Hood River Post Acute

Inspectors wroteBased on Interview and record review it was determined the facility failed to ensure residents using psychotropic medications received gradual dose reductions for 4 of 5 sampled residents (#s 4, 8, 9, and 71) reviewed for medications. This placed residents at risk for unnecessary uses of psychotropic medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 2 of 2 sample residents (#s 10 and 14) reviewed for advance directives. This placed residents at risk for healthcare decisions to be in conflict with resident wishes.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure privacy was maintained when care was provided for 1 of 3 sampled resident (#11) reviewed for dignity. This placed residents at risk for a lack of privacy during care. Findings involved:The facility's Resident Rights Policy from 8/2019 revealed:-Employees shall treat all residents with kindness, respect, and dignity. Federal and states laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 4 sampled residents (#82) reviewed for discharge. This placed residents at risk for lack of medical services.

Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#83) reviewed for accidents. This placed residents at risk for further falls.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received care and services related to the use of an indwelling catheter for 1 of 2 sampled residents (#56) reviewed for catheter care. This placed residents at risk for catheter care complications.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain healthy parameters of nutritional status for 1 of 2 sample residents (#10) reviewed for nutrition. This placed residents at risk for impaired nutrition.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure precautions were in place for 1 of 6 sampled hallways (400 hall) reviewed for enhanced barrier precautions. This placed the residents at risk of acquiring an infection.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to store foods at appropriate temperatures for 1 of 3 kitchen refrigerators reviewed for food safety. The facility's failure was determined to be an immediate jeopardy situation because raw meat stored outside of an acceptable temperature was planned to be used for an upcoming meal.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents for 1 of 2 units observed for required postings. This placed residents at risk for lack of information on how to file a complaint or how to report concerns.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure sanitary laundry services were provided for 2 of 6 halls reviewed for infection control. This placed residents at risk for cross contamination.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a consent was obtained prior to administering antidepressant medications to residents for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 2 sampled residents (#6) reviewed for care planning. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were allowed to retain personal possessions for 1 of 1 sampled resident (#9) reviewed for choices. This placed residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents had access to their personal funds on an ongoing basis for 2 of 2 sampled residents (#s 1 and 9). This placed residents at risk for lack of access to personal funds.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a homelike environment and adequate hot water temperatures for 1 of 1 facility shower room reviewed for a homelike environment. This placed residents at risk for a cluttered and damaged shower environment as well as cold showers.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 2 sampled residents (#s 9 and 26) reviewed for PASARR. This placed residents at risk for not receiving specialized services.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 2 of 4 sampled residents (#s 14 and 35) reviewed for weights and assistive devices. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an on-going program to support individual activity interests and preferences for 1 of 2 sampled residents (#25) reviewed for activities. This placed residents at risk for lack of social interaction and isolation.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while transferring residents for 1 of 1 sampled resident (#31) reviewed for accidents. This failure resulted in avoidable skin tears to Resident 31's right arm.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 2 sampled residents (#1) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#101) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure adequate supervision and a safe environment for 1 of 3 sampled residents (#100) reviewed for elopement. This placed residents at risk for injury from accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food was served at an appetizing temperature for 3 of 4 halls and 3 of 3 sampled residents (#s 10, 40 and 350) reviewed for food. This placed residents at risk for an unappetizing dining experience.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents' care-planned interventions were followed for 1 of 1 sampled resident (#45) identified with a fall with injury. As a result, Resident 45 sustained a left arm fracture on 12/23/19. The facility identified the noncompliance and immediately initiated a plan of correction which included staff education, staff reminders to read residents' care plans daily and implement care planned interventions and no further accidents occurred. This incident was identified as meeting the criteria for past noncompliance.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor, obtain physician's orders and failed to implement a treatment for 1 of 1 sampled resident (#350) reviewed for pressure ulcers. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's food preference was honored for 1 of 3 (#40) sampled residents reviewed for food. This placed residents at risk for food preferences not being honored.

Inspectors wroteBased on interview and record review it was determined the facility failed to document interventions to ensure resident's privacy was respected for 1 of 1 sampled resident (#41) reviewed for privacy. This placed residents at risk for an incomplete clinical record and unmet needs.