Oregon Veterans Home

Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 5 sampled residents (#s 10, 23, 84, 97, and 103) reviewed for use of anticoagulants. This placed residents at risk for inaccurate medication assessments. Findings include: 1. Resident 10 admitted to the facility in 2018 with diagnoses including dementia and anxiety. The 10/29/24 and 1/21/25 Quarterly MDSes indicated Resident 10 received an anticoagulant medication. No evidence was found in Resident 10's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 10 was not on an anticoagulant and the 10/29/24 and 1/21/25 Quarterly MDS entries were inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication. 2. Resident 23 admitted to the facility in 2024 with diagnoses including dementia and heart failure. The 11/30/24…

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 protect the resident's right to be free from physical abuse by Resident 76 for 1 of 3 sampled residents (#106) reviewed for physical abuse. This placed residents at risk for physical, mental, or psychosocial harm. Findings include: Resident 106 admitted to the facility in 2/2024 with diagnoses including heart failure and dementia. Resident 106 passed away on 11/2/24. Resident 76 admitted to the facility in 1/2023 with diagnoses including dementia and anxiety disorder. Resident 76's, Behavior Care Plan dated 4/24/23 indicated the resident expressed agitation with others, typically related to noise. Staff were to encourage Resident 76 to go to her/his room or another quiet area if there was music playing and she/he was getting agitated. A 9/17/24 Resident to Resident Conflict report indicated that day an altercation occurred in the residents' shared room. The report stated Resident 106 was choked by Resident 76. Staff reported hearing yelling coming from the room and when they arrived, they observed 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 report an allegation of sexual abuse to the State Survey Agency for 2 of 3 residents (#s 54 and 307) reviewed for sexual abuse. This placed residents at risk for a lack of protective measures to prevent further abuse. Findings include: 1. Resident 54 admitted to the facility in 4/2021 with diagnoses including diabetes and a leg fracture. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. Resident 54's 9/16/24 St. Louis University Mental Status (SLUMS) Examination indicated the resident had a score of 16/30, indicating cognitive impairment or possible dementia. On 1/8/25 a public complaint was received indicating Resident 108 was known to inappropriately touch female residents during activities. Witness 2 (Complainant) stated Resident 108 put her/his hand up their shirts or down their pants. Witness 2 stated Resident 108 put her/his hand up Resident 54's shirt five or six months ago. There was no further information provided. On 3/11/25 at 1:19 PM and 3/13/25 at…

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 an allegation of abuse for 3 of 6 sampled residents (#s 54, 106, and 307) reviewed for abuse. This placed residents at risk for lack of protective measures to prevent a reoccurrence. Findings include: The facility's 10/7/24 Freedom from Abuse and Abuse Investigation Policy stated, The facility will investigate all charges of abuse and report findings to the appropriate local and state agencies. 1. Resident 54 admitted to the facility in 4/2021 with diagnoses including diabetes and a leg fracture. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. Resident 54's 9/16/24 St. Louis University Mental Status (SLUMS) Examination indicated the resident had a score of 16/30, indicating cognitive impairment or possible dementia. On 1/8/25 a public complaint was received indicating Resident 108 was known to inappropriately touch female residents during activities. Witness 2 (Complainant) stated Resident 108 would put her/his hand up their shirts or…

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 physician orders related to bowel care were followed for 1 of 5 sampled residents (#79) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications. Findings include: Resident 79 was admitted to the facility in 5/2023 with diagnosis including dementia and diabetes. A 7/16/24 physician order indicated Resident 79 was to receive a bowel care medication, Lactulose, once a day for constipation and the medication was to be held if the resident had two loose stools the day prior. A review of the 1/2025, 2/2025, and 3/2025 bowel records revealed the resident had two or more loose stools on the following dates: 1/3/25, 1/4/25, 1/10/25, 2/25/25, and 3/4/25. A review of the 1/2025, 2/2025, and 3/2025 MARs revealed Resident 79 was administered Lactulose on days it was to be held per the physician order on the following dates: 1/4/25, 1/5/25, 1/11/25, 2/26/25, and 3/5/25. On 3/13/25 at 2:39 PM Staff 4 (CMA) stated Resident 79 was consistent with having loose…

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 assessed after significant weight loss was identified for 2 of 3 sampled residents (#s 62 and 74) reviewed for weight loss. This placed residents at risk for severe weight loss. Findings include: 1. Resident 62 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease. The 2/20/23 admission MDS indicated Resident 62 had no weight loss and was on a therapeutic diet. The resident's Care Plan for risk for altered nutritional status, revised on 2/24/23, indicated a goal of maintaining weight and did not indicate the resident had any weight loss. Resident's 62's weight records indicated the following (weight in pounds): - 2/20/23: 142 - 9/12/23: 136 - 9/28/23: 125 - 10/5/23: 127 - 10/23/23: 125 The weight loss of 11 pounds from 9/12/23 to 9/28/23 indicated a significant weight loss of 8% in 16 days. A review of the resident's clinical record revealed no evidence Resident 62's weight loss was assessed and no indication new interventions were put in place 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 observation, interview and record review it was determined the facility failed to obtain a physician's order for supplemental oxygen, ensure oxygen tubing was changed and oxygen equipment was maintained for 1 of 1 sampled resident (#25) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 25 was admitted to the facility in 2022 with diagnoses including obstructive sleep apnea (Pauses in breathing during sleep due to airway blockage). The facility's 2012 Oxygen Administration Procedure related to Physician's Orders and equipment maintenance included the following: - Check the Physician's Order for oxygen liter flow and method of administration. - Check and clean oxygen equipment and change oxygen tubing at regular intervals. On 10/31/23 at 8:41 AM Resident 25 was observed to have an oxygen concentrator (machine that filters air into purified oxygen) in her/his room. The oxygen concentrator had dust accumulation on the top of the concentrator and concentrator filter. The humidification bottle and oxygen tubing…

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 care and services were in place to treat an emergency related to a resident's dialysis port for 1 of 1 sampled resident (#62) reviewed for dialysis. This placed residents at risk for blood loss. Findings include: Resident 62 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease. Resident 62's Care Plan, revised on 3/6/23, indicated the resident received hemodialysis (a process of artificially removing toxins from the blood using an external filtering system) via a port in the resident's chest. The care plan did not include any interventions related to emergent blood loss from the port. On 10/30/23 at 2:23 PM no emergency supplies were observed in Resident 62's room. On 10/31/23 at 1:07 PM Staff 6 (RN) stated she was not sure what she would do if Resident 62 was bleeding from the port. On 10/31/23 at 1:38 PM Staff 3 (RNCM) stated if Resident 62 was bleeding from the port she would try to stop it and call 911. When asked if the facility had supplies 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 provide ROM and RA services for 4 of 4 sampled residents (#s 7, 72, 83 and 85) reviewed for positioning and mobility. This placed residents at risk for a decline in mobility. Findings include: 1. Resident 7 was admitted to the facility in 2018 with diagnoses including dementia and Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). A Facility Restorative Care Referral form (generated by the therapy department PT) dated 1/17/22 indicated the resident was to have an RA walking program to maintain mobility. The resident was a contact guard assist (CGA) with walking and needed cues for balance, steering her/his front wheel walker (FWW) and safety. Special instructions included walking to the bathroom, dining room or activities. Resident 7's care plan dated 1/25/22 indicated the resident had limited physical mobility related to Huntington's Disease, chorea movements (involuntary, irregular, unpredictable muscle movements) and dementia. The goal was for 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 handle and utilize PPE and clean reusable equipment between uses according to CDC guidelines for 1 of 1 facility, ensure AGP procedures were adhered to for 1 of 4 sampled residents (#68) reviewed for infection control, and ensure catheters were properly contained for 2 of 3 sampled residents (#s 55 and 81) reviewed for urinary catheters. This placed residents at risk for infection. Findings include: 1. A review of the undated Policy and Procedure for AGP (Aerosol-generating procedures) revealed the following: -AGP included CPAP (continuous positive airway pressure). -When conducting AGP for patients suspected or known exposure to COVID-19, health care personnel should utilize PPE for special contact droplet precautions. -Staff are to wear N95, eye protection, gown and gloves. -When conducting AGP staff to provide a private room for residents who utilized AGP and close off room where procedure took place for two hours after…

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 dependent residents were provided services to maintain hygiene for 2 of 4 sampled residents (#s 55 and 84) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 55 was admitted to the facility in 2018 with diagnoses including depression and COPD (long-term lung disease that makes it difficult to breath). A 1/13/22 physician order indicated staff to check and trim Resident 55's fingernails every four weeks. The 8/12/22 Quarterly MDS indicated Resident 55 required extensive one person assist with personal hygiene. Resident 55's 6/29/18 care plan indicated the resident was at risk for impaired ADL function related to impaired mobility and weakness and required extensive assistance with all hygiene. On 10/5/22 at 8:18 AM and 10/7/22 at 12:17 PM Resident 55 was observed sitting in her/his wheelchair. The resident's fingernails were long, uncut and appeared dark brown in color. Resident 55 stated she/he was not able to trim her/his fingernails for a few…

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 gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (# 87) reviewed for unnecessary psychotropic medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 87 was admitted to the facility in 2018 with diagnoses including Alzheimer's dementia and Post-Traumatic Stress Disorder (PTSD). A review of Resident 87's MAR/TAR for 9/2022 and 10/2022 revealed the resident was on a number of psychotropic and opioid medications: olanzapine, donepezil, sertraline, trazadone, Fentanyl, topiramate sprinkle and oxycodone scheduled and PRN . Four of the medications were Central Nervous System Drugs: olanzapine, sertraline, trazodone and topiramate. Two were antidepressants: sertraline and trazodone. Eight of the resident's medications had major drug interaction warnings. The 10/2022 MAR also contained the following order: naloxone 4 mg actuation spray. One spray in alternating nostrils as…

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.