Avamere Riverpark Of Eugene

Based on interview and record review it was determined the facility failed to ensure residents did not receive unnecessary medications for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for side effects related to blood pressure medications. Findings include:Resident 4 was admitted to the facility in 12/2022 with diagnoses including heart failure and arterial fibrillation (an irregular heartbeat). A review of orders revealed a 6/11/24 order for metoprolol succinate (a medication used to treat high blood pressure), hold for a heart rate less than 60 beats per minute. A review of Resident 4's 1/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on:-1/10/26 heart rate was 59 per minute-1/22/26 heart rate was 59 per minute-1/24/26 heart rate was 52 per minute-1/29/26 heart rate was 52 per minute A review of Resident 4's 2/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on:-2/10/26 heart rate was 56 per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to ensure medications, were stored properly for 1 of 3 medication carts reviewed. This placed residents at risk for reduced medication effectiveness. Findings include:On 2/25/26 South Hall medication cart observations revealed Resident 15's insulin had been removed from the refrigerator and was not dated. Staff to 22 (LPN) confirmed the insulin should've been dated after staff removed the insulin from the refrigerator. Resident 6's insulin dated 2/18/26 was observed unopened on the medication cart. Staff 22 confirmed the insulin should've been kept refrigerated until used.On 2/25/26 at 4:01 PM, Staff 3 (Regional Director of Clinical) stated all nursing staff are expected to follow proper medication storage requirements, including refrigeration and dating of insulin.

Based on observation, interview, and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#57) reviewed for ADLs. This placed residents at risk for inaccurate medical records. Findings include:1. Resident 57 admitted to the facility in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. On 2/23/26 at 2:50 PM Resident 57 stated staff did not assist her/him with oral hygiene despite resident requests. On 2/24/26 at 11:34 AM, Resident 57 stated she/he required total assistance from staff to brush her/his teeth. When asked where the oral hygiene supplies were located, this resident indicated she/he did not know and had never seen a toothbrush in her/his room.On 2/27/26 at 9:11 AM Resident 57 reported she/he received assistance with brushing her/his teeth once that week on day shift on 2/25/26. Resident 57 stated she/he was not offered additional opportunities for oral hygiene.Resident 57's 2/24/26 Task: GG-Oral Hygiene report indicated oral hygiene was completed by Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. Resident 16 was admitted to the facility in 7/2022 with diagnoses which included stroke. A 5/5/25 Bowel and Bladder Evaluation indicated Resident 16 was a candidate for scheduled toileting (timed voiding). A 5/5/25 quarterly MDS indicated Resident 16 was cognitively intact. A 6/3/25 care plan revealed Resident 16 was incontinent of bowel and bladder. Resident 16 had a history of urgency incontinence. Interventions included assisting with using the bathroom before breakfast and after lunch per preference to anticipate needs, resident used briefs, provide incontinentence care as needed, and provide peri care (cleaning of the genital area) after an incontinent episode. A public complaint was received on 6/23/25 alleging in 6/2025 Resident 16 was not cleaned properly after a bowel movement. The brief was clean, but Resident 16 had dried feces over groin area, buttocks and down her/his thighs. On 7/8/25 at 9:16 AM, Witness 1 (Complainant) stated twice in 6/2025 she found Resident 16 with dried feces on her/him. Witness 1 stated the first instance involved dried feces on her/his back,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#39) reviewed for medication administration. This placed residents at risk for lack of dignity. Findings include: Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes. On 10/10/24 at 11:50 AM Staff 28 (RN) performed a CBG (blood sugar measurement) check on Resident 39 in the dining room without permission from the resident with multiple residents in the dining room. Resident 39 required an insulin injection, Staff 28 raised the resident's shirt and administered the insulin into her/his abdomen. Resident 39 asked Staff 28 to administer the injection in her/his arm multiple times. Another resident in proximity to Resident 39 looked away during her/his insulin administration. On 10/10/24 at 12:05 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) acknowledged Staff 28 failed to protect Resident 39's dignity by performing a CBG check in the dining room, and by lifting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident's representative was included in the care planning process for 1 of 2 sampled residents (#77) reviewed for communication. This placed residents at risk for lack of input in the care planning process. Findings include: Resident 77 admitted to the facility in 12/2023 with diagnoses including stroke and aphasia (language disorder). An 4/18/24 Comprehensive Plan of Care Review indicated N/A (not applicable) related to the attendance of the responsible party. A 7/22/24 Annual MDS indicated Resident 77's BIMS assessment could not be completed, she/he was rarely understood and she/he used nonverbal communication to express her/his needs. A 7/23/24 Comprehensive Plan of Care Review indicated N/A related to the attendance of the responsible party. An 10/7/24 resident profile for Resident 77 indicated Witness 1 (Family Member) was her/his main contact. On 10/7/24 at 4:01 PM Witness 1 stated she did not receive invitations to Resident 77's care conferences and she was in the facility weekly. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to notify the physician regarding refusals and changes in condition for 3 of 9 sampled residents (#s 26, 42, and 442) reviewed for medications, and change of condition. This placed residents at risk for lack of physician involvement. Findings include: The facilities 2/2021 Requesting, Refusing, and/or Discontinuing Care or Treatment Policy indicated; -the healthcare practitioner must be notified of refusal of treatment. 1. Resident 26 admitted to the facility in 10/2017 with diagnoses including kidney failure. A 9/25/24 physician order indicated staff were to complete daily weights, and call the physician for a weight gain of two to three pounds per day over a two-day period or five pounds in one week. A review of the 9/2024 and 10/2024 TARs indicated Resident 26 refused daily weights from 9/25/24 through 10/9/24. A 9/25/24 physician order indicated staff were to check Resident 26's CBG (blood sugar measurement) level four times a day and to notify the physician for a CBG level less than 70 or greater than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure the required parties were notified of resident hospitalizations for 3 of 7 sampled residents (#s 42, 44, and 89) reviewed for hospitalization and change of condition. This placed residents at risk for lack of advocacy. Findings include: 1. Resident 42 admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure. A 9/12/24 Progress Note indicated Resident 42 was transported to the emergency department due to complaints of uncontrolled pain. A 9/12/24 MDS Discharge Assessment was completed with an anticipated return from the hospital. Review of Resident 42's clinical record revealed no transfer notice was provided to Resident 42, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman. On 10/11/24 at 12:29 PM Staff 2 (DNS) acknowledged a transfer notice was not provided to Resident 42, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman. 2. Resident 44 admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 3 of 7 sampled residents (#s 42, 44, and 89) reviewed for hospitalization and change of condition. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 42 was admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure. A 9/12/24 progress note indicated Resident 42 was transported to the emergency department due to complaints of uncontrolled pain. A 9/12/24 MDS Discharge Assessment was completed with return anticipated. A reviewed of Resident 42's clinical record revealed no documentation the resident or her/his representative was provided information regarding the facilty bed hold policy. On 10/11/24 at 11:09 AM Staff 14 (LPN) stated she did not understand the process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to complete comprehensive care plans within the required timelines and revise care plan interventions for 2 of 7 sampled residents (#s 38 and 42) reviewed for change of condition, ADL care and edema. This placed residents at risk for unmet needs. Findings include: 1. Resident 38 admitted to the facility in 8/2022 with diagnoses including kidney disease and UTI. On 10/7/24 at 11:25 AM Resident 38 reported recurrent UTIs every three months, and also reported chronic bladder discomfort, burning with urination, and a sense of urinary urgency. The 7/21/23 care plan documented Resident 38 was at risk for UTIs with history of UTIs. There were no documented updates or revisions to the goals or interventions since the original date of care plan initiation on 7/21/23. On 10/9/24 at 5:17 PM Staff 3 (LPN-Resident Care Manager) reported the 7/21/23 care plan included Resident 38's recurring UTIs however the interventions were not revised or updated since the date the care plan was initiated. On 10/11/24 at 8:18 AM Staff 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure professional standards were followed for 2 of 6 sampled residents (#s 39 and 442) for medication administration. This placed residents at risk for adverse side effects and cross contamination. Findings include: Per OAR [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per OAR [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities to dependent residents for 2 of 3 sampled residents (#s 21 and 37) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include: 1. Resident 37 admitted to the facility in 7/2023 with diagnoses including stroke. The 7/15/24 Annual MDS revealed Resident 37's cognition was severely impaired, her/his family was involved in her/his care and indicated she/he enjoyed listening to music, spending time outside, and participating in religious activities. Resident 37's comprehensive care plan revealed her/his activities of interests were gospel music, Christmas, and bible study. The care plan interventions included staff were to provide one on one time, help Resident 37 go to activities, remind her/him of the activities she/he enjoyed, and leave music on for Resident 37. The 10/2024 Activities Calendar included weekly bible study social visits and weekly bible study. Resident 37's medical record included no documentation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to properly assess pressure ulcers for 2 of 4 sampled residents (#s 13 and 62) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: 1. Resident 13 admitted to the facility in 7/2024 with diagnoses including muscle weakness. The 7/28/24 admission MDS indicated Resident 13 was at risk for pressure ulcers due to incontinence and decreased mobility. The 7/25/24 care plan revised on 9/26/24 indicated Resident 13 had current skin concerns including pressure injuries to the bilateral buttocks. A 9/24/24 incident report indicated Resident 13 was being monitored for redness and a CNA found two large blisters. There was no documentation which indicated where the pressure ulcers were located on the resident. A 9/25/24 Weekly Skin assessment indicated the resident's skin was intact. A 9/25/24 Wound Evaluation indicated the resident had a pressure ulcer to her/his sacrum (bone at the end of the lower back). The 10/1/24 Wound Evaluation indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to supervise a resident while eating for 1 of 4 sampled residents (#292) reviewed for change of condition. This placed residents at risk for aspiration or choking. Findings include: Resident 292 admitted to the facility in 2/2024 with diagnoses including dementia. A 2/20/24 admission MDS revealed Resident 292 had swallowing difficulties. A review of Resident 292's 3/11/24 care plan revealed an intervention of close supervision while eating. A 3/19/24 investigation revealed on 3/14/24 after 10:30 PM Staff 24 (former staff member) assisted Resident 292 into the Central Dining Room, gave her/him a peanut butter and jelly sandwich and then went to the Central Nursing Station to chart. Staff 24 stated she asked Staff 26 (LPN) to supervise Resident 292 while she/he ate. Staff 26 was charting at the Central Nursing Station and was not in the dining room. On 10/10/24 at 11:09 AM Staff 22 (CNA) stated close supervision of a resident meant the staff were to remain within arm's length of the resident while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to thoroughly assess and monitor respiratory status and maintain respiratory equipment for 2 of 2 sampled residents (#s 17 and 42) reviewed for respiratory services. This placed residents at risk for worsening respiratory status. Findings include: 1. Resident 17 admitted to the facility in 7/2023 with diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), congestive heart failure (a long-term condition that occurs when the heart is unable to pump enough blood to meet the body's needs) and pulmonary hypertension (a condition that affects the blood vessels in the lungs, making it harder for blood to flow to the lungs and causing the heart to work harder to pump blood). A 9/22/24 Progress Note indicated Resident 17 had a wet productive cough, generalized body aches and tested negative for COVID 19. A 9/23/24 Progress Note indicated Resident 17 had increased weakness, a moist cough, lethargy, nausea, coarse lungs sounds, COVID 19 negative and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing for 2 of 8 sampled residents (#s 42 and 76) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 42 admitted to the facility in 6/2024 with diagnoses including heart failure, diabetes and severe obesity. A 6/14/24 admission MDS indicated Resident 42 was occasionally incontinent of bladder and required substantial to maximum assistance with toileting hygiene. A 9/26/24 through 10/9/24 CNA Task for Toileting Hygiene document identified Resident 42 required substantial assistance or was dependent on staff for toileting hygiene for 20 of 40 opportunities. An 10/3/24 revised care plan indicated staff were to provide intermittent supervision for Resident 42's personal hygiene including her/his perineum (genital area) and care after incontinent episodes. On 10/7/24 at 1:59 PM Resident 42 stated she/he urinated often due to her/his medication and frequently waited up to an hour for assistance with toileting hygiene. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. This placed residents at risk for adverse side effects of medications. Findings include: Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). An 4/6/24 physician order indicated staff were to administer lithium ER (extended release antipsychotic for bipolar disorder). On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding. On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes resolved with a neutral party and not in court) for 2 of 5 sampled residents (#s 13 and 76) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1.Resident 13 admitted to the facility in 7/2024 with diagnoses including muscle weakness. A 7/28/24 Medicare 5-Day MDS indicated Resident 13 was cognitively intact. An 10/7/24 facility provided list of residents who signed a facility Arbitration Agreement indicated Resident 13 signed an Arbitration Agreement. On 10/10/24 at 11:56 AM Resident 13 stated she/he was not aware of signing an arbitration agreement. On 10/11/24 at 3:00 PM Witness 3 (Family Member) stated she did not recall speaking to anyone regarding arbitration agreements when the arbitration form was offered. On 10/11/24 at 8:51 AM Staff 1 (Administrator) acknowledged they should ensure residents or their representatives understood the arbitration agreement.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident uses for 1 of 1 sampled resident (#39) reviewed during CBG checks. This placed all residents who required CBG checks at risk for bloodborne illness. Findings include: Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes. On 10/9/24 at 11:50 AM Staff 28 (RN) was observed to check Resident 39's CBG (blood sugar measurement) level in the dining room. Staff 28 placed the glucometer on the North medication cart and cleaned the glucometer with small alcohol prep wipes. On 10/9/24 at 12:10 PM Staff 28 stated she always used alcohol prep wipes to sanitize the glucometer, and she was not aware of another sanitizing wipe. On 10/9/24 12:15 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) stated the glucometer should be sanitized with the proper sanitizing wipes.

Based on observation, interview, and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 2 sampled residents (#17) reviewed for respiratory care. This placed residents at risk for antibiotic resistant organisms. Findings include: Resident 17 admitted to the facility in 7/2023 with diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), congestive heart failure (a long-term condition that occurs when the heart is unable to pump enough blood to meet the body's needs) and pulmonary hypertension (a condition that affects the blood vessels in the lungs, making it harder for blood to flow to the lungs and causing the heart to work harder to pump blood). A 9/22/24 Progress Note indicated Resident 17 had a wet productive cough, generalized body aches and tested negative for COVID 19. A 9/24/24 Progress Note indicated a provider visit with Resident 17 and a new antibiotic order was received for an upper respiratory infection (an illness that affects the upper respiratory system). On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and record review it was determined the facility failed to follow physician orders and follow the care plan for 3 of 10 sampled residents (#s 3, 5 and 9) reviewed for medications and ADLs. This placed residents at risk for unmet care needs. Findings include: 1. Resident 9 was admitted to the facility in January 2023 with diagnoses including chronic pain syndrome. Review of a physician order dated 1/5/23, revealed the resident was to receive Morphine (narcotic pain medication) 100 mg three times a day. The resident was to receive the Morphine at 8:00 AM, 2:00 PM and 9:00 PM. Review of a progress note dated 10/11/23 at 5:12 AM, revealed the facility was out of the resident's Morphine and the resident was upset and cursing at the nurse. Review of an October 2023 MAR revealed the resident was not administered Morphine on 10/11/23 at 8:00 AM. Review of a progress note dated 12/11/23 at 4:59 AM, revealed the facility was out of the resident's Morphine and the resident was upset. At 11:11 AM, Resident 9 reported a pain level of 10/10 and was administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide risk and benefits for the flu vaccine and/or provide vaccines for 4 of 5 sampled residents (#s 7, 13, 22 and 55) reviewed for immunizations. This placed residents at risk for illness and lack of informed consent. Findings include: 1. Resident 7 was admitted to the facility in 2020 with diagnoses including a stroke. Review of the resident's clinical record revealed the resident received PCV13 (pneumonia vaccine) in 2019. No documentation was found to indicate additional pneumonia vaccines were offered or provided as required. On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) verified the resident was not offered additional pneumonia vaccines. 2. Resident 13 was admitted to the facility in 2020 with diagnoses including heart disease. Review of the resident's record revealed there was no documentation the flu vaccine was offered for the 2022/2023 flu season. On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) stated she was not able to find any documentation related the resident's 2022/2023 flu vaccine. 3. Resident 22 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident was treated with respect for 1 of 1 sampled resident (#34) reviewed for dignity. This placed residents at risk for lack of respectful encounters. Findings include: Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder. A 1/13/23 revised care plan indicated Resident 34 had a history of receiving verbal aggression, staff were to stop activity if it was bothersome to her/him and monitor her/his emotional and physical distress. Staff were also to recognize Resident 34's experience and approach Resident 34 calmly. An 4/13/23 Quarterly MDS indicated Resident 34 had no verbal aggression towards others and was cognitively intact. A 5/1/23 FRI alleged on 4/29/23 Resident 34 was mistreated by Staff 6 (LPN) when Staff 6 came into Resident 34's room and yelled at her/him. Staff 6 was suspended pending investigation and Resident 34 requested Staff 6 no longer provide any of her/his care. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a cognitively impaired resident's representative was provided risk and benefits of a psychotropic medication prior to initiation and failed to ensure a resident's right to implement medication options was honored for 2 of 5 sampled residents (#s 63 and 76) reviewed for unnecessary medications. This placed residents at risk for lack of appropriate medical treatment decisions. Findings include: 1. Resident 63 was admitted to the facility in 2022 with diagnoses including major depressive disorder. Resident 63's 12/2022 admission weight was 146.8 pounds and her/his weight on 6/23/23 was 172 pounds. The 4/2023 through 6/2023 Behavior Monitoring Record and MAR indicated Resident 63 did not have negative behaviors and received amitriptyline (an antidepressant medication) daily for depression. A 6/11/23 Quarterly MDS revealed Resident 63 was cognitively intact. A 7/2/23 Epocrates (a professional website that provides clinical references on drugs) reference revealed a common reaction to the use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to include a resident in the plan of care for 1 of 1 sampled resident (#34) reviewed for urinary catheter. This placed residents at risk for lack of inclusion in the care planning process. Findings include: Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder. An 4/13/21 revised care plan indicated to provide urinary catheter care each shift, empty the catheter as needed and Resident 34 preferred to perform her/his own catheter care. An 4/13/23 Quarterly MDS indicated Resident 34 had an urinary catheter and was cognitively intact. A 1/5/23 physician order indicated a Foley (flexible tube) urinary catheter was to be changed monthly. The 6/2023 TAR indicated the urinary catheter was changed on 6/18/23 by Staff 6 (LPN). A 6/25/23 progress note indicated Resident 34 requested a new urinary catheter and bag due to clogging and changed her/his urinary catheter independently with no difficulty. On 6/27/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess residents' ability to self-administer medications for 1 of 1 sampled resident (#34) reviewed for non-pressure skin conditions. This placed resident at risk for adverse medication reactions. Findings include: Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder. An 4/13/23 Quarterly MDS revealed Resident 34 was cognitively intact and had no impairment to her/his upper extremities. A 6/8/23 progress note revealed Resident 34 was seen by a NP because of a rash on her/his hand. A 6/12/23 physician order indicated to apply hydrocortisone solution (medication use to treat skin irritation) to Resident 34's hand twice daily for two weeks. On 6/28/23 at 12:01 PM Resident 34 was observed with a tube of hydrocortisone cream dated 6/8/23. Resident 34 stated the medication was in her/his possession since it was first ordered and she/he applied the medication as needed. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to accurately assess a resident's gradual dose reduction (GDR) status for 1 of 5 sampled residents (#14) and to accurately assess a resident's dental status for 1 of 1 sampled resident (#76) reviewed for unnecessary medications and dental status. This placed residents at risk for unassessed needs. Findings include: 1. Resident 14 was admitted to the facility in 1/2022 with diagnoses including depression and bipolar disorder. The 5/2/23 Quarterly MDS indicated Resident 14 had a GDR on 2/17/23 for Abilify (antipsychotic), Trazodone (antidepressant) and Lexapro (antidepressant). On 6/30/23 at 8:45 AM Staff 1 (LPN-Resident Care Manager), Staff 2 (DNS) and Staff 5 (LPN-Resident Care Manager) acknowledged Resident 14 did not have a GDR on 2/17/23 and Resident 14's Quarterly MDS dated [DATE] was coded incorrectly. 2. Resident 76 was admitted to the facility in 6/2023 with diagnoses including traumatic brain injury. A 6/5/23 admission MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to update resident care plans to reflect edema, ROM and infection control precautions for 3 of 8 sampled resident (#s 49, 66 and 69) reviewed for edema, rehabilitation and unecessary medications. This placed residents at risk for lack of resident centered interventions. Findings include: 1. Resident 49 was admitted to the facility 5/23/23 with diagnoses including a fall and cervical neck fracture. A 5/23/23 Nursing admission Database indicated the resident did not have edema (swelling/fluid retention). NP Progress Notes dated 6/8/23 indicated the resident was seen for hypertension follow-up and had newly identified edema to both legs and feet. The resident was assessed to not be short of breath and the NP ordered labs and additional medications. Resident 49's Comprehensive Care Plan last updated 6/20/23 did not have an identified focus area of edema, with goals or interventions to prevent edema. On 6/26/23 at 2:22 PM Resident 49 was observed to have edema to both legs and the resident's legs were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to a ensure an order discrepancy related to pain medication was clarified and ensure a resident was assessed after falls for 2 of 7 sampled residents (#s 48 and 76) reviewed for pain and accidents. This placed residents at risk for increased pain and unidentified injuries. Findings include: 1. Resident 48 was admitted to the facility 6/15/23 with diagnoses including knee replacement. Hospital Discharge Medications revealed tramadol was to be administered every six hours. The order was not PRN. A hard copy of the prescription (required to be sent to the pharmacy in order for the medication to be filled), attached to the order form, was for tramadol PRN. The resident's clinical record did not contain documentation to indicate the resident's physician was notified of the tramadol order discrepancy. On 6/29/23 at 10:14 AM Staff 1 (LPN-Resident Care Manager) stated if the admission orders did not correlate with the hard copy of the prescription to be sent to the pharmacy, the staff were to call the physician for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident's fall was investigated for 1 of 4 sampled residents (#76) reviewed for accidents. This placed residents at risk for unassessed risk factors. Findings include: Resident 76 was admitted to the facility in 2023 with diagnoses including traumatic brain injury. Review of the resident's Progress Notes revealed on 6/10/23 the resident fell two times. One time the resident fell from her/his recliner and another time the resident fell while she/he attempted to put her/his socks on. A review of 6/10/23 fall investigations revealed there was no investigation for the resident's fall from the recliner. On 6/28/23 at 10:10 AM Staff 2 (DNS) stated each fall was to be investigated to ensure risk factors were taken into account. Staff 2 acknowledged only one investigation was completed for the two falls which occurred on 6/10/23.

Based on interview and record review it was determined the facility failed to obtain specialized physician appointments for 1 of 1 sampled resident (#76) reviewed for bowel and bladder. This placed residents at risk for lack of specialized care. Findings include: Resident 76 was admitted to the facility 6/1/23 with diagnoses including brain injury and urine retention. 6/1/23 hospital admission orders included the resident was to have urology and neurology follow-up appointments. On 6/28/23 at 10:23 AM Staff 1 (LPN-Resident Care Manager) stated when a resident admitted from the hospital the nursing staff forwarded referrals for specialists to the social service department. Staff 1 indicated she was not aware of any appointments for Resident 76. On 6/28/23 at 11:40 AM Staff 21 (Social Services) stated if a resident came directly from a hospital the nursing staff were to fax the specialist the referral form for an appointment. Staff 21 stated she was not notified the resident needed referrals to the urologist or neurologist but stated it was listed on the admission paperwork.

Based on interview and record review it was determined the facility failed to reorder pain medications in a timely manner for 1 of 3 sampled residents (#49) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include: Resident 49 was admitted to the facility 5/23/23 with diagnoses including cervical (neck) fractures. 5/23/23 hospital admission orders included orders for oxycodone (narcotic pain medication). The prescription did not have any refills and the pharmacy was to only dispense ten tablets. Resident 49's 5/2023 MAR revealed the resident took one oxycodone on 5/23/23, three tablets on 5/24/23 and 5/25/23 and two tablets on 5/26/23. The last tablet was administered at approximately 11:00 AM. Only one dose on 5/25/23 at 8:41 PM was documented as ineffective. The following two doses on 5/26/23 were documented as effective. Progress Notes from 5/24/23 through 5/27/23 revealed the resident was alert, oriented, pleasant and reported neck pain. The notes did not indicate the resident had unresolved pain. A 5/29/23 admission MDS and CAAs indicated Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to monitor a resident for psychotropic medication side effects for 2 of 5 sampled residents (#s 52 and 76) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 76 was admitted to the facility in 2023 with diagnoses including brain injury. admission orders dated 6/1/23 revealed the resident was to receive trazodone (antidepressant) PRN for inability to sleep and fluoxetine (antidepressant) every day. A Pharmacist Communication form dated 6/1/23 indicated the resident was administered fluoxetine daily and trazodone. The combined use of the medications placed the resident at risk for serotonin syndrome (can cause symptoms ranging from tremors to death). The form directed staff to keep the Pharmacist Communication form in the MAR while the resident took both medications and to monitor the resident for symptoms including tremor, fast heart rate, low grade fever, confusion, muscle spasm and impaired mobility. Staff were to monitor for high fever,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure resident records were complete for 1 of 3 sampled residents (#49) reviewed for pain. This placed residents at risk for lack of pertinent medical assessment documentation in the clinical record. Findings include: Resident 49 was admitted to the facility in 2023 with diagnoses including cervical (neck) fractures. 5/23/23 hospital admission orders included orders for oxycodone (narcotic pain medication). The prescription did not have any refills and the pharmacy was to only dispense ten tablets. Progress Notes from 5/24/23 through 5/27/23 revealed the resident was alert, oriented pleasant and reported neck pain. The notes did not indicate the resident had unresolved pain and did not indicate the resident had to be transported to the hospital to obtain pain medication. A 5/30/23 MDS indicated Resident 49 was cognitively intact. On 6/26/23 12:18 PM Resident 49 stated on one weekend the facility ran out of her/his pain medication and she/he had to go to the hospital to get pain medication. On 6/29/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure the care plan was followed regarding infection control precautions for 1 of 3 sampled residents (#79) reviewed for pressure ulcers. This placed residents at risk for infections. Findings include: Resident 79 was admitted to the facility in 2023 with diagnoses including a pressure ulcer. A care plan dated 6/13/23 revealed the resident had a history of multi-drug resistant organisms in the lungs and was on enhanced barrier precautions. Staff were to wear a gown and gloves during care including when staff assisted the resident with showers. On 6/29/23 at 9:18 AM a sign was observed by the entrance of Resident 79's room. The sign indicated the resident was on enhanced barrier precautions. The instructions indicated staff must wear mask, gown and gloves when providing high contact care. Staff 23 (CNA) was observed to exit Resident 79's room with a mask on. Staff 23 escorted Resident 79 to another room and shut the door. On 6/29/23 at 9:36 AM Staff 23 stated she did not often work with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.