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F0679
D

Failure to Provide Person-Centered Activities for Residents

Portland, Oregon Survey Completed on 04-28-2025

Penalty

Fine: $149,783
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing, person-centered activity program for two of three sampled residents, resulting in unmet psychosocial and quality of life needs. For one resident with dementia, assessments and care plans indicated preferences for activities such as reading, listening to music, spending time outdoors, and participating in religious services. Despite these documented preferences, the resident was frequently observed alone in their room, either in bed or in a wheelchair, often yelling for help. There were no books, newspapers, magazines, music, or TV available in the room, and the resident was not observed participating in group or one-to-one activities. Staff interviews confirmed the absence of activity materials and a lack of engagement with the resident's stated interests, with staff unaware of or not providing the preferred activities. Another resident, admitted with necrotizing fasciitis, had an activity assessment and care plan indicating the importance of listening to music, keeping up with the news, and having reading materials. Observations revealed that this resident was also left in their room without music, TV, or other activity materials, and staff did not offer to assist with turning on the TV or music. The resident expressed not knowing what activities were available and indicated interest in listening to music, podcasts, or audiobooks, but these were not provided. Staff interviews further revealed a lack of awareness of the resident's preferences and a failure to offer or facilitate the use of available activity resources. The facility's own policy required activities to be based on comprehensive, resident-centered assessments and to reflect individual preferences, with documentation in the medical record. However, both direct observation and staff interviews demonstrated that these requirements were not met for the two residents, as their preferences were not honored and activity materials were not provided or facilitated, despite being documented in their care plans and assessments.

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