Mirabella Portland

Based on observation, interview and record review it was determined the facility failed to follow fall prevention techniques for 1 of 4 residents (# 16) reviewed for accidents. This placed residents at risk for falls. Findings include:

Resident 16 was admitted to the facility in 7/2020 with diagnoses including dementia.

A 10/23/24 Fall Risk Evaluation determined Resident 16 to be at high risk for falls.

A 11/18/24 CNA Pocket Guide regarding transfers stated Resident 16 required the assistance of one person with the use of a front wheel walker (FWW) and gait belt with a focus on turning clockwise when available.

On 11/19/24 at 12:13 PM Resident 16 was observed being assisted by Staff 4 (CNA) with a standing transfer with the use of a FWW. Resident 16 was observed without a gait belt turning counter-clockwise when she/he was observed falling backwards onto the ground.

On 11/19/24 at 12:36 PM Staff 4 stated Resident 16 experienced a fall during a standing transfer. Staff 4 confirmed Resident 16 was not wearing a gait belt and "probably should have been wearing one." Staff 4 stated she was not aware of specific instructions regarding fall prevention techniques for Resident 16.

On 11/19/24 at 12:38 PM Staff 2 (DNS) confirmed the CNA Pocket Guide was updated daily and was provided to nursing staff at the start of their shifts to provide care need information to staff. Staff 2 stated Resident 16 did not experience a significant injury as result of the fall. Staff 2 stated Resident 16 should have been wearing a gait belt and assisted with turning clockwise to reduce the risk of falls.

*********************************

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

Refer to F689

*********************************

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#76) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 76 was admitted to the facility in 2020 with diagnoses including dementia.

A Nursing Facility Reported Incident Form dated 3/13/23 indicated Resident 76 was physically abused by Staff 13 (Former contracted radiology technician). The incident was witnessed by Staff 10 (CNA), Staff 11 (CNA) and Staff 12 (agency CNA).

A facility incident investigation report dated 3/13/23 indicated Resident 76 was in pain and confused on 3/13/23. Staff 13 hit the resident's forearm four times, restrained the resident's right arm and was verbally abusive toward the resident. Staff 10, Staff 11 and Staff 12 notified Staff 4 (LPN) who assessed the resident and no injuries were noted.

A handwritten signed witness statement by Staff 10 dated 3/13/23 indicated she, Staff 11 and Staff 12 were assisting Staff 13 to position Resident 76 for x-rays. The resident was "in a lot of pain, very agitated, confused and scared" and the resident was "flailing" her/his arms. Staff 13 held the resident's arms down, hit the resident's forearm and told the resident "your mother is here and she's not going to like this." Staff 13 seemed flustered and frustrated throughout the process because Resident 76 was not cooperating perfectly even though it was clear the resident was confused and in an immense amount of pain.

A handwritten signed witness statement by Staff 11 dated 3/13/23 indicated she, Staff 10 and Staff 12 were helping position Resident 76 for an x-ray. The resident was positioned but would move out of position several times. Staff 13 became more irritated and physical, pinned the resident's arms down, slapped the resident's forearm and said "stop or your mom will be mad at you."

A handwritten signed witness statement by Staff 12 dated 3/13/23 indicated she, Staff 10 and Staff 11 were trying to position and calm Resident 76. The resident was very confused, agitated and in a lot of pain. Staff 13 was frustrated, annoyed and impatient because the resident would not stop moving. Staff 13 tightly held the resident's arm down by the wrist which did not work and the resident touched the x-ray equipment. Staff 13 "snapped" and said "something along the lines of 'you better not break that it's a $100,000'" and then started swatting the resident's forearm about four times. Staff 13 then said "you better stop moving or your mom will be mad at you!!!" Staff 4 entered the room and moved between Staff 13 and the resident. Staff 11 reported the incident immediately.

Progress Notes dated 3/14/23 and 3/16/23 indicated Resident 76 was on hospice and died at 5:30 AM on 3/16/23.

A written statement by Staff 13 dated 3/14/23 was received for review on 8/25/23 from Witness 2 (Senior Human Resources Business Partner for the contracted diagnostic company). In the statement Staff 13 wrote "...due to pain the CNAs and I did have to restrain [the resident's] hands at different times and hold [the resident's] ankles to obtain the exams." and "Earlier in the exam the patient started talking to their Mother and Grandmother making them happy they cooperated in completing the exams. (Since my training is to "join their world" I went along with that line of talk) to get the patient to cooperate and it did work for a bit."

On 8/22/23 at 1:27 PM Staff 10 stated [on 3/13/23] around dinner time they were attempting to position and calm Resident 76 for x-rays. The resident was confused and moving around. The resident grabbed at the x-ray equipment and Staff 13 hit the resident's hand out of the way. Staff 13 told the resident to behave or her/his mom would be mad. Staff 11 was crying and Staff 4 entered the room and helped to calm the resident.

On 8/23/23 at 9:56 AM Staff 11 stated the incident occurred [on 3/13/23] around dinner time. Staff 4 told her someone needed to go into Resident 76's room with Staff 13. The resident was confused and moving around. Staff 13 held the resident's wrist down, slapped her/his wrist and told the resident to stay still or her/his mom would be mad. Staff 13 slapped the resident's wrist three to four times loud enough to hear the impact. Staff 11 stated Staff 4 entered the room, she left the room, started to cry and called Staff 1 (Administrator) to report the incident.

On 8/23/23 at 10:04 AM the facility's staffing agency was requested to have Staff 12 contact the Surveyor. As of 8/25/23 Staff 12 had not contacted the Surveyor.

On 8/23/23 at 1:19 PM Staff 4 stated when she came to Resident 76's room it was reported to her the x-ray process was not going well. She entered the room and attempted to calm the resident. Staff 13 was pushing to complete the x-rays but she stopped the process because she was not going to allow the resident to become more distressed. Staff 4 stated she assessed the resident, no injury was noted and the resident was not in additional distress. Staff 4 stated she immediately started an incident report and notified Staff 1.

On 8/24/23 at 9:17 AM Staff 1 (Administrator) confirmed Resident 76 was abused by Staff 13.

On 8/25/23 at 2:05 PM a request was made to Witness 2 for Staff 13 to call the surveyor. No return call was received as of 8/28/23.


,

Based on interview and record review it was determined the facility failed to complete an Admission or Annual MDS (Minimum Data Set) assessment in the required time frame for 4 of 14 sampled residents (#s 6, 8, 16 and 77) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include:

The facility's 6/2022 MDS policy and procedure specified the following:
-The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0.
-The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan.

On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Admission or Annual MDS assessments:
-Resident 6's Admission MDS was due 6/23/23 and was 61 days overdue;
-Resident 8's Annual MDS was due 6/23/23 and was 61 days overdue;
-Resident 16's Annual MDS was due 6/30/23 and was 54 days overdue;
-Resident 77's Admission MDS was due 7/13/23 and was 41 days overdue.

On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Admission or Annual MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted.

On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Admission and Annual MDS assessments and the nursing staff were working on getting them caught up.

Based on interview and record review it was determined the facility failed to complete a Quarterly MDS (Minimum Data Set) assessment in the required time frame for 10 of 14 sampled residents (#s 1, 4, 5, 10, 13, 15, 18, 20, 22, and 23) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include:

The facility's 6/2022 MDS policy and procedure specified the following:
-The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0.
-The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan.

On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Quarterly MDS assessments:
-Resident 4's Quarterly 3 MDS was due 6/15/23 and was 69 days overdue;
-Resident 1's Quarterly 3 MDS was due 6/16/23 and was 68 days overdue;
-Resident 22's Quarterly 2 MDS was due 6/27/23 and was 56 days overdue;
-Resident 20's Quarterly 3 MDS was due 7/5/23 and was 49 days overdue;
-Resident 18's Quarterly 2 MDS was due 7/7/23 and was 47 days overdue;
-Resident 15's Quarterly 2 MDS was due 7/17/23 and was 37 days overdue;
-Resident 23's Quarterly 1 MDS was due 7/19/23 and was 35 days overdue;
-Resident 10's Quarterly 1 MDS was due 7/27/23 and was 27 days overdue;
-Resident 13's Quarterly 2 MDS was due 8/3/23 and was 20 days overdue;
-Resident 5's Quarterly 1 MDS was due 8/10/23 and was 13 days overdue.

On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Quarterly MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted.

On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Quarterly MDS assessments and the nursing staff were working on getting them caught up.

3. On 8/24/23 at 11:32 AM a medication cart near the conference room was observed unlocked and unattended by staff. Staff 8 (LPN) exited a nearby resident room and approached the cart. Staff 8 acknowledged the cart was unlocked and it should have been locked.


, Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 1 of 1 medication carts and 1 of 1 treatment carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include:

The facility's Medication and Accounting Policy and Procedure dated 7/21 indicated:
-It was the policy of the facility to store medications in a safe and locked place that was not accessible to persons other than employees responsible for the supervision of medications.

1. On 8/22/23 at 10:15 AM a treatment cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 9 (RN) verified the cart was unlocked.

2. On 8/24/23 at 8:16 AM a medication cart was observed to be unlocked across from the spa room. The nurse was not in view of the cart. Staff 8 (LPN) verified the cart was unlocked.

On 8/24/23 at 10:50 AM Staff 1 (Administrator) stated it was her expectation the carts remained locked when not in use.

********************
OAR 411-085-0360 Abuse

Refer to F600

********************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636 and F638

********************
OAR 411-086-0260 Pharmacy Sevices: Phamaceutical Services

Refer to F761

********************

Based on interview and record review it was determined the facility failed to obtain and maintain an advance directive for 2 of 2 sampled residents (# 8 and 23) reviewed for advance directives. This placed residents at risk for not having their health care wishes followed. Findings include:

1. Resident 23 was admitted to the facility in 2019 with diagnoses including depression.

The resident's 6/2022 MDS indicated the resident was cognitively impaired.

Resident 23's record did not include an advance directive or legal documentation for a responsible person to make medical decisions for the resident.

A 10/5/21 Care Conference form indicated the resident had an advance directive.

The resident's medical record did not indicate the family or responsible party was provided advance directive information.

On 7/28/22 at 9:19 AM Staff 9 (Social Service Director) acknowledged Resident 23 did not have an advance directive and there was no documentation to indicate the resident or responsible party was provided advance directive information.

, 2. Resident 8 was admitted to the facility in 2018 with diagnoses including a brain injury.

Resident 8's care conference notes from 6/1/20 through 6/13/22 included seven notes indicating Resident 8 had an advance directive and one note indicating she/he did not.

No evidence was found in the facility's electronic health record to indicate Resident 8 had a current advance directive.

On 7/27/22 at 2:41 PM Staff 9 (Social Services Director) confirmed the facility did not have a copy of Resident 8's advance directive in the resident's record.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for for 1 of 1 sampled resident (#27) randomly observed. This placed residents at risk for an un-homelike environment. Findings include:

Resident 27 was admitted to the facility in 2018 with diagnoses including dementia.

On 7/26/22 at 9:19 AM a large brown irregular shaped stained area approximately 12 inches in diameter was observed on the carpet between the foot of Resident 27's bed and bathroom. There was no odor noted in the room.

On 7/26/22 at 10:31 AM Witness 3 (Spouse) stated the carpet in the resident's room was dirty and she/he was not sure what caused the stain.

On 7/27/22 at 10:18 AM Staff 13 (Housekeeping) stated when carpets were dirty they called maintenance and the maintenance staff cleaned the carpets.

On 7/27/22 at 10:20 AM Staff 14 (Housekeeping) stated Resident 27's carpet was dirty for approximately one month and she told Staff 15 (Maintenance) the carpet needed to be cleaned about 15 days ago.

On 7/29/22 at 11:09 AM Staff 15 stated housekeeping staff notified him when there was a carpet stain that needed to be cleaned. He was not aware of a stain in Resident 27's room and acknowledged the carpet was stained.

Based on interview and record review it was determined the facility failed to provide snacks for 1 of 1 sampled resident (#80) reviewed for meal choices. This placed residents at risk for unintended change in nutritional status. Findings include:

Resident 80 was admitted to the facility in 2021 with diagnoses including dementia.

Resident 80's functional nutritional Care Plan included the resident was to be offered snacks three times a day initiated on 10/27/21.

A review of daily snack pass sheets, many of which were undated and only went back as far as 1/27/22 through 6/13/22, revealed Resident 80 was not offered three snacks per day.

On 8/2/22 Staff 19 (Dietary Manager) confirmed the snack pass sheets indicated Resident 80 was generally only offered one to two snacks daily.

Based on interview and record review it was determined the facility failed to provide bathing for 1 of 2 sampled residents (#80) reviewed for ADLs. This placed residents at risk for lack of person hygiene and infections. Findings include:

Resident 80 was admitted to the facility in 2021 with diagnoses including dementia.

Resident 80's functional mobility Care Plan initiated on 10/18/21 indicated the resident required staff assistance with bathing.

A review of Resident 80's bathing record from 10/2021 through 6/2022 revealed the following:
- In 10/2021 no baths were provided.
- In 11/2021 two baths were provided.
- In 12/2021 one bath was provided.
- In 1/2022 no baths were provided.
- In 2/2022 two baths were provided.
- In 3/2022 four baths were provided from 3/3/22 through 3/7/22.
- In 4/2022 seven baths were provided from 4/11/22 through 4/27/22.
- In 5/2022 nine baths were provided from 5/8/22 through 5/29/22.
- In 6/2022 four baths were provided from 6/1/22 though 6/15/22.

On 7/29/22 Staff 8 (RNCM) stated Resident 80 was not resistive to bathing and there was no evidence to support the resident received routine bathing cares.

Based on interview and record review it was determined the facility failed to ensure a resident was provided an activity program to meet a resident's needs for 1 of 2 sampled residents (#11) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include:

Resident 11 was admitted to the facility in 2022 with diagnoses including Parkinson's disease. Resident 11 resided in the Health Center.

Resident 11's 2/2/22 Activity History and Personal Preference form indicated it was very important to do things with groups of people.

The July 2022 Daily Activity Lists revealed multiple activities in the Memory Care Unit including group exercises. There were no group exercises offered in the Health Center.

On 7/29/22 at 1:36 PM group exercise was observed in the Memory Care Unit. Staff 10 (RN) stated all the residents who participated in the activity resided in the Memory Care Unit.

On 7/29/22 at 10:47 AM Resident 11 stated she/he would attend most exercise group activities on a daily basis if they were not located in the Memory Care Unit.

On 7/28/22 at 9:43 AM Staff 16 (Activity Director) stated there were group activities on the Health Center side a couple times a week but most of the activities were on the Memory Care Unit. Staff 16 stated he was not aware residents, including Resident 11, did not want to go the Memory care unit. Staff 16 acknowledged there were no group exercise programs offered to the residents on the Health Center side of the facility.

Based on interview and record review it was determined the facility failed to ensure a resident was monitored after first developing signs of a UTI for 1 of 2 sampled residents (#19) reviewed for UTIs and failed to follow physician orders for medications for 2 of 11 sampled residents (#s 17 and 18) reviewed for medications. This placed residents at risk for delayed care and adverse medication reactions. Findings include:

1. Resident 19 was admitted to the facility in 2018 with diagnoses including dementia.

A Progress Note by Staff 6 (LPN) dated 7/19/22 indicated Resident 19 had increased urination and the symptoms started on 7/16/22. There was no documentation prior to 7/19/22 to indicate the resident was monitored for signs of a UTI.

On 8/1/22 at 8:52 AM Staff 6 stated Resident 19 had mixed incontinence. Staff assisted the resident every two hours during the day, every four hours at night and upon the resident's request. Staff 6 stated he worked on 7/16/22 and Resident 19 had increased urination which indicated a possible UTI and staff were going to monitor the resident. Staff 6 stated on 7/16/22 he notified the oncoming shift to monitor the resident. Staff 6 indicated he did not work from 7/16/22 until 7/19/22. Staff 6 reviewed the progress notes and acknowledged there were no notes to indicate the staff assessed the resident for signs of a UTI.

On 8/1/22 at 10:19 AM Staff 2 (DNS) stated when a resident had a change in condition, staff were to put the resident on alert charting, monitor and assess the resident and document in the resident's record. Staff 2 acknowledged Resident 6 first developed symptoms on 7/16/22 but there were no assessments until 7/19/22.
, 2. Resident 18 was admitted to the facility in 2022 with diagnoses including pain.

Resident 18's 7/2022 MAR revealed a physician's order for diclofenac sodium gel 1% (topical cream to treat pain) apply two grams three times a day to both knees, left hip and right shoulder. Maximum daily dose 16 grams to all joints. The MAR indicated the medication was administered three times a day for 24 of 28 days reviewed.

On 7/29/22 at 9:40 AM Staff 6 (LPN) confirmed two grams of diclofenac administered to all four sites equaled 24 grams per day which was in excess of the maximum 16 grams per day as ordered.

3. Resident 17 was admitted to the facility in 2018 with diagnoses including macular degeneration (eye disease which causes blurred vision) and cataract (cloudy lens of the eye).

A physician's order dated 11/23/20 indicated Resident 17 was ordered Systane Ultra (for dry eyes) eye drops, one drop in each eye, once daily in the morning and PRN for eye irritation and burning, and Systane gel one drop in each eye at bedtime.

Resident 17's 7/2022 MAR revealed Systane eye drops were scheduled and administered at 3:00 PM, 8:00 PM and 12:00 AM (midnight) daily. The MAR also indicated Systane gel drops were administered daily at 11:00 PM. (There was only a one hour separation from the administration of the gel at 11:00 PM and the regular drops at midnight.)

On 7/29/22 at 11:38 AM Staff 8 (RNCM) was asked why there were two different orders for Systane eye drops. and why they were ordered to be administered one hour apart at 11 PM and 12 AM. Staff 8 stated it was an error but did not clarify which order was in error.

Based on observation, interview and record review it was determined the facility failed to ensure a safe environment free from toxic flowers and plants in 1 of 1 facility and failed to identify the root cause of a resident's fall and implement fall interventions for 1 of 1 sampled resident (#80) reviewed for accidents. This placed residents at risk for injury. Findings include:

1. Resident 80 was admitted to the facility in 2021 with diagnoses including dementia.

Resident 80's fall Care Plan initiated on 10/18/21 indicated the resident was a high risk for falls. Interventions included every 15 minute safety checks initiated on 11/1/21.

A Progress Note dated 12/5/21 indicated the resident was a high fall risk and was checked on by staff every 25 to 30 minutes.

A review of facility incident reports revealed Resident 80 fell eight times between 1/9/22 and 5/3/2022. None of the eight incident reports included an evaluation or analysis to identify specific hazards, risks and trends, or the development of targeted interventions to reduce the potential for additional falls. None of the reports included an analysis and rationale to demonstrate abuse and neglect had been ruled out. The reports included the following:

- On 1/9/22 the resident fell with a family member present and incurred abrasions to her/his head and hand.

- On 1/9/22 the resident was found crawling on the floor next to her/his wheelchair. No injuries were noted but the report did not indicate when the resident was last assisted or checked on by staff.

- On 2/16/22 the resident was found on the floor near her/his bed with a 1 cm by 2 cm laceration to the left brow. The report did not indicate when the resident was last assisted or checked on by staff, however, a Progress Note dated 2/16/22 indicated staff had last assisted the resident 10 minutes prior to the fall.

- On 2/26/22 the resident was heard screaming and was found on her/his knees on the floor. The report did not indicate when the resident was last assisted or checked on by staff.

- On 3/27/22 the resident was witnessed by staff as she/he slid out of her/his wheelchair onto the floor.

- On 4/13/22 the resident was found on the floor near her/his wheelchair. The report did not indicate when the resident was last assisted or checked on by staff.

- On 4/30/22 the resident was heard to fall out of bed as staff were entering the resident's room. Staff last assisted the resident 19 minutes prior to the fall.

- On 5/3/22 the resident had an assisted fall to the floor.

On 8/1/22 at 11:14 AM Resident 80's fall incident reports were discussed with Staff 2 (DNS). Staff 2 acknowledged the lack of root cause analysis and care plan changes related to the resident's falls. She stated they were behind on charting. Staff 2 stated Staff 1 (Administrator) had not signed off on any of the incident reports yet.

On 8/1/22 at 11:32 AM Staff 1 stated she had not signed off on any of the incident reports because they were not closed yet and stated they were behind on their documentation.

On 8/2/22 at 12:59 Staff 2 (DNS) stated there was no documentation of the care planned 15 minute safety checks.

, 2. Multiple random observations from 7/25/22 through 8/2/22 between the hours of 8:30 AM and 4:00 PM revealed living plants in numerous resident rooms and common areas of the Health Center and Memory Care Unit of the facility. Residents were frequently observed unsupervised in the Memory Care Unit common living area near plants and residents self-ambulated in the hallways and sat at the nursing station where flowers and plants were readily accessible.

On 7/27/22 at 3:11 PM Staff 12 (Memory Care Coordinator) provided a list of living plants accessible to residents in the following areas of the Memory Care Unit: living room, front table, nursing station, dining room, plant table, resident rooms, indoor therapy garden and outdoor therapy garden. There were approximately 38 living plants listed including hydrangea and anthurium.

According to the University of California: Safe and Poisonous Garden Plants, Division of Agriculture and Natural Resources, dated 2022 (https://ucanr.edu/sites/poisonous_safe_plants/), two living plants located on the Memory Care Unit were identified as toxic to humans. These included hydrangeas located at the nursing station and resident room 228 and an anthurium plant located in resident room 225.

On 7/27/22 at 2:45 PM Staff 12 stated the facility contracted with an organization that provided plants for the facility's indoor therapy garden and those plants were non-toxic; however, the facility did not have a system in place to identify toxic flowers and plants brought into the facility by staff or family members. Staff 12 was unable to state if any flowers and plants in the common areas or resident rooms on the Memory Care Unit were considered toxic to humans.

On 7/29/22 at 11:30 AM Staff 1 (Administrator) confirmed the facility did not have a system in place to identify potentially toxic flowers and plants brought into the facility and understood this was a safety concern, especially in the Memory Care Unit.

On 7/29/22 at 2:13 PM Staff 12 confirmed hydrangeas and anthurium were toxic to humans.

Based on observation and interview it was determined the facility kitchen staff failed to handle and prepare food in a sanitary manner for 1 of 3 kitchens reviewed. This placed residents at risk for foodborne illness. Findings include:

On 7/28/22 at 11:34 AM Staff 18 (Cook) was observed to wear gloves and plate lunch meals for residents in the 2nd-floor kitchen. She opened the refrigerator, removed containers of meat, cheese, spread, and bread, and placed them on the counter while she wore the same gloves. Staff 18 did not change her gloves before she assembled grilled beef and cheese sandwiches. With the same gloves she returned the bread, cheese, and spread to the refrigerator.

Staff 18 then changed her gloves without performing hand hygiene, opened a different refrigerator wearing the new gloves, retrieved a salad container to the counter, and used her gloved hands to scoop portions of roasted potato wedges onto plates. She did not use the utensils that were readily available to scoop the potatoes.

Throughout this process Staff 18 was observed to place plated meals in the insulated tray carts and returned to handle food without changing gloves and performing appropriate hand hygiene after touching potentially contaminated surfaces.

On 7/28/22 at 11:40 AM Staff 18 reported, "I can use my gloved hands to pull food out of the fridge and containers and place it on the flat top but then I change gloves when I turn around to the steam table to work with food that has already been cooked."

On 8/2/22 at 2:45 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of hand hygiene and appropriate glove use by Staff 18.

Based on observation and interview it was determined the facility failed to ensure hand hygiene was performed between tasks for 2 of 2 staff (#s 10 and 17) who were randomly observed for hand hygiene. This placed residents at risk for cross contamination. Findings include:

1. On 7/28/22 at 10:35 AM Staff 17 (Server) was observed to deliver food to Room 231, left the room, did not perform hand hygiene and then delivered food to Room 232. Staff 17 stated she did not usually do hand hygiene when passing snacks.

On 8/1/22 at 10:03 AM Staff 2 (DNS) indicated hand hygiene was to be performed upon leaving each resident room.

2. On 8/2/22 at 10:29 AM Staff 10 (LPN) was observed to remove gloves and walk to the medication cart. Staff 10 then made contact with a computer keyboard, opened the medication cart and then started to prepare a resident's medications. Staff 10 did not wash her hands. Staff 10 acknowledged she did not wash her hands after removing the gloves and before starting to prepare a resident's medications.

Based on interview and record review it was determined the facility failed to ensure a resident's prophylactic use of an antibiotic was reviewed and a rationale for continued use was documented for 1 of 2 sampled residents (#23) reviewed for antibiotic usage. This placed residents at risk for adverse medication consequences and drug resistant infections. Findings include:

Resident 23 was admitted to the facility in 2019 with diagnoses including UTIs.

Resident 23's 6/4/21 CAA indicated she/he was incontinent of urine and was at risk for infection. Staff were to monitor the resident for UTIs. There was no information related to the resident's prophylactic use of an antibiotic.

A Progress Note dated 7/25/22 indicated Resident 23 was not on antibiotics.

A 7/25/22 Physician Visit note indicated the resident had recurrent UTIs, functional incontinence with a decline in mobility and was on prophylactic nitrofurantoin (antibiotic). The note indicated the resident's last UTI was 10/2021 which was resistant to nitrofurantoin. The plan was to continue the nitrofurantoin.

On 8/1/22 at 12:02 PM Witness 4 (Pharmacist) stated there was a risk with any long-term use of antibiotics for the development of bacteria which were resistant to antibiotics. The facility needed to weigh the overall health of the resident and the risk factors which could develop and the benefits of the resident acquiring fewer UTIs. Witness 4 also stated on 5/29/19 the pharmacist consultant's review regarding the nitrofurantoin indicated the resident's kidney function should be monitored and nitrofurantoin was not recommended per Beers list (Potentially Harmful Drugs in the Elderly). The pharmacist recommended an alternative medication, trimethoprim (antibiotic), to administer in place of the nitrofurantoin. The physician did not accept the recommendation.

Resident 23's 3/7/22 Laboratory results revealed the resident's current creatinine (kidney function) level was 0.79 (normal 0.60-1.10).

The resident's records did not have current pharmacy reviews specific to the use of the nitrofurantoin.

On 7/29/22 at 12:00 PM Staff 8 (RNCM) stated Resident 23 had a history of frequent UTIs and was on nitrofurantoin since 2018. Staff 8 reviewed the resident's record and did not find a rationale with risk versus benefits for the continued use of the nitrofurantoin to ensure it was still the best medication for the resident.

On 8/1/22 at 10:03 AM Staff 2 (DNS) stated they did not review the residents on prophylactic antibiotic as part of the antibiotic stewardship program.

On 8/2/22 at 11:18 AM Staff 1 (Administrator) stated the review of residents on prophylactic antibiotics will be added to the antibiotic stewardship program.

OAR 411-086-0040 Admission of Residents (Advanced Directive)

Refer to F578
***************
OAR 411-087-0100 Physical Environment: Generally

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

Refer to F656
***************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677 and F684
***************
OAR 411-086-0230 Activity Services

Refer to F-679
***************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F689 and F757
***************
OAR 411-086-0250 Dietary Services

F812
***************
OAR 411-086-0330 Infection Control and Universal Precautions

F880 and F881
***************

The findings of the state licensure and memory care unit health survey conducted on 7/25/22 to 8/2/22 are documented in this report. It was determined the facility was in compliance with OAR 411 Division 57.

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 07/25/2022 and 07/31/2022, 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 observation, interview and record review it was determined the facility failed to identify a chair which prevented rising as a restraint for 1 of 1 sampled resident (#1) reviewed for physical restraints. This placed residents at risk for decreased mobility. Findings include:

Resident 1 was admitted on 5/2019 with diagnoses including Alzheimer's disease and dementia with behavioral disturbance.

A 7/17/20 Fall Risk Evaluation identified the resident to be at risk for falls.

The 7/18/20 Admission MDS identified Resident 1 as severely cognitively impaired. The resident required extensive assistance with most ADLs, was dependent with transfers, and had falls with and without injury in the past six months.

A Fall Care Plan, last revised on 10/7/20, identified a history of frequent falls related to poor safety awareness, mobility limitations, restlessness and medication use. Approaches included the use of a recliner in the unit living room with a rolling tray table when a 1:1 staff was not present. It identified that Resident 1 would attempt to rise independently from other chairs.

The recliner chair with the rolling tray table was not identified, assessed or care planned as a restraint for Resident 1.

On 5/11/21 at 12:12 PM, Resident 1 was approached by staff while she/he sat in the recliner chair with a rolling tray table in front of her/his lap and feet up. Staff lowered the footrest and Resident 1 immediately attempted to lean forward, moving towards the front of the chair. Staff intervened to assure safety.

On 5/11/21 at 12:32 PM, Resident 1 was assisted to leave the dining room in her/his wheelchair. The resident moved her/his feet to propel the wheelchair while leaning forward with her/his upper body. Staff intervened to assure safe positioning in the wheelchair.

Resident 1 was observed to sit in the recliner with feet up and a rolling tray table in front of her/him when 1:1 staff was not available on 5/11/21 through 5/13/21. The resident made no attempt to get out of the recliner chair.

In a 5/14/21 interview at 1:58 PM, Staff 11 (CNA) stated when the resident was sitting in a wheelchair, she/he would bend over and was at risk for falls. Resident 1 seemed to like the recliner and when paired with a rolling tray table, she/he did not try to get up.

In a 5/14/21 interview at 2:24 PM, Staff 10 (LPN) stated the resident used the recliner after she/he fractured a hip. When the resident moved within the recliner chair, staff approached and asked if she/he needed something. According to Staff 10, the rolling tray table created a potential risk to the resident as it could cause the resident to be off balance if the resident moved the table.

In a 5/14/21 interview at 3:01 PM, Staff 4 (RNCM) stated the resident had multiple falls in the past, but was less ambulatory after a fall with a fractured hip. The recliner chair was used due to a need for increased supervision related to her/his fall risk. Staff 4 had not observed the resident attempting to get out of the recliner, but agreed the resident often leaned forward when in the wheelchair and might do this if her/his feet were down in the recliner. Physical therapy was now involved due to declining ambulation and a tendency to lean to the left when seated. Staff 4 confirmed the recliner chair had not been identified as a restraint and an assessment of the risks and benefits related to this device would have been supportive of the resident.

Based on observation, interview and record review, it was determined the facility failed to develop a baseline care plan to address dental and nutritional problems for 1 of 1 sample resident (#185) reviewed for dental and nutrition. This placed residents at risk for unmet dental and nutritional needs. Findings include:

Resident 185 was admitted in 4/2021 with diagnoses including malnutrition.

A Clinical Nursing Evaluation dated 4/30/21 indicated the resident had known weight loss, was to receive a regular textured diet and had problems with her/his teeth.

A Nutrition Evaluation dated 5/5/21 indicated Resident 185 had a history of a 35 pound weight loss over the past two years and difficulty chewing. The plan indicated to obtain weekly weights, offer snacks three times a day and to add a high calorie nutritional supplement two times a day.

On 5/11/21 at 10:35 AM, Resident 185 was observed to have several missing front teeth and appeared very thin. Resident 185 stated her/his teeth had fallen out. Resident 185 added she/he had lost weight, did not have an appetite and ate less.

On 5/11/21 the baseline care plan initiated on 4/30/21 was reviewed and did not include information related to dental problems or nutrition and weight loss.

Weight records noted weights on 5/2/21 as 86.6 lbs. and again on 5/12/21 as 85.8 lbs.

On 5/13/21 the baseline care plan was revised to include the high calorie nutritional supplement.

On 5/13/21 at 8:03 AM, Staff 6 (RN) stated Resident 185 took a long time to take her/his medications, and ate okay. Staff 6 thought the resident had no swallowing issues and was not aware of any dental problems.

On 5/14/21 at 4:22 PM, Staff 2 (DNS) agreed there was no information related to dental or nutritional problems on Resident 185's baseline care plan.

Based on observation, interview and record review, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for disposing, cleaning and storing of personal protective equipment (PPE) for 1 of 1 sampled resident (#184) reviewed for infection control related to COVID-19 and failed to follow manufacture's guidance related to use of disinfection products for infection control precautions in relation to COVID-19 prevention. This placed residents and staff at risk for infection and illness related to the COVID-19 virus. Findings include:

1. According to the CDC Strategies for Optimizing the Supply of Isolation Gown, updated 1/21/21:

Once personal protective equipment (PPE) supplies and availability return to normal, healthcare facilities should promptly resume conventional practices.

Re-use of isolation gowns. The risks to healthcare provider (HCP) and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits.

According to CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic):

Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses.

According to Oregon Health Authority guidance:

If eye protection is being reused, establish a dedicated area in the facility to clean, disinfect, and store eye protection between uses (preferably near facility entrance/exit). Disinfection should occur immediately after removing eye protection. Social distancing should be observed at and around the disinfection station. Personal protective equipment should not be shared between staff.

After cleaning/disinfection/drying, eye protection can be stored in a transparent plastic bag or container, and labeled with the staff member name to prevent accidental sharing between staff.

Resident 184 was admitted to the facility in 5/2021 and placed on 14-day droplet precautions that required all staff and visitors wear full PPE. The resident was in a private room.

On 5/14/21 at 3:03 PM, the door to Resident 184's room was open. Directly inside the doorway of the room were five hooks placed on the wall, three on the left side behind the opened door and two on the right side. Each of the five hooks had a blue disposable isolation gown hanging on it. Four face shields, three on the left side and one on the right side, were also hanging on the same hooks with the inside of each face shield directly facing the hanging isolation gowns.

A PPE cart was located right outside of Resident 184's room. The cart contained new PPE supplies (gloves, blue disposable isolation gowns, masks, and two different containers of disinfecting wipes) and plastic bags.

On 5/14/21 at 3:46 PM, Staff 5 (CNA) entered Resident 184's room after donning full PPE (mask, disposable isolation gown, gloves and face shield) to provide care. After providing care, Staff 5 noticed the five hanging isolation gowns and disposed of four of them in a covered trash receptacle in the resident's room, leaving one isolation gown still hanging. Staff 5 left the four face shields hanging on their hooks. Staff 5 then hung up her face shield on one of the hooks without disinfecting or storing it in a plastic bag. Staff 5 exited the room after doffing the rest of her PPE.

When asked about the use, storage and disposal of PPE, Staff 5 stated she used the disposable isolation gown once and disposed of it immediately afterwards. She stated this process had recently changed as staff had previously used the same gown for their entire shift. Staff 5 then stated the hanging isolation gowns she disposed of belonged to other staff who had cared for the resident earlier in the day. In regards to her face shield, Staff 5 stated she received a new face shield each shift. Since Resident 184 was the only resident on droplet precautions, Staff 5 used the same face shield throughout her entire shift and stored the face shield in the resident's room. Staff 5 stated she did not disinfect her face shield between uses in the resident's room or store the face shield in a storage bag afterwards.

In an interview on 5/13/21 at 12:30 PM, Staff 1 (Administrator) stated the facility had a three months supply of PPE, including disposable isolation gowns. She stated there should not be any reuse of PPE.

In an interview on 5/14/21 at 4:41 PM, Staff 3 (Assistant DNS and Infection Preventionist) stated staff should not be reusing disposable isolation gowns and should be disinfecting face shields between use and appropriately storing them. Staff 3 acknowledged this was not done.




,
2. Centers for Disease Control "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic" revised 7/15/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly.

The disinfecting solution (Signet Neutral Disinfectant) used within the facility had manufacturer's instructions which stated "treated surfaces must remain wet for 10 minutes ... allow to air dry."

On 5/10/21 at 10:36 AM, Staff 8 (Housekeeping) was interviewed about disinfection of surfaces in residents' rooms and communal areas. Staff 8 stated that Signet Neutral Disinfectant was sprayed on surfaces, left on for five seconds, then wiped away.

On 5/12/21 at 10:35 AM, Staff 9 (Housekeeping) was observed using Signet Neutral Disinfectant on surfaces in an isolation precaution room. Staff 9 sprayed the disinfecting product on surfaces and wiped those surfaces dry immediately. Staff 9 was interviewed about use of Signet Neutral Disinfectant. Staff 9 stated they sprayed the product on a surface, waited 30 seconds, and then wiped it off.

On 5/12/21 at 1:48 PM, Staff 7 (Housekeeping Supervisor) was interviewed about disinfection products used in the facility. Staff 7 stated the contact time for Signet Neutral Disinfectant was 30 seconds. The concentrate dispenser label was reviewed regarding contact time for the disinfectant with Staff 7 to which she corrected her previous statement, stating that 10 minutes was the correct contact time for that product.

On 5/14/21 at 4:05 PM, Staff 1 (Administrator) stated an understanding of the need for a 10 minute contact time with Signet Neutral Disinfectant in order to disinfect surfaces.

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

Refer to F604
***************************
OAR 411-086-0040 - Admission of Residents

Refer to F655
***************************
OAR 411-086-0330 - Infection Control and Universal Precautions

Refer to F880
***************************

The findings of the Memory Care Community health survey conducted 5/10/21 through 5/14/21 are documented in this report. It was determined the facility was in substantial compliance with OAR 411 Division 57.

Based on interview and record review it was determined the facility failed to prevent abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for injury. Findings included:

Resident 1 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease and dementia with behavior disturbances.

The facility's Abuse and Incident Reporting Policy, revised 9/2020, indicated the facility's policy is to protect the rights, safety and well-being of residents from all forms of physical, verbal, sexual and mental abuse.

Resident 1's annual MDS dated 7/18/20 indicated the resident had severe cognitive impairment and physical behaviors including hitting, kicking, grabbing and pushing.

Resident 1's care plan dated 11/23/19 indicated the resident was at risk for self-directed and other-directed harm. Interventions included to allow the resident personal space (if safe) and to utilize diversion techniques as needed.

A facility incident report for the 10/2/20 incident revealed a CNA hit Resident 1 on the top of her/his hand when the resident became physically aggressive. The facility investigation concluded abuse occurred, the care plan was not followed because the CNA did not give the resident personal space and indicated the resident did not incur an injury.

On 2/25/21 at 2:00 PM Staff 1 (Administrator) and on 3/2/21 at 1:40 PM Staff 3 (Assistant DNS) both confirmed a CNA did hit Resident 1 on the top of her/his hand, it was determined as abuse and the CNA was terminated from employment with the facility after the incident.

Based on observation, interview and record review it was determined the facility failed to prevent falls for 1 of 3 residents (#1) reviewed for falls. This placed residents at risk for injury. Findings include:

Resident 1 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease, dementia with behaviors and muscle weakness.

Resident 1's annual MDS dated 7/18/20 indicated the resident was severely cognitively impaired, at risk for falls and had frequent falls due to dementia with behavior disturbances.

The resident's Fall Risk Evaluation dated 10/18/20 indicated the Resident was at high risk for falls.

Resident 1's care plan indicated the resident was at risk for falls and was updated on 10/8/20 to toilet the resident every hour during the day rather than every two hours.

A progress note dated 10/31/20 indicated Resident 1 was observed in the dining room in her/his wheelchair trying to reach for something on the floor and slid out of the wheelchair to the floor. The resident sustained a small skin tear which was immediately treated and went back to eating breakfast.

An Incident Reported dated 10/31/20 revealed Resident 1 had an unavoidable fall with injury the morning of 10/31/20. It was determined the care plan had not been followed since the resident had not been toileted for four hours.

On 2/22/21 4:43 PM Witness 1 (Complainant) stated on a Saturday morning in 10/2020 (she did not recall the exact date) Resident 1 had not been toileted for five hours and as a result fell in the dining room.

Observations of Resident 1 on 2/22/21 and 2/25/21 revealed she/he was at risk for falls and care plan interventions were in place.

On 2/23/21 at 2:11 PM Staff 3 (Assistant DNS) and on 2/25/21 at 3:11 PM Staff 2 (DNS) both confirmed Resident 1's fall with injury on 10/31/20 was avoidable because the care plan was not followed.

****************************************

OAR 411-085-0360 Abuse

Refer to F600

****************************************

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

Refer to F689

****************************************