Every finding on record at Marquis Oregon City Post Acute Rehab

Based on interview and record review it was determined the facility failed to conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne pathogens. Findings include:The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.A review of the facility's revised 4/5/24 Water Management Program-Legionella revealed the following:-The facility's policy is to establish procedures to reduce the risk of Legionella and other opportunistic pathogens in the facility's water system.-A risk assessment is to be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.A review of the facility's Identifying Buildings at Increased Risk assessment indicated the assessment was completed on 3/27/24.On 2/26/26 at 11:05 AM Staff 1 (Administrator) and Staff 3 (Maintenance Director) acknowledged the annual risk analysis assessment for potential areas of growth and spread of water-borne pathogens, such as Legionella, in the facility's main water system was not completed since 3/27/24.

Based on observation, interview, and record review it was determined the facility failed to ensure resident accessible outside space was free from environmental hazards for 1 of 1 memory care outdoor area reviewed for safety and failed to safely transfer 1 of 1 sampled resident (#44) reviewed for ADLs. This placed residents at risk for injury and elopement. Findings include: 1. The facility's undated Friendship House Disclosure Statement revealed:-The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. Exits from the entire hall are locked to prevent unsafe wandering. Residents living at Friendship House are free to wander about the common area and outside secured yard. On 2/25/26 at 9:30 AM a walkthrough of the secure memory care fenced courtyard and concurrent interview with Staff 1 (Administrator) revealed the following: -The walkway in the courtyard had moss growth and was slippery when walked on, this was acknowledged by Staff 1.-A box of fertilizer was observed in an open plastic box and was next to the table in the courtyard, Staff 1 stated the fertilizer was a hazard to the memory care residents.On 2/26/26 at 11:33 AM Staff 2 (DNS) provided a list which indicated 10 residents in the memory care unit were actively exit seeking. On 2/27/26 at 9:14 AM Staff 1 confirmed the memory care outside space presented safety risks to the residents in the memory care. 2. Resident 44 admitted to the facility in 5/2020 with diagnoses including dementia.Resident 44's comprehensive care plan revised 9/3/24 revealed Resident 44 required a sit to stand mechanical lift and two staff for all transfers.On 2/23/26 at 11:49 AM Staff 9 (CNA) was observed to transfer Resident 44 from her/his bed to a wheelchair without the assistance of as second staff member while using a sit to stand lift. On 2/25/26 at 11:19 AM Staff 9 stated Resident 44 required two staff for safe sit to stand transfers. Staff 9 stated she transferred Resident 44 independently on 2/23/26 and it was a lapse of judgement. On 2/26/26 at 11:26 AM Staff 2 (DNS) stated she was aware of the 2/23/26 transfer and stated Resident 44 required two staff for safe sit to stand transfers due to Resident 44 often moving during the sit to stand mechanical transfers.

Based on observation and interview the facility failed to ensure a clean, home-like environment for 1 of 1 memory care units and 1 of 1 dining halls observed. This placed residents at risk for lessened quality of life. Findings include: On 10/22/24 at 11:58 AM an observation during lunch service in the main dining room revealed the light fixtures had built up debris and dead insects inside eight of eight ceiling lights. On 10/24/24 at 10:45 AM an observation near the exit of the Memory Care Unit revealed debris and dead insects accumulated on two vent covers, and in one ceiling light fixture. On 10/24/24 at 11:19 AM and 11:57 AM Staff 14 (Maintenance Director) stated he usually cleaned vents annually and cleaned the light fixtures when he noticed they were dirty or someone told him they needed cleaning. Staff 14 stated the design of the lights was perfect for catching dust and insects like a bowl. Staff 14 acknowledged the vents and light fixtures were not clean.

Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 18% with six errors in 33 opportunities. This placed residents at risk for inaccurate medication dosage and adverse consequences related to medications. Findings include: 1. Resident 14 admitted to the facility in 11/2019 with diagnoses including dementia. A review of Resident 14's physician orders revealed a 9/25/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 9:24 AM Staff 13 (CMA) was observed administering medication to Resident 14. Staff 13 did not administer acidophilus pectin. A review of Resident 14's MAR revealed Staff 13 indicated she administered acidophilus pectin with the morning medications on 10/23/24. On 10/23/24 at 9:57 AM Staff 13 stated she did not administer acidophilus pectin. Staff 13 stated there was no acidophilus pectin in the medication cart and she was going to get a bottle from the medication storage room and administer it. On 10/23/24 at 10:04 AM Staff 4 (RNCM) stated medications were to be signed out when they were given and Staff 13 should have obtained the medication prior to signing it out. 2. Resident 19 admitted to the facility in 9/2024 with diagnoses including right knee pain. A review of Resident 19's physician orders revealed a 9/25/24 order for Lidocaine 5% patch: apply two patches, one to the posterior right knee and one to the anterior right knee. On 10/23/24 at 9:06 AM Staff 13 (CMA) was observed applying one lidocaine patch to Resident 19's right knee. On 10/23/24 at 9:58 AM Staff 13 stated she was unaware the orders stated to apply two lidocaine patches. On 10/23/24 at 10:10 AM Staff 12 (RNCM) stated she expected staff to read and follow the physician orders. Staff 12 stated two lidocaine patches should have been applied per physician orders. 3. Resident 45 admitted to the facility in 7/2024 with diagnoses including depression. a. A review of Resident 45's physician orders revealed an 10/22/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's medications. Staff 13 did not administer acidophilus pectin. On 10/23/24 at 10:02 Staff 13 acknowledged she did not administer acidophilus pectin. Staff 13 stated there was no acidophilus/pectin in the medication cart and she was going to get a bottle from the medication storage room and administer the medication. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated medications were to be signed out when they were given and Staff 13 should have obtained the medication prior to signing it out. b. A review of Resident 45's physician orders revealed a 10/22/24 order for apripazole (a medication to treat depression) 7.5 mg daily. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's medications. Staff 13 administered apripazole 5 mg. On 10/23/24 at 10:02 Staff 13 acknowledged she did not administer the correct dose of apripazole. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated staff were expected to read and follow physician orders. c. A review of Resident 45's physician orders revealed a 10/22/24 order for budesonide formoterol fumarate inhaler: rinse with water and spit after each dose. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's budesonide formoterol fumarate inhaler without having Resident 45 rinse and spit after each dose. On 10/23/24 at 10:02 AM Staff 13 acknowledged she did not have Resident 45 rinse and spit after administering her/his inhaler. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated staff were expected to read and follow physician orders. 4. Resident 255 admitted to the facility in 10/2024 with diagnoses including chronic obstructive pulmonary disease. A review of Resident 255's physician orders revealed a 10/21/24 order for aclidinium bromide inhaler: rinse mouth after use. On 10/23/24 at 8:58 AM Staff 13 (CMA) was observed administering Resident 255's aclidinium bromide inhaler. Staff 13 did not have Resident 255 rinse her/his mouth after using the inhaler. On 10/23/24 at 10:00 AM Staff 13 stated she was unaware of the instructions to rinse the mouth after use of Resident 255's inhaler. On 10/23/24 at 10:10 AM Staff 12 (RNCM) stated staff were expected to read and follow physician's orders.

Based on observation and interview it was determined the facility failed to ensure medication storage was free of expired biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On [DATE] at 1:52 PM the medication storage refrigerator was observed to have three open vials of aplisol (tuberculosis test solution) with open dates in ,d+[DATE]. Each bottle indicated to discard 30 days after opening. On [DATE] at 1:56 PM Staff 2 (DNS) stated aplisol was to be discarded per the manufacturer's recommendation, 30 days after opening the vial. Staff 2 acknowledged all three vials of aplisol were open for greater than 30 days and needed to be discarded.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 1 resident (# 32) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include: Resident 38 was admitted to the facility in 6/2023 with diagnoses including dementia with behavioral disturbance. Resident 32 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbance. A 9/20/24 Behavior/Psychotropic Meeting report included Resident 38 exhibited behavior problems including grabbing others on 9/11/24 and screaming at others on 9/23/24. A 9/25/24 Resident to Resident Event Assessment reported Staff 16 (CNA) heard two residents yelling in a room. Staff 16 entered the room and found Resident 38 straddling Resident 32 with her/his hands around Resident 32's neck. Staff 16 was required to intervene to remove Resident 38 off of Resident 32. The report indicated Resident 38 reported, [Resident 32] was yelling and I told [her/him] I was going to kick [her/his] ass. The report indicated at that point Resident 38 got out of bed and put her/his hands around Resident 32's neck. On 10/23/24 at 10:05 AM Staff 16 (CNA) recalled the incident and stated he overheard yelling from Resident 32 and Resident 38's shared room. Staff 16 stated he was required to pull Resident 38 off Resident 32 and remove Resident 32 from the shared room. Staff 16 stated Resident 32 was distressed initially after the incident, but was able to calm down after an hour or two. On 10/23/24 at 10:14 AM Staff 17 (LPN) recalled Resident 32 stating she/he did not want to return to the room shared with Resident 38 after the incident. On 10/23/24 at 12:32 PM Staff 2 (DNS) confirmed the incident occurred and stated Resident 38's behavior towards Resident 32 was unacceptable. The identified deficient practice was determined to be past noncompliance as the facility put interventions in place to prevent additional incidents and in-serviced staff. The deficient practice was determined to be corrected on 10/10/24.

Based on interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to the use of hearing devices for 1 of 2 sampled residents (#9) reviewed for hearing. This placed residents at risk for unassessed needs. Findings include: Resident 9 was admitted to the facility in 2019 with diagnoses including Parkinson's and anxiety. The 8/14/24 Annual MDS indicated the resident did not use hearing aids. The 8/14/24 Communication CAA revealed Resident 9 had a hard time hearing and often needed staff to raise their voice level when speaking to the resident. Staff were to speak in an elevated tone and face the resident when conversing. The CAA indicated Resident 9 did not use hearing aid devices but may eventually need hearing aids if her/his hearing worsened. On 10/23/24 at 3:05 PM and 10/24/24 at 11:52 AM Staff 3 (Social Services) stated the resident utilized hearing aids. Staff 3 stated she completed the 8/14/24 Annual MDS and Communication CAA, and acknowledged both were inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure staff assisted a resident with wearing hearing aids for 1 of 2 sampled residents (#35) reviewed for hearing. This placed residents at risk for a decline in communication. Findings include: Resident 35 was admitted to the facility in 7/2024 with diagnoses including dementia and anxiety. Review of Resident 35's Care Plan, revised on 8/16/24, revealed the resident had adequate hearing with hearing aids. Staff were instructed to place Resident 35's hearing aids in her/his ears in the morning, remove them at night, and place them on a charger on the night stand in a green container. Resident 35 might decline to wear her/his hearing aids due to them not being comfortable. A 9/11/24 Significant Change MDS revealed Resident 35 used hearing aids and her/his hearing was adequate. Resident 10 had a BIMS score of 10, indicating moderate cognitive impairment. A review of Resident 35's clinical record revealed no indication Resident 35 refused to have her/his hearing aids placed in her/his ears. On 10/21/24 at 11:24 AM Witness 2 (Family Member) stated when she visited Resident 35 during the day, the resident never had her/his hearing aids in. Witness 2 stated she placed them in the resident's ears and brought the concern up with staff but was not sure if anything was done to address the concern. On 10/22/24 at 11:00 AM Resident 35 stated she/he required assistance with putting her/his hearing aids in and staff did not always offer to assist with the hearing aids. Resident 35 stated she/he was hard of hearing without them. Random observations from 10/22/24 through 10/24/24 revealed Resident 35 had two hearing aids on her/his night stand in a green container being charged and not in Resident 35's ears. On 10/23/24 at 10:07 AM Resident 35 was heard asking staff to put in her/his hearing aids, however, no staff responded to her/his request, and multiple staff were in and out of the resident's room. On 10/23/24 at 10:44 AM Staff 5 (CNA), and at 1:01 PM Staff 6 (CNA), both stated Resident 35 was very hard of hearing and used hearing aids. Staff 5 acknowledged Resident 35 did not have her/his hearing aids in. Staff 5 and Staff 6 stated at times Resident 35 refused to wear the hearing aids, and they were supposed to document the refusals and report to the charge nurse. On 10/23/24 at 3:39 PM Staff 7 (CNA) stated Resident 35 was hard of hearing and required assistance with her/his hearing aids. Staff 7 stated the resident did not always have them in her/his ears when he came on shift. Staff 7 stated the hearing aids definitely helped with Resident 35's hearing. On 10/24/24 at 1:56 PM, Staff 4 (RNCM) stated Resident 35 required assistance with hearing aids being placed in her/his ears. Staff 4 stated Witness 2 reported concerns regarding the resident's hearing aids not being placed in her/his ears. Staff 4 stated she expected staff to offer to place Resident 35's hearing aids in the resident's ears. If Resident 35 refused, staff were to document in the clinical record and report the refusal to the charge nurse. Staff 4 acknowledged Resident 35's hearing aids were not being offered or placed in her/his ears.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 7 admitted to the facility in 3/2020, with diagnoses including unspecified dementia and acute kidney failure. Resident 7's Quarterly MDS dated [DATE] revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident 8 admitted to the facility in 8/2022 with diagnoses including Alzheimer's Disease and diabetes. Resident 8's Progress Note revealed on 9/14/22, she/he was observed trying to touch other residents in the groin area. When confronted by staff, Resident 8 would stop what she/he was doing and move onto the next closest female/male and start to grab their hands and then slowly rub their leg and try to creep her/his hand slowly to their groin area. Patient was redirected several times. Resident 8's Quarterly MDS dated [DATE] revealed a BIMS score of 9, which indicated moderate cognitive impairment. Resident 8's most recent care plan, revised on 7/10/23 revealed the resident had both verbal and physical inappropriate sexual behaviors, which included a history of inappropriately touching residents of the opposite gender since 2022. Resident 8's care plan interventions included one to one supervision as needed, supervision during group activities and meal times, staff to seat resident next to the same gender in group activities and line of sight supervision if one to one supervision could not be provided. On 3/13/23 the State Survey Agency (SSA) received a Facility Reported Incident (FRI), which revealed on 3/13/23 at 3:25 PM, Resident 8 was observed by staff with her/his hand down the front of Resident 7's pants. The residents were in the dining room watching a movie and Staff 9 (Former Activities Director) left the dining room briefly. When Staff 9 returned to the dining room, she observed the incident. The residents were separated and assessed by Staff 9. The report indicated Resident 7 did not experience psychosocial distress as a result of the incident. A Progress Note dated 3/13/23 at 11:40 PM, revealed after the incident Resident 8 was placed on 15 minute checks. Resident 8 was not interviewed due to discharging from the facility. On 7/24/24 at 9:59 AM, Resident 7 was observed to be lying in bed. She/he had no recall of the incident. On 7/24/24 at 10:15 AM, Staff 10 (CNA) recalled both residents and noted Resident 8 was just a little too friendly with residents of the opposite gender and was to be closely supervised while out of her/his room. On 7/26/24 at 1:55 PM, Staff 7 (Life Enrichment Coordinator) recalled the incident and stated staff were instructed to keep an eye on Resident 8, not leave her/him with other female/male residents due to her/his behaviors which included her/him rubbing or touching other resident's bodies without their consent. On 7/29/23 at 11:38 AM, Staff 5 (RCM) stated Resident 8 was placed on one to one supervision in 7/2023 due to another incident involving a different resident. She stated the 3/2023 incident with Resident 7 resulted in Resident 8 being placed on 15 minute checks and not seated by residents of the opposite gender. On 7/29/24 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings.

Based on interview and record review it was determined the facility failed to follow the plan of care for 1 of 3 sampled residents (#1) reviewed for falls. This placed residents at risk for increased falls. Findings include: Resident 1 admitted to the facility on [DATE] with diagnoses including [CONDITION(S)]. Resident 1's Admission MDS dated [DATE] revealed she/he had a BIMS score of 13 (cognitively intact). Resident 1's care plan updated 10/24/22 included TRANSFERS: Provide me with one person constant guidance and physical assist w/quad cane & gait belt. The investigation revealed on 11/2/22 Resident 1 was being pushed in the wheelchair by his wife to the bathroom when Staff 7 (CNA) came into room and took Resident 1 to the toilet. Resident 1 stood up, grabbed the transfer bar in the bathroom then lost balance and sat herself/himself down on the floor. Staff 5 (LPN) checked Resident 1 for injuries and assisted her/him up from the floor. Resident 1 had no injuries and did not hit her/his head. In interview on 10/15/22 at 10:41 AM and 10/17/22 at 7:47 AM, Staff 7 (CNA) stated Resident 1 did not have a gait belt on when she/he was transferred. The gait belt was in Resident 1's room, not in the bathroom. In interview on 10/15/22 at 2:38 PM Staff 5 (LPN) stated she checked Resident 1 for injuries and found none. Staff 5 stated Resident 1 told she/he had not hit her/his head. In interview on 10/16/22 at 12:16 PM Staff 2 (DNS) confirmed the gait belt was not used during the transfer on 11/2/22.

Based on interview and record review it was determined the facility failed to report injuries of unknown origin for 1 of 3 residents (#1) reviewed for abuse. This placed residents at risk for abuse and a delayed investigation. Findings include: The facility's 8/2020 Abuse, Neglect and Exploitation-Clinical Protocol indicated all personnel must immediately report any suspected abuse or incidents of abuse to the Administrator .when an alleged or suspected case of abuse or serious bodily injury is reported the facility Administrator or his/her designee will notify the following persons or agencies that an investigation is being conducted within two hours of the allegation being made: a. The state licensing/certification agency responsible for surveying/licensing the facility Resident 1 admitted to the facility in 7/2020 with [DIAGNOSES REDACTED]. The 7/26/20 Hospital Discharge Summary indicated Resident 1 had three near falls reported by family prior to hospital admission. The 7/26/20 Admission Skin Integrity assessment indicated Resident 1 admitted to the facility with multiple bruises and abrasions, including bruises to the right foot and ankle. The 8/2/20 Admission MDS indicated Resident 1 was rarely/never understood and her/his cognitive skills were moderately impaired. The resident required extensive two-person assistance for bed-mobility, toileting and transfers, was only able to stabilize while walking with staff, and required a walker or wheelchair for mobility. An 8/12/20 Progress Note indicated Resident 1 was found to have a laceration to the right medial heel, [MEDICAL CONDITION] and bruising to arch of foot and toes reported by a CNA. The in-house medical provider performed an assessment and the resident had no pain and tolerated the assessment without concern. An in-house foot x-ray was ordered. The 8/12/20 x-ray indicated Resident 1 had a recent fracture to the right tibia and fibula. An 8/12/20 Progress Note indicated Resident 1 was sent to the hospital for further evaluation. Hospital Records from 8/12/20 indicated Resident 1 sustained a closed [MEDICAL CONDITION] tibia, a blister of the right heel and significant bruising. The notes indicated the cause or timeframe of the injury was unclear. During the exam Resident 1 had surprisingly little tenderness to palpation and passively moved the ankle and toes at random without apparent pain, however seemed painful without passive movements and to palpation of the right heel. An Abuse Investigation was initiated by the facility on 8/12/20 and completed 8/13/20. The report indicated all staff who worked with Resident 1 from 8/7/20 through 8/12/20 were interviewed and therapy notes were reviewed. Resident 1 was unable to state what occurred due to cognitive limitations. Staff did not report any falls, issues with transfers, noted pain or observed injuries other than bruising present on admission. The report did not indicate the State Survey Agency was notified. On 1/15/20 at 11:30 AM Staff 2 (DNS) acknowledged the State Survey Agency was not notified of Resident 1's injury of unknown origin.

Based on observation, interview and record review it was determined the facility failed to ensure food was appropriately handled and stored, and staff performed hand hygiene in 1 of 1 kitchens. This placed residents at risk for food borne illness. Findings include: 1. On 9/22/20 at 9:35 AM Staff 5 (Dietary Aide) was observed in Staff 4's (HR/Staffing) office across the hall from the kitchen. Staff 5 re-entered the kitchen but did not wash her hands. On 9/22/20 at 10:55 AM Staff 3 (Dietary Manager) stated staff should wash their hands each time they enter the kitchen. 2. On 9/22/20 at 9:30 AM the back counter in the kitchen was observed with a partially full container of liquid eggs, an open tub of butter and open bag of sliced bread. Several flies were seen flying near the food. The counter was not clean and had numerous crumbs and bits of food debris. The food was not currently being used by staff and was left untouched during several minutes of observation. Staff 6 (Cook) stated he did not know why the food was left out on the counter. Staff 6 asked Staff 7 (Cook) about the food, Staff 7 did not provide an explanation but started to put the eggs and butter away. Staff 6 wrapped up the bread. On 9/22/20 at 10:55 AM Staff 3 (Dietary Manager) stated the eggs should have been put away, the lid should have been on the butter and the bread should have been wrapped up.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to recommended COVID-19 infection control recommendations in 1 of 1 utility halls. This placed residents at increased risk for COVID19. Findings include: Facility in-service records dated 4/28/20 through 4/30/20 indicated Staff 4 (HR/Staffing) and Staff 8 (RNCM) were provided training including Proper use of personal protective equipment (PPE) and when staff are required to use PPE. Oregon Public Health Division guidance to Nursing facilities dated 7/20/20 indicated Due to the accelerated spread of COVID-19 in Oregon, we are issuing an updated recommendation that all LTCF staff wear both masks and eye protection upon facility entry for the duration of the COVID-19 pandemic. The facility's Universal Mask/Eye Protection Usage in Facility - COVID19 policy and procedure updated 7/28/20 indicated staff were to wear masks and eye protection while in the facility. On 9/22/20 at 9:47 AM Staff 4 (HR/Staffing) was observed at the back entrance to the facility screening Staff 8 (RNCM) who had just entered the building. Staff 4 was not wearing a mask and was within a few feet distance from Staff 8. Staff 4 verified he was not wearing a mask when he screened Staff 8. On 9/22/20 at 11:08 AM Staff 8 stated she did not notice Staff 4 was not wearing a mask when he screened her.

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the State Survey Agency within 24 hours for 1 of 8 sampled residents (#3) for abuse. This placed residents at risk for lack of timely investigations. Findings include: Resident 3 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/2/19 Annual MDS Cognitive Loss/Dementia CAA indicated Resident 3 had a [DIAGNOSES REDACTED]. The resident often was confused and had anxious behaviors such as yelling and screaming for help. The 7/19/19 Resident to Resident Event Assessment indicated Resident 3 was in the dining room calling out repeatedly and CNA staff assisted her/him to the day room and the resident refused to stay in the dayroom. The CNA staff then assisted Resident 3 to the hallway between the dining room and dayroom and she/he was calm. CNA staff continued helping other residents into the day room. Resident 5 was sitting in a wheelchair at a table in the dining room still finishing dinner. The CNA in the dayroom noticed Resident 3 was no longer in the hallway and heard her/him calling out, Where am I? and Why am I here? from the dining room. Resident 3 had self-propelled in the wheelchair into the dining room. The CNA went to the dining room to assist Resident 3 and heard Resident 5 ask Resident 3 What's wrong? and then heard a slap sound. Resident 5 was facing Resident 3 and Resident 3 punched Resident 5 on the right upper arm, as indicated by Resident 5 rubbing her/his arm (the slap and punch was not witnessed by staff). Resident 5 stated (she/he) walloped me on the arm a good one, indicating a closed fist making a punching motion. Afterwards, Resident 3 could not answer questions about the incident due to cognitive deficits. The residents were immediately separated. Resident 5 was calm and uninjured. Due to the nature of the incident the resident-to-resident event resulted in physical abuse with Resident 3 being the instigator. On 8/29/19 at 1:58 PM Staff 20 (RNCM) stated the altercation between Resident 3 and Resident 5 occurred on 7/19/19 and was not reported to the State Survey Agency until 7/22/19.

Based on interview and record review it was determined the facility failed to revise and update a care plan related to a skin impairment for 1 of 2 sampled residents (#34) reviewed for hospitalization . This placed residents at risk for unmet care needs. Findings include: Resident 34 was admitted to the facility in 2019 with a [DIAGNOSES REDACTED]. Resident 34's Bedside care plan dated 7/11/19 indicated the resident received anticoagulant medication (used to treat and prevent blood clots). An intervention included to observe and report any bruising or bleeding. The care plan also indicated the resident was a risk for skin conditions and had interventions including air mattress, pressure reducing cushion and to float heels. Review of progress notes indicated the resident discharged from the facility on 8/15/19 and returned to the facility from the hospital with a stent placed on her/his right leg on 8/16/19. Review of Resident 34's medical record indicated the Bedside care plan was not updated to include the resident's skin impairment of the stent in the right leg. On 8/29/19 at 12:52 PM Staff 10 (CNA) stated Resident 34 was assisted with ADLs including transfers and catheter care. Staff 10 stated the resident left to the hospital and returned to the facility with a surgical wound on her/his right thigh. She stated the resident's skin impairment was not on the Bedside care plan and the resident informed her of the wound. She stated it would have been helpful to have information about the resident's surgical wound on the Bedside care plan so staff would not cause more damage during care. On 8/30/19 at 8:39 AM Staff 12 (RN) stated Resident 34 readmitted to the facility with a stent placed in her/his leg. Staff 12 stated it was important for the CNAs to observe for pain, redness and drainage associated with the surgical wound on the resident's right leg. She further stated Resident 34 was at increased risk for bleeding and clotting especially after a new surgery. On 8/29/19 at 1:30 PM Staff 11 (RNCM) stated Resident 34's surgical wound was on the care plan for the nurses to refer to and was not available for CNAs. She stated CNAs were informed of the resident's surgical wound only by verbal report from the nurse. Staff 11 confirmed Resident 34's skin impairment of the surgical stent on her/his right leg was not on the Bedside care plan for the CNAs to refer to.

Based on interview and record review it was determined the facility failed to ensure the physician was notified of repeated refusals of [MEDICAL CONDITION] medication for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 35 admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Review of the 8/2019 MAR indicated [REDACTED]. Resident 35 was documented to refuse the [MEDICATION NAME] nine of 27 days reviewed. Review of Resident 35's medical record revealed no indication Resident 35's physician was notified of the refusals of [MEDICATION NAME]. On 8/28/19 at 11:02 AM Staff 20 (RNCM) acknowledged the 8/2019 MAR indicated [REDACTED].

Based on interview and record review it was determined the facility failed to follow-up on pharmacist recommendations for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 35 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. A 4/4/19 physician order [REDACTED]. Review of Resident 35's medical record revealed a 5/2019 pharmacist recommendation to consider a dose decrease of Resident 35's [MEDICATION NAME]. Review of Resident 35's medical record on 8/28/19 revealed no indication her/his physician was provided the 5/2019 pharmacist recommendation for consideration. On 8/28/19 at 12:09 PM Staff 1 (Administrator) confirmed Resident 35's physician had not been notified of the 5/2019 pharmacist recommendation until 8/28/19.

Based on interview and record review it was determined the facility failed to accurately document behaviors in the medical record for 4 of 4 sampled residents (#s 1, 2, 3 and 4) reviewed for abuse. This placed residents at risk for inaccurate medical information and assessments. Findings include: 1. Resident 1 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/8/19 Resident to Resident Event Assessment revealed Resident 1 hit, scratched and yelled at Resident 2. The 7/8/19 behavior monitoring task documentation revealed Resident 1 had no behaviors on 7/8/19. The 7/8/19 progress notes revealed no documentation of the resident to resident incident. On 7/17/19 at 11:59 AM Staff 3 (RNCM) verified Resident 1's 7/8/19 progress notes did not include the resident to resident incident and the behavior monitoring documentation indicated Resident 1 did not have any behaviors on 7/8/19. Staff 3 stated these were documentation errors. 2. Resident 2 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 7/8/19 Resident to Resident Event Assessment revealed Resident 2 was the victim of a resident to resident incident which involved Resident 1. Resident 2 sustained scratches to her/his left back and shoulder. Review of Resident 2's medical record revealed no documentation in the progress notes or any other area of the medical record she/he was involved in a resident to resident incident. On 7/17/19 at 11:59 AM Staff 3 (RNCM) verified Resident 2 did not have any documentation in her/his medical record of the 7/8/19 resident to resident incident. Staff 3 stated this omission was a documentation error. 3. Resident 3 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/8/19 Resident to Resident Event Assessment revealed Resident 3 hit and yelled at Resident 4 during a resident to resident incident. The 7/4/19 behavior monitoring task documentation revealed Resident 3 had no behaviors on 7/4/19. On 7/17/19 at 11:59 AM Staff 3 (RNCM) verified Resident 3's behavior monitoring documentation indicated Resident 3 did not have any behaviors on 7/4/19 and this was inaccurately documented. 4. Resident 4 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/8/19 Resident to Resident Event Assessment revealed Resident 4 held onto Resident 3's wheelchair and restrained her/him. Resident 3 responded by yelling and hitting Resident 4. Resident 4 then hit Resident 3 in the face. The 7/4/19 behavior monitoring task documentation revealed Resident 4 had no behaviors on 7/4/19. On 7/17/19 at 11:59 AM Staff 3 (RNCM) verified Resident 4's behavior monitoring documentation indicated Resident 4 did not have any behaviors on 7/4/19 and was this inaccurately documented.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 4 sampled Residents (#s 1 and 4) reviewed for abuse. This placed residents at risk for resident to resident abuse. Findings include: 1. Resident 1 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 6/18/19 Behavior [MEDICAL CONDITION] Meeting notes revealed an increase in documented behaviors since 4/2019. The dosage for [MEDICATION NAME] (antidepressant medication) was increased in 4/2019. In 6/2019 the physician suggested adding [MEDICATION NAME] (antipsychotic medication) but Resident 1's healthcare power of attorney (POA) declined the medication. The 6/28/19 Comprehensive Care Plan for verbal aggression indicated Resident 1 could be verbally aggressive towards others and threaten to hit or hurt others. The 6/28/19 physical aggression care plan indicated Resident 1 could be physically aggressive and abusive related to her/his cognitive impairment, sensory overload and phobic anxiety disorder. The goal was to maintain composure every day with peers. Interventions included to be cognizant to not invade Resident 1's personal space. The interventions were revised on 7/9/19 to indicate Resident 1 had physical behaviors such as threatening others with physical gestures and a history of pushing, shoving, hitting, slapping, grabbing and scratching other residents, throwing objects, and pulling others by their clothing. The 7/8/19 Resident to Resident Event Assessment indicated Resident 2 walked down the hall towards her/his room, Resident 1 was in the hall standing outside her/his room. When Resident 2 passed Resident 1, Resident 1 hit Resident 2 with her/his fist on Resident 2's back and then grabbed the back neckline of Resident 2's shirt and pulled hard. Resident 1 then scratched Resident 2 on the left side of her/his back and shoulder area. Resident 1 pulled Resident 2 backwards but Resident 2 did not fall. The assessment further indicated Resident 1 was involved in two prior resident to resident incidents. On 7/1/19 Resident 1 yelled at a resident who passed by, grabbed her/his arm and attempted to scratch her/him. On 3/23/19 Resident 1 had a verbal and then physical altercation with another resident; Resident 1 was believed to be the instigator of the event. The assessment indicated Resident 1 had an increase in behaviors since 4/2019. The assessment concluded Resident 1 physically abused Resident 2. The 7/8/19 progress notes did not document the occurrence of the resident to resident incident. On 7/17/19 at 11:59 AM Staff 3 (RNCM) verified the 7/8/19 resident to resident incident occurred as documented in the 7/8/19 Resident to Resident Event Assessment and stated Resident 1's unprovoked actions were deliberate, she/he scratched and attacked Resident 2. Staff 3 stated Resident 1's actions were very unpredictable. Staff 3 verified Resident 1's behaviors had escalated since 4/2019 and the only change to Resident 1's plan of care was an increase in the [MEDICATION NAME] in April, a denial by Resident 1's POA for addition medications in (MONTH) and a care plan revision on 6/28/19 to indicate Resident 1 could be physically aggressive and abusive. Staff 3 further stated the facility attempted to take Resident 1 off the unit more often for a two week trial but the behaviors increased. On 7/17/19 at 1:11 PM Staff 4 (Life Enrichment Coordinator/Social Services) stated the two week trial of out of unit activities occurred from 7/3/19 through 7/17/19. 2. Resident 4 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 8/8/18 Admission MDS indicated Resident 4 had physical and verbal behaviors towards others. The 5/28/19 Behavior [MEDICAL CONDITION] Meeting indicated Resident 4 exhibited behaviors of kicking, hitting and slapping with a physical decline and resistive to care since the previous review. These behaviors were only exhibited when staff provided care. Review of the comprehensive care plan revealed no care plan for aggressive behaviors or negative interactions with other residents. The 7/4/19 Resident to Resident Event Assessment revealed Resident 4 was wandering in the dining room, walked up behind and stood next to Resident 3 while she/he held the handle of Resident 3's wheelchair. Resident 3 became agitated and upset that Resident 4 was touching her/his wheelchair, began to scream to not touch her/his wheelchair, then hit Resident 4 to which Resident 4 made a fist and punched the side of Resident 3's head. The assessment indicated the triggering event was Resident 4 not letting go of the wheelchair handle. The assessment indicated Resident 4 had one prior resident to resident incident on 9/4/18 when she/he approached another resident, grabbed her/his arm and throat. The incident was unprovoked. The summary indicated physical abuse was substantiated. The progress notes revealed no monitoring of Resident 4's behaviors after the 7/4/19 incident. On 7/17/19 at 12:25 PM Staff 3 (RNCM) verified the 7/4/19 resident to resident incident occurred as documented in the 7/4/19 Resident to Resident Event Assessment. Staff 3 stated it was Resident 4's intention to hold onto and restrain Resident 3's wheelchair. Staff 3 verified no monitoring of Resident 4 occurred after the resident to resident incident and facility policy was to monitor the resident each shift for 72 hours. Staff 3 further stated Resident 4 was involved in a prior resident to resident incident, felt it was an isolated incident so the care plan was not revised.

Based on interview and record review it was determined the facility failed to complete or revise a comprehensive care plan for 3 of 4 sampled residents (#s 1, 3 and 4) reviewed for abuse. This placed residents at risk for unassessed and un-careplanned needs. Findings include: 1. Resident 1 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 1's medical record revealed the following resident to resident incidents: * 3/23/19 Resident 1 had a verbal and then physical altercation with another resident. * 7/1/19 Resident 1 yelled at a resident who passed by, grabbed her/his arm and attempted to scratch her/him. * 7/8/19 Resident 1 had a physical altercation with Resident 2 when she/he hit, grabbed and scratched her/him. The facility investigation substantiated Resident 1 physically abused Resident 2. The 6/18/19 Behavior [MEDICAL CONDITION] Meeting notes revealed in increase in documented behaviors since 4/2019. Review of Resident 2's Comprehensive Care Plan revealed the following plans of care in place: * 12/18/17 Behavior Monitoring/Behavioral Health Services: Specific and standard behavior interventions were listed which instructed staff what to do after a behavior occurred. The care plan did not indicate what behaviors Resident 2 had or what behaviors were to be monitored. * The 6/28/19 Physical Aggression care plan indicated Resident 1 could be physically aggressive and abusive related to her/his cognitive impairment, sensory overload and phobic anxiety disorder. The goal was to maintain composure every day with peers. Interventions included to be cognizant to not invade Resident 1's personal space. The goals and interventions were revised on 7/9/19 to indicate Resident 1 would be provided 1:1 supervision by a staff member when out of the room and had physical behaviors such as threatening others with physical gestures and a history of pushing, shoving, hitting, slapping, grabbing and scratching other residents, throwing objects, and pulling others by their clothing. * The 12/18/17 Comprehensive Care Plan for manipulative, repetitive and verbal aggression revised on 6/28/19 indicated Resident 1 could be verbally aggressive towards others and threaten to hit or hurt others. Interventions were revised on 6/28/19 which instructed staff to redirect Resident 1 from the public area to a low-stimulation area when behavior was disruptive, unacceptable or threatening to others. The care plan was revised again on 7/9/19 to indicate Resident 1 needed constant 1:1 supervision by staff when out of her/his room to ensure the safety and wellbeing of others. On 7/17/19 at 11:59 AM Staff 3 (RNCM) acknowledged the 3/23/19, 7/1/19 and 7/8/19 resident to resident incidents and stated Resident 1's actions were very unpredictable. Staff 3 verified Resident 1's behaviors had escalated since 4/2019 and the only change to Resident 1's Comprehensive care plan was a revision on 6/28/19 to indicate Resident 1 could be physically aggressive and abusive. Resident 3 acknowledged Resident 1's Comprehensive Care Plan was not updated or revised after the 3/23/19 and 7/1/19 resident to resident incidents to include Resident 1 was physically abusive to other residents. On 7/17/19 at 1:11 PM Staff 4 (Life Enrichment Coordinator/Social Services) stated she did not update the comprehensive care after the 3/23/19 resident to resident incident to include Resident 1 was physically aggressive with other residents. Staff 4 acknowledged the Comprehensive Care Plan needed to be revised to reflect Resident 1's current status. 2. Resident 3 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/16/19 Comprehensive Care Plan for physical aggression instructed staff to be cognizant of other residents invading Resident 3's personal space. The 5/29/18 Comprehensive Care Plan for ineffective coping indicated Resident 3 was irritable, territorial of her/his personal space and would yell or scream at others on a consistent basis throughout each day. The 7/4/19 Resident to Resident Event Assessment revealed Resident 3 was involved in resident to resident physical altercations on 3/29/19, 4/9/19 and 7/4/19. On 7/17/19 at 12:20 PM Staff 3 (RNCM) stated Resident 3's Comprehensive Care Plan did not indicate Resident 3 was involved in any resident to resident physical altercations and acknowledged this information should be included in the Comprehensive Care Plan. 3. Resident 4 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/4/19 Resident to Resident Event Assessment revealed Resident 4 was involved in physical altercations with other residents on 9/4/18 and 7/4/19. A review of the current Comprehensive Care Plan revealed no care plan for aggressive behaviors or negative interactions with other residents. On 7/17/19 at 12:25 PM Staff 3 (RNCM) acknowledged Resident 4 was aggressive with other residents on 9/4/18 and 7/4/19 and her/his current Comprehensive Care Plan did not reflect these incidents and physical aggression.

Based on interview and record review it was determined the facility failed to ensure a resident was provided sufficient supervision to prevent accidents for 1 of 4 sampled residents (#1) reviewed for falls. Resident 1 was left unattended in the bathroom, fell and sustained a fracture. Findings include: According to the Oregon Standards and Authorized Duties for the Certified Nursing Assistant and Certification Medication Aide .851-063-0090 Conduct Unbecoming a Nursing Assistant .(3) Conduct related to client safety and integrity(a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities; (b) Failing to implement the plan of care developed by the registered nurse . Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 2/1/17 indicated the resident was a fall risk with poor short term memory problems. The resident's care plan showed the resident required constant supervision with physical assistance for hygiene/grooming and transfers. The resident was noted to require constant supervision and physical assistance for safety when toileting. A Fall/Post Fall assessment dated [DATE] indicated the resident was found on her/his back perpendicular to the toilet. The resident was grasping the toilet with her/his right hand and shoulders were propped against the adjacent wall. The resident was transferred to the toilet by Staff 3 (CNA) prior to the fall and the wheelchair was placed next to the resident. Staff 3 left the resident on the toilet unattended and left the room to assist another resident. The resident stated she/he stood up and turned around to flush the toilet and fell . The resident showed significant pain to the right thigh and knee and was unable to stand. The resident was transferred to the hospital for evaluation. A hospital after visit summary dated 2/22/17 indicated the resident had a closed [MEDICAL CONDITION] femur shaft. The resident's fracture was not surgically repaired. The resident was discharged back to the facility with previous hospice orders in place and an antibiotic for a newly diagnosed UTI. The resident was no longer able to stand with or without assistance and was to remain bed bound. In interview on 4/25/17 at 12:18 pm Staff 3 (CNA) indicated the resident wanted to use the bathroom so she transferred the resident onto the toilet. The resident was given the call light and told to call when she/he was done. Staff 3 left the room and went to assist another resident in their room. Staff 3 stated as she was returning to Resident 1's room she stopped to assist an additional resident. Staff 3 was then approached by Staff 4 (Housekeeping) and told Resident 1 was on the floor. Staff 3 went to the resident's room and found her/him on the ground in the bathroom. The nurse came in right after to assess the resident. Staff 3 stated Staff 5 (CNA) assisted to get the resident up off the floor. Staff 3 further indicated she was not aware at the time of the fall that the resident required constant supervision. Staff 3 further indicated she normally checked the resident care plans once or twice a week. Staff 3 stated she had worked with Resident 1 on other occasions and had left the resident alone in the bathroom several times while she went to assist other residents. Resident 1 would turn the call light on when she/he was done and Staff 3 would return to Resident 1's room to help her/him finish in the bathroom. In interview on 4/25/17 at 9:40 am and 10:00 am Staff 2 (DNS) indicated the resident was on Hospice prior to sustaining the fracture. The resident had no previous falls in the bathroom but was a fall risk. Staff 2 indicated the resident was care planned for constant supervision for toileting. The resident should not have been left alone in the bathroom. Staff 2 stated Staff 3 (CNA) was disciplined and all staff were inserviced as a reminder of the definition of constant supervision and the importance of following the care plan. Refer to F-323

Based on interview and record review it was determined the facility failed to ensure a resident was provided sufficient supervision to prevent accidents for 1 of 4 sampled residents (#1) reviewed for falls. Resident 1 was left unattended in the bathroom, fell and sustained a fracture. Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 2/1/17 indicated the resident was a fall risk with poor short term memory problems. The resident's care plan showed the resident required constant supervision with physical assistance for hygiene/grooming and transfers. The resident was noted to require constant supervision and physical assistance for safety when toileting. A Fall/Post Fall assessment dated [DATE] indicated the resident was found on her/his back perpendicular to the toilet. The resident was grasping the toilet with her/his right hand and shoulders were propped against the adjacent wall. The resident was transferred to the toilet by Staff 3 (CNA) prior to the fall and the wheelchair was placed next to the resident. Staff 3 left the resident on the toilet unattended and left the room to assist another resident. The resident stated she/he stood up and turned around to flush the toilet and fell . The resident showed significant pain to the right thigh and knee and was unable to stand. The resident was transferred to the hospital for evaluation. A hospital after visit summary dated 2/22/17 indicated the resident had a closed fracture of the right femur shaft. The resident's fracture was not surgically repaired. The resident was discharged back to the facility with previous hospice orders in place and an antibiotic for a newly diagnosed UTI. The resident was no longer able to stand with or without assistance and was to remain bed bound. In interview on 4/25/17 at 12:18 pm Staff 3 (CNA) indicated the resident wanted to use the bathroom so she transferred the resident onto the toilet. The resident was given the call light and told to call when she/he was done. Staff 3 left the room and went to assist another resident in their room. Staff 3 stated as she was returning to Resident 1's room she stopped to assist an additional resident. Staff 3 was then approached by Staff 4 (Housekeeping) and told Resident 1 was on the floor. Staff 3 went to the resident's room and found her/him on the ground in the bathroom. The nurse came in right after to assess the resident. Staff 3 stated Staff 5 (CNA) assisted to get the resident up off the floor. Staff 3 further indicated she was not aware at the time of the fall that the resident required constant supervision. Staff 3 further indicated she normally checked the resident care plans once or twice a week. Staff 3 stated she had worked with Resident 1 on other occasions and had left the resident alone in the bathroom several times while she went to assist other residents. Resident 1 would turn the call light on when she/he was done and Staff 3 would return to Resident 1's room to help her/him finish in the bathroom. In an interview on 4/25/17 at 12:50 pm Staff 5 (CNA) indicated he was not involved with the resident's fall. Staff 5 stated he has worked with the resident on other occasions. The resident was a fall risk and had some confusion. He would not leave any resident who was a fall risk alone in the bathroom. Staff 5 stated depending on the resident he may leave the door ajar while he stood outside but the resident would still be in line of sight if they were a fall risk or were confused. Staff 5 stated Resident 1 was care planned not to be left alone in the bathroom and he would not leave the resident unattended. In an interview on 4/27/17 at 9:35 am Staff 6 (RN) indicated she was told the resident was on the floor. When she arrived at the resident's room she found the resident on the floor in the bathroom. The resident was in a lot of pain visually and expressed pain verbally. Staff 6 stated the resident was able to pin point the area with pain as the right thigh and knee. The resident was made comfortable and upon receipt of Hospice orders, was sent to the hospital for evaluation. Staff 6 stated that Staff 3 placed the resident in the bathroom and left the room; the resident was not to be left alone in the bathroom. In interview on 4/25/17 at 9:40 am and 10:00 am Staff 2 (DNS) indicated the resident was on Hospice prior to sustaining the fracture. The resident had no previous falls in the bathroom but was a fall risk. Staff 2 indicated the resident was care planned for constant supervision for toileting. The resident should not have been left alone in the bathroom. Staff 2 stated Staff 3 (CNA) was disciplined and all staff were inserviced as a reminder of the definition of constant supervision and the importance of following the care plan.