Nehalem Valley Care Center

Based on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 28 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: A review of the Direct Care Staff Daily Reports from 2/2/24 through 3/1/24 revealed the following days with no RN coverage: -2/10/24 -2/11/24 -3/1/24 On 3/5/24 at 9:10 AM Staff 18 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified dates.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were six errors in 27 opportunities resulting in a 22 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnoses including stroke. The 2/23/24 physician order indicated Resident 14 was to receive Eliquis (anticoagulant medication) 2.5 mg once daily. The 3/2024 MARs indicated Eliquis was to be administered in the morning. On 3/3/24 at 12:34 PM Staff 7 (RN) was observed to administer the morning dose of Eliquis. Staff 7 acknowledged the medication was administered late as she was still passing morning medications. 2. Resident 2 admitted to the facility in 2015 with diagnoses including chronic pain and opioid dependence. The 2/4/24 physician order indicated Resident 2 was to receive methadone (opioid medication) twice daily for opioid dependence. The 3/2024 MARs indicated methadone was scheduled at 9:30 AM and 9:30 PM. 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 observation, interview, and record review it was determined the facility failed to ensure medications were secured and failed to ensure proper labeling of biologicals for 1 of 1 facility reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to potentially harmful medications. Findings include: 1. On 3/3/24 at 12:10 PM Staff 7 (RN) was observed standing at a medication cart in the dining room preparing medications. There were several resident medication cards containing medication, and a cup that contained one white pill sitting on top of the cart. Staff 7 walked down the hall and left the medication cart unlocked and unattended with the medications sitting on top of the cart. There were several residents in the dining room. On 3/3/24 at 12:13 PM Staff 7 returned to the medication cart and acknowledged the top of the cart had resident medication cards, as well as a pill in a cup, resident medications were inside the cart and the cart was left unlocked and unattended. 2. On 3/3/24 at 1:03 PM…

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

Based on observation and interview it was determined the facility failed to ensure the dietary manager met the required qualifications for 1 of 1 kitchen reviewed for competent staffing. This placed residents at risk for unmet nutritional needs. Findings include: On 3/6/24 at 2:31 PM Staff 14 (Dietary Manager) was observed to direct staff while working in the kitchen. Staff 14 stated he worked in the kitchen for three years and was employed as the dietary manager for two years. Staff 14 stated he was not a certified dietary manager and did not take the classes to become a dietary manager. On 3/7/24 at 8:57 AM Staff 1 (Administrator) acknowledged Staff 14 did not meet the qualifications for the Dietary Manager position.

Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 3/3/24 at 12:19 PM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items: -two moldy bell peppers stored in a bag, undated. -a half gallon of unopened whip cream with a use by date of 2/22/24. -slices of white cheese - three different bundles - no label and undated. On 3/3/24 at 12:30 PM in the prep area, the surveyor observed two opened 50-pound bags, one bag of bread crumbs was rolled down closed, the second bag of all-purpose flour was torn open and the flour open to the air under a prep table. In the prep area, a five-gallon bucket was positioned on the floor under an open drop ceiling tile with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of admission for 1 of 2 sampled residents (#131) reviewed for ADL care. This placed residents at risk for lack of care and services. Findings include: Resident 131 admitted to the facility on [DATE] with diagnoses including stroke and muscle weakness. Resident 131's care plan revealed the first care area was initiated on 2/12/24; the resident had right sided hemiplegia (paralysis to one side of the body) and required assistance with ostomy care, dressing, bed mobility, showering, personal hygiene, oral care and transfers. On 3/5/24 at 2:14 PM Staff 2 (DNS) acknowledged the baseline care plan was not completed within the required 48 hours after admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to update resident care plans for 1 of 1 sampled resident (#132) reviewed for hospice. This placed residents at risk for lack of appropriate care. Findings include: Resident 132 admitted to the facility on [DATE] on hospice status and had diagnoses including heart failure and weakness. The 3/3/24 request for a physician order indicated Resident 132 had boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) heels and an order was requested for booties. This was signed on 3/4/24 with no additional instructions. The 3/2024 TARs indicated the following was to start on 3/5/24: -Ensure Prevalon boots (boots used to keep the heels elevated off the mattress to relieve pressure) were worn while in bed to assist with offloading bilateral heels every shift. The 3/6/24 care plan indicated Resident 132 had skin impairment to both heels and Prevalon boots and skin prep applied as ordered.…

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 provide nail care and oral care to a dependent resident for 1 of 2 sampled residents (#131) reviewed for ADLs. This placed residents at risk for lack of grooming and skin impairments. Finding include: Resident 131 admitted to the facility on [DATE] with diagnoses including stroke and muscle weakness. 1. On 3/4/24 at 10:23 AM Resident 131 stated she/he had not brushed her/his teeth since admitting to the facility on 2/8/24 and staff did not provide a toothbrush or toothpaste, and did not offer to assist her/him with oral care. Resident 131 stated it would be nice to have someone brush my teeth. On 3/4/24 at 10:23 AM Resident 131's room was observed and there was no toothbrush or toothpaste found. Resident 131's teeth appeared to be unclean and her/his breath had a foul odor. On 3/4/24 at 2:28 PM Staff 2 (DNS) observed Resident 131's room and was unable to locate a toothbrush or toothpaste. Resident 131 told Staff 2 she/he…

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 for 1 of 1 sampled resident (#4) reviewed for oxygen. This placed residents at risk for lack of respiratory care. Findings include: Resident 4 admitted to the facility in 2014 with diagnoses including chronic obstructive pulmonary disease. The 12/30/23 physician order indicated Resident 4 was to receive oxygen at two liters via nasal cannula to keep oxygen saturation greater than 90%. On 3/6/24 at 12:07 PM Resident 4 was observed to receive oxygen via a nasal cannula. The oxygen filter was observed to have light gray dust particles on the outside that were removed when touched. The humidifier bottle was observed to be empty. On 3/6/24 at 1:50 PM Staff 2 (DNS) observed Resident 4's oxygen filter and acknowledged the filter contained dust and acknowledged the humidifier was empty.

Based on interview and record review it was determined the facility failed to ensure records were accurate, complete, and readily accessible for 2 of 6 sampled residents (#s 14 and 16) reviewed during medication pass. This placed residents at risk for unmet care needs. Findings include: 1. Resident 14 readmitted to the facility in 2022 with diagnoses including atrial fibrillation (AFIB) (irregular heart rhythm). a. The 1/19/24 physician order indicated Resident 14 was to receive Eliquis 5 mg BID for AFIB. The 2/22/24 prescription refill request indicated Resident 14 had a dose change to Eliquis 2.5 mg once daily due to having blood in the urine. The 2/23/24 physician order indicated Resident 14 was to receive Eliquis 5 mg BID for AFIB. Resident 14's 2/2024 and 3/2024 MARs indicated the following: -2/1-2/19 Eliquis 5 mg at 9:00 AM and 9:00 PM. -2/20 Eliquis 5 mg at 9:00 AM. -2/21 Eliquis 5 mg was not administered-the MAR indicated it was due every other day. -2/22 Eliquis 5 mg at 9:00 AM -2/23 Eliquis 5 mg was not administered-the MAR indicated it was due every other day. -2/24-3/5…

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 a resident received coordination for end-of-life care for 1 of 1 sampled resident (#132) reviewed for hospice. This placed residents at risk for a lack of coordination of care. Findings include: Resident 132 admitted to the facility on [DATE] on hospice and had diagnoses including heart failure and weakness. On 3/5/24 Resident 132's clinical record was reviewed, and hospice notes were not located. On 3/5/24 at 2:38 PM Staff 8 (LPN) stated hospice staff visited Resident 132 but she was not sure how hospice staff communicated with the facility. On 3/6/24 at 2:40 PM Staff 3 (LPN Resident Care Manager) stated when hospice staff visited Resident 132 it was hit or miss for communication. Staff 3 stated if hospice staff had a question they asked the charge nurse and usually it was regarding bowel movements or pain medications. Staff 3 further stated new orders from hospice were written on a blank piece of paper and left with the nurse,…

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

Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 2/5/23 at 10:53 AM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items: -gallon carton of buttermilk (undated opened carton without a discard date); -ranch dressing (undated opened bottle without a discard date); -barbecue sauce (undated opened bottle without a discard date; food debris was observed on the outside of the bottle); -enchilada sauce (opened plastic jar dated 9/1 without a discard date); -cocktail sauce (undated opened plastic jar without a discard date); -sour cream (undated opened 5 gallon tub without a discard date); -mild chunky salsa (undated opened plastic jar without a discard…

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.

1. Based on observation, interview and record review it was determined the facility failed to process and transport laundry so as to prevent the spread of infection for 1 of 1 laundry rooms and 2 of 2 laundry carts reviewed for infection control. This placed residents at risk for receiving contaminated laundry and infection. Findings include. a. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 2/6/23 at 3:45 PM Staff 31 (Maintenance Director) stated housekeeping staff loaded and started the final load of laundry at the end of their shift each day, which typically occurred between 3:30 PM to 4:00 PM. Staff 31 stated the load of laundry was left in the washing machine overnight until laundry staff loaded the wet laundry into the dryer at the start of their shift the next morning at around 6:00 AM. On 2/7/23 at 4:53 PM a load of wet laundry was observed in the washing machine and no laundry staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to provide a homelike environment for 4 of 7 residents (#s 8, 18, 19, and 20), 1 of 2 halls, and 1 of 1 community shower room reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include: The facility's Maintenance Service Policy and Procedure, revised 12/2009, revealed the maintenance department was responsible to maintain the building, grounds and equipment. Functions of the maintenance personnel was to maintain the building in compliance with current federal, state and local laws, regulations and guidelines. 1. On 2/5/23 the following concerns were identified: - at 3:40 PM Resident 8's window frame was cracked, missing a piece of the window sill, a section of the window blinds were missing, her/his walls had scuffs and missing paint. - at 1:50 PM Resident 18's window seal was cracked and lifted to allow cold air into her/his room. - at 11:31 AM Resident 19's window seal…

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 provide sufficient nursing staff to attain and maintain the highest practicable wellbeing for 3 of 8 sampled residents (#s 8, 17, 273) and 2 of 2 halls reviewed for staffing. This placed residents at risk for lack of timely assistance for ADL care needs. Findings include: 1. Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke. Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact. On 2/5/23 at 11:52 AM Resident 8 stated she/he waited up to an hour for staff to respond to her/his call light and regularly waited over 30 minutes for staff to respond. On 2/8/23 at 8:41 AM Staff 10 (CNA) stated staff were expected to answer resident call lights within five minutes but that was not always realistic. Staff 10 stated she was not able to consistently complete all of her assigned duties, including answering call lights in a timely manner. A review of Resident 8's Alarm History…

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 employ kitchen staff who met the required qualifications for 1 of 1 kitchen reviewed for competent staffing. This placed residents at risk for unmet nutritional needs. Findings include: On 2/7/23 at 9:27 AM Staff 7 (Kitchen Manager) was observed working in the kitchen and directed staff. He reported he did not yet have Dietary Manager qualifications because he did not complete the required coursework. He stated Staff 1 (Administrator) planned to arrange for him to enroll in the required courses. On 2/7/23 at 1:04 PM Staff 1 reported he did not yet enroll Staff 7 in the required training to be the facility's Dietary Manager. He stated he did not know when the training was scheduled to start.

2. During the Resident Council meeting on 2/7/23 at 2:30 PM, the residents reported the lack of snack availability and the limited number of juices allowed due to budget costs. The residents stated the snacks often ran out and staff told them the kitchen was closed, therefore no snacks were available. Residents reported they obtained their own snacks due the diagnoses of diabetes and if their blood sugar dropped they needed a snack. Residents also reported the y were limited of two juices per meal and they were only allowed water or coffee between meals due to the budget. Signs directed staff to follow this rule. On 2/7/23 at 9:38 PM Staff 12 (CNA) stated she recalled in the fall of 2022 and in 2/2023 snacks were limited and not always available to residents. Staff 12 stated kitchen staff were not good at ensuring there was enough snacks made and stocked appropriately. Staff 12 stated there was no access to the kitchen once it was closed. On 2/8/23 at 10:54 AM Staff 28 (CMA/Staffing Coordinator) stated snacks were an issue because in the fall of 2022 a resident could only receive…

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 call lights were functioning for 2 of 2 halls and 1 of 1 sampled resident (#10) reviewed for pain and call lights. This placed residents at risk for unmet needs. Findings include: A public complaint was received by the State Agency on 1/12/23 which alleged the facility's call light system did not function sometimes. On 2/5/23 at 1:14 PM, during initial tour, Resident 18 stated the call light system did not always work. She/he stated other residents told her/him their call lights did not function correctly sometimes. On 2/7/23 at 2:30 PM the Resident Council met and reported the call light system did not always function. On 2/9/23 at 11:15 AM Resident 10 stated her/his call light did not always function correctly. Resident 10 stated when her/his call light did not work, the only way to get the staff's attention was to yell for help. A Call light Alarm History report was requested for Resident 10 for 1/1/23 to 2/8/23. The facility provided 225 pages, with an average 24 entries per page, of Alarm…

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 proper functioning ventilation system to prevent odors throughout the facility for 2 of 2 halls reviewed for environment. This resulted with residents living with poor ventilation which did not prevent pervasive odors. Findings include: The facility's Maintenance Service Policy and Procedure, revised 12/2009, revealed the maintenance department was responsible to maintain the building, grounds and equipment. Functions of the maintenance personnel was to maintain the building in compliance with current federal, state and local laws, regulations and guidelines. Random observations from 2/5/23 through 2/9/23, between 8:00 AM to 5:00 PM revealed strong odors that permeated out into the two hallways and perceived to originate from resident rooms. The odors were constantly present during the observation time. On 2/9/23 at 11:53 AM Staff 31 (Maintenance Director) walked through the facility with the surveyor. Staff 31 confirmed the strong odors on both hallways. Staff 31 reported he replaced…

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 resident rooms were free from pests for 1 of 2 halls reviewed for environment. This placed residents at risk for pest infestation. Findings include: The facility's Pest Control Policy and Procedure, revised 5/2018, revealed the facility shall maintain an effective pest control program and identified a pest control company which provided services to the facility. Fruit flies were observed in the facility on the following: -2/5/23 at 12:52 PM in room [ROOM NUMBER]. -2/6/23 at 2:37 PM in room [ROOM NUMBER]. -2/7/23 at 8:46 AM in the south hallway. -2/7/23 at 12:03 PM in the conference room. -2/7/23 at 12:09 PM room [ROOM NUMBER]. -2/7/23 at 3:23 PM small dining room. -2/8/23 at 9:22 AM south hall. -2/9/23 at 12:34 PM public restroom. On 2/7/23 at 12:09 PM Resident 18 acknowledged the fruit flies in her/his room. Resident 18 stated she/he previously reported to the facility the concern of fruit flies in her/his room. 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 ensure residents were treated in a dignified manner for 1 of 1 sampled resident (#9) reviewed for abuse. This placed residents at risk for diminished quality of life. Findings include: The facility's 2/2021 Dignity Policy & Procedure specified residents were treated with dignity and respect at all times. Resident 9 was admitted to the facility in 1/2022 with diagnoses including surgical aftercare. Resident 9's 12/15/22 Annual MDS indicated the resident was cognitively intact and required staff assistance with ADLs. A 1/9/23 facility Event Report, completed by Staff 16 (RN), indicated there was an incident of alleged verbal abuse on 1/8/23 at 1:40 PM. The report specified Staff 27 (Personal Care Assistant) reported Staff 26 (Former agency CNA) talked loudly and yelled at Resident 9. The incident occurred in Resident 9's room while Staff 26 provided incontinence care. The report indicated Resident 9 felt safe and she/he did not have a change in mood or behavior after the incident. Resident 9's Progress Notes…

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 married residents were able to share a room when requested for 1 of 1 sampled resident (#8) reviewed for choices. This placed residents at risk for diminished quality of life. Findings include: Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke. Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact. Resident 10 was admitted to the facility in 1/2018 with diagnoses including blindness and depression. Resident 10's 1/19/23 Quarterly MDS revealed the resident was cognitively intact. On 2/5/23 at 3:26 PM Resident 8 stated she/he married Resident 10 on 10/31/22. Resident 8 stated she/he asked the facility management about sharing a room and bed with her/his spouse after getting married and was told neither was a possibility. Resident 8 stated she/he felt depressed about not being able to share a room or bed with her/his spouse and the whole situation was very upsetting. On 2/7/23 at 8:28 AM Resident 10 stated she/he asked the former…

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

Based on interview and record review it was determined the facility failed to complete a thorough investigation of an allegation of abuse for 1 of 1 sampled resident (# 9) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations. Findings include: The 10/2005 Oregon Nursing Facility Abuse Reporting and Investigation Guide for Providers specified a thorough investigation is a systematic collection of information that describes and explains an incident or series of incidents. The investigation seeks to determine if abuse occurred, how the incident occurred, and how to prevent further occurrences. Critical component(s) of any investigation include the timely initiation of the investigation and the thoroughness of the investigation. The evidence data should be accurate and appropriate to include testimonial, documented, pictorial and physical evidence as applicable to come to a conclusion and it is important that conclusions not be reached without adequate information. Each investigation must seek to answer who, what, where, when, why and how, through…

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 develop and implement a comprehensive care plan to meet residents' needs for 3 of 12 sampled residents (#s 1, 8 and 16) reviewed for ADLs, nutrition, positioning and bowel and bladder. This placed residents at risk for not receiving appropriate adaptive equipment and incontinent care needs. Findings include: 1. Resident 1 was admitted to the facility in 2/2022 with diagnoses including cellulitis and a brain injury. The 9/6/22 Bedside Care Plan (a tool used by CNAs to provide care) indicated the resident attempted to toilet herself/himself throughout the day and night, unfortunately Resident 1 was unable to ensure she/he was cleaned properly/new brief application. Staff were to provide incontinence assistance frequently throughout each shift which included peri-care (cleaning private areas of a resident) and changing of Resident 1's brief. A revised care plan dated 1/10/23 revealed Resident 1 had a diagnosis of urinary incontinence related to functional mobility, was at risk for pressure…

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 care plans were revised to accurately reflect the resident needs for 1 of 4 sampled residents (# 15) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 15 admitted to the facility in 11/2020 with diagnoses including dementia and anxiety. A 1/12/23 Quarterly MDS indicated Resident 15's BIMS score was eight indicating moderate cognitive impairment. Resident 15 was totally dependent on one-person assistance with personal hygiene and required extensive one-person assistance with dressing. A revised care plan dated 1/16/23 revealed Resident 15 had an ADL deficit related to stroke and decreased physical functioning and dementia. Staff were directed to provided one-person assistance with dressing and personal hygiene. -The care plan did not indicate Resident 15 refused ADL care needs except at times did not allow staff to brush her/his teeth. -A review of the electronic record did not reveal Resident 15 refused to have her/his clothing changed. Random…

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 qualified staff administered medicated powders for 1 of 3 sampled residents (#1) reviewed for bowel and bladder care. This placed residents at risk for receiving inadequate treatment. Findings include: The Oregon State Board of Nursing Scope of Practice Standards for Certified Nursing Assistants, Oregon Administrative Rule [PHONE NUMBER] outlined the following: Skin Care to include application of non-prescription pediculicides; application of topical barrier creams and ointments for skin care; maintenance of skin integrity; prevention of pressure, friction, and shearing; and use of anti-pressure devices. Resident 1 was admitted to the facility in 2/2022 with diagnoses including cellulitis and a brain injury. A physician order dated 10/23/22 directed staff to apply Nystatin powder (anti-fungal) to peri-area twice daily and ensure area was dry prior to applying the powder. A Fax Sheet dated 11/16/22 from Staff 14 (LPN) revealed…

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 grooming assitance and nail care for 4 of 8 sampled residents (#s 1, 14, 15 and 16) reviewed for bowel and bladder and ADL care. This placed residents at risk for unmet needs. Findings include: 1. Resident 15 admitted to the facility in 11/2020 with diagnoses including dementia and anxiety. A 1/12/23 Quarterly MDS indicated Resident 15's BIMS score was eight indicating moderate cognitive impairment. Resident 15 was totally dependent on one-person assistance with personal hygiene and required extensive one-person assistance with dressing. A revised care plan dated 1/16/23 revealed Resident 15 had an ADL deficit related to stroke and decreased physical functioning and dementia. Staff were directed to provide one-person assistance with dressing and personal hygiene. Random observations from 2/5/23 through 2/6/23 revealed Resident 15 in the same blue long sleeve t-shirt which had food stains and food particles all over the entire front of the residents t-shirt. On 2/7/23 at 9:43 AM 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 observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 1 of 1 sampled resident (#10) reviewed for pain. This placed residents at risk for unmet psychosocial needs. Findings include: The facility's 6/2018 Activity Programs Policy statement indicated the activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident . Activity programs included activities which promoted the following: self-esteem; comfort; pleasure; education; creativity; success; and independence. Resident 10 admitted to the facility in 1/2018 with diagnoses including blindness, pain and depression. Resident 10's 11/10/22 activities care plan revealed she/he used discouraging remarks and language when around other residents, which made other residents uncomfortable and upset. The goal was for Resident 10 to be allowed to participate in facility activities while not impacting other residents' quality of life. 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 follow physician orders for 2 of 5 sampled residents (#s 16 and 273) reviewed for edema and positioning. This placed residents at risk for adverse outcomes related to edema and positioning. Findings include: 1. Resident 273 was admitted to the facility in 1/2023 with diagnoses including edema (swelling caused by excess fluid in body tissues). A physician's order dated 1/12/23 indicated Resident 273 was to be weighed daily and weight changes were to be reported to the resident's provider. Resident 273's 1/18/23 Dehydration/Fluid Maintenance CAA indicated staff were to ensure accurate weights were taken daily each morning before breakfast and the charge nurse was to monitor for any increased swelling and notify the resident's provider. A review of Resident 273's daily weight records from 1/20/23 through 2/8/23 revealed missing weights on the following days: 1/25/23, 1/26/23, 1/30/23, 2/2/23, 2/3/23 and 2/4/23. A review of Resident 273's daily weight records from 1/20/23 through 2/7/23 revealed the following…

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 interventions were in place and followed to reduce the risk of accidents for 3 of 6 sampled residents (#s 6, 8 and 273) reviewed for nutrition and accidents. This placed residents at risk for repeated choking incidents and falls. Findings include: 1. Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke and hemiplegia (paralysis of one side of the body). Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact, was independent with eating outside of set-up assistance from staff and did not experience any swallowing issues. A 2/1/23 facility Event Report, completed by Staff 6 (LPN/Resident Care Manager) revealed the following on 2/1/23 at 12:22 PM: - Description: Choking event; - Event Details: Resident ate lunch and a piece of bread got stuck in her/his throat; - Location: Resident spouse's room; - Notes: During lunch, the resident sat up in her/his wheelchair in her/his spouse's room when she/he had a choking episode. The 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 observation, interview and record review it was determined the facility failed to implement a restorative nursing program to ensure residents maintained strength and independence with ADLs for 1 of 1 sampled resident (#20) reviewed for rehabilitation services. This placed residents at risk for decreased range of motion and ability to participate in daily tasks. Findings include: Resident 20 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke). A review of Resident 20's skilled therapy notes revealed she/he was discharged from PT and OT on 4/27/22. A review of the signed 4/2022 physician orders revealed Resident 20 was to receive RA arm exercises once a day on Sunday, Monday, Wednesday and Friday and ambulation assistance from two staff members with a front-wheel walker and a wheelchair on Tuesday, Thursday and Saturday. On 2/5/23 at 1:58 PM Resident 20 stated she/he required assistance of two people to walk due to weakness and tremors. Resident 20 reported, They aren't doing as much as they should. I feel like I'm getting weaker. 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 use antibiotic protocols for 1 of 4 sampled residents (#15) reviewed for ADLs. This placed residents at risk for developing antibiotic resistance. Findings include: The CDC Core Elements of Antibiotic Stewardship (https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html) dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridioides difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core elements of a facility Antibiotic Stewardship Program should include analysis of infections and causative bacteria along with resistant data specific to both the facility 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.