Every finding on record at Willamette Community Health Solutions

Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator, Compliance Coordinator and Facilities Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 418). Findings include: On 6/17/2024, during record review between 11:00 am and 12:15 pm, the facility failed to develop and implement EP policies and procedures, based on the risks identified in the Hazards Vulnerability Assessment (HVA). Surveyor was accompanied by the Facility Administrator, Compliance Coordinator and Facilities Staff who acknowledged the existence of these conditions.

Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator, Compliance Coordinator and Facilities Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 418). Findings include: On 6/17/2024, during document review between 11:00 am and 12:15 pm, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include defined policies and/or protocols for medical, and pharmaceutical supplies of staff. Surveyor was accompanied by the Facility Administrator, Compliance Coordinator and Facilities Staff who acknowledged the existence of these conditions

Based on document review and interviews during the survey, it was determined through ongoing dialog with the Facility Administrator, Compliance Coordinator and Facilities Staff that the facility failed to comply with the Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 418). Findings include: On 6/17/2024, during record review between 11:00 am and 12:15 pm, the facility failed to provide a defined system to track the location of on-duty staff during an emergency. Surveyor was accompanied by the Facility Administrator, Compliance Coordinator and Facilities Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator, Compliance Coordinator and that the facility failed to maintain exit illumination on emergency power for a minimum of 1-1/2 hour duration annually for the entire facility. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.9.1 and 7.9). Findings include: On 6/17/2024, during record review between 12:30 pm and 1:30 pm, there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility. Surveyor was accompanied by the Facility Administrator, Compliance Coordinator, and Facilities Staff who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Facility Administrator, Compliance Coordinator and Facilities Staff that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 – 19.7.1.7). Findings include: 1. On 6/17/2024, during record review between 12:30 pm and 1:30 pm, the facility had no documentation for fire drills conducted for 2nd quarter day shift and 1st quarter, 3rd quarter, and 4th quarter night shift. 2. On 6/17/2024, during record review between 12:30 pm and 1:30 pm, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire and Staff Performance during the drill. Surveyor was accompanied by the Facility Administrator, Compliance Coordinator, and Facilities Staff who acknowledged the existence of these conditions.

Based on interview and record review, it was determined the hospice interdisciplinary group failed to revise and document the individualized plan of care as frequently as the patient's condition required for 1 of 22 patients reviewed (Patient #12). --- Findings: Review of the RN routine visit titled "Visit Details," dated 05/24/2024, revealed in the "SAFETY" section "Fall was witnessed peripherally by caregiver; unable to tell what caused the fall. [Patient] had almost all of the skin on the top of [patient's] hand torn off, a skin tear to [patient's] elbow and another on [patient's] arm." Review of the "Physician Order Form" dated 05/31/2024, revealed "Wound care: Orders for home upon discharge today 4pm. 1. Gently clean areas with NS and pat dry. 2. Place ABD pad over open areas on hand and wrist. Place non-stick telfa pad above elbow. 3. Wrap hand, arm and elbow with gauze. Use coban over the gauze wrapped loosely. Cover all with compression tube. [Skilled Nurse] to assess and measure weekly. Change daily or sooner if wet." Review of the "Patient Activity" dated 06/05/2024 "IDT: Q2wk" meeting under section "Prep Notes" revealed, "[Patient #12's name] is the 71 yo pt of [physician's name], living at home with [their spouse], on hospice for Parkinson's disease without dyskinesia, with fluctuations. [Patient #12] recently returned home after a respite at [facility name] while [the spouse] had surgery. [Patient #12] had 3 falls while at EH resulting in minor injuries. [Patient #12] was very agitated in the environment and [their] quetiapine was increased in an effort to calm [Patient #12]. It has been adjusted down since returning home. [Patient #12] has a consistent tremor of both hands. [Patient #12] is often confused about time and place. SN will continue to follow weekly and PRN. [nurse's name], RN Case Manager." Under section "Summary," revealed, "POC reviewed in IDT meeting. Patient remains eligible for Hospice services at this time per IDT." The section for "Actions Taken" was blank. The IDT meeting and the plan of care failed to address the presence of wound and the wound care Patient #12 was receiving. During an interview with Employee #2 on 6/14//2024 beginning at 10:30 AM, the above finding was discussed. Employee #2 searched the medical record for additional information and stated, "Yes, the IDT doesn't talk about care planning of those injuries."

Based on interview and medical record review, it was determined the hospice failed to ensure that care and services were provided in accordance with the care plan for 1 of 22 active patient records reviewed (Patients #12). --- Findings: Review of the "PLAN OF CARE" revealed Patient #12 was admitted on 03/05/2024 with a terminal diagnosis of Parkinson's Disease. The "Physician Order Form," dated 05/25/2024, revealed "Wound care: Orders for home upon discharge today 4pm. 1. Gently clean areas with NS and pat dry. 2. Place ABD pad over open areas on hand and wrist. Place non-stick telfa pad above elbow. 3. Wrap hand, arm and elbow with gauze. Use coban over the gauze wrapped loosely. Cover all with compression tube. SN to assess and measure weekly. Change daily or sooner if wet." Review of an RN visit titled "Visit Details," dated 05/31/24, revealed wound assessment for wounds 1, 2, and 3. The assessment failed to include measurements as ordered in the physician order to measure weekly. Wound assessments were completed but measurements of the wounds were not performed on RN visits on 05/31/2024, 06/01/2024, and 06/10/2024. During an interview on 6/14/2024 10:30 AM, Employee #2 was made aware of and acknowledged the findings.

Based on interview and record review, it was determined that the agency failed to ensure the temperature for four patient freezers was consistently recorded in the temperature log. --- Review of the document dated May 2024 and titled "TEMP LOG" revealed, on dates 5/4/204, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 5/29/2024, 5/30/20024, and 5/31/2025 the temperature log for PT (patient) fridge, PT freezer, PT back freezer, Family Fridge and Freezer were left blank. Similar findings were observed for the previous 12 months beginning with June 2023 to April 2024. During an interview on 5/28/2024 at 4:00 PM, Employee #3 stated, "It has been a battle to have them [nurses and CNA's] write the temperature in the log on weekends when the cook is not here."