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F0584
D

Failure to Protect Resident Property and Ensure Comfortable Sound Levels

Portland, Oregon Survey Completed on 09-22-2025

Penalty

No penalty information released
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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 maintain a homelike environment by not exercising reasonable care for the protection of residents' personal property and by not ensuring comfortable sound levels for residents. One resident, admitted with Parkinsonism and cognitively intact, reported missing personal items such as dress shirts and pants shortly after admission. The resident and a family member stated that the missing items were reported to multiple staff members, but no action was taken to recover or replace the items. Interviews with CNAs revealed a lack of training on handling missing property, and the Housekeeping/Laundry Supervisor acknowledged frequent mix-ups of resident belongings due to high staff turnover and agency staff usage. The Administrator stated that missing items should be reported and replaced within seven days, but was unaware of the specific case involving this resident. Another resident, admitted with gram-negative sepsis and anxiety disorder and with moderate cognitive impairment, experienced significant sleep disruption due to excessive noise from a neighboring resident's television. The neighbor, who also had moderate cognitive impairment and preferred watching television, played the television at a volume that was clearly audible in the affected resident's room, even with doors closed. The affected resident reported only sleeping about three hours per night and expressed distress over the situation. Multiple staff and a private caregiver confirmed ongoing complaints about the noise, and staff interventions such as providing headphones were only temporarily effective, as the neighbor eventually stopped using them and continued to play the television loudly. Staff interviews indicated that complaints about the noise were reported to CNAs and, in some cases, to nurses, but the issue persisted. The Administrator acknowledged awareness of the situation and stated that headphones had been provided, but was not fully aware of the extent of the problem at night. The facility's failure to address these issues resulted in a lack of a homelike environment, lost sleep, and unaddressed loss of personal property for the residents involved.

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