Lacamas Creek Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 10, 2021

  <AMENDED CITATION> Based on observation, interview and record review, the facility failed to identify and implement appropriate measures to reduce the risk of avoidable accidents from a steep unmaintained fire access road off the facility's patio, for one of three sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for falls, injury, diminished quality of life and death. These failures caused harm to Resident #1 when the resident was able to exit the facility patio to the steep unmaintained fire access road in his wheelchair, and fell , resulting in a fractured nose, and multiple trauma to the face and hands. Findings included . Resident #1 was admitted to the facility on [DATE] with diagnoses including left hip replacement. […]

• No harm, potential for more than minimal, widespreadF812Oct 31, 2023

  Based on observation and interview, the facility failed to ensure food preparation dishes were properly cleaned and air dried to provide safe, sanitary food preparation when the kitchen was reviewed for sanitization and storage. This failure placed residents at risk of foodborne illness and a diminished quality of life. Findings included . On 10/23/2023 at 10:30 AM, observations showed a rack of food preparation dishes including wet quarter pans and wet 6-inch pans stacked on top of each other; stacking of the wet pans would not allow for required air drying. Additionally, two quarter pans were noted to have food debris in the bottom and on the sides of the dish. […]

• No harm, potential for more than minimal, patternF623Oct 31, 2023

  Based on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 9 of 13 sampled residents (2, 4, 10, 26, 48, 316, 318, 319 & 320) reviewed for transfer notifications regarding hospitalization . This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF625Oct 31, 2023

  Based on interview and record review, the facility failed to provide a written bed hold notice to the resident and/or the resident's representative at the time of transfer to the hospital for 9 of 13 sampled residents (2, 4, 10, 316, 318, 319, 320, 26 & 48) reviewed for bed hold notifications. This failure placed residents and/or their representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was moderately cognitively impaired. Resident 2's Electronic Medical Record (EMR) documented a transfer to an acute-care hospital on 05/16/2023 and 08/11/2023. […]

• No harm, potential for more than minimal, patternF656Oct 31, 2023

  Based on interview and record review, the facility failed to ensure comprehensive care plans were individualized to promote the highest physical, emotional and psychosocial well-being and failed to ensure an anticoagulant care plan was in place for 4 of 7 sampled residents (2, 4, 8 & 45) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a negative impact on their quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was incontinent of bowel and bladder. […]