Forest Grove Post Acute

Inspectors wroteBased on interview and record review it was determined the facility failed to provide medication per the physician order for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of needed medication.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain orders related to unplanned removal of an indwelling catheter for 1 of 1 sampled resident (#1) reviewed for catheter care. This placed residents at risk for urinary retention.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure PRN psychotropic medication orders were discontinued after 14 days for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary psychotropic medication and adverse side effects of psychotropic medication.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assess residents for smoking safety and provide supervision for smoking residents for 2 of 3 sampled residents (#s 57 and 78) reviewed for accidents. This placed residents at risk for smoking related accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 5 of 7 sampled residents (#s 13, 15, 16, 17 and 19) reviewed for respiratory care. This placed residents at risk for respiratory complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#4) reviewed for pressure ulcers. This failure resulted in Resident 4's pressure ulcer worsening.

Inspectors wroteBased on Interview and record review was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNAs (#14, 18, 19, 20 and 21) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 7 out of 30 days reviewed for staffing. This placed residents, the public and staff at risk for lack of accurate staffing information.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 1 of 1 medication storage refrigerator reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy.

Inspectors wroteBased on interview and record review, it was determined the facility failed to treat residents with dignity and respect for 1 of 2 sampled residents (#32) reviewed for dignity. This placed residents at risk for lack of dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely fashion for 1 of 3 sampled residents (#29) reviewed for Beneficiary Protection Notification. This placed residents at risk for unknown financial liabilities.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide assistance with incontinence care in a timely manner for 2 of 3 residents (#s 30 and 56) reviewed for ADLs. This placed residents at risk of delayed assistance with personal hygiene and increased risk of skin impairment.

Inspectors wroteBased on interview and record review it was determined the facility failed to order home health and in home care giving service to ensure a safe discharge for 1 of 2 sampled residents (#4) reviewed for discharge. This placed residents at risk for unsafe discharge.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to have sufficient staff for residents who required one to one supervision for 1 of 1 sampled resident (#11) reviewed for behavioral health. This failure resulted in an immediate jeopardy situation in which Resident 11 was able to self-harm and was hospitalized .

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Staff 9 (RN), Staff 10 (LPN), Staff 17 (LPN), Staff 19 (RN) Staff 29 (LPN) and Staff 30 (RN) adhered to professional standards related to provision and documentation of treatments for 2 of 7 sampled residents (#s 23 and 225) reviewed for pressure ulcers and skin conditions. This failure resulted in Resident 23 experiencing a worsening pressure ulcer and placed other residents at risk for worsening skin conditions.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to implement interventions to prevent and treat pressure ulcers for 2 of 4 sampled residents (#s 23 and 268) reviewed for pressure ulcers. This resulted in Resident 23 experiencing a worsened pressure ulcer and placed residents at risk for the development of pressure ulcers.

Inspectors wroteBased on observation and interview it was determined the facility failed to store and handle food in a sanitary manner and to maintain kitchen equipment in sanitary condition in 1 of 1 kitchen reviewed. This placed residents at risk for food-borne illness.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a safe kitchen environment for residents, staff and visitors in the facility for one kitchen reviewed. This placed residents at risk for unmet safety needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure orders were in place to treat and monitor surgical sites and to provide bowel medication and treatment when indicated for 4 of 8 sampled residents (#s 28, 35, 53, and 225) reviewed for non-pressure skin conditions, constipation and unnecessary medication. This placed residents at risk for infection, worsening skin conditions and impacted bowels.

Inspectors wroteBased on observation and interview it was determined the facility failed to keep a resident room in good repair for 1 of 1 sampled resident (#27) reviewed for environment. This placed residents at risk for lack of a homelike environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident who was unable to carry out necessary ADLs received bathing to maintain personal hygiene for 1 of 1 sampled resident (#268) reviewed for ADL care. This placed residents at risk for a lack of hygiene.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure behavioral health plans were revised and to ensure behavior monitoring logs were complete for 2 of 2 sampled residents (#s 11 and 40) reviewed for mood and behavior. This placed residents at risk for a lack of complete assessment and care related to mental health needs 1. Resident 40 admitted to the facility in 2016 with diagnoses including bipolar disorder with psychotic features, and resided in the locked behavioral health unit (Unit). a. The 12/2/18 Behavioral Symptoms CAA indicated Resident 40 cycled with behaviors and often lashed out at staff. The CAA further indicated the resident could be difficult to redirect at these times. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately document in the medical record for 1 of 4 sampled residents (#23) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical documents and unmet needs.