Oregon Living and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy for obtaining vital signs for residents receiving skilled services for 3 of 3 residents (R1, R2, R3) reviewed for quality of care in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's pain was managed for 1 of 3 (R1) residents reviewed for pain in the sample of 5.

Inspectors wroteThe facility failed to ensure accurate reconciliation and disposition of controlled substances. The facility also failed to have adequate policies for the reconciliation and disposition of controlled substances. These failures resulted in the facility being unable to account for a resident's controlled substances. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to prevent the diversion of a resident's controlled substance. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of misappropriation of resident property to the State Agency as well as local law enforcement. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent a confused resident (R1) from wandering into another resident's (R2) room. This failure resulted in both residents being found in bed together and R2 was inappropriately exposed. This failure affected one (R1) of three residents reviewed for quality of care in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a dermatologist referral was sent when residents were experiencing skin rashes as ordered by the physician for six of ten residents (R1, R7, R8, R9, R10) reviewed for quality of care in the sample of ten.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was prepared appropriately to meet the needs of a resident with chewing difficulties for 1 of 3 residents (R1) reviewed for therapeutic diets in the sample size of 3. This failure resulted in R1 receiving diced ham instead of ground ham as recommended for a mechanical soft diet per facility's dietary spreadsheet recommendations and led to R1 having a choking episode.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident refrigerator was kept at a temperature at or below 41 degrees Fahrenheit. This applies to all residents in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot liquids were served at a safe temperature for all residents residing in the facility, failed to ensure a resident was transferred with a gait belt for 1 resident (R41).

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross contamination during incontinence care, thoroughly clean a glucometer and blood pressure wrist cuff after use, and ensure hand hygiene was completed during medication administration for 4 of 4 residents (R73, R1, R60, & R10) reviewed for infection control in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of misappropriation of resident property to the local health department and failed to report two allegations of misappropriation of resident property to the local authorities. This applies to 2 of 3 residents (R54 and R61) in the sample of 36.

Inspectors wroteThe facility failed to ensure hospice interventions were implemented as ordered for 1 of 1 resident (R6) reviewed for hospice in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete weekly wound assessments for a resident (R5), failed to identify a new pressure ulcer for a resident (R5), failed to develop a pressure ulcer care plan for a resident (R39). These failures apply to 2 of 4 residents reviewed for pressure ulcers in the sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to obtain accurate weights for a resident, failed to implement dietician recommendations for a resident. These failures apply to 1 of 1 residents (R44) reviewed for nutrition in the sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a cognitively impaired resident was treated with dignity and respect by not preventing a staff member from communicating to the resident (R1) in an inappropriate and unprofessional manner while providing personal care services. This failure affected 1 of 4 (R1) residents reviewed for dignity in a sample size of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's peripheral intravenous access site was flushed for 1 of 1 residents (R1) reviewed for intravenous catheters in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment for 4 of 4 residents (R1, R2, R6, R7) reviewed for residents rights in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dishes were submerged in the sanitizing sink for at least 60 seconds and failed to ensure sanitized dishes were handled with clean hands. This has the potential to effect all 66 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure opened, multi-dose vials/bottles of medication, including insulin pens and eye drops, were labeled with expiration dates for 5 of 5 residents (R15, R23, R41, R59, R14) reviewed for medication storage in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving a pureed diet received a full four ounce (oz) scoop of pureed hamburger. This applies to 4 of 4 residents (R26, R24, R8, R55) reviewed for pureed diets in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to implement and follow Enhanced Barrier Precautions (EBP) for 4 of 17 residents (R51, R10, R13, R14) reviewed for infection control in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure professional standards were met by nursing during medication administration. This failure applies to 1 of 3 residents (R23) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with dysphagia was assessed by speech therapy after a choking episode and failed to ensure residents were transferred in a safe manner. These failures apply to 3 of 17 residents (R10, R51, R40) reviewed for safety and supervision in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a resident's urinary catheter tubing and urinary drainage bag below the level of a resident's bladder to prevent infection for 1 of 4 residents (R51) reviewed for urinary catheter care in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were monitored during medication administration for 2 of 17 residents (R53, R19) reviewed for medication administration in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to respond to the pharmacist's notification that a resident's PRN (as needed) anti-anxiety medication order had no end date. This failure applies to 1 of 5 residents (R6) reviewed for psychotropic medications in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure as needed (PRN) anti-psychotic medications had a stop date of fourteen days. This applies to 2 of 5 residents (R56, R6) reviewed for unnecessary medications in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications on time and as ordered. There were 28 medication administration opportunities with 5 errors resulting in a 17.86% error rate. This failure applies to 1 of 3 residents (R23) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' medications were administered as prescribed to avoid significant medication errors for 2 of 17 residents (R23, R25) reviewed for medication administration errors in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident with dementia in a manner to prevent choking on a non-food item for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency. This failure resulted in R10 requiring emergency care after choking on pizza. This applies to 1of 19 (R10) residents reviewed for mechanically altered diets in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was a Registered Nurse (RN) working 8 hours a day, 7 days a week. This affects all the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dishwasher sanitization levels were maintained. This affects all the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed food was made in a way to conserve flavor and nutritive value for 10 residents (R1, R2, R9, R10, R19, R20, R25, R36, R47, R58) on pureed diets.

Inspectors wroteBased on observation, interview and record review the facility failed to have preventive measures in place or follow the wound care physician orders for a resident with a stage II pressure ulcer for 1 or 1 residents (R23) reviewed for pressure ulcers in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were safely positioned in their wheelchairs for 2 of 6 residents (R59 and R19) reviewed for safety and supervision in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored in a manner to prevent cross contamination, failed to document the rate of oxygen administration, and failed to document the rationale and assessment for a resident receiving oxygen for 1 of 1 resident (R5) reviewed for oxygen administration in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care and before touching anything else in the resident's room for 1 of 3 residents (R45) reviewed for infection control in the sample of 19.