Tigard Rehabilitation and Care

Resident 6 was admitted to the facility on 4/17/25 with diagnoses including heart failure and diabetes.A 4/17/25 Clinical Admission Progress Note, completed by Staff 4 (LPN), indicated Resident 6 had some redness with a small healing blister to her/his front left knee that was present upon admission.The 4/18/25 care plan revealed Resident 6 had impaired skin integrity due to a current blister on the left thigh/shin and immobility.A review of Resident 6GÇÖs medical record, including a review of the 4/2025 TAR, revealed no assessment of the wound and no monitoring of the wound.-á-áResident 6 discharged to the hospital on 4/22/25 for an unrelated diagnosis.On 11/13/25 at 2:45 PM Staff 4 confirmed he completed Resident 6GÇÖs clinical admission assessment that included a full body skin check. Staff 4 stated when skin impairments were identified he placed a note on the TAR to monitor them. Staff 4 confirmed Resident 6 had a blister on her/his left knee. Staff 4 reviewed the TAR and acknowledged he did not implement monitoring of Resident 6GÇÖs blister.On 11/14/25 at 1:48 PM Staff 25 (LPN Resident Care Manager) confirmed there were no assessments completed for Resident 6GÇÖs blister on the left knee.On 11/14/25 at 2:25 PM Staff 2 (DNS) stated if a skin impairment like a blister was noted upon admission it was expected to be documented in the admission progress note, added to the TAR, the resident placed on alert charting, and a risk management note started. Staff 2 acknowledged Resident 6GÇÖs blister was not assessed or monitored during her/his stay at the facility.

The facility's 4/2018 Pressure Ulcer/Skin Breakdown - Clinical Protocol - Assessment and Recognition specified the nurse shall describe and document/report the following:Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (leaking fluid) or necrotic (dying/dead) tissue and pain assessment.The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment:-á - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing;-á - Document the results of all wound assessments;-á - Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor.Resident 7 was admitted to the facility in 10/2025 with a diagnosis of osteomyelitis of vertebrae (bone infection).Resident 7's 10/29/25 Admission MDS was not completed.-á A Progress Note dated 11/1/25 completed by Staff 26 (LPN) indicated she was informed by a CNA of an ""open sore on the upper part"" of Resident 7's buttock.A 11/1/25 Skin Integrity Report, initiated by Staff 26, indicated a new open sore on the upper part of the residentGÇÖs buttock and indicated the Resident Care Manager and Physician was notified. A note added on 11/3/25 indicated a new pressure injury to the left buttock wound which measured 1.5 x 1.1 cm and a new pressure injury to the coccyx which measured 3.1 x 5 x 0.3 cm.There was no evidence in Resident 7's health record to indicate a comprehensive assessment of the wound including measurement, location, stage, and other characteristics was completed after the wound was identified on 11/1/25 and before 11/3/25.Resident 7's 11/3/25 Physician Orders included the following: wound treatment to coccyx and sacrum wound bed, wash, pat dry, apply hydrogel to the sacrum and medihoney to coccyx wound bed, place large sacral dressing to cover both wounds. every day and PRN.There was no evidence wound care orders were obtained prior to 11/3/25.-áResident 7's TAR revealed wound care was not provided until 11/4/25.On 11/14/25 at 12:20 PM Staff 26 stated she remembered a CNA notified her on 11/1/25 that Resident 7 had a new open area. Staff 26 stated she looked at the open area on resident 7's left buttock, cleaned the wound, covered it, and initiated a Skin Integrity Report. Staff 26 stated she did not measure the wound, did not obtain orders from the provider, did not document any wound treatment, and did not initiate any house wound orders on the TAR.On 11/14/25 at 12:57 PM Staff 2 (DNS) stated when a new skin issue was discovered, a Skin Integrity Report was to be initiated. She expected the nurse on duty to assess and measure the wound right away, complete wound care, implement a treatment protocol on the TAR, and place the resident on alert charting. Staff 2 acknowledged Resident 7's wound was identified on 11/1/25 and was not comprehensively assessed and measured until 11/3/25. Staff 2 confirmed there was no evidence in Resident 7's health record to indicate wound care was provided from 11/1/25 through 11/3/25.

The facilityGÇÖs policy for reconciling controlled substances, revised 11/2022, stated the system for reconciling the receipt, dispensing and disposition of controlled substances included the following:-Records of personnel access and usage;-Medication administration records;-Declining inventory records; and-Destruction, waste and return to pharmacy records.-Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile and inventory the count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DNS.A 3/27/25 FRI indicated narcotic medication for two residents was missing and unaccounted for.A 3/31/25 investigation report revealed the facility was unable to determine what happened to the missing narcotic medication.On 11/14/25 at 11:13 AM Staff 8 (CMA) stated she remembered hearing about missing narcotic medication and denied knowing any information related to the incident.On 11/14/25 at 1:03 PM Staff 6 (LPN) stated she remembered reports of two missing narcotic cards but denied knowledge of what happened to the medication.On 11/14/25 at 12:32 PM Staff 3 (Former DNS) stated during a review of one of the facilityGÇÖs narcotic books on 3/26/25 it was determined two narcotic cards were missing. Staff 3 stated as a result of the investigation completed on 3/31/25, an immediate audit of all narcotics was completed, and education was provided to all staff responsible for managing medication.The deficient practice was identified as Past Noncompliance based on the following:The deficient practice was identified by the facility and was corrected on 4/1/25 when the facility completed a root cause analysis of the incident and identified a system failure related to managing narcotic medication. The plan of correction included: A full audit of all narcotic books was completed; no additional discrepancies were found. Education was provided to staff to include the facility's updated protocol for counting narcotic medication which included to count the number of narcotics in each book and record the amount next to staff initials on the signature/sign off page upon each shift change. All narcotics were inputted into new narcotic books to reflect correct records of each narcotic medication.

Resident 5 admitted to the facility in 2011 with diagnoses including anxiety, mood and personality disorder. The 7/20/23 Care Plan indicated Resident 5 had behaviors of refusing cares, refusing all wound cares and other cares including bathing and hygiene tasks. Resident 5 was not easily directed and interventions by staff escalated the residentGÇÖs agitation. Resident 5 had history of being verbally and physically aggressive toward staff. Interventions included: to not argue with the resident and to discontinue attempts to treat if she/he became agitated and reapproach later. A 1/6/25 Facility Reported Incident indicated the following:--á -á -á -á -á - On 1/4/25 Resident 5 told Staff 21 (RN) to go to Hell when attempting to complete wound care. Staff 21 was heard by CNA Staff reply to Resident 5, GÇ£IGÇÖm already in Hell. YouGÇÖre SatanGÇÖs bitch, arenGÇÖt you?GÇ¥ Staff 21 also threatened to call the police on Resident 5 for assault because the resident grabbed the collar of Staff 21GÇÖs isolation gown.-á--á -á -á -á -á - Staff 19GÇÖs (CNA) witness statement indicated she and Staff 20 (CNA) went to provide a brief change to Resident 5. Staff 19 indicated Resident 5 was not accepting cares, but they were able to start changing the residentGÇÖs brief. Staff 21 came into the room to complete wound care. Resident 5 became upset because of the brand of cream being used. Resident 5 became agitated and grabbed Staff 21GÇÖs gown, tore it and told her to GÇ£Go to Hell."" Staff 21 was heard replying, GÇ£IGÇÖm already there and youGÇÖre SatanGÇÖs bitch.GÇ¥ Staff 21 stated she was going to call the police and press charges on Resident 5 for assault.-á--á -á -á -á -á- Staff 20's witness statement indicated she and Staff 19 went to change Resident 5GÇÖs brief and Staff 21 also went into the room to complete wound care. Resident 5 did not want to be changed and was not calming down. Staff 21 informed her and Staff 19, GÇ£it was fine, keep changing [her/him].GÇ¥ Resident 5 was upset about the cream being used and both Resident 5 and Staff 21 were yelling back and forth at each other.-á--á -á -á -á -á - Staff 21 indicated Resident 5 was calling her names and told her to go to Hell. Staff 21 told the resident wound care had to be done, and she/he needed to be changed, the resident continued to yell. Staff 21 indicated Resident 5 grabbed her and she told the resident she could report her/him. Staff 21 indicated she stated she was in Hell but did not recall saying anything else.-á--á -á -á -á -á - Resident 5 indicated she/he told Staff 21 to get out and Staff 21 told her/him she was going to call -áGÇ£themGÇ¥ to take her/him away. Resident 5 was unable to recall any other statements made by Staff 21. --á -á -á -á -á- The investigation indicated Resident 5GÇÖs care plan was not followed related to staff not discontinuing attempts to treat and provide care when the resident became agitated. No psychosocial harm was found, and Staff 21 was terminated. Abuse was unable to be ruled out related to the verbal abuse toward Resident 5.-áOn 7/10/25 at 11:07 AM Resident 5 was unable to recall the incident that occurred between her/him and Staff 21. On 7/10/25 at 1:10 PM Staff 19 stated she and Staff 20 went into Resident 5GÇÖs room with Staff 21 to change the residentGÇÖs brief and complete wound care. Staff 19 stated they were all wearing gowns due to the resident being on Enhanced Barriers Precautions. Staff 19 stated Resident 5 lashed out and grabbed Staff 21GÇÖs gown and told her to GÇ£go to HellGÇ¥. Staff 19 stated Staff 21 told the resident that she was already there, and she/he was GÇ£SatanGÇÖs bitch.GÇ¥ Staff 19 stated they were able to change the resident, but she/he continued to lash out and Staff 21 threatened to call the police on the resident for assaulting staff. Staff 19 stated Resident 5 had a history of being resistive to care. Staff 19 stated when Resident 5 was being resistive to cares staff were to leave the room, reassess and reapproach. Staff 19 stated Staff 21 told her and Staff 20 to keep going with providing the brief change and to not worry about it even though Resident 5 was resistive.On 7/10/25 at 12:14 PM Staff 20 stated Resident 5 had known behaviors of refusing cares. Staff 20 stated her, and Staff 19 went into Resident 5GÇÖs room to change her/his brief and Staff 21 was also in the room to complete wound care. Staff 20 stated Resident 5 was not complying with care and refusing to be changed. Staff 20 stated Staff 21 told her and Staff 19 to go ahead and change the resident even though she/he was GÇ£freaking outGÇ¥ and told them to get out. Staff 20 stated both Staff 21 and Resident 5 were yelling at each other. Staff 20 stated she heard Staff 21 telling Resident 5 she/he was GÇ£SatanGÇÖs bitch.GÇ¥ Staff 20 stated when Resident 5 was resistive to cares, staff were to walk away and reapproach. On 7/10/25 at 12:57 PM Staff 21 stated Resident 5 was hateful and on 1/4/25 Resident 5 was calling her names, trying to hit and kick her and told her to go to Hell. Staff 21 stated she told Resident 5 that she was already there and then proceeded to say something under her breath. Staff 21 stated CNA staff overheard her and reported it. Staff 21 stated she did not argue about what she reportedly said. Staff 21 further stated she was directed by Staff 15 (Former DNS) to GÇ£forceGÇ¥ brief changes at least once a day which triggered the residentGÇÖs behaviors.On 7/14/25 at 11:45 AM Staff 15 stated on 1/4/25 Staff 21 attempted to complete a treatment on Resident 5. Resident 5 was noncompliant, and verbiage was said by Staff 21. Staff 15 denied having any conversations with Staff 21 to GÇ£forceGÇ¥ brief changes on Resident 5. Staff 15 stated staff were to encourage cares to be completed and if Resident 5 continued to refuse then to reapproach at a later time. On 7/10/25 at 1:30 PM Staff 1 (Administrator) acknowledged the 1/4/25 incident between Staff 21 and Resident 5 resulted in abuse. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care. Findings include:

Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.

A 10/12/24 Admission MDS revealed Resident 52's preferred language was Spanish and she/he needed an interpreter to communicate with health care staff.

A 10/28/24 care plan revealed Resident 52 spoke Spanish.

A review of the medical record revealed the following English language documents were issued to and signed by Resident 52:
- 10/14/24 Portable Orders for Life-Sustaining Treatment (POLST),
- 10/22/24 Notice of Medicare Non-Coverage,
- 10/29/24 Notice of Medicare Non-Coverage,
- 1/9/25 SNF Discharge Instructions/Recapitulation of Stay.

On 1/14/25 at 11:52 AM Witness 2 (Complainant) stated she visited with Resident 52 and she/he complained the facility provided documents to her/him in English only and requested she translated documents to Resident 52.

Unable to interview Resident 52 due to her/his phone being disconnected.

On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 spoke Spanish with very little English.

On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated Resident 52 had variable English skills and required a translator for communication. Staff 18 did not know if Resident 52 read English and stated she/he needed her/his Notice of Medicare Non-Coverage to be issued in Spanish.

On 1/15/25 at 2:40 PM Staff 19 (LPN) confirmed Resident 52 spoke Spanish with very little English.

On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 spoke Spanish and the facility failed to provide documents to her/him in a language she/he could understand.

Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include:

A facility Mail and Electronic Communication policy, revised in 2017, stated, "Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries)."

During the resident council meeting on 1/14/25 at 2:00 PM residents stated their mail was not delivered to them on Saturdays.

On 1/15/25 at 10:04 AM Staff 20 (Activities Director) stated mail was delivered Monday through Friday only. Staff 20 stated mail delivered to the facility on Saturdays was not given to resdients until the next Monday morning.

On 1/15/25 at 11:31 AM Staff 1 (Administrator) stated resident mail was to be delivered to the residents on the same day it was delivered to the facility.

Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed residents at risk for unmet needs. Findings include:

Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.

An 10/16/24 Utilization Review assessment revealed Resident 52 had chronic suicidal ideation comments.

An 10/26/24 Progress Note revealed Resident 52 yelled and swung at staff, was combatiative, and refused to have her/his vitals done.

A 11/5/24 Progress Note with a licensed clinical social worker revealed Resident 52 was referred to her by the facility for a depressed mood. Resident 52 expressed feeling depressed following recent medical complications and loss of independence, had depressed mood, sadness, feelings of helplessness, difficulties concentrating, and some irritability. Resident 52 expressed recent suicidal ideation with no intent or plan.

A review of Resident 52's medical record revealed no monitoring for mood or behaviors.

A review of Resident 52's comprehensive care plan revealed nothing related to mood, history of suicidal ideation, adjustment, or behaviors.

On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 was in a "weird slump for a bit" when asked about her/his mood.

On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated she was unaware of any mood issues for Resident 52.

On 1/15/25 at 10:46 AM Staff 21 (CNA) stated Resident 52 complained about not having family support and expressed wanting to die.

On 1/15/25 at 2:40 PM Staff 19 (LPN) stated Resident 52 expressed being tired of being sick and wanted to be done with life. Staff 19 referred her/him to Staff 18.

On 1/16/25 at 12:42 PM Staff 4 (LPN Resident Care Manager) stated Resident 52 had a chronic low mood and had suicidal ideation without a plan or active suicidal behaviors. Staff 4 stated Resident 52 was seen by a licensed clinical social worker for her/his mood issues.

On 1/17/25 at 7:32 AM Staff 18 stated Resident 52 had "passive" suicidal ideation and saw mental health support in the facility but that was about adjustment issues and not related to any suicidal behaviors. Staff 18 stated she did not feel Resident 52 had actual suicidal ideation or mood issues so she did not do a care plan related to it.

On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 had mood and behavior issues and she expected those issues to be addressed in her/his care plan.

Based on interview and record review it was determined the facility failed to provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings Include:

Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.

An 10/5/24 hospital progress note revealed Resident 52 had a a right foot ulcer.

An 10/8/24 Clinical Admission revealed a right lateral (outer edge) foot diabetic foot ulcer was identified.

Daily Skilled Evaluations completed 10/9/24 through 10/18/24, 10/20/24 through 11/1/24, 11/4/24, and 11/5/24, identified Resident 52's right lateral foot diabetic ulcer was not evaluated.

10/14/24, 10/17/24, 10/25/24, 11/1/24, and 11/19/24 Physician Progress Notes revealed no information related to Resident 52's right lateral foot diabetic ulcer.

A 11/21/24 Skin Check assessment revealed Resident 52 was identified to also have a venous ulcer (a chronic wound that occurs when blood pools in the veins of the legs, damaging the skin and causing an open sore) on the left front lower leg and a venous ulcer on the left shin; both were indicated to have been identified on admission.

A 11/26/24 Progress Note revealed Resident 52 had newly identified wounds to her/his left lower extremity, right foot, and buttocks. New wound orders were requested.

A 11/26/24 Skin Integrity Issue investigation revealed Resident 52 had a wound noted on 10/8/24 but there were no orders for treatment. Staff 6 (Assistant DNS) completed a skin assessment of Resident 52 and discovered two additional wounds to her/his left lower leg and one pressure wound. Resident 52 stated the wound to the left leg was present for years. Orders for wound care were requested and obtained at that time for the four wounds.

On 11/27/24 physician orders were received for wound care to Resident 52's wounds.

On 1/16/25 at 11:10 AM Staff 6 stated she was aware of Resident 52's wounds. Staff 6 stated the facility identified Resident 52 had a wound on her/his right foot at the 10/8/24 admission, but orders for treatment were not obtained until 11/27/24. Staff 6 reviewed the 11/21/24 Skin Check assessment and confirmed the left front lateral lower leg wound and left shin venous ulcer wounds were identified as present on admission and Resident 52 stated the wounds were there for a long time. Staff 6 stated the facility failed to provide treatment for these wounds until 11/27/24.

Based on interview and record review it was determined the facility failed to ensure residents were assessed after weight loss was identified for 1 of 3 sampled residents (# 34) reviewed for nutrition. This placed residents at risk continued weight loss. Findings include:

Resident 34 admitted to the facility on 6/24/24 with diagnoses including malnutrition and type 1 diabetes.

The 8/13/24 Care Plan indicated Resident 34 had a nutritional problem related to ongoing malnutrition and weight loss since admit. The goal was for Resident 34's weight to be within acceptable parameters set by the RD and Interdisciplinary team. Interventions included distant supervision, high protein foods and supplements.

Review of Resident 34's Weight Summary report indicated the following:
- 6/25/24 weight of 200.6 pounds.
- 7/10/24 through 9/4/24 weight averaging 205.5 pounds.
- 9/16/24 no weight taken.
- On 9/23/24 Resident 34's weight was 174.6 pounds (32.5-pound weight loss).

On 9/26/24 a progress note indicated the identified weight of 174.6 pounds and a reweigh was requested.

Review of the Weight Summary Report indicated Resident 34 was not weighed again until 10/7/24 with a weight of 175.2 pounds (two weeks after the 9/26/24 reweigh request).

Review of Resident 34's medical record indicated no new nutritional interventions were implemented between 9/26/24 and 10/7/24.

Review of Resident 34's progress notes indicated she/he was sent to the hospital on 10/14/24 related to diabetes and returned to the facility on 10/19/24.

A 10/15/24 nutritional progress note indicated a reweigh was previously requested. Resident 34 was due for review by the Nutritional at Risk (NAR) group but left to the hospital and would be reviewed in NAR upon return.

Review of NAR Assessments indicated no review of Resident 34 was completed between 9/26/24 (first identified weight loss) and 10/14/24 (two and a half weeks later) when the resident discharged to the hospital. The first noted NAR assessment was completed on 10/22/24 (three days after readmission to the facility).

Observations made from 1/13/25 through 1/15/25 revealed Resident 34 was able to feed himself with adaptive equipment. Resident 34 was observed to eat 100% of her/his meals.

On 1/16/25 at 9:39 AM and 3:22 PM Staff 13 (RD) stated she reviewed the weight report weekly and determined who needed to be further assessed for being at risk for weight loss. Staff 13 stated a re-weigh request was to be completed by the following morning to determine accuracy. Staff 13 stated a resident was to be reviewed in NAR within a week of being identified for weight loss. Staff 13 acknowledged Resident 34's re-weigh recommendation was not completed timely, and Resident 34 was not reviewed in NAR until 10/22/24 resulting in a delay in nutritional interventions.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include:

On 1/14/25 at 1:30 PM Staff 2 (DNS) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA). No performance reviews were provided.

On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged no performance reviews were completed for the identified CNA staff.

Based on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses.

A review of the facility policy "Refrigerator and Freezer" policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee.

On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25.

On 1/14/25 at 1:09 PM Staff 16 (Dietary Manager) stated he was not aware of the process for monitoring the resident foods refrigerator utilized by the care team. He stated he had taken the temperature of the refrigerator on 1/10/25 when he placed the log on the front of the refrigerator.

On 1/15/25 at 9:59 AM foods were observed with no dates or names in both compartments of the resident refrigerator in the dining room. Staff 17 (CNA) stated she was not sure what the policy was for labeling and dating foods. The resident snack refrigerator behind the nurses station was also observed. The temperature log only had one recorded temperature, dated 1/14/15.

In an interview on 1/16/25 at 1:00 PM Staff 16 acknowledged refrigerator temperatures were to be monitored and recorded daily, and refrigerator food was to be labeled and dated.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 8 of 31 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

On 1/14/24, the facility provided documenation indicating four residents were approved for the bariatric rate.

A review of the Direct Care Staff Daily Reports from 12/13/24 through 1/13/25 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts:
- 12/13/24
- 12/14/24
- 12/20/24
- 12/26/24
- 12/27/24
- 12/29/24
- 12/30/24
- 1/13/25

On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged the state minimum bariatric CNA staffing ratios were not met for the identified dates. No further information was provided.

********************************
OAR 411-085-0310 Residents' Rights: Generally

Refer to F552 and F576
********************************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

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

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

Refer to F692
********************************
OAR 411-086-0310 Employee Orientation and In-Service Training

Refer to F730
********************************
OAR 411-086-0250 Dietary Services

Refer to F812
********************************

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect. This placed residents at risk for a decrease in their quality of life.

Resident 2 admitted to the facility in 11/2023, with diagnoses including hyperlipidemia (a condition caused by high levels of fat in the blood).

Resident 1 admitted to the facility in 2/2024, with diagnoses including chronic systolic heart failure.

A 7/17/24 Facility Reported Incident indicated Resident 1 was observed having a verbal altercation with Resident 2 in the facility parking lot. It was reported the altercation began after Resident 2 requested Resident 1 to return a spare wheelchair that Resident 1 had borrowed. Resident 1 during the verbal altercation was observed spitting in Resident 2's face before staff intervened and separated both residents.

A 7/17/24 witness statement by Staff 3 (Medical Records Director) and Staff 4 (ADNS) indicated Resident 1 spat in the face of Resident 2 during the resident's verbal altercation.

On 10/1/24 at 3:23 PM Resident 2 stated Resident 1 had "spit in her/his face" during the argument. Resident 2 stated she/he felt offended and disrespected and it was emotionally difficult for her/him. Resident 2 confirmed she/he had not been abused by Resident 1 during the altercation. Resident 2 stated she/he declined a physical assessment be conducted by staff and had not been injured during the altercation between Resident 1.

On 10/2/24 at 12:13 PM Resident 1 denied spitting in Resident 2's face but confirmed she/he had "gotten in her/his face" during the verbal altercation as she/he was "pissed off."

On 10/2/24 at 12:42 PM Staff 3 indicated that she witnessed Resident 1 "talking aggressively" regarding Resident 2's wheelchair. Staff 3 stated that during the altercation, Resident 1 was witnessed spitting in the face of Resident 2. Staff 3 stepped in and separated both parties and escorted Resident 2 back to her/his room for clinical assessment. Staff 3 stated Resident 2 had declined assessment due to no injuries being sustained during the incident.

On 10/2/24 at 12:52 PM Staff 4 stated she observed Resident 1 yelling in the face of Resident 2. Staff 4 stated Resident 1 was upset with Resident 2 when she/he asked for a wheelchair that Resident 1 had borrowed. Staff 4 confirmed that during the incident, Resident 1 was witnessed spitting in the face of Resident 2. Staff 4 stated she assisted Staff 3 in separating both residents and stayed with Resident 1 outside while she/he calmed down. Staff 3 stated both residents were placed on safety monitoring and confirmed no additional incidents occurred.

On 10/10/24 at 12:55 PM Staff 2 (DNS) and Staff 4 (ADNS) confirmed findings and provided no additional information.

OAR 411-085-0310 - Residents' Rights: Generally

Refer to F557
********************

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential repeat sexual abuse incidents. Findings include:

Resident 1 was admitted to the facility in 11/2023, with diagnoses including severe sepsis and post-traumatic stress disorder.

A 11/8/23 Admission MDS Assessment, Section C: Cognitive Patterns, identified Resident 1 with severe cognitive impairment.

Resident 1's 11/17/23 Care Plan identified the resident with a history of trauma related to domestic violence with interventions, including maintaining personal space boundaries and announcing self before approaching.

Resident 2 was admitted to the facility in 8/2023, with diagnoses including encephalopathy and dementia with behavioral disturbance.

An 11/24/23 Quarterly MDS Assessment, Section C: Cognitive Patterns, identified Resident 2 with severe cognitive impairment.

Resident 2's 8/18/23 Care Plan identified the resident with inappropriate sexual behavior related to touching and kissing other residents.

A 4/29/24 Facility Reported Incident revealed Resident 2 was found with her/his hand down Resident 1's brief while she/he was asleep. Resident 2 was reported to have been removed from the room after and was transferred to a different hallway soon after the incident. Tigard police were notified on the morning of 4/30/24 who identified Resident 1 with a history of engaging in inappropriate sexual behaviors.

On 5/2/24 at 12:59 PM, Resident 2 stated she/he went to visit Resident 1 on 4/29/24 but did not recall touching Resident 1 during their visit.

On 5/2/24 at 1:24 PM, Staff 3 (CMA) stated she witnessed Resident 2 with her/his hand inside the front of Resident 1's brief towards the resident's genitals exposing her/his right hip and buttocks.

A review of facility progress notes and risk management report indicated Resident 2 was discovered in Resident 1's room on the evening of 4/29/24 and placed her/his hand down Resident 1's brief while she/he was asleep. Facility immediately placed Resident 2 on the opposite side of the facility.

On 5/2/24 at 2:08 PM, Staff 5 (Receptionist) stated Resident 2 had been placed on a one on one monitoring schedule to assure resident safety and prevent further occurrence of sexually inappropriate behaviors.

Observation of Resident 2 from 5/2/24 to 5/3/24 revealed the resident with an assigned one on one staff member.

On 5/3/24 at 11:25 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2 placed her/his hand down the front of Resident 1's brief while she/he was sleeping in her/his room. Staff 2 stated Resident 2 was placed with a one on one staff member indefinitely.

OAR 411-085-0360 - Abuse

Refer to F600
********************

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of money for 1 of 2 sampled residents (#11) reviewed for misappropriation. This placed residents at risk for loss of property. Findings include:

Resident 10 was admitted to the facility in 9/2023 with diagnoses including fracture of the left pubis.

A 12/29/23 Admissions Assessment identified Resident 10 with moderate cognitive impairment.

Resident 10's 2/15/24 Care Plan identified the resident with behavioral issues including yelling and panhandling cash for cigarettes from other residents and staff.

Resident 11 was admitted to the facility in 3/2023 with diagnoses including viral hepatitis and anemia.

A 12/24/23 Quarterly Assessment identified Resident 11 with severe cognitive impairment.

Resident 11's 8/18/23 Care Plan identified Resident 11 with ineffective coping related to cognitive memory deficits including poor insight and difficulty with problem solving.

A 3/8/24 Incident Report revealed Resident 10 was found to have taken money from Resident 11 in Resident 11's room. Resident 10 was then asked by the facility to return the money to Resident 11 and had refused. Resident 10 was then witnessed placing the money in her/his pocket before leaving the facility to purchase cigarettes.

On 4/8/24 at 11:40 AM Resident 10 stated she/he had taken Resident 11's money for the use of purchasing cigarettes at the local gas station.

On 4/10/24 at 2:52 PM Staff 5 (LPN) confirmed findings and stated Resident 10 had a history of panhandling residents with cognitive impairment for money as a means to purchase cigarettes.

On 4/11/24 at 2:15 PM Staff 1 (Administrator) stated the facility substantiated misappropriation of Resident 11's money.

Based on interview and record review it was determined the facility failed to treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include:

Resident 8 admitted to the facility in 5/2023, with diagnosis including diabetes.

Resident 8's 10/10/23 physican orders instructed staff to clean the right toe diabetic wound with wound cleanser, apply a thin layer of AD (ointment) to the wound and periwound, and to secure the wound with bordered foam. The dressing was to be changed three times per week and as needed.

Resident 8's October 2023 TAR revealed no wound care was done between 10/11/23 through 10/27/23.

On 4/10/24 at 11:15 AM, Staff 2 (DNS) verified wound treatments were not completed from 10/11/23 through 10/27/23.

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

Refer to F602

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

Refer to F684

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

Based on interview and record review it was determined the facility failed to ensure resident narcotic medications were not misappropriated for 1 of 1 resident (# 4) reviewed for pain medications. This placed residents at risk for loss of property. Findings include:

Resident 4 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure.

Resident 4's 10/31/23 Admission MDS identified Resident 4 with moderate cognitive impairment.

Resident 4's 10/24/23 Care Plan revised on 10/30/23 indicated resident 4 had pain related to restless leg syndrome, cellulitis, and a wound to the lower left leg.

Resident 4's Medication Administration Record identified the use of Fentanyl Transdermal Patches to manage Resident 4's pain.

A review of Resident 4's November Narcotic Administration Record reviewed form 11/9/23 to 11/13/23 revealed a missing Fentanyl Transdermal Patch.

On 12/8/23 at 10:09 AM Staff 2 (DNS) acknowledged that the Fentanyl Transdermal Patch could not be located.

On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed the facility was unable to locate the Fentanyl Transdermal Patch.

Based on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for safety and coordination of care. Findings include:

Resident 2 was admitted to the facility in 2023 with diagnoses including schizoaffective disorder and stimulant abuse.

An 11/1/23 Admission MDS identified Resident 2 had no cognitive impairment.

Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself.

An 11/27/23 Nursing Care Note identified Resident 2 was unarousable while care staff attempted to provide catheter care. Resident 2's head was positioned in a downward angle. Care staff contacted emergency care services and resident 2 was noted to have refused to be transferred to the hospital.

An 11/28/23 Provider Note indicated after the emergency event, Resident 2 tested positive for illegal substances.

On 12/4/23 at 10:17 AM Staff 3 (RCM) confirmed resident 2 tested positive for illegal substances per physician order.

On 12/4/23 at 10:51 AM Staff 6 (CNA) revealed Resident 2 had a lighter in her/his room.

On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

Based on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substances for 1 of 1 sampled resident (#2) reviewed for behavioral emotional health. This placed residents at risk for a decline in mood and potential risk for reduced quality of life. Findings include:

Resident 2 was admitted to the facility in 10/2023 with diagnoses including schizoaffective disorder and stimulant abuse.

Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself.

Resident 2's 11/1/23 Care Plan identified the facility was to provide Resident 2 with continued resources related to drug addiction counseling.

On 12/4/23 at 12:19 PM Staff 4 (SSD) stated Resident 2 declined the offer of drug support services and counseling. Staff 4 indicated these services were offered and documented in Resident 2's clinical record. Staff 4 confirmed no additional drug addiction services or resources were provided to Resident 2.

A review of Resident 2's clinical record revealed no attempts or continued resources were provided to Resident 2 for drug addiction resources and services.

On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

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

Refer to F602

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

Refer to F689

******************************
OAR 410-180-0340 Professional Standards

Refer to F740