Forest Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Forest Grove Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 14, 2024

  Based on interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#4) reviewed for pressure ulcers. This failure resulted in Resident 4's pressure ulcer worsening. Findings include: Resident 4 admitted to the facility in 2017 with diagnoses including hypertension and diabetes. The undated facility Event Summary Report indicated the following: -Resident 4 had a dressing in place dated 12/27/23 to her/his right ankle. -On 12/27/23 Staff 8 (LPN) measured Resident 4's wound on the right ankle and measurements were given to the Staff 12 (Former DNS) as requested. […]

• Actual harm, isolatedF600Sep 2, 2022

  Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from verbal abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include: The facility 2/2019 Abuse Screening, Training, Identification, Investigation, Reporting and Protection Policy defined verbal abuse as the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms. […]

• No harm, potential for more than minimal, widespreadF730Jun 14, 2024

  Based on Interview and record review was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNAs (#14, 18, 19, 20 and 21) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 6/14/24 at 11:06 AM a review of facility personnel records with Staff 2 (Interim Administrator) indicated the following: - Staff 14 (CNA) was hired on 8/20/20; no annual performance review was completed. […]

• No harm, potential for more than minimal, patternF695Dec 18, 2024

  Based on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 5 of 7 sampled residents (#s 13, 15, 16, 17 and 19) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: 1. Resident 13 was admitted to the facility in 9/2024, with diagnoses including chronic respiratory failure with hypoxia (lack of oxygen) and heart failure. Resident 13's 9/20/24 Physician's Orders indicated staff was to administer oxygen continuously at 1 liter per minute via nasal cannula. […]

• No harm, potential for more than minimal, patternF732Jun 14, 2024

  Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 7 out of 30 days reviewed for staffing. This placed residents, the public and staff at risk for lack of accurate staffing information. Findings include: On 6/10/24 at 3:51 PM the Direct Care Staff Daily reports were provided from 5/7/24 through 6/10/24. The forms revealed seven instances where portions of the form were left blank or were incomplete. The incomplete information included census, number of staff working and number of hours worked. On 6/14/24 at 10:21 AM Staff 1 (Administrator) and Staff 22 (Corporate Consultant) acknowledged the Direct Care Staff Daily reports were incomplete for 7 out of 30 days. […]