Lacamas Creek Post Acute

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that allegations of abuse were reported timely for 1 of 3 (Resident 1) sampled residents reviewed for abuse/neglect. This failure placed residents at risk for potential physical abuse, and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that trauma informed care was integrated into the care plan for 1 of 3 (Resident 1) sampled residents reviewed for trauma informed care. This failure placed residents at risk of not receiving mental health (MH) interventions that therapeutically supported the resident and could lead to a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative of a need to alter treatment significantly, for 1 of 3 sampled residents (Resident 1) reviewed for change in condition. This failure placed Resident 1 at risk of continued pain, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to follow physician orders to obtain daily weights, for 2 of 3 sampled residents (Resident 1 and Resident 2), with diagnosis of heart failure. This failure placed the residents at risk of worsening heart failure, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance with completing the advance directives (AD); and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 1 of 5 sampled residents (Resident 27) reviewed for ADs. This failure placed residents at a potential risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to initiate bowel interventions for 1 of 5 residents (Resident 27) reviewed for constipation. This failure to initiate interventions placed residents at risk of discomfort, experiencing health complications and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement infection control practices when providing wound care for 1 of 1 residents (Resident 28) reviewed for pressure ulcers. This failure placed residents at risk for potential infection and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected residents' health status and/or care needs for 3 of 21 sampled residents (39, 41, & 59) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 2 of 6 sampled residents (5 & 32) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews for 1 of 2 sampled Nursing Assistants (NA) (Staff G) whose personnel and training record were reviewed. These failures placed residents at risk for receiving care from unskilled staff.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement in a manner that residents understood for 2 of 3 sampled residents (28 & 46) reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a trial without consent, lack of adequate resolution of violation of rights and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed and without gaps between the mattress and bed rails for 1 of 3 sampled residents (22) reviewed resident beds. This failure placed residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff received Dementia training for 1 of 5 sampled staff (F) reviewed for staff in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 2 of 6 sampled residents (Residents 1 & 2) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food preparation dishes were properly cleaned and air dried to provide safe, sanitary food preparation when the kitchen was reviewed for sanitization and storage. This failure placed residents at risk of foodborne illness and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 9 of 13 sampled residents (2, 4, 10, 26, 48, 316, 318, 319 & 320) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice to the resident and/or the resident's representative at the time of transfer to the hospital for 9 of 13 sampled residents (2, 4, 10, 316, 318, 319, 320, 26 & 48) reviewed for bed hold notifications. This failure placed residents and/or their representatives at risk of not being informed regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were individualized to promote the highest physical, emotional and psychosocial well-being and failed to ensure an anticoagulant care plan was in place for 4 of 7 sampled residents (2, 4, 8 & 45) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a negative impact on their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 3 of 3 sampled residents (26, 17 & 51) reviewed for activities. This failure placed residents at risk for becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility's activity program was directed by a trained and qualified activities professional for the ongoing assessment, development, and/or revision of individualized activity programs for the current activities scheduled in the facility for 1 of 1 Activity Directors (Staff G) reviewed for activities professional qualifications. This failure placed residents at risk for unmet recreation needs, boredom, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff responded to call lights in a timely manner to provide necessary care and services for 1 of 5 halls (300). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide daily nurse monitoring for side effects of anticoagulant use in 3 of 3 sampled residents (2, 8 & 46) reviewed for unnecessary medications related to anticoagulant use. This failure placed residents at risk of unidentified adverse side effects, poor outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication refrigerator temperature logs were consistently maintained in 2 of 2 sampled medication rooms and failed to ensure a multi-dose vial of PPD (purified protein derivative, a medication used in a skin test to diagnose tuberculosis, a contagious disease) was labeled appropriately with an open date for 1 of 2 sampled medications refrigerators (100 Hall Med Room) reviewed for medication storage. These failures placed residents at risk for receiving compromised or ineffective medications with unknown potency.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff properly wore N-95 masks for 1 of 4 nurses (Staff O) on the evening shift; preformed hand hygiene and implement hygienic use of gloves, and adhered to transmission-based precautions on 5 of 5 halls (Halls 100, 200, 300, 400 & 500) reviewed for infection control. These failures placed residents, staff and visitor at risk of contracting an infectious disease, developing infections and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided a pest free environment for 1 of 5 halls (400 Hall) reviewed for a clean, comfortable and homelike environment. This failure placed residents at risk of infectious disease and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure electronic discharged Minimum Data Set (MDS), a required assessment tool, were submitted to the Center for Medicare & Medicaid Services (CMS) within the required time frame for 1 of 1 sampled resident (53) reviewed for resident assessment. This failure placed residents at risk of not have an accurate assessment in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR, an assessment used to ensure individuals with serious mental illness, intellectual or developmental disabilities and/or related conditions receive appropriate placement and services) assessment was completed to reflect accurate mental health diagnoses and failed to obtain a Level 1 PASARR 30 days after an exempted hospital discharge for 2 of 5 sampled residents (41 & 26) reviewed for PASARR. These failures placed residents at risk for not receiving necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to include residents and/or their representative in care conferences and having input into care decisions for 1 of 7 sampled residents (Resident 51) reviewed for care plan revisions. This failure placed residents at risk of not being fully informed about care decisions, not being able to provide input about care and treatment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care with activities of daily living (ADLs) for dependent residents including fingernail care for 1 of 4 sampled residents (26) reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves.

Inspectors wroteBased on interview and record review, the facility failed to ensure bowel interventions were initiated and failed to ensure resident weight gain was reported to the physician as ordered for 2 of 6 sampled residents (60 & 4) reviewed for quality of care related to bowel management and weight gain. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement strategies for pressure ulcer prevention including turning and repositioning, air mattress, and zinc cream for 1 of 3 sampled residents (Resident 51) reviewed for pressure ulcer care. This failure placed residents at a high risk for recurrence of a recently closed pressure ulcer.

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen equipment was monitored and sanitary for 1 of 1 sampled resident (Resident 17) reviewed for respiratory services. This failure placed residents at risk for unsanitary oxygen equipment, respiratory infections and a poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health care and services for 1 of 1 sampled residents (41) reviewed for behavioral health services. This failure placed residents at risk for not receiving necessary services to meet their mental health needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for target behaviors for 1 of 5 sampled residents (Resident 4) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine was offered in a timely manner to 1 of 5 sampled residents (26) reviewed for immunizations. This failure placed residents at risk for developing pneumonia with potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 8 of 11 sampled residents (1, 2, 3, 4, 5, 6, 7 & 8) reviewed for ADLs for dependent residents. This failure placed residents at risk for poor hygiene and a diminished quality of life.