Every finding on record at Avamere Rehabilitation of Clackamas

Based on observation, interview and record review it was determined the facility failed to provide a clean and comfortable homelike environment for 1 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: On 9/29/25 through 10/1/25 from 8:00 AM to 4:00 PM, resident rooms one, two and four in the [NAME] Hall were observed to be used for storage of new furniture and past resident belongings. Observations of the three rooms included:-Five mattresses stacked on top of an unoccupied bed. The right side of the room was used for storage of a metal rack, two floor mats, a knee wedge, hangers, bath basin, gown, a bag of tortillas and four side tables. On the floor, a drawer from unknown origin was left on the floor and a yellow bath basin was placed on top.-Six mattresses stacked on top of an unoccupied bed. On top of the mattress, several blue blankets were placed on top of the mattresses. A sign above an unoccupied bed stated, emergency overflow bed only.-Three floor mats on top of an empty bed. A blue blanket was placed on top of the floor mats. Two bed frames and two side tables were placed in random places on the left side of the room. On 9/29/25 at 1:32 PM, Resident 48 stated her/his room was an overflow room for staff to store furniture. On 9/29/25 at 1:44 PM, Resident 17 stated the extra furniture in her/his room was there since admission. On 10/1/25 at 8:59 AM, Resident 10 stated the furniture in her/his room bugged her/him but the facility didn't have enough storage. Staff told her/him they tried to move the furniture, but they were short staffed. Resident 10 stated she/he kept the curtain closed to avoid seeing the mess. On 10/1/25 at 9:23 AM, Staff 9 (CNA) stated the resident rooms were used for extra furniture.On 10/1/25 at 11:08 AM, Staff 8 (CNA) stated unoccupied areas in resident rooms were used for extra furniture. Staff 8 stated the facility stored extra equipment including furniture in a trailer next to the facility. On 10/1/25 at 12:58 PM, Staff 1 (Administrator) stated unoccupied resident rooms were used for temporary storage of new furniture. Staff 1 stated he was unaware new furniture was stored in occupied resident rooms. Staff 1 stated one of the rooms was previously unoccupied, but they had a last-minute admission, and he was unaware the resident wanted the furniture removed. Staff 1 stated the shed was not ready for storage. Staff 1 acknowledged storing furniture in occupied resident rooms was not a homelike environment.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#5) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include:Resident 5 was admitted to the facility in 8/2025 with diagnoses including stroke and dysphagia (difficulty swallowing).Resident 5's Quarterly MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.Resident 5's care plan dated 8/28/25 indicated the resident required total assistance with personal hygiene. Resident 5 was observed on 9/29/25 at 1:11 PM, 9/30/25 at 12:59 PM and on 12/4/25 at 11:53 AM with a significant amount of visible facial hair.On 9/30/25 at 1:10 PM Resident 5 stated she/he did not want to have facial hair and wanted staff to take care of her/his facial hair. Resident 5 stated she/he relied on staff to shave unwanted facial hair.On 10/1/25 at 12:07, Staff 10 (CNA) stated she noticed Resident 5's facial hair, which was very visible. Staff 10 indicated Resident 5 was dependent on staff to shave her/him.On 10/1/25 at 12:20 PM, Staff 11 (CNA) stated she obtained information to care for resident 5 from the care plan and acknowledged Resident 5 had a noticeable amount of facial hair.On 10/1/25 at 12:26 PM, Staff 2 (DNS) stated it was her expectation for Resident 5 to have her/his shaving preferences followed and confirmed the resident was dependent on staff for ADL care.

Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent an injury during toileting for 1 of 1 sampled resident (#60) reviewed for falls. This placed residents at risk for injury during transfers and inadequate ADL assistance. Findings include:Resident 60 admitted to the facility in 5/2025 with diagnoses including stroke with left sided weakness.A review of Resident 60's care plan dated 4/29/25 revealed she/he required assistance from two staff members for all transfers and toileting due to high fall risk and multiple falls since admission.A facility investigation created and signed by Staff 2 (DNS) on 5/13/25 indicated Staff 7 (Former NA) transferred Resident 60 to the toilet. Staff 7 attempted to change Resident 60's brief while the resident was seated on the toilet and the resident jerked suddenly which caused the resident to hit her/his head on the mobility bar along the wall, resulting in a large bump on the side of the resident's head.On 12/4/25 at 11:47 AM Staff 2 confirmed Staff 7 did not follow Resident 60's care plan to have two staff assist with toileting Resident 60.

Based on observation, interview and record review it was determined the facility failed to implement appropriate contact precautions and properly store wound care supplies for 1 of 1 resident (#24) reviewed for hospice. This placed residents at risk for the spread of infection. Findings include:The Center for Disease Control's (CDC) 4/3/24 website, section titled, Transmission Based Precautions, specified Contact Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.The facility's Transmission-Based Precautions policy dated 8/2019 stated:3. When Transmission-Based Precautions are implemented, the Infection Preventionist: -Clearly identifies the type of precautions, the anticipated duration and the personal equipment (PPE) that must be used;-Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and the type of precautions;-The signage informs staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.Resident 24 was admitted to the facility in 6/2025 with diagnoses including type 2 diabetes and MRSA (a bacterial infection resistant to several antibiotics).a. On 9/29/25 at 9:57 AM, 12/2/25 at 12:40 PM and on 12/3/25 at 9:22 AM room [ROOM NUMBER] was observed to have a full trash bag laying on the floor behind the door, an open bag of incontinence briefs laying on the floor and multiple sterile treatments supplies were opened and in a box on the floor. No staff were present in the room or hallway at the time of the observations.On 12/3/25 at 9:30 AM, Staff 8 (CNA) confirmed the trash bag was on the floor and verified opened sterile wound treatment supplies were being stored on the floor.On 12/3/25 at 9:58 AM, Staff 16 (RN) verified sterile treatment supplies were stored in a box on the floor in room [ROOM NUMBER].On 12/3/25 at 11:20 AM, Staff 5 (IP) and Staff 4 (RNCM) stated it was their expectation for sterile wound care supplies be stored appropriately and off the floor.On 12/3/25 at 11:31 AM, Staff 2 (DNS) stated the storage of sterile supplies on the floor was not consistent with facility practice and should have been addressed immediately by staff.b. On 9/29/25 at 9:57 AM, 12/2/25 at 12:40 PM and on 12/3/25 at 9:22 AM Resident 24 was observed to have scabs and wound dressings on her/his feet and bilateral ankles. Resident 24's room was not identified to require contact precautions.On 12/3/25 at 9:30 AM Staff 8 (CNA) stated Resident 24 was not on contact precautions and she did not wear PPE while providing care for the resident.On 12/3/25 at 9:58 AM Staff 16 (RN) stated Resident 24 was previously on contact precautions but was not any longer, and she wore gloves only when performing dressing changes.On 12/3/25 at 11:20 AM Staff 5 and Staff 4 observed Resident 24's feet and identified an open wound. Both stated the open wound was not reported to them and the resident should have been on contact precautions based on the presence of the wound.On 12/3/25 at 11:31 AM Staff 2 stated it was her expectation open wounds were reported promptly and contact precautions implemented as required. Staff 2 confirmed Resident 24 should have been on contact precautions once the open wound was identified.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions related to elopement for 1 of 1 sampled resident (#32) reviewed for elopement. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for an unsafe elopement and injury. Findings include: The facility's revised 3/2019 Wandering and Elopement policy states the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The facility's revised 7/18/24 Avamere Living-Code Pink Guidelines, an Elopement, Exit seeking, Wandering Assessment, stated the facility will complete the Code Pink Documentation tool when the resident is identified as at risk for elopement, exit seeking or wandering. Resident 32 admitted to the facility in 3/2024, with diagnoses including dementia and congestive heart failure. Resident 32's 6/19/24 Care Plan indicated Resident 32 may leave facility premises only if accompanied by a responsible party for therapeutic leave. Resident 32's 8/15/24 AvaElopement Risk Evaluation indicated the resident was disoriented, cognitively impaired with poor decision-making skills, known history of elopement, able to self-propel wheelchair independently and a moderate risk for wandering. On 8/19/24 at 12:41 PM, a complaint was received by the State Survey Agency (SSA), which alleged Resident 32 arrived on 8/16/24 via a medical transport bus to a brand-new appointment with a new practitioner, unattended and disoriented. Paperwork received from the nursing facility stated the resident had dementia and was an elopement risk. The receiving clinic recognized the residents' risk for elopement and assigned a staff member to monitor the resident. On 9/16/24 at 10:59 AM Resident 32 stated she/he was unable to recall the recent clinic visit. On 9/16/24 at 11:05 AM Staff 4 (CNA) stated she arranged for Resident 32's transportation to the new clinic and ordered Hand To Hand: Specific instructions when the resident arrived to the clinic she/he was not to be left alone. Staff 4 stated the facility did not send staff with the resident. On 9/16/24 at 11:52 AM Staff 2 (DNS) stated medical transport takes residents to their appointments and then picks them back up. Staff 2 stated the facility did not send staff with Resident 32 for the clinic appointment and acknowledged Resident 32 was not able to communicate and was an elopement risk. Staff 2 stated the expectation was for Resident 32 to be accompanied by a responsible party. On 9/17/24 at 12:05 PM Staff 3 (RNCM) stated she had received a phone call from the clinic stating Resident 32 was confused and could not give them any information. Staff 3 stated she knew Resident 32 was an elopement risk but assumed the driver from the medical transport would escort the resident in to the clinic. On 9/18/24 at 10:27 AM Staff 5 (RN Charge Nurse) stated Resident 32 needed redirection due to being forgetful and acknowledged Resident 32 was an elopement risk. Staff 5 stated she did not know if the resident could leave the facility by her/himself. On 9/18/24 at 10:52 AM Witness 2 (Medical Transport Driver) stated she did not know what the term Hand To Hand meant when transporting residents. On 9/20/24 at 3:00 PM Staff 1 (Administrator) and Staff 2 were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to follow Resident 32's care plan to have a responsible party accompany the resident to an outside appointment. On 9/20/24 at 4:51 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. The care plan for Resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks. 2. All staff on evening shift on 9/20/24, have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments. 3. All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift within the week will have been educated by 9/26/24. 4. All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary. 5. To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement for one week, weekly for three weeks, and then monthly until substantial compliance is achieved. 6. All findings to be reported to the Quality Assurance and Performance Improvement Committee. On 9/23/24 at 2:20 PM, the IJ was removed as confirmed by onsite verification.

Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use for 1 of 1 sampled resident (# 299) reviewed during CBG checks. This failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include: The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions. On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a three-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use. On 7/17/24 at 11:55 AM Staff 2 (DNS) provided a list of 15 residents who required CBG checks, which included Resident 15. Resident 15's clinical record indicated she/he admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV) and required CBG checks three times a day and used a shared glucometer. Resident 15's Diabetic Administration Record indicated Staff 3 first completed Resident 15's CBG checks twice on 6/14/24. On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls. On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached. On 7/17/24 at 2:15 PM the facility was informed that the facility's failure to improperly clean and sanitize the common use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 7/17/24 at 5:30 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. Glucometers in the facility have been immediately collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens prior to the next CBG checks. 2. Staff 3 was suspended, will receive 1:1 education/training on glucometer disinfection between uses, and dedicating CBG equipment for residents with diagnoses of bloodborne pathogens prior to return to work. 3. Licensed nurses, prior to start of shift, will be educated on the proper procedure for disinfecting blood glucose monitors and complete a Blood Glucose Monitoring Competency and will have dedicated CBG equipment for residents with bloodborne pathogens. 4. Resident 15 was provided with dedicated blood glucose monitoring equipment. 5. Residents in the facility will be audited for diagnoses of bloodborne pathogens and provided with dedicated blood glucose monitoring equipment if indicated. 6. The Medical Director was notified. Residents potentially exposed also notified. Testing will be offered as requested. 7. To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for routine blood glucose checks x 1 week, weekly x 3 weeks, monthly x 2 months to ensure proper disinfection. 8. All findings to be reported to the QAPI Committee. On 7/18/24 at 2:30 PM it was determined the immediacy was removed after verification of completion of the IJ removal plan.

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for a lessened quality of life. Findings include: The facility's 2021 Homelike Environment Policy revealed residents were provided with a safe, clean, comfortable and homelike environment. Comfortable and adequate lighting was provided in all areas of the facility. Resident 24 admitted to the facility in 2019 with diagnoses including hypertension (high blood pressure) and depression. Resident 24's 4/21/24 Annual MDS indication she/he was cognitively intact. On 7/16/24 at 9:24 AM Resident 24 stated she/he was going to an activity in the dining room where the lighting was bad, and her/his vision was not so great so she/he sat by the window or the doors to see better. On 7/16/24 at 3:40 PM Resident 24 stated the lights in the dining room could be brighter because when residents were in activities in the dining room, other residents would ask if the lights could be turned on, but the lights were already on. During the Resident Council meeting on 7/16/24 at 1:00 PM the council members stated the lights in the dining room, where they had activity groups, had light bulbs out for a while and made it difficult to see. On 7/16/24 at 1:53 PM the dining room was observed with three of the six ceiling lights to not produce light. The dining room floor had four large pieces of black tape on the light-colored floor and the flooring was buckled up near the soda machine. On 7/17/24 at 11:10 AM the shared bathroom between room one and room three was observed with brown and yellow stained caulking around the base of the toilet. The floor was stained with brown markings and appeared dirty. On 7/17/24 at 11:12 AM the shared bathroom between room two and room four was observed with brown and yellow stained caulking around the base of the toilet and appeared dirty. On 7/17/24 at 11:13 AM room four's wall under the window was observed with the paneling peeling away from the wall in several spots. On 7/19/24 at 9:58 AM Staff 11 (Maintenance Director) confirmed the lights in the dining room were not working properly and needed new bulbs. Staff 11 stated he found out about the lights on Tuesday (7/16/24) from the Resident Council meeting and was unaware prior to 7/16/24. Staff 11 confirmed the taped flooring in the dining room and the other identified areas were in disrepair. Staff 11 stated the facility did not have a plan in place to fix flooring repairs. Staff 11 acknowledged the stained caulking in the shared resident bathrooms between rooms one and three and rooms two and four. Staff 11 stated the caulking needed to be repaired. Staff 11 acknowledged the paneling pulled away from the wall in room four and stated the facility did not have a plan in place to fix the wall. On 7/19/24 at 10:10 AM Staff 1 (Administrator) confirmed the needed repairs of lights in the dining room, flooring in the dining room, shared resident bathrooms between rooms one and three and rooms two and four, and the wall in room four. Staff 1 stated he expected a plan to be in place to make the repairs.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers for 1 of 2 licensed nurses (Staff #3) reviewed for infection control and medication administration. This placed residents at significant risk for bloodborne illness. Findings include: Per [NAME] [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per [NAME] [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: (a) Developing, modifying or implementing policies that jeopardize client safety; The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA registered wipes. The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions. On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a 3-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use. On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls. On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached. Refer to F880.

Based on interview and record review it was determined the facility failed to implement resident-centered care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 1 of 1 sampled resident (#18) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors. Findings include: The facility's revised 2018 Dementia - Clinical Protocol revealed for individuals with confirmed dementia, the IDT (Inter-Disciplinary Team) would identify a resident-centered care plan to maximize their remaining function and quality of life. Resident 18 admitted to the facility in 2020 with diagnoses including dementia with agitation and depression. Resident 18's 8/21/23 Annual MDS indicated behaviors including rejection of care, combative behavior and agitation. Resident 18's 5/21/24 Quarterly MDS assessed her/him as severely cognitively impaired. Review of Resident 18's 7/18/24 behavioral care plan identified her/him as confrontational, rude, demanding, suspicious, manipulative and anxious. The care plan identified behaviors of verbal aggression, physical aggression, yelling, hitting, interference with roommate's care, and history of false accusative statements. The care planned interventions were that sometimes she/he would calm down when chocolate was given, discharge planning, separate from other residents, approach calmly and unhurriedly, notify physician if behaviors interfered with medical needs, leave the room and leave her/him alone to give space. Review of Resident 18's 7/18/24 ADL care plan revealed she/he refused ADLs and showers. The interventions were to document refusals and re-approach at a different time. No other interventions for ADLs and shower refusals were documented. On 7/19/24 at 8:43 AM Staff 10 (CNA) stated she received her information to care for residents from the care plan and shift reports from other staff members. Staff 10 stated Resident 18 had behaviors often, ate meals in her/his room due to behaviors and the staff kept her/him away from people. No other interventions were provided to prevent negative behaviors. On 5/19/24 at 9:13 AM Staff 2 (DNS) acknowledged Resident 18's care plan was not resident centered. Staff 2 acknowledged the interventions were for staff and were not specific to Resident 18 as an individual. Staff 2 reported some interventions were attempted but they were not documented or care planned in Resident 18's health record. No further information was provided.

Based on observation, interview, and record review it was determined the facility failed to re-evaluate elopement risks and revise care plan interventions to prevent repeated elopements for 1 of 1 sample residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include: Resident 1 admitted to the facility in 3/2024, with diagnosis including dementia and Type 2 diabetes. Resident 1's 3/16/24 Elopement Assessment identified she/he was a moderate risk for elopement. Resident 1's 4/15/24 Care Plan indicated the resident presented as a high risk for wandering and elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was also revealed to be a significant fall risk due to cognitive impairment related to dementia. No additional interventions were identified. A 4/24/24 Facility Incident Reported revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located according to the facility's investigation to have been found at the local market. Facility door alarms were in place but was revealed to have not alerted staff when resident exited the facility. Residents SLUMS score was revealed to be 12/30 indicating significant cognitive impairment. On 4/24/24 Resident 1's care plan interventions included working with the resident to determine reasons for wanting to leave the facility. No additional interventions were identified. A 5/31/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Facility indicated during internal review that staff were unaware of resident's whereabouts and unaware she/he could not leave the facility on her/his own. Facility investigation revealed care staff were not aware of Resident 1's elopement and prior interventions were determined to be unsuccessful. Resident 1 was located at the local market and returned to the facility by care staff. On 5/31/24 Resident 1's care plan interventions included placing the resident on 15 minute checks. A 6/10/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Resident was located at Clackamas Town Center by spouse. Resident 1 was picked up by the facility. There was no documented evidence the facility re-evaluated Resident 1's elopement risk to identify her/his risk factors and to develop targeted interventions or to determine the need for increased supervision to prevent reoccurring elopements. On 6/18/24 at 11:27 AM, Resident 1's room was observed to be located between two emergency exit doors. On 6/18/24 at 11:34 AM, Staff 3 (CNA) stated Resident 1 consistently wanted to elope from the facility and continued to present as an elopement risk for the facility due to Resident 1's elusiveness and not having staff to monitor the resident every 15 minutes. Staff 3 was unaware of any additional interventions in place for Resident 1. On 6/18/24 at 12:17 PM, Staff 7 (RNCM) stated Resident 1 was not appropriate for a nursing facility due to residents consistent wandering behaviors and was more suitable for a memory care facility. Staff 7 indicated Resident 1 was capable of leaving the facility without notifying anyone. Staff 7 stated no additional interventions other then fifteen minute checks were implemented in the resident's care plan. On 6/18/24 at 3:06 PM, Staff 2 (DNS) stated no additional communication, assessments, or interventions were put into place for Resident 1 outside of the fifteen minute checks due to the facility's belief in additional interventions or assessments to be unnecessary. On 6/18/24 at 3:14 PM, (Staff 5) CNA stated Resident 1 was smart enough to elope from the building by waiting for care staff to get busy then walk out through the front door or side door. Staff 5 stated only fifteen minute interventions were in place and was unaware of any additional interventions identified. On 6/20/24 at 11:04 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility failed to implement additional interventions to prevent Resident 1's elopements. Staff 2 (DNS) acknowledged the facility failed to re-evaluate Resident 1's elopement risk and failed to revise care plan interventions to prevent Resident 1's elopements.

Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms and linen supplies were maintained for 2 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: 1. A 5/3/23 at 10:06 AM observation of room [ROOM NUMBER] and bathroom revealed duct tape on the floor under the sink and across the toilet threshold. The grout around the toilet was uneven and patchy, there were tiles on the floor and wall in the shower stall that were cracked and broken. The dry wall leading toward the bathroom was cracked near the ceiling and the frame around the bathroom door was separated. There was a gap between the wall and ceiling along three of the bathroom walls (except the window wall). The exhaust vent did not turn on when tested . The resident in room [ROOM NUMBER] stated she/he used that bathroom. A 5/1/23 at 11:49 AM observation of the bathroom between rooms [ROOM NUMBERS] revealed the linoleum around the toilet and across the width of the bathroom floor was separated which exposed subflooring. The bathroom was used daily. A 5/1/23 at 12:24 PM observation of room [ROOM NUMBER] and bathroom revealed the toilet riser was missing paint and visibly rusted in several spots. The linoleum was separated close to the toilet and a rust-colored ring was noted around the base of the toilet. The molding was separated from the wall under the sink, and the caulk and drywall was cracked above the sink. The floor was stained gray and brown in multiple locations, and there were several chips out of the bathroom door which exposed the wood underneath. A 5/1/23 at 12:31 PM observation of room [ROOM NUMBER] and bathroom revealed gray stains on the floor, a commode with non-cleanable tape, caulk missing at the base of the toilet, and the base of the toilet was stained brown. The commode was rusted, and the floor had several dark nicks and scratches. A 5/1/23 at 12:43 PM observation of room [ROOM NUMBER] and bathroom revealed a persistent urine odor, and the toilet seat did not fit the toilet (oversized). The caulk was missing from the base of the toilet and the floor surrounding the toilet was rusted and brown in color. On 5/4/23 at 11:43 AM Staff 5 (Maintenance Director) stated the Facility had discussed two of the bathroom remodels however did not plan on all of them. Staff 5 confirmed all observed concerns and acknowledged the identified findings. On 5/4/23 at 12:10 PM Staff 1 (Administrator) acknowledged the observed damage and confirmed repairs were needed. 47005 2. On 5/1/23 at 9:52 AM Resident 40 stated her/his shower was delayed on Sunday, 4/30/23 due to the facility not having any clean towels or linen. On 5/2/23 at 1:37 PM Staff 7 (Housekeeping Manager) stated the weekend staff did not show up to work on Saturday and Sunday. Staff 7 was not aware there was no housekeeping staff present in the facility until he was notified by the DNS on Sunday morning. On 5/2/23 at 1:59 PM Staff 2 (DNS) stated Staff 8 (CNA) called her on Sunday morning stating there was no clean linen or towels in the facility and staff were cutting up bed sheets to use as washcloths. Staff 2 called Staff 7 immediately, who came in to provide laundry and housekeeping services. On 5/5/23 at 8:48 AM Staff 8 (CNA) stated she was told by other CNA staff there was no clean towels or linen in the facility. Staff 8 called Staff 2 to inform her of the linen and towel shortage. Staff 8 stated she did not call Staff 7 because she did not have his number. On 5/5/23 9:10 AM Staff 1 (Administrator) stated she was called on Sunday regarding the linen shortage.

Based on observation, interview and record review it was determined the facility failed to provide palatable meals for 2 of 2 sampled residents (#s 12 and 30) reviewed for food quality. This placed residents at risk for impaired nutrition. Findings include: 1. Resident 12 was admitted to the facility in 2023 with diagnoses including pneumonia, dysphagia (difficulty swallowing) and malnutrition. Resident 12's 4/24/23 Care Plan indicated the resident had altered nutrition related to diagnoses of malnutrition and dysphagia. Resident 12's 4/26/23 ordered diet was a regular diet with minced and moist texture. A Registered Dietitian assessment dated [DATE] indicated the resident had an underweight BMI (body mass index). On 5/1/23 at 1:06 PM Resident 12 reported the texture, preparation and appearance of the food was not good. The resident stated the meal served at lunch was minced to death and she/he was not able to identify what it was. On 5/4/23 at 12:15 PM surveyors sampled two meals (regular and minced/moist) consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was observed to be overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked. The minced and moist food was not appetizing in appearance. The plate had two scoops of pale colored food (pork and orzo) and one scoop of green colored food. The food was lacking in flavor and the texture had a pureed (ground finely) consistency. On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledged the findings identified. 34324 2. Resident 30 admitted to the facility in 2022 with diagnoses including anxiety. The 10/10/22 Care Plan indicated Resident 30 was independent with eating. A 3/28/23 progress note indicated Resident 30 was cognitively intact and was able to direct her/his own care. On 5/1/23 at 10:50 AM Resident 30 stated the food was not always good and kitchen staff did not know how to cook the food. On 5/4/23 at 12:15 PM surveyors sampled a regular diet meal consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked. On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledeged the findings indentified.

Based on observation, interview and record review it was determined the facility failed to ensure oxygen filters were cleaned for 1 of 1 sampled resident (#4) reviewed for respiratory care. This placed residents at risk for lack of respiratory care. Findings include: The facility's 2001 policy related to respiratory support indicated washable filters were to be rinsed under running water once a week to remove dust and debris. Resident 4 admitted to the facility in 2020 with diagnoses including palliative care. A physician order dated 2/10/23 indicated Resident 4 was to have 0-2 liters of supplemental oxygen PRN to maintain saturation of more than 88 percent. A 4/24/23 hospice note indicated Resident 4 used 2 liters of oxygen continuously. Review of the 4/2023 MAR indicate Resident 4 received 2 liters of oxygen routinely. On 5/1/23 at 11:17 AM Resident 4 was observed to have oxygen in place. Resident 4 stated she/he used oxygen all the time. The oxygen filter was observed to have a thick layer of dust covering the entire filter. On 5/2/23 at 12:47 PM Staff 2 (DNS) stated night shift staff was responsible for maintaining and cleaning resident oxygen equipment, including the filters. Staff 2 acknowledged Resident 4's oxygen filter was dirty and covered in dust.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 24 admitted to the facility in 2022 with diagnoses including depressive disorder. The 3/3/23 pharmacy recommendation indicated the following: -Resident 24 was taking Lexapro (antidepressant medication) 7.5 mg for depression and was due for a gradual dose reduction (GDR) assessment; The pharmacy recommendation was not signed by the provider until 4/27/23 (55 days later) and indicated no change to Resident 24's Lexapro. On 5/3/23 at 2:03 PM at Staff 2 (DNS) acknowledged the facility did not follow up with the pharmacy recommendation timely.

Based on interview and record review it was determined the facility failed to withhold bowel medication as indicated for 2 of 5 sampled residents (#s 3 and 24) reviewed for medication. This placed residents at risk for adverse side effects of bowel medication. Findings include: 1. Resident 3 was admitted to the facility in 2019 with diagnoses including stroke. Resident 3's 5/4/23 physician's orders included the following medications: - Miralax (laxative) BID for bowel care. - Senna (laxative) BID for bowel care. Resident 3's Bowel elimination records from 4/4/23 through 4/30/23 revealed she/he had loose stools or diarrhea documented on 17 of 30 days for a total of 24 occurrences. Resident 3's 4/2023 MAR indicated: - The resident's scheduled Miralax was administered routinely every day from 4/1/23 through 4/30/23. - The resident's scheduled senna was administered routinely every day from 4/1/23 through 4/30/23 except for the refusal of two doses. Resident 3's 4/19/23 Care Plan indicated the resident had loose stools and diarrhea with a goal of reduced episodes of diarrhea. On 5/4/23 at 11:05 AM Staff 10 (Agency RN) stated the CNAs reported loose stools to the CMA. The CMA then communicated this information to the nurse. Staff 10 reported she was not informed Resident 3 had loose stools or diarrhea. On 5/4/23 at 12:58 PM Staff 2 (DNS) acknowledged Resident 3 had loose stools or diarrhea documented in April 2023 and the scheduled bowel care medications (Miralax and senna) were administered for all but two doses. She stated if a resident had a loose stool it should be communicated so this information could be passed on to the doctor to determine if the bowel care medication should be held or discontinued. 34702 2. Resident 24 admitted to the facility in 2022 with diagnoses including heart failure. The 3/29/23 physician orders indicated Resident 24 was to receive the following: -polyethylene glycol powder (laxative medication) give 1 scoop in juice in the morning for bowel care; -senna 8.6 mg (laxative medication) one tab in the evening for bowel care. Hold for loose stool or more than 2 bowel movements daily; -senna-docusate sodium 8.6-50 mg (laxative medication) 2 tabs twice daily for stool softener. A review of MARs from 4/4/23 through 5/3/23 indicated the following: -Resident 24 received polyethylene glycol on 29 occasions and refused the medication four times; -Resident 24 received all doses of senna 8.6 mg in the evening as ordered; -Resident 24 received all doses of senna-docusate sodium 8.6-50 mg 2 tabs twice daily as ordered. A review of Resident 24's bowel records from 4/4/23 through 5/3/23 indicated the resident had loose stools on 17 occasions. On 5/3/23 at 1:05 PM Staff 2 (DNS) acknowledged Resident 24 had loose stools on 17 occasions between 4/4/23 and 5/3/23 and acknowledged the bowel medication was not held per the orders and not held per indication of use.

Based on observation and interview it was determined the facility failed to ensure garbage storage areas were maintained in a sanitary manner to prevent the presence and feeding of pests, and to ensure garbage storage area dumpsters were covered condition for 1 of 1 facility storage areas reviewed for sanitary garbage storage. This placed residents at risk for presence of pests. Findings include: On 5/1/23 at 9:09 AM during the initial kitchen tour including the outside garbage storage area Staff 9 (Cook) stated the trash compacter was broken for over a year and the facility brought in a large dumpster. A large, approximately 20 feet by 10 feet uncovered dumpster with two hinged doors at the front was observed at back side of the building. On 5/2/23 at 12:58 PM one of the dumpster doors opened was observed open; trash bags and a pair of used gloves dangled off the edge of the dumpster. On 5/3/23 at 10:12 AM one of the the dumpster doors was observed open and one garbage bag hung over the front edge; two black crows were observed by the dumpster opening. On 5/3/23 at 10:25 AM Resident 29 stated she/he saw cats and birds in the dumpster at times. On 5/4/23 at 1:55 PM Staff 6 (Dietary Manager) stated she was aware the dumpster required a cover to stop the risk of pests and rodents, but was not involved in the decision-making process for the dumpster. On 5/4/23 at 2:09 PM Staff 5 (Maintenance Director) stated the trash compactor broke almost two years ago, and the two large uncovered dumpster was in use for almost a year. Staff 5 stated one of the dumpster doors was always left open because some staff were not able to throw trash bags into the dumpster from above. On 5/5/23 at 9:07 AM Staff 1 (Administrator) acknowledged the dumpster was not covered and was not aware it had to be covered.

Based on observation, interview, and record review it was determined the facility failed to follow the plan of care for 1 of 3 sampled residents (#4) reviewed for falls. This failure resulted in Resident 4 experiencing a fall with a fracture. This placed residents at risk for increased falls. Findings include: Resident 4 admitted to the facility on [DATE] with diagnoses including dementia. Resident 4's Quarterly MDS dated [DATE] revealed she/he had a BIMS score of 5 (severely impaired). Resident 4's care plan dated 7/21/22 included padded fall mats on both bedsides when in bed, wider bed for comfort and a scoop mattress to prevent rolling out of bed. A 9/24/22 facility investigation revealed on 9/24/22 Resident 4 was found on the floor next to her/his bed and no fall mats were present. Staff 5 (LPN) checked Resident 4 for injuries. Staff 5 called for x-rays which revealed a broken left femur. In an interview on 11/29/22 at 2:18 PM Staff 6 (CNA) stated she did not put the fall mats next to Resident 4's bed on 9/24/22. She didn't see the mats and thought the resident no longer needed them. In an interview on 11/30/22 at 11:20 AM Staff 5 (LPN) stated he checked Resident 4 for injuries and pain on 9/24/22 after the fall. Resident 4 stated her/his knee hurt. The LN medicated the resident and call for x-rays. In an interview on 11/29/22 at 2:04 PM Staff 3 (RNCM) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture. In an interview on 11/29/22 at 2:06 PM Staff 2 (DNS) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture.

Based on interview and record review it was determined the facility failed to promptly assess and monitor 2 of 3 sampled residents (#s 1 and 4) reviewed for change of condition. Resident 1 experienced an acute change of condition (Oxygen saturation level of 41%) which indicated the resident was in respiratory distress. The facility failed to recognize the situation (acute decline in condition) which required an additional nursing assessment, treatment and monitoring. This placed the resident at risk for a medical emergency which resulted in an immediate jeopardy situation. Findings include: 1. Resident 1 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Resident 1's Physician Ordered Life Sustaining Treatment form (POLST) dated [DATE] revealed the resident was a full code and the resident wanted full treatment. The [DATE] care plan revealed the resident had inadequate or compromised respiratory function. Staff were to monitor for signs and symptoms of respiratory problems including loss of consciousness, shortness of breath, rapid shallow respirations and abnormal breath sounds. On [DATE] a public complaint was received which indicated on [DATE] around 3:35 AM Witness 1 (Complainant) found Resident 1 alone, unresponsive and had emesis coming from her/his mouth. The emergency medical technicians (EMTs) performed CPR for 30 minutes and the resident died . The [DATE] progress note at 3:45 AM revealed Resident 1 called the CNA into her/his room (no time was noted) and indicated she/he did not feel well and wanted her/his O2 Sats checked. The resident indicated she/he was unable to breathe and Staff 3 (RN) checked the Resident 1's O2 Sats which was 41% (respiratory distress). Staff 3 (RN) called 911 and the EMTs arrived promptly and started CPR. At 5:36 AM the progress note revealed the EMTs worked on the resident for a half an hour with no positive result and the resident died . The [DATE] Emergency Medical Technician Medical Care Report revealed the EMTs were dispatched to the facility at 3:35 AM and found Resident 1 alone in her/his room with emesis coming from her/his mouth and appeared to not be breathing. They determined the resident was in [MEDICAL CONDITION] and moved the resident to the floor to start CPR. They worked the code for 30 minutes and the resident died at 4:14 AM. Resident 1's record revealed Staff 3 did not complete a full assessment of the resident prior to leaving the resident alone in her/his room with an O2 Sat of 41%. There was no documentation of the facility monitoring the resident while the resident was experiencing respiratory distress. On [DATE] at 6:45 AM Staff 4 (CNA) indicated around 2:30 AM he answered Resident 1's call light and determined there was something wrong with the resident. Staff 4 immediately told Staff 3 there was something wrong with Resident 1. Staff 3 took the resident's O2 Sats which was 41% (respiratory distress). Staff 3 left the room to get oxygen and call 911. Staff 4 indicated he left Resident 1's room after Staff 3 left to answer call lights. He indicated the resident was left alone in her/his room. On [DATE] at 3:39 PM Staff 3 indicated Staff 4 alerted her of Resident 1's shortness of breath around 2:30 AM and she took her/his O2 Sats and was 41%. She was unable to recall if she completed any other assessment of the resident. Staff 3 indicated she left the room for around five minutes. The resident was alone so she could retrieve oxygen and call 911. Staff 3 indicated she did not think anyone was in the room with her/him during Resident 1's respiratory event. The EMTs arrived (3:34 AM) prior to Staff 3 returning to Resident 1's room and found the resident unconscious and the EMTs performed CPR on the resident. Staff 3 also indicated she did not document an assessment of the resident or how the resident was monitored once she determined the resident had O2 Sats of 41%. Staff 3 and 4 failed to stay with Resident 1 to further assess and monitor the resident's condition. The facility could not ensure the resident received adequate care and services during Resident 1's acute change of condition prior to the arrival of the EMTs. On [DATE] at 1:12 PM the facility was notified the failure to complete a thorough assessment, monitor and supervise Resident 1 who had an O2 Sat of 41% which placed Resident 1 in respiratory distress. Following consultation with the survey management team, this was determined to be an immediate jeopardy situation, An acceptable plan to abate the immediate jeopardy situation was submitted to the survey team by the facility on [DATE] at 4:56 PM. The plan included: -House audit was completed for POLST or Advanced Directives. Residents who currently did not have a POLST would be interviewed for their wishes. The POLST would be filled out with the resident and sent to the physician for signature. If the resident was cognitively impaired this would be done with the resident's health care representative. If there were no health care representative, the physicians orders would be followed. -Complete an audit of licensed nursed for CPR certification. The facility would ensure that each shift had a CPR certified licensed staff working. -The POLST/CPR books were reviewed to ensure they had the most current information on each resident. -The current nursing staff working today ([DATE]) would be inserviced on assuring completion of a through physical assessment of patient monitoring in a medical emergency. All licensed staff would be trained on Emergency Procedures regarding CPR as outlined per the policy. All nursing staff not currently in the building would receive an inservice prior to the beginning of their next shift. For nursing staff not on shift the inservice would be done in-person, as availability allowed or complete the training by phone if the staff member was unable to come into the building within the next 48 hours. The training would be completed within the next 48 hours, by February 27, 2020. -The facility would implement mock code drills to test the proficiency of licensed staff and coach them on areas of improvement. The drills would occur for each shift monthly until substantial compliance was achieved. -Results of the drills would be reviewed monthly at Quality Assurance and quarterly at the Quality Assurance and Performance Improvement (QAPI) meeting until substantial compliance was achieved for two consecutive QAPI meetings. On [DATE] the plan was reviewed including training documentation and the immediate Jeopardy was removed. 2. Resident 4 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:34 AM Witness 1 (Complainant) indicated on [DATE] around 9:54 AM the EMTs found Resident 1 alone in her/his room unresponsive and were unable to locate staff to help them. The [DATE] care plan revealed the resident had difficulty breathing due to ascites and staff were to evaluate for respiratory complaints, changes in the resident's breathing, complaints of shortness of breath and the inability to speak without being breathless. Staff were to report the changes to the nurse. The [DATE] progress note revealed Resident 4 was stuporic aroused with touch but fell back to sleep. Emergency transportation (EMT) was called. When the EMTs arrived around 9:54 AM they were concerned the resident should have been sent out sooner and wondered about the staffing levels of the licensed nurses. Resident 4 was unresponsive and was transported to the hospital. The [DATE] Emergency Medical Technician Patient Care Report revealed the EMT's were dispatched to the facility at 9:54 AM and entered the room and found two resident's in the room alone and did not know which resident was in distress. The EMTs found Staff 3 and she indicated the resident had been like that since yesterday. The EMTs found the resident unresponsive and started patient care and then transported the resident to the hospital. On [DATE] at 4:02 PM Staff 3 (RN) indicated she worked the night shift and the resident did not really wake up to take her/his morning medications at 5:15 AM. The resident took a few sips of water and then went back to sleep. She gave report to Staff 7 (LPN) at change of shift the resident may need to be sent out. Staff 3 indicated she did not chart on the resident's change of condition. On [DATE] at 11:36 AM Staff 12 (CNA) indicated when she started her shift she obtained vitals on the resident around 6:15 AM and Resident 4 was not as responsive as normal. Resident 4's vitals were within normal limits and placed her/his oxygen mask back on and left the room. When she returned around 6:45 AM she saw Resident 4 was not her/himself and informed Staff 7. Staff 7 checked the resident and called 911 to have her/him sent to the hospital. The resident was still responsive but not her/his normal self. On [DATE] at 11:21 AM Staff 7 indicated when she started her shift Staff 3 gave her an oral report that Resident 4 was not acting like her/himself by not staying awake but able to answer questions. She tried looking for documentation from the evening shift but was unable to find any documentation on the resident's change of condition. She was notified by Staff 12 the resident was not feeling well and checked the resident and decided the resident needed to be sent out to the hospital because of the resident's compromised liver functions. She indicated she called 911 a little after 9:00 AM and the emergency medical technicians arrived shortly after the call. She indicated she did not stay with the resident because she prepared paperwork for the transport to the hospital. On [DATE] at 11:27 AM Staff 2 (DNS) indicated Staff 3 should have documented on the resident's decline and alerted the physician.

Based on interview and record review it was determined the facility failed to ensure Staff 3 (RN) and Staff 4 (CNA) adhered to professional standards of practice related to assessing and monitoring residents with a change of condition and the documentation of treatment. Staff 3 failed to assess, monitor and treat Resident 1 during an acute change of condition. The resident died at the facility. Findings include: Per the Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Registered Nurses includes: (5) Standards related to the RN's responsibility for client advocacy, including (b): Intervene on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; [DATE] Conduct Derogatory to the Standards of Nursing Defined includes: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment; (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (b) Failure to document nursing interventions and nursing practice implementation in a timely, accurate, thorough, and clear manner. This includes failing to document a late entry within a reasonable time period; (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; (B) Documenting the provision of services that were not provided; (C) Failing to document information pertinent to a client's care; (E) Falsifying data; (G) Entering late entry documentation into the record that does not demonstrate the date and time of the initial event documented, the date and time the late entry is being placed into the record, and the signature of the licensee entering the late entry to the record. Oregon Administrative Rule 851-¿045-¿0070 Conduct Derogatory to the Standards of Nursing Defined included: Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. Oregon Administrative Rule 851¿-063¿-0090 Conduct Unbecoming a Nursing Assistant included: Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities. Resident 1 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. On [DATE] a public complaint was received which indicated on [DATE] around 3:35 AM Witness 1 (Complainant) found Resident 1 alone, unresponsive and had emesis from her/his mouth. The emergency medical technicians (EMTs) performed CPR for almost an hour and the resident died . The [DATE] progress note at 3:45 AM revealed Resident 1 called the CNA into her/his room and indicated she/he did not feel well and wanted her/his O2 Sats checked. The resident indicated she/he was unable to breathe and Staff 3 (RN) checked the Resident 1's O2 Sats which was 41% (respiratory distress). Staff 3 (RN) called 911. The EMTs arrived promptly and started CPR. At 5:36 AM the progress note revealed the EMTs worked on the resident for half an hour with no positive result and the time of death was called at (4:24) AM. Staff 3 did not document a full assessment of the resident or how the resident was monitored during the resident's time of respiratory distress. On [DATE] at 6:45 AM Staff 4 (CNA) indicated he was in the resident's room when she/he had a low saturation rate of 41% and left the resident alone to answer call lights. He indicated he did not stay with the resident prior to the EMTs arriving and the resident was most likely alone. On [DATE] at 3:39 PM Staff 3 (RN) indicated Staff 4 alerted her of the resident's shortness of breath and she took her/his O2 Sats which was 41%. She was unable to recall if she completed any other assessment of the resident. Staff 3 left the resident alone to retrieve oxygen and called 911. Staff 3 indicated she did not think anyone was in the room with her/him during Resident 1's respiratory event. The EMTs arrived prior to Staff 3 returning to Resident 1's room which was around five minutes and found the resident unconscious and the EMTs performed CPR on the resident. Staff 3 also indicated she did not document an assessment of the resident of how the resident was monitored once she determined the resident had O2 Sats of 41%. On [DATE] at 12:45 PM Staff 2 (DNS) indicated she would expect Staff 3 to complete a full assessment of Resident 1 while in respiratory distress and to monitor the resident and not leave the resident alone. She acknowledged there was no documentation in the record pertaining to an assessment or monitoring of Resident 1. Refer to F 684 example 1

Based on interview and record review it was determined the facility failed to ensure complete and accurate records for 2 of 5 sampled residents (#s 1 and 4) reviewed for death and change of condition. This placed residents at risk for unmet care needs. Findings include: 1. Resident 1 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. On [DATE] a public complaint was received which indicated on [DATE] Witness 1 (Complainant) found Resident 1 alone, unresponsive and had emesis from her/his mouth. The emergency medical technicians (EMTs) performed CPR for a half hour and the resident died . The [DATE] progress notes revealed there was no nursing assessment of the resident or documentation to show how the resident was monitored after Staff 3 (RN) took the resident's O2 Sats which was 41%. On [DATE] at 3:39 PM Staff 3 indicated she did not document an assessment of the resident or how the resident was monitored once she determined the resident had O2 Sats of 41%. On [DATE] at 12:45 PM Staff 2 (DNS) indicated she would expect the nurses to complete a full assessment of a resident in respiratory distress and acknowledged there was no documentation in the record pertaining to an assessment or monitoring of the resident. 2. Resident 4 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. On [DATE] a public complaint was received which indicated on [DATE] at 9:45 AM Witness 1 (Complainant) found Resident 4 alone in her/his room and unresponsive. On [DATE] at 4:02 PM Staff 3 (RN) indicated the resident did not wake up for early morning medications at 5:30 AM and the resident did have a sip of water. She told Staff 11 (LPN) at shift change that the resident needed to be sent out. Staff 3 indicated she did not document an assessment of the resident in the progress notes. She just gave Staff 11 a verbal report. On [DATE] at 11:21 AM Staff 11 indicated she received a verbal report from Staff 3 at shift change in which Resident 4 did not wake up like she/he normally did and probably needed to be sent to the hospital. Staff 11 indicated she looked in the record for progress notes from the previous licensed nurse on duty but was unable to find documentation of Resident 4's events. On [DATE] at 1:53 PM Staff 2 (DNS) indicated she would expect Staff 3 to document Resident 4's change of condition during her shift.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED]. As a result, Resident 1 experienced a change in condition, pain and received hospital treatment related to a fecal impaction. Findings include: The facility's Bowel Care Protocol noted "If a resident has not had a bowel, must be medium or large, movement for two consecutive days", the protocol was to be "observed" after a physician order [REDACTED]." Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with bowel care physician orders, which included [MEDICATION NAME] PRN. The 4/15/13 Admission Progress Note documented Resident 1's bowel pattern was "constipated. Needs laxative or enema 2 + times a week.." According to the Follow Up Question Report for Bowel Documentation, from 4/15/13 to 4/23/13, the resident had no BMs (bowel movements), except for a small BM on 4/15/13 and 4/23/13, a timeframe of nine days. According to the 4/2013 MAR, Resident 1 received the PRN [MEDICATION NAME] on 4/18/13, 4/22/13 and 4/23/13. A 4/22/13 Progress Note indicated the resident had hypoactive bowel tones. The physician was faxed regarding Resident 1's lack of BMs in eight days. A 4/23/13 Care Conference Record noted the resident had a "lack of bowel movement." A 4/23/13 Progress Note documented the resident continued to have hypoactive bowel tones in all quadrants. Physician orders [REDACTED]. The 4/23/13 bowel care physician orders [REDACTED]. A 4/22/13 Fax to the physician, which was noted on 4/24/13, indicated the physician ordered for Fleets enema to be administered PRN if there were no results from the suppository. A 4/24/13 10:51 am Progress Note disclosed Resident 1 had a small emesis that morning. She/he had a small and medium BM on night shift. A 4/24/13 2:21 pm Progress Note revealed Resident 1 complained of nausea. A 4/25/13 2:42 am Progress Note disclosed Resident 1 reported "I just don't feel good." and had complained of nausea, which was treated with medication. According to the 4/2013 MAR, Resident 1 was given [MEDICATION NAME] (a medication to treat nausea) on 4/24/13 and 4/25/13. A 4/25/13 1:09 pm Progress Note revealed Resident 1 had a small amount of watery stool. The resident was checked for a possible impaction and was found to have semi-hard stool. The physician was contacted, who gave orders for a mineral oil enema and for [MEDICATION NAME] to be administered every six hours until the resident had a large BM. A 4/25/13 6:19 pm Progress Note disclosed Resident 1 had "Only watery diarrhea this shift." A 4/25/13 9:20 pm Progress Note revealed Resident 1 had a large amount of watery diarrhea that shift, however, a digital exam revealed stool was still present in the rectal vault. A 4/26/13 12:02 am Progress Note indicated Resident 1 had multiple watery stools that shift. The resident complained of abdominal discomfort as generalized from the sternum to the pubic area. The resident had hyperactive sounds in the right upper and lower quadrants. A 4/26/13 2:30 am Progress Note disclosed Resident 1 had another watery stool. During a digital exam, a "large solid" was found. A 4/26/13 8:59 am Progress Note revealed the resident was "painful, hypotensive and unable to take fluids or food." The resident still had watery diarrhea and stool remained in the rectal vault. The bowel tones were hyperactive, the resident was weak and "nervous", which the resident reported caused nausea. The physician was contacted, who sent the resident to the emergency room . According to the 4/26/13 Emergency Department Notes, x-ray results confirmed a possible nonobstructive fecal impaction of the rectal vault. The resident underwent [REDACTED]. According to the Follow Up Question Report for Bowel Documentation, from 5/8/13 to 5/20/13, the resident either had no or small BMs, a period of 13 days. According to the 5/2013 MAR/TAR, the resident did not receive the [MEDICATION NAME] PRN. The resident received a [MEDICATION NAME] suppository on 5/14/13, after seven days with no BM, followed by a Fleet enema on 5/15/13. A 5/15/13 1:04 pm Progress Note disclosed Resident 1 went out of the facility for an appointment. The resident had received an enema earlier because of no BM. It noted the resident only had a small BM. In interview on 7/1/13 at 10:25 am, Witness 1 reported that on 5/15/13, Resident 1 had been given an enema prior to coming to an appointment. Upon arrival to the appointment, "everything came loose." At the time of the survey, there was no documented follow up in the clinical record of the resident's bowel status while out of the facility. After the 5/15/13 incident the resident continued to have no BMs for five days with no PRN treatment given. In interview on 6/28/13 at 9:15 am, Resident 1 stated she/he recalled the facility giving her/him some laxative, which did not work. The resident stated it was painful and had to go to the hospital. "They had to dig it out, it hurt." In interviews on 6/27/13 at 1:30 pm and on 6/28/13 at 1:00 pm, Staff 4, RNCM, stated the bowel protocol was to be initiated after the resident went six shifts with no BMs. At that point, staff were to start interventions. Staff 4 confirmed the bowel care physician orders [REDACTED]. Staff 4 stated the system included the evening shift CMA reviewing the bowel report, creating a bowel care list and initiating treatment. If no results, the day shift CNA and licensed nurse followed up with treatments. Staff 4 stated she and the charge nurse were to review the bowel care list, however, the computerized system did not always trigger the report timely, describing it as "a flawed system." In interview on 7/1/13 at 2:38 pm, Staff 10, RN, stated there was a communication breakdown from the medication aides making the bowel list. Staff 10 stated she had not previously looked at the bowel list every day, "maybe only occasionally." Staff 10 stated "it was never set up for me to see it (bowel care list) every day." In interview on 7/1/13 at 3:00 pm, Staff 11, CMA, stated she did not recall if Resident 1 was on the bowel care list. Staff 11 stated she informed the evening shift nurse about the bowel list and passed the information along to the next shift. Staff 11 stated she placed the list in the RNCM's box at the nurse's station. In interview on 7/2/13 at 2:48 pm, Staff 18, RN, stated she did recall the resident's bowel care being an issue before the hospitalization , however, it became a heavy focus after the hospitalization . Staff 18 stated the medication aides were responsible for bowel care and unless it was brought to her attention, she did not know what was going on until there were reports of pain or vomiting. Staff 18 stated she was not aware of the resident's lack of BMs in 5/2013, after the hospitalization .