Avalon Care Center - Portland

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 2 facility kitchens (dining room kitchenette) reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: On 5/28/24 at 11:34 AM during the initial tour of the dining room kitchenette, the following was observed: Refrigerator: -One piece of cake with whipping cream not covered, labeled or dated. -One small plastic container of an unknown substance not labeled or dated. -One covered plate with a pork chop, baked potato and corn not labeled or dated. -One tray with multiple covered juice drinks not labeled or dated. -One opened container of prune juice on the top shelf that spilled to the lower shelves and out onto the floor. Freezer: -Seven small plastic containers with unknown substances not labeled or dated. -Two individual strawberry yogurt containers with a use by date of 5/20/24. -Two opened one pint ice cream containers with resident names not dated. -One opened gallon 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 ensure resident needs and preferences related to lighting were accommodated for 1 of 3 sampled residents (# 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:34 AM Resident 13 stated her/his overbed light switch only had a short cord and she/he could not reach it to turn her/his light on or off. Resident 13 stated she/he reported it to staff but she/he was still waiting for it to be fixed. On 6/3/24 at 1:42 PM Staff 19 (Maintenance Director) stated he expected CNAs to report maintenance issues to him using the facility's work order system. He also stated he is notified 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 obtain copies of advance directives and inform residents of the right to formulate advance directives for 2 of 2 sampled residents (#s 8 and 13) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored. Findings include: 1. Resident 8 was admitted to the facility in 8/2017 with diagnoses including Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel) and morbid (severe) obesity. Resident 8's 2/16/24 Quarterly MDS revealed she/he was cognitively intact. Resident 8's Care Plan revealed the following: -Focus: I have a Living Will or other Advance Directive: Health Care Agent. -Goal: I will have my desires and wishes followed according to my signed directive. -Interventions: Facility will place my Advance Directive in my medical record. Staff will review my healthcare directives with me at least quarterly to verify that my wishes have not changed. Staff will understand and follow my healthcare directives. (Date…

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 a resident's representative of an appointment out of the facility for 1 of 1 sampled resident (#289) reviewed for notification of change. This placed residents at risk of their representatives being uninformed. Findings include: Resident 289 was admitted to the facility in 12/2016 with diagnoses including chronic congestive heart failure (a long-term condition in which the heart cannot pump blood efficiently) and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 289's 8/29/22 CAA related to cognition revealed she/he had severe cognitive decline including impaired memory and decision making. Resident 289's admission agreement indicated her/his representative/legal guardian was her/his daughter. A review of Resident 289's health record revealed she/he was sent out of the facility for an appointment on 11/10/2022. No evidence was found in Resident 289's health record to indicate her/his representative was notified she/he would be…

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 maintain a homelike environment for 1 of 3 sampled residents (# 13) reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:40 AM a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of Resident 13's bed. On 6/3/24 at 1:42 PM 19 (Maintenance Director) acknowledged the gouge in the wall and stated it should have been fixed prior to the resident moving into the room. On 6/3/24 at 3:39 PM Staff 1 (Administrator) stated the gouge in Resident 13's wall was unacceptable and she expected residents' rooms to be painted and homelike before they move in.

Based on interview and record review it was determined the facility failed to ensure written summary of a baseline care plan was provided to residents within 48 hours of admission for 2 of 4 sampled residents (#s 7 and 241) reviewed for baseline care plans. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 7 was admitted to the facility in 5/2024 with diagnoses including kidney failure and anxiety. On 5/31/24 Resident 7's clinical record was reviewed. No record was found to show Resident 7 had a baseline care plan reviewed or provided to her/him. On 5/31/24 at 7:40 AM Resident 7 stated she/he had not been provided a baseline care plan. On 5/31/24 at 10:39 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) stated they were not aware baseline care plans were to be provided to and reviewed with residents. 2. Resident 241 was admitted to the facility in 5/2024 with diagnoses including heart failure and high cholesterol. On 5/31/24 Resident 241's clinical record was reviewed. No record was found to show Resident 241 had a baseline care plan…

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 develop a person-centered comprehensive care plan for 1 of 4 residents (#16) reviewed for mood and behavior. This placed residents at risk for lack of care planning. Findings include: Resident 16 was admitted to the facility in 1/2024 with diagnoses including post-traumatic stress disorder (PTSD). The Mood State CAA from Resident 16's 2/6/24 admission MDS noted Resident 16 had a diagnosis of PTSD and the care plan addressed the PTSD symptoms with interventions to assist with mood. A review of Resident 16's comprehensive care plan (last revised 4/14/24) revealed no focus, goals or interventions for Resident 16's PTSD symptoms. On 6/3/24 at 9:30 AM Staff 16 (Social Services Director) stated he completed a PTSD evaluation for Resident 16, and thought he completed the comprehensive care plan. Staff 16 confirmed Resident 16's comprehensive care plan related to PTSD symptoms with interventions to assist with mood was not completed.

Based on observation, interview and record review it was determined the facility failed to follow physician orders regarding wound care for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs. Findings include: Resident 241 was admitted to the facility in 1/2018 with diagnoses including lymphedemia (swelling of the extremities) and erythmia (skin redness caused by swelling or irritation). A cognitive assessment from 1/18/24 indicated Resident 241 had normal cognitive function. A Physician Order from 4/3/24 instructed staff to apply ACE wraps to both lower extremities in the morning before Resident 241 got out of bed and take them off at night. Review of the 5/2024 TAR revealed the ACE wraps were documented as not applied to Resident 241's lower extremities on the following dates: - 5/20/24, - 5/21/24, - 5/22/24, - 5/23/24, - 5/24/24, - 5/25/24, - 5/26/24, - 5/28/24, - 5/29/24, - 5/30/24 and - 5/31/24. On 5/28/24 at 1:13 PM Resident 241 was observed wearing ACE wraps which appeared ragged and nearly falling off. Resident 241 stated…

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 adequate care and hazard removal for 2 of 2 residents (#s 239 and 240) reviewed for accidents. This placed residents at risk of injury. Findings include: 1. Resident 239 was admitted to the facility in 5/2022 with diagnoses including obesity and dementia. A Care Plan from 3/16/23 included instructions for two staff members to be present when providing all care. An 8/18/23 Progress Note stated Resident 239 rolled out of bed onto the floor when care was provided. On 5/30/24 at 1:13 PM Staff 10 (CNA) stated she recalled Resident 239 falling out of bed. Staff 10 stated care was provided by only one staff member when Resident 239 experienced the fall out of bed when care was being provided. On 5/31/24 at 2:37 PM Staff 1 (Administrator) confirmed Resident 239 was ordered to receive care from two staff members but care was only provided by one staff member when the fall occurred. 2. Resident 240 was admitted to the facility in 5/2024 with diagnoses including dementia. A cognitive assessment…

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 maintain oxygen equipment and ensure oxygen was administered as ordered for 2 of 3 sampled residents (#s 4 and 21) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure. Findings include: 1. Resident 4 was admitted to the facility in 8/2023 with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease (COPD). The 4/25/24 Quarterly MDS indicated Resident 4 was cognitively intact. On 5/28/24 at 1:28 PM Resident 4 was observed to use an oxygen concentrator. The external filter on the oxygen concentrator was observed to have a thick layer of dust. On 5/29/24 at 8:44 AM Staff 7 (LPN) observed the resident's equipment and acknowledged the external filter of the oxygen concentrator was not clean. On 5/29/24 at 8:56 AM Staff 2 (DNS) stated it was her expectation the external filters were cleaned once a month. 2. Resident 21 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and chronic respiratory…

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 accurately document wound care being provided which followed physician's orders for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs. Findings include: Resident 241 was initially admitted to the facility in 1/2018 with diagnoses including lymphedemia (swelling of the extremities) and erythmia (skin redness caused by swelling or irritation). A cognitive assessment from 1/18/24 indicated Resident 241 had normal cognitive function. A Physician Order from 4/3/24 instructed staff to apply ACE wraps to both lower extremities in the morning before Resident 241 got out of bed and to take them off at night. Review of the 5/2024 TAR revealed ACE wraps were documented as being off of Resident 241's lower extremities on the following dates: - 5/20/24, - 5/21/24, - 5/22/24, - 5/23/24, - 5/24/24, - 5/25/24, - 5/26/24, - 5/28/24, - 5/29/24, - 5/30/24 and - 5/31/24. On 5/28/24 at 1:13 PM Resident 241 was observed wearing ACE wraps which appeared ragged 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 interview and record review it was determined the facility failed to ensure RN coverage for 8 consecutive hours per day 7 days per week for 30 out of 127 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 9/30/22 and 2/1/23 through 3/7/23 revealed there was no RN coverage for eight consecutive hours on: -7/17, 7/31, 8/1, 8/7, 8/8, 8/9, 8/10, 8/14, 8/15, 8/16, 8/19, 8/20, 8/24, 8/31, 9/6, 9/9, 9/13, 9/20, 9/22, 9/27, 9/29, 9/30; -2/4, 2/11, 2/12, 2/13, 2/18, 2/20, 2/28, 3/6. On 3/8/23 at 9:46 AM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated the facility had struggled to hire RN's.

Based on interview and record review it was determined the facility failed to ensure a psychotropic medication consent was provided for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for not being informed of risks and benefits of medications. Findings include: Resident 30 was admitted to the facility in 2019 with diagnoses including Parkinson's disease (a central nervous system disorder that affects movement), depression, and anxiety disorder. Resident 30's admission Record dated 3/8/23 indicated her/his family member was the resident's responsible party. Resident 30's 11/29/22 Quarterly MDS indicated the resident had severe cognitive impairment. Resident 30's physician orders dated 12/11/22 indicated the resident had orders for the following scheduled medications: - Seroquel (antipsychotic medication) twice daily for psychotic disorder with hallucinations. - Zoloft (psychotropic medication used to treat depression) once daily for depression related to anxiety disorder. - mirtazapine (psychotropic medication used to treat…

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 provided information related to the formulation of an Advance Directive for 3 of 3 sampled residents (#10, #23, #32) reviewed for Advance Directives. This placed residents at risk for not having their treatment decisions honored. Findings include: 1. Resident 10 was admitted to the facility in 2018 with diagnoses including multiple sclerosis (degenerative neurological disease). Resident 10's admission Record dated 3/6/23 indicated the resident was her/his own responsible party. Resident 10's clinical record revealed no documentation to indicate the resident had an Advance Directive or was provided information concerning the right to formulate an Advance Directive. On 3/9/23 at 10:37 AM Staff 1 (Administrator) stated there was no documentation Resident 10 was provided written information concerning her/his right to formulate an Advanced Directive. 2. Resident 23 was admitted to the facility in 2023 with diagnoses including stroke. A review of Resident 23's digital and physical clinical…

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 grievances were documented and resolved in a timely manner for 1 of 1 sampled resident (#5) reviewed for personal property. This placed residents at risk for unaddressed concerns and unmet care needs. Findings include: Resident 5 admitted to the facility in 2022 with diagnoses including major depressive disorder. On 3/6/23 at 12:15 PM Resident 5 stated an unknown CNA broke her/his watch band more than a month ago and the facility had not replaced it. On 3/9/23 at 10:47 AM Staff 1 (Administrator) stated he offered to replace Resident 5's watch band. Staff 1 stated he received the watch and was researching a new band for the resident. Staff 1 reported the resident asked for her/his watch back and the item was returned to the resident and was not repaired. On 3/9/23 at 11:06 AM Staff 1 reported there was no documentation regarding this grievance. On 3/14/23 at 9:24 AM Staff 5 (Social Service Director) stated grievances were documented on a grievance log including documentation detailing 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 interview and record review it was determined the facility failed to thoroughly investigate accidents for 1 of 1 sampled resident (# 21) reviewed for skin conditions. This placed residents at risk for abuse. Findings include: 1. Resident 21 was admitted to the facility in 2023 with diagnoses including diabetes. On 3/6/23 at 10:20 AM Resident 21 stated her/his leg was pinched in a mechanical lift on 12/30/22. An incident report dated 12/30/22 indicated Resident 21 informed staff there was an accident earlier in the day on 12/30/22 involving a mechanical lift transfer. On 3/9/23 at 11:54 AM Staff 2 (DNS) confirmed an accident occurred causing a bruise and small cut to Resident 21's toe. Staff 2 further confirmed an incident report should have been completed. 2. Resident 21 was admitted to the facility in 2023 with diagnoses including diabetes. An incident report dated 12/30/22 indicated Resident 21 had an unwitnessed accident with her/his power chair where she/he was found against the closet door. The incident report indicated Resident 21 believed she/he may have run into 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 administer oxygen and medications according to physician's orders for 2 of 6 sampled residents (#s 10 and 30) reviewed for medications and oxygen administration. This placed residents at risk for pain and unnecessary oxygen administration. Findings include: 1. Resident 10 was admitted to the facility in 2018 with diagnoses including multiple sclerosis (degenerative neurological disease). a. Resident 10's current physician's orders as of 3/6/23 indicated the resident had an order for oxygen at three liters per minute PRN to keep O2 sats above 90%. On 3/6/23 at 9:45 AM and 3/7/23 at 10:23 AM Resident 10 was observed in bed receiving oxygen at three liters per minute continuously. Resident 10's TAR, Progress Notes and O2 Sats Summary for 3/6/23 and 3/7/23 revealed no documentation to indicate which staff had initiated the oxygen administration, an assessment to indicate the need for oxygen administration or resident O2 sats below 90%. On 3/7/23 at 11:53 AM Staff 10 (LPN) stated he did not…

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 adequate supervision for 1 of 1 sampled resident (#30) reviewed for accidents. This failure placed residents at increased risk for falls. Findings include: Resident 30 was admitted to the facility in 2019 with diagnoses including Parkinson's disease (a central nervous system disorder that affects movement) and Alzheimer's disease (brain disorder). Resident 30's 11/29/22 Quarterly MDS indicated the resident had severe cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility and transfers. The MDS indicated the resident was not steady to transfer between the bed and her/his wheelchair and was only able to stabilize with staff assistance. Resident 30's Fall Risk assessment dated [DATE] indicated she/he was at risk for falls due to multiple chronic diagnoses, decreased muscular coordination and non-ambulatory status. Resident 30's Care Plan dated 12/3/22 contained a fall…

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 respiratory equipment was properly maintained for 1 of 1 sampled resident (#28) reviewed for respiratory care. This placed residents at risk for infection. Findings include: Resident 28 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease. Resident 28's current physician orders indicated her/his oxygen tubing was to be changed weekly on Mondays. On 3/6/23 at 10:10 AM Staff 19 (LPN) confirmed the date on Resident 28's nasal canula read 2/21/23. On 3/6/23 at 12:30 PM Staff 19 stated she did not know who was responsible for changing the oxygen tubing. On 3/9/23 at 2:28 PM Staff 2 (DNS) confirmed Resident 28's oxygen tubing read 2/21/23 and should have been changed weekly for resident health.

Based on interview and record review it was determined the facility failed to ensure there was appropriate evaluation and monitoring of psychotropic medications for 1 of 5 sampled resident (#21) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: Resident 21 was admitted to the facility in 2023 with diagnoses including heart failure. A review of Resident 21's clinical record revealed the resident had orders for the following psychotropic medications: - Sertraline (Anti-depressant) - Abilify (Antipsychotic) - Buspirone (Anti-anxiety) The most recent Abnormal Involuntary Movement Scale (AIMS) in Resident 21's record was dated 8/27/22. The most recent Psychotropic medication review in Resident 21's record was dated 9/28/22. On 3/13/23 at 12:18 PM staff 2 (DNS) confirmed the AIMS should have been completed at least every 3-6 months, and psychotropic review should have been completed at least monthly.

Based on observation, interview and record review it was determined the facility failed to handle, label and store food in a sanitary manner for 1 of 1 kitchen and 1 of 1 dining room reviewed for sanitary food handling and serving practices. This placed residents at risk of cross contamination and foodborne illness. Findings include: 1. On 3/8/23 at 10:23 AM a tray in the main dining room refrigerator was observed to contain 12 individually-covered beverages. Ten of the 12 beverages were not labeled or dated. A tray that contained nine uncovered puddings and two uncovered fruit cups was observed on the counter adjacent to the refrigerator. On 3/8/23 between 11:00 AM and 11:35 AM six residents were observed participating in a chair yoga activity with Staff 18 (Activities Assistant) in the area immediately adjacent to the counter and tray of uncovered puddings and fruit cups. On 3/8/23 at 1:00 PM one remaining cup of uncovered pudding was observed on the counter. Staff 4 (Dietary Manager) verified the temperature of the pudding was 62 degrees F and stated these items should have been…

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.