Avamere Health Services of Rogue Valley

In the surveyor’s words

From the most serious findings on record at Avamere Health Services of Rogue Valley, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 13, 2022

  Based on observation, interview and record review it was determined the facility failed to follow infection control standards related to COVID-19 for 1 of 2 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy (IJ) situation. The facility was in the midst of a COVID-19 outbreak and staff were observed to mishandle and wear inappropriate PPE when entering an isolation room for a COVID-19 exposure placing residents at risk to contract COVID-19, a life-threatening illness. Findings include: On 1/3/22 after entering the facility, the survey team was notified of a new COVID-19 outbreak. Based on infection control standards and current guidance related to a COVID-19 outbreak, facility staff were to wear N95 masks and eye protection. […]

• Immediate jeopardy, isolatedF806Jan 13, 2022

  Based on observation, interview and record review it was determined the facility failed to prevent residents from being served food to which they were allergic for 1 of 2 sampled residents (#41) reviewed for food. This deficient practice was determined to be an immediate jeopardy situation. Resident 41 was served two consecutive meals which contained foods to which the resident was allergic. The response to consuming these foods could cause anaphylactic shock (life threatening allergic reaction) which could lead to death. Findings include: Resident 41 was admitted to the facility in 11/2021 with diagnoses including diabetes and food allergies. Resident 41's 6/1/21 Nutrition CAA indicated the resident was at high risk for nutritional problems due to multiple food allergies. […]

• Actual harm, isolatedF689Nov 23, 2022

  Based on interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 3 sampled residents (#4) reviewed for falls. Resident 4 sustained a fracture to the left arm. Findings include: Resident 4 was admitted to the facility in 11/2021 with diagnoses including [CONDITION(S)] ([CONDITION(S)]), dementia and fatigue. A 11/24/21 care plan indicated Resident 4 was at risk for falls and was on a toileting schedule to assist her/him with self-transferring to the toilet and to place a bedside commode next to the bed at night for safety related to self-transferring. A 11/28/21 Admission MDS indicated Resident 4 required limited one-person assistance with transfers and supervision with toilet use. […]

• Actual harm, isolatedF835Nov 23, 2022

  Based on the lack of effective systems for ensuring adequate staffing levels and an adequate call light system, the facility administration failed to utilize its resources effectively and efficiently to ensure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. These failures placed residents at risk for delayed care. Findings include: 1. Deficient practice was identified regarding the facility's failure to ensure adequate RN and CNA staffing. In an interview on 11/22/22 at 11:03 AM Staff 1 (Assistant Administrator), Staff 2 (DNS), Staff 10 (Administrator) and Staff 81 (Regional Nurse Consultant) stated the facility followed the State minimum required staffing ratios for CNAs and the facility staffed to the acuity of the residents. […]

• No harm, potential for more than minimal, widespreadF725Nov 23, 2022

  Based on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 9 of 9 sampled residents (#s 1, 2, 8, 11, 13, 15, 17, 19 and 20) and 2 of 3 wings (Wing 1 and Wing 2) reviewed for call light wait times and incontinent care. This placed residents at risk for unmet needs. Findings include: 1. Resident 1 was admitted to the facility in 2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/1/18 care plan indicated Resident 1 was incontinent of bowel and had mixed incontinence of bladder. Resident 1 had an ADL self-care performance deficit with limited mobility and required assistance of one person for toilet use, or a bed pan. […]