East Portland Care Center

Based on interview and record review it was determined the facility failed to ensure a transfer notice with appeal rights was provided in writing to the resident or their representative, and the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization for 1 of 1 sampled resident (#3) reviewed for hospitalizations. This placed residents at risk for lack of access to an advocate to inform them of their options and rights, and lack of information regarding discharge. Findings include:

The facility's Bed Hold Policy: Bed-Holds and Returns with revision date 10/2022 stated all residents of the facility were to be provided with written notice at least twice; once in the admission packet, and again at the time of transfer or if the transfer was an emergency within 24 hours.

Resident 3 admitted to the facility in 1/2025 with diagnoses including hypothermia (body temperature too low) and sepsis (severe infection).

A 1/29/25 Admission MDS indicated Resident 3 was cognitively intact.

A review of Resident 3's health record revealed she/he was transferred to the hospital on 2/15/25.

No evidence was found in Resident 3's health record to indicate a transfer notice with appeals rights was provided to the resident or their representative upon transfer. Resident 3's health record also had no indication the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization.

On 2/26/25 8:45 AM Staff 3 (DNS/RNCM) stated a transfer notice was to be sent with a resident at time of transfer by the facility nurse and the RNCM was to follow up to ensure the notice was given to the resident. She stated she was not aware the Office of the State Long-Term Care Ombudsman was to be notified at time of transfer. She verified a transfer notice was not given to Resident 3 or her/his representative, and the Office of the State Long-Term Care Ombudsman was not notified of the resident's hospitalization. She stated the expectation was for the facility bed hold policy to be followed with every transfer out of the facility.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled residents (#s 5,10 and 20) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include:

The facility's Activity Programs-Staffing Policy, revised 6/2018, indicated the following:
The activity director/coordinator's responsibilities included the following:
-completing or delegating the completion of the activities component of the comprehensive assessment;
-ensuring activity goals and approaches reflected in the residents' care plans were individualized to match the skills, abilities and interests/preferences of each resident;
-monitoring and evaluating the residents' responses to activities and revising the approaches as appropriate;
-developing, implementing, supervising and evaluating activity programs at least quarterly;
-sufficient activity personnel were on duty to meet the needs of the residents and the functions of the activities program.

1. Resident 10 was admitted to the facility in 12/2020 with diagnoses included non-traumatic subarachnoid hemorrhage (bleeding in the brain not due to any head trauma), mild cognitive impairment and failure to thrive.

Resident 10's 12/3/20 Admission Activities Assessment indicated the resident was very social and enjoyed being around people, loved to watch old TV shows such as "I Love Lucy" and "The Brady Bunch", and liked to play dominos and bingo. The resident's identified preferences included arts and crafts, music and watching TV.

Resident 10's Activity Care Plan, last revised 5/9/24, included one-to-one visits, pet visits, sensory one-to-one activities including hand massages, watching old TV shows including cartoons and animal shows, coloring, painting, visiting with others, going on walks and being outside.

Resident 10's 9/30/24 Annual MDS revealed the resident had no cognitive impairments. Resident 10 reported it was somewhat to very important to use the phone in private, have books/newspapers/magazines to read, listen to music, be around animals, keep up with the news, do things in groups of people, do favorite activities, go outside when the weather was nice and participate in religious services or practices.

Resident 10's 12/20/24 Activity Quarterly Review indicated the resident participated in group activities, enjoyed one-to-one activities and walks outside.

The 12/18/24 Resident Council Meeting Minutes indicated residents wanted more bingo and a gaming system.

The facility's Activity Calendar revealed the following scheduled activities:

-2/24/25
10:00 AM: 1:1 Visits
1:00 PM: Bingo

-2/25/25
11:00 AM: Games and Music
1:00 PM: Bingo
3:00 PM: Smoothie Day

-2/26/25
10:00 AM: 1:1 Visits
1:00 PM: Bingo
3:00 PM: Birthday Party

Resident 10's Activity Participation Logs for 1/2025 and 2/2025 indicated Resident 10 participated in a reminiscing activity on 1/2/25.

Random observations of Resident 10 conducted from 2/23/25 through 2/25/25 between the hours of 8:00 AM and 4:30 PM revealed Resident 10 resided in the only upstairs bedroom of a two story house, with one roommate and no other residents around. Resident 10 was not observed out of her/his room, at anytime. The resident was observed watching shows on her/his tablet, lying in bed with the lights off, sleeping or sitting at the edge of the bed. Resident 10 was not observed in any group or one-to-one activities and no books, newspapers, magazines or music was observed in the resident's room. On 2/24/25 bingo was scheduled but did not occur and on 2/25/25 games, music and bingo were scheduled but did not occur.

On 2/23/25 at 11:01 AM, Resident 10 stated she/he liked to socialize and play bingo but was unable to participate because she/he could no longer walk, therefore, could not go downstairs where the majority of residents resided and group activities occurred. Resident 10 stated she/he was no longer able to socialize with other "seniors" because she/he could no longer go downstairs.

On 2/25/25 at 8:24 AM, Staff 9 (CNA) stated Resident 10 liked to be downstairs to watch television and play bingo. Staff 9 stated Resident 10 was unable to walk, and was unable to go downstairs for approximately the last month and a-half. Staff 9 stated there were no activities occurring in the facility except "maybe" bingo once a month, there were no "real activities here" and there was "nothing" going on in Resident 10's room except for the resident watching her/his tablet.

On 2/13/25 at 10:13 AM, Staff 11 (Activity Director/Social Service Director) stated he was new to the position and served as the activity director for approximately three months. Staff 11 stated he received two weeks of training which occurred concurrently with his medical records training and he had no previous experience running an activities program in a long-term care setting. Staff 11 stated it was his responsibility to complete the activities section on the MDS, complete an admission/annual activity assessment, develop the residents' activity care plans, complete quarterly activity reviews and document all activities in residents' electronic health records. Staff 11 stated Resident 10 enjoyed coming downstairs for bingo and playing games such as Uno, checkers or chess. Staff 11 reported Resident 10 had been one of his "most active" residents who regularly participated in group activities but the resident was no longer able to walk downstairs, so was unable to participate in activities. Staff 11 stated his job also included social service director and working in medical records and, because of his schedule, he usually missed two to three scheduled activities a week.

On 2/26/25 at 12:52 PM Staff 2 (Administrator-In-Training) and at 1:11 PM Staff 1 (Administrator) were present for an interview. Staff 2 stated he was aware activities were an issue but did not realize the extent of the problem. Staff 2 acknowledged scheduled activities were being missed. Staff 1 stated he expected activities to be planned based on residents' requests, preferences, physical and mental abilities, and activities occurred every day and at various times of the day.

2. Resident 20 was admitted to the facility in 8/2024 with diagnoses including end-stage renal disease, major depressive disorder and anxiety disorder.

Resident 20's 8/12/24 Admission Activities Assessment indicated the resident enjoyed relaxing, being outdoors, music, nature, long-boarding and reading. The resident had a list of preferred activities and was open to trying new activities at the facility.

Resident 20's 8/18/24 Annual MDS revealed the resident had no cognitive impairments. The resident's activity preferences and interests were not assessed.

Resident 20's Activities Care Plan, last revised 11/27/24, indicated to identify at least two activities the resident liked to participate in, Resident 20 would participate in two preferred activities per week, arrange 1:1 visits with the resident and remind Resident 20 when an activity was to occur.

Resident 20's 11/29/24 Admission Activities Assessment indicated the resident enjoyed music, board games and watching television.

The 12/18/24 Resident Council Meeting Minutes indicated residents wanted more bingo and a gaming system.

The facility's Activity Calendar revealed the following scheduled activities:

-2/24/25
10:00 AM: 1:1 Visits
1:00 PM: Bingo

-2/25/25
11:00 AM: Games and Music
1:00 PM: Bingo
3:00 PM: Smoothie Day

-2/26/25
10:00 AM: 1:1 Visits
1:00 PM: Bingo
3:00 PM: Birthday Party

Resident 20's 1/2025 and 2/2025 Activity Participation Logs indicated the resident played video games on 1/2/25 and 1/6/25.

Random observations of Resident 20 conducted from 2/23/25 through 2/25/25 between the hours of 8:00 AM and 4:30 PM revealed the resident was often in her/his room with ear phones on, sleeping or sitting at the edge of the bed. The resident was observed walking in the hallways of the facility, at times. The resident left the facility for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys stop working properly). On 2/24/25 bingo was scheduled but did not occur and on 2/25/25 games, music and bingo were scheduled but did not occur.

On 2/23/25 at 10:01 AM and 2/24/25 at 1:04 PM, Resident 20 stated there were no activities in the facility and she/he was "stuck" staring at the walls in her/his room or watching television. Resident 20 reported she/he was "an artist" but there were no art supplies except color crayons and coloring pages designed for kids and there were no enrichment activities like arts/crafts, exercising or chair yoga. Resident 20 stated Staff 11 (Activity Director/Social Service Director) was so busy he was unable to walk with the resident when it was nice outside. Resident 20 reported she/he "spoke-up" at Resident Council and tried to offer ideas and solutions for the lack of activities.

On 2/25/25 at 8:24 AM, Staff 9 (CNA) stated Resident 20 liked bingo and "hanging-out" with people. Staff 9 stated there were no activities occurring in the facility except "maybe" bingo once a month, there were no "real activities here" and there was "nothing" going on in Resident 20's room that he was aware of.

On 2/25/25 at 10:13 AM, Staff 11 stated he was new to the position of activity director and had been in this role for approximately three months. Staff 11 stated he received two weeks of training which occurred concurrently with his medical records training and he had no previous experience running an activities program in a long-term care setting. Staff 11 stated it was his responsibility to complete the activities section on the MDS, complete an admission/annual activity assessment, develop the residents' activity care plans, complete quarterly activity reviews and document all activities in residents' electronic health records. Staff 11 stated Resident 20 liked to watch anime and play bingo and Uno with the group. Staff 11 stated his job also included social service director and working in medical records and, because of his schedule, he usually missed two to three scheduled activities a week.

On 2/26/25 at 12:52 PM Staff 2 (Administrator-In-Training) and at 1:11 PM Staff 1 (Administrator) were present for an interview. Staff 2 stated he was aware activities were an issue but did not realize the extent of the problem. Staff 2 acknowledged scheduled activities were being missed. Staff 1 stated he expected activities to be planned based on residents' requests, preferences, physical and mental abilities, and activities occurred every day and at various times of the day.



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3. Resident 5 was admitted to the facility in 8/2024 with diagnoses including heart failure.

An 8/27/24 Activity Admission Assessment revealed Resident 5 was interested in participating in activities.

A 9/3/24 Annual MDS indicated Resident 5 had no cognitive impairments and was interested in participating in group activities.

Resident 5's Care Plan revised on 12/9/24 included goals of increased participation in activities with interventions including giving Resident 5 verbal reminders of activities before the start of activities.

A review of Resident 5's activity Task Records from 1/25/25 through 2/24/25 revealed Resident 5 did not participate in any activities.

On 2/23/25 at 9:33 AM Resident 5 stated she/he was rarely invited to activities and activities rarely occurred as scheduled.

Review of the 2/2025 Activity Calendar revealed the following activities were scheduled on 2/24/25:
- Games and Music at 11:00 AM
- Bingo at 1:00 PM

Random observations on 2/24/25 from 8:00 AM through 4:00 PM revealed no scheduled games, music or bingo occurred.

On 2/25/25 at 8:24 AM Staff 9 (CNA) stated the only activity he ever observed occurring was bingo which only happened once a month.

On 2/25/25 at 10:17 AM Staff 11 (Activity Director/Social Services Director) stated Resident 5's activity participation was documented in the activity logs, but he had not completed any documentation specifically regarding Resident 5's participation. Staff 11 acknowledged activities did not occur as scheduled due to the challenges of fulfilling responsibilities as both the Activity Director and the Social Service Director.

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include:

On 2/25/25 at 10:17 AM Staff 11 (Activity Director/Social Services Director) stated one of his roles at the facility was to organize and lead activities. Staff 11 stated he was told a certification was not necessary to performed the duties of an Activity Director and confirmed he had not started or completed the necessary training required.

On 2/26/25 at 1:11 PM Staff 1 (Administrator) confirmed Staff 11 did not have the necessary Activity Director certification.

Based on observation, interview and records review it was determined the facility failed to assess safety with smoking for 1 of 1 resident (#19) reviewed for smoking. This placed residents at risk for unsafe smoking. Findings include:

The facilities 8/2022 Smoking Policy for Residents states resident smoking status is evaluated upon admission. If a smoker, the evaluation includes:
- current level of tobacco consumption;
- method of tobacco consumption;
- desire to quit smoking; and
- ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).

Resident 19 was admitted to the facility in 1/2025 which diagnoses including congestive heart failure.

A review of Resident 19's clinical record revealed no indication a smoking assessment was completed or if the resident was an independent smoker.

On 2/23/25 at 10:07 AM a list of residents who smoke was received from Staff 1 (Administrator) and Resident 19 was not included on the list.

On 2/25/25 at 12:15 PM Resident 19 was observed independently entering the smoking area with smoking supplies.

On 2/25/25 at 12:20 PM Staff 1 was observed entering the smoking area. At 12:25 PM Staff 1 reentered the facility holding Resident 19's cigarettes and lighter. Staff 1 stated "I'm going to be back to do a smoking assessment on [her/him]."

On 2/25/25 at 12:42 PM Staff 9 (CNA) stated Resident 19 kept her/his own smoking supplies and went out on her/his own to smoke since the resident was admitted to the facility.

On 2/25/25 at 1:29 PM Staff 3 (DNS/RNCM) acknowledged Resident 19 was not assessed for smoking safety and should have been prior to being allowed to smoke independently for Resident 19's safety.

Based on observation, interview and record review it was determined the facility failed to ensure dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (# 20) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include:

Resident 20 was admitted to the facility in 8/2024 with diagnoses including diabetes, end-stage renal disease and dependence on dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly).

Resident 20's 8/18/24 Admission MDS indicated the resident had no cognitive impairments and received dialysis.

Resident 20's 1/26/25 Dialysis Care Plan indicated the resident received dialysis on Tuesday, Thursday and Saturday.

From 2/1/25 through 2/25/25, Resident 20 had 10 dialysis treatments.

A review of Resident 20's Dialysis Communication Forms from 2/1/25 through 2/25/25 revealed the following days when the facility did not have pre-dialysis and post-dialysis information:
-2/4/25, 2/6/25 and 2/15/25.

A review of Resident 20's health record revealed no evidence nursing staff contacted the dialysis center to obtain a verbal or electronic report on 2/4/25, 2/6/25 or 2/15/25.

On 2/25/25 at 1:36 PM, Resident 20 was out of the facility for dialysis and at 2:01 PM, she/he was observed returning to the facility from her/his scheduled dialysis appointment.

On 2/23/25 at 10:01 AM, Resident 20 stated she/he went to dialysis three times a week; on Tuesday, Thursday and Saturday. Resident 20 stated the facility did not consistently complete the Dialysis Communication Form and nursing did not always assess her/him upon returning back to the facility from the dialysis center for several hours after she/he returned.

On 2/26/25 at 8:09 AM and 12:16 PM Staff 3 (DNS/RNCM) stated the top portion of the Dialysis Communication Form was to be completed by the nurse and sent with the resident to dialysis. She stated upon the resident's return, the dialysis center should have completed the mid-portion of the Dialysis Communication Form, the nurse assessed the resident and then completed the last section of the report. Staff 3 confirmed the facility did not have pre-dialysis and post-dialysis information for Resident 20 on 2/4/25, 2/6/25 and 2/15/25 and there was no evidence nursing staff contacted the dialysis center to obtain a verbal or electronic report. Staff 3 stated she expected communication between the facility and dialysis center via the Dialysis Communication Form for each dialysis visit and, if information was missing, she expected staff to contact the dialysis center to obtain the information.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day, seven days per week for 33 of 61 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include:

The facility's Staffing, Sufficient and Competent Nursing Policy, last revised 8/2022, indicated the following:
-A registered nurse provided services at least eight consecutive hours every 24 hours, seven days a week.

A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following:

In 7/2024, nine days were reviewed and revealed four days without appropriate RN coverage on 7/16/24, 7/20/24, 7/22/24 and 7/23/24.

In 8/2024, 22 days were reviewed and revealed 12 days without appropriate RN coverage on 8/4/24, 8/5/24, 8/6/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24 and 8/24/24.

In 9/2024, 30 days were reviewed and revealed 17 days without appropriate RN coverage on 9/1/24, 9/3/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/21/24, 9/23/24, 9/24/24, 9/26/24, 9/28/24, 9/29/24 and 9/30/24.

On 2/25/25 at 4:01 PM and 2/26/25 at 12:04 PM, Staff 1 (Administrator) and Staff 2 (Administrator-In-Training) reported RN coverage for the facility had been challenging for several months. Staff 1 and Staff 2 reviewed the DCSDRs for 7/2024, 8/2024 and 9/2024 and staff payroll records, and acknowledged the lack of RN coverage on the days identified.

Based on observation, interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include:

The facility's Staffing, Sufficient and Competent Nursing Policy, last revised 8/2022, indicated the following:
-Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) were posted in the facility for every shift.

A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following:

From 1/21/25 through 2/22/25, 32 days were reviewed and revealed 11 days when portions of the DCSDRs were incomplete or inaccurate on 1/23/25, 1/24/25, 1/29/25, 1/30/25, 1/31/25, 2/12/25, 2/13/25, 2/14/25, 2/20/25, 2/21/25 and 2/20/25.

On 2/25/25 at 4:01 PM, Staff 1 (Administrator) and Staff 2 (Administrator-In-Training) reviewed the 1/21/25 through 2/22/25 DCSDRs and verified the reports were incomplete or inaccurate on the days identified. Staff 1 and Staff 2 stated they expected the DCSDRs to be completed accurately and with all information included.

Based on observation, interview and record review it was determined the facility failed to properly dispose of expired medications for 1 of 1 resident medication storage refrigerators and 1 of 1 medical storage rooms reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include:

The facility's Storage of Medications policy with revision date 11/2020 did not address vials of medications but indicated outdated medications were to be destroyed by the facility. The manufacturer insert indicated an open and in use multi-dose vial of Tuberculin should be thrown away after 30 days to avoid oxidation and degradation.

During a review of the resident medication storage refrigerator on 2/24/25 at 11:33 AM Staff 12 (LPN) verified the following expired medication was found:
- one open and used multi-dose vial of Tuberculin (solution used in testing for Tuberculosis) with an open date of 1/22/25.

On 2/24/25 at 11:36 AM Staff 12 stated the facility policy was to throw away open vials after 30 days.

During a review of the medication storage room on 2/24/25 at 1:22 PM Staff 2 (Administrator-In-Training) verified the following expired medications were found:
- two bottles of Sarna lotion (lotion for relief of itching) with 9/2022 expiration dates.
- three bottles of Sarna lotion with 3/2023 expiration dates.

On 2/24/25 at 1:25 PM Staff 2 stated the facility policy for expired medications was to throw away the expired medications and order replacements if needed.

Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 4 of 4 kitchen refrigerators and 1 of 1 unit refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

Review of the US FDA 2022 Food Code indicated the following:
-Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded.
-Food must be labeled with a use-by-date if stored for at least 24 hours.
-Food could be stored up to seven days.

The facility's Food Receiving and Storage Policy, last revised 10/2017, revealed the following:
-Foods shall be received and stored in a manner that complies with safe food handling practices.
-All foods stored in the refrigerator or freezer will be covered, labeled and dated ("use by" date).
-All food belonging to residents must be labeled with the resident's name, the item and the "use by" date.
-Beverages must be dated when opened and discarded after 24 hours.

1. On 2/23/25 at 9:02 AM, a brief kitchen tour was completed and revealed the following:
-In refrigerator number one, a block of cheese slices was unlabeled and undated and a plastic to-go container with a white grated substance was unlabeled and undated.
-In refrigerator number two, two pitchers of red liquid were unlabeled and undated.
-In refrigerator number four, 24 one pound cubes of butter were undated and three five pound blocks of cheese were unlabeled and undated.

On 2/23/25 at 9:02 AM, Staff 5 (Cook) confirmed the items identified in refrigerator one, refrigerator two and refrigerator four were not properly labeled or dated.

On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items to be labeled and dated.

2. On 2/25/25 at 10:00 AM and 10:09 AM, Staff 6 (Cook) and Staff 13 (CNA) reviewed the residents' refrigerator which contained numerous food and beverage items. The following food and beverages were observed to be stored as follows:
-a previously opened, one liter bottle of soda pop was unlabeled and undated.
-a previously opened 12 ounce bottle of cola was unlabeled and undated.
-a previously opened 12 ounce bottle of tea was unlabeled and undated.
-a dirty and stained cloth bag containing a bottle of liquid and various food items was unlabeled and undated.

On 2/25/25 at 10:09 AM, Staff 6 and Staff 13 confirmed the above mentioned food and beverage items located in the residents' refrigerator were not properly labeled or dated and a dirty cloth bag of beverages and food should not be stored in the refrigerator due to concerns with cross contamination.

On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items in the residents' refrigerator should be labeled and dated.

3. On 2/26/25 at 9:45 AM, a follow-up kitchen visit was completed with Staff 4 (Dietary Manager) which revealed the following:
-In refrigerator number one, seven individual servings of brown sauce in plastic to-go cups were unlabeled and undated and four, one pound cubes of butter were undated.
-In refrigerator number three, a plastic to-go container of pasta was unlabeled and undated.
-In refrigerator number four, 22 one pound cubes of butter were undated and three five pound blocks of cheese were unlabeled and undated.

On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items to be labeled and dated.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 3 sampled staff (#10) and staff employed two or more years for 2 of 3 sampled staff (#s 7 and 9) reviewed for background checks. This placed residents at risk for abuse. Findings include:

The facility's Background Screening Investigations Policy, last revised 3/2019, indicated the following:
-The Director of Personnel or designee conducted background checks on all potential direct access employees and contractors. Background and criminal checks were initiated within two days of an offer of employment or contract agreement and completed prior to employment.

On 2/25/25 at 11:32 AM, during a review of background checks for three randomly selected new hire staff and three randomly selected staff employed two years or more, Staff 2 (Administrator-In-Training) stated the following:

-Staff 10 (Administrator), hire date 2/17/25, had no background check completed;
-Staff 7 (Cook), hire date 1/16/22, most recent background check was completed on 1/11/22; a two year background check should have been completed on 1/11/24.
-Staff 9 (CNA), hire date 3/23/20, most recent background check was completed on 3/18/21; a two year background check should have been completed on 3/18/23.

On 2/25/25 at 11:32 AM, Staff 2 reported Staff 10's preliminary background check determination was closed on 2/20/25 due to Staff 10 not submitting required information. Staff 2 stated he was not aware Staff 10's background check was closed. Staff 2 verified Staff 7 and Staff 9 were employed for two years or more and did not have background checks completed every two years, as required. Staff 2 stated he expected all staff to have preliminary or approved background checks in place.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift for 43 of 93 days reviewed for staffing. This placed residents at risk for unmet assessments and care needs. Findings include:

A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following:

In 7/2024, nine days were reviewed and revealed four days without appropriate RN coverage on 7/16/24, 7/20/24, 7/22/24 and 7/23/24.

In 8/2024, 22 days were reviewed and revealed 12 days without appropriate RN coverage on 8/4/24, 8/5/24, 8/6/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24 and 8/24/24.

In 9/2024, 30 days were reviewed and revealed 17 days without appropriate RN coverage on 9/1/24, 9/3/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/21/24, 9/23/24, 9/24/24, 9/26/24, 9/28/24, 9/29/24 and 9/30/24.

From 1/21/25 through 2/22/25, 32 days were reviewed and revealed 10 days without appropriate RN coverage on 1/22/25, 1/23/25, 1/24/25, 1/31/25, 2/5/25, 2/6/25, 2/7/25, 2/13/25, 2/20/25 and 2/21/25.

On 2/25/25 at 4:01 PM and 2/26/25 at 12:04 PM, Staff 1 (Administrator) and Staff 2 (Administrator-In-Training) reported RN coverage for the facility had been challenging for several months. Staff 1 and Staff 2 reviewed the DCSDRs for 7/2024, 8/2024, 9/2024 and 1/21 through 2/22/25 and acknowledged the lack of RN coverage on the days identified.

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OAR 411-088-0080 Notice Requirements

Refer to F623
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OAR 411-086-0230 Activity Services

Refer to F679 and F680
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OAR 411-086-0350 Smoking

Refer to F689
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OAR 411-086-0110 Nursing Services

Refer to F698
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F727 and F732
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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OAR 411-086-0250 Dietary Services

Refer to F812

Based on interview and record review it was determined the facility failed to ensure a resident representative was provided written notice of the facility bed hold policy for 1 of 3 sampled residents (#1) reviewed for bowel care. This placed residents and responsible parties at risk for lack of knowledge related to rights to return to the facility. Findings include:

Resident 1 was admitted to the facility in 2023 with a diagnosis of a stroke.

Resident 1's record revealed she/he had an appointed guardian.

A Bed-Holds and Returns policy last revised 3/2022 revealed residents were to receive written information in the admission packet about the bed-hold policy and within 24 hours of an emergency transfer.

Progress Notes revealed Resident 1 was sent to the emergency department on 2/21/24. The notes indicated the guardian was contacted on 2/27/24, the guardian reported she/he wanted the facility to hold the resident's bed and was then was notified by the facility she/he would be financially responsible to place a hold for the resident's bed. The 2/28/24 note indicated the guardian deliberated the cost of the bed-hold, did not want to hold Resident 1's bed and the facility notified the guardian the resident's belongings would be stored at the facility until they were able to pick up the items.

On 3/7/24 at 2:13 PM Witness 1 (Hospital Case Manager) stated when she spoke to Resident 1's guardian she/he indicated she/he did not receive written information about the bed-hold policy and was told by phone she/he had to pay in order to allow Resident 1 to be readmitted to the facility. Resident 1's guardian could not afford to hold the bed and did not understand the resident could go back to the facility.

On 3/7/24 and 3/8/24 via e-mail Staff 6 (Administrator In Training) indicated Resident 1's guardian was notified by phone and not in writing of the facility's bed-hold policy after the resident was discharged from the facility. On 3/8/24 Staff 6 also stated the resident's guardian was not provided an admission agreement which contained a bed-hold policy when the resident was initially admitted to the facility.

Based on interview and record review it was determined the facility failed to ensure bowel status was assessed and a bowel care medication regimen was administered as ordered for 1 of 3 sampled residents (#1) reviewed for bowel care. Resident 1 developed abdominal pain, was admitted to the hospital and required surgery to remove part of the large intestine due to impaction (hardened stool stuck in the rectum or lower colon due to chronic constipation-occurs when constipated for a long time) and a colostomy (surgical procedure used to bring the healthy end of the large intestine through the abdominal wall for feces to leave the body) was placed. Findings include:

Resident 1 was admitted to the facility 10/4/23 with diagnoses including developmental delay and stroke.

An 10/3/23 hospital physician Progress Note revealed Resident 1 had a diagnosis of "severe constipation, chronic-improved" and had a history of chronic constipation with past "frequent" admissions. The resident was to continue senna (laxative) and Miralax (Miralax) at a high frequency in the hopes of getting more doses in her/him as the resident often refused the medication. The goal was for the resident to have one bowel movement per day. The note also indicated the resident's family reported Miralax was an effective medication regimen at home.

An 10/4/23 hospital Discharge Order included glycolax (generic for Miralax) administered four times a day.

Review of the 10/2023 MAR revealed Resident 1's physician order for glycolax four times a day was not initiated.

Progress Notes for 10/2023 revealed no staff communication with Resident 1's physician requesting to discontinue the glycolax four times a day.

A care plan initiated 10/4/23 did not address the resident's history of constipation.

An 10/11/23 admission MDS and associated CAAs did not address Resident 1's history of constipation, past hospitalizations for constipation or goals identified in the resident's hospital records for the resident to have one bowel movement a day.

Resident 1's 1/2024 bowel record revealed she/he had up to three bowel movements a day except on 1/2/24 when the resident did not have a bowel movement. 11 of 63 bowel movements were documented as small.

A 2/2024 bowel record revealed the following:
-2/1/24 no bowel movement
-2/2/24 small soft bowel movement on the night shift
-2/3/24 and 2/4/24 no bowel movement
-2/5/24 medium soft bowel movement on the day shift
-2/6/24 through 2/11/24 no bowel moment
-2/12/24 small soft bowel movement on night shift
-2/13/24 large formed bowel movement on the evening shift
-2/14/24 and 2/15/24 no bowel movement
-2/16/24 small soft bowel movement on the evening shift and a large soft bowel movement on the night shift
-2/17/24 small soft bowel movements on day and night shifts
-2/18/24-2/20/24 no bowel movement
(Resident 1 had nine bowel movements in 20 days. Resident 1 was discharged on 2/21/24 at approximately 1:00 AM).

On 3/6/24 at 2:18 PM Staff 5 (CNA) stated when Resident 1 had a bowel movement on 2/17/21 it was the size of a small plastic spoon and was the consistency of peanut butter.

On 3/7/24 at 1:03 PM Staff 4 (CNA) stated when Resident 1 had a bowel movement on 2/17/24 it was the size of a golf ball. Staff 4 stated on 2/20/24 when the resident went to the hospital her/his stomach was very big and it was not like that on 2/17/24. If it was big, she would have reported it to the nurse.

Resident 1's 2/2024 MAR from 2/1/24 through 2/20/24 revealed the following:

-Sennosides (treats constipation) BID was refused 9 of 40 opportunities.

-Bisacodyl rectal suppository was to be administered if the resident did not have a bowel movement for greater than 48 hours.
-there were no documented refusals when the resident did not have a bowel movement from 2/6/24-2/11/24
-Resident one refused bisacodyl on 2/13/24 (Lactulose/laxative was administered; see below)
-One dose was administered on 2/20/24 at 12:03 AM prior to the resident's discharge to the hospital

-Lactulose BID if bisocodyl was refused.
-Lactulose was administered on 2/5/25 but no indication a bisocodyl suppository was refused
-Lactulose was administered on 2/9/24 but no indication a bisacodyl suppository was refused (documented as ineffective but not readministered)
-Lactulose was administered on 2/13/24 after the suppository was refused
-Lactulose was administered on 2/20/24 prior to the resident's hospitalization

Glycolax every four hours PRN:
-a dose was administered on 2/3/24,was documented as ineffective, the resident was not administered another dose and the resident did not have a bowel movement on 2/3/24
-a dose was administered 2/10/24 at 10:03 PM and documented as ineffective and another dose was not given until 2/12/24 at 7:08 AM
-a dose was administered on 2/13/24 at 9:34 PM and effectiveness was documented as "unknown". No dose was re-administered when the resident did not have a bowel movement on 2/14/24.

Progress notes revealed on 2/13/23 Resident 1 did not have a bowel moment for three days, had hypoactive bowel sounds (reduced regularity of sound indicating slowed bowel activity), her/his abdomen was distended and non-tender. Resident 1 stated she/he passed gas, refused a suppository and was administered Lactulose. On 2/21/24 the note indicated Resident 1 screamed in pain, her/his abdomen was slighted distended and reported something was not right. The resident was administered a suppository at approximately 12:00 AM, the physician was notified and the resident was sent to the hospital.

Resident 1's record did not include additional assessments when the resident did not have a bowel movement from 2/6/24 through 2/11/24 or an assessment related to the change in the resident's bowel pattern from 1/2024 to 2/2024.

A 2/15/24 Managed Risk Agreement indicated Resident 1 refused ADL care, dietary recommendations, physician visits, CBGs, insulin, therapy, mental health services and interactions with staff. The form did not address bowel care refusals.

A 2/21/24 at 1:29 AM Emergency Department Provider Note indicated Resident 1 vomited upon arrival to the hospital and had a firm, distended, tender abdomen. The resident had imaging which showed a "very large" colon with "very large stool burden." Resident 1's diagnosis was fecal impaction and stercoral colitis (chronic constipation leads to fecal impaction, colon distention and masses of dehydrated fecal material). Aggressive bowel care was provided.

A 2/24/24 Operative Report revealed Resident 1 had stercoral colitis and a large bowel obstruction. Findings included an "immensely" dilated rectum and "immense" stool burden with "no possibility" of cleaning out the colon resulting in a colostomy.

On 3/7/24 at 9:12 AM Staff 1 (DNS) stated the initial screening of documents for new admissions to the facility was usually completed by the DNS or the RNCM. The DNS or RNCM reviewed the documents provided by the hospital including the history and the orders. Staff 1 acknowledged the facility had the information related to the resident's history of constipation, the resident's frequent hospitalizations related to constipation, and the facility did not assess and implement a care plan specific to the resident's bowel care needs. Staff 1 stated the orders were initially entered into the computer by the RNCM and the floor nurses reviewed the hospital orders prior to the first medication administration. A request was made to Staff 1 to provide documentation at the time of the resident's admission to the facility the staff clarified with the physician the glycolax was not to be administered four times a day and only PRN. No additional information was provided.

***************
OAR 411-088-0050 Right to Return from Hospital

Refer to F625
***************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
***************

Based on interview and record review it was determined the facility failed to notify the physician of a worsening wound and weight loss for 2 of 2 sampled residents (#18 and #72) reviewed for wounds and nutrition. This placed residents at risk for inappropriate treatment, delayed healing and weight loss. Findings include:

1. Resident 72 was admitted to the facility in 2003 with diagnoses including stroke.

Resident 72's Progress Notes from 9/21/22 through 10/7/22 revealed the following:

- On 9/22/22 the resident's right big toenail was loose and bleeding after the resident's sock was removed. The provider gave treatment orders to apply a band-aid to secure the nail and change the band-aid daily.

- On 9/27/22 the resident's toenail was coming off while in the shower with a moderate amount of bleeding. Pressure was applied, cleaned with wound cleanser and wrapped with gauze bandage wrap. A referral was received for the resident to be seen by a podiatrist. No notification to the physician or request for new treatment orders was found in the resident's clinical record.

- On 9/30/22 no signs of infection were noted to the resident's right big toe and second toe. The note did not indicate what the issue was with the second toe or why it was monitored for infection.

- On 10/7/22 the resident's right big toe and second right toenails "came off", there were no signs or symptoms of infection and they both appeared healed.

On 10/18/23 at 10:45 AM, 11:38 AM and 12:27 PM Staff 2 (DNS) acknowledged there was no indication the physician was notified when the condition worsened.

Refer to F684

, 2. Resident 18 was admitted to the facility in 2023 with diagnoses including brain damage.

Review of weight records from 8/2023 through 10/2023 revealed Resident 18 weighed 127.4 on 8/9/23. On 10/15/23 Resident 18 weighed 113.1 pounds which was an 11.22% loss.

Review of Resident 18's 8/2023 through 10/2023 records revealed no physician notification was made regarding Resident 18's unplanned weight loss.

On 10/19/23 at 10:48 AM Staff 2 (DNS) confirmed Resident 18's physician should have been notified of Resident 18's unplanned weight loss.

Based on observations and interviews it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include:

Observations of the facility's general environment and residents' rooms from 10/17/23 through 10/20/23 identified the following issues:
-Rooms 6 and 7 had missing light covers on their walls.
-Rooms 8 and 10 had missing portions of blinds on the windows.
-Room 7's sink had pulled away from the wall approximately 1 inch leaving a gap between the sink and wall.
-The wood frame of the awning covering the outdoor smoking area had a broken rafter and rotten wood.
-The wooden threshold between a door and the smoking area had a two inch gap where the wood was missing. The remaining wood of the threshold contained divots and was missing paint.

On 10/19/23 at 11:20 AM a facility walk through was completed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). Staff 1 and Staff 6 both acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident for dementia for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs. Findings include:

Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia.

Resident 8's 8/28/23 CAA for Cognitive Loss/Dementia failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident or a rationale for the care planning decision.

On 10/19/23 at 9:48 AM the CAA was reviewed with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) who acknowledged the assessment was not comprehensive.

Based on interview and record review it was determined the facility failed to timely assess a resident for a significant change in condition for 1 of 1 sampled resident (#8) reviewed for dementia, hospice and unnecessary medications. This placed residents at risk for unmet care needs. Findings include:

Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia.

A physician's order dated 8/11/23 indicated Resident 8 was admitted to hospice on 8/11/23.

Resident 8's significant change in status MDS was dated 8/28/23.

On 10/19/23 at 9:48 AM the MDS assessment date was reviewed with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) who acknowledged the assessment was completed late.

Based on interview and record review it was determined the facility failed to accurately assess a resident for behaviors for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs. Findings include:

Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia.

Resident 8's 8/28/23 MDS indicated the resident had no indicators for psychosis or behavioral symptoms.

Resident 8's 10/19/23 Care Plan indicated the resident's behavior was monitored due to the resident's tendency to yell aggressively, curse, engage in inappropriate behavior toward female staff and argue with her/his roommate.

On 10/19/23 at 9:48 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) verified Resident 8's care plan was accurate, the resident was on behavior monitoring and the MDS assessment was not correct.

Based on interview and record review it was determined the facility failed to provide wound care and obtain physician's orders for wound care for 1 of 1 sampled resident (#72) reviewed for wounds. This placed residents at risk for infection and delayed healing. Findings include:

Resident 72 was admitted to the facility in 2003 with diagnoses including stroke.

Resident 72's Progress Notes from 9/21/22 through 10/7/22 revealed the following:

- On 9/22/22 the resident's right big toenail was loose and bleeding after the resident's sock was removed. The provider gave treatment orders to apply a band-aid to secure the nail and change the band-aid daily.

- On 9/27/22 the resident's toenail was coming off while in the shower with a moderate amount of bleeding. Pressure was applied, cleaned with wound cleanser and wrapped with gauze bandage wrap. A referral was received for the resident to be seen by a podiatrist. No notification to the physician or request for new treatment orders was found in the resident's clinical record.

- On 9/30/22 no signs of infection were noted to the resident's right big toe and second toe. The note did not indicate what the issue was with the second toe or why it was monitored for infection.

- On 10/2/22 no signs of infection were noted to the right big toe and second toe. Cleaned with wound cleaner and [left] open to air (no bandage was applied). No physician's order for this treatment was found in the resident's clinical record.

- On 10/4/22 No bleeding from the right foot. Cleaned with wound cleaner and left open to air.

- On 10/7/22 the resident's right big toe and second right toenails "came off", there were no signs or symptoms of infection and they both appeared healed.

Resident 72's 9/2022 and 10/2022 TARs revealed no indication treatment was provided to the resident's right big toe.

On 10/18/23 at 10:45 AM, 11:38 AM and 12:27 PM Staff 2 (DNS) acknowledged there was no indication daily treatment was provided as ordered on 9/22/22, no indication the physician was notified when the condition worsened or updated treatment orders were provided.

Based on observation, interview and record review it was determined the facility failed to assess and monitor weight loss for 1 of 1 sampled resident (#18) reviewed for nutrition. This placed residents at risk for unidentified weight changes. Findings include:

Resident 18 was admitted to the facility in 7/2023 with diagnoses including brain damage.

Review of weight records from 8/2023 through 10/2023 revealed Resident 18 weighed 127.4 on 8/9/23. On 10/15/23 Resident 18 weighed 113.1 pounds which was an 11.22% weight loss.

Review of Resident 18's Dietary Orders from 8/2023 through 10/2023 revealed only a single change was made on 8/25/23 with an increase of banana flakes given twice a day to three times a day. No other dietary changes were made for Resident 18.

On 10/19/23 at 10:48 AM Staff 2 (DNS) stated Resident 18's weight loss was unplanned and dietary modification were not attempted to appropriately address this unplanned weight loss.

On 10/19/23 at 2:23 PM Staff 16 (Dietary Manager) confirmed no additional changes after 8/25/23 were made for Resident 18's dietary orders regarding her/his unplanned weight loss.

Based on interview and record review it was determined the facility failed to ensure an RN worked eight consecutive hours per day seven days per week for 46 of 97 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include:

Review of the Direct Care Staff Daily Reports from 1/1/23 through 1/25/23, 2/19/23 through 2/28/23, 3/1/23 through 3/31/23 and 9/16/23 through 10/16/23 revealed the following days in 2023 with no RN coverage for eight consecutive hours:

-January: 1, 2, 9, 10, 12, 13, 16, 17, 22, 23 and 24.
-February: 19, 20, 21, 22, 24, 25, 26, 27 and 28.
-March: 3, 4, 5, 6, 7, 12, 13, 14, 16, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31.
-September: 17.
-October: 1, 8 and 15.

On 10/18/23 at 1:10 PM Staff 1 (Administrator) and Staff 5 (HR/Hiring Specialist) confirmed the facility lacked RN coverage on the identified dates.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 2 of 5 sampled residents (#s 8 and 9) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include:

1. Resident 8 was admitted to the facility in 2022 with diagnoses including anemia.

Monthly pharmacist reviews of Resident 8's medication regimen revealed the following:
- On 8/7/23 the pharmacist recommended the resident's vitamin B12 supplement be discontinued because a 7/14/23 laboratory test indicated the resident's B12 level was 695 (normal range is 160 to 950).
- On 9/11/23 the pharmacist made a repeat recommendation to discontinue the vitamin B12.
- On 10/9/23 the pharmacist made a repeat recommendation to discontinue the vitamin B12.

Resident 8's clinical record revealed no indication the pharmacist's repeated recommendations to discontinue the vitamin B12 were followed up.

On 10/19/23 at 11:48 AM Staff 2 (DNS) stated she had no explanation for why the pharmacist's recommendations were not followed up.
,
2. Resident 9 was admitted to the facility in 2023 with diagnoses including stroke and anxiety disorder.

Monthly pharmacist reviews of Resident 9's medication regimen revealed the following:
-On 9/11/23 the pharmacist recommendation advised the prescriber to reassess if PRN lorazepam was needed. If the medication was continued, then rationale and duration of treatment was required. No response from the provider was found in Resident 9's health care record or provided by the facility.

-On 10/9/23 the pharmacist made a repeat recommendation which again advised the prescriber to reassess if PRN lorazepam was needed. If the medication was continued, then rationale and duration of treatment was required. No response from the provider was found in Resident 9's health care record or provided by the facility.

On 10/20/23 at 10:30 AM Staff 2 (DNS) confirmed the facility did not receive a response from Resident 9's provider regarding the 9/2023 and 10/2023 pharmacist's recommendations.

Based on interview and record review it was determined the facility failed to discontinue a medication per physician's order for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include:

Resident 8 was admitted to the facility in 2022 with diagnoses including anemia.

Resident 8's 10/2023 MAR revealed the resident had a physician's order for vitamin B12 daily with a start date of 10/8/23. The MAR revealed the vitamin B12 was administered from 10/1/23 through 10/19/23.

A physician's order dated 10/10/23 indicated the vitamin B12 was discontinued.

On 10/19/23 at 11:48 AM Staff 2 (DNS) and Staff 15 (RNCM) verified the vitamin B12 should have been discontinued on 10/10/23 and was administered to the resident from 10/10/23 through 10/19/23.

Based on interview and record review it was determined the facility failed to ensure PRN psychotropic medications were ordered with duration of treatment and rationale for 2 of 5 sampled residents (#s 8 and 9) reviewed for unnecessary medications. This placed residents at risk for unnecessary psychotropic medications. Findings include:

1. Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia.

Resident 8's 10/2023 MAR revealed the resident had a physician's order for lorazepam (antianxiety medication) PRN with a start date of 8/14/23 and was discontinued on 10/10/23.

A pharmacist's recommendation dated 10/9/23 indicated Resident 8 needed to be evaluated in person by the physician, document a rationale and duration to extend the PRN lorazepam beyond 14 days.

The physician's response, to the pharmacist's recommendation, dated 10/10/23 indicated "Continue for 90 days" with a rationale "Hospice Care Package".

On 10/19/23 at 12:41 PM Staff 1 (Administrator) acknowledged the rationale to continue the lorazepam was not adequate.

, 2. Resident 9 was admitted to the facility in 2023 with diagnoses including stroke and anxiety disorder.

An 8/14/23 Physician Order indicated Resident 9 was prescribed lorazepam (a psychotropic medication used to treat anxiety) every four hours PRN anxiety, agitation, inability to relax and/or insomnia. The medication had an end date of 10/10/23. The resident received lorazepam on the following days in 2023:
-8/15/23, 9/10/23, 9/11/23, 9/12/23, 9/17/23, 10/1/23 and 10/8/23.

A review of Resident 9's health care record revealed no rationale was provided for use of PRN lorazepam beyond 14 days.

A 10/10/23 Physician Order indicated Resident 9 was prescribed lorazepam every four hours PRN anxiety, agitation, inability to relax and/or insomnia. The resident received lorazepam on the following days in 2023:
-10/14/23, 10/18/23 and 10/19/23.

A review of Resident 9's health care record revealed no duration of treatment or rationale for use of PRN lorazepam beyond 14 days.

A 9/2023 and 10/2023 pharmacist's recommendation indicated Resident 9 needed to be evaluated in person by the physician, document a rationale and duration to extend the PRN lorazepam beyond 14 days.

On 10/20/23 at 10:30 AM Staff 2 (DNS) confirmed there was no rationale and/or duration of treatment for continued use of the resident's PRN lorazepam. Staff 1 (Administrator) stated he expected all providers to follow the regulations regarding PRN psychotropic medications.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from medication error rates of five percent or greater for 4 of 6 sampled residents (#s 2, 4, 10 and 15) reviewed for medication administration. The facility's medication error rate was 18.5 percent. This placed residents at risk for adverse medication consequences. Findings include:

1. Resident 10 was admitted to the facility in 2022 with diagnoses including rib fractures.

Resident 10's 10/2023 MAR included a physician's order for morphine sulphate (narcotic pain medication) 5 mg TID at 8:00 AM, 2:00 PM and 8:00 PM.

On 10/18/23 at 10:15 AM Staff 8 (CMA) administered 5 mg of morphine sulphate to Resident 10.

On 10/18/23 at 1:10 PM Staff 8 acknowledged the morphine sulphate was administered late.

On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times.

2. Resident 2 was readmitted to the facility 2023 with diagnoses including hip pain and palliative care.

Resident 2's 10/2023 MAR included a physician's order for acetaminophen 650 mg (pain medication) TID at 8:00 AM, 2:00 PM and 8:00 PM.

a. On 10/18/23 at 10:31 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 2.

On 10/18/23 at 1:10 PM Staff 8 acknowledged the acetaminophen was administered late.

b. On 10/20/23 at 9:42 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 2.

On 10/20/23 at 9:42 AM Staff 8 acknowledged the acetaminophen was administered late.

On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times.

3. Resident 15 was admitted to the facility in 2022 with diagnoses including diabetes.

Resident 15's 10/2023 MAR included a physician's order for insulin glargine (treats high blood sugar) 50 unit injection.

On 10/18/23 at 11:46 AM Staff 9 (LPN) prepared Resident 8's insulin glargine injector pen. Staff 9 did not prime the pen by activating a 2 unit test dose to remove air from the needle. Staff 9 was stopped before she administered the insulin to the resident. Staff 9 then activated a test dose.

On 10/18/23 at 1:15 PM Staff 2 (DNS) verified insulin pens were supposed to be primed before use.

4. Resident 4 was readmitted to the facility in 2023 with diagnoses including chronic pain.

Resident 4's 10/2023 MAR included a physician's order for acetaminophen 650 mg (pain medication) BID at 7:00 AM and 7:00 PM.

On 10/20/23 at 9:21 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 4.

On 10/20/23 at 9:36 AM Staff 8 acknowledged the acetaminophen was administered late.

On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include:

Resident 8 was admitted to the facility in 2022 with diagnoses including high blood pressure.

Resident 8's 9/2023 and 10/2023 MARs revealed the resident had a physician's order for metoprolol (treats high blood pressure) with a start date of 2/18/23 and parameters to not administer the medication if the resident's heart rate was less than 60. The MARs indicated the resident's heart rate was less than 60 and the medication was administered on: 9/2/23, 9/3/23, 9/5/23, 9/9/23, 9/20/23, 9/27/23, 9/23/23, 10/2/23, 10/3/23, 10/5/23, 10/7/23, 10/17/23 and 10/19/23.

On 10/20/23 at 10:25 AM and 10:31 AM Staff 15 (RNCM) and Staff 2 (DNS) acknowledged the metoprolol should not have been administered when the resident's heart rate was less than 60.

Based on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 3 and 8) reviewed for hospice and unnecessary medications. This placed resident at risk for inaccurate treatment. Findings include:

1. Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia.

A physician's order dated 8/11/23 indicated Resident 8 was admitted to hospice on 8/11/23 with a terminal diagnosis of unspecified illness.

On 10/19/23 at 9:48 AM Staff 1 (Administrator) acknowledged the resident's hospice admission order did not include a qualifying terminal diagnosis for admission to hospice.

2. Resident 3 was admitted to the facility in 2003 with diagnoses including diabetes.

Resident 3's 10/2023 signed Physician Orders indicated as of 11/2022 the resident was to have a Hemoglobin A1C lab test (blood test that measures blood sugar levels over a three month period) completed every six months due to long-term psychotropic medication use.

A 5/5/23 progress note indicated Resident 3's Hemoglobin A1C lab was discontinued per hospice.

A review of Resident 3's health care record revealed no evidence the physician's order for a Hemoglobin A1C lab test was discontinued as instructed in the 5/5/23 progress note.

On 10/19/23 at 8:54 AM Staff 2 (DNS) stated physician orders to complete Resident 3's Hemoglobin A1C lab test currently remained active and she had the resident's physician write a discontinuation order for the lab test on 10/19/23.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 13 and 14) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include:

On 10/19/23 at 12:29 PM Staff 10 (Business Office Manager) provided a list of training hours for the sampled staff and confirmed the following:
-Staff 13 (CNA): 0 annual training hours;
-Staff 14 (CNA): 3 annual training hours.

On 10/20/23 at 10:30 AM Staff 1 (Administrator) was notified of the findings of this investigation and acknowledged Staff 13 and Staff 14 lacked the required 12 hours of annual training.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 52 of 97 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include:

Review of the Direct Care Staff Daily Reports from 1/1/23 through 1/25/23, 2/19/23 through 2/28/23, 3/1/23 through 3/31/23 and 9/16/23 through 10/16/23 revealed the following days in 2023 with no RN coverage on day or evening shift:

-January: 1, 2, 5, 6, 9, 10, 12, 13, 16, 17, 22, 23 and 24.
-February: 19, 20, 21, 22, 24, 25, 26, 27 and 28.
-March: 3, 4, 5, 6, 7, 8, 9, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31.
-September: 17.
-October: 1, 8 and 15.

On 10/18/23 at 1:10 PM Staff 1 (Administrator) and Staff 5 (HR/Hiring Specialist) confirmed the facility lacked RN coverage on the identified dates.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 31 of 31 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

From 9/16/23 through 10/16/23 the facility had three residents approved for the state bariatric rate.

A review of the Direct Care Staff Daily Reports from 9/16/23 through 10/16/23 revealed 31 out of 31 days when one or more shifts did not meet the state minimum bariatric CNA staffing ratio.

On 10/18/23 at 1:10 PM Staff 1 (Administrator) and Staff 5 (HR/Hiring Specialist) acknowledged the failure to meet state minimum bariatric CNA staffing ratios. Staff 1 and Staff 5 stated they counted CMAs towards their state minimum bariatric CNA ratio.

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OAR 411-086-0040 Admission of Residents

Refer to F578
********************
OAR 411-085-0310 Residents' Rights: Generally

Refer to F580
********************
OAR 411-087-0100 Physical Environment: Generally

Refer to F584
********************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636 and F637
********************
OAR 411-086-0300 Clinical Records

Refer to F641
********************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684, F759 and F760
********************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care

Refer to F692, F757 and F758
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F727
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OAR 411-086-0260 Pharmaceutical Services

Refer to F756
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OAR 411-086-0300 Clinical Records

Refer to F842
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OAR 411-086-0310 Employee Orientation and In-Service Training

Refer to F947
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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 12/19/2022 and 12/25/2022, 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 12/05/2022 and 12/11/2022, 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 11/14/2022 and 11/20/2022, 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 11/07/2022 and 11/13/2022, 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 10/31/2022 and 11/06/2022, 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 10/24/2022 and 10/30/2022, 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.