Aidan Senior Living at Reedsport

Based on interview and record review it was determined the facility failed to revise care plan interventions for 5 of 6 sampled residents (#s 7, 8, 12, 13, and 19) reviewed for accidents, nutrition, dignity, activities, and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 7 was admitted to the facility in 2019 with a diagnosis of diabetes. Progress notes revealed the following: -11/5/23 Resident 7 choked on food and was sent to the emergency room for evaluation and treatment. -11/30/23 Resident 7 choked in bed. Resident 7 was aware of her/his need to eat meals out of bed. -12/4/23 Resident 7 was found flat in bed and was choking. A 11/30/23 RD assessment indicated the resident had recent choking events and it was likely related to position and the resident did not have swallowing issues. The note indicated the RD agreed with the plan to provide all meals for the resident out of bed. On 12/11/23 during lunch observation, Resident 7 did not eat in the dining room. On 12/11/23 at 2:25 PM Resident 7 was observed in bed with her/his head of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to maintain cleanliness for 1 of 1 Kitchen and 1 of 1 dining room. This placed residents at risk for cross contamination. Findings include: 1. On [DATE], during initial kitchen tour, the dry storage area fan above the door, which moves air from the kitchen into the dry storage area, was observed to be covered in black chunks of dirt and debris. The door from the outside into the kitchen was open, with screen door closed. The screen door was covered in a layer of dust. On [DATE] at 10:12 AM Staff 6 (Dietary Manager) stated he did not have a scheduled time to clean the fan and screen door. Staff 6 stated he would assign a staff member to clean them when he noticed they needed cleaned and confirmed they needed cleaned. 2. A 11/2023 Refrigerator Temperature Log for the dining room revealed for the month of 11/2023 the refrigerator temperature was not checked 19 out of 30 days. On [DATE] at 7:02 AM, in the main dining room, 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 review a consent for medications with a resident's representative for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia. A 11/26/21 facility admission documentation revealed Witness 1 (Family) signed the resident's paperwork as Resident 12's responsible party. An Informed Consent for Psychotropic Drugs dated 10/20/23 revealed Resident 12 was administered mirtazapine (antidepressant) and olanzapine (antipsychotic). The consent was signed by two staff and not Witness 1. On 12/12/23 at 2:50 PM Staff 2 (DNS) stated, annually, the facility reviewed and obtained new consents for residents' psychotropic medication administration. Staff 2 acknowledged Resident 12's consent was signed by two staff members and not Witness 1 and stated she was not sure if the resident's family was called in regards to the resident's current medication dose. No additional…

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 the risks and benefits for the use of psychotropic medications prior to administration for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia. A 11/2023 signed physician orders instructed staff to administer sertraline (a medication used to treat depression) once a day for dementia, and anxiety starting on 9/27/23. A review of clinical records found Resident 18 was not provided the risk and benefits of taking sertraline. On 12/14/23 at 9:32 AM Staff 2 (DNS) and Staff 3 (RN Consultant) confirmed Resident 18's risk and benefits for sertraline was not completed timely.

Based on interview and record review it was determined the facility failed to assist a resident with completing an advance directive for 1 of 4 sampled residents (#2) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: Resident 2 was admitted to the facility in 2021 with diagnoses of stroke and diabetes. A 4/26/23 Care Plan revealed Resident 2 had blindness in both eyes from diabetes. A 5/24/23 Care Conference meeting form revealed Resident 2 requested a staff member read the advance directive to her/him to see if she/he would like help filling it out. A 9/26/23 Annual BIMS revealed Resident 2 was cognitively intact. Resident 2's record did not reveal staff reviewed the advance directive with her/him. On 12/13/23 at 11:15 AM Staff 3 (RN Consultant) stated she would look to see if staff reviewed the advance directive with the resident. No additional information was provided.

Based on interview and record review it was determined the facility failed to provided a two day notice prior to the ending of skilled services for 1 of 3 sampled residents (#71) reviewed for beneficiary notifications. This placed residents at risk for lack of timely appeals. Findings include: Resident 71 was admitted to the facility in 2023 with a diagnosis of liver disease. Resident 71's Notice of Medicare Non-Coverage form revealed her/his services ended on 10/31/23. The notice was provided on 10/30/23. On 12/13/23 at 3:09 PM Staff 5 (Activities Director) stated she was trained the two day notice included the day the resident was discharged from the facility and not when the services ended. Staff 5 acknowledged the resident discharged on 11/1/23 and the notice was given on 10/30/23, one day before services ended.

Based on interview and record review it was determined the facility failed to developed care plans for 2 of 2 sampled residents (#s 12 and 18) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: 1. Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia. A 11/28/23 Activities Participation Review form revealed Resident 12 liked to observe other residents during group activities more than participating and reported to staff she/he wanted to color. Review of the comprehensive care plan last updated 10/16/23 revealed there was no activity focus with goals and interventions. On 12/12/23 at 2:22 PM and 12/13/23 at 11:16 PM Staff 5 (Activities Director) stated Resident 12 had dementia and her/his activity involvement fluctuated but she/he liked to color, watch movies, listen to music and watch her/his peers while they participated in an activity. Staff 5 acknowledged Resident 12 did not have a care plan related to activities. 2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia. An…

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 a resident's nails were trimmed for 1 of 1 sampled resident (#8) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include: Resident 8 was admitted to the facility in 2021 with diagnoses including heart disease and diabetes. An 10/10/23 annual MDS and CAAs revealed Resident 8 required extensive assist with ADLs. A care plan last revised on 10/26/23 revealed Resident 8 was dependent on staff for cares including showers. Resident 8 was to receive showers every Monday and Thursday. 11/2023 and 12/2023 TARs revealed Resident 8 was to receive diabetic nail care every Monday evening and she/he refused on on 11/27/23, 12/4/23, and 12/11/23. No documentation was found the staff reapproached the resident after refusals. On 12/11/23 at 1:07 PM Resident 8 was observed with long fingernails with brown debris underneath the nails. The resident stated she/he was not able to independently cut her/his nails. On 12/13/23 at 12:37 PM Staff 11 (CNA) stated if a resident 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 CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 8, 11, and 12) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 12/13/23 indicated the following employees did not receive their annual performance evaluations: -Staff 12 (CNA), hired on 6/1/78, no evaluation on file for 6/1/22 through 12/13/23. -Staff 11 (CNA), hired on 7/29/19, no evaluation on file for 7/29/22 through 12/13/23. -Staff 8 (CNA), hired on 11/9/17, no evaluation on file for 11/9/22 through 12/13/23. On 12/14/23 at 9:04 AM Staff 2 (DNS) stated she did not find annual performance reviews for the above listed staff.

Based on interview and record review it was determined the facility failed to ensure proper monitoring prior to medication administration for 2 of 5 sampled residents (#s 7 and 18) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 7 was admitted to the facility in 2019 with diagnoses of heart disease and diabetes. A 12/2023 MAR revealed Resident 7 was to be administered Metoprolol two times a day and her/his blood pressure and pulse were to be obtained prior to administration. If the pulse was under 50 beats per minute and the top number of the blood pressure was under 100 the medication was to be held. The blood pressure and pulse were not obtained on 12/7/23 though the 12/12/23 morning dose. On 12/14/23 at 10:08 AM Staff 2 (DNS) acknowledged the blood pressure and pulse were not obtained on the identified dates. 2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of chronic kidney disease. A review of Resident 18's comprehensive care plan revealed no information about Resident 18 receiving 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 residents did not receive unnecessary psychotropic medications for 2 of 5 sampled residents (#s 8 and 18) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medications. Finding include: 1. Resident 8 was admitted to the facility in 2019 with a diagnosis of post-traumatic stress disorder. Resident 8's care plan last updated 10/2023 revealed she/he at times had triggers related to trauma, had vivid dreams and was administered an antianxiety medication. Interventions for mood and behaviors included to provide activities, identify the cause of the behavior, remove the trigger, and to provide consistent routines. A 12/2023 MAR and associated progress notes revealed the resident was administered Ativan (anti-anxiety) eight times from 12/1/23 though 12/10/23 and there were no non-pharmacological interventions provided prior to administration. On 12/13/23 at 7:42 PM Staff 23 (RN) stated he worked with Resident 8 on the evening shift and the resident often…

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 provided routine dental care for 1 of 2 sampled residents (#11) reviewed for dental. This placed residents at risk for dental pain. Findings include: Resident 11 was admitted to the facility in 12/2022 with a diagnosis of a stroke. A 12/6/22 admission MDS indicated Resident 11 was cognitively intact and did not have dental issues. On 12/11/23 at 11:24 AM Resident 11 stated she/he fell prior to admission to the facility and fractured her/his back teeth. The teeth did not hurt, but she/he did not go to a dentist for an exam and normally was examined yearly. On 12/14/23 at 10:08 AM Staff 2 (DNS) stated Resident 11 did not report dental pain and acknowledged Resident 11 was not provided routine dental care since admission to the facility.

Based on interview and record review it was determined the facility failed to ensure antibiotics were not used unless indicated for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for the development of antibiotic resistant organisms. Findings include: Resident 18 was admitted to the facility in 2023 with a diagnosis of diabetes. A 12/1/23 through 12/6/23 vital sign log revealed Resident 18 did not have a temperature greater than 98.5 degrees Fahrenheit (normal 98.6). A 12/6/23 nurse practitioner note indicated the resident was examined and was assessed to probably have pneumonia and the diagnoses was based on presentation and history. The note indicated a chest x-ray was not going to be obtained because it would take the facility an extended amount of time to obtain the x-ray. A 12/6/23 Progress Note indicated Resident 18 was started on an antibiotic for pneumonia. On 12/14/23 at 10:14 AM Staff 2 (DNS) stated Resident 18 was diagnosed with pneumonia and the resident was not tested for other types of respiratory infections prior to 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 ensure pneumonia vaccines were offered for 3 of 5 sampled residents (#s 3, 5, and 9) reviewed for immunizations. This placed residents at risk for pneumonia. Findings include: 1. Resident 3 was admitted to the facility in 2018 with a diagnosis of chronic lung disease. Resident 3's clinical record revealed she/he received a pneumonia vaccine in 2019 but did not indicate the type of vaccine and was potentially eligible to receive another vaccine. On 12/13/23 at 9:46 AM a request was made to Staff 2 (DNS) to provide documentation Resident 3's vaccines were complete. No additional information was provided. 2. Resident 5 was admitted to the facility in 2019 with a diagnosis of a neuromuscular disease. Resident 5's clinical record revealed she/he received a pneumonia vaccine and was eligible to receive another vaccine. There was no documentation to indicate the resident was offered an additional vaccine. On 12/13/23 at 9:46 AM a request was made to Staff 2 (DNS) to provide documentation Resident 5 was offered an…

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 have a system in place to ensure CNA staff received required 12 hours of in-service training annually for 2 of 5 sampled CNAs (#s 9 and 10) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 9 (CNA), hired 6/9/21, had six hours of documented training from 6/9/22 through 6/9/23. -Staff 10 (CNA), hired 1/27/20, had six hours of documented training from 1/27/22 through 1/27/23. On 12/14/23 at 9:04 AM Staff 9's and Staff 10's training hours were reviewed with Staff 2 (DNS). No additional documentation of training was provided.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from mental and verbal abuse by staff and a resident for 2 of 4 sampled residents (#s 501 and 502) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 501 was admitted to the facility in 2022 with diagnoses including stroke and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood. On 5/30/23 Resident 501 reported to Staff 11 (Social Service Assistant) she/he had high anxiety and increased muscle spasms due to the stress she/he felt because she/he overheard Staff 6 (CNA) tell another CNA she could not be alone with the resident because the resident was targeting her. Staff 6 would also not assist other staff in providing appropriate and timely care for the resident which upset Resident 501 because the resident did not understand why Staff 6 was avoiding her/him or what she/he had done wrong. When interviewed…

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 incidents for 5 of 7 sampled residents (#s 1, 2, 5, 16, and 17) reviewed for abuse and accidents. This placed residents at risk for abuse. Findings include: 1. Resident 17 admitted to the facility in 1/2022 with diagnoses including diabetes and depression. On 10/14/22 a Written Warning report revealed the following: - Staff 11 (CNA) had four individual complaints within the last week (10/7/14 through 10/14/22) regarding treatments of residents, specifically her attitude when providing care and the way she spoke to the residents. -Resident 17's statement indicated Staff 11 had a rude tone when she/he asked to be placed on the bed pan and Resident 17 could do it herself/himself. Resident 17 did not want assistance from Staff 11 because of her attitude. -Resident 3, Resident 17's roommate indicated Staff 11 was grumpy but did not want to give any other information regarding the incident due to possible retaliation from Staff 11. -Staff 9 (CNA) and Staff 7 (LPN) statements verified 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.

Based on interview and record review it was determined the facility failed to ensure a resident was treated with respect and dignity for 1 of 5 sampled residents (#17) reviewed for abuse. This placed residents at risk for lack of self-worth. Findings include: Resident 17 admitted to the facility in 1/2022 with diagnoses including diabetes and depression. On 10/14/22 a Written Warning report revealed the following: - Staff 11 (CNA) had four individual complaints within the last week (10/7/14 through 10/14/22) regarding treatments of residents, specifically her attitude when providing care and the way she spoke to the residents. -Resident 17's statement indicated Staff 11 had a rude tone when she/he asked to be placed on the bed pan and Resident 17 could do it herself/himself. Resident 17 did not want assistance from Staff 11 because of her attitude. -Resident 3, Resident 17's roommate indicated Staff 11 was just grumpy but did not want to give any other information regarding the incident due to possible retaliation from Staff 11. -Staff 9 (CNA) and Staff 7 (LPN) statements verified…

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 accurately assess, monitor and document skin issues for 1 of 1 sampled resident (#9) reviewed for skin conditions. This placed residents at risk for additional skin issues. Findings include: Resident 9 was admitted to the facility in 2021 with diagnoses including diabetes and bed confinement status. The facility's Skin and Wound Care Documentation form dated 8/6/20 included the following: -All skin and wound issues would be updated weekly by the LN. -A new skin and wound care progress record would be completed each week with a short narrative regarding the progress of the skin/wound issue. -The LN was to make a note with the size of the wound by length and width (to show progression and if healing or not). -Narrative nursing notes should include description or issue, surrounding area, drainage, measurements, date and intials. -Once the skin and wound issue is resolved the progress record and chart should be placed in the record. -Now tracking skin and wound in the electronic record. -Notify the MD and 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 provide adequate foot care for 1 of 1 sampled resident (#9) reviewed for ADL care. This placed residents at risk for unmet foot care needs. Findings include: Resident 9 was admitted to the facility in 2021 with diagnoses including diabetes and bed confinement status. Resident 9's care plan initiated 10/14/21 related to the diabetes diagnosis included staff were to inspect the resident's feet daily for open areas, sores, pressure areas, blisters, edema or redness. Resident 9's care plan dated 10/12/21 revealed the resident was on anticoagulant (prevent or reduce coagulation of blood, prolonging the clotting time) medication and staff should complete a daily skin inspection. A physician order dated 10/18/21 indicated the licensed nurse was to complete diabetic nail care once weekly, every Monday, on the evening shift of shower day. On 10/20/22 at 12:56 PM Resident 9's feet were observed. The skin on the feet and legs was very dry and flaky. The resident's toe nails were overgrown. The nails 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 provide ROM/RA services for 3 of 4 residents (#s 12, 13 and 17) reviewed for positioning and mobility. This placed residents at risk for decline in mobility. Findings include: 1. Resident 13 was admitted to the facility in 2021 with diagnoses including multiple sclerosis. On 10/17/22 at 2:46 PM Resident 13 stated she/he wanted more therapy. Resident 13 added she/he was not receiving assistance with exercises, got some stretching but it was not consistent. Review of the medical record indicated Resident 13 had a restorative program developed to maintain her/his ROM. There was no documentation after 8/5/22 indicating Resident 13 received her/his restorative program. On 10/20/22 at 12:19 PM Staff 2 (Assistant DNS) stated restorative services were not being provided due to lack of enough staff. Staff 2 added staff were expected to provide ROM with care and should be documenting the ROM provided. 2. Resident 17 was admitted to the facility in 1/2022 with diagnoses including diabetes and depression. On 10/17/22…

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 assess the risk of entrapment, attempt alternatives and explain the risk and benefits for the use of side rails for 1 of 2 sampled residents (#5) reviewed for accidents. This placed residents at risk for side rail injuries. Findings include: Resident 5 was admitted to the facility in 2022 with diagnoses including Parkinson's disease. Resident 5 had an order which stated may use side rails based on Restraint/device assessment dated 4/4/22. On 4/28/22 a fall investigation noted Resident 5 likely had a nightmare, attempted to get out of bed and fell on the floor. New interventions included a low bed and fall mats on both sides of the bed. There was no information related to the use or position of the side rails in the investigation notes. Resident 5 had an order dated 4/28/22 for full bed length mobility bars. On 10/18/22 at 10:30 PM Resident 5 was observed in bed with fall mats in place, the bed was in the low position and both side rails were up with pillows leaning against the rails. Physical…

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.