Every finding on record at Marquis Wilsonville Post Acute Rehab

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 2 sampled residents (#44) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include:A 3/2015 Oxygen Administration facility policy indicated oxygen concentrator filters were to be cleaned weekly. Resident 44 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Resident 44's physician order dated 3/30/26 revealed she/he required supplemental oxygen use to maintain oxygen saturation. On 4/6/26 at 1:49 PM and on 4/7/26 at 11:30 AM the oxygen concentrator was observed to have an external foam filter with a thick layer of dust. On 4/7/26 at 3:30 PM Staff 3 (Interim DNS/Corporate RN) acknowledged Resident 44's concentrator foam filter was covered in a thick layer of dust. Staff 3 stated she expected the filters to be checked and cleaned weekly.

Based on observation, interview and record review it was determined the facility failed to provide adequate nail care for 1 of 1 sampled resident (#32) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 32 was admitted to the facility in 3/2026 with diagnoses including fracture of the left leg.Resident 32's 3/25/26 Personal Hygiene Care Plan directed the resident's hygiene needs would be met and the resident required constant supervision and physical assistance from staff with hand washing. Resident 32's 3/31/26 admission MDS indicated the resident was cognitively impaired and required substantial to maximum staff assistance for personal hygiene. Observations from 4/6/26 through 4/7/26 between the hours of 8:37 AM and 12:44 PM revealed Resident 32's fingernails and cuticles on both hands were coated in dark, black thick debris collected underneath the nails and built up around the cuticles.Resident 32's health record did not include documented evidence specific to the provision of nail care. On 4/6/26 at 10:14 AM Resident 32 was unable to provide information related to personal hygiene abilities and nail care preferences. On 4/6/26 at 3:19 PM and 3:50 PM Witness 1 (Spouse) stated she saw Resident 32's nails and was unsure if the substance coating the fingernails and cuticles was blood, feces or food and stated it bothered her to see Resident 32's nails in that condition. Witness 1 stated she visited on 4/4/26 and Resident 32's nails looked the same. Witness 1 stated Resident 32 took pride in her/his appearance and would not like her/his nails to be dirty. On 4/7/26 at 12:47 PM Staff 11 (CNA) stated Resident 32 was dependent on staff for her/his ADLs, including hygiene care. Staff 11 stated she was Resident's 32's assigned CNA for day shift and did not provide hand or nail care. On 4/7/26 at 1:43 PM Staff 12 (LPN) stated CNAs were responsible to provide ADLs, including hand washing and ensuring fingernails were clean. Staff 12 stated CNAs should offer and attempt to provide nail care if fingernails were long or dirty. Staff 12 stated she saw Resident 32's fingernails during the morning medication administration and stated the resident's nails were very dirty. On 4/7/26 at 1:54 PM Staff 4 (RNCM) observed Resident 32's fingernails and cuticles on both hands. Staff 4 stated the resident's nails were dirty and stated she was unsure how long the nails were in this condition. Staff 4 stated staff should notice if fingernails and cuticles were dirty and provide appropriate care to ensure they were clean. On 4/9/26 at 12:02 PM Staff 3 (Interim DNS/Corporate RN) was informed of the observations of Resident 32's dirty fingernails and cuticles from 4/6/26 through 4/7/26. Staff 2 stated staff notified her regarding Resident 32's dirty fingernails and stated the resident's nails were disgusting and unacceptable. Staff 2 indicated Resident 32 was resistive to ADL care at times and stated she educated staff to find ways to reapproach the resident to ensure adequate nail care was provided. Staff 2 indicated there were missed opportunities to notice and provide nail care for Resident 32.

Based on interview and record review it was determined the facility failed to ensure the State Long Term Care Ombudsman Office was notified of resident discharges as required for 1 of 1 facility reviewed for discharge. Findings include: The facility's undated Notice Transfer Discharge Policy & Procedure specified the facility business office will notify the state ombudsman office of all transfers and discharges monthly, or by cadence defined by the state ombudsman's office. On 4/9/26 at 3:14 PM and 3:41 PM Staff 9 (Business Office Manager) stated a list of discharged residents was not sent to the state ombudsman office since 10/2025. On 4/10/26 at 10:44 AM Staff 1 (Administrator) stated the facility process included sending a monthly update of discharged residents to the state ombudsman office. Staff 1 explained the facility experienced business office staffing changes and acknowledged the list of residents was not sent to the state ombudsman office.

Based on interview and record review it was determined the facility failed to ensure the resident was involved and informed of the discharge plan for 1 of 2 sampled residents (#30) reviewed for care planning. This placed residents at risk for being uninformed about their discharge plan. Findings include: Resident 30 was admitted to the facility in 11/2024 with diagnoses including Raynaud's syndrome (disorder of the blood vessels). Resident 30's 9/15/24 Admission MDS indicated the resident was cognitively intact. Resident 30's 11/8/24 Discharge Care Plan, created by Staff 5 (Social Services) indicated the following: - Anticipated discharge plan is to: HLOC, prefers AFH No other information was found on the Care Plan related to Resident 30's discharge plan. Resident 30's 11/14/24 Care Conference indicated the discharge plan was reviewed with the resident and the projected discharge date was 12/11/24. On 12/16/24 at 11:44 AM Resident 30 stated she/he did not feel included in the discharge plan. The resident stated nobody ever talked to me or kept her/him informed about where or when she/he would be discharged from the facility. The resident said it was confusing because various staff relayed conflicting information about what day she/he was leaving the facility. The resident stated there was no discussion after the 12/11/24 projected discharge date and she/he felt very stressed. On 12/17/24 at 2:24 PM Resident 30's health record revealed no evidence of communication to indicate the resident was informed and updated regarding the 12/11/24 projected discharge date . No documentation was found regarding discharge planning other than the 11/14/24 Care Conference. On 12/18/24 at 10:50 AM Staff 4 (RNCM) stated each of us randomly have conversations with Resident 30 related to the discharge plan but the conversations were not documented. Staff 4 stated Staff 5 was primarily responsible for discharge planning. On 12/18/24 at 11:30 AM Staff 5 was asked to explain the process to ensure residents were included in their discharge plan and Staff 5 stated she talked to the residents weekly. Staff 5 reviewed Resident 30's health record and acknowledged there was no documentation of the weekly conversations. Staff 5 stated she was not consistent with documentation and acknowledged there was no documentation to indicate Resident 30 was informed and updated regarding the discharge plan since the 11/14/24 Care Conference.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were followed up on for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 10 was admitted to the facility in 2/2024 with diagnoses including depression and hypotension. Monthly pharmacist reviews of Resident 10's medication regimen revealed the following: -On 11/4/24 the pharmacist recommendation advised the prescriber to discontinue PRN haloperidol after 14 days (11/15/24). If necessary, write a new order x 14 days only after direct examination and documentation is completed. No response from the provider was found in Resident 10's health care record or provided by the facility. -On 11/4/24 the pharmacist recommendation advised the prescriber to provide the following rationale and duration: It is appropriate for PRN lorazepam to be extended beyond 14 days. Medication necessary to help with comfort as resident transitions towards end-of-life. Continue order for 6 months at which time continued use will be re-evaluated. No response from the provider was found in Resident 10's health care record until 12/5/24. On 12/19/24 at 4:00 PM Staff 3 (Resident Care Manager) confirmed the facility did not receive a response from Resident 10's provider regarding the 11/2024 pharmacist's recommendations until 12/5/24.

Based on observation, interview and record review it was determined the facility failed to ensure residents received vision services for 1 of 1 sampled resident (#27) reviewed for vision. This placed residents at risk for unmet vision needs. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including macular degeneration (vision impairment). Resident 27's 9/15/24 Admission MDS indicated the resident wore glasses and it was very important to read. The vision CAA, completed by Staff 5 (Social Services) indicated the following: - Ensure glasses were clean and appropriately worn; - Resident has macular degeneration that impairs vision. [Resident] has a visual deficit and has glasses [she/he] does not use because [she/he] needs a new glasses prescription. [Resident stated] They aren't the correct prescription any way. Resident 27's health record revealed no evidence the facility facilitated vision services to ensure the resident was assessed for glasses and had the appropriate prescription. 12/16/24 at 4:14 PM Witness 2 (Family) stated Resident 27 required prescription glasses to see and when they visited, Resident 27 was not wearing her/his glasses. On 12/16/24 at 10:33 AM and 12/17/24 at 1:15 PM Resident 27 did not wear glasses. Resident 27 was unable to answer questions related to the use of glasses. On 12/18/24 at 3:51 PM Staff 5 stated she completed the 9/15/24 Vision CAA and thought she followed up on the resident's need for an appointment and new prescription glasses. Staff 5 reviewed Resident 27's health record and acknowledged she did not follow up regarding Resident 27's need for a vision assessment and appointment.

Based on observation, interview and record review it was determined the facility failed to provide adequate bathing and grooming for 1 of 1 sampled resident (#27) reviewed for ADLs. This placed residents at risk for poor hygiene and grooming. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including Alzheimer's disease, restlessness and agitation. Resident 27's 9/15/24 Admission MDS indicated the resident had severe cognitive impairment and required moderate staff assistance for personal hygiene and grooming. Resident 27's 9/2024 Bathing and Personal Hygiene Care Plan indicated the resident required staff assistance and constant supervision for bathing and personal hygiene and the resident's hygiene needs will be met. Resident 27's Bath/Shower Task Flowsheet revealed the resident did not receive a bath/shower for 27 days between 11/19/24 through 12/15/24. On 12/16/24 at 4:11 PM Witness 2 (Family) stated the resident used to be clean shaven all the time. On 12/16/24 at 10:33 AM and 12/17/24 at 1:15 PM Resident 27 had long, unkempt facial hair. Resident 27 was unable to answer questions related to her/his bathing, hygiene and grooming. On 12/17/24 at 1:27 PM and 2:01 PM Staff 10 (CNA) and Staff 11 (CNA) stated Resident 27 required a moderate amount of staff assistance for bathing, hygiene and grooming and stated the resident frequently refused bathing, hygiene and grooming. Staff 10 and Staff 11 stated if a resident refused care, the process included to redirect the resident and offer care several additional times. Staff stated if those approaches were unsuccessful, they reported the refusals to the nurse. On 12/17/24 at 1:47 PM Staff 12 (RN) stated if a resident refused care, CNAs reported the refusal to the nurse and it was documented in the health record. Staff 12 stated the resident was put on alert charting and monitored for behaviors, and staff were to make additional attempts to provide bathing, hygiene and grooming. Staff 12 stated she was unaware if Resident 27 refused bathing, hygiene and grooming and was not notified of any refusals of care. Resident 27's health record revealed no documentation related to refusals of bathing, hygiene or grooming, no alert charting and no evidence the resident was offered alternative bathing, hygiene or grooming opportunities between 11/19/24 and 12/15/24. On 12/18/24 at 1:41 PM Staff 2 (DNS) was notified of the findings of this investigation and acknowledged the resident did not receive bathing, hygiene or grooming care for 27 days. Staff 2 stated if a resident refused bathing, hygiene and grooming everyday, attempts should be made to modify the approach and plan of care to ensure bathing, hygiene and grooming was provided.

Based on interview and record review it was determined the facility failed to develop a comprehensive, person-centered care plan for 1 of 1 sampled resident (#27) reviewed for ADLs. This placed residents at risk for unmet bathing, grooming and vision needs. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including Alzheimer's disease and macular degeneration (vision impairment). a. Resident 27's 9/15/24 Admission MDS indicated the resident wore glasses and it was very important to read. The vision CAA, completed by Staff 5 (Social Services) indicated the following: - ensure glasses were clean and appropriately worn. Resident 27's 9/2024 Care Plan did not include a focus, goals or interventions related to her/his vision and the use of glasses. On 12/17/24 at 1:27 PM, 1:47 PM and 2:01 PM Staff 10 (CNA), Staff 11 (CNA) and Staff 12 (RN) stated they referred to the Care Plan to determine Resident 27's care needs. Staff 10, Staff 11 and Staff 12 stated they were not sure if Resident 27 wore glasses. On 12/18/24 at 11:22 AM Staff 5 stated her role included building the Care Plan to reflect vision needs. Staff 5 acknowledged the Care Plan did not include information regarding Resident 27's use of glasses. On 12/18/24 at 1:41 PM Staff 2 (DNS) was notified of the findings of this investigation and acknowledged Resident 27's Care Plan lacked a focus, goal and interventions related to the resident's vision needs. b. Resident 27's 9/15/24 Admission MDS indicated the resident required moderate staff assistance for personal hygiene and grooming. Resident 27's 11/14/24 Behavior Assessment indicated the following: - resident has mixed incontinence of bowel and incontinent of bladder - refuses cares - refuses staff attempts with hygiene. Resident refuses care from staff - takes multiple approaches before resident accepts cares. Resident 27's 11/19/24 - 12/15/24 Bath/Shower Task Flowsheet revealed the resident refused seven of seven bathing opportunities and did not receive a bath or shower. Resident 27's 11/25/24 Bathing and Personal hygiene Care Plan included the following interventions: - constant supervision with physical assist combing hair, brushing teeth, shaving, washing/drying face, hands and perineum; - one person to provide physical assist with bathing. The Care Plan did not include person centered interventions related to refusals of personal hygiene and grooming care. On 12/18/24 at 10:54 AM Staff 3 (LPN Resident Care Manager) reviewed Resident 27's Care Plan. Staff 3 acknowledged the Care Plan did not reflect Resident 27's refusal of hygiene and grooming care and lacked person centered interventions.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medication for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for adverse medication side effects. Findings include: Resident 3 admitted to the facility on [DATE] with diagnoses including stroke and post hospital procedure for intestinal obstruction. The 4/16/24 hospital orders indicated Resident 3 was to receive loperamide 2 mg (antidiarrheal medication) two capsules twice daily and one capsule every six hours as needed for diarrhea. The 4/17/24 order indicated Resident 3 was to receive Miralax powder (laxative medication) once daily for bowel care. Hold for loose stools. The 4/2024 MARs indicated Resident 3 received Miralax once daily from 4/17/24 through 4/29/24. Resident 3's bowel records indicated the following dates when she/he had loose or watery stools on one or more occasions: -4/17/24 -4/18/24 -4/19/24 -4/21/24 -4/23/24 -4/24/24 -4/27/24 -4/28/24 On 8/7/24 at 12:08 PM Staff 2 (DNS) stated Resident 3 admitted with loperamide orders. Miralax was added for constipation and staff were to hold the Miralax for loose stools. Staff 2 acknowledged Resident 3 received an antidiarrheal medication in addition to a laxative and the resident had loose stools on the identified dates.

1. Based on interview and record review it was determined the facility failed to ensure the care plan reflected management of potential complications associated with a tracheostomy tube for 1 of 1 sampled resident (#17) reviewed for respiratory care. This placed the resident at risk for delayed care. Findings include: Resident 17 was admitted to the facility on ,d+[DATE] with diagnoses including acute and chronic respiratory failure and history of stroke. The resident had a permanent tracheostomy (an opening in the front of the neck into the windpipe [trachea] with a tube in the opening to keep it open for breathing.) Resident 17's comprehensive Care Plan dated 12/12/22 (last reviewed 7/10/23) included a focus area related to impaired/compromised respiratory function and ability to communicate related to the tracheostomy. The care plan did not include information related to the availability of spare inner or outer tracheostomy tubes at the resident's bedside or emergency management of complications associated with the tracheostomy tube. On 8/23/23 at 11:34 AM Staff 4 (LPN) confirmed she was familiar with Resident 17 and her/his care needs. Staff 4 stated she was not sure where emergency supplies were located but assumed the crash cart (emergency resuscitation supply cart) would have them and if not, she would utilize 911 to send the resident to the emergency room . On 8/23/23 at 11:38 AM Staff 5 (Resident Care Manager) stated Resident 17 had replacement tracheostomy supplies in a box at her/his bedside. Staff 5 confirmed this information was not on the care plan. Surveyor: Tsujimura, Mark 2. Based on interview and record review it was determined the facility failed to ensure care plan interventions were implemented and followed for 1 of 1 sampled resident (#137) reviewed for ADLs. This placed residents at increased risk for injury. Findings include: Resident 137 was admitted to the facility in 2/2023 with diagnoses including elbow fracture and chronic back pain. Record review of Resident 137's 2/9/23 care plan indicated she/he required two-person assistance for transfers and bed mobility. A FRI report dated 2/17/23 revealed Staff 3 (Agency CNA) failed to follow Resident 137's care plan for transfers. The resident's care plan indicated she/he was to receive two-person assistance for transfers. Staff 3 did not have another CNA to assist her when transferring the resident. Resident 137 reported increased back pain after the transfer. On 8/24/23 at 9:45 AM Staff 2 (DNS) stated she started an investigation after being informed by Resident 137's daughter that the resident was transferred by one staff and not two as her/his care plan indicated. During the investigation Staff 3 admitted to not reviewing the resident's care plan and was not aware of the resident being a two-person assist for transfers. Staff 3 transferred the resident on her own and did not have another staff member assist her. Staff 2 further stated Resident 137 was assessed and monitored after the one-person transfer and no increased pain or adverse outcomes were noted. 27792

1. Based on interview and record review it was determined the facility failed to ensure emergency services were summoned and interventions provided upon a resident's significant change in condition for 1 of 3 sampled residents (#1) reviewed for change of condition. Resident 1 had a significant change of condition, was not provided medical interventions, emergency services were not summoned and she/he died . Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 1's POLST (Portable Orders for Life-Sustaining Treatment) indicated the resident did not want to be resuscitated if she/he did not have respirations or a pulse, but wanted to be transported to the hospital if indicated. An [DATE] Nursing Admission Assessment indicated the resident had a good memory and was able to understand what was being said to her/him. Progress Notes from [DATE] through [DATE] included the following: -[DATE] Nurse Practitioner note revealed the resident reported she/he was doing well, appetite was improving and was tolerating food. The resident participated in therapy and walked with a walker. The resident's vital signs were stable except for an occasional low blood pressure. The resident appeared well, all body systems were assessed to be without negative findings and the resident was alert, oriented and had good insight and judgement. The staff did not report concerns. -[DATE] nursing note revealed the resident was alert, oriented, cooperative, participated in therapy and tolerated ADLs without issue. -[DATE] social service note indicated the resident was two weeks from discharge. -[DATE] nursing note indicated the resident had abdominal pain, the physician was notified, was evaluated in the emergency room and returned the same day in stable condition. A [DATE] at 8:27 AM Progress Note by Staff 1 (LPN) indicated at the start of the night shift [[DATE] at 10:00 PM] the resident was at her/his baseline mental status and reported abdominal pain. The resident was administered pain medication which was not effective. Staff 1 reviewed the resident's record and identified the resident did not have a bowel movement for a couple of days. Staff 1 offered the resident a [MEDICATION(S)] and the resident accepted the medication. The note indicated toward the end of the shift the resident continued to have abdominal pain and at approximately 5:30 AM Staff 1 went to check on the resident and administer the resident her/his morning medication. At that time Resident 1 was not able to form words and spoke word salad (unintelligible combination of words). The resident's pulse was 50 (normal range ,d+[DATE]) temperature was 96.9 (normal-98.6) and respirations were 16 (normal range ,d+[DATE]). The resident's O2 sats were not able to be obtained because the resident's fingers were too cold and the resident's blood pressure was also not obtainable. At approximately 5:45 AM Staff 1 placed a telephone call to Resident 1's physician. Prior to the physician returning the phone call, Staff 1 went back to Resident 1's room and found the resident deceased . On [DATE] at 4:40 PM and [DATE] at 9:12 AM Staff 1 stated emergency services were to be called prior to notification of the resident's physician if a resident had critical symptoms. Staff 1 indicated if a resident showed signs of a stroke emergency services would be called prior to physician notification. Staff 1 indicated possible signs of a stroke included garbled speech and weakness to one side. Staff 1 stated on [DATE] around 10:00 PM Resident 1 reported pain and he assessed and provided the resident medications. Staff 1 stated he periodically checked on the resident throughout the shift and the resident was fine. At approximately 5:30 AM he entered the resident's room to administer the resident her/his morning medications. The resident's voice was quiet and she/he spoke word salad. Staff 1 stated the word salad may have been signs of a stroke. Staff 1 verified he was not able to obtain the resident's blood pressure or O2 sats. Staff 1 further indicated the resident did not normally wear oxygen and verified he did not apply oxygen. Staff 1 left the room to call the resident's physician. Ten minutes later he went to check on the resident and the resident was dead. Staff 1 stated the CNA staff was not with the resident after he identified the resident to have a change in condition. Staff 1 was not able to provide a rationale for calling the physician versus calling emergency services. On [DATE] 8:48 AM with Staff 2 and Staff 3 (Administrator) Staff 2 stated if a resident had an acute change of condition which was different from the resident's baseline, emergency services was to be called prior to physician notification. Staff 2 stated Resident 1 had a significant change in condition and emergency services should have been called first. Staff 2 also stated Staff 1 did not provide any interventions, including oxygen, and should have. On [DATE] at 12:34 PM Staff 2 and Staff 3 were notified of the IJ situation and an immediate plan of correction was requested. On [DATE] at 1:02 PM Staff 2 provided an acceptable plan of correction which included: -All residents potentially impacted by this citation. -Immediate inservicing initiated by DNS on [DATE] to be completed by [DATE] at 10:00 PM for all licensed staff on change of condition and calling emergency services, as needed. -DNS to 1:1 inservice the LPN identified on [DATE] on change of condition and emergency services. -DNS and designee to audit change of condition every shift for the next three days, then all change of conditions daily for two weeks, then weekly for four weeks for 90 days. -Audits will be reviewed by quality assurance team monthly for six months, to ensure ongoing compliance. On [DATE] at 1:22 PM the IJ removal plan was verified through observation by the surveyor. No additional concerns related to the immediate jeopardy situation were identified. 2. Based on interview and record review it was determined the facility failed to ensure call lights were answered in a timely manner for 1 of 3 sampled residents (#1) reviewed for call lights. This placed residents at risk for delayed care. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Call History report for Resident 1's room from [DATE] through [DATE] revealed on [DATE] at 6:24 PM Resident 1 activated her/his call light. It took staff 48 minutes to respond to the resident's request. On [DATE] 9:24 AM Witness 1 (Family) stated Resident 1 often reported staff took 45 minutes to answer her/his call light. It was an ongoing issue. Witness 1 stated there were no reported outcomes with the long wait times. On [DATE] at 1:42 PM Staff 2 (DNS) and Staff 3 (Administrator) indicated a timely call light response time would be approximately 15 to 20 minutes. Staff 2 and Staff 3 acknowledged Resident 1 had to wait 48 minutes before staff responded to her/his call light.

Based on interview and record review it was determined the facility failed to ensure a pharmacy recommendation was acted upon to ensure a laboratory test was obtained for 1 of 3 sampled residents (#4) reviewed for change in condition. Resident 4 was admitted to the hospital with a gastrointestinal (stomach/intestinal) bleed. Findings include: Resident 4 was admitted to the facility in 2022 with diagnoses included an infected knee replacement. Per Online Epocrates (web based medication reference): [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (prevents clots)-Avoid combination: combination may decrease [MEDICATION(S)] levels, efficacy; may increase risk of bleeding, including life-threatening affects. A September 2022 MAR revealed Resident 4 was administered [MEDICATION(S)] from 9/6/22 through 9/29/22 and [MEDICATION(S)] 9/9/22 though 9/22/22. The [MEDICATION(S)] was held on 9/23/22, 9/24/22 and 9/25/22 and administered on 9/26/22 and 9/27/22. A 9/13/22 pharmacy review form revealed the use of [MEDICATION(S)] and [MEDICATION(S)] should be avoided, as concurrent use may increase risk for clots. A recommendation was made to monitor the resident closely for blood clots and a recommendation was also made to monitor the [MEDICATION(S)] plasma level to assess the therapeutic level. The resident's nurse practitioner agreed to the recommendations and signed the orders on 9/15/22. On 10/10/22 at 10:31 AM Witness 2 (Pharmacy Consultant) stated depending on the pharmacy reference used, one reference could indicate the combination affects of [MEDICATION(S)] and [MEDICATION(S)] could lead to increased clotting and another could indicate increased bleeding, Witness 2 verified a recommendation was made for staff to obtain Resident 4's [MEDICATION(S)] plasma level. The resident's record indicated the resident was monitored for blood clots but did not indicate a [MEDICATION(S)] plasma level was obtained. A 9/30/22 Progress Note revealed the resident had a low red blood count, O2 sat was 90% (normal 95-100%) and had increased swelling and bruising to the right knee. The resident's physician was notified and the resident was sent to the hospital for evaluation and treatment. A 10/3/22 hospital Discharge Summary revealed the resident was identified to have severe [CONDITION(S)] on routine blood work and probable gastrointestinal (stomach/intestinal) blood loss due to antibiotic/[MEDICATION(S)] induced coagulopathy (inability to clot) which was probably due to [MEDICATION(S)]/[MEDICATION(S)] (antibiotic)/[MEDICATION(S)] interaction. The resident was administered two units of blood. On 10/7/22 at 1:03 PM Staff 4 (RNCM) stated after the pharmacy made a recommendation, the form was sent to the physician. After the physician reviewed the recommendation and signed the form, the nurse processed the order. Staff 4 stated the order for the [MEDICATION(S)] level was put in the computer but was then canceled. Staff 4 did not know the reason the order was canceled and acknowledged the [MEDICATION(S)] blood level was not obtained. A request was made to Staff 4 to provide a rationale for the discontinuation of the [MEDICATION(S)] plasma level. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a Significant Change MDS was completed when a resident was admitted to hospice services for 1 of 1 sampled residents (#2) reviewed for hospice. This placed residents at risk for unidentified needs. Finding include: Resident 2 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Consent for Election for Hospice Benefit form revealed Resident 2 elected to receive hospice services with a start date of 12/14/21. Resident 2's record did not have a Significant Change MDS completed after 12/14/21. On 10/13/22 at 11:59 AM Staff 2 (DNS) acknowledged the Significant Change MDS was not completed 14 days after the resident elected to receive hospice services.

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 6 of 6 sampled residents (#s 4, 7, 19, 21, 22 and 24) reviewed for advanced directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 4, 7, 19, 21, 22, and 24 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 7/12/22 at 12:07 PM Staff 4 (Admissions Director) stated the facility did not have a process for discussing advance directives with residents upon admission to the facility. Staff 4 was unable to provide documentation or verify residents were notified of their right to formulate an advance directive. On 7/12/22 at 2:57 PM Staff 1 (Administrator) stated she expected residents are offered an advanced directive upon admission and that they are reviewed quarterly.

Based on observation, interview and record review it was determined the facility failed to obtain dental services for 1 of 1 sampled residents (#17) reviewed for dental. This placed residents at risk for dental pain and difficulty eating. Findings include: Resident 17 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/11/22 at 1:45 PM Resident 17 was observed with numerous missing teeth and the resident stated sometimes it was hard for her/him to eat food because of the missing teeth. Resident 17's 9/28/21 Dental CAA indicated the resident likely had dental caries (cavities) and the resident's diet was downgraded to mechanical soft textures. The resident would be scheduled by the Social Services department to be seen by the mobile dentist. A Progress Note dated 3/7/22 by Staff 3 (SSD) indicated Resident 17's medical information was sent to the mobile dentist and the resident and resident's family were notified the dentist would schedule the resident to be seen. A review of Resident 17's medical record revealed no further information regarding scheduling the resident for, or being seen by the dentist. On 7/12/22 at 12:33 PM Staff 3 stated the mobile dentist informed him they could not see the resident and the resident would have to make an appointment for an outside dentist. Staff 3 stated he told Resident's former RN Care Manager they needed to make the appointment. Staff 3 confirmed he did not document either of his discussions with the mobile dentist or the RN Care Manager. On 7/13/22 at 8:28 AM Staff 12 (RNCM) stated she was the RN Care Manager for Resident 17 for approximately three weeks. Staff 12 stated she had neither read nor conducted any dental assessments of Resident 17. Staff 17 had no additional information to provide regarding Resident 17's dental status.

Based on observation, interview and record review it was determined the facility failed to ensure medication was administered with a physician's order and ensure physician orders were followed for 2 of 5 sampled residents (#s 4 and 17) reviewed for skin impairment and medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 4 admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order dated 4/14/22 indicated Resident 4 was to receive [MEDICATION(S)] extended release daily for cardiac arrhythmia. Staff were to monitor the resident's heart rate and notify the physician of a heart rate greater that 85 bpm (beats per minute). Resident 4's 4/29/22 care plan indicated she/he had impaired cardiac function and interventions included to administer medications per physician order. Resident 4's 6/2022 and 7/2022 MARs indicated she/he received metropolol [MEDICATION(S)] and had a heart rate greater than 85 bpm on the following dates: - 6/4: 88 bpm - 6/14: 87 bpm - 6/15: 91 bpm - 6/24: 88 bpm - 6/25: 87 bpm - 6/26: 90 bpm - 7/1: 88 bpm - 7/9: 88 bpm There was no indication in the resident's medical record the physician was notified of a heart rate greater than 85 bpm for the dates identified. On 7/14/22 at 1:07 PM Staff 2 (DNS) acknowledged there was no indication the physician was notified of Resident 4's heart rate greater than 85 bpm for the dates identified. 2. Resident 17 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/11/22 at 1:14 PM Resident 17 was observed with a square shaped white patch or bandage approximately four inches by four inches in size on both lower legs. On 7/12/22 at 12:41 PM Staff 6 (RN) stated Resident 17 used [MEDICATION(S)] (pain medication) patches. Resident 17's current physician's orders revealed no order for [MEDICATION(S)] patches. On 7/12/22 at 12:41 PM Staff 6 confirmed the resident did not have a physician's order for [MEDICATION(S)] patches and stated the medication aide usually applied them to the resident. On 7/13/22 at 7:15 AM Staff 7 (CMA) stated Resident 17 received [MEDICATION(S)] patches to both knees for pain. Staff 7 stated she was probably the person who applied the patches to Resident 17 on 7/11/22. Staff 7 confirmed the resident did not have a physician's order for [MEDICATION(S)] patches.

Based on observations, interview and record review it was determined the facility failed to ensure aspiration precautions were followed for 1 of 3 sampled residents (#5) reviewed for nutrition. This placed resident at risk for aspiration. Findings include: Resident 5 was admitted to the facility in 2022 with diagnoses including cerebral infarction (stroke) and dysphagia (difficulty swallowing). Resident 5's 4/25/22 Admission MDS indicated Resident 5 had a swallowing disorder and received nutrition by a gastrostomy feeding tube (inserted through the stomach). A 6/29/22 physician order indicated Resident 5 was advanced to a puree texture with mildly thick liquids for lunch only and aspiration precautions which included no straws. Observations on 7/11/22 at 12:50 PM and 7/12/22 at 12:11 PM revealed Resident 5 was up in her/his wheelchair for lunch and with straws in her/his drinks. Resident 5 was able to drink thickened liquids using the straw with no choking or coughing. On 7/12/22 at 1:20 PM Staff 2 (DNS) stated to prevent risk of aspiration Resident 5 should not have straws in her/his drinks.

Based on interview and record review, it was determined the facility failed to ensure COVID-19 test results were documented in resident records for 4 of 5 sampled residents (#s 1, 3, 4 and 5) reviewed for COVID-19 outbreak testing. This placed residents at risk of incorrect COVID-19 surveillance and tracking information. Findings include: Review of Resident 1, 3, 4, and 5's records revealed bi-weekly COVID-19 test results conducted in 1/2022 were not documented in the residents' clinical records. In an interview on 2/4/22 at 2:50 PM, Staff 2 (DNS) and Staff 3 (Regional RN) were asked about COVID-19 testing and test results for residents. They stated resident COVID-19 test results were received from the lab used by the facility for COVID-19 testing but the results were not placed into individual resident records. They acknowledged COVID-19 test results were not in Resident 1, 3, 4 and 5's clinical records.

Based on interview and record review it was determined the facility failed to ensure a snack or meal was provided in a timely manner after rapid-acting insulin was administered for 1 of 1 sampled resident (#33) reviewed for medication errors. This failure resulted in Resident 33 experiencing a severe hypoglycemic (low blood sugar) event requiring emergency medical services and treatment at the hospital. Findings include: Resident 33 was admitted to the facility in 3/2021 and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 33 received Novolog insulin which the manufacturer identified as an injectable rapid acting insulin used to lower blood glucose and was administered subcutaneously within 5-10 minutes before a meal. On 4/6/21 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility scheduled administration times of 7:00 AM, 11:00 AM and 4:00 PM. The 4/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 33's blood sugar level average for the month of April was 190. On 4/7/21 at 6:59 PM nursing progress note revealed Resident 33 was slumped over in bed and difficult to wake. Emergency Medical Services (EMS) was called. The resident's blood sugar level was 31 (indicating severe [CONDITION(S)]) and an injection of [MEDICATION(S)] was administered. EMS arrived and transported the resident to the hospital emergency department. The 4/7/21 hospital emergency department discharge summary revealed Resident 33 was taken to the hospital emergency department for a hypoglycemic episode due to delayed administration of food after insulin administration. As a result, Resident 33 became unresponsive from severe [CONDITION(S)] with a blood sugar level of 31. An 4/8/21 at 8:47 AM nursing progress note revealed Resident 33 had a cough. An urgent chest x-ray was ordered to rule out aspiration, which staff felt might have been related to the previous night's episode of low blood sugar and emergent treatment. An 4/8/21 at 5:39 PM nursing progress note revealed chest x-ray results showed right lower lung mild infiltrate. Resident 33's temperature was 99.4 degrees and the resident reported coughing and shortness of breath. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's investigation on 4/8/21 of Resident 33's severe hypoglycemic event revealed a delay of 90 minutes from the administration of insulin at 4:00 PM to the arrival of the resident's dinner tray at 5:30 PM. On 4/29/21 at 1:48 PM Staff 7 (CNA) reported she was Resident 33's primary CNA on evening shift and was aware the resident was diabetic. Staff 7 stated on 4/7/21, dinner meal trays arrived by 5:30 PM (dinner meal trays were usually scheduled for 5:00 PM.) Staff 7 stated she noticed Resident 33's head was off to the side and the meal tray was not touched. Staff 7 realized the resident's blood sugars were low and notified the nurse. The nurse checked the resident's blood sugars which were reported as 31. EMS was immediately called. Staff 7 stated Resident 33 had a low blood sugar episode that evening due to too much of a time difference between when the resident received her/his insulin and the resident's dinner tray was served. Staff 7 reported Resident 33 stated I kept waiting and waiting for my tray. Staff 7 stated the resident recalled it was 5:20 PM before she blacked out. On 4/30/21 at 12:38 PM Staff 6 (LPN) acknowledged Novolog insulin was short acting and patients needed to eat within 30 minutes of administration. Staff 6 stated the protocol when administering Novolog insulin was to follow up after the injection to make sure the patient was not hypoglycemic. During an interview with Staff 2 (DNS) and Staff 4 (RNCM) on 4/30/21 at 5:05 PM, Staff 2 stated it was standard nursing practice and the nurse's responsibility to ensure the resident ate a meal within 15-20 minutes after an insulin injection was administered. Staff 2 confirmed Staff 6 failed to ensure Resident 33 ate food in a timely manner after Novolog insulin was administered. Staff 2 reported the scheduled times of 7:00 AM, 11:00 AM and 4:00 PM for blood sugar checks were initially chosen on admission. Staff 2 stated Resident 33 was upset and fearful the day after the incident occurred. Staff 2 stated as a result of the [CONDITION(S)], Resident 33 experienced an aspiration incident. Resident 33's chest x-ray showed mild lung infiltate and the resident received an antibiotic medication.

Based on interview and record review it was determined the facility failed to ensure adequate RN staffing for 5 of 29 days reviewed for sufficient RN staffing. This placed residents at risk for unmet medical needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 4/1/21 through 4/29/21 revealed five days without RN coverage on any shift. The identified dates were: - 4/3/21 - 4/5/21 - 4/11/21 - 4/17/21 - 4/25/21 During an interview on 4/30/21 at 11:23 AM with Staff 1 (Administrator) and Staff 3 (Staffing Director), the staff acknowledged the lack of RN coverage on the identified dates.

Based on interview and record review it was determined the facility failed to monitor fluid intake and address low fluid intake to maintain hydration status for 1 of 1 sampled resident (#140) reviewed for hydration. Resident 140 required hospitalization with [DIAGNOSES REDACTED]. Findings include: Resident 140 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A Hospital Discharge Order dated 4/21/16 directed Resident 140 was to have fluids restricted to 2000 cc per day and was to take 40 mg of [MEDICATION NAME], a diuretic pill, daily for [MEDICAL CONDITION]. A Fluid Restriction assessment dated [DATE] acknowledged the resident had been restricted to 2000 cc (2 Liters) of fluid per day. Daily Fluid intake documentation (total intake calculated by adding daily fluid consumed with all meals, snacks and medication administration), verified Resident 140 consumed less than half of the daily fluid limit amount ordered by the hospital physician upon discharge, on all but one day of her/his stay in the facility. She/he consumed 970 cc on 4/22/16, 620 cc on 4/23/16, 930 cc on 4/24/16, 990 cc on 4/25/16, 910 cc on 4/26/16, 820 cc on 4/27/16, 660 cc on 4/28/16, 340 cc on 4/29/16, 960 cc on 4/30/16 and 1240 cc on 5/1/16. Her/his average daily fluid intake was 844 cc while a resident in the facility. A lab report dated 5/1/16 confirmed the resident had an elevated creatinine level of 2.35 and BUN of 61, indicating dehydration and kidney failure. A Nursing Progress Note dated 5/2/16 stated Resident 140 had increased lethargy and loose stools. She/he had been seen by the physician on 4/29/16 where an attempt to draw a lab sample was unsuccessful. Labs were drawn at the facility and results were received. Based on those lab results, the physician requested the resident to be sent to the emergency department for evaluation and treatment of [REDACTED]. A Hospital Inpatient Progress Note dated 5/3/16 stated Resident 140 presented with [MEDICAL CONDITION]. In an interview on 5/3/16 at 10:10 am, Witness 2 (Family) stated she/he had asked staff to give Resident 140 water and felt the resident was dehydrated. She/he stated her/his concerns had been voiced to several staff members. Witness 2 stated she/he had taken the resident to the hospital on [DATE] and the resident was admitted with dehydration and [MEDICAL CONDITION]. Witness 2 stated the resident was not dehydrated when she/he was admitted to the facility. In interviews on 5/4/16 at 8:02 am and 5/5/16 at 10:45 am, Staff 7 (RN) stated Resident 140 did not always drink her/his fluids and confirmed Witness 2 had reported to her Resident 140 was not dehydrated when admitted to the facility, but she/he was concerned the resident had become dehydrated. Staff 7 stated that they were more concerned about a resident getting too much fluid when on a fluid restriction and might not focus on getting too little fluid. In an interview on 5/4/16 at 9:43 am Staff 6 (CNA) stated she had never witnessed the resident drink more than 120 cc of fluid and the resident did not like thickened liquids. Staff 6 also verified that she had not notified anyone of Resident 140 having low fluid intake. In an interview on 5/4/16 at 10:05 am Staff 5 (CNA) confirmed Resident 140 did not drink much fluid because she had not liked the thickened liquid. In an interview on 5/4/16 at 1:03 pm Staff 4 (RNCM) confirmed Witness 2 had stated Resident 140 did not look right and she/he felt the resident was not receiving enough fluids. She stated she would expect staff to notify her within four to five meals if a resident had low fluid intake. She confirmed she did not receive any notification of low fluid intake for Resident 140 until Witness 2 voiced concerns on 4/28/16. In an interview on 5/6/16 at 10:09 am, Witness 1 (Physician) confirmed she was not notified of Resident 140's low fluid intake at any time prior to 4/28/16. She stated she was never made aware of the resident having orders for fluid restrictions. She confirmed dehydration and kidney failure may have been preventable had she been notified earlier of Resident 140 being on fluid restrictions and having had low fluid intake.

Based on observation, interview and record review it was determined the facility failed to ensure care planned fall interventions were followed for 1 of 4 sampled residents (#1) reviewed for falls. Resident 1 sustained injuries which included an abrasion, bruises, skin tear, head injury, and experienced pain which impaired normal activities. X-rays were done to rule out fractures. Findings include: Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The Care Plan dated 2/19/10 included the resident was at risk for falls related to a history of falls, gait disturbance and limited mobility. Interventions included a 2 person assist for bed mobility and transfers. An Incident Report dated 4/17/13 indicated Resident 1 was left sitting on the side of the bed while Staff 1, CNA went to get a Sara Lift to assist the resident to bed. When reentering the room Staff 1 heard the resident call out to "hurry." She saw the resident on the floor on her/his stomach, with her/his head on the floor. Resident 1's documented statement in the 4/17/13 Incident Report included "The staff went to get something and sort of left me there on the edge of the bed... I told them to hurry hurry." The Incident Report indicated the resident had the following injuries from the fall: Abrasion: Right knee 1 cm x 0.6 cm with bruise Bruise: Right knee 4.8 cm x 2.4 cm light purple/blue; Left side of forehead above eyebrow: 7 cm x 4.6 cm purple/blue Under left eye: 3 cm x 0.8 cm brown Skin tear: Left above elbow 2.4 cm x 0.6 cm Nurses' Progress Notes indicated on 4/17/13 at 7:30 pm the resident was found on the floor face down after sliding off the bed. A head injury was reported to the resident's physician. One hour after the fall, the resident complained of generalized pain and was given oxycodone 5 mg for pain severity of 7/10. At 9:18 pm the pain medication was noted as effective in reducing pain to a severity of 4/10. Nurses' Progress Notes on 4/18/13 included the following: 3:13 am - resident complained of pain "all-over" with a severity of 7/10. Pain medication given was "effective." 9:20 am - resident complained of pain with severity of 7/10 and oxycodone 5 mg was given; it was effective. 12:25 pm - resident was given pain medication for right upper extremity and right lower extremity pain related to the fall. A physician's orders [REDACTED]. 12:37 pm - physician responded with orders for treatment of [REDACTED]. 6:55 pm - physician's orders [REDACTED]. X-rays were done at 7:52 pm. On 5/10/13 at 11:00 am Resident 1 recalled the accident and stated the CNA left the resident sitting on the edge (of the bed). The resident told the CNA (she/he) was scared and the CNA said she would be right back. Resident 1 stated (she/he) went "straight down" and hit the left side of (her/his) face. The surveyor observed a discolored, swollen, raised area on the left side of the resident's forehead. The resident stated (she/he) had a black eye from the fall, and (she/he) might have "blacked out" when (she/he) hit the floor. Resident 1 also stated (she/he) stayed in bed for 1 - 2 days after the fall because of pain and discomfort from the fall. On 5/10/13 at 12:30 pm Staff 2, DNS stated the X-rays were negative for fractures. Staff 2 confirmed Staff 1 did not follow the care plan and the resident fell with injuries.

Based on interview and record review it was determined the facility failed to ensure professional standards of practice were followed related to care planned fall interventions for 1 of 4 sampled residents (#1) reviewed for falls. Resident 1 sustained injuries which included an abrasion, bruises, skin tear, head injury, and experienced pain which impaired normal activities. X-rays were done to rule out fractures. Findings include: 851-063-0030 Authorized Duties and Standards for Certified Nursing Assistants (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The Care Plan dated 2/19/10 included the resident was at risk for falls related to a history of falls, gait disturbance and limited mobility. Interventions included a 2 person assist for bed mobility and transfers. An Incident Report dated 4/17/13 indicated Resident 1 was left sitting on the side of the bed while Staff 1, CNA went to get a Sara Lift to assist the resident to bed. The resident fell to the floor. The investigation by facility staff found Staff 1 did not follow the care plan for two person assist to transfer, to and from bed. Resident 1's documented statement in the 4/17/13 Incident Report included "The staff went to get something and sort of left me there on the edge of the bed... I told them to hurry hurry." The 4/17/13 Incident Report indicated the resident had the following injuries from the fall: Abrasion: Right knee 1 cm x 0.6 cm with bruise Bruise: Right knee 4.8 cm x 2.4 cm light purple/blue; Left side of forehead above eyebrow: 7 cm x 4.6 cm purple/blue Under left eye: 3 cm x 0.8 cm brown Skin tear: Left above elbow 2.4 cm x 0.6 cm Nurses' Progress Notes on 4/18/13 included the following: 3:13 am - resident complained of pain "all-over" with a severity of 7/10. Pain medication given was "effective." 9:20 am - resident complained of pain with severity of 7/10 and [MEDICATION NAME] 5 mg was given; it was effective. 12:25 pm - resident was given pain medication for right upper extremity and right lower extremity pain related to the fall. A physician's orders [REDACTED]. 12:37 pm - physician responded with orders for treatment of [REDACTED]. 6:55 pm - physician's orders [REDACTED]. X-rays were done at 7:52 pm. On 5/10/13 at 11:00 am Resident 1 recalled the accident and stated the CNA left the resident sitting on the edge (of the bed). The resident told the CNA (she/he) was scared and the CNA said she would be right back. Resident 1 stated (she/he) went "straight down" and hit the left side of (her/his) face. The surveyor observed a discolored, swollen, raised area on the left side of the resident's forehead. The resident stated (she/he) had a black eye from the fall, and (she/he) might have "blacked out" when (she/he) hit the floor. Resident 1 also stated (she/he) stayed in bed for 1 - 2 days after the fall because of pain and discomfort from the fall. On 5/10/13 at 11:50 am a voicemail was left for Staff 1, requesting an interview. No return call from Staff 1 was received. On 5/10/13 at 12:30 pm Staff 2, DNS stated X-rays were done and were negative for fractures. Staff 2 confirmed Staff 1 did not follow the care plan. Staff 1 was terminated and reported to the Oregon Board of Nursing for further investigation.