Citations in Oregon
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Oregon.
Statistics for Oregon (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Oregon
Surveyors observed that a CMA pre-prepared and stored multiple residents' medications in plastic cups labeled only with room numbers in a medication cart, including in the narcotic drawer, rather than storing them in their original packaging and locked compartments as required. The DON confirmed this was not proper medication storage.
Staff did not consistently follow transmission-based precautions for a resident with C. diff, including entering the room without PPE, failing to perform hand hygiene after contact, and allowing the resident to ambulate in common areas despite isolation requirements. Staff interviews confirmed knowledge of the protocols, but adherence was lacking.
A resident receiving duloxetine and Wellbutrin for depression was not informed of the risks and benefits of these psychotropic medications, as confirmed by the DON and a review of the medical record.
A resident with asthma and congestive heart failure was found to have a large section of missing sheet rock and debris behind their bed, resulting from the bed hitting the wall. The damage, which had been present for several months, was not repaired despite staff and maintenance being aware of the issue. The Administrator confirmed the repair was not completed in a timely manner.
A resident with a history of major depressive disorder and PTSD, who was cognitively intact, reported that staff mocked her delusions on multiple occasions. Although the resident shared these concerns with Social Services, no documentation or investigation occurred because the resident feared retaliation and did not want to file a grievance. The administrator was not informed of the allegations, resulting in a failure to investigate the reported mental abuse.
A resident with schizoaffective disorder, bipolar type, and probable developmental delay did not receive a required PASARR Level II assessment for serious mental illness and intellectual/developmental disability, despite recommendations and supporting documentation. Social services staff were unaware of the need to request the assessment, and the administrator confirmed it was not completed.
A resident with hearing impairment was left without properly fitting or working hearing aids, despite repeated reports to staff and documentation of the issue. Staff interviews revealed that the devices had not functioned since admission, and social services did not take steps to repair or replace them, resulting in the resident being unable to hear adequately.
A resident with limited mobility and a history of pleural effusion was not provided restorative services to maintain or improve range of motion after discharge from PT, despite expressing interest and being identified as a good candidate. Staff interviews revealed the resident was not enrolled in the restorative program due to a full caseload and lack of follow-up, resulting in the resident not receiving ROM exercises.
Staff were observed discarding used PPE in garbage bins located outside resident rooms, rather than inside as required by CDC Enhanced Barrier Precautions. Facility management had directed staff to follow this practice, and the RN Infection Preventionist confirmed the facility was not adhering to CDC guidelines, resulting in a failure to implement proper infection control measures.
The facility did not have an RN on duty for at least 8 consecutive hours on several days, as confirmed by staffing records and the administrator. This resulted in periods where residents' assessment needs may not have been met.
Improper Storage and Pre-Preparation of Medications in Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage of biologicals and medications in accordance with its own policies and accepted professional standards. During observation, six plastic medication cups containing medications and labeled only with resident room numbers were found in the top drawer of a medication cart, and an additional unlabeled medication cup with pills was found in the narcotic locked box of the same cart. These medications were pre-prepared for administration to multiple residents, including those receiving medications such as atorvastatin, gabapentin, sertraline, simvastatin, docusate, topiramate, dicyclomine, prazosin, senokot, trazodone, buspirone, Tylenol, calcium supplements, icosapent, baclofen, Prilosec, hydroxyzine, risperdal, sucralfate, morphine, dilaudid, aripiprazole, mirtazapine, and tamsulosin. A certified medication aide (CMA) acknowledged that she routinely prepped scheduled medications early and left them in the medication cart, labeling the cups with room numbers and placing them in the top shelf or narcotic drawer. She stated this was her usual process due to challenges in administering medications in a timely manner, and admitted it was not best practice. The Director of Nursing confirmed the presence of pre-prepped medications in the cart and acknowledged that this was not proper medication storage.
Failure to Follow Transmission-Based Precautions for Resident with C. diff
Penalty
Summary
Staff failed to consistently follow transmission-based precautions for a resident admitted with Clostridioides difficile (c-diff), who was on enteric precautions. Observations revealed that a CNA entered the resident's room without donning personal protective equipment (PPE) and subsequently exited the room, handled a lunch tray, and accessed common areas without performing hand hygiene. The CNA acknowledged awareness of the resident's precaution status but believed PPE was not required for meal delivery and admitted to not washing hands after leaving the room. Further observations showed another CNA provided care to the resident while wearing gloves but without a gown, and admitted to removing PPE before completing all care tasks. Additionally, the resident was observed ambulating in the hallway during a therapy session without PPE, despite being on transmission-based precautions and expected to remain in their room. Interviews with staff confirmed that education on precautions had been provided and signage was posted, but staff did not consistently adhere to the required protocols.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A resident admitted with a diagnosis of depression was prescribed duloxetine and Wellbutrin, both antidepressant medications, as indicated in the physician orders and medication administration record. Despite receiving these medications daily, there was no documentation in the medical record that the resident had been informed in advance about the risks and benefits associated with either medication. During an interview, the Director of Nursing confirmed that the resident had not been provided with this information.
Failure to Maintain a Homelike and Safe Resident Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who had been admitted with asthma and congestive heart failure. The resident's care plan included interventions to minimize exposure to asthma triggers. However, a large section of sheet rock was missing from the wall behind the resident's bed, with debris and dust scattered on the baseboard and floor. The resident reported that the damage was caused by the bed hitting the wall and that it had not been repaired. Staff interviews confirmed that the wall had been in disrepair for at least five and a half to eight months. The Maintenance Director acknowledged awareness of the issue but stated repairs had not been completed due to other projects. The Administrator also acknowledged the wall was not repaired in a timely manner.
Failure to Investigate Allegations of Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of mental abuse for a resident with major depressive disorder and post-traumatic stress disorder, who was cognitively intact. The resident reported that staff had mocked and made fun of her delusions on several occasions, and stated that she had reported these incidents to someone in April, but no action was taken. The resident expressed that the mocking had a negative mental impact and made her reluctant to report further delusions. Social Services staff confirmed that the resident reported staff making fun of her, but because the resident did not want to file a grievance due to fear of retaliation, no progress note was made and the concerns were not escalated to facility administration for investigation. The administrator was unaware of the allegations and acknowledged that all reports of abuse should be investigated, regardless of whether a formal grievance was filed.
Failure to Complete Required PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II evaluation was completed for a resident admitted with diagnoses including schizoaffective disorder, bipolar type, and probable developmental delay. A PASARR Mental Health Evaluation conducted indicated the need for a Level II assessment for serious mental illness and intellectual or developmental disability. Despite this recommendation and supporting documentation from a hospital discharge summary, there was no evidence in the resident's medical record that a PASARR Level II for intellectual or developmental disability was completed. During interviews, both the Social Services Director and Social Services Coordinator acknowledged they did not request the required assessment and were unaware of when such a request should be made. The Administrator confirmed that the assessment was not completed as required.
Failure to Ensure Resident Access to Functional Hearing Aids
Penalty
Summary
A resident with a history of bipolar disorder was admitted to the facility and was documented as being able to hear adequately with the use of hearing aids. However, progress notes indicated that the resident's hearing aids were not working at the time of admission and subsequently became broken. Despite the resident's repeated reports to staff that the hearing aids did not work and did not fit properly, no effective action was taken to repair or replace them. Staff interviews confirmed that the hearing aids had not fit or worked since admission, and the resident had not worn them for about a week due to their condition. The hearing aids, along with unused batteries, were found stored in a cup at the resident's bedside, and no sound was coming from them. Social services staff were either unaware of the resident's need for hearing aids or acknowledged knowing about the issue but did not make efforts to address it. The Director of Nursing Services stated that staff were expected to report such issues so that social services could intervene, but she was unaware of the problem. As a result, the resident was left without functional hearing aids, requiring others to speak loudly and closely to be understood, which the resident found overstimulating. This lack of action led to the resident not having access to necessary hearing assistance devices.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of pleural effusion, who had previously received physical therapy, was not offered restorative services to maintain or improve range of motion (ROM) after discharge from therapy. The resident expressed interest in continuing physical therapy or restorative services during a care conference, and a progress note indicated the resident would be a good fit for a restorative program. Despite this, there was no evidence in the clinical record that restorative services were provided. The resident reported not receiving physical therapy for over two months and not being offered ROM exercises, even though they wished to participate in restorative services. Staff interviews revealed confusion and lack of follow-through regarding the resident's enrollment in restorative services. One CNA believed the resident was receiving restorative care but had not observed participation, while another confirmed the resident was not on the restorative list. The restorative aide stated the resident was discussed for possible inclusion but was not added due to a full caseload. The RN case manager was unsure why the resident was not enrolled after expressing interest, and the regional administrator acknowledged the expectation that residents who express interest should be offered restorative services.
Failure to Follow CDC Enhanced Barrier Precautions for PPE Disposal
Penalty
Summary
The facility failed to follow CDC Infection Control Guidelines related to Enhanced Barrier Precautions for all 13 sampled resident rooms reviewed for infection control. Specifically, the CDC's guidelines require that a trash bin for discarding personal protective equipment (PPE) be placed inside the resident room and near the exit, so that used PPE can be removed and discarded prior to exiting the room. However, observations revealed that in each of the sampled rooms, the garbage bins for used PPE were placed outside the resident rooms in the hallway, rather than inside as required. Staff were observed donning PPE, entering resident rooms, and then doffing and discarding used PPE in bins located outside the rooms after exiting, contrary to CDC guidelines. Interviews with staff confirmed that they had been instructed by facility management to discard used PPE in garbage bins outside the resident rooms. The RN Infection Preventionist acknowledged that the facility was not following CDC guidelines regarding the placement of garbage bins for PPE disposal. These actions and facility practices resulted in a failure to implement proper infection prevention and control measures as outlined by the CDC, placing residents at risk for exposure to infections and cross-contamination.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for at least 8 consecutive hours per day, 7 days per week, as required. Review of the Direct Care Staff Daily Report showed that there were no RNs scheduled on five specific dates within the 34-day review period. This was confirmed by the facility administrator, who acknowledged the absence of RN coverage on those dates. The lack of RN coverage placed residents at risk for unmet assessment needs during those times.
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