DALLAS RETIREMENT VILLAGE HEALTH CENTER
Non profit - Other
121 Beds
Independent
Data: November 2025
Trust Grade
60/100
#53 of 127 in OR
Photo by Dallas Retirement Village
Photo by Dallas Retirement Village
Photo by Dallas Retirement Village
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Dallas Retirement Village Health Center has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #53 out of 127 nursing homes in Oregon, placing it in the top half of facilities in the state, and is #2 out of 2 in Polk County, meaning only one other local option is available. The facility is improving, with issues dropping from 31 in 2023 to just 4 in 2024, showcasing a commitment to better care. Staffing is a strength, earning a 4 out of 5 stars with turnover at 48%, which is just below the state average. While there have been no fines, some concerns were noted, such as wet laundry left in machines overnight and incomplete facility assessments that could affect care quality. Overall, the center has strengths in staffing and recent improvements but also needs to address certain procedural gaps.
- Trust Score
- C+
- In Oregon
- #53/127
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Oregon facilities.
- Skilled Nurses ✓ Good
- Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for Oregon. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 41%
No red flags
31 → 4 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 31 issues
2024: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Oregon average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 48%
Near Oregon avg (46%)
Higher turnover may affect care consistency
The Ugly 49 deficiencies on record
Dec 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
2. On 12/2/24 at 10:25 AM, a communal refrigerator in the facility's pantry area was observed with the following:
-One clear container filled with meat covered in gravy with no date.
-One clear conta...
Read full inspector narrative →
2. On 12/2/24 at 10:25 AM, a communal refrigerator in the facility's pantry area was observed with the following:
-One clear container filled with meat covered in gravy with no date.
-One clear container with a red top containing left over white cake with white and chocolate frosting with no date.
On 12/2/24 at 10:32 AM, Staff 1 (Administrator) stated it was her expectation food items were to be dated and labeled with the residents room number in which the item belonged to.
Based on observation and interview it was determined the facility failed to serve, store, and label food in a sanitary manner for 1 of 2 dining rooms and 1 of 2 facility refrigerators observed for dining. This placed residents at risk for contamination and at risk for food borne illness. Findings include:
1. On 12/4/24 at 1:00 PM, Staff 15 (Dietary Aid) was observed serving lunch in the second floor kitchen. While Staff 15 served a meal ticket fell off the serving station into the dining room. Staff 15 walked out of the kitchen, picked up the meal ticket with her gloved hand, returned to the kitchen with the meal ticket, placed it back on the service station, and touched multiple service items while wearing the same gloves. Staff 15 confirmed the meal ticket should not have been placed back on the service station once it fell on the floor and her gloves should have been changed after she touched the floor.
On 12/4/24 at 1:43 PM, Staff 16 (Dietary Manager) confirmed once the meal ticket fell it should not be placed back on the service station.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review it was determined the facility failed to ensure medication storage temperatures were logged and failed to ensure proper labeling of biologicals for 3...
Read full inspector narrative →
Based on observation, interview, and record review it was determined the facility failed to ensure medication storage temperatures were logged and failed to ensure proper labeling of biologicals for 3 of 3 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include:
1. On 12/4/24 at 9:15 AM, one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the nurses' station three medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening.
On 12/4/24 at 9:15 AM, Staff 11 (LPN) acknowledged the vial of tuberculin was open and not labeled with an open date.
On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for staff to label tuberculin with an open date.
2. On 12/4/24 at 8:56 AM, the nurses' station one hall medication room refrigerator temperature logs was observed to be blank from 11/1/24 through 11/25/24.
On 12/4/24 at 8:56 AM, Staff 12 (LPN) acknowledged the temperature logs were blank on the identified dates.
On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented from 11/1/24 through 11/25/24.
3. On 12/4/24 at 9:08 AM, the nurses' station two hall medication room refrigerator temperature logs was observed to be blank on 11/17/24 and 11/29/24.
On 12/4/24 at 9:08 AM, Staff 13 (RNCM) acknowledged the temperature logs were blank on the identified dates.
On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented on 11/17/24 and 11/29/24.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
5. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left...
Read full inspector narrative →
5. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight.
On 12/4/24 at 1:34 PM, Staff 8 (Laundry) stated his shift ended at 10:30 PM and he had the last shift of the day. Staff 8 stated when wet laundry was not completed in the washing machine at the end of his shift, he left the wet laundry in the washing machine overnight.
On 12/4/24 at 1:38 PM, Staff 9 (Laundry) stated her shift started at 5:30 AM and she transferred the wet laundry to the dryer and did not rewash the laundry.
On 12/5/24 at 1:24 PM, Staff 10 (Environmental Services Department Manager) stated wet laundry was left in the washing machine overnight and was placed in the dryer the next morning. The wet laundry was never rewashed as it would take too long to do so.
On 12/5/24 at 1:37 PM, Staff 1 (Administrator) stated she was unaware of a laundry policy regarding damp laundry left in the washing machine overnight.
3. Resident 83 admitted to the facility on 10/2024, with diagnoses including bilateral post-surgical femoral artery resection and repair.
On 12/1/24 Resident 83 tested positive for COVID and was placed on Contact and Droplet Precautions, signage at the door and personal protective equipment (PPE) cart was placed outside of the resident's door.
On 12/3/24 at 1:16 PM, observed Staff 19 (CNA) exit a resident room while wearing a face mask without completing hand hygiene and retrieved a lunch tray for Resident 83. Staff 19 donned gown and gloves and entered Resident 83's room. Staff 19 exited the room, doffed gown and gloves, kept the same face mask and went back to retrieve another lunch tray to deliver.
On 12/3/24 at 1:30 PM, Staff 19 acknowledged he should have sanitized his hands before and after handling the foods trays, worn full PPE and changed his face mask.
On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to complete hand hygiene before and after entering a resident room and wear full PPE when entering an isolation room to decrease the spread of COVID in the facility.
4. Resident 84 admitted to the facility on 11/2024, with diagnosis including clostridioides difficile (C. diff).
On 11/25/24 Resident 84 tested positive for COVID and was placed on Contact and Droplet Precautions, signage was placed on the resident's door, and personal protective equipment (PPE) cart was placed outside of the resident's door.
On 12/4/24 at 10:04 AM, Staff 20 (RN) was observed to place her face mask on the PPE cart without a barrier and entered the isolation room on the COVID hall. Staff 20 exited Resident 84's room and donned the same face mask she had put on the PPE cart.
On 12/4/24 at 10:10 AM, Staff 20 stated she should have put on a new face mask after exiting Resident 84's room.
On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to use and wear proper PPE at all times to decrease the spread of COVID in the facility.
2. Resident 33 admitted to the facility in 6/2020, with diagnoses including lung cancer.
On 12/02/24 at 2:18 PM, Resident 33's room was observed to have a sign which indicated staff were to follow enhanced barrier precautions when providing high contact activities, there was a cart outside the door which contained gloves, masks, and gowns.
On 12/3/24 at 1:16 PM, Staff 17 (CNA) entered Resident 33's room and assisted her/him in using a bedpan. Staff 17 wore gloves and a mask but did not wear an isolation gown.
On 12/3/24 at 1:21 PM, Staff 17 exited Resident 33's room, confirmed she assisted her/him with toileting. Staff 17 stated she knew Resident 33 required additional precautions previously, but she was told Resident 33 no longer needed the additional precautions.
On 12/4/24 at 9:50 AM, Staff 18 (CNA) entered Resident 33's room and assisted her/him in using the toilet. Staff 18 wore a mask and gloves but did not wear an isolation gown.
On 12/4/24 at 10:01 AM, Staff 18 was asked about Resident 33's enhanced barrier precautions, she stated the staff were to wash their hands instead of sanitizing, but was not aware of the need to wear a gown during any care activities.
On 12/4/24 at 2:20 PM, Staff 3 (Assistant Director of Nurses) stated the staff were to wear a gown, gloves and mask when they provided high contact care such as toileting for all residents on enhanced barrier precautions. Staff 3 confirmed Resident 33 was on enhanced barrier precautions and the staff should have worn gloves, gown, and a mask when they assisted her/him with toileting.
Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG glucometers were properly cleaned and sanitized between resident use, failed to follow transmission based precautions, and failed to process laundry to produce hygienically clean laundry to prevent the spread of infection for 4 of 6 sampled residents (#s 33, 80, 83, and 84) and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for bloodborne illness, exposure to infections, and contaminated laundry. Findings include:
1. The facility's 3/2024 Blood Glucose Monitoring policy indicated to follow the manufacturer instructions for cleaning and disinfection of the meter.
The Even Care G3 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes.
Resident 80 admitted to the facility in 2023 with diagnoses including diabetes.
On 12/2/24 at 11:34 AM, Staff 14 (LPN) was observed to obtain a CBG from Resident 80. Staff 14 exited the room and cleaned the glucometer with alcohol wipes. Staff 14 stated she used alcohol wipes on a regular basis to clean the glucometer. Staff 14 stated she was assigned rooms 130-144 and the community use glucometer was used for five different residents on the hall.
On 12/2/24 at 12:28 PM and at 1:00 PM, Staff 11 (LPN) stated she already completed resident CBG checks for the day and was assigned rooms 201-216. Staff 11 stated she primarily used alcohol wipes to clean the glucometer and the community use glucometer was used for three different residents on the hall.
On 12/2/24 at 12:03 PM and on 12/3/24 at 9:27 AM, Staff 2 (DNS) stated the expectation was for staff to use EPA wipes between every glucometer use and ensure proper dwell times were reached.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be fre...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by staff for 1 of 4 sampled resident (#1) reviewed for abuse. This placed residents at risk for physical abuse. Findings include.
On 11/4/24, the State Survey Agency received a public complaint which alleged Resident 1 was treated roughly and slapped by a CNA.
Resident 1 was admitted to the facility in 9/2024, with diagnoses including post-traumatic hydrocephalus (traumatic brain injury, TBI).
A 9/18/24 admission care plan indicated Resident 1 had left sided weakness, required substantial-total assist with bed mobility and spoke Spanish.
A 9/19/24 admission MDS indicated the resident had severe cognitive impairment.
On 11/7/24 at 9:41 AM, Resident 1 was observed to be resting comfortably in bed with bolsters on each side of the bed, the bed was lowered, fall mats were in place, the bed was up against the wall, and the call light was within reach. The residents spouse was in the room. Resident 1 was sleeping off and on with no signs of distress.
On 11/7/24 at 1:56 PM, Staff 5 (CNA) stated if he was aware a resident was being abused he would make sure the resident was safe and report it to the nurse.
On 11/7/24 at 2:08 PM, Staff 7 (RN) stated if she was aware a resident was being abused she would make sure the resident was safe, alert the Administrator and file a report with the state.
On 11/7/24 at 2:44 PM, Staff 8 (CNA) stated she always worked on the skilled side of the facility and enjoyed working double shifts from evenings to night shift. Staff 8 stated if residents were bed bound, she was able to turn residents by herself. Staff 8 stated she had never been rough with Resident 1, never caused physical abuse to Resident 1 and had never slapped Resident 1.
On 11/8/24 at 1:17 PM, Staff 9 (CNA) assisted with Spanish translation. Staff 9 asked Resident 1 (in Spanish) if she/he felt safe at the facility. Resident 1 answered 'No' and when asked why, Resident 1 was unable to answer. Resident 1's demeanor was calm.
On 11/12/24, the State Survey Agency received a public complaint. The anonymous complainant included video footage of Resident 1 and Staff 8 on 10/27/24.
On 11/13/24 at 12:58 PM, Witness 3 (Client Care Surveyor, Interpreter) interviewed Resident 1 via phone with the surveyor in the room. Resident 1 stated she/he was aware there was a camera in the room. When Resident 1 was asked if any of the staff had been rough with her/him, Resident 1 started to cry and was upset. Resident 1 stated she/he did not feel safe in the facility.
On 11/13/24 at 2:39 PM, Staff 8 (CNA) stated Resident 1 was a 'heavy turn' and stated most of the time she was able to turn Resident 1 in the bed by herself. Staff 8 stated she was not rough with the resident when she provided care and did not slap the resident. God no I wouldn't slap a resident. Staff 8 was made aware Resident 1 had a camera in her/his room on the same day of her interview.
On 11/13/24 at 2:39 PM, the video footage of Resident 1 taken on 10/27/24 at 2:13 AM was reviewed with Staff 8 (CNA). Staff 8 denied the CNA in the room was her. I don't have a scrub top like that. I have never treated a patient like that. Look, that is not my hair!
The 10/27/24 staff schedule revealed Staff 8 (CNA) worked a double shift from evening shift to night shift. Staff 8 was assigned to Resident 1 in room [ROOM NUMBER].
On 11/13/24 at 2:45 PM, the video was reviewed by the surveyor, Staff 1 (Administrator) and Staff 2 (DNS). Staff 1 and Staff 2 identified Resident 1 and Staff 8 (CNA) in the video. The video revealed Resident 1 in bed on 10/27/24 at 2:13 AM. Staff 8 was observed to forcefully and roughly push Resident 1's legs to the side in the bed while Staff 8 performed a linen change. Resident 1 can be heard saying, No, no, no and Ai yai yai (Spanish for oh no or oh my god) while Staff 8 pushed Resident 1's legs side to side. At one point, Staff 8 used a slapping motion in the direction of Resident 1's face. The slap was heard on the audio. Staff 8 was then seen grabbing Resident 1's right hand and arm and pushing it away.
On 11/13/24 at 2:49 PM, Staff 1 (Administrator), Staff 2 (DNS) and the state surveyor, reviewed facility video footage taken from the hallway on 10/27/24 between 2:00 AM and 2:30AM. Staff 8 (CNA) was observed to walk out of room [ROOM NUMBER] where Resident 1 resided.
On 11/13/24 at 3:20 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 8 (CNA) was rough, aggressive and made a 'slapping motion' at Resident 1. Staff 1 stated the care provided in the video by Staff 8 was not conducted according to the facility standards and expectations. Staff 8 was sent home.
Jul 2023
25 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to treat a resident with dignity for 1 of 1 sampled resident (#47) reviewed for dignity. This placed residents at risk for la...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to treat a resident with dignity for 1 of 1 sampled resident (#47) reviewed for dignity. This placed residents at risk for lack of dignity and quality of life. Findings include:
Resident 47 was admitted to the facility in 2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression.
Resident 47's 6/11/23 Quarterly MDS indicated a moderately severe score for depression.
Resident 47's 6/12/23 Care Plan for psychosocial well-being indicated staff were to involve the resident in all aspects of care to encourage resident empowerment.
A Progress Note dated 7/18/23 indicated the resident complained of itching in her/his private genital area. A physician's order was received for the resident to be administered Diflucan (anti-fungal medication) orally one time a day for three days for the yeast infection.
Resident 47's provider progress note dated 7/27/23 indicated Resident 47 continued to experience genital discomfort and itchiness. A physical exam was performed and the resident was ordered a cream for her/his genital area for symptoms of burning and itching.
On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 reported she/he was not sexually aroused and was humiliated by this information and cried.
On 7/28/23 at 9:50 AM Staff 28 (CNA) stated Resident 47 moaned during peri-care from the itching and pain. Staff 28 stated she was told by Staff 20 (LPN) the resident was changed from a one-person staff assist to a two-person staff assist due to reports about the resident being sexually aroused with cares.
On 7/28/23 at 10:50 AM Staff 27 (CNA) stated she had a conversation with Resident 47 which occurred after the resident was changed from a one-person staff assist to a two-person staff assist to provide cares. The resident told her Staff 16 reported there was a staff complaint that the resident enjoyed peri-care in a sexual manner. Staff 27 reported the resident was upset and cried.
On 7/28/23 at 11:47 AM Staff 16 stated she had a conversation with Resident 47 in 7/2023 about staff reports of feeling uncomfortable when providing the resident peri-care. Staff 16 told the resident staff reported her/his response to peri-care appeared to be sexual arousal. Staff 16 reported the resident was shocked and upset as a result of the conversation.
On 7/28/23 at 1:48 PM Staff 17 (RNCM) stated two agency CNAs on evening shift reported being uncomfortable when providing peri-care to the resident as the resident made sounds like it was pleasurable. Staff 17 stated no other CNAs had concerns with providing peri-care to Resident 47. Staff 17 stated the resident was changed to a two-person assist for all cares due to the situation.
A review of Resident 47's clinical record revealed no documentation to indicate the facility thoroughly investigated or took into consideration the resident's diagnosed condition.
On 7/31/23 at 11:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated two agency staff from evening shift reported concerns regarding Resident 47's sexual response during peri-care. The situation was discussed in a morning meeting. Staff 16 discussed the concern with the resident and how it made staff uncomfortable. Staff 1 and Staff 2 reported Resident 47 did not previously demonstrat sexual behavior and they did not interview other staff to see if they had concerns regarding this behavior. Based on the concern expressed by the two agency staff the resident was changed from one-person staff assist to two-person staff assist for all cares. Staff 1 and Staff 2 indicated there was no follow-up or monitoring regarding the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure residents were treated with respect for their personal possissions for 1 of 1 sampled resident (#56) reviewed for choices. This placed ...
Read full inspector narrative →
Based on observation and interview the facility failed to ensure residents were treated with respect for their personal possissions for 1 of 1 sampled resident (#56) reviewed for choices. This placed residents at risk for lack of respecting private belongings. Findings include:
Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke.
On 7/24/23 at 12:16 PM Resident 56 stated on multiple occasions she/he requested for staff to ask permission before they retrieved something from her/his nightstand. Resident 56 stated staff continued to retrieve items from her/his nightstand without asking and this was very upsetting because it's my private stuff! Resident 56 was observed to be anxious and tearful when she/he expressed the concern. The night stand had the top drawer opened approximately four inches and the resident's personal items were visible inside the drawer.
On 7/27/23 at 10:31 AM Staff 21 (LPN) stated Resident 56 had concerns regarding staff opening and grabbing things out of her/his nightstand without asking. Staff 21 stated the resident was upset because of her/his personal papers and own private items in the nightstand. Staff 21 stated this was an ongoing issue mostly with agency staff but all staff were expected to ask permission before getting into Resident 56's nightstand.
On 7/27/23 at 11:37 AM Staff 19 (CNA) stated Resident 56 had ongoing concerns with staff not asking permission prior to getting into her/his nightstand and was very upset and tearful. Staff 19 stated all staff were expected to ask permission before just grabbing items out of Resident 56's nightstand.
On 7/28/23 at 2:03 PM Staff 17 (RNCM) stated she was unaware Resident 56 had concerns regarding staff getting into her/his nightstand without permission. Staff 17 stated she expected staff to ask permission prior to accessing items in Resident 56's nightstand.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to obtain copies of Advance Directive for 1 of 4 sampled residents (#5) reviewed for Advance Directives. This placed resident...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to obtain copies of Advance Directive for 1 of 4 sampled residents (#5) reviewed for Advance Directives. This placed residents at risk for lack of end of life choices being honored. Findings include:
Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness.
Resident 5's 5/23/23 admission MDS indicated she/he was cognitively intact.
Resident 5's 5/23/23 Health Center admission Agreement indicated the resident had an Advance Directive.
Resident 5's 6/6/23 Care Conference Note indicated the resident's Advance Directive was not reviewed.
Resident 5's clinical record revealed there was no copy of her/his Advance Directive.
On 7/26/23 at 11:00 AM Staff 16 (Social Service Director) stated upon admission residents were asked if they had an Advance Directive and if so to provide a copy. Staff 16 stated if a copy of the resident Advance Directive was not provided on admission, her process was to follow-up within a few days to obtain a copy. Staff 16 stated she did not follow-up with Resident 5 to obtain a copy of her/his Advance Directive.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of Advance Beneficiary Notification (ABN) for 1 of 4 sampled residents (#98) rev...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of Advance Beneficiary Notification (ABN) for 1 of 4 sampled residents (#98) reviewed for discharge. This placed residents at risk for financial hardship. Findings include:
Resident 98 admitted to the facility with Medicare Part A services on 5/30/23. The resident's last covered day of Medicare Part A services was 7/7/23.
A 7/5/23 progress note indicated Staff 22 (Social Services Assistant) provided a NOMNC (Notification of Medicare Non-Coverage) to Resident 98 and the resident was informed if she/he did not discharge by midnight on 7/8/23 she/he would be charged $455 a day.
There was no evidence in the clinical record to indicate a written Advanced Beneficiary Notification (ABN) was provided to explain the financial responsibilities for Resident 98.
On 7/28/23 at 9:51 AM and 12:30 PM Staff 22 stated she provided Resident 98 with the NOMNC and verbally explained the daily cost rate if the resident were to remain in the facility. Staff 22 stated if an ABN was provided then it would have been uploaded the same day in the medical record. Staff 22 acknowledged she did not provide an ABN to Resident 98.
Refer to F660
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident grievance was addressed for 1 of 2 sampled residents (#76) reviewed for personal property. This placed r...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure a resident grievance was addressed for 1 of 2 sampled residents (#76) reviewed for personal property. This placed residents at risk for unresolved concerns and loss of personal property. Findings include:
Resident 76 was admitted in 6/2023 with diagnoses including cancer.
On 7/24/23 at 10:23 AM Resident 76 stated she/he was missing a crocheted bed spread and a green night gown for over a month. Resident 76 stated she/he reported the missing items and staff did not follow up.
The 7/17/23 grievance form filled out by Resident 76's family member indicated the resident was missing a crocheted blanket (missing for two months) and a green night gown (missing for one month). The bottom of the grievance was not completed and there was no indication there was a resolution to the grievance as of 7/27/23.
On 7/27/23 at 1:33 PM Staff 16 (Social Service Director) acknowledged Resident 76's 7/17/23 grievance indicated the crocheted blanket and night gown were missing for one or two months. Staff 16 stated the facility policy was to respond to grievances within seven days and there was no resolution to the grievance as of 7/27/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness.
Resident 5's 5/22/23 Care P...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness.
Resident 5's 5/22/23 Care Plan for discharge planning indicated a referral for durable medical equipment was to be ordered for discharge. The Care Plan indicated to follow-up with the physician to obtain orders for discharge including durable medical equipment.
Resident 5's Discharge summary dated [DATE] indicated a referral was made for durable medical equipment for discharge.
Resident 5's clinical record revealed she/he was discharged from the facility on 6/23/23 to a family member's home.
On 7/27/23 at 10:00 AM Staff 16 (Social Service Director) stated when Resident 5 was discharged from the facility on 6/23/23 the resident required a hospital bed and she made a referral for the bed to be delivered to the resident's home. Staff 16 stated the request for the hospital bed was denied for lack of documentation from the physician about the resident's need for the hospital bed and the bed was not delivered to the resident's home.
On 7/27/23 at 10:15 AM Staff 25 (LPN) stated Resident 5 needed a hospital bed for discharge.
On 7/31/23 at 8:04 AM Staff 7 (Physical Therapist/Director of Rehabilitation) stated during a weekly Utilization Meeting the resident's discharge needs were discussed and stated Resident 5 would have benefited from the use of a hospital bed.
On 7/31/23 at 11:00 AM Staff 2 (DNS) stated her expectation was for any necessary medical equipment to be delivered to the resident's place of discharge prior to the resident being discharged . Staff 2 stated the facility did not have a physician's order for Resident 5's hospital bed on discharge.
This is a repeat citation and was previously cited from the 5/1/23 complaint survey.
Based on interview and record review it was determined the facility failed to safe, resident-centered discharges for 2 of 4 sampled residents (#s 5 and 98) reviewed for discharge. This placed residents at risk for unmet care needs after discharge. Findings include:
1. Resident 98 admitted to the facility on [DATE] and discharged on 7/8/23 with diagnoses including respiratory failure and fibromyalgia (widespread muscle pain).
A concern was reported to the State Agency on 7/11/23 which indicated Resident 98 was approved to stay at the facility under Medicaid after her/his skilled days ended. Facility staff informed Resident 98 if she/he did not discharge by 7/8/23 she/he would be charged $500 a day. Resident 98 discharged home on 7/8/23. Resident 98 was referred to a home health agency which she/he requested to not use.
Review of progress notes revealed the following:
-6/12/23 Resident 98 informed Staff 16 (Social Services Director) that she/he was unsure if she/he was ready to discharge home and needed more time to work on her/his goals. Resident 98 indicated she/he did not want to live at the facility forever but wanted to stay until she/he was ready to discharge home.
-6/27/23 Resident 98 was in the process of looking into long term placement at the facility and Social Services was working with her/his case worker.
-7/5/23 Staff 22 (Social Services Assistant) provided Resident 98 with a NOMNC (Notification of Medicare Non-Coverage). Resident 98 wanted to file an appeal and was informed if she/he lost the appeal then she/he would be expected to discharge on [DATE] to avoid any out of pocket costs to the facility. If Resident 98 did not discharge by midnight on 7/8/23 she/he would have to pay $455 a day. At this time, [the resident] discharge plan is to go home. Resident 98 also requested a different home health provider than she/he previously had.
On 6/29/23 Staff 30 (Medical Records) received an email indicating Resident 98 was approved for ICF (long-term level of care) under Medicaid.
Review of therapy discharge notes indicated the following:
-7/7/23 PT summary indicated discharge home was not recommended due to no supervision during the day and multiple balance issues during transfers and falling into the chair.
-7/7/23 OT summary indicated a safety concern for discharge to independent home was noted but [resident] felt she/he was unable to financially manage.
A 7/8/23 discharge summary indicated Resident 98 admitted to the facility for therapy services. Resident 98 was identified to be cognitively intact. Resident was noted to be impulsive with poor safety awareness resulting in several non-injury falls in the facility. Resident 98 discharged home with home health orders.
On 7/25/23 at 10:09 AM Witness 1 (Case Manager) stated Resident 98 wanted to remain in the facility and was approved to remain in the facility ICF. Witness 1 stated Social Services was aware as an approval notice was sent via email on 6/29/23. Witness 1 stated the resident was told she/he would have to pay $500 a day if she/he stayed at the facility past her/his skilled days. Witness 1 stated Resident 98 would not have to pay out of pocket because the resident was covered under Medicaid.
On 7/27/23 at 12:39 PM Resident 98 stated she/he wanted to remain in the facility longer. Resident 98 stated she/he was going to appeal the NOMNC but was told she/he would have to pay per day if she/he lost the appeal and stayed past Saturday (7/8/23). Resident 98 stated the facility did not inform her/him that she/he was approved to stay at the facility ICF under Medicaid. Resident 98 further stated she/he told Social Services that she/he did not want the same home health agency as before and was disappointed when the same home health agency was sent. Resident 98 stated it took home health two weeks to see her/him and no bath aide showed up.
On 7/28/23 at 9:32 AM Staff 30 stated she received an email indicating Resident 98 was approved for ICF on 6/29/23. Staff 30 stated the email was forwarded to Staff 16 on 7/1/23.
On 7/28/23 at 9:51 AM Staff 22 stated she assisted with Resident 98's discharge. Staff 22 stated Staff 16 usually reached out the Medicaid office to determine if a resident was on Medicaid. Staff 22 stated she did not believe Resident 98 was on Medicaid. Staff 22 stated Resident 98 needed to pay privately if she/he stayed past 7/8/23. Staff 22 stated the resident did not want to pay as she/he indicated she/he could not afford the $455 daily rate. Staff 22 stated she and Staff 16 talked with Resident 98's case manager but were not sure if she/he was approved for ICF and had to pay anything towards her/his stay. Staff 22 stated she was not aware Resident 98 was approved to stay at the facility ICF under Medicaid as of 6/29/23. Staff 22 further stated there were several options for home health agencies and Resident 98 indicated she/he did not want the same home health agency she/he had previously. Staff 22 stated she made sure Resident 98 was not referred to the same home health agency.
On 7/28/23 at 10:50 AM Staff 16 stated Resident 98 admitted to the facility with skilled services and discharged home with home health. Staff 16 stated she was in contact with Witness 1 and stated on 6/22/23 she requested information on the resident's ICF approval status. Staff 16 stated on 6/28/23 she reached out to Witness 1 to find out if Resident 98 was going to have an out of pocket cost to remain at the facility. Staff 16 stated Witness 1 emailed her on 6/29/23 informing her Resident 98 was approved for ICF under Medicaid. Staff 16 stated she responded back to Witness 1 on 6/29/23 to get an estimate of the resident's cost to stay at the facility but did not get a response back. Staff 16 stated she did not follow up with Witness 1 after 6/29/23. Staff 16 stated she did not know if Staff 22 was aware Resident 98 was approved for ICF. Staff 16 stated the 7/5/23 progress note was a template and the daily rate of $455 given to Resident 98 was the standard rate and the resident would have been told the information regardless. Staff 16 acknowledged she was responsible for Resident 98's discharge and the information provided to her/him. Staff 16 further stated she was aware Resident 98 did not want the same home health agency as she/he previously had but talked to the resident about using the same agency because they were already aware of her/him and could see the resident right away. Staff 16 acknowledged she referred Resident 98 to the same home health agency she/he requested not to have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 4 sampled residents (#89) reviewed for discharge. This placed residents at risk for ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 4 sampled residents (#89) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include:
Resident 89 was admitted to the facility in 6/2023 with diagnoses including stroke. The resident discharged home on 7/17/23 on a resident initiated discharge.
A review of Resident 89's medical record indicated there was no discharge summary documentation.
On 7/31/23 at 11:13 AM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 89.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
2. Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture.
A 7/17/23 signed physician order indicated Resident 249 was to maintain an [Aspen] cervical neck collar...
Read full inspector narrative →
2. Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture.
A 7/17/23 signed physician order indicated Resident 249 was to maintain an [Aspen] cervical neck collar at all times for spinal precautions.
An undated In Room Care Plan revealed Resident 249's head of the bed was to be at 30 degrees at all times and the resident was to have her/his Aspen neck collar on at all times.
On 7/25/23 at 2:53 PM Resident 249 was observed in bed with a cervical neck collar on. Resident 249 stated she/he was provided a bed bath on 7/19/23 and a CNA staff removed her/his cervical neck brace, which was not to be removed. Resident 249 stated she/he reported the incident to nursing staff because of increased pain deeper pain than before. Resident 249 stated staff wanted to send her/him to the hospital but she/he refused and was administered pain medication to alleviate the pain.
On 7/26/23 at 2:55 PM Staff 6 (CNA) stated she provided Resident 249 a bed bath on 7/19/23 and took the neck brace off to remove her/his shirt and put the neck brace on once she completed the bed bath. Staff 6 stated she did not review the In Room Care Plan and was not sure if Resident 249 had a temporary care plan in her/his room and was not sure if the neck brace was to be removed or not.
On 7/26/23 at 6:03 PM Staff 5 (Agency/RN) stated Resident 249 had a neck brace on and the neck brace was not to be removed per physician orders. Staff 5 stated Resident 249 reported she/he was provided a bed bath and Staff 6 removed her/his neck brace and experienced excruciating pain. Staff 5 spoke to the physician and was told to send Resident 249 out to the hospital but the resident refused. Staff 5 stated she/he was administered pain medication to alleviate her/his discomfort.
On 7/27/23 at 4:11 PM Staff 4 (Agency/RN) stated she was aware Resident 249's cervical neck brace was removed during a bed bath. Staff 4 stated she expected staff to follow physician orders and all staff were to review the In Room Care Plan prior to assisting residents. Staff 4 stated Resident 249 was administered pain medication to help alleviate her/his pain.
On 7/31/23 at 10:21 AM Staff 2 (DNS) stated Resident 249's neck brace was not to be removed and she expected staff to implement and follow physician orders. Staff 2 further stated staff were expected to review care plans prior to providing residents care.
Based on observation, interview and record review it was determined the facility failed to follow physician orders and implement bowel care for 2 of 2 sampled residents (#s 24 and 249) reviewed for choices and constipation. This placed residents at risk for increased pain. Findings include:
1. Resident 24 admitted to the facility in 2015 with diagnoses including constipation.
The 7/20/23 care plan indicated Resident 24 required extensive assistance for toileting.
The 6/14/23 physician orders indicated Resident 24 was to receive the following:
-Fiber-Stat liquid give 30 ml PO every 12 hours PRN constipation.
-Milk of Magnesia (MOM) 400 mg/5 ml give 30 ml PO PRN constipation once daily.
-bisacodyl suppository 10 mg insert one suppository rectally PRN for constipation once daily.
Resident 24's 6/2023 and 7/2023 bowel records revealed the following days with no bowel movements:
-7/3/23; 7/4/23; 7/5/23; 7/6/23 and 7/7/23 (five days).
-7/9/23; 7/10/23; 7/11/23; 7/12/23; 7/13/23 and 7/14/23 (six days).
There was no indication Resident 24 received or refused the ordered bowel medications on the identified dates.
On 7/24/23 at 11:53 AM and 7/31/23 at 10:21 AM Staff 24 (LPN) reviewed the identified dates with no bowel movement and stated Resident 24 sometimes goes a few days without having a bowel movement. Staff 24 stated if the resident did not have bowel movement for 72 hours staff were to offer Fiber Stat on day shift, MOM on swing shift and a suppository on night shift. Staff 24 further stated the resident's bowel medications were PRN and nursing staff did not document refusals.
On 7/31/23 at 11:11 AM Staff 2 (DNS) acknowledged Resident 24 did not have bowel movements on the identified dates or documented refusals of bowel care. Staff 2 stated the expectation was after 72 hours of no bowel movement staff were to give fiber stat as ordered on day shift, MOM on evening shift and suppository on night shift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#56) re...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#56) reviewed for vision. This placed residents at risk for impaired vision. Findings include:
Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke.
On 7/24/23 at 12:32 PM Resident 56 was observed wearing glasses and the right side of the glasses was wrapped in blue string to hold them together. Resident 56 stated she/he wore glasses all the time in order to see and the glasses were broken for greater than a month and staff were aware. Resident 56 stated first staff tried to glue the right side of the glasses together and then used string to fix the glasses.
No evidence was found in the clinical record regarding Resident 56's broken glasses or any indication vision services were initiated or new glasses were ordered.
On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 wore glasses all the time in order to see and her/his glasses were broken three different times and were broken greater than a month. Staff 21 stated someone used the blue string to hold the glasses together and she reported her concern to Staff 16 (Social Service Director) but nothing was done.
On 7/27/23 at 10:31 AM Staff 20 (LPN) stated she was aware Resident 56 wore glasses and they were broken for roughly two months. Staff 21 stated she informed Staff 16 regarding the broken glasses.
On 7/27/23 at 11:37 AM Staff 19 (CNA) stated Resident 56's glasses were broken for roughly two months and she used the blue string to hold the glasses together. When asked who she reported concerns to Staff 19 stated she reported the concern to the charge nurse and Staff 16.
On 7/28/23 at 12:20 PM Staff 16 stated she was unaware of Resident 56's broken glasses and staff were expected to report these concerns to her.
On 7/31/23 at 10:26 AM Staff 2 (DNS) acknowledged Resident 56's glasses were broken and staff were expected to verbally report concerns but could complete a grievance regarding the broken glasses which was addressed by Staff 16.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 2 sampled residents (#32) reviewed for respiratory c...
Read full inspector narrative →
Based on observation, record review and interview it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include:
Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease).
Multiple observations from 7/25/23 through 7/28/23 revealed Resident 32 used a high-flow oxygen concentrator (oxygen supply system delivering 100% humidified and heated oxygen) through a nasal cannula (lightweight tubing with two prongs placed in nostrils).
Resident 32's physician orders dated 6/9/23 indicated:
-to use oxygen as needed via the nasal cannula to keep oxygen level at 90%.
-change humidification bottle and tubing on concentrator every three days on night shift and date the bottle and tubing when done.
-change the tubing and cannula every week on Sunday night shift. Date the tubing when changed.
-clean the exterior of the concentrator once a week on Sunday night shift.
-exchange external filter on the concentrator with a clean filter. Clean dirty filter with warm soapy water, rinse well and allow filter to dry completely, then store for next exchange every week on Sunday night shift.
The 7/2023 TAR indicated on 7/23/23 the exchange of external filter on concentrator was completed by the night shift nurse.
Observations from 7/25/23 through 7/28/23 revealed the external filter on the concentrator had a layer of dust when touched with a finger and left a noticeable mark. The concentrator machine also had a build up of noticeable dust.
On 7/26/23 at 1:39 PM Staff 20 (LPN) and 7/27/23 at 9:55 AM Staff 17 (RNCM) both stated the night shift nurses were responsible for cleaning Resident 32's oxygen concentrator.
On 7/28/23 at 11:02 AM Staff 2 (DNS) observed and acknowledged the external filter and concentrator had a build up of dust and the filter was not clean.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents received pain medication as order...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 1 sampled resident (#248) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include:
Resident 248 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (abnormal heart beat).
The 7/6/23 hospital physician orders indicated Resident 248 had chronic back pain and was to receive pregabalin (pain medication) 75 mg every eight hours.
The 7/2023 MAR indicated Resident 248 did not receive pregabalin as ordered on the following occasions:
-7/6/23 at 10:00 PM
-7/7/23 at 6:00 AM
-7/7/23 at 2:00 PM
-7/7/23 at 10:00 PM
Progress notes indicated the pregabalin was not available on 7/6/23 and 7/7/23.
The 7/6/23 admission Summary and admission Evaluation indicated the following:
-Resident 248 stated her/his lower legs were on fire;
-Resident 248 had a lot of pain and to make sure pain regimen is on schedule;
-Resident 248 had a history of passing out/being unresponsive if she/he was in too much pain;
-Resident 248 had very severe, horrible constant pain in the back and the legs, medication helped alleviate the pain and movement made the pain worse.
The pain level summary indicated Resident 248 had pain that ranged from 0-4 on four occasions and 5-10 on nine occasions from 7/6/23 at 6:55 PM through 7/8/23 at 4:52 AM (prior to receiving the ordered pregabalin).
On 7/24/23 at 2:14 PM Resident 248 stated she/he did not receive scheduled pain medications due to the facility not having them available.
On 7/28/23 at 8:45 AM Staff 2 (DNS) acknowledged Resident 248 had chronic pain and missed the four doses of pregabalin on the identified dates.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to provide appropriate pre and post dialysis assessments and accurate documentation for 2 of 2 sampled resident ...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to provide appropriate pre and post dialysis assessments and accurate documentation for 2 of 2 sampled resident (#s 30 and 58) reviewed for dialysis. This placed residents at risk for lack of dialysis assessments and complications. Findings include:
1. Resident 30 was re-admitted to the facility in 2023 with diagnoses including end-stage renal disease.
Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact.
Resident 30's 7/20/23 Care Plan revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility.
On 7/26/23 at 12:19 PM Resident 30 stated no one checked her/his new dialysis port after dialysis. Resident 30 stated she/he had a blood clot in the old dialysis site in her/his right arm and surgery was done on 7/19/23 to relocate the dialysis site to her/his neck. Resident 30 stated she/he took a piece of paper with vital signs and current weight to the dialysis center, gave it to the dialysis nurse who wrote things down and then gave it to the facility nurse upon return.
On 7/26/23 at 12:33 PM Staff 14 (LPN) stated when a resident returned with dialysis paperwork she entered new orders in the computer, conducted a quick pain assessment, checked the resident's medications, checked for any new skin bruising and offered the resident lunch.
On 7/26/23 at 1:10 PM Staff 10 (CNA) stated when a resident returned from dialysis he checked vital signs and obtained a post-dialysis weight. Staff 10 stated the resident dropped off the Dialysis Communication Report (a document designed to share information between the facility and the dialysis clinic and to document pre and post dialysis assessments of the resident by both the facility and the dialysis clinic) at the nurse's station.
On 7/26/23 at 1:18 PM Staff 17 (RNCM) stated when a resident returned from dialysis the Dialysis Communication Form was given to the nurse to complete, a copy was made and put in her box and she reviewed it for new orders.
A review of Resident 30's clinical record revealed 56 Dialysis Communications Reports. Of the 56 reports, 43 did not include a post dialysis assessment by the facility. No other post-dialysis assessments were found in the clinical record.
On 7/27/23 at 8:41 AM Staff 17 and Staff 2 (DNS) acknowledged the post-dialysis assessment was not completed for 43 out of the 56 forms. Staff 2 stated she expected the nurses to conduct a post-dialysis assessment and fill out the form.
2. Resident 58 admitted to the facility in 3/2023 with diagnosis including Chronic Kidney Disease.
A Physicians Order dated 3/25/23 indicated the dialysis communication form was to be filled out by the facility pre and post dialysis. Any new orders/communication from the dialysis center were processed from the form. The form was filed in the hard chart. Also note the dialysis access site was assessed upon arrival back from the facility. The status was documented on the dialysis communication form.
Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) services three times a week outside the facility.
On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated when Resident 58 returned from dialysis obtained vital signs, weighed the resident and offered the resident lunch. Staff 11 stated he was not aware of the location of the resident's dialysis fistula (access site) and obtained the resident's blood pressure from the resident's legs.
On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he was not aware of the location of Resident 58's dialysis fistula and thought it was in the resident's left upper extremity.
On 7/27/23 at 8:28 AM Resident 58 was observed to self-propel the wheelchair out of the dining room. Observations of Resident 58 did not reveal a dialysis fistula in either arm. Resident 58 stated she/he had a central catheter (dialysis catheter in a large vessel in the neck) and stated no one checked it when she/he returned from dialysis.
On 7/31/23 10:42 AM Staff 4 (LPN) stated when Resident 58 returned from dialysis she completed a quick pain assessment, checked the resident's skin for new bruises, checked the resident's medications, offered Resident 58 lunch and let the resident rest.
A review of Resident 58's clinical record revealed 13 Dialysis Communication Forms (a document designed to share information between the facility and the dialysis clinic and to document pre and post dialysis assessments of the resident by both the facility and the dialysis clinic). Of the 13 reports located the following information was missing or incomplete on the following days:
-4/23/23, 5/1/23, 5/22/23, 6/9/23, 6/21/23, 6/30/23, 7/12/23, 7/14/23, 7/17/23: Pre-Dialysis Assessment and Post-Dialysis assessments were not completed by the facility.
-5/19/23 and 6/12/23 Pre-Dialysis Assessment were not completed by the facility.
-There were no other Dialysis Communication Forms located in Resident 58's clinical record.
On 7/27/23 at 4:00 PM Staff 2 (DNS) stated nurses were expected to complete the dialysis communication form prior to Resident 58's appointment and post dialysis upon Resident 58's return from facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure transportation was provided to a medical appointment for 1 of 1 sampled resident (#249) reviewed for follow up appo...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure transportation was provided to a medical appointment for 1 of 1 sampled resident (#249) reviewed for follow up appointments. This placed residents at risk for delayed care. Findings include:
Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture.
A 7/17/23 hospital discharge order revealed Resident 249 had a follow up orthopedic appointment scheduled on 7/20/23 at 3:45 PM.
No evidence was found in the clinical record regarding transportation being scheduled for the 7/20/23 appointment.
On 7/24/23 at 2:44 PM Resident 249 stated the facility did not schedule transportation for her/his orthopedic appointment on 7/20/23 due to poor communication and the appointment had to be rescheduled.
On 7/27/23 at 4:11 PM Staff 4 (Agency/RN) stated she was aware of the missed appointment for Resident 249 and was not sure how the appointment was missed but possibly was overlooked when staff reviewed her/his admission orders.
On 7/28/23 at 9:41 AM Staff 30 (Medical Record Director) stated they received appointment/transportation requests from the nursing staff and she scheduled transportation/medical appointment for residents. Staff 30 stated the 7/20/23 appointment for Resident 249 was overlooked upon admission.
On 7/28/23 at 10:23 AM Witness 7 (Family Member) stated Resident 249 had a follow up appointment with an orthopedic clinic which was scheduled while she/he was in the hospital but Resident 249 missed the appointment because the facility did not set up/provide transportation to the appointment. Witness 7 stated she emailed Staff 16 (Social Service Director) but never heard back from her.
On 7/28/23 at 12:38 PM Staff 16 stated she received the email from Witness 7 and let medical records know because they were responsible for setting up transportation for the residents. Staff 16 was aware Resident 249 missed her/his scheduled 7/20/23 follow up appointment due to no transportation.
On 7/31/23 at 10:21 AM Staff 2 (DNS) stated staff were expected to review all new orders upon admission to ensure medical appointments and transportation were scheduled. Staff 2 acknowledged Resident 249 missed her/his follow up appointment on 7/20/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner for 1 of 5 sampled residents (#32) revi...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner for 1 of 5 sampled residents (#32) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include:
Resident 32 was admitted to the facility in 9/2019 with diagnoses including schizophrenia (serious mental disorder that affects how a person perceives and interprets reality), depression and anxiety.
Pharmacy recommendations from 4/24/23, 5/22/23 and 6/26/23, revealed the following: evaluation of physician's orders to determine if Resident 32 was at the lowest effective dose for Abilify (an antipsychotic), Olanzapine (an antipsychotic), Lexapro (an antidepressant), Duloxetine (an antidepressant), Buspirone (an antianxiety medication), and Clonazepam (an antianxiety medication).
Resident 32's record revealed no documentation of any physician follow-up or response to the 4/24/23, 5/22/23 and 6/26/23 pharmacy recommendations.
On 7/28/23 at 11:10 AM Staff 2 (DNS) acknowledged there was no follow up to the 4/24/23, 5/22/23 and 6/26/23 pharmacy recommendations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to complete quarterly psychotropic medication reviews for 2 of 5 sampled residents (#s 17 and 42) reviewed for medications. T...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to complete quarterly psychotropic medication reviews for 2 of 5 sampled residents (#s 17 and 42) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include:
1. Resident 17 admitted to the facility in 2023 with diagnoses including anxiety and depression.
Review of the 6/8/23 physician orders indicated Resident 17 received clonazepam (antianxiety), duloxetine (antidepressant), quetiapine (antipsychotic) and melatonin.
A Lifestyles form with review dates of 3/28/23, 3/29/23, 4/26/23 and 6/27/23 listed Resident 17's psychotropic medications with the diagnoses, and order date. The form indicated sleep and behaviors with no other information provided.
A progress note dated 6/28/23 indicated the facility IDT team and pharmacy reviewed Resident 17's psychotropic medications and to see the Quarterly Psychotropic Medication Assessment.
Review of Resident 17's medical record revealed no indication of a Quarterly Psychotropic Medication Assessment completed.
On 7/27/23 at 8:56 AM Staff 16 (Social Services Director) stated she wrote the 6/28/23 progress note, and the Quarterly Psychotropic Medication Assessment was not completed for Resident 17. Staff 16 stated she was behind in completing the quarterly psychotropic medication assessments.
2. Resident 42 admitted to the facility in 2021 with diagnoses including hallucinations, anxiety, insomnia, and anxiety.
A 3/23/23 Psychotropic Medication Assessment indicated Resident 42 received clozapine (antipsychotic), trazadone (antidepressant), melatonin and venlafaxine (antidepressant).
Review of Resident 42's medical record indicated no Psychotropic Medication Assessment was completed for June.
On 7/27/23 at 8:56 AM Staff 16 (Social Services Director) stated the Quarterly Psychotropic Medication Assessment was not yet completed for Resident 42. Staff 16 acknowledged a psychotropic medication review was to be completed at least quarterly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided to 1 of 1 sampled resident (#56) reviewed for dental services. T...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided to 1 of 1 sampled resident (#56) reviewed for dental services. This placed residents at risk for a lessened quality of life. Findings include:
Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke.
On 7/24/23 at 12:32 PM Resident 56 was observed missing one of her/his upper teeth on the right side of her/his mouth. Resident 56 stated her/his tooth fell out two plus weeks prior, staff were aware and supposed to get the missing tooth fixed but nothing occurred.
No evidence was found in the clinical record regarding Resident 56's missing tooth or any indication dental services were initiated or a dental appointment was made.
On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 was missing one of her/his upper teeth for greater than two weeks and was not sure if any staff reported the concern to Staff 16 (Social Service Director).
On 7/27/23 at 10:31 AM Staff 20 (LPN) stated she was aware Resident 56 had a missing upper tooth for approximately six weeks and she reported the concern to Staff 16.
On 7/28/23 at 12:20 PM Staff 16 stated she was unaware Resident 56 was missing a tooth and staff were expected to report concerns to her.
On 7/31/23 at 10:26 AM Staff 2 (DNS) acknowledged Resident 56 was missing a tooth and staff were expected to verbally report concerns and could complete a grievance regarding the missing tooth which would be addressed by Staff 16.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide rehabilitation services for 1 of 1 sampled resident (#17) reviewed for rehabilitation services. This placed reside...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to provide rehabilitation services for 1 of 1 sampled resident (#17) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include:
Resident 17 admitted to the facility in 2023 with diagnoses including pain and fibromyalgia (widespread muscle pain).
On 5/12/23 a concern was reported to the State Agency which indicated Resident 17 did not receive therapy as ordered and only received one session the following week.
On 7/24/23 at 10:55 AM and 7/26/23 at 9:52 AM Resident 17 stated she/he did not receive therapy when she/he was supposed to. Resident 17 stated she/he never refused therapy and was never out of the building to miss therapy. Resident 17 stated she was never approached to make-up for the missed sessions.
Review of the 5/2023 therapy notes indicated Resident 17 was to receive OT three times a week and PT two times a week.
Review of therapy the Service Log Matrix indicated Resident 17 received one session of PT (one session missed) and one session of OT (two session missed) during the week of 5/7/23 to 5/13/23.
On 7/26/23 at 8:58 AM Staff 23 (Physical Therapy Director) acknowledged Resident 17 missed two session of OT and one session of PT for the time frame indicated and did not offer any explanation for why the sessions were missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to provide a safe environment for the storage of oxygen tanks for 1 of 2 sampled residents (#32) reviewed for re...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to provide a safe environment for the storage of oxygen tanks for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for accidents. Findings include:
Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease).
Multiple observations from 7/25/23 through 7/28/23 revealed empty and unsecured oxygen tanks stored inside Resident 32's doorway and right outside of Resident 32's door.
On 7/28/23 at 10:21 AM Staff 19 (CNA) stated oxygen tanks were to be secured or stored in a locked closet by the nurses station.
On 7/28/23 at 10:23 AM Staff 2 (DNS) provided the facility's Oxygen Administration policy revised 7/2023, which stated Oxygen tanks must be stored securely in a stand.
On 7/28/23 at 11:02 AM Staff 2 was shown the unsecured oxygen tanks and Staff 2 stated oxygen tanks needed to be either secured or stored in the locked oxygen closet by the nurses station.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
b. Resident 22 admitted to the facility in 11/2018 with diagnoses including Parkinson's disease and depression.
On 7/25/23 at 10:16 AM Resident 22 and Witness 4 (Family Member) expressed their frustr...
Read full inspector narrative →
b. Resident 22 admitted to the facility in 11/2018 with diagnoses including Parkinson's disease and depression.
On 7/25/23 at 10:16 AM Resident 22 and Witness 4 (Family Member) expressed their frustrations since the D Hall Dining room closed. Resident 22 stated she/he and her/his neighbors were upset as several of them ate and socialized together in the D Hall Dining room. Resident 22 stated she/he was not given a straight answer as to why the D Hall Dining was closed. She/he was told the residents had to eat in the main dining room or their rooms. The facility eventually opened a new dining room (the Sun Rise Room) and invited residents. Resident 22 stated the Sun Rise Room was on the other side of the building and she/he did not want to go that far and remained in her/his room to eat all meals. Witness 4 stated several residents who went to the D Hall Dining room now ate all meals in their rooms. Resident 22 experienced cold food by the time the meal tray arrived. The D Hall Dining room had a microwave for staff to reheat cold food but it was no longer was available. Staff now walked to the main dining room to retrieve tea/coffee. Resident 22 worried the extra time it took staff to walk back and forth took time away from other residents who needed help. Resident 22 further stated she/he attended Resident Council meetings and brought concerns regarding the closure of the D Hall Dining. Resident 22 stated management did not address her/his concerns and she/he missed going to the D Hall Dining room.
c. Resident 37 admitted to the facility in 1/2019 with diagnoses including diabetes.
On 7/31/23 at 9:52 AM Resident 37 stated when the D Hall Dining room closed, staff had to bring down each meal tray from the main dining to residents room. Resident 37 stated the soup on her/his meal tray was cold daily. She/he asked staff to heat up the cold soup, but not anymore because, it's not fair to the CNAs to have to walk all the way down there to the main dining room when they are already so busy taking care of us residents. Resident 37 was not made aware when the D Hall Dining room was closed. She/he verbalized concerns to the CNAs and nurses and was frustrated management did not do anything.
Observations of the 7/27/23 lunch meal for the D Hall revealed multiple residents eating in their rooms. Staff had to carry each residents' meal tray individually to the residents' rooms. The first tray was delivered at 12:21 PM and the last tray was delivered at 12:53 PM. This took staff a total of 32 minutes. There were a total of 10 trays delivered to residents' in their rooms. Staff had to walk approximately 280 feet back and forth from the main dining room to residents room, every time they had to deliver a meal tray.
On 7/27/23 at 1:09 PM Staff 1 (Administrator) stated D Hall Dining was closed back in 5/2023 because only five residents utilized the services. Staff 1 stated they opened up the Sunrise Room which had plenty of space for residents and family. Staff 1 stated residents and family were not happy regarding the closure at first and had to work out the kinks which took a few months. When asked about accommodation of needs or honoring resident choices Staff 1 indicated she encouraged residents and family to give the new process time. Staff 1 stated she was unaware of ongoing complaints regarding D Hall Dining being closed and had not attended resident council but relied on staff to report concerns regarding D Hall Dining concerns.
Based on observation, interview, and record review it was determined the facility failed to honor resident dining room choices and preferences for 3 of 3 sampled residents (#s 22, 37 and 50) reviewed for honoring choices. This placed residents at risk for increased isolation, lack of socialization and lack of self-determination. Findings include:
Review of Resident Council Minutes revealed the following:
4/19/22:
-Residents aired their concerns about D Hall Pantry/Dining Room closing and having to eat in the main dining room.
-Too far for CNAs to travel, if something was forgotten on the meal tray.
-Meals were delivered late.
-Too much was expected from the CNAs so they were unable to do their job well.
-Main dining room was loud, socializing was difficult, not a nice place to enjoy a meal and with so much going on and so many people crammed into a small space.
-Resident 22 wrote concerns regarding the D Hall Pantry/Dining Room which revealed the following:
-There is a sign in the front that states Residents Do Not Live in Our Facility. We Work in Their
Home.
-Lately residents felt we had been invaded in our home and lost control of our care.
-We were never asked for our opinion regarding our wants or needs.
-Meals were delivered and CNAs did not stay long enough to make sure the meals were
correct or hot. If anything was wrong it took 10 or 15 minutes before the concern was
corrected and the meals were cold because of the extra time it took to pass out meal trays.
The response/resolution from Staff 1 (Administrator) requested the residents to give the new dining situation a chance. In regards to meals delivared to resident's, CNAs were instructed to delivar a meal tray to whatever meal tray came up in the kitchen regardless of what hall the residents were on.
5/17/23: Resident Council was canceled due to Norovirus (a contagious virus that causes vomiting and diarrhea) outbreak.
6/28/23 and 7/19/23:
Dining hours were 8:00 AM to 9:00 AM breakfast, 12:00 PM to 1:00 PM lunch and 5:00 PM to 6:00 PM dinner.
-Residents stated meals were not delivered to their rooms until after hours.
-Food was still periodically served cold on hot plates.
-Inconsistent portions being served.
-CNAs put residents to bed prior to meals being delivered.
There was no indication or documentation the concerns related to dining from 6/2023 through 7/2023 were addressed or any follow up conversations regarding how residents were feeling regarding the closure of the D Hall Pantry/Dining Room.
On 7/27/23 at 12:50 PM Staff 27 (CNA), at 1:00 PM Staff 32 (CNA) and at 3:15 PM Staff 17 (RNCM) all stated the residents who lived on the D Hall enjoyed the togetherness by having meals in the D Hall Dining room. One resident was so upset she/he cried as the resident did not want to go to the main dining room. Family members were also upset the D Hall Dining room was closed as they spent time with their family members and socialized with other residents in the D Hall Dining room during meals.
On 7/27/23 at 2:35 PM Staff 33 (Activity Director) stated several residents were upset at the 4/19/23 Resident Council meeting and voiced their concerns after being informed the D Hall Dining room was being closed. Residents stated CNAs went a long distance to pick up their meal trays, drinks, and anything else that was forgotten in the main dining room. This resulted in longer call lights during meals and took time away from the residents. Management's response to the residents' concerns was to give the new dining situation a chance. The Sun Rise Room (a smaller room near the main dining room) was opened, but the residents from D Hall did not go because it was too far from their rooms.
a. Resident 50 admitted to the facility in 9/2022 with diagnoses including Guillain-Barre syndrome (body's immune system attacks the nerves) and osteoarthritis.
A Dallas Retirement Village Concern and Grievance Form Dated 4/10/23 from Resident 50 revealed the following concerns:
-The D Hall Dining room was closed and moved to the main dining room so more residents would come out of their rooms and socialize. Where are they?
-Resident 50 preferred to eat breakfast in her/his room and most of the time the meal was lukewarm.
-During lunch and dinner in the main dining area the TV, music and noise from the kitchen was overwhelming and communication was almost impossible.
-One of the first days in the main dining another resident was crying and when asked why she/he was crying she/he stated, I don't eat here, change for some people was really hard without notification.
-A few days in the main dining and multiple residents were not being attended too appropriately.
-There was more care and easier communication with the small dining room than in the main dining.
-Resident 50 ate her/his lunch as fast as possible because of the noise level and lack of socialization.
The Summary of Findings/Action taken/Conclusion: Staff 16 (Social Service Director) spoke with Resident 50 about other dining options moving forward and explained the reason for the closure. The facility opened up a new dining room (the Sun Rise Room) and notified residents and invited the residents down for meals.
On 7/24/23 at 11:50 AM Resident 50 stated since the facility closed the D Hall Dining the food was not always hot, but cold and the closure of the D Hall Dining area was very upsetting to her/him. Resident 50 stated staff had to go to the main dining/kitchen to warm-up food when her/his food was cold because staff no longer had access to a microwave. Resident 50 stated the main dining was too loud and hard to socialize with others and the new dining spot opened up was on the other side of the building.
On 7/26/23 at 11:38 AM Staff 21 (CNA) and at 10:15 AM Staff 27 (CNA) both stated residents were very upset about the closure of the D Hall Dining and meals delivered to the D Hall were often cold even on a plate warmer because of the distance staff traveled to deliver meals. Staff 21 and Staff 27 stated if they needed to warm up a cold meal they returned to the main dining area to use the microwave because there was no longer one on the D Hall. Staff 27 stated a meeting was held regarding the closure of the D Hall Dining for family and residents but was just to inform them of the decision.
On 7/27/23 at 10:31 AM Staff 20 (LPN) stated Resident 50 and other residents were upset regarding the closure of the D Hall Dining. Staff 20 stated meals were delivered to each residents' room one at a time from the kitchen for those residents who stayed in their rooms or did not care to go to the main dining for meals. Staff 20 further stated D Hall was the farthest from the kitchen and once meals were delivered to residents in their rooms they were often cold. Staff 20 further stated if residents requested staff to reheat the food it took a while because there was no microwave on the D Hall unit and this was an ongoing issue.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment for 4 of 6 halls reviewed for environment. This placed residents at risk for living in an unclean and an unhomelike environment. Findings include:
On 7/24/23 and 7/28/23 the following observations were made:
-room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot by one and a half feet across and adjacent to the stain was another black stain which measured approximately six inches by one foot across.
-room [ROOM NUMBER]: Had a dark black stain which measured approximately seven inches by 19.5 inches across, adjacent to that was two smaller black spots the size of approximately two silver dollars.
-room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot four inches by six inches wide.
-room [ROOM NUMBER]: Had huge gouges in the wall behind the recliner with sheet rock exposed. The wall heater was partially disconnected from the wall and had a broken plastic vent.
-room [ROOM NUMBER]: The pads on the wheelchair arm rests and wheelchair were covered with dried orange food substance.
-The carpets near the D hall dining room had multiple scattered black stains in/down the hallway.
-room [ROOM NUMBER]: Had a large dark black stain on the carpet.
-The day room at the end of D hall had several scattered black stains on the carpet.
On 7/28/23 at 2:00 PM Staff 23 (Maintenance Director) made observations of the identified rooms and acknowledged the multiple stained carpets, broken wall heater and the unclean wheelchair.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to ensure food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen and for 4 of 4 sampled residents (#s 17, 22, 47 and 50) reviewed for food service. This placed residents at risk for food that was not palatable or appetizing. Findings include:
Interview with residents indicated the following:
-On 7/24/23 at 11:50 AM Resident 50 stated the food was not always hot. Resident 50 stated the food was not great tasting and lacked quality.
-On 7/24/23 at 12:09 PM Resident 17 stated the food was terrible and she/he often refused to eat it. Resident 17 stated the food was served cold most of the time.
-On 7/24/23 at 2:49 PM Resident 47 stated the food was terrible and cold when it was delivered.
-On 7/25/23 at 10:16 AM Resident 22 stated she/he ate in her/his room and experienced cold food by the time it arrived to her/his room. Resident 22 stated when they had the smaller dining room staff were able to warm up food in the microwave but now staff had to walk all the way to the big dining room to reheat food which took time. Resident 22 stated butter did not melt when placed on the vegetables due to the food not being warm enough. Resident 22 further stated the issue was brought up in Resident Council, but nothing was done.
Review of Resident Council notes revealed the following:
- 4/2023 residents indicated the meatloaf was flavorless, the pasta was overcooked, and weekend meals were served late.
- 6/2023 residents indicated food was served cold even when on the hot plates.
On 7/27/23 at 1:03 PM a test tray was sampled with the survey team; the meal consisted of chicken strips, french fries and cooked carrots. The french fries were lukewarm and soggy, and the carrots were overdone.
On 7/27/23 at 1:09 PM Staff 1 (Administrator) acknowledged the fries were lukewarm and mushy and the carrots were overdone.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
4. Resident 32 was admitted to the facility in 9/2019 with diagnoses including diabetes, stage 3 chronic kidney disease, and severe obesity.
Resident 32's 6/2023 and 7/2023 MARs indicated the followi...
Read full inspector narrative →
4. Resident 32 was admitted to the facility in 9/2019 with diagnoses including diabetes, stage 3 chronic kidney disease, and severe obesity.
Resident 32's 6/2023 and 7/2023 MARs indicated the following:
-Insulin Aspart Solution 100 unit/ml- inject as per SS for diabetes start date 10/18/22:
If CBG was 200 to 399 staff were to inject six units below the skin at bedtime
If CBG was 400 to 800 staff were to inject 10 units below the skin with meals
A review of the resident's clinical record revealed a signed physician order dated 6/8/23 which directed staff to administer the insulin only at bedtime and not with meals. The 6/8/23 order did not change the ordered amount of insulin but clarified that the insulin was only to be administered at bedtime, and not with meals. However, the 6/8/23 was not transcribed on Resident 32's MARs so the order was unchanged since 10/18/22.
No evidence was found in the resident's medical record to indicate the order was administered with meals instead of at bedtime despite the error on the MARs.
On 7/27/23 at 3:40 PM Staff 17 (RNCM) acknowledged the 6/8/23 order was not entered and verified Resident 32's 6/2023 and 7/2023 MARs' instructions were inaccurate.
5. Resident 89 was admitted to the facility in 6/2023 with diagnoses including a stroke.
Resident 89's discharge summary was incomplete and in accurate. The Resident/Responsible Party signature line and Nurse signature line were blank and included a discharge date of 8/20/22. Resident 89's correct discharge was 7/17/23. The medications listed on the 8/20/22 discharge summary were not the same medications Resident 89 was ordered prior to her/his 7/17/23 discharge.
On 7/31/23 at 11:13 AM Staff 2 (DNS) acknowledged the 8/20/22 discharge summary was not correct for Resident 89. She/he was unable to provide other documentation.
2. Resident 47 was admitted to the facility in 2023 with diagnoses including pneumonia, PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression.
Resident 47's 6/12/23 Care Plan indicated staff were to observe the resident for signs of anxiety and depression (including crying), and if present to document the symptom occurrences in the clinical record.
On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 denied being sexually aroused during peri-care and stated the conversation upset her/him and she/he cried.
On 7/28/23 at 11:47 AM Staff 16 stated in early July 2023 she had a conversation with Resident 47 about staff reports of feeling uncomfortable when the resident was provided peri-care due to the resident's sexual arousal response. Staff 16 stated the resident was shocked and upset as a result of the conversation. Staff 16 stated she did not document the conversation with the resident in the clinical record.
No information was found in the the clinical record regarding the above incident.
On 7/28/23 at 1:48 PM Staff 17 (RNCM) verified there was no documentation in Resident 47's progress notes regarding the incident.
On 7/31/23 at 11:05 AM Staff 2 (DNS) confirmed she expected staff to document interactions regarding this incident.
Refer to F550.
3. Resident 30 admitted to the facility in 2022 with diagnoses including end-stage renal disease.
Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact.
Resident 30's Care Plan dated 7/20/23 revealed the resident received dialysis (a process used to remove waste products from the blood when the kidneys stop working) three times a week outside of the facility.
A Progress Note dated 7/20/23 at 2:55 AM indicated the resident returned to the facility via stretcher from Salem Hospital emergency room for a fistula clot.
A Progress Note dated 7/21/23 at 4:20 AM indicated the resident had a wrap covering the previous AV shunt (tube used for dialysis) in the left upper extremity and a new dialysis shunt was placed in the resident's right lateral neck following a 7/19/23 emergency room visit.
On 7/26/23 at 12:19 PM Resident 30 stated staff did not check the new dialysis site in her/his neck.
A review of Resident 30's TARs from 7/1/23 through 7/31/23 revealed staff were monitoring the following:
Dialysis-Fistula patency check: Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear a bruit of blood flow through the access. This should be done daily. Staff check marked it was completed.
Dialysis-Fistula Care CMS (circulation, movement, sensation) check: check the color and temp of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals every day and evening shift. Staff check marked it was completed.
Facility would monitor hemodialysis central lines at a minimum of twice a day for bleeding and s/s of infection: Staff check marked it was completed.
On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 30 did not have a fistula in her/his arm and the 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site.
Based on observation, interview and record review it was determined the facility failed to ensure records were complete and accurate for 5 of 8 sampled residents (#s 30, 32, 47, 58 and 89) reviewed for medications, dialysis and planned discharge. This placed residents at risk for inaccurate medical records. Findings include:
1. Resident 58 admitted to the facility in 3/2023 with diagnoses including Chronic Kidney Disease.
Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week outside the facility.
On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated he did not know where Resident 58's dialysis fistula (a surgical connection between an artery and a vein) was located and used the resident's legs for blood pressures.
On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he thought Resident 58's dialysis fistula was in her/his left upper extremity.
On 7/27/23 at 8:28 AM Resident 58 stated staff did not monitor her/his dialysis catheter in her/his neck. Observation of Resident 58's upper extremities revealed no dialysis fistulas.
A review of Resident 58's TARs from 4/2023 through 7/2023 revealed staff were monitoring the following:
-Resident 58 had a dialysis fistula and staff were to check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. Every day and evening shift for dialysis care.
-Dialysis fistula care. Staff were to check the color and temperature of the fingers and the radial pulse of the access arm when performing routine care and at regular intervals. Every day and evening shift for dialysis care.
-Staff were to check the fistula patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. This was done daily or as ordered by the physician every day shift for dialysis site patency check.
On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 58 did not have a fistula and the 4/2023 through 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk ...
Read full inspector narrative →
Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and quality of life. Findings include:
On 7/31/23 at 12:20 PM the 6/8/23 Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following:
-Facility staffing levels;
-Staff competencies that were necessary to provide the level and types of care needed for the resident population;
-Ethnic or cultural factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services;
-The facility's resources, including but not limited to all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; and contracts, memorandums of understanding.
On 7/31/23 at 12:30 PM Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not include the identified information.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0846
(Tag F0846)
Could have caused harm · This affected most or all residents
Based on interview and record review, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residen...
Read full inspector narrative →
Based on interview and record review, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residents at risk for displacement. Findings include:
On 7/31/23 the facility was asked to provide a policy and procedure in the event of a pending or potential facility closure.
On 7/31/23 at 11:31 AM Staff 1 (Administrator) stated the facility did not have a policy and procedure for pending or potential facility closure.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide a qualified social service worker. This pl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide a qualified social service worker. This placed all residents at risk for unmet medically related emotional and social service needs of the residents. Findings include:
The Facility assessment dated [DATE] revealed the following information regarding qualifications for the Social Service Director:
-(A) Have bachelor's or master's degree in behavioral sciences with at least on years' experience in a health care setting; or
-(B) An associate degree in behavioral sciences with two years' experience in a health care setting; or
-(C) Receive regular on-site consultation, no less often than quarterly, from an individual who has a bachelor's or master's degree in social work or related behavioral science, and one year's experience in a long-term care setting working directly with individual resident, and have written procedures for referring resident in need of social services to appropriate resources;
-The Social Service Director of a facility with more than 120 beds shall be full-time and shall meet requirements in either paragraph (A) or (B) of this rule.
A review of Staff 16's (Social Service Director) work history/resume indicated she did not have one year of supervised work experience in a health care setting working directly with individuals.
The facility's approved bed capacity was 121 beds and included Medicare and Medicaid contracts with a license expiration date of 8/31/23.
On 7/31/23 at 8:46 AM and 7/28/23 at 10:50 AM Staff 16 (Social Service Director) stated her degree was in criminal justice with a minor in human services. Staff 16 stated she was hired in 11/2022 and the facility had her complete a 10-hour online course for social service work. Staff 16 stated she only received one day of training from the previous social service director before that individual left. Staff 16 stated she corresponded with a Social Service Director from another facility but only for the first two or three months. Staff 16 stated she did not correspond with anyone currently regarding social service concerns and she had no prior experience in a long-term care facility setting. Staff 16 further stated she was in charge of training the social service assistants including Staff 22 (Social Service Assistant).
During the survey the following concerns were identified related to social services and determined to reflect a systemic failure to provide adequate social services to all residents within the facility:
-Residents Rights/treated with dignity (Refer to F550).
-Follow up related to Advance Directives (Refer to F578).
-Medicaid/medicare Coverage/liability (Refer to F582).
-Grievances (Refer to F585).
-Discharge planning process (Refer to F660).
-Maintaining vision services (Refer to F685).
-Provisions of medically related services regarding medical appointments (Refer to F745).
-Psychotropic medication assessments (Refer to F758).
-Routine and dental services (Refer to F790).
-Residents medical records accurate and complete (Refer to F842).
May 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure dignity and respect for 2 of 4 sampled residents' (#s 4 and 5) reviewed for dignity. This placed resid...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure dignity and respect for 2 of 4 sampled residents' (#s 4 and 5) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include:
Resident 4 was admitted to the facility in 3/2018 with diagnoses including dementia.
A 12/14/22 Care Plan identified Resident 4 was at risk for alteration in psychosocial mood including decreased verbalization due to depression.
Resident 5 was admitted to the facility in 1/2022 with diagnoses including major depressive disorder.
A 9/22/22 Care Plan identified Resident 5 was at risk for alteration in psychosocial well being including negative feelings due to depression.
A 6/23/22 Facility Incident Report revealed Staff 19 (CNA) engaged in inappropriate conversations and wore inappropriate attire in front of Residents 4 and 5. The facility indicated Staff 19 discussed with Residents 4 and 5 her recent breast augmentation and reported Staff 19 would often wear inappropriate articles of clothing as a means to expose her breast area which was uncomfortable for Residents 4 and 5.
On 4/25/23 at 1:15 PM Staff 18 (LPN) confirmed Staff 19 referred to her recent breast augmentation to Residents 4 and 5 on numerous occasions and often wore attire that would expose parts of breasts to other residents.
On 4/25/23 at 1:37 PM Staff 15 (LPN) stated Staff 19 was disciplined several times related to the discussion of her breasts with residents. Staff 15 stated Staff 19 continued to engage in these discussions despite several warnings.
On 4/25/23 at 1:57 PM Staff 2 (DNS) confirmed findings related to Staff 19's behavior regarding discussions related to Staff 19's recent breast augmentation.
On 4/25/23 at 4:04 PM Staff 19 confirmed she discussed with Residents 4 and 5 regarding her recent breast augmentation.
On 5/1/23 at 12:30 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 5 sampled resident (#12) reviewed for abuse. This placed residents...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 5 sampled resident (#12) reviewed for abuse. This placed residents at risk for skin injuries. Findings include:
Resident 12 was admitted to the facility in 5/2022 with diagnoses including cerebral infarction (stroke).
A 10/31/22 Care Plan identified Resident 12 with displayed behaviors of crying, screaming, yelling, hallucinations, rejection of care, and suicidal ideation.
A 4/13/22 Facility Incident Report revealed Staff 21 (CNA) held Resident 12's arm's down during performed care tasks. Staff 21 reported she attempted to place Resident 12 into bed which caused Resident 12 to become combative. Staff 21 confirmed she grabbed Resident 12 arms and held her/him down to provide care for the resident and scratched Resident 12's arm as a result.
On 5/1/23 at 12:16 PM Staff 1 (Administrator) confirmed findings and stated Resident 12's scratch marks on her/his arm were caused by Staff 21.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to report an incident of injury of unknown source to the appropriate State Agency within 24 hours for 1 of 1 sa...
Read full inspector narrative →
Based on observation, interview, and record review it was determined the facility failed to report an incident of injury of unknown source to the appropriate State Agency within 24 hours for 1 of 1 sampled resident (#2) reviewed for incidents. This placed resident at risk for further incidents and potential for abuse. Findings include:
Resident 2 was admitted to the facility 5/2020 with diagnoses including cerebral infarction (stroke).
A 4/17/23 BIMS evaluation identified Resident 2 as cognitively impaired.
On 4/24/23 at 10:34 AM Witness 2 (Complainant) identified on 4/12/23 a notable bruise under the left eye of Resident 2. Witness 2 upon assessment indicated she was unable to determine the source of the bruised left eye.
A 4/12/23 Facility Incident Report revealed the facility identified Resident 2 had a bruised left eye of unknown origin.
On 4/24/23 at 10:54 AM Staff 2 (DNS) stated the facility did not file a report with the State Agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to thoroughly investigate and rule out potential abuse for 1 of 1 sampled resident (#2) reviewed for abuse. Thi...
Read full inspector narrative →
Based on observation, interview, and record review it was determined the facility failed to thoroughly investigate and rule out potential abuse for 1 of 1 sampled resident (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include:
Resident 2 was admitted to the facility 5/2020 with diagnoses including cerebral infarction (stroke).
A 4/17/23 BIMS evaluation identified Resident 2 as cognitively impaired.
On 4/24/23 at 10:34 AM Witness 2 (Complainant) identified on 4/12/23 a notable bruise under the left eye of Resident 2. Witness 2 upon assessment indicated she was unable to determine the source of the bruised left eye.
A 4/12/23 Facility Incident Report revealed facility identified Resident 2 with a bruised left eye of unknown origin.
On 4/24/23 at 10:54 AM Staff 2 (DNS) stated the facility did not conduct an investigation as they concluded the source of the bruise was due to Resident 2 sleeping with her/his glasses on. Staff 2 confirmed no assessment was completed to verify the facility's conclusion.
On 4/24/23 at 11:03 AM Staff 4 (RNCM) and Staff 1 (Administrator) stated Resident 2 informed the facility she/he's source of the bruised left eye was caused by the resident leaving her/his glasses on while asleep the night before and not as a result of being hit in eye. Staff 1 confirmed no investigation was conducted by the facility as the facility believed the source of the injury was caused by Resident 2 leaving her/his glasses on overnight.
On 4/24/23 at 11:36 AM Resident 2 stated she/he did not have a history of leaving her/his glasses on while sleeping due to fear of them breaking. Resident 2 confirmed the appearance of a bruise on her/his left eye but did not recall how it was obtained or informing the facility of how it was obtained.
On 4/24/23 at 11:39 AM Staff 5 (LPN) indicated Resident 2 did not have a history of sleeping with her/his glasses on. Staff 5 reported she discovered the black eye on 4/12/23 and confirmed Resident 2 had not worn her/his glasses to bed the night before.
A Review of Resident 2's clinical record revealed no statement from Resident 12 related to the source of the bruised left eye, no investigation for injury of unknown origin was documented and no skin assessment completed for day of incident.
On 5/1/23 at 12:30 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#18) reviewed for discharge. This placed residents at risk for unmet care needs after discharge. Findings include:
Resident 18 admitted to the facility in 12/2022 with diagnoses including chronic respiratory failure, heart failure, malnutrition and anxiety disorder.
On 4/16/23 at 12:43 PM Witness 9 (Complainant) stated Resident 18 was unsafely discharged home and had no assistance with bathing. Witness 9 stated Resident 18 was Medicaid approved to stay in the ICF (intermediate) level of care however the facility told the resident if she/he planned to remain at the facility for ICF care it would cost Resident 18 hundreds of dollars every day and would lose her/his social security benefits.
The 2/8/23 Physician Order indicated Resident 18 could discharge home with home health services on 2/9/23.
Resident 18's MDS schedule revealed Resident 18 was discharged to the hospital on 2/8/23, re-admitted to the facility on [DATE] and discharged to the community (home) on 3/18/23.
The 3/3/23 Social Service Note revealed the resident's representative worked to get Resident 18 approved for Medicaid and planned to request Resident 18 transfer to the ICF level of care however if she/he was not approved by the time of discharge the resident would go home because she/he could not afford the out of pocket cost of ICF.
The 3/17/23 Functional Abilities and Goals assessment indicated Resident 18 required supervision and physical assistance with showering.
The 3/18/23 Discharge Summary revealed Resident 18 discharged home.
Review of Resident 18's medical record revealed no physician order to discharge home after Resident 18 re-admitted from the hospital.
On 4/25/23 at 9:11 AM Witness 11 (Case Manager) stated Resident 18 was approved for Medicaid services on 12/28/22, if Resident 18 needed more assistance she/he was approved to stay in the ICF level of care and stated the facility did not reach out to him prior to discharge. Witness 11 further stated Home Health Physical Therapy did not start until 4/10/23 and Resident 18 physically lost all that she/he had gained during her/his SNF stay at the facility.
On 4/25/23 at 9:42 AM Staff 6 (Social Service Director) stated she knew Resident 18 was approved for Medicaid services but her understanding was the Resident would be responsible for $450 a day for care and when she discussed this with Resident 18 she/he was adamant she/he could not afford to stay. Staff 6 verified she did not get updated discharge or home health orders to discharge Resident 18 home but instead used the 2/8/23 discharge order. Staff 6 stated she initiated contact for home health services but last communicated with the home health agency on 3/11/23 and did not verify the services would start at the time of Resident 18's discharge.
On 4/25/23 at 11:19 AM Staff 1 (Administrator) stated the facility was unaware Resident 18 was approved for Medicaid ICF services and stated if they had known the facility would have pushed for [her/him] to stay ICF long term. Staff 1 further stated the facilty did not think Resident 18's discharge home was safe and attempted to set the resident up with home health, equipment and APS (Adult Protective Services) was involved.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure medications were administered as ordered for 1 of 3 sampled residents (#3) reviewed for medications. This placed re...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure medications were administered as ordered for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for decreased efficacy. Findings include:
Resident 3 admitted to the facility in 9/2022 with diagnoses including right femur fracture and stroke.
The 2/2/23 Physician Order revealed an order for Plavix (antiplatelet medication) 75 mg to be administered daily.
The February 2023 MARs revealed Plavix 75 mg was to administered daily at 6:00 PM.
The 2/10/22 Facility Investigation indicated Resident 3 verbalized a concern about receiving her/his Plavix a few hours late with a specific LPN. When Resident 3 requested the medication from the LPN, the LPN informed the resident she did not want to walk back down to the medication cart to get the medication. The investigation determined late administration of the Plavix occurred on two separate occasions and neglect of care was substantiated.
On 4/25/23 at 12:35 PM Staff 2 (DNS) stated Resident 3 was administered Plavix late on 2/8/23 and 2/9/23.
Dec 2022
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident's family concern was responded to in a timely manner for 1 of 3 sampled residents (#1) reviewed for inco...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure a resident's family concern was responded to in a timely manner for 1 of 3 sampled residents (#1) reviewed for incontinence. This placed residents and involved parties at risk for unresolved concerns. Findings include:
A facility Grievance Policy last reviewed 1/2018 revealed the facility was to support and assist the residents and their representative in their right to file a grievance in order to resolve concerns. Grievances and/or complaints could be submitted orally or in writing. The person submitting the grievance would receive a response within seven days and may obtain a written response upon request.
Resident 1 was admitted to the facility in 2022 with diagnoses including a stroke.
A 9/17/22 admission CAA indicated Resident 1 had a stroke, was not able to speak but could appropriately nod her/his head yes and no. The resident was not able to move her/his right side and required assistance to transfer and perform ADLs. The resident was frequently incontinent and it was unclear if the resident's ability to sense her/his need for toileting was related to the resident's impaired communication. Staff were to initiate routine toileting.
A 9/22/22 Care Conference Notes form indicated the RNCM and Social Services Director (SSD) attended (staff names not specified), the resident and family did not attend but family called prior to the conference. When the family called they reported when they visited on two occasions, on the evening shift, the resident was found to have soaked incontinent briefs.
On 12/29/22 at 11:56 PM Staff 1 (Former Social Service Director/SSD) stated she vaguely recalled the resident and may have spoken to the resident's family but did not recall the nature of the conversation. If the family had concerns related to incontinence the issue would be referred to the RNCM to investigate. The RNCM was then responsible to ask staff to see if the resident was, in fact, left soiled.
On 12/22/22 at 10:13 AM and 10:24 AM Staff 2 (RNCM) stated she vaguely recalled the care conference and the concern related to Resident 1 being left soiled on the evening shift. Staff 2 looked at the resident's care plan and stated the care plan was updated the day after the care conference, so she likely spoke to staff but could not recall.
On 12/21/22 at 2:56 PM Witness 2 (Family) stated the facility did not communicate with her after the care conference related to the resident's soaked incontinence briefs.
On 12/29/22 at 12:54 PM Staff 3 (DNS) stated if family called and reported a concern related to care, they were to look into the concern and follow up with the family. It was expected the RNCM would communicate with the family member to let them know if any changes were made to address the identified concerns. A request was made to Staff 3 to provide documentation to verify Resident 1's family concern was looked into to ensure care was provided and follow up was made to the family. No additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident's medication was not misapporpriated for 1 of 3 sampled residents (#2) reviewed for lost and stolen item...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure a resident's medication was not misapporpriated for 1 of 3 sampled residents (#2) reviewed for lost and stolen items. This placed residents at risk for pain. Findings include:
Resident 2 was admitted to the facility in 2017 with diagnoses including chronic pain and had orders for baclofen (muscle relaxant)10 mg.
Resident 5 was admitted to the facility in 2022 with diagnoses including pain and had orders for baclofen 10 mg.
A 12/9/22 FRI and associated investigation revealed on 12/9/22 Staff 4 (Agency LPN) reported Resident 2's baclofen card was located in Resident 5's mediation slot. A line was drawn through Resident 2's name and Resident 5's name was written on the card. All staff who administered medications were interviewed and it was not able to be determined who placed Resident's 2 baclofen card in Residents 5 medication slot to be used or when it occurred.
On 12/22/22 at 12:32 PM Staff 4 stated she worked in the facility a few days prior and she did not see Resident 2's card in Resident 5's medications slot. She reported the concern immediately.
Resident 2's December 2022 MAR revealed she/he received her/his baclofen as ordered.
Resident 2' December 2022 Progress Notes did not indicate the resident had unrelieved pain.
Resident 5's December 2022 MAR revealed she/he received her/his baclofen as ordered.
The facility completed the investigation of the incident on 12/12/22 which included an audit of the medication cart. On 12/16/22 the Past Noncompliance was corrected when the facility implemented the Plan of Correction which included: 1. Staff education on facility Mission, Nursing Standards of Practice, Abuse Policy including misappropriation of property, process to correctly obtain medications, when to notify a physician for missed medications, consequences of infarctions and employee expectations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure investigations were completed timely for 2 of 3 sampled residents (#s 1 and 6) reviewed for falls. This placed resi...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure investigations were completed timely for 2 of 3 sampled residents (#s 1 and 6) reviewed for falls. This placed residents at risk for continued falls. Findings include:
A facility Event Management Policy last reviewed 3/2021 revealed event investigation summaries were to be completed no later than five days after the event. Causative factors were to be reviewed and the care plan was to be updated as needed to prevent reoccurrences.
1. Resident 1 was admitted to the facility in 2022 with diagnoses including a stroke.
A base line care plan initiated on 9/12/22 indicated Resident 1 was at risk for falls and staff were to keep frequently used items within reach and staff were to frequently observe the resident.
a. A 9/14/22 Fall investigation revealed Resident 2 was found on the floor, the call light was not activated and a staff member was with the resident moments prior to the fall.
An 11/21/22 Incident Note indicated it was a follow-up note to the 9/14/22 fall. The cause of the fall was that the resident's belongings were likely not close to the resident. This analysis was completed more than two months after the fall.
On 12/22/22 at 10:07 AM Staff 5 (RN) stated she was not the resident's RNCM but was helping out. The summary analysis should be completed in less than one week and was not sure the reason it was not completed timely.
On 12/29/22 at 12:53 PM Staff 3 (DNS) stated she was not sure the reason Resident 1's fall investigation was not completed within five days.
b. A Fall investigation dated 9/26/22 indicated Resident 1 was found on the floor, the call light was not activated and the resident indicated she/he attempted to self-transfer.
A 12/21/22 Incident Note indicated it was a follow-up to the 9/26/22 fall. The resident was found on the floor after an unsuccessful self-transfer and was seen just minutes before the fall. The root cause of the fall was poor safety awareness.
On 12/22/22 at 10:34 AM Staff 2 (RNCM) stated she often did the fall follow-ups and updated the care plans after the falls but did not document the investigation summary. Staff 2 acknowledged the investigative summary should be completed within five days.
On 12/29/22 at 12:53 PM Staff 3 (DNS) was not sure the reason Resident 1's fall investigations were not completed within five days.
2. Resident 6 was admitted to the facility in 2020 with diagnoses including brain bleed.
A care plan initiated 8/2020 indicated Resident 6 was at risk for falls and staff were to place a bolster (wedge) to the left side of her/his bed at night and the right side was to be against the wall.
a. An 11/24/22 fall investigation indicated the resident was observed on the floor and had a recent room change.
An Incident Note dated 12/7/22 indicated it was a follow-up note for 11/24/22 fall. The root cause of the fall was weakness and a new environment. The resident was just moved to the Covid-19 unit and the room was not set up like her/his room and it was likely disorienting for the resident.
On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days.
b. An 11/29/22 at 9:13 PM Fall investigation indicated Resident 6 was found with her/his legs off the bed and her/his upper body remained on the bed. The resident was confused and was assessed to have a small open area to the right knee.
An Incident Note dated 12/7/22 indicated it was a follow-up to the 11/29/22 fall. The analysis indicated the resident was in a new environment and the resident did not have a bolster on her/his bed. However, the bolster did not always keep the resident from falling or attempting to get out of bed. The note indicated the resident was currently back to her/his normal room and the bolster was in place.
On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed. The staff initiating the fall investigation should make note of the interventions and implement if not present at the time of the fall.
Refer to F689 example 2.
c. A 12/1/22 at 10:41 PM revealed there resident had an unwitnessed fall and was found kneeling on her/his knees.
An Incident Note dated 12/7/22 indicated it was a follow up note to the 12/1/22 fall when the resident was found on the floor on her/his knees. The resident was found to have a skin tear to the elbow. The note indicated the bolster remained off the bed as the resident was not in her/his permanent room.
On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed.
Refer to F689 example 2.
d. A 12/1/22 at 2:31 AM Witnessed Fall Investigation indicated the resident rolled out of bed. The resident was confused at the time of the fall.
A 12/7/22 Incident Note indicated the note was a follow-up to the 12/1/22 fall. The resident was observed to roll out of bed. The root cause of the fall was the resident's bolster was not in place and the resident was in a new room due to Covid-19.
On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed.
Refer to F689 example 2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident was assisted with showers for 1 of 3 sampled residents (#3) reviewed for bathing. This placed residents ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure a resident was assisted with showers for 1 of 3 sampled residents (#3) reviewed for bathing. This placed residents at risk for lack of hygiene. Findings include:
Resident 3 was admitted to the facility 11/1/22 with diagnoses including bone infection of the right foot and ankle. Resident 3 discharged on 12/8/22.
An 11/13/22 admission CAA indicated Resident 3 was cognitively intact and was unable to walk due to pain to the right foot. Due to her decrease in her/his ability to do her/his ADLs a care plan was developed.
A care plan initiated 11/14/22 indicated the resident at times refused showers but staff were to encourage her/him to shower and one staff was to assist the resident as needed twice a week and PRN.
An 11/2022 through 12/2022 Bathing record revealed the resident refused one shower and received one shower. The resident had nine missed bathing opportunities for her/his facility stay.
On 12/29/22 at 9:26 AM Resident 3 stated at one point she/he did not get assistance with showers for at least 10 days.
On 12/22/22 at 10:57 AM Staff 2 (RNCM) acknowledged only three showers were documented including one shower which was provided by therapy. A request was made for documentation to show bathing was offered to Resident 3. No additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based observation, interview and record review it was determined the facility failed to ensure fall interventions were in place for 2 of 3 sampled residents (#s 4 and 6) reviewed for falls. This place...
Read full inspector narrative →
Based observation, interview and record review it was determined the facility failed to ensure fall interventions were in place for 2 of 3 sampled residents (#s 4 and 6) reviewed for falls. This placed residents at risk for injury. Findings include:
1. Resident 4 was admitted to the facility in 2022 with diagnoses including a fractured leg.
A 10/18/22 admission CAA indicated the resident was cognitively impaired, had poor safety awareness and did not request staff for assistance. The resident's call light was to be kept within reach, but the resident was not yet seen using the call light. Additional interventions indicated the resident's bed was also to be kept at knee height in case the resident attempted to stand without assistance.
Resident 4's 10/26/22 care plan reflected the bed was to be at knee height and the call light was to be within reach.
a. On 12/21/22 at 2:03 PM Resident 4 was observed in bed and the bed was at least hip height.
On 12/21/22 at 2:11 PM Staff 6 (CNA) stated she just left the resident's room and acknowledged the bed was not lowered to knee height after care was provided.
b. On 12/22/22 at 9:35 AM Resident 4 was observed in bed. The resident's call light was on the floor. Staff 4 (LPN) was notified and acknowledged the call light was not within the resident's reach and stated the resident at times used the call light.
On 12/22/22 at 9:39 AM Staff 7 (CNA) stated when he assisted the resident up for breakfast the resident's call light cord was tangled in the bed control and when the bed was elevated the call light must have fallen off the bed.
2. Resident 6 was readmitted to the facility 11/2022 on hospice services.
An 11/2022 Significant Change MDS and CAAs revealed the resident was cognitively impaired, did not request assistance for her/his needs and had a history of multiple falls in the past year related to impulsiveness and poor safety awareness. The resident often attempted to transfer her/himself. Multiple interventions were to be implemented including at night a bolster (wedge shaped pillow) was to be placed on the left side of the bed.
An 11/29/22 at 9:13 PM Unwitnessed fall investigation and associated Incident Note (post fall review) revealed Resident 6 was observed with her/his legs out of the bed and her/his upper body in bed, and attempted to get out of bed bed without assistance. The resident was recently moved to a new room due to Covid-19 infection and was not familiar with her/his environment and the bed lacked a bolster. The note indicated the bolster did not always stop the resident from exiting the bed.
Fall investigations revealed Resident 6 fell two times on 12/1/22. On 12/1/22 at 2:31 AM the resident was witnessed to roll out of bed. The resident stated she/he was going to church. On 12/1/22 at 10:41 PM the resident was found kneeling by her/his bed. The resident stated she/he was trying to get up to see her/his spouse. The associated Incident Notes indicated the resident did not have the bolster on the bed for both falls.
On 12/22/22 at 10:38 AM Staff 2 (RNCM) stated she was not sure the reason the bolster was not taken with Resident 6 to the Covid-19 unit. The bolster did not prevent falls because Resident 6 was able to go over and/or around the bolster but it was a fall intervention that was not in place at the time of the 11/29/22 and 12/1/22 falls.
On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged the resident was to have the bolster in place at night, the resident fell three times on the night shift while on the Covid-19 unit and the resident's bolster was not in place. The nurse initiating the investigation should have reviewed the care plan to ensure all interventions were in place at the time of the fall. Staff 3 stated when she completed the post fall review she identified the bolster was not in place.
Jul 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
3. Resident 66 admitted to the facility in 2018 with diagnoses including diabetes.
A 3/10/22 Annual MDS revealed Resident 66 had a BIMS score of 15 which indicated she/he was cognitively intact.
Care...
Read full inspector narrative →
3. Resident 66 admitted to the facility in 2018 with diagnoses including diabetes.
A 3/10/22 Annual MDS revealed Resident 66 had a BIMS score of 15 which indicated she/he was cognitively intact.
Care Conference Notes on 3/15/22 and 6/7/22 revealed a care conferences were held for Resident 66 and there was no documentation regarding an advance directive being offered or reviewed.
In an interview on 6/30/22 at 2:44 PM Staff 6 (RN Unit Manager) stated the facility preferred to have Physician's Order for Life Sustaining Treatment (POLST) for the residents and was unaware of the process for advance directives.
In an interview on 6/30/22 at 3:14 PM Staff 5 (Social Services Director) stated POLSTs were reviewed, however was unaware of the process for advance directives.
On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings.
Based on interview and record review it was determined the facility failed to obtain copies of Advance Directives if available or periodically review resident's wishes to execute an advance directive for 3 of 3 sampled residents (#s 28, 60, 66) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include:
1. Resident 28 admitted to the facility in 2021 with diagnoses including heart disease and high blood pressure.
A review of the medical record revealed Resident 28 did not have an advance directive and there was no information to indicate the facility periodically followed up with the resident related to her/his desire to execute an advance directive.
On 6/30/22 at 11:48 AM Staff 4 (LPN/Health Center Navigator) stated residents were asked at admission about advance directives. Staff 4 added if a resident was interested in executing an advance directive they were referred to social services for assist.
On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings.
2. Resident 60 admitted to the facility in 2021 with diagnoses including diabetes and end stage kidney disease.
A review of the medical record did not include information related to advance directives.
On 6/30/22 at 12:25 PM Resident 60 was asked about advance directives. Resident 60 did not know what an advance directive was, denied having one or the facility asking about advance directives.
On 6/30/22 at 11:48 AM Staff 4 (LPN/Health Center Navigator) stated residents were asked at admission about advance directives. Staff 4 added if a resident was interested in executing an advance directive they were referred to social services for assist.
On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to notify a resident's representative for 1 of 3 sampled residents (#53) reviewed for change in condition. This placed reside...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to notify a resident's representative for 1 of 3 sampled residents (#53) reviewed for change in condition. This placed resident responsible parties at risk for not being informed. Findings include:
Resident 53 admitted to the facility in 5/2020 with diagnoses including bilateral amputations below the knees and diabetes.
A Physician Progress Note dated 8/25/21 revealed Resident 25 was seen by a physician and had a polyp (a growth in the outside ear canal or middle ear) removed in her/his left ear canal.
No documentation was found in the clinical records Resident 53's representative was notified of the medical procedure to remove the polyp.
On 6/30/22 at 5:00 PM Witness 2 (Complainant) confirmed Witness 1 was not notified of the procedure on 8/25/21.
On 7/1/22 at 3:11 PM Staff 11 (RN/Nurse Manager) stated Witness 1 was not notified of the 8/25/21 appointment or procedure. Staff 11 stated she expected staff to notify family of upcoming appointments or procedures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#21) reviewed for hospice. This placed residents at risk for ...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#21) reviewed for hospice. This placed residents at risk for unmet care needs. Findings include:
Resident 21 was admitted to the facility in 2016 with diagnoses including heart disease and depression and admitted to hospice services in 10/2021.
Random observations from 6/27/22 through 6/30/22 revealed Resident 21 was up in the wheelchair at meal times or in bed.
Resident 21's care plan was revised on 10/28/21 for terminal diagnosis and admission to hospice services.
The care plan was not revised to include the absence of a spouse for support or visits, lack of participation in facility activities, current day to day routines, decline in ADL abilities, location of dining, refusals of denture care and discharge plan.
On 6/30/22 at 2:40 PM Staff 3 (RN Nurse Manager) was asked about care plan revisions and agreed Resident 21's care plan did not reflect her/his current needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to assess and monitor bruising for 1 of 1 sampled residents (# 59) reviewed for skin conditions. This placed res...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to assess and monitor bruising for 1 of 1 sampled residents (# 59) reviewed for skin conditions. This placed residents at risk for unmet needs. Findings include:
Resident 59 was admitted to the facility in 3/2022 with diagnoses including diabetes.
On 6/29/22 at 1:50 PM and 6/30/22 at 2:49 PM Resident 59 was observed to have multiple bruises to her/his left arm and hand. The bruises were dark purple and dime size to a half dollar size.
A review of Resident 59's medical record revealed no documentation, assessment or monitoring for the bruises.
On 7/1/22 at 8:35 AM Staff 14 (LPN) acknowledged they were aware of Resident 59's bruises but had not completed a skin sheet, assessment nor monitored the bruises.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure safety interventions were in place for 1 of 1 sampled resident (#30) reviewed for accidents. This plac...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure safety interventions were in place for 1 of 1 sampled resident (#30) reviewed for accidents. This placed residents at risk for elopement. Findings include:
Resident 30 admitted to the facility in 5/2018 with diagnoses including dementia and depression.
An 8/10/18 care plan revealed Resident 30 had an ADL self-care performance deficit related to dementia and weakness. Resident 30 used her/his wheelchair to self-propel around the facility. A revised 12/16/21 care plan revealed Resident 30 wandered which placed her/him at risk for elopement and she/he wore a Wander Guard (a device thatsets off an alarms) bracelet to alert staff if she/he attempted to elope.
Elopement incident dated 3/23/22 revealed the following:
-On 3/19/22 Resident 30 was found by staff in the front parking lot outside of the lobby but did not leave the facility property. Resident 30 was returned to the dining area for breakfast and scheduled medications.
-Resident 30 had a Wander-Guard on her/his wrist during the incident but because staff where unable to hear Resident 30's alarm they were unaware of her/his location.
-Resident 30 was unable to explain why she/he was outside but was distressed about being outside and cold.
Elopement incident dated 6/28/22 revealed the following:
-On 6/10/22 Resident 30 was found outside the building in the enclosed courtyard at approximately 3:15 AM she/he was last seen at approximately 3:00 AM when she/he woke up for a snack.
-Resident 30 was heard yelling outside in the enclosed courtyard.
-Resident 30 was assisted inside, warmed up and consoled because it had been raining outside and when staff brought Resident 30 in her/his clothes were soaked.
-The door Resident 30 exited on 6/10/22 would not have sounded an alarm because other residents could exit the door to go outside into the enclosed courtyard area. The facility placed a stop sign to the back door of the courtyard to dissuade Resident 30 from going out in the courtyard without staff assistance.
-On 6/12/22 Resident 30 had no recollection of the 6/10/22 incident.
Random observations on 6/27/22 through 6/29/22 revealed Resident 30 was able to self-propel in her/his wheelchair without assistance throughout the facility.
On 6/30/22 at 8:16 AM Staff 11 (CNA) stated she was not present for either of the elopements but indicated Resident 30 was to have frequent checks because she/he wandered a lot and she/he was hard to keep track of in the building. Staff 11 stated Resident 30 wore a Wander-Guard.
On 7/1/22 at 11:59 AM Staff 13 (LPN) stated she recalled the incident on 3/19/22 because she was going to administer Resident 30's medication and was unable to locate her/him. Staff 13 stated Resident 30 was found outside the front lobby area and the alarm had sounded due to her/his Wander-Guard going off but staff could not hear the alarm because she/he was too far away and there was not a staff person at the front desk entrance of the building. Staff 13 further stated staff were to check on Resident 30 every 15 minutes for safety but was difficult to do at times.
On 7/1/22 at 1:32 PM Staff 10 (CNA) and at 12:56 PM Staff 12 (CNA) stated Resident 30 was pleasantly confused and she/he could self-propel in her/his wheelchair throughout the facility. Staff 10 and Staff 12 stated they were supposed to check on Resident 30 every 15 minutes but were not always able to check on her/him that frequently.
On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated she completed both incident reports on the 3/11/22 and 6/10/22 elopements and both incidents she/he was found outside confused, cold and distressed. Staff 3 stated Resident 30 could not recall either incident from 3/11/22 or 6/10/22 the following day. Staff 3 stated on the 3/11/22 incident staff could not hear the alarm sounding because of where Resident 30 was located. Staff 3 stated the 6/10/22 incident the exit door on the D hall would not have sounded because it did not have an alarm on it. Staff 3 further stated staff were expected to check on Resident 30 every 15 to 30 minutes for safety purposes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
3. Resident 30 admitted to the facility in 5/2018 with diagnoses including dementia and depression.
A physician order dated 12/11/21 revealed Resident 30 received Risperidone (an antipsychotic) three ...
Read full inspector narrative →
3. Resident 30 admitted to the facility in 5/2018 with diagnoses including dementia and depression.
A physician order dated 12/11/21 revealed Resident 30 received Risperidone (an antipsychotic) three times daily for dementia with behaviors.
The 4/25/22, 5/30/22 and 6/27/22 Consultant Pharmacist Medication Regimen recommended a GDR (gradual dose reduction) to Risperidone. A review of Resident 30's clinical record revealed no documentation from the physician to address the pharmacist's recommendation to attempt a GDR or present a clinical rational for continued use of Risperidone. No adverse consequences were documented for the continued use of Risperidone.
On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated they struggled with physicians responding to pharmacy recommendations for Resident 30 and acknowledged no response was received for the 4/25/22, 5/30/22 or 6/27/22 GDR reduction recommendation for Risperidone.
2. Resident 41 admitted to the facility in 4/2022 with diagnoses including dementia and anxiety.
A physician order dated 4/28/22 revealed Resident 41 received Haloperidol (an antipsychotic) every two hours as needed for nausea, vomiting, hallucinations and agitation.
A physician order dated 4/28/22 revealed Resident 41 received Lorazepam (an antianxiety) every two hours as needed for restlessness, anxiety and insomnia.
The 4/27/22, 5/30/22 and 6/27/22 Consultant Pharmacist Medication Regimen recommended to discontinue as needed medications or add a stop date which did not exceed the 14 days from initiation. If the as needed medications could not be discontinued at this time, current regulations required the provider to directly examine the resident to determine if the medications were still needed and document the specific condition being treated prior to issuing a new as needed order. A review of Resident 41's clinical record revealed no documentation from the physician to address the pharmacist's recommendation.
On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated they struggled with physicians responding to pharmacy recommendations for Resident 41 and acknowledged no response was received for the 4/25/22, 5/30/22 or 6/27/22 recommendations for Haloperidol and Lorazepam.
Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 3 of 5 sampled residents (#s 28, 30 and 41) reviewed for unnecessary medications. This placed residents at risk for medication complications. Findings include:
1. Resident 28 admitted to the facility in 2021 with diagnoses including heart disease and high blood pressure.
A recommendation for a gradual dose reduction (GDR) of an antidepressant was made in 5/2022 and repeated in 6/2022.
On 6/30/22 at 2:53 PM Staff 3 (RN Nurse Manager) was asked about pharmacy recommendations and stated they were sent to the provider for consideration. Staff 3 stated she followed up each week and if the provider failed to address the recommendation after 30 days, the recommendations were sent to the Medical Director by the DNS.
On 7/1/22 at 3:37 PM Staff 2 (DNS) stated she sent a list of the pharmacy recommendations to the medical director that were not addressed by the providers. Staff 2 added the medical director signed the recommendations as acknowledgment but did nothing to assist the facility to get other providers to address the recommendations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/28/22 hall F was placed on droplet and contact precautions related to an exposure to COVID 19.
On 6/28/22 at 3:25 PM Res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/28/22 hall F was placed on droplet and contact precautions related to an exposure to COVID 19.
On 6/28/22 at 3:25 PM Resident rooms 217, 218, 219, 221, 222, 223, 224, 225, 226, 227 and 230 were all observed to have a garbage can in the hallway outside the bedroom doors, all garbage cans were observed to have no lids and were filled with used gowns.
On 6/28/22 at 3:34 PM Staff 17 (Housekeeper) removed her gown and gloves in doorway, exited room [ROOM NUMBER] and disposed of her gown and gloves in the garbage can in the hallway next to the bedroom door.
On 6/28/22 at 3:35 PM Staff 18 (CNA) removed her gown and gloves in the doorway, exited room [ROOM NUMBER] and disposed of her gown and gloves in the garbage can in the hallway next to the bedroom door.
In an interview on 6/28/22 at 3:39 PM Staff 19 (LPN) stated staff were directed to dispose of used PPE in the garbage cans in the hallway.
In an interview on 6/28/22 at 5:45 PM Staff 2 (DNS) stated the staff were to dispose of gloves and gowns in the garbage cans in resident rooms. Staff 2 acknowledged the staff were not safely disposing of PPE.
On 6/30/22 at 9:34 AM room [ROOM NUMBER] was observed to have a garbage can outside the room in the hallway, the garbage can was overflowing with used gowns.
In an interview on 6/30/22 at 11:48 AM Staff 7 (Director of Staff Development) acknowledged the garbage cans with used PPE were again in the hallway that morning.
Based on observation and interview it was determined the facility failed to dispose of personal protective equipment safely for 2 of 5 resident halls (A and F) reviewed for infection control. This placed residents at risk for further infection. Findings include:
1. On 6/27/22 at 11:45 AM observations of hall A revealed three rooms (107, 109 and 113) on droplet and contact precautions. The three rooms were observed to have garbage cans in the hallway outside the bedroom doors, all garbage cans overflowed with used gowns and gloves.
On 6/28/22 at 2:25 PM Resident room [ROOM NUMBER] was observed to have a garbage can in the hallway outside the bedroom door. The garbage can overflowed with used gowns and gloves.
On 6/28/22 at 5:45 PM Staff 2 (DNS) stated staff were to dispose of gloves and gowns in the garbage cans in resident rooms. Staff 2 acknowledged staff had not safely disposed of PPE.
On 6/29/22 at 2:33 PM Staff 20 (RN) stated she was told to placed garbage cans outside of the resident's door for the dirty gloves and gowns. Staff 20 stated staff should have put the dirty gloves and gowns in the garbage can in the resident's room after they had doffed their PPE.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for food trays served from 1 of 1 facility kitchen...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for food trays served from 1 of 1 facility kitchens and 4 of 4 sampled residents (#s 5, 7, 60 and 66) reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include:
Interviews revealed the following food concerns:
On 6/27/22 at 3:12 PM Resident 5 stated the food had no flavor was not hot and the soups were always cold.
On 6/28/22 at 9:54 AM Resident 7 stated meals were not always hot when she/he received them.
On 6/28/22 at 12:16 PM Resident 66 stated the meals had no flavor and were sometimes cold.
On 6/28/22 at 3:13 PM Resident 60 was asked about food quality and she/he stated it was getting better but the hot food was not hot.
On 6/30/22 at 1:03 PM two lunch trays were provided to survey staff and each meal was served on a plate. One plate had mashed potatoes with gravy, breaded rosemary chicken and steamed mixed vegetables. The second plate had boneless ribs with barbecue sauce over them and buttered noodles. The kitchen staff did not provide a salad, soup or dessert which was part of the lunch items. All meals were tasted and the survey team agreed the ribs were cold, the breaded chicken was soggy with no flavor and the noodles had no taste. The vegetables were not flavored and hard to chew additionally the gravy over the top of the mashed potatoes was salty.
On 6/30/22 at 1:10 PM Staff 1 (Administrator) and Staff 2 (DNS) were present and agreed there were temperature issues with the identified meals. Staff 2 stated the ribs and rosemary chicken were warm and the chicken breading had no flavor and was chewy. Staff 2 further stated the noodles had no butter flavor, the steamed vegetables were not flavored and hard to chew, and the gravy was salty.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on observation and interview it was determined the facility failed to ensure survey results were in a readily accessible area for residents and visitors for 1 of 1 survey result binders reviewed...
Read full inspector narrative →
Based on observation and interview it was determined the facility failed to ensure survey results were in a readily accessible area for residents and visitors for 1 of 1 survey result binders reviewed for public information. This placed residents and visitors at risk for not being informed of the facility's survey history. Findings include:
On 6/30/22 at 12:42 PM a laminated sheet of paper reading Survey Information Available Upon Request was observed on a table in the reception area of the facility.
On 6/30/22 at 12:44 PM the survey result binder was requested from Staff 8 (Receptionist). Staff 8 provided the survey result binder from behind the reception desk. There were no signs at the reception desk indicating where the binder was located or if residents and visitors were free to go behind the desk and retrieve it.
On 6/30/22 at 2:02 PM Staff 1 (Administrator) acknowledged the survey result binder was kept behind the reception desk and stated residents and visitors could ask staff to retrieve it.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Oregon facilities.
Concerns
- • 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Dallas Retirement Village's CMS Rating?
CMS assigns DALLAS RETIREMENT VILLAGE HEALTH CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Dallas Retirement Village Staffed?
CMS rates DALLAS RETIREMENT VILLAGE HEALTH CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 48%, compared to the Oregon average of 46%.
What Have Inspectors Found at Dallas Retirement Village?
State health inspectors documented 49 deficiencies at DALLAS RETIREMENT VILLAGE HEALTH CENTER during 2022 to 2024. These included: 48 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Dallas Retirement Village?
DALLAS RETIREMENT VILLAGE HEALTH CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 121 certified beds and approximately 99 residents (about 82% occupancy), it is a mid-sized facility located in DALLAS, Oregon.
How Does Dallas Retirement Village Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, DALLAS RETIREMENT VILLAGE HEALTH CENTER's overall rating (3 stars) matches the state average, staff turnover (48%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Dallas Retirement Village?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Dallas Retirement Village Safe?
Based on CMS inspection data, DALLAS RETIREMENT VILLAGE HEALTH CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Dallas Retirement Village Stick Around?
DALLAS RETIREMENT VILLAGE HEALTH CENTER has a staff turnover rate of 48%, which is about average for Oregon nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Dallas Retirement Village Ever Fined?
DALLAS RETIREMENT VILLAGE HEALTH CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Dallas Retirement Village on Any Federal Watch List?
DALLAS RETIREMENT VILLAGE HEALTH CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.