The findings of the complaint (Intake #s 26395, 26756 and 27055) health survey conducted 2/3/21 through 2/17/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
The sample was comprised of 5 current residents and 1 closed record. The facility had a census of 83 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake #s 26395, 26756 and 27055) health survey conducted 3/22/21 through 3/23/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on interview and record review it was determined the facility failed to provide bathing for 1 of 3 sampled residents (#2) who were reviewed for bathing assistance. This placed residents at risk for lack of personal hygiene. Findings include:
Resident 2 was admitted to the facility in 2020 with diagnoses including muscle weakness and pain.
On 10/6/20 at 3:50 PM Witness 2 (Complainant) stated when she/he saw the resident it looked like the resident was not bathed in a week or two.
A review of the resident's point of care bathing record revealed only one bath was documented as provided from 8/20/20 through 10/5/20.
A review of facility staff assignment sheets indicated the resident refused bathing on 8/26/20 and 9/28/20.
On 2/10/21 at 10:01 AM and 12:54 PM Staff 3 (Administrator) stated there were no additional bathing records and bathing was supposed to be charted by staff in the point of care system. Staff 3 stated residents were scheduled for two showers per week and if they refused a shower they were offered a bed bath.
1. Resident has discharged from the facility.2. Completed full house audit to ensure scheduled showers and bathing for all residents.3. All residents within 72 hours who admit to the facility are assigned a shower and bathing schedule and put in task for documentation.4. DNS or Designee will perform weekly audits to be completed every Friday to ensure showers are given and all refusals are documented. A risk and benefits will be discussed with the patient and/or family for multiple refusals.5. The results of the audits will be presented to the QA committee for tracking for two quarters.
Based on interview and record review it was determined the facility failed to provide wound care for 1 of 3 sampled residents (#2) who were reviewed for wound treatment. This placed residents at risk for infection and delayed healing. Findings include:
Resident 2 was admitted to the facility in 2020 with diagnoses including anxiety.
On 10/6/20 a public complaint was received which alleged Resident 2 developed facial sores due to poor hygiene. Witness 2 (Complainant) stated Resident 2 picked at her/his face but the sores appeared as though they were not cared for.
Resident 2's Progress Notes revealed:
- On 9/8/20 the resident had multiple scabs on the forehead, chin and cheeks.
- On 9/15/20 the resident had scattered scratches on the face.
- On 10/1/20 the resident had visible, itchy skin lesions (wounds) on the face.
A review of Resident 2's Progress Notes from 9/8/20 through 10/5/20 and the resident's September and October TARs revealed no comprehensive wound assessments, wound treatment orders or wound care provided for the resident's facial wounds.
On 2/10/21 at 12:54 PM - Staff 3 (Administrator) and Staff 4 (LPN) stated Resident 2 had wounds all over her/his face and confirmed there were no wound care orders or treatments.
1. Resident has discharged from the facility.2. Complete full house skin audit for all residents.3. Shower audit sheets will be utilized with showers and documented on our shower/skin audit forms.4. In-service C.N.A's and Nurses on utilizing shower/skin audit sheets.5. DNS or Designee will perform 5 random weekly audits to ensure skin issues are addressed and treatments are in place.6. The results of the audits will be presented to the QA committee for tracking for two quarters.
The findings of the complaint (Intake #s 26395, 26756 and 27055) health survey conducted 2/3/21 through 2/17/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 2/17/21.
The sample was comprised of 5 current residents and 1 closed record. The facility had a census of 83 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the revisit complaint (intake #s 26395, 26756 and 27055) health survey conducted 3/21/22 through 3/23/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-086-0100 Nursing Services: Resident Care
Refer to F677
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OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
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