pain.
- 8/2/23 at 10:14 PM: "PRN did not control pain, resident continues to call out, wince in pain, is tense, restless."
- 8/3/23 at 5:40 AM: Resident has been up all shift in her/his wheelchair...continues to call out, try to get up unassisted and call out in pain. She/he told this LN her/his pain is in the lower back, left hip or left leg at different times..She/he had her/his PRN dose at 2030 but continues to complain of pain.
- 8/3/23 at 2:23 PM: Resident was re-evaluated and it was determined current pain regimen was ineffective..Resident was sitting in her/his wheelchair, again identifying that her/his bilateral lower extremities were in pain.
- 8/3/23 at 3:39 PM: "New orders to start oxycodone [a pain medication] 5 mg every 6 hours scheduled and Norco 5/325 BID for breakthrough pain. There is to be 3 hours between the oxycodone and Norco doses."
- 8/4/23 at 2:58 AM: "Resident appeared to be restless when assisted to bed at the beginning of this shift complaining of back pain and leg pain."
- 8/4/23 at 1:53 PM: "Resident anxious at times, asking staff to sit with her/him. Complaint of back pain."
- 8/4/23 at 10:37 PM: "Resident started fidgeting, complained of left hip pain, restless, calling out for help...Received order for left hip x-ray STAT."
- 8/5/23 at 2:06 AM: "X-ray results: Acute Superiorly Displaced Subcapital Fracture of the Left Femoral Neck - Orders to send to ED for evaluation and treatment."

Resident 3's 7/2023 MAR documented she/he was administered PRN Norco (a pain medication) 5/325 mg a total of 42 doses on the following dates:
-On 7/1/23 - 1 time;
-On 7/3/23 - 1 time;
-On 7/4/23 - 2 times;
-On 7/5/23 - 1 time;
-On 7/6/23 - 1 time;
-On 7/7/23 - 1 time;
-On 7/8/23 - 1 time;
-On 7/9/23 - 1 time;
-On 7/10/23 - 2 times;
-On 7/11/23 - 1 time;
-On 7/14/23 - 1 time;
-On 7/15/23 - 1 time;
-On 7/16/23 - 2 times;
-On 7/17/23 - 1 time;
-On 7/18/23 - 1 time;
-On 7/19/23 - 1 time;
-On 7/20/23 - 1 time;
-On 7/21/23 - 2 times
-On 7/22/23 - 2 times;
-On 7/23/23 - 2 times;
-On 7/24/23 - 2 times
-On 7/25/23 - 1 time;
-On 7/26/23 - 1 time;
-On 7/27/23 - 2 times;
-On 7/28/23 - 2 times;
-On 7/29/23 - 3 times;
-On 7/30/23 - 2 times;
-On 7/31/23 - 3 times.

Staff 3 was not available for interview during the survey period.

On 4/8/24 at 9:23 AM, Witness 2 (Complainant) stated Resident 3 complained of pain while in the facility after she/he experienced several falls. Witness 2 stated she had to yell to facility staff over the phone to get x-rays and this was when the hip fracture was discovered.

On 4/9/24 at 1:10 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the x-rays should have been rescheduled immediately after the service provider initially canceled on 7/11/23.

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OAR 411-085-0360: Abuse

Refer to F600

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OAR 411-086-0110: Nursing Services: Resident Care

Refer to F684

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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 04/01/2024 and 04/07/2024, 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 03/04/2024 and 03/10/2024, 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 07/31/2023 and 08/06/2023, 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 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 02/21/2022 and 02/27/2022, 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 11/15/2021 and 11/21/2021, 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.