Marquis Oregon City Post Acute Rehab

Based on interview and record review it was determined the facility failed to conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne pathogens. Findings include:The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.A review of the facility's revised 4/5/24 Water Management Program-Legionella revealed the following:-The facility's policy is to establish procedures to reduce the risk of Legionella and other opportunistic pathogens in the facility's water system.-A risk assessment is to be conducted by the water management team annually…

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 resident accessible outside space was free from environmental hazards for 1 of 1 memory care outdoor area reviewed for safety and failed to safely transfer 1 of 1 sampled resident (#44) reviewed for ADLs. This placed residents at risk for injury and elopement. Findings include: 1. The facility's undated Friendship House Disclosure Statement revealed:-The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. Exits from the entire hall are locked to prevent unsafe wandering. Residents living at Friendship House are free to wander about the common area and outside secured yard. On 2/25/26 at 9:30 AM a walkthrough of the secure memory care fenced courtyard and concurrent interview with Staff 1 (Administrator) revealed the following: -The walkway in…

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 the facility failed to ensure a clean, home-like environment for 1 of 1 memory care units and 1 of 1 dining halls observed. This placed residents at risk for lessened quality of life. Findings include: On 10/22/24 at 11:58 AM an observation during lunch service in the main dining room revealed the light fixtures had built up debris and dead insects inside eight of eight ceiling lights. On 10/24/24 at 10:45 AM an observation near the exit of the Memory Care Unit revealed debris and dead insects accumulated on two vent covers, and in one ceiling light fixture. On 10/24/24 at 11:19 AM and 11:57 AM Staff 14 (Maintenance Director) stated he usually cleaned vents annually and cleaned the light fixtures when he noticed they were dirty or someone told him they needed cleaning. Staff 14 stated the design of the lights was perfect for catching dust and insects like a bowl. Staff 14 acknowledged the vents and light fixtures were not clean.

Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 18% with six errors in 33 opportunities. This placed residents at risk for inaccurate medication dosage and adverse consequences related to medications. Findings include: 1. Resident 14 admitted to the facility in 11/2019 with diagnoses including dementia. A review of Resident 14's physician orders revealed a 9/25/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 9:24 AM Staff 13 (CMA) was observed administering medication to Resident 14. Staff 13 did not administer acidophilus pectin. A review of Resident 14's MAR revealed Staff 13 indicated she administered acidophilus pectin with the morning medications on 10/23/24. On 10/23/24 at 9:57 AM Staff 13 stated she did not administer acidophilus pectin. Staff 13 stated there was no acidophilus pectin in the medication cart and she was going to get a bottle from the medication storage room and administer it. On 10/23/24 at 10:04 AM Staff 4 (RNCM) stated medications…

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 and interview it was determined the facility failed to ensure medication storage was free of expired biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On [DATE] at 1:52 PM the medication storage refrigerator was observed to have three open vials of aplisol (tuberculosis test solution) with open dates in 7/2024. Each bottle indicated to discard 30 days after opening. On [DATE] at 1:56 PM Staff 2 (DNS) stated aplisol was to be discarded per the manufacturer's recommendation, 30 days after opening the vial. Staff 2 acknowledged all three vials of aplisol were open for greater than 30 days and needed to be discarded.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 1 resident (# 32) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include: Resident 38 was admitted to the facility in 6/2023 with diagnoses including dementia with behavioral disturbance. Resident 32 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbance. A 9/20/24 Behavior/Psychotropic Meeting report included Resident 38 exhibited behavior problems including grabbing others on 9/11/24 and screaming at others on 9/23/24. A 9/25/24 Resident to Resident Event Assessment reported Staff 16 (CNA) heard two residents yelling in a room. Staff 16 entered the room and found Resident 38 straddling Resident 32 with her/his hands around Resident 32's neck. Staff 16 was required to intervene to remove Resident 38 off of Resident 32. The report indicated Resident 38 reported, [Resident 32] was yelling and I told [her/him] I was going to kick…

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 MDS was coded accurately related to the use of hearing devices for 1 of 2 sampled residents (#9) reviewed for hearing. This placed residents at risk for unassessed needs. Findings include: Resident 9 was admitted to the facility in 2019 with diagnoses including Parkinson's and anxiety. The 8/14/24 Annual MDS indicated the resident did not use hearing aids. The 8/14/24 Communication CAA revealed Resident 9 had a hard time hearing and often needed staff to raise their voice level when speaking to the resident. Staff were to speak in an elevated tone and face the resident when conversing. The CAA indicated Resident 9 did not use hearing aid devices but may eventually need hearing aids if her/his hearing worsened. On 10/23/24 at 3:05 PM and 10/24/24 at 11:52 AM Staff 3 (Social Services) stated the resident utilized hearing aids. Staff 3 stated she completed the 8/14/24 Annual MDS and Communication CAA, and acknowledged both were inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure staff assisted a resident with wearing hearing aids for 1 of 2 sampled residents (#35) reviewed for hearing. This placed residents at risk for a decline in communication. Findings include: Resident 35 was admitted to the facility in 7/2024 with diagnoses including dementia and anxiety. Review of Resident 35's Care Plan, revised on 8/16/24, revealed the resident had adequate hearing with hearing aids. Staff were instructed to place Resident 35's hearing aids in her/his ears in the morning, remove them at night, and place them on a charger on the night stand in a green container. Resident 35 might decline to wear her/his hearing aids due to them not being comfortable. A 9/11/24 Significant Change MDS revealed Resident 35 used hearing aids and her/his hearing was adequate. Resident 10 had a BIMS score of 10, indicating moderate cognitive impairment. A review of Resident 35's clinical record revealed no indication Resident 35 refused to have her/his hearing aids placed in her/his ears. 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 ensure residents were free from abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 7 admitted to the facility in 3/2020, with diagnoses including unspecified dementia and acute kidney failure. Resident 7's Quarterly MDS dated [DATE] revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident 8 admitted to the facility in 8/2022 with diagnoses including Alzheimer's Disease and diabetes. Resident 8's Progress Note revealed on 9/14/22, she/he was observed trying to touch other residents in the groin area. When confronted by staff, Resident 8 would stop what she/he was doing and move onto the next closest female/male and start to grab their hands and then slowly rub their leg and try to creep her/his hand slowly to their groin area. Patient was redirected several times. Resident 8's Quarterly MDS dated [DATE] revealed a BIMS score of 9, which…

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 report an allegation of abuse to the State Survey Agency within 24 hours for 1 of 8 sampled residents (#3) for abuse. This placed residents at risk for lack of timely investigations. Findings include: Resident 3 admitted to the facility in 2017 with diagnoses including dementia. The 2/2/19 Annual MDS Cognitive Loss/Dementia CAA indicated Resident 3 had a diagnosis of dementia, had short term memory loss and difficulty recalling some long-term memories. The resident often was confused and had anxious behaviors such as yelling and screaming for help. The 7/19/19 Resident to Resident Event Assessment indicated Resident 3 was in the dining room calling out repeatedly and CNA staff assisted her/him to the day room and the resident refused to stay in the dayroom. The CNA staff then assisted Resident 3 to the hallway between the dining room and dayroom and she/he was calm. CNA staff continued helping other residents into the day room. Resident 5 was sitting in a wheelchair at a table in the dining room still…

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 revise and update a care plan related to a skin impairment for 1 of 2 sampled residents (#34) reviewed for hospitalization. This placed residents at risk for unmet care needs. Findings include: Resident 34 was admitted to the facility in 2019 with a diagnoses including acute embolism and thrombosis of the right femoral vein (blood clot inside the right leg). Resident 34's Bedside care plan dated 7/11/19 indicated the resident received anticoagulant medication (used to treat and prevent blood clots). An intervention included to observe and report any bruising or bleeding. The care plan also indicated the resident was a risk for skin conditions and had interventions including air mattress, pressure reducing cushion and to float heels. Review of progress notes indicated the resident discharged from the facility on 8/15/19 and returned to the facility from the hospital with a stent placed on her/his right leg on 8/16/19. Review of Resident 34's medical record indicated the Bedside care plan was not updated to…

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 physician was notified of repeated refusals of thyroid medication for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 35 admitted to the facility in 3/2019 with diagnoses including hypothyroidism (underactive thyroid). Review of the 8/2019 MAR revealed Resident 35 was to receive Levothyroxine Sodium Tablet (medication used to treat hypothyroidism) one time daily. Resident 35 was documented to refuse the Levothyroxine nine of 27 days reviewed. Review of Resident 35's medical record revealed no indication Resident 35's physician was notified of the refusals of Levothyroxine. On 8/28/19 at 11:02 AM Staff 20 (RNCM) acknowledged the 8/2019 MAR indicated Resident 35 refused her/his Levothyroxine nine of 27 days and the physician was not notified of the indicated refusal dates.

Based on interview and record review it was determined the facility failed to follow-up on pharmacist recommendations for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 35 admitted to the facility in 2019 with diagnoses including dementia. A 4/4/19 physician order indicated Resident 35 began Namenda (dementia medication) once daily. Review of Resident 35's medical record revealed a 5/2019 pharmacist recommendation to consider a dose decrease of Resident 35's Namenda. Review of Resident 35's medical record on 8/28/19 revealed no indication her/his physician was provided the 5/2019 pharmacist recommendation for consideration. On 8/28/19 at 12:09 PM Staff 1 (Administrator) confirmed Resident 35's physician had not been notified of the 5/2019 pharmacist recommendation until 8/28/19.