HIGHLAND HOUSE NURSING & REHABILITATION CENTER
For profit - Limited Liability company
119 Beds
VOLARE HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
33/100
#89 of 127 in OR
Photo by Minn Tun
Photo by Minn Tun
Photo by Minn Tun
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Highland House Nursing & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #89 out of 127 nursing homes in Oregon, placing it in the bottom half statewide, and #3 of 4 in Josephine County, meaning only one other local facility is rated lower. While the facility is improving, with issues decreasing from 31 in 2024 to just 4 in 2025, there are still serious concerns, including a critical incident of alleged sexual abuse involving a staff member. Staffing is a mixed bag; they have a below-average rating of 2 out of 5 stars and a staff turnover rate of 54%, which is around the state average. Additionally, the facility has concerning RN coverage, being below 89% of Oregon facilities, which may impact the quality of care, although they have good quality measures. Overall, families should weigh the facility's improvements against its serious past issues and current staffing challenges.
- Trust Score
- F
- In Oregon
- #89/127
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $36,852 in fines. Lower than most Oregon facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Oregon. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 65 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 30%
Review needed
31 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 31 issues
2025: 4 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Oregon average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Oregon avg (46%)
Higher turnover may affect care consistency
Federal Fines: $36,852
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: VOLARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 65 deficiencies on record
1 life-threatening
Apr 2025
4 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
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 6 sampled residents (#12) reviewed for abuse. This placed ...
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Based on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 6 sampled residents (#12) reviewed for abuse. This placed residents at risk for being treated with a lack of respect and dignity. Findings include:
Resident 12 admitted to the facility in 11/2024, with diagnoses including Parkinson's Disease. Resident 12 was on Hospice Services and passed away on 3/9/25.
The 2/17/25 facility investigation revealed several staff attempted to assist Resident 12 to sit down in her/his wheelchair. Resident 12 displayed agitation, which included spitting on the ground and toward staff members. Staff 6 (CNA) flicked the resident on the back of her/his hand and stated, If you're going to be mean to me, I'm going to be mean to you. The resident experienced no negative outcome as a result of the interaction.
The 2/18/25 Progress Note indicated Resident 11 was combative with staff and Hospice was notified of her/his behavioral changes.
The 2/19/25 Progress Note indicated Resident 12 had possible psychosocial distress and increased agitation. Hospice was notified and new medication orders were received.
On 4/2/25 at 2:30 PM, Staff 6 stated he flicked Resident 12 on the back of the hand and made the statement in attempt to be playful and calm the resident down. Staff 6 stated the resident was combative and he attempted to light the mood because they had a history of working together. Staff stated he was trying to be playful so Resident 12 would know staff were there to help her/him.
On 4/2/25 at 10:45 AM, Staff 1 (Administrator) verified Resident 12 was not treated with respect or dignity by Staff 6.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to accurately assess facility acquired pressure ulcers for 1 of 3 sampled residents (#11) reviewed for skin conditions. This ...
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Based on interview and record review it was determined the facility failed to accurately assess facility acquired pressure ulcers for 1 of 3 sampled residents (#11) reviewed for skin conditions. This placed residents at risk for unassessed and worsening pressure ulcers. Findings include:
The National Pressure Injury Advisory Panel defined shearing as a pressure injury when tissue layers moved over the top of each other, and a Stage 3 pressure ulcer as a full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle are not exposed and some slough (dead tissue often appearing as a yellow, tan, or white fibrous material) may be present but does not obscure the depth of tissue loss.
Resident 11 was admitted to the facility in 1/2025, with diagnoses including intestinal bypass and failure to thrive. The resident discharged on 2/10/25.
The 1/9/25 Nursing admission Evaluation revealed Resident 11 had a red coccyx upon admission.
The 1/11/2025 admission MDS indicated Resident 11 was at risk for pressure ulcers and had no pressure ulcers.
The 2/5/25 Wound Evaluation indicated Resident 11 had coccyx shearing. The evaluation indicated the wound had 90% granulation tissue, 10% slough, and light serosanguineous drainage. No wound measurements or staging were completed and the evaluation incorrectly indicated the wound was present on admission. The description of the wound described a Stage 3 pressure ulcer.
On 4/2/25 at 3:20 PM, Staff 3 (LPN Unit Manager) acknowledged the skin wound evaluation incorrectly identified the coccyx wound as present on admission, the description of the wound defined a Stage 3 pressure ulcer and the assessment was not fully comprehensive.
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 on interview and record review it was determined the facility failed to evaluate a potential unavoidable accident of a feeding tube being dislodged to prevent recurrence for 1 of 3 sampled resid...
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Based on interview and record review it was determined the facility failed to evaluate a potential unavoidable accident of a feeding tube being dislodged to prevent recurrence for 1 of 3 sampled residents (#11) reviewed for safety. This placed residents at risk for dislodged feeding tubes. Findings include:
Resident 11 admitted to the facility in 1/2025, with diagnoses including failure to thrive and malnutrition.
Resident 11's 1/9/25 Hospital Records revealed a J-tube (feeding tube inserted into stomach or small intestine) was surgically placed.
The 1/11/25 admission MDS revealed Resident 11 had a J-tube for enteral feedings (nutritional support).
The 2/10/25 Progress Note indicated Staff 7 (CNA) transported Resident 11 to the shower room and when she removed the blanket, the J-tube dislodged and fell out. Staff 7 indicated the J-tube was intact when she placed a bath blanket over her/him in preparation to go to the shower room. The note further revealed an order was received to transfer the resident to the hospital for the J-tube replacement.
Review of Resident 11's medical record revealed no documented evidence the resident's accident of her/his J-tube (feeding tube inserted into stomach or small intestine) dislodging was evaluated or investigated to determine how the resident's J-tube had dislodged and how to prevent recurrence.
Staff 7 was not interviewed due to no contact information.
On 4/2/25 at 2:00 PM, Staff 2 (DNS) stated she did not know how the J-tube dislodged and an incident report or facility investigation was not completed because the facility did not complete them for tubes that fell out.
On 4/3/25 at 9:40 AM, Witness 12 (Family) stated staff reported when they pulled the blanket off Resident 11 they also pulled the J-tube out.
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 F0760
(Tag F0760)
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 significant medication errors for 1 of 4 sampled residents (#13) reviewed for medications....
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Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#13) reviewed for medications. This placed residents at risk for respiratory distress. Findings include:
Resident 13 admitted to the facility in 3/2025, with diagnoses including failure to thrive. Resident 13 was on hospice services.
Resident 13's 3/20/25 Progress Note indicated she/he was seen by a hospice nurse and the resident's methadone order was increased to 7.5 mg twice daily.
Resident 13's 3/20/25 Hospice Order instructed staff to discontinue the previous order for methadone liquid 5 mg twice daily and to increase the methadone liquid 10 mg/ml to 7.5 ml to equal 7.5 mg by mouth every 12 hours for pain management (7.5 ml equaled 75 mg).
The 3/2025 MAR indicated Resident 13 was administered 7.5 ml (75 mg) of Methadone on 3/20/25 at 8:00 PM by Staff 10 (CMA).
Resident 13's 3/21/25 Hospice Orders included orders for Naloxone HCL nasal spray 4 mg one dose now (medication to reverse narcotic medication effects) and oxygen at 2 liters per minute prn for O2 sats less than or equal to 88%. The order also clarified the previous methadone order to specify 7.5 mg was 0.75 ml.
Resident 13's 3/21/25 Progress Note indicated Naloxone HCL and oxygen were administered to the resident and the hospice nurse remained in the room for approximately one hour after medication administration.
On 4/1/25 at 3:18 PM, Staff 10 (CMA) verified she gave Resident 13 7.5 ml of methadone instead of 0.75 ml. Staff 10 further stated when she saw the revised dose in the MAR she consulted with Staff 11 (Charge Nurse LPN) because she thought the new dose should be 0.75 ml. Staff 10 stated Staff 11 reviewed the original order and instructed Staff 10 to administer the medication as 7.5 ml to the resident.
Staff 11 was contacted three times by telephone on 4/2/25 at 7:38 AM and 2:00 PM and 4/3/25 at 9:18 AM. Staff 11 did not respond to the voicemail requests for an interview.
Aug 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
Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This placed res...
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Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This placed residents at risk for unwanted sexual abuse. Findings include:
Resident 1 was admitted to the facility in 11/2023 with diagnoses including altered mental status.
Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia.
Resident 3 was admitted to the facility in 1/2024 with diagnoses including dementia.
Review of a progress note dated 7/22/24 at 8:50 PM revealed Resident 1 was observed with her/his hand down the front of Resident 2's pants. The residents were separated and the administrator was notified.
Review of a physician note dated 7/25/24 at 1:26 PM revealed Resident 1 was caught with her/his hands down the pants of a female resident and in bed with her/his roommate. Resident 1 was placed in a private room and had 1:1 supervision by facility staff. Resident 1 was alert and oriented to place only during the physician visit.
Review of a facility investigation dated 7/29/24 revealed on 7/22/24 at 7:45 AM Staff 3 (LPN) observed Resident 1 and Resident 2 sitting in wheelchairs, in the hallway, next to each other. When Staff 3 exited a room she observed Resident 1 with their hand in the pants of Resident 2. Staff 3 separated the residents and notified Staff 1 (Administrator). The investigation indicated Resident 2 was not harmed and had no recollection of the incident. Resident 1 was immediately moved to a different hallway with Resident 3. On 7/24/24 at 4:25 AM Staff 2 (CNA) entered the room with Resident 1 and Resident 3 and found Resident 1 in bed with Resident 3. Staff 2 observed Resident 1's hand on Resident 3's penis. Staff 2 notified the charge nurse and Resident 1 and Resident 3 were separated and Resident 1 was moved to a private room with 1:1 supervision by facility staff. Resident 3 was interviewed and had no recollection of the incident. The facility investigation acknowledged both events occurred and no psychosocial harm occurred.
In an interview on 8/2/24 at 9:51 AM Resident 3, who was alert, not oriented to place and able to answer questions, said she/he never had a roommate. Resident 3 also stated facility staff treat her/him well and had never been abused by another resident.
In an interview on 8/2/24 at 10:01 AM Resident 1, who was alert, not fully oriented and able to answer questions, indicated she/he did not remember touching Resident 2 or Resident 3 and never had a roommate. Resident 1 did not know where she/he lived or how long she/he had been at the facility.
In an interview on 8/2/24 at 10:25 AM Resident 2 said she/he had no concerns with care and did not remember the incident with Resident 1. Resident 2 was alert but not oriented to placed and time.
In an interview on 8/2/24 at 2:58 PM Staff 2 said on 7/24/24 at 4:25 PM she observed Resident 1 in bed with Resident 3 and Resident 1 had her/his hand on Resident 3's penis.
In an interview on 8/7/24 at 8:26 AM Staff 3 said on the evening of 7/22/24 Resident 1 was observed with his/her hand down the front of Resident 2's pants. Staff 3 said the residents were immediately separated and Resident 1 was moved to a different room in a different hallway.
In an interview on 8/7/24 at 9:21 AM Staff 1 acknowledged Resident 1 had inappropriate sexual contact with Resident 2 and sexually abused Resident 3.
It was determined this citation met the criteria for Past Non-compliance based on the following:
The facility was found in non-compliance with the regulatory requirement at F600 at the time of Resident 2's 7/22/24 and Resident 3's 7/24/24 sexual abuse.
The facility reported the incident to the State Agency on 7/22/24 and 7/24/24.
The abuse of Resident 2 and 3 occurred after the most recent complaint survey of 7/16/24 and before this current survey of 8/7/24.
The facility corrected the non-compliance by completion of an incident investigation, identified the regulatory non-compliance and in-serviced all staff on the following resident care plans and abuse policies and procedures. The facility conducted weekly audits to keep residents safe from further abuse and no additional incidents occurred since 7/24/24.
Jul 2024
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
Based on interview and record review it was determined a facility employee sexually abused 6 of 10 sampled residents (#s 6, 7, 8, 9, 10 and 11) who were reviewed for sexual abuse. As a result of the p...
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Based on interview and record review it was determined a facility employee sexually abused 6 of 10 sampled residents (#s 6, 7, 8, 9, 10 and 11) who were reviewed for sexual abuse. As a result of the pattern of sexual abuse, it was determined to be an immediate jeopardy situation and residents experienced psychosocial harm. Findings include:
1. Resident 6 was admitted to the facility in April 2024, with diagnoses including a stroke.
Review of a progress note dated 6/16/24 at 9:45 AM revealed Resident 6 reported to staff that a night shift male CNA came into her/his room every hour to provide incontinence care and played with her/his clit. Resident 6 requested Staff 2 to not provide care for her/him anymore.
Review of a facility's investigation completed on 6/21/24 revealed on 6/16/24 Resident 6 reported to facility staff an allegation of sexual abuse by Staff 2 (CNA). Resident 6 indicated Staff 2 would enter the resident's room every hour to provide incontinence care even though the resident did not require incontinence care and was playing with my clit. The resident also indicated on one occasion Staff 2 stood by the resident's closet with his hand in his pants. Resident 6 thought Staff 2 was masturbating. The investigation indicated Staff 2 acknowledged inappropriately touching Resident 6 three times on 6/16/24 on her/his vagina and clitoris while providing incontinence care during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). The investigation concluded Resident 6 was sexually abused by Staff 2.
In an interview on 6/25/24 at 11:55 AM, Resident 6, who was alert and oriented and able to answer questions, said Staff 2 had inappropriately touched the resident's vagina and clitoris on three occasions. Resident 6 stated she/he had increased anxiety and difficulty sleeping, but was glad Staff 2 did not work at the facility anymore.
In an interview on 6/25/24 at 12:00 PM, Staff 1 (CNA) said Resident 6 reported to her the night shift CNA (Staff 2) sexually abused Resident 6 and did not want Staff 2 to provide care for her/him anymore. Staff 1 said Resident 6 had problems sleeping for the next three to four days after the abuse.
2. Resident 7 was admitted to the facility in May 2024, with diagnoses including Post-Traumatic Stress Disorder (PTSD) and depression.
Review of a facility's investigation completed on 6/21/24 revealed on 6/18/24 Resident 7 reported to staff she/he was molested and was waiting for police. Resident 7 indicated she/he had been molested multiple times by a male CNA (Staff 2) who was tall with red hair. The resident indicated Staff 2 had touched and spoke to her/him inappropriately. The investigation included an interview with Resident 7 who reported Staff 2 touched her/his breasts and vagina and Staff 2 would touch himself during these occurrences. Resident 7 was visibly upset and distressed when talking to staff about the incident. The investigation indicated Staff 2 acknowledged inappropriately touching Resident 7 on two occasions during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement).
In an interview on 6/26/24 at 7:47 AM, Resident 7 stated she/he was sexually abused by Staff 2 (CNA) on the night shift. Resident 7 stated Staff 2 touched her/his breasts and vagina and was afraid and experienced anxiety because of the abuse. Resident 7 said she/he would not be returning to the facility. During the interview, this surveyor observed the resident lying in bed visibly shaking.
3. Resident 8 was admitted to the facility in March 2024, with diagnoses including diabetes. Resident 8 was discharged from the facility and was unable to be interviewed.
Based on the reasonable person concept, the surveyor concludes Resident 8 suffered psychosocial harm as a result of being sexually abused.
Review of a facility's investigation dated completed on 6/21/24 indicated Staff 2 acknowledged he inappropriately touched Resident 8 two times on the vagina and penetrated her/his vagina with his fingers during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement).
4. Resident 9 was admitted to the facility in March 2024, with diagnoses including kidney failure.
Based on the reasonable person concept, the surveyor concludes Resident 9 suffered psychosocial harm as a result of being sexually abused.
Review of a facility's investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 9 on one occasion on the vaginal area while the resident was sleeping during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). Staff 2 also indicated Resident 9 woke up and told him to leave her/his room.
In an interview on 6/25/24 at 10:22 AM, Resident 9, who was alert and oriented and able to answer questions, stated on one occasion Staff 2 tried to touch her/him inappropriately and she/he told him to go away.
5. Resident 10 was admitted to the facility in June 2024, with diagnoses including a cervical fracture. Resident 10 was discharged from the facility and was unable to be interviewed.
Based on the reasonable person concept, the surveyor concludes Resident 10 suffered psychosocial harm as a result of being sexually abused.
Review of a facility investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 10 on one occasion on the vaginal area while the resident was sleeping during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement).
6. Resident 11 was admitted to the facility in April 2024, with diagnoses including diabetes. Resident 11 was not interviewable.
Based on the reasonable person concept, the surveyor concludes Resident 11 suffered psychosocial harm as a result of being sexually abused.
Review of a facility's investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 11 on one occasion where he penetrated the resident's anus during incontinence care during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement).
In an interview on 6/26/24 at 11:22 AM, Staff 3 (Administrator) acknowledged Resident 6, 7, 8, 9, 10 and 11 were sexually abused by Staff 2 and was present when Staff 2 admitted to sexually abusing multiple residents at the facility.
In an interview on 6/26/24 at 12:15 PM, Staff 4 (DNS) acknowledged Resident 6, 7, 8, 9, 10 and 11 were sexually abused by Staff 2 and was present when Staff 2 admitted to sexually abusing multiple residents at the facility.
In an interview on 6/27/24 at 12:17 PM, Witness 11 (Law Enforcement) confirmed Staff 2 admitted to the inappropriate sexual contact with multiple residents at the facility. Witness 11 indicated Staff 2 was arrested, taken to jail and faced multiple criminal charges.
On 7/16/24 at 10:16 AM, Staff 3 (Administrator) was notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the sexual abuse of six resident by Staff 2.
It was determined this citation met the criteria for Past Non-Compliance based on the following:
The facility was in non-compliance with the regulatory requirement of F600 at the time of the reported 6/16/24 sexual abuse allegation. The facility reported the incident to the State Survey Agency (SSA) on 6/16/24.
The abuse of Resident 6, 7, 8, 9, 10, and 11 occurred after the most recent annual recertification survey of 6/14/24 and before the current survey of 7/16/24.
On 6/18/24, the Past Noncompliance was corrected when the facility completed a thorough investigation and determined sexual abuse had occurred. The facility's Plan of Correction included:
-Alleged perpetrator immediately suspended;
-All cognitively intact residents interviewed to ensure no additional residents were sexually abused;
-Staff interviewed from various shifts and departments to ensure there were no observations or complaints of abuse in the past 3 months with cognitively intact or cognitively impaired residents;
-Provider and residents' families notified;
-Care plans for the residents involved in the allegation were updated to include female-only caregivers;
-Residents involved in the allegation placed on alert charting and referred to the facility's psychologist;
-Skin assessments focused on identifying sexual trauma conducted;
-Local law enforcement notified;
-Audits conducted weekly until substantial compliance reached, then monthly for two months with verification of sustained compliance;
-Audit trends will be reported to facility QAPI for three months for review and further recommendations.
Jun 2024
29 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
3. Resident 335 admitted to the facility on 6/2024 with diagnoses including dementia.
A 6/11/24 review of Resident 335's orders revealed a 6/7/24 order for quetiapine fumarate (an antipsychotic medica...
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3. Resident 335 admitted to the facility on 6/2024 with diagnoses including dementia.
A 6/11/24 review of Resident 335's orders revealed a 6/7/24 order for quetiapine fumarate (an antipsychotic medication) and a 6/7/24 order for sertraline (an antidepressant medication).
A 6/11/24 review of Resident 335's medical record revealed no evidence of a consent for quetiapine fumarate and sertraline.
A 6/11/24 review of Resident 335's June 2024 MAR revealed she/he had taken quetiapine fumarate and sertraline on 6/8/24, 6/9/24 and 6/10/24.
On 6/13/24 at 3:25 PM Staff 27 (LPN Unit Manager) stated Resident 335's son had not signed the consent for quetiapine fumarate and sertraline yet.
2. Resident 33 was admitted to the facility on 8/2021 with diagnoses including diabetes.
Review of Resident 33's care plan dated 9/30/21, indicated Resident 33 was a diabetic and on a controlled carboydrate diet with regular texture and regular thin liquids. Staff were to discuss and encourage appropriate portion sizes, dietary restrictions, snacks and compliance with nutritional regimen.
There was no documented evidence the physician or interdisciplinary team informed the resident of the risk to the resident's health status when not following a diabetic diet.
On 6/11/24 at 1:43 PM Resident 33 was observed in bed with three small empty ice cream containers and one liter of soda, which was empty on her/his bedside table next to the bed. The resident was asleep in bed.
6/12/24 at 8:23 AM Staff 17 (CNA) and at 10:48 AM Staff 6 (CNA) stated Resident 33 was non-compliant with her/his diabetic diet. Staff 17 and Staff 6 stated the resident often ate 100% of her/his meals at the facility and ordered fast food in addition. Staff 17 stated the resident drank one in a half liters of soda almost daily and freqently requested snacks.
On 6/12/24 at 11:16 AM Resident 33 stated she/he was a diabetic and liked to eat whatever she/he wanted. Resident 33 stated she/he had fast food delivered often.
On 6/12/24 at 7:28 PM, Staff 18 (LPN) and on 6/13/24 at 9:35 AM, Staff 21 (LPN) stated Resident 33 was non-compliant with her/his diabetic diet. The resident blood sugars consistently ranged in upper 200s to 300s. Staff 18 and Staff 21 stated the resident ordered pizza three to four times weekly, consumed excessive soda pop and indulged in multiple unhealthy snacks. Staff 18 and Staff 21 stated education was provided, and when residents were non-compliant, a risk and benefts form should be completed. Staff 18 and Staff 21 acknowledged a risk and benefits was not completed for Resident 33.
On 6/13/24 at 10:16 AM and 11:10 AM, Staff 2 (DNS), Staff 27 (LPN and Unit Manager) and Staff 30 (LPN Unit Manager) stated Resident 33 was non-compliant with her/his diabetic diet and expected staff to educate, inform the physician and complete a risk and benefits form with Resident 33. Staff 2, Staff 27 and Staff 30 acknowledged the form was not completed.
Based on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risk and benefits for the use of an antipsychotic medication and the risk and benefits of not following a prescribed diet for 3 of 6 sampled residents (#s 16, 33, and 335) reviewed for medications and diet. This placed residents' and resident responsible parties at risk for lack of informed consent and decision making. Findings include:
1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.
A 3/2023 MAR instructed staff to administer aripiprazole (an antipsychotic medication treat depression and schizophrenia) one time a day related to schizophrenia with a start date of 3/3/23.
There was no documentation found in Resident 16's clinical record to show she/he had a diagnosis of schizophrenia.
Resident 16's 5/17/23 Antispychotic Medication Informed Consent indicated she/he had a physician order for aripiprazole for depression and anxiety, and the resident experienced inconsolable fear and crying. An informed consent was provided to Resident 16.
Resident 16's 11/7/23 Mood Stablizer Medication Informed Consent indicated she/he had a physician order for aripiprazole (an antipsychotic medication) for schizophrenia and mood lability (rapid, exaggerated changes in mood).
A 12/2023 MAR instructed staff to administer aripiprazole 10 milligrams one time a day which discontinued on 12/22/23 and aripiprazole 7.5 milligrams was started on 12/23/23.
There was no documentation in Resident 16's clinical record she/he was notified of her/his diagnosis change or the change in her/his dosage amount.
On 6/14/24 at 9:35 AM Resident 16 stated she/he could not remember when she/he was diagnosed with schizophrenia, but she was no longer taking the medication for it and whoever diagnosed her/him stated it would not be for long.
In an interview on 6/14/24 at 10:52 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated if a resident was out of the facility for 30 or more days, they would have them sign a consent again. If there was a dosage change or if change of diagnosis, they would notify the resident of the change but would not complete a new consent. Staff 2 indicated it should be documented when residents were notified.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's representative of a fall for 1 of 2 sampled resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's representative of a fall for 1 of 2 sampled residents (#89) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents. Findings include:
Resident 89 was admitted to the facility in 12/2022 with diagnoses including a fractured leg and pelvis.
The MDS dated [DATE] revealed Resident 89 had a BIMS score of nine, which indicated the resident had moderate cognitive impairment.
Resident 89's undated admission Record revealed Witness 1 (Family Member) was Resident 89's emergency contact.
On 6/5/24 at 12:48 PM Witness 1 stated Resident 89 fell out of bed at the facility two days after her/his admission. Witness 1 stated Resident 89 informed Witness 1 of the fall, but was unsure how the resident had fallen out of bed. Witness 1 was upset because facility staff did not notify her of the incident or potential injuries.
On 6/12/24 at 4:00 PM Staff 21 (LPN) stated Resident 89 had an unwitnessed fall out of bed on 12/23/22 and acknowledged Witness 1 was not notified of the incident.
On 6/13/24 at 11:01 AM Staff 2 (DNS) stated Witness 1 was the emergency contact and should have been notified about Resident 89's unwitnessed fall on 12/23/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined the facility failed to maintain privacy and confidentiality of resident records in 1 of 1 Social Services office. This placed residents at risk for...
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Based on observation and interview it was determined the facility failed to maintain privacy and confidentiality of resident records in 1 of 1 Social Services office. This placed residents at risk for lack of privacy and confidentiality. Findings include:
On 6/14/24 at 10:18 AM Staff 36's (Social Services Director) office door was observed open with no staff present. The left computer monitor screen was visible with a resident's electronic health record and the right computer monitor screen was open and accessible email. The office was observed to contain with many papers with residents names and information which included transportation forms, State of Oregon letters to residents, completed discharge checklists, completed requests to transfer and individual resident care conference information.
On 6/14/24 from 10:18 AM to 10:38 AM multiple staff and residents were observed in the area of Staff 36's office and were able to access the resident records.
On 6/14/24 at 10:38 AM Staff 36 stated she left her office door open while she was in the facility to let people know she was in the facility working. Staff 36 confirmed unauthorized people had access to the resident records in her office when she was not in the office.
On 6/14/24 at 12:37 PM Staff 1 (Administrator) confirmed he expected resident records to be secured with no access to unauthorized individuals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to assess the use of a physical restraint for 1 of 1 sampled resident (#57) reviewed for restraints. This place...
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Based on observation, interview, and record review it was determined the facility failed to assess the use of a physical restraint for 1 of 1 sampled resident (#57) reviewed for restraints. This placed residents at risk for potential abuse or neglect. Findings include:
Resident 64 was admitted to the facility in 2023 with diagnosis of brain damage and anxiety.
A 9/26/23 Fall Risk Evaluation indicated Resident 64 experienced multiple falls in the past three months. Resident 64 exhibited balance issues while standing and had a seizure disorder. Resident 64 was at risk for falls.
A 10/14/23 care plan indicated Resident 64 experienced decreased mobility and was at risk for falls. Interventions included a fall mat to the right side of the bed, anticipate her/his needs, bed against the wall and to ensure commonly used items were in reach.
A 4/5/24 MDS assessed Resident 64 with no physical restraints in place and had no falls since the resident's last MDS assessment. Resident 64 was rarely understood.
On 6/12/24 at 9:13 AM, and on 6/13/24 5:42 AM, and at 8:05 am Resident 64 was observed in bed with a scoop mattress (A concave-shaped bed that prevents users from rolling off and falling.)
There was no documentation in Resident 64's clinical record to indicate the resident's scoop mattress was assessed for a potential physical restraint.
In an interview on 6/14/24 at 10:32 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated it would be expected for an evaluation to be completed for the use of a scoop mattress.
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
2. Resident 91 was admitted to the facility in 8/2022 with diagnoses including intervertebral disc displacement of the spine.
An 8/19/22 MDS assessed Resident 91 as moderately cognitively impaired.
A ...
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2. Resident 91 was admitted to the facility in 8/2022 with diagnoses including intervertebral disc displacement of the spine.
An 8/19/22 MDS assessed Resident 91 as moderately cognitively impaired.
A Grievance Form dated 3/19/23 alleged three CNAs were rude and short with Resident 91 and one CNA pushed Resident 91 causing pain. The Grievance Summary Report was completed by Staff 24 (former Administrator), and indicated interviews were completed with the CNA who wrote the grievance, the RN who spoke with Resident 91 and with Resident 91. In the Greivance Summary Report, Resident 91 alleged two CNAs were rude to him and said he was, too heavy. No other interviews were provided and the was no evidence the allegation of one of the CNAs pushed Resident 91 resulting in pain was addressed. In the Grievance Summary Report indicated Resident 91's concern was resolved, and she/he was not harmed and was happy knowing Staff 23 (former agency CNA) was not returning to the facility.
On 6/12/24 at 2:44 PM Staff 25 (former DNS) stated she did not recall the incident with Resident 91, but stated it was her understanding Staff 23's contract was canceled due to poor attendance and a poor attitude.
On 6/13/24 at 10:24 AM Staff 23 denied the allegation. Staff 23 stated the facility canceled her contract on 3/21/23 without interviewing her.
On 6/13/24 at 11:15 AM Staff 24 stated she did not recall the incident with Resident 91.
On 6/13/24 at 2:01 PM Staff 22 (former Staffing Coordinator) stated she was not involved in the decision to cancel Staff 23's contract. Staff 22 stated she had never received a complaint about Staff 23, and she was an, excellent CMA who did not call in.
On 6/14/24 at 11:48 AM Staff 1 (Administrator) acknowledged he was unable to evidence the allegation of abuse from Resident 91 was investigated or reported to the State. Staff 1 stated he would have, handled it differently.
Based on observation, interview, and record review, it was determined the facility failed to report a resident to resident altercation for 2 of 11 sampled residents (#s 20 and 91 ) reviewed for abuse. This placed residents at risk for ongoing abuse.
1. Resident 20 was admitted to the facility in 2020 with a diagnosis of heart disease.
A 12/16/23 Annual MDS revealed Resident 20 was cognitively impaired.
Resident 20's Care Plan initiated 12/10/21 revealed Resident 20 propelled in a wheelchair.
Review of Resident 20's clinical record revealed there were no resident to resident altercations identified in 11/2023.
Resident 30 was admitted to the facility in 2020 with a diagnosis of seizures.
Resident 30's Care Plan initiated in 2020 revealed Resident 30 was physically aggressive towards others due to a head injury. Staff were to intervene if the resident showed agitation to prevent escalated behaviors.
A 12/20/23 Psychotropic Medication Review revealed Resident 30 had aggressive behavior.
Review of Resident 30's clinical record revealed in 11/2023 she/he was not in a resident to resident altercation
On 6/10/24 at 6:56 PM Staff 43 (Former LPN) stated around the last week of 11/2023 Resident 30 hit Resident 20. The documentation should be in the residents' clinical record. Staff 43 stated the management team did not update the residents' care plans to ensure the incident did not reoccur.
On 6/11/24 at 1:23 PM Staff 6 (CNA) stated she did not witness when Resident 30 hit Resident 20 but recalled the incident. Staff 6 stated Resident 20 was confused, able to propel and cleaned the hall railings throughout the facility. Resident 30 did not propel but often hit at staff. Staff 6 stated if Resident 20 was within Resident 30's reach and Resident 30 was agitated, Resident 30 would hit.
On 6/11/24 at 10:32 AM Staff 2 (DNS) stated he did not have an incident report related to a resident to resident incident for Resident 20 and Resident 30.
On 6/11/24 at 1:26 PM Staff 41 (RN) stated he did not observe the incident when Resident 30 hit Resident 20 but heard about it.
On 6/11/24 01:29 PM Staff 28 (LPN) stated she recalled an incident when Resident 30 hit Resident 20. She recalled the information on the nursing report. Staff 28 stated Resident 30 was more aggressive at that time and if Resident 20 was within reach Resident 30 could hit her/him.
On 6/11/24 at 2:00 PM Staff 30 (LPN Resident Care Manager) stated she recalled an incident when Resident 30 hit someone. She did not recall who Resident 30 hit but did not see any notes in the residents' files.
On 6/11/24 at 4:02 PM Staff 50 (LPN) stated she recalled Resident 30 hit Resident 20 but did not witness the incident. She also recalled Resident 30 was placed on 1:1 (one staff monitors one resident) due to the incident.
On 6/11/24 at 5:19 PM Staff 47 (CNA) stated she heard on night shift Resident 30 hit Resident 20. Resident 30 was 1:1 for about three days to ensure Resident 30 did not hit other residents.
On 6/12/24 at 8:51 AM Staff 44 (CNA) stated at the end of 11/2023 Resident 20 was cleaning the rails in the hall. Resident 30 hit Resident 20 when Resident 20 was within reach. Staff 44 stated the incident was reported to a nurse, but she did not recall the nurse.
On 6/12/24 at 3:38 PM Staff 1 (Administrator) stated it was his expectation for staff to report resident to resident incidents. He was not aware of an incident when Resident 30 hit Resident 20.
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 investigate for abuse for 1 of 6 sampled residents (#65) reviewed for dignity and respect. This placed residents at risk f...
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Based on interview and record review it was determined the facility failed to investigate for abuse for 1 of 6 sampled residents (#65) reviewed for dignity and respect. This placed residents at risk for abuse. Findings include:
Resident 65 admitted to the facility in 2/2024 with diagnoses including kidney failure.
An 8/15/24 care plan revealed Resident 65 had a history of trauma. Interventions included staff were to avoid re-traumatizing the resident with thoughtful approaches to care and avoid being rude to Resident 65.
An 8/23/24 Social Services Note indicated Resident 65 stated she/he had issues with Staff 4 (CNA), Staff 5 (CNA), and Staff 6 (CNA). Resident 65 stated they were rude and refused to provide her/him a shower and they did not listen to the residents. Resident 65 stated they needed to listen to the residents during resident care, and she/he did not want Staff 4 and Staff 6 in her/his room.
No documentation was found in Resident 65's clinical record an investigation was completed for alleged abuse.
On 9/4/24 at 12:38 PM Resident 65 stated two CNAs were talking, they pointed at her/him and were laughing. Resident 65 stated she/he informed Staff 4 (Assistant Social Worker) about the concern. Resident 65 stated she/he no longer completed grievances because the staff did not reprimand staff. Resident 65 stated she/he requested the CNAs who laughed at her/him no longer provide her/him care.
On 9/5/24 at 7:41 AM Staff 4 stated she was never accused of being rude or disrespectful to a resident, she worked with all the residents in the facility, and was never asked not to work with any of the residents.
On 9/5/24 at 8:32 AM Staff 3 (Regional Director of Clinical) confirmed an investigation should have been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to comprehensively assess residents related to behaviors for 1 of 2 sampled residents (#25) reviewed for behavio...
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Based on observation, interview and record review it was determined the facility failed to comprehensively assess residents related to behaviors for 1 of 2 sampled residents (#25) reviewed for behavioral health assessments. This placed residents at risk for unassessed behavioral emotional healthcare needs and services. Findings include:
Resident 25 admitted to the facility in 2017 with a diagnoses including Schizoaffective Disorder (mental health and mood condition).
Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition. Resident 25 was assessed with no behaviors exhibited.
On 6/12/24 at 10:43 AM Resident 25 was observed to sit in the hallway, repetitively grab and abruptly move her/his coffee cup, talk to her/himself and stated fuck you to a staff who walked past her/him.
On 6/13/24 at 9:08 AM Resident 25 was observed to sit in the hallway, push and pull her/his bedside table, talk to her/himself and said fuck you to Staff 2 (DNS) as he attempted to give a Resident 25 a high-five greeting.
On 6/13/24 at 10:21 AM Staff 6 (CNA) stated Resident 25's present behaviors included swearing at people, clashing with her/his roommate as they both will mimic and yell at each other, pick at and smear feces, resist care by shouting and hitting staff.
On 6/13/24 at 3:29 PM Staff 42 (CNA) stated Resident 25 continued to often pull feces from her/his body and smeared on her/himself, resist care by hitting and pulling on staff, yelling, swinging and swearing at others.
On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 acknowledged they expected resident assessments to be comprehensive and behaviors were expected to be assessed accurately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 2 sampled residents (#57) ...
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Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 2 sampled residents (#57) reviewed for change of condition. This placed residents at risk for unassessed needs. Findings include:
Resident 57 was admitted to the facility in 2023 with diagnoses including stroke.
A 11/13/23 admission MDS indicated the following:
-Cognitively intact.
-No depression concerns.
-Set up or clean-up assistance for upper body dressing.
-Supervision or touching assistance for personal hygiene.
-Occasional bladder incontinence.
-No falls since admission, but a history of falling in the last month.
A 5/15/24 Quarterly MDS revealed the following:
-Moderately impaired.
-Feeling down and depressed two to six days in the seven-day look back period.
-Partial moderate assistance for upper body dressing.
-Substantial to maximal assistance for personal hygiene.
-Frequent bladder incontinence.
-Two or more falls since prior assessment.
-Hypoglycemic (low blood sugars).
The 5/29/24 care plan revealed
-Requires substantial assist of one staff for personal hygiene.
-Had a new diagnosis of diabetes.
-At risk for falls
There was no documentation in Resident 57's clinical record which indicated a significant change assessment was considered or ruled out.
In an interview on 6/14/24 at 11:00 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated they would look into why a significant change MDS was not completed. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were referred to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screenin...
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Based on interview and record review it was determined the facility failed to ensure residents were referred to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation (evaluation for individuals with a mental disorder or intellectual disability) for 1 of 1 sampled resident (#25) reviewed for PASARR's. This placed residents at risk for not receiving specialized mental health services. Findings include:
Resident 25 admitted to the facility in 2017 with diagnoses including schizoaffective disorder (serious mental condition with breakdowns in thoughts, emotions, and behaviors), bipolar disorder (extreme mood swings) and Post-Traumatic Stress Disorder (mental condition with intense emotional and/or physical reaction).
Resident 25's 5/6/24 Annual MDS indicated she/he was not considered to have a serious mental illness and therefore no Level ll PASARR was completed.
A review of Resident 25's Electronic Health Record revealed there was no Level Il PASARR referral or evaluation completed.
In an interview on 6/14/24 at 10:38 AM Staff 36 (Social Services Director) stated she was aware of Resident 25's mental health diagnoses and challenging behaviors. She confirmed Resident 25 did not have a Level ll PASARR evaluation or referral for an evaluation completed.
On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of a completed Level ll PASARR and an effective system for referrals was needed.
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 F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 335 was admitted to the facility on [DATE] with diagnoses including left femur (thigh bone) fracture after a fall an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 335 was admitted to the facility on [DATE] with diagnoses including left femur (thigh bone) fracture after a fall and dementia.
A review of Resident 335's medications revealed a 6/7/24 order for psychotropic (medications that affect a person's mental state) medications quetiapine fumarate and sertraline.
A 6/10/24 BIMS (brief interview for mental status) Evaluation indicated Resident 335 had severe cognitive impairment.
A /10/24 review of Resident 335's care plan revealed no evidence of a fall, dementia or use of psychotropic medication care plan.
On 6/10/24 at 1:08 PM Resident 335 was observed standing beside her/his bed, using the bed side table for support.
On 6/10/24 at 2:03 PM Resident 335 was observed ambulating to the door to her/his room.
On 6/11/4 at 9:39 AM Staff 31 (CNA) stated Resident 335 was not at risk for falls.
On 6/11/24 at 9:45 AM Staff 33 (CNA) stated she did not usually work with Resident 335 and did not know Resident 335.
On 6/11/24 at 9:45 AM Staff 34 (CNA) stated she did not get report and did not know Resident 335.
On 6/11/24 at 9:47 AM Staff 35 (CNA) stated Resident 335 was at risk for falls, does not remember to use her/his call light and would ambulate in her/his room without assistance.
On 6/11/24 at 10:22 AM Staff 31 (Director of Rehabilitation) stated Resident 335 had impaired balance, was a high fall risk, had impaired cognition and poor safety awareness.
On 6/11/24 at 10:51 AM Staff 27 (LPN Unit Manager) and Staff 30 (LPN Unit Manager) stated the admission nurse was responsible for the baseline care plan and the Unit Managers would follow up to validate the baseline care plan was completed within 72 hours of admission. Staff 30 stated Resident 335 was at risk for falls and should have had a care plan in place for being at risk for falls.
On 6/11/24 at 1:25 PM Resident 335 was observed transferring her/himself form the chair to the bed.
On 6/11/24 at 1:36 PM Resident 335 was observed ambulating in her/his room without pants on, a CNA assisted Resident 335.
On 6/11/24 at 3:51 PM Staff 42 (CNA) stated she did not know Resident 335 and as far as she knew, Resident 335 was not at risk for falls.
On 6/13/24 at 3:25 PM Staff 27 stated Resident 335 had a diagnosis of dementia and was taking psychotropic medications. Staff 27 acknowledged Resident 335 should have, but did not, have a baseline care plan for the dementia diagnoses or for the the psychotropic medications.
On 6/14/24 at 11:54 AM Staff 2 (DNS) stated he expected the baseline care plan to be in place within 48 hours of admission, and the baseline care plan should include fall risk, psychotropic medications and dementia diagnosis. Staff acknowledged Resident 335's baseline care plan was not completed within 48 hours of admission.
Based on interview and record review it was determined the facility failed to ensure a baseline care plan was developed for 2 of 12 sampled resident (#s 134 and 335) reviewed for dialysis, accidents, and medications. This placed residents at risk for unmet care needs. Findings include:
1. Resident 134 was admitted to the facility 12/2/23 with a diagnosis of kidney disease.
A 12/2/24 hospital After Visit Summary revealed Resident 134 was to receive dialysis three times a week and her/his first scheduled treatment was 12/4/23.
Review of Resident 134's baseline care plan revealed there was no information related to when she/he was scheduled for dialysis or the type and location of Resident 134's dialysis access.
On 6/11/24 at 2:06 PM Staff 30 (LPN Resident Care Manager) stated a base line care plan was developed by the nurse who did the initial admission paperwork and by the resident care managers as they reviewed the resident's hospital paperwork. Staff 30 acknowledged a baseline care plan for dialysis was not initiated even though it was on the admission orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility staff failed to follow professional standards of practice for a diagnosed mental disorder for 1 of 6 (#16) sampled residents reviewe...
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Based on interview and record review it was determined the facility staff failed to follow professional standards of practice for a diagnosed mental disorder for 1 of 6 (#16) sampled residents reviewed for medications. Findings include:
Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.
A 2/21/23 hospital History and Physical revealed Resident 16 was seen for right hip pain after sustaining a fall. A review of past medical history revealed no diagnosis of schizophrenia. Resident was on the medication aripiprazole (an antipsychotic medication used to treat depression and schizophrenia) and escitalopram (an antidepressant to treat depression and anxiety). A psychiatric evaluation revealed mood, behavior, thought content and judgement were normal.
A 3/2023 MAR instructed Staff to administer aripiprazole one time a day for schizophrenia.
A 3/6/23 admission MDS indicated Resident 16 was cognitively intact with no hallucinations, delusions or behaviors exhibited during the seven day look back period. The assessment also indicated Resident 16 did not have a diagnosis of schizophrenia. The psychotropic care area indicated Resident was on aripiprazole an antidepressant and escitalopram for depression and anxiety.
A 5/17/23 Antipsychotic Medication Informed consent revealed Resident 16 was physician ordered to take aripiprazole for depression and anxiety. Resident 16 experienced inconsolable fear and crying.
A 9/6/23 Quarterly MDS indicated Resident 16 was cognitively intact with no hallucinations, delusions or behaviors exhibited during the seven day look back period. The assessment also indicated Resident 16 did not have a diagnosis of schizophrenia.
A 9/2023 and 10/2023 Documentation Survey Reports revealed no documented behaviors for Resident 16.
A 10/17/24 Nursing Note revealed the diagnosis of schizophrenia was added. Resident 16 was perscribed aripiprazole for this condition.
A 10/25/23 Psych Consultants revealed Resident 16 was seen from a facility referral and Resident 16 stated My mind is straight. Resident 16 then stated she/he saw black bugs flying in her/his room and saw them crawling on the window blinds. Resident 16 stated people think she/he was seeing things, but she/he knows they are there. Resident 16 was diagnosed with depression and schizophrenia. Resident 16 denied history of mental health treatment or hallucinations. Resident 16 needed ongoing assessment for mood and cognitive states Resident 16 needed to participate in psychotherapy to address difficulties with paranoia and hallucinations.
A 10/25/23 Lab result indicated Resident 16 had a UTI.
A 10/30/23 hospital History and Physical revealed Resident 16 was seen for an irregular heart rate which varied from 40 to 200 beats per minute. Past Medical History revealed no diagnosis of schizophrenia. Resident 16 was on medications aripiprazole and escitalopram. A psychiatric evaluation revealed mood, behavior, and thought content were normal.
No documentation was found in Resident 16's clinical records which indicated she/he had a history of schizophrenia.
A Medical Diagnosis report revealed Resident 16 had a diagnosis of schizophrenia with classification as an admitting diagnosis which was created on 10/17/23.
On 6/14/24 at 9:35 AM Resident 16 stated she/he could not remember when she/he was diagnosed with schizophrenia, but she/he was no longer taking the medication for it and whoever diagnosed her/him stated it would not be for long.
On 6/14/24 at 10:12 AM Staff 37 (CNA) stated she never observed Resident 16 hallucinate or have delusions. Staff 37 stated at times she/he would report a CNA did not assist her/him when they had.
In an interview on 6/14/24 at 10:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) Staff 1 stated Resident 16 previous caregiver stated Resident 16 was diagnosed with schizophrenia. Staff 1 also stated Resident 16 had symptoms for a long time and behaviors for an extended period. Staff 1 stated they would investigate additional history. No additional information was provided.
CONCERN
(D)
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 a resident had glasses for 1 of 3 sampled residents (#20) reviewed for communication-sensory. This pla...
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Based on observation, interview and record review it was determined the facility failed to ensure a resident had glasses for 1 of 3 sampled residents (#20) reviewed for communication-sensory. This placed residents at risk for unmet vision needs. Findings include:
Resident 20 was admitted to the facility in 2021 with a diagnosis of dementia.
A 3/17/23 quarterly MDS indicated Resident 20 had adequate vision with corrective lenses.
On 6/10/24 at 12:36 PM Witness 3 (Spouse) stated Resident 20 liked to read and wore glasses, but the glasses were broken.
On 6/10/24 at 1:46 PM Resident 20 was observed to read and she/he did not wear glasses. Staff 52 stated Resident 20's glasses were broken for some time.
On 6/12/24 at 2:36 PM Staff 53 (CNA) stated Resident 20's lens was missing since at least 12/2023.
On 6/12/24 at 2:23 PM Staff 36 (Social Service Director) stated on 6/11/23 she just found an unsigned note on her desk reporting one of Resident 20's lens was broken. Staff 36 was not aware of of the issue and Resident 20 did not have any scheduled vision appointments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
3. Resident 63 was admitted to the facility in 2024 with diagnoses including falls and anxiety.
An 4/29/24 care plan indicated Resident 63 required a bedside commode for toileting.
The 5/13/24, 5/22/...
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3. Resident 63 was admitted to the facility in 2024 with diagnoses including falls and anxiety.
An 4/29/24 care plan indicated Resident 63 required a bedside commode for toileting.
The 5/13/24, 5/22/24, and 5/29/24 Fall incident reports concluded Resident 63 fell while attempting to self-transfer in the bathroom.
On 6/13/24 at 9:42 AM an observation of Resident 63's room revealed no bedside commode. Staff 44 (CNA) confirmed that a bedside commode would be helpful to prevent falls.
On 6/13/24 at 11:01 AM Staff 59 (Resident Care Manager-LPN) acknowledged the care plan was not followed.
2. Resident 57 was admitted to the facility in 2023 with diagnoses including stroke.
A 11/22/23 care plan indicated Resident 57 was at risk for falls and a history of falls. Resident 57 exhibited impulsive behavior, often getting up out of bed without using the call light. Interventions included to ambulate Resident 57 during the day and evening, anticipate needs, call light in reach, bedside commode next to the bed and encourage its use, commonly used items in reach and a sign posted to remind Resident 57 to call for assistance before getting out of bed.
A 5/15/24 MDS indicated Resident 57 was moderately impaired required one person supervision with transfers and had two or more falls since prior assessment.
A 6/6/24 Witnessed Fall investigation indicated Staff 40 (Housekeeper) observed Resident 57 attempting to transfer to the bathroom without assistance, using a front wheel walker. Resident 57 lost her/his balance and fell backwards against the bed. The resident sustained some bruising on mid back, possibly from a previous fall. At the time Resident 57 had on regular socks and not nonskid socks. Resident 57 was noted to have repeated falls, to be impulsive, and not wait for assistance. The root cause was attributed to poor safety awareness and cognitive impairment exacerbated by the use of regular socks.
On 6/11/24 at 5:35 AM Resident 57 was in her/his bed. The bed was positioned against the wall and a fall mat lay on the floor beside it. The bedside table was out of reach, and no bedside commode was visible. Fall mat intervention was not indicated on the care plan.
On 6/12/24 at 9:12 AM Resident 57 was in bed with the bed against the wall and no fall mat on the floor. The bedside commode was up against the wall by the door, away from the bed. At 12:06 PM Resident 57 was observed self-transferring from her/his wheelchair to the bed on her/his own. At 12:08 PM, Resident 57 mentioned not knowing what the sign on the bedside table said.
On 6/13/24, at 5:41 AM and 8:03 AM Resident 57 was in bed with the bedside commode positioned next to the wall near the door not near the bed. A walker was placed beside the bed, while the wheelchair was approximately five feet away from the bed. At 12:25 PM the bed was rearranged, with the head of the bed now against the wall instead of the side.
At 6/13/24 at 9:33 AM Staff 40 stated on 6/6/24, she witnessed Resident 57 attempting to get up from bed, grabbing the walker, and moving toward the bathroom. Resident 57 fell with upper body on the bed and lower body on the floor. Staff 40 yelled for assistance. Staff 41 (RN) arrived and questioned Staff 37 (CNA) about the absence of the bedside commode and fall mat near Resident 57's bed.
In an interview on 6/14/24 at 10:19 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated would expect staff to follow the care plan.
Based on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 3 of 6 sampled residents (#51, 57 and 63) reviewed for accidents. This placed residents at risk for accidents. Findings include:
1. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
An Unwitnessed Fall investigation dated 3/14/24 revealed on 3/14/24 Resident 51 slipped out of bed. Interventions to prevent future falls included staff readjusted the mattress to ensure it was centered on the bed frame and nonslip material was to be applied under the mattress.
A care plan updated 3/14/24 revealed to prevent falls Resident 51 was to have nonslip material applied to the bed mattress to ensure the mattress did not slip.
A 3/20/24 quarterly MDS revealed Resident 51 was cognitively intact.
On 6/10/24 at 12:25 PM Resident 51 stated her/his mattress did not fit the bed frame and caused her/him to fall. Resident 51 also stated staff did not provide her/him with a new mattress.
On 6/11/24 at 4:51 PM with Resident 51's permission, Staff 53 (CNA) looked under Resident 51's bed and nonslip material was not observed. Resident 51's mattress was also observed to have bed brackets on the bed frame to keep the mattress in place but the mattress was too big and it was positioned on top of the brackets and not within the brackets.
On 6/11/24 at 5:01 PM Staff 1 (Administrator) stated the mattress was too large and would be addressed.
On 6/11/24 at 5:09 PM Staff 2 (DNS) stated the maintenance staff applied brackets to the bed frame to keep the mattress from slipping off the bed. Staff were to put nonslip material on the edge of the bed frame to prevent the mattress from slipping.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure nutritional supplements were provided for 1 of 3 sampled residents (#19) reviewed for nutrition. This placed reside...
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Based on interview and record review it was determined the facility failed to ensure nutritional supplements were provided for 1 of 3 sampled residents (#19) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:
Resident 19 was admitted to the facility in 2018 with a diagnosis of diabetes.
A 2/1/24 Nutritional Screen indicated Resident 19 was to be provided a diabetic nutritional supplement BID to prevent weight loss.
An 4/2024 MAR revealed Resident 19 received a supplement BID through 4/7/24 and was out of the facility through 4/16/24. Resident 19's supplement was not restarted after 4/16/24.
An 4/20/24 Nutritional Screen revealed Resident 19 was assessed and the plan was to continue with the current plan and to monitor the resident for weight loss.
On 6/13/24 at 9:18 AM Staff 30 (LPN Resident Care Manager) stated the resident was hospitalized in 4/2024 and acknowledged the resident's supplement was not restarted upon readmission to the facility.
CONCERN
(D)
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, interview, and record review, it was determined the facility failed to obtain orders for oxygen and clean a resident's oxygen equipment for 1 of 1 sampled resident (#51) reviewed...
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Based on observation, interview, and record review, it was determined the facility failed to obtain orders for oxygen and clean a resident's oxygen equipment for 1 of 1 sampled resident (#51) reviewed for respiratory care. This placed residents at risk for unsanitary conditions and lack of monitoring. Findings include:
Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
On 6/10/24 at 12:39 PM Resident 51 was observed to wear a nasal canula (device to administer oxygen through the nose). The back of Resident 51's oxygen concentrator (machine which takes air from the surroundings, extracts oxygen and filters it into purified oxygen) was observed to have a thick layer of dust over the vent.
Resident 51's clinical record did not contain orders for oxygen.
On 6/11/24 at 2:25 PM with Staff 55 (LPN) Resident 51's concentrator was observed to have a thick layer of dust on the vents. Staff 55 stated she was new to the facility but the equipment was to be cleaned weekly and the amount of dust on the vents indicated it was not cleaned for a long time. Staff 55 stated a nurse could initiate oxygen but needed to obtain orders from a physician for continued use.
On 6/11/24 02:33 PM Staff 2 (DNS) verified there were no oxygen orders in the resident's clinical record.
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** 2. Resident 339 admitted to the facility on [DATE] at 11:45 AM with diagnoses including left femur (thigh bone) fracture.
On 6/1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 339 admitted to the facility on [DATE] at 11:45 AM with diagnoses including left femur (thigh bone) fracture.
On 6/14/24 at 8:52 AM Witness 9 (Family Member) stated Resident 339 called on 6/13/24 during the night and stated she/he had not had any pain medications since admission.
On 6/14/24 at 9:30 AM Resident 339 stated she/he requested pain medication on 6/13/24 after admission at 11:45 AM and during the night on 6/14/24 but did not receive any pain medications until 8:30 AM on 6/14/24.
On 6/14/24 at 9:48 AM Staff 7 (CNA) stated she worked with Resident 339 during the night of 6/13/24 through 6/14/24. Staff 7 stated Resident 339 requested pain medications during the night and she informed the nurse.
A review of Resident 339's 6/2024 MAR revealed Resident 339 had not received her/his pain medications until 6/14/24 at 8:09 AM.
On 6/14/24 at 11:10 AM Staff 2 (DNS) stated the emergency medication kit had Resident 339's pain medications. At 11:55 AM Staff 2 stated every nurse had access to the emergency medication kit and Resident 339 should have received her/his pain medications when she/he requested it.
Based on interview and record review it was determined the facility failed to ensure pain medications were available for 2 of 3 sampled residents (#85, and 339) reviewed for pain. This placed residents at risk for increased pain. Findings include:
1. Resident 85 was admitted to the facility in 2023 with diagnoses including arm and leg fractures.
A 11/17/23 Pain Assessment revealed Resident 85 did not have pain at the time of the assessment but reported pain interfered with her/his sleep and social activities.
A 11/22/23 admission MDS revealed Resident 85 reported constant pain for the last five days.
A 11/2023 MAR and associated progress notes revealed the following:
-Resident 85 was to be administered oxycodone every four hours while awake. From 11/24/23 through 11/27/23 Resident 85 was not administered the medication six times.
-From 11/27/23 Percocet was to be administered every four hours. Notes indicated the medication was not available.
-No additional medications were added for pain relief.
Resident 85's pain levels from 11/24/23 through 11/28/23 ranged from four to nine (pain levels four to six=moderate pain, seven and greater=severe pain).
A 11/27/23 Physical Therapy note revealed Resident 85 reported a pain level of six for her/his leg and a pain level of eight for her/his wrist. Resident 85 reported she/he was frustrated with not having proper pain medications.
Resident 85's clinical record revealed she/he had surgery on 11/29/23 and returned the same day.
On 6/10/24 at 6:56 PM Staff 43 (Former RN) stated Resident 85 was not administered pain medications as prescribed.
On 6/13/24 at 2:01 PM Staff 27 (LPN Resident Care Manager) stated Resident 85 was admitted to the facility for a short period of time. Staff 27 stated she was aware the resident had pain and was scheduled for surgery in late 11/2023. Staff 27 was not aware of pain control issues and staff were able to pull pain medications from the emergency supply if the medications were not available in the medication cart.
On 6/14/24 at 10:00 AM and 12:53 PM Staff 2 (DNS) stated Resident 85 was on multiple pain medications and in 11/2023 there was an oxycodone shortage. A request was made to Staff 2 to provide documentation additional pain medications were added to the resident's pain regimen when the medications were documented as not available. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
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 resident who was a trauma survivor receiv...
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**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 resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and account for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 sampled residents (#25) reviewed for Behavioral-Emotional. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include:
Resident 25 admitted to the facility in 2017 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction).
Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition and a PTSD diagnosis.
Resident 25's 6/11/24 SS (social service) Post-Traumatic Checklist assessed her/him to experience anger outbursts, difficulty concentrating, unable to answer complicated questions and was irritable. Interventions for the verbal outbursts were to talk calmly or walk away. It was assessed as not helpful to keep talking to her/him. No other interventions or triggers were identified.
Resident 25's SS Psychosocial Evaluation revealed in the section Describe Trauma: any time they may experience anxiety, sensitive to touch or noise or nightmares as the following: she/he does suffer from PTSD r/t [related] to trauma experienced while in the service. No other information was documented.
On 6/13/24 at 10:21 AM Staff 6 (CNA) stated she obtained information to care for Resident 25 from the [NAME] (care plan for CNAs), at report to each other during change of shift and I just know [her/him] because I've worked with [her/him] so long. Staff 6 stated Resident 25 experienced behaviors and certain things would set [her/him] off.
On 6/13/24 at 3:29 PM Staff 42 (CNA) stated Resident 25 was often resistive to care and would hit or yell at staff. Staff 42 obtained her information to care for Resident 25 from the [NAME].
Resident 25's 6/13/24 [NAME] section for Behavior/Mood directed staff to provide the following:
-Non-Medication Interventions in place routinely;
-Approach in a slow non-threatening manner;
-Remove to a safe environment PRN for increased behavior;
-Remove to a quieter environment PRN to decrease over stimulation;
-Do not force or rush care;
-One on One PRN.
Resident 25's PTSD care plan directed staff to provide the following:
-Avoid continuing to talk to her/him when she/he expressed feeling stressed, upset, or overwhelmed, give her/him time to calm down;
-Resident expressed feeling stressed, upset, or overwhelmed with the following behaviors or ways of responding: making verbal threats;
-Resident preferred the approach from facility personnel when he/she felt upset, stressed, or overwhelmed: talk calmly or walk away;
-Staff to avoid and resist re-traumatizing her/him with thoughtful approaches to care.
No evidence was found in Resident 25's health record related to the development and implementation of individualized interventions, for assessed triggers of trauma which may re-traumatize the resident or identify ways to mitigate or decrease the effect of the trigger on the resident.
On 6/14/24 at 10:38 AM Staff 36 (Social Service Director) stated she was aware of Resident 25's behaviors. Staff 36 was unaware of specific behaviors Resident 25 exhibited related to PTSD or what triggered the PTSD. Staff 36 stated to her knowledge the triggers were not assessed or care planned for individual residents.
On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the need for residents to have triggers identified for a PTSD diagnosis to prevent re-traumatization. Staff 2 acknowledged the resident care plans were expected to be resident centered for the individual.
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 a resident was transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis. This placed reside...
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Based on interview and record review it was determined the facility failed to ensure a resident was transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis. This placed residents at risk for worsening kidney function. Findings include:
Resident 134 was admitted to the facility in 2023 with a diagnosis of kidney disease.
12/2/23 hospital orders revealed Resident 134 was to receive dialysis at a dialysis center on Mondays, Wednesdays, and Fridays.
On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency the facility did not follow up with transportation for Resident 134 and On 12/11/23 (Monday) she/he missed a dialysis treatment.
On 6/10/24 at 6:56 PM Staff 43 stated the facility was aware Resident 134 required transportation to the dialysis unit, the paperwork was submitted, but they did not transport the resident.
On 6/20/24 via e-mail, Staff 2 (DNS) indicated Resident 134 did not go to dialysis. No additional information was provided for the rationale Resident 134 did not attend dialysis.
On 6/21/24 Witness 10 (Dialysis RN) verified Resident 134 did not get dialysis treatment on 12/11/23 due to lack of transportation. Witness 10 stated if a resident resided in a nursing facility the facility was to assist the resident to and from the dialysis unit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 5 halls (200 hall) reviewed for infection control. This placed r...
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Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 5 halls (200 hall) reviewed for infection control. This placed residents at risk for cross contamination. Findings include:
On 6/14/24 at 10:08 AM, Staff 37 (CNA) was observed carrying dirty linens down the 200 hall and entering the soiled linen room. Staff 37 acknowledged not having bags in her pocket and was aware that linens should be placed in a bag before transport.
In an interview on 6/14/24 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the expectation of staff were to place dirty linen in a bag for transport from resident room to soiled linen room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
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 not administered an antibiotic without indication for 1 of 3 sampled residents (#86) reviewed for UT...
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Based on interview and record review it was determined the facility failed to ensure a resident was not administered an antibiotic without indication for 1 of 3 sampled residents (#86) reviewed for UTI. This placed residents at risk for drug resistant infections. Findings include:
Resident 86 was admitted to the facility in 2023 with a diagnosis of UTI.
A 10/7/23 Progress Note revealed Resident 86 had increased confusion. The physician was notified and Resident 86 was sent to the hospital for evaluation, treatment, and returned on 10/8/23.
Resident 86's urine culture results dated 10/7/23 revealed there was a mixed growth of skin and or genital organisms indicating an improper collection. The form revealed a new sample was to be submitted if clinically indicated.
A 10/2023 MAR revealed Resident 86 was administered antibiotics from 10/10/23 through 10/16/23 for an UTI.
On 6/14/24 at 9:29 AM Staff 2(DNS) stated 72 hours after an antibiotic was started the facility staff were to review the test results to ensure an antibiotic was indicated. Staff 2 stated a 72 hour review was not documented in the resident 86's record and the 10/7/23 UA results did not indicate antibiotics should be administered.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
4. Resident 95 admitted to the facility in 5/2023 with diagnoses including a femur (thigh) fracture.
Resident 95's 5/25/23 admission MDS assessed her/him as cognitively intact.
Review of an investigat...
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4. Resident 95 admitted to the facility in 5/2023 with diagnoses including a femur (thigh) fracture.
Resident 95's 5/25/23 admission MDS assessed her/him as cognitively intact.
Review of an investigation dated 6/1/23, revealed Resident 95 made a verbal complaint to Staff 10 (former Social Services Assistant). Resident 95 reported Staff 39 (former Physical Therapy Assistant) called her/him trash.
Staff 1's (Administrator) completed investigation dated 6/1/23 which concluded Staff 39 used the word trash that was not the best choice of words.
On 6/13/24 at 12:34 PM Resident 95 stated she/he was called a piece of trash by Staff 39 and it hurt her/his feelings.
On 6/13/24 at 2:51 PM Staff 1 acknowledged the incident and expected residents to be treated with dignity and respect.
3. Witness 2 (Resident) was admitted to the facility in 2024 with diagnoses including depression.
A 4/2024 MDS indicated Witness 2 was cognitively intact with no concerns with behaviors.
On 6/10/24 at 6:56 PM, Staff 43 (Former RN) reported Staff 32 (CNA) was not respectful to the residents. The concern was reported to the facility management and Staff 32 continued to be disrespectful.
On 6/11/24 at 7:32 AM and 6/12/24 at 10:03 AM Witness 2 stated some staff members were sarcastic and lacked compassion. Witness 2 expressed concern about potential retaliation and requested anonymity. Witness 2 confirmed Staff 32 (CNA) treated her/him rudely, using sarcasm and rushing during interaction. Although there were a couple of other staff members involved, Witness 2 considered Staff 32 to be the worst. Witness 2 stated she/he did not turn in a grievance because she/he did not want to experience the day to day awkwardness with staff.
On 6/12/24 at 9:35 AM Staff 30 (LPN Resident Care Manager) and Staff 27 (LPN Resident Care Manager) stated they heard about issues with Staff 32's interactions with residents. Staff 27 was uncertain which residents expressed concerns. Management was supposed to address these issues if a complaint was filed. Staff 27 mentioned that Staff 32 had been between different units due to staff-to-staff interactions rather than staff to resident interactions.
On 6/12/24 at 9:47 AM and 06/14/24 at 10:34 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated Staff 32 was removed from various units within the facility due to resident complaints about interactions related to Staff 32's attitude. Staff 1 stated it was an expectation for staff to treat residents with dignity and respect.
On 6/12/24 at 10:57 AM, Staff 45 (Former Staffing) stated she relocated Staff 32 from multiple halls due to residents' complaints of mistreatment. Although management was aware of the issue, they did not address it.
Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 4 of 15 sampled residents (Witness 2 and Resident #s 51, 65, and 95) reviewed for dignity and abuse. This placed residents at risk for depression. Findings include:
1. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
A 3/20/24 Quarterly MDS revealed Resident 51 was cognitively intact.
On 6/10/24 at 12:27 PM Resident 51 stated staff did not treat her/him with respect. During this interview Staff 4 (CNA) entered Resident 51's room. Resident 51 informed Staff 4 she/he was having a conversation. Staff 4 stated she could pick up the resident's lunch try even if Resident 51 was talking. After Staff 4 left the room, Resident 51 stated she/he did not feel the staff treated her/him with respect.
On 6/10/24 at 1:30 PM Staff 4 stated she entered Resident 51's room because the resident's call light was activated. Staff 4 acknowledged Resident 51 stated she/he was in a conversation but Staff 4 stated she could provide resident care even if the resident was talking.
On 6/12/24 at 3:36 PM Staff 1 (Administrator) acknowledged Staff 4 interrupted Resident 51's conversation to pick up a lunch tray.
2. Resident 65 was admitted to the facility in 2024 with a diagnosis of pain.
A 5/26/24 Quarterly MDS revealed Resident 65 was cognitively intact.
A 6/6/24 Investigation Summary revealed on 5/30/24 Resident 65 reported to social services, Staff 32 (CNA)made rude comments about her/him. The investigation indicated Staff 32 told Resident 65 she/he stinks down there. Resident 65 reported the concern occurred prior to 5/30/24 and did not report the concern sooner due to fear of retaliation.
On 6/11/24 at 4:42 PM Staff 41 (RN) stated Staff 32 was condescending to residents and recently was moved from resident care due to her behavior. Staff 41 stated management would communicate with Staff 32 and her attitude would improve for a short period of time and then return.
On 6/12/24 10:19 AM Staff 32 (CNA) stated Resident 65 had a skin condition and in order to make it better Staff 32 informed Resident 65 it would be best to take a shower. Staff 32 stated she felt the resident was upset of the comment because Staff 15 (CNA) was in the room at the time of the interaction and Staff 15 was the opposite gender as Resident 65.
On 6/12/24 at 11:43 AM Resident 65 stated Staff 32 did not treat her/him with respect. Resident 65 stated Staff 32 made comments about her/his body odor and stated she/he stunk. Resident 65 stated she/he was offered grievance forms by multiple staff. Resident 65 stated previously when she/he was informed Staff 32 was assigned to be her/his CNA it caused her/him anxiety. Resident 65 also stated even when she/he heard Staff 32's voice in the hall it upset her/him. Resident 65 stated Staff 32 no longer worked with her/him because Staff 32 was moved to a different unit.
On 6/12/24 at 12:17 PM Staff 15 stated she/he was in the room when Staff 32 made a comment related to Resident 65 and bathing. Staff 15 stated Staff 32 told Resident 65 she/he had a smell about her/him. Staff 15 stated Staff 32 should have communicated with the resident in a less offensive manner. Staff 15 stated she/he communicated with Staff 32 on how her/his approach could be altered to be less offensive.
On 6/12/24 at 9:45 AM Staff 2 (DNS) stated there have been reported concerns related to Staff 32 and her interactions with residents including Resident 65. Staff 2 stated it was usually a personality mismatch and not abuse or mistreatment. Staff 2 stated Staff 32 no longer worked in the unit where Resident 65 resided.
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
5. Resident 90 was admitted to the facility in 2023 with diagnosis of neck fracture.
A 7/5/23 at 1:27 AM Alert Note indicated Resident 90 was agitated and was kept up by the fireworks and one sounded ...
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5. Resident 90 was admitted to the facility in 2023 with diagnosis of neck fracture.
A 7/5/23 at 1:27 AM Alert Note indicated Resident 90 was agitated and was kept up by the fireworks and one sounded like it had come through her/his window.
On 7/6/23 the State Survey Agency received a public complaint which indicated nights were noisy with people in the hallway and carts going up and down the hallway by the resident.
At 6/10/24 at 2:20 PM Resident 90 confirmed the 7/6/23 complaint with concerns of loud noises at night while she/he stayed in the facility.
On 6/11/24 at 5:51 AM a cart with full plastic bags was wheeled down the 300 hall with a squeaky wheel. Another staff member rolling two yellow garbage pails down the 300 hall could be observed and heard while standing in the 200 hallway. At 6:09 AM staff was heard talking loudly at the nurses' station.
On 6/13/24 at 5:56 AM, a cart was heard rolling loudly by the nurse's station. At 6:02 AM Staff 16 (CNA) was observed wheeling to large garbage cans loudly down the 200 hall and entered the soiled linens room the sound of the cans was loud. Staff 16 stated residents did complain of the loud noise of the garbage cans. As well as other noises during the night such as residents yelling, coughing, or having their TV up too loud. Staff 16 stated she had brought up the noisy garbage cans wheels up to management, but she had not heard anything back for a possible change.
In an interview on 6/14/24 at 10:30 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated they would expect noise levels to be quiet during sleeping hours and for staff to be quiet during shift change from night shift to day shift.
Based on observation and interview it was determined the facility failed to ensure a resident's wheelchair, residents' walls and floors were in good repair and failed to provide comfortable sound levels for 5 of 13 sampled residents (#s 20, 29, 51, 90, and 137) reviewed for environment. This placed residents at risk for skin tears and unhomelike conditions. Findings include:
1. Resident 20 was admitted to the facility in 2021 with a diagnosis including heart disease.
On 6/10/24 at 2:30 PM a bathroom tile was observed to be missing on Resident 23's bathroom floor in front of the toilet. There was also a patched area on the bathroom wall with no paint to cover the caulking. The patch was approximately two feet wide and two feet long.
On 6/12/24 at 2:13 PM Staff 2 (Administrator) observed the missing tile and the patched wall.
On 6/12/24 at 2:48 PM Staff 46 (Maintenance) stated rooms were patched and then were painted when the residents were not in the room. Patching was a priority and not painting.
2. Resident 29 was admitted to the facility in 2017 with diagnosis of stroke.
On 6/10/24 at 3:18 PM a patch on the wall to the left of the bathroom door was observed. The patch was not painted to cover the caulking. The patched area was approximately 5 inches by 12 inches.
On 6/12/24 at 2:13 PM Staff 2 (Administrator) acknowledged the caulking was not painted.
On 6/12/24 at 2:48 PM Staff 46 (Maintenance) stated rooms were patched and then were painted when the residents were not in the room. Patching walls was a priority but not painting.
3. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
A 3/20/24 quarterly MDS revealed Resident 51 was cognitively intact.
On 6/10/24 at 12:30 PM a patched area on the wall was observed above the resident's head of the bed but the caulking was not painted. Resident 51 stated the wall was patched and not painted since she/he was admitted to the room.
On 6/12/24 at 2:13 PM Staff 2 (Administrator) acknowledged the caulking was not painted.
On 6/12/24 at 2:48 PM Staff 46 (Maintenance) stated rooms were patched and then were painted when residents were not in the room. Patching was a priority not painting.
4. Resident 137 was admitted to the facility in 2024 with a diagnosis of a stroke.
On 6/10/24 at 2:54 PM Resident 137's wheelchair armrests were observed covered with green tape.
On 6/12/24 at 2:46 PM Staff 30 (LPN Resident Care Manager) observed the tape on the resident's wheelchair and acknowledged the surface could be rough on the skin and difficulty to clean.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communicate with a resident or resident's representative regarding the resolutio...
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Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 6 of 14 sampled residents (#s 8, 83, 84, 86, 87, and 90) reviewed for abuse and dignity. This placed residents at risk for unaddressed concerns and grievances. Findings include:
1. Resident 8 was admitted to the facility in 4/2024 with diagnoses including a fracture of the right leg.
A 6/6/24 Grievance Form revealed Resident 8 had a concern related to a male CNA providing persona care after she/he had requested a female CNA and the male CNA made Resident 8 feel uncomfortable after he requested to change her gown.
A 6/7/24 grievance resolution reveled an investigation related to a male CNA requesting to change Resident 8's gown, no evidence of addressing Resident 8's concern related to a male CNA providing personal care.
On 6/10/24 at 12:11 PM Resident 8 stated a male CNA came in during the night to provide personal care. Resident 8 stated she/he told the male CNA she/he preferred a female CNA. Resident 8 stated the male CNA walked out of the room and came back a few minutes later, proceeded to provide Resident 8's personal care needs and then requested to change Resident 8's gown. Resident 8 stated she/he said no to the gown change, and the male CNA left. Resident 9 stated this incident was reported to Staff 2 (DNS) , and she/he had not seen the male CNA since.
6/10/24 review of Resident 8's care plan revealed no evidence of Resident 8's request for female CNAs only for personal care.
On 6/11/24 at 2:19 PM Staff 57 (CNA) stated Resident 8 had expressed wanting female CNAs on multiple occasions. Staff 42 stated Resident 8 would allow care from a few male CNAs and Staff 2 was aware of Resident 8's preference for female CNAs to provide personal care.
On 6/13/24 at 3:03 PM Staff 29 (CNA) stated Resident 8 had expressed wanting female CNAs for personal care, and he was one of the male CNAs Resident 8 allowed to give her/him personal care but he continued to have a female CNA provide personal care if able.
On 6/14/24 at 11:44 AM Staff 2 stated he verbally reviewed Resident 8's grievance related to male CNAs with her/him, but acknowledged there was no written resolution and Resident 8's preference was not on her/his care plan.
2. Resident 90 was admitted to the facility in 2023 with diagnosis of neck fracture.
On 7/6/23 the State Survey Agency (SSA) received a public complaint which indicated a staff member stated to Resident 90 to sit down and behave herself/himself or they are going to get her/him and staff threw her/his personal items when making her/his bed.
A 7/9/23 at 8:49 PM a Nursing Note indicated Resident 90 reported to Staff 11 (LPN) that staff were throwing things and behaving rudely. Resident 90 began crying and expressed a desire to leave the facility.
On 6/10/24 at 2:20 PM Resident 90 stated a staff members was upset and threw her/his personal items around the room. Resident 90 also stated the staff member had been rude on multiple occasions during her/his stay at the facility.
On 6/11/24 at 10:53 AM Staff 1 (Administrator) stated Staff 11 did not report the concern from the 7/9/24 nursing note and no investigation or grievances was completed for Resident 90.
On 6/12/24 at 8:26 AM Staff 10 (Former Social Services Director) stated Resident 90 reported staff being rude and throwing items. Staff 10 informed the resident's concerns to Staff 1 (Administrator). Staff 10 acknowledged she placed a grievance form on Resident 90's table but did not assist the resident with completing.
In an interview on 6/14/24 at 10:27 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the expectation would be for staff to call Staff 1 immediately if there was a report of staff throwing things or being rude. Staff 1 stated the process was if the resident wanted to file a grievance they would complete an investigation. The minimum would have been a grievance.
3. Resident 83 was admitted to the facility 11/23/24 with a diagnosis of heart disease.
Resident 83's room history revealed she/he resided on the Illinois unit and was later discharged from the facility.
A 12/2/23 admission MDS revealed Resident 83 was cognitively intact.
On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency Staff 32 (CNA) did not treat residents with respect, including Resident 83. Staff 43 stated Resident 83 filed a grievance and management did nothing about the incident.
On 6/10/24 at 6:56 PM Staff 43 stated Staff 15 was often rude to residents. Resident 83 filed a grievance and nothing was done.
On 6/12/24 at 12:17 PM Staff 15 stated residents reported they did not like the manner in which Staff 32 treated them. Staff 15 stated she/he offered residents grievance forms if they had concerns.
On 6/12/24 at 8:51 AM Staff 44 (CNA) stated Staff 32 was gruff and rude to residents. Staff 44 stated she observed the interactions and in the past it was reported to management. Staff 44 stated she would not want her mother treated in the manner Staff 32 treated residents.
On 6/12/24 at 9:35 AM Staff 30 (LPN Resident Care Manager) and Staff 27 (LPN Resident Care Manager) stated they heard there were issues with Staff 32 and her/his interactions with residents. Staff 27 was not sure which residents had concerns. Management was to address issues if complaints were filed. Staff 27 also stated she thought Staff 32 was moved from different units, including Illinois unit, due to staff to staff interactions and not staff to resident interactions.
On 6/12/24 at 9:47 AM Staff 2 (DNS) stated Staff 32 was removed from different units due to resident reports of interactions related to Staff 32. The interactions were not abuse it was more related to Staff 32's attitude.
On 6/12/24 10:48 AM Staff 1 (Administrator) stated he did not have a grievance or investigation related to Staff 32 and Resident 83.
On 6/12/24 at 10:57 AM Staff 45 (Former Staffing) stated she had to move Staff 32 from multiple units do to residents' reports of mistreatment. Staff 45 stated management was aware of the issue related to Staff 32 but did not address the concerns.
4. Resident 84 was admitted to the facility in 2023 with a diagnosis of diabetes.
Resident 84's room history revealed she/he resided on the Illinois unit and was later discharged from the facility.
A 12/2/23 admission MDS revealed Resident 84 was cognitively intact.
On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency Staff 32 (CNA) did not treat residents with respect, including Resident 84. Staff 43 stated Resident 84 filed a grievance and management did nothing about the incident.
On 6/10/24 at 6:56 PM Staff 43 stated Staff 32 was often rude to residents. Resident 84 filed a grievance and nothing was done.
On 6/12/24 at 9:35 AM Staff 30 (LPN Resident Care Manager) and Staff 27 (LPN Resident Care Manager) stated they heard there were issues with Staff 32 and her/his interactions with residents. Staff 27 was not sure which residents had concerns. Management was to address issues if a complaint was filed. Staff 27 also stated she thought Staff 32 was moved from different units, including Illinois unit, due to staff to staff interactions and not staff to resident interactions.
On 6/12/24 at 9:47 AM Staff 2 (DNS) stated Staff 32 was removed from different units due to residents' reports of interactions related to Staff 32. The interactions were not abuse it was more related to Staff 32's attitude.
On 6/12/24 at 10:19 AM Staff 32 denied treating residents in a undignified manner and denied being moved to different units related to her interactions with residents.
On 6/12/24 at 10:48 AM Staff 1 (Administrator) stated he did not have a grievance or investigation related to Staff 32 and Resident 84.
On 6/12/24 at 10:57 AM Staff 45 (Former Staffing) stated she had to move Staff 32 from multiple units due to residents' reports of mistreatment. Staff 45 stated management was aware of the issue but did not address the concerns. Staff 45 stated Resient 84 filed a complaint about Staff 32.
5. Resident 86 was admitted to the facility in 2023 with a diagnosis of diabetes.
Resident 86's room history revealed at one time she/he resided on the Illinois unit and later was discharged from the facility.
A 9/21/23 admission MDS revealed Resident 86 was cognitively intact.
On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency Staff 32 (CNA) did not treat residents with respect, including Resident 86. Staff 43 stated Resident 86 filed a grievance and management did nothing about the incident.
On 6/10/24 at 6:56 PM Staff 43 stated Staff 32 was often rude to residents. Resident 86 filed a grievance and nothing was done.
On 6/12/24 at 9:35 AM Staff 30 (LPN Resident Care Manager) and Staff 27 (LPN Resident Care Manager) stated they heard there were issues with Staff 32 and her/his interactions with residents. Staff 27 was not sure which residents had concerns. Management was to address issues if a complaint was filed. Staff 27 also stated she thought Staff 32 was moved from different units, including Illinois unit, due to staff to staff interactions and not staff to resident interactions.
On 6/12/24 at 9:47 AM Staff 2 (DNS) stated Staff 32 was removed from different units due to residents' reports of interactions related to Staff 32. The interactions were not abuse it was more related to Staff 32's attitude.
On 6/12/24 10:19 AM Staff 32 denied treating residents in a undignified manner and denied being moved to different units related to her/his interactions with residents.
On 6/12/24 10:48 AM Staff 1 (Administrator) stated he did not have a grievance or investigation related to Staff 32 and Resident 86.
On 6/12/24 at 10:57 AM Staff 45 (Former Staffing) stated she had to move Staff 32 from multiple units due to residents' reports of mistreatment. Staff 45 stated management was aware of the issue but did not address the concerns. Staff 45 stated Resident 86 filed a complaint about Staff 32.
6. Resident 87 was admitted to the facility in 2023 with a diagnosis of heart disease.
A 9/23/23 quarterly MDS revealed Resident 87 was cognitively intact.
Resident 87's room history revealed she/he resided on the Illinois unit and later was discharged from the facility.
On 12/12/23 Staff 43 (Former RN) reported to the State agency Staff 32 (CNA) did not treat residents with respect, including Resident 87. Staff 43 stated Resident 87 filed a grievance and management did nothing about the incident.
On 6/10/24 at 6:56 PM Staff 43 stated Staff 32 was often rude to residents. Resident 87 filed a grievance and nothing was done.
On 6/12/24 at 9:35 AM Staff 30 (LPN Resident Care Manager) and Staff 27 (LPN Resident Care Manager) stated they heard there were issues with Staff 32 and her/his interactions with residents. Staff 27 was not sure which residents had concerns. Management was to address the issues if a complaint was filed. Staff 27 also stated she thought Staff 32 was moved from different units, including Illinois unit, due to staff to staff interactions and not staff to resident interactions.
On 6/12/24 at 9:47 AM Staff 2 (DNS) stated Staff 32 was removed from different units due to resident reports of interactions related to Staff 32. The interactions were not abuse it was related to Staff 32's attitude.
On 6/12/24 at 10:19 AM Staff 32 denied treating residents in a undignified manner and denied being moved to different units related to interactions with residents.
On 6/12/24 10:48 AM Staff 1 (Administrator) stated he did not have a grievance or investigation related to Staff 32 and Resident 87.
On 6/12/24 at 10:57 AM Staff 45 (Former Staffing) stated she had to move Staff 32 from multiple units due to residents' reports of mistreatment. Staff 45 stated management was aware of the issue but did not address the concerns. Staff 45 stated Resident 87 filed a complaint about Staff 32.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 21 was admitted to the facility on [DATE] with diagnoses including cervical vertebra (neck) fracture.
A 4/5/24 Compr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 21 was admitted to the facility on [DATE] with diagnoses including cervical vertebra (neck) fracture.
A 4/5/24 Comprehensive MDS Assessment was signed completed on 4/10/24.
On 6/11/24 at 8:34 AM Resident 21 stated she/he did not recall if she/he had a care conference since admission.
A 6/11/24 medical record review revealed Resident 21 had a care conference on 4/4/24, the day after admission, and no other care conferences were located in the resident's record.
On 6/12/24 Staff 36 (Social Service Director) stated new admissions have care conferences within three days of admission, before discharge, within in 14 days of admission if the resident is staying longer than 20 days and then every 90 days.
On 6/12/24 at 1:49 PM Staff 27 (LPN Unit Manager) stated new admissions have care conferences within three days after admission, as needed and every 90 days.
On 6/14/24 at 11:53 AM Staff 1 (Administrator) acknowledged new admissions need to have a care conference completed within seven days after completing the Comprehensive MDS Assessment.
5. Resident 49 was admitted to the facility on [DATE] with diagnoses including left rib fracture.
A 5/11/24 Comprehensive MDS Assessment was signed completed on 5/21/24.
On 6/10/24 at 1:32 PM Witness 8 (Resident Representative) stated she was unaware if Resident 49 had a care conference since admission.
On 6/12/24 Staff 36 (Social Service Director) stated new admissions have care conferences within three days of admission, before discharge, within in 14 days of admission if the resident is staying longer then 20 days and than every 90 days.
On 6/12/24 at 1:49 PM Staff 27 (LPN Unit Manager) stated new admissions have care conferences within three days after admission, as needed and every 90 days.
On 6/14/24 at 11:53 AM Staff 1 (Administrator) acknowledged new admissions need to have a care conference completed within seven days after completing the Comprehensive MDS Assessment, by day 21.
6. Resident 25 admitted to the facility in 2017 with diagnoses including a stroke.
Resident 25's Quarterly MDS was completed on 11/5/23.
Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition.
On 6/11/24 at 8:26 AM Witness 5 stated he did not know if there was a change in staff, but we use to have quarterly care conference meetings and that seems like it's not happening any longer. Witness 5 could not recall the last time he contributed to Resident 25's care planning process or participated in a care conference meeting.
No evidence was found in Resident 25's medical record to indicate options for alternate care conference meeting times, the reason for lack of resident representative participation, or steps taken to facilitate participation. No care conference meeting occurred between 1/17/24 to 6/11/24.
On 6/14/24 at 10:38 AM Staff 36 (Social Service Director) stated she was responsible to schedule a care conference meeting for care planning in conjunction with each resident's comprehensive and quarterly MDS assessments. Staff 36 acknowledged it was six months since Resident 25's last care conference meeting, she contacted her/his representative the day prior to the care conference meeting and did not reattempt care conference meetings for resident representatives who were unable to attend.
On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged they expected care conference meeting to be held in conjunction with the Quarterly and Annual MDS assessments and resident representatives were expected to be involved if the resident was not able to advocate for themselves.
Based on interview and record review it was determined the facility failed to revise and update a care plan intervention for 6 of 11 sampled residents (#s 16, 19, 21, 25, 49 and 51) reviewed for medications care planning, dental and respiratory. This placed residents at risk for unmet of care needs. Findings include:
1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.
A 10/17/23 Nursing Note revealed the provider add the diagnosis of schizophrenia to Resident 16's dignosis list. Resident 16 is prescribed aripiprazole (an antipsychotic medicine that is used to treat schizophrenia)for this condition.
A 10/25/23 Psych Consultants report revealed Resident 16 was seen from a facility referral and Resident 16 stated My mind is straight. Resident 16 then stated she/he saw black bugs flying in her/his room and saw them crawling on the window blinds. Resident 16 stated people think she/he was seeing things, but she/he knows they are there. Resident 16 was diagnosed with depression and schizophrenia. Resident 16 denied a history of mental health treatment or hallucinations. Resident 16 needed ongoing assessment for her/his mood and cognitive states as well as psychotherapy to address difficulties with paranoia and hallucinations.
A 6/11/24 care plan revealed Resident 16 was diagnosed with schizophrenia. The care plan was not updated for approximatly eight months after the diagnosis of schizophrenia.
In an interview on 6/14/24 at 10:50 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the expectation of staff would be to update Resident 16's care plan sooner than 6/11/24 when she/he was diagnosed in 10/2023.
2. Resident 19 was admitted to the facility in 2018 with a diagnosis of heart disease.
On 6/10/24 at 4:09 PM Resident 19 was observed not to have two upper front teeth.
Resident 19's 7/12/23 dental visit note revealed impressions were made for a removable partial denture.
On 6/13/24 at 9:32 AM Staff 51 (CNA) stated Resident 19 had missing front teeth and Staff 51 was not aware Resident 19 had a partial. Staff 19 stated if a resident had a partial it was on the [NAME] (CNA guide for resident specific Care)
On 6/13/24 at 9:15 AM Staff 30 (LPN Resident Care Manager) stated Resident 19 had dental partials since 4/2024 but the care plan was not revised.
3. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
A 3/31/24 Progress Note revealed Resident 51 was administered oxygen.
On 6/10/24 at 12:39 PM Resident 51 was observed to wear a nasal canula (device that provides oxygen through a person's nose).
Review of Resident 51's Care Plan initiated 6/2023 revealed there was no focus care area related to oxygen.
On 6/11/24 at 2:25 PM Staff 27 (LPN Resident Care Manager) stated at times Resident 51 was administered oxygen but the care plan was not revised to reflect the resident's oxygen needs.
Refer to F695
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
2. Resident 33 was admitted to the facility in 8/2021 with diagnoses including diabetes.
A physician order dated 1/16/24, indicated Resident 33 was to receive Senna (a laxative)two tablets two times d...
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2. Resident 33 was admitted to the facility in 8/2021 with diagnoses including diabetes.
A physician order dated 1/16/24, indicated Resident 33 was to receive Senna (a laxative)two tablets two times daily.
The 5/2024 and 6/2024 MARs indicated Resident 33 did not receive the medication 32 times from 5/1/24 through 6/11/24.
On 6/12/24 at 7:28 PM Staff 18 (LPN) stated Resident 33 refused her/his Senna medication. Staff 18 stated she recorded refusals in the medical records and after multiple refusals, she would alert the physician. Staff 18 stated she was unsure if she reported Resident 33's refusals.
On 6/13/24 at 10:16 AM Staff 27 (LPN Unit Manager) and Staff 30 (LPN Unit Manager) acknowledged Resident 33 refused her/his Senna medication on multiple occasions. Staff 27 and Staff 30 stated staff were expected to notify the physician after every refusal.
Based on interview and record review it was determined the facility failed to follow physician orders and monitor for 5 of 14 sampled residents (#s 16, 33, 51, 133, and 134) reviewed for medications, antibiotics, dialysis, and edema. This placed residents at risk for adverse side effects and constipation. Findings include:
1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.
a. A 5/2024 MAR instructed staff to administer metoprolol tartrate (to treat high blood pressure) every 12 hours for heart health and to hold the medication if Resident 16's blood pressure was below 100/60 or heart rate was below 60. On the following days and shifts Resident 16's blood pressure was not within physician ordered parameters and she/he was administered metoprolol: 5/2/24 day shift, 5/4/24 day shift, 5/7/24 evening shift, 5/8/24 evening shift, 5/9/24 day shift, 5/10/24 evening shift, 5/15/24 evening shift, 5/16/24 day shift, 5/17/24 evening shift, 5/18/24 evening shift, 5/19/24 evening shift, 5/23/24 evening shift, 5/26/24 evening shift, and 5/28/24 evening shift.
A 6/2024 MAR instructed staff to administer metoprolol tartrate every 12 hours for heart health and to hold the medication if Resident 16's blood pressure was below 100/60 or heart rate was below 60. Resident 16's blood pressure was not within physician ordered parameters and she/he was administered metoprolol on the following shifts: 6/2/24 evening shift, 6/3/24 day and evening shift, 6/4/24 day shift, 6/5/24 day shift, 6/8/24 day shift, 6/10/24 day shift, and 6/11/24 evening shift. On evening shift Resident 16 was administered medication when heart rate was below 60 on 6/10/24 and 6/11/24.
A review of Resident 16's Heart Rate report revealed:
Her/his Heart rate was not documented as obtained.
-5/1/24 evening shift.
-5/3/24 evening shift.
-5/5/24 evening shift.
-5/6/24 evening shift.
-5/8/24 day shift.
-5/11/24 day shift.
-5/12/24 evening shift.
-5/14/24 evening shift.
-5/16/24 evening shift.
-5/19/24 day shift.
-5/20/24 evening shift.
-5/21/24 evening shift.
-5/24/24 evening shift.
-5/26/24 day shift.
-5/27/24 evening shift.
-5/29/24 evening shift.
-5/30/24 evening shift.
-6/1/24 evening shift.
Heart rate below 60 beats per minute.
-6/10/24 at 2:28 PM 59.
-6/11/24 at 2:56 PM 59.
A review of Resident 16's Blood Pressure report revealed:
Her/his blood pressure not documented as obtained.
-5/8/24 day shift.
-5/12/24 evening shift.
-5/16/24 evening shift.
-5/19/24 day shift.
-5/24/24 evening shift.
-5/26/24 day shift
-5/27/24 evening shift.
-5/29/24 evening shift.
-5/31/24 evening shift.
-6/3/24 evening shift.
Her/his blood pressure was documented as below 100/60:
-5/2/24 6:21 AM 103/52.
-5/4/24 6:33 AM 98/55.
-5/7/24 3:21 PM 107/56.
-5/8/24 3:42 PM 115/56.
-5/9/24 8:42 AM 101/52.
-5/10/24 3:08 PM 116/52.
-5/15/24 3:19 PM 105/55.
-5/16/24 6:55 AM 114/55.
-5/17/24 2:49 PM 105/59.
-5/18/24 2:54 PM 107/57.
-5/19/24 2:35 PM 104/58.
-5/23/24 3:29 PM 101/58.
-5/26/24 3:17 PM 106/47.
-5/28/24 3:28 PM 108/51.
In an interview on 6/14/24 at 10:19 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated if the physician did not specify if one measurement was out of parameter the staff should hold the medication.
b. A 5/2024 MAR instructed staff to administer Furosemide as needed for fluid retention for weight gain of more than two pounds. No medication was administered in 5/2024 no documentation of weights were on the MAR to identify if there was a weight gain.
A review of the Weight Summary report revealed in 5/2024 Resident 16's weight was obtained 12 instances out of 31 opportunities. From 5/4/24 to 5/5/24 Resident went from 152 to 154 a weight gain of two pounds. From 5/25/24 to 5/29/24 Resident 16 went from 150 pounds to 155 pounds a weight gain of five pounds.
In an interview on 6/14/24 at 10:19 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated they would expect daily weights to be completed.
3. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.
An Unwitnessed Fall investigation revealed Resident 51 slipped out of bed on 3/14/24. The investigation indicated neurological assessments were initiated.
Progress Notes revealed the following:
-3/14/24 no assessment documented related to a fall
-3/15/24 no assessment related to a fall
-3/16/24 Resident 51 previously fell and reported pain to the wrist and back. Pain medications were effective
-3/18/24 Resident 51 did not have an injury from a previous fall and was able to walk without pain.
Resident 51's clinical record did not contain neurological assessments after the 3/14/24 fall.
On 6/10/24 at 12:25 PM Staff 30 (LPN Resident Care Manager) reviewed Resident 51's chart and acknowledged staff did not monitor the resident after her/his fall.
On 6/11/24 05:09 PM Staff 2 (DNS) stated after a fall staff were to monitor a resident twice a day. A request was made to Staff 2 to provide neurological assessments for Resident 51's fall. No additional information was provided.
Refer to F689
4. Resident 133 was admitted to the facility in 2023 with a diagnosis of infection.
Resident 133's 11/2023 MAR revealed staff were to administer an antibiotic every four hours. The MAR revealed the resident did not receive antibiotics on five occasions.
Resident 133's 12/2023 MAR revealed staff were to administer an antibiotic every four hours. The MAR revealed the resident was not administered the prescribed antibiotic on three occasions.
On 6/13/24 at 7:41 AM Staff 28 (LPN) stated when a medication was administered staff had to enter yes in the electronic record and then save the response after the medication was administered. If a resident was not available or refused a medication the response was changed to refused, resident not available or see nurse's note. Staff 28 stated the MAR should not be blank for scheduled medications.
On 6/13/24 at 2:35 PM Staff 2 (DNS) stated he would provide documentation if Resident 133 was not in the facility due to appointments to support the missed antibiotic administration. No additional information was provided.
5. Resident 134 was admitted to the facility in 2023 with a diagnosis of kidney disease.
Progress Notes revealed the following:
-12/9/23 Resident 134 had pain with urination and the resident's physician was notified
A 12/11/23 Provider Note revealed Resident 134 had pain with urination and staff were to obtain a urine sample.
Review of the resident's record revealed there were no results for a urine sample for the 12/11/23 orders.
On 6/11/24 at 1:37 PM a request was made to Staff 2 (DNS) to provide results from the 12/11/23 physician order UA. No additional information was provided.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed resi...
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Based on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include:
A review of the Direct Care Staff Daily Reports (DCSDR) from 5/9/24 through 6/9/24 revealed no census documented on 6/5/24 day and evening shift, 6/6/24 evening shift, or 6/8/24 night shift.
On 6/11/24 at 5:25 AM the DCSDR was observed posted by the nurses station. The night shift was blank for resident census, number of staff and hours worked.
On 6/12/24 at 8:02 AM the DCSDR was observed to have 6/11/24 posted. No census was documented for evening shift or night shift. At 9:17 AM the 6/12/24 DCSDR was posted with no census documented on the day shift.
In an interview on 6/14/24 at 10:22 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) reported it was expected to have an accurate DCSDR posted within one hour of a shift change.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
4. Resident 63 was admitted to the facility in 2024 with diagnoses including anxiety and asthma.
A pharmacy review dated 4/29/24 recommended following the use of Symbicort (inhaler medication) Residen...
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4. Resident 63 was admitted to the facility in 2024 with diagnoses including anxiety and asthma.
A pharmacy review dated 4/29/24 recommended following the use of Symbicort (inhaler medication) Resident 63 was to rinse her/his mouth with water.
The 4/2024 and 5/2024 MARs did not include the order to rinse Resident 63's mouth with water after using Symbicort.
According to the 6/2024 MAR the facility documented the new orders for Resident 63 to rinse her/his mouth with water following use of Symbicort on 6/5/24.
On 6/14/24 at 11:43 AM Staff 2 (DNS) confirmed the pharmacy recommendations were not implemented timely.
2. Resident 33 was admitted to the facility in 8/2021 with diagnoses including insomnia and anxiety.
The 6/2024 MAR included a 10/18/23 order for temazepam (treats insomnia) one capsule to be administered at bedtime for insomnia.
A 4/26/24 and 5/31/24 pharmacist Consultation Report recommended discontinuation of the temazepam. The report noted, No change. Resident assessed and was determined regimen is currently at the lowest optimal dose and continues to be beneficial for resident's psychiatric symptoms, outweigh any apparent risk. Discontinue the temazepam or change the temazepam from daily to Monday, Wednesday, Friday and Sunday.
The pharmacy recommendation was not signed until 6/11/24 and indicated to see if patient willing to discontinue the temazepm.
On 6/12/24 at 1:56 PM Staff 48 (Consultant Pharmacist) stated she completed the monthly pharmacy reviews and she recommended a reduction to Resident 33's temazapen. Staff 48 stated common practice was a 30-day response time when a recommendation was given, but often took 60 days or longer to receive a response from the physician.
On 6/13/24 at 10:16 AM and 11:10 AM, Staff 2 (DNS), Staff 27 (LPN and Unit Manager) and Staff 30 (LPN Unit Manager) stated Resident 33's temazapen was not followed up on promptly. Staff 2 stated he expected staff to follow up on pharmacy recommendations weekly to prevent oversights or delays.
Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 4 of 6 sampled residents (#s 16, 33, 63, and 51) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include:
1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.
a. A 10/28/23 Recommendation Summary for Medical Director and DON indicated Resident 16 required a gradual dose reduction assessment. The recommendation proposed lowering the dosage of aripiprazole (antipsychotic medication treat depression and schizophrenia) from 10 milligrams to 7.5 millagrams. The physician did not sign or date the recommendation, or provide a clinical rationale for maintaining the current medication dosage.
A 11/2023 and 12/2023 MARs instructed staff to administer aripiprazole 10 milligrams once a day from 11/7/23 through 12/22/23.
During an interview on 6/14/24 at 10:49 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) expressed the recommendations should be implemented within the month.
b. A 4/28/24 Nursing Recommendations from the pharmacy indicated Resident 16 was taking the antipsychotic aripiprazole. Standards of practice required an assessment for abnormal involuntary movement (AIMs) every six months and was due in 5/2024. A handwritten note next to the recommendation indicated completion, although it lacked a specific date.
No other documentation was found in clinical records the AIMS evaluation was completed in 5/2024.
In an interview on 6/14/24 at 10:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the recommendations should be implemented in the month.
3. Resident 51 was admitted to the facility in 2023 with a diagnosis of Cancer.
A 4/30/24 Pharmacy report recommended Resident 51's ferrous sulfate (supplement) should be discontinued because the resident's iron level was normal and docusate (treats constipation) because it was not an effective medication.
A 6/2024 MAR revealed Resident 51 continued to be administered ferrous sulfate and docusate.
On 6/11/24 at 2:33 PM a request was made to Staff 2 (DNS) to provide documentation Resident 51's physician declined 4/31/24 pharmacy recommendations. No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration rate was 7.41% with two errors in 27 op...
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Based on interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for ineffective medication regimen. Findings include:
1. Resident 34 was admitted to the facility in 2019 with a diagnosis of chronic pain.
A 10/3/23 Order revealed staff were to apply an external pain patch to both knees.
A 4/4/24 quarterly MDS revealed Resident 34 was cognitively intact.
On 6/11/24 at 8:21 AM Staff 56 (CMA) was observed to apply a medicated pain patch to Resident 34's right arm and right leg.
On 6/12/24 at 8:18 AM Resident 34 stated she/he only used the patch on the right arm and leg and did not require it on the left knee.
On 6/12/24 08:20 AM Staff 56 stated she applied the patch only in the locations Resident 34 preferred.
On 6/12/24 at 9:19 AM Staff 30 (LPN Resident Care Manager) stated if a resident did not want the patch applied to the location ordered the order should be clarified. Staff 30 stated the patch was currently ordered to be applied to both knees.
2. Resident 10 was admitted to the facility in 2024 with a diagnosis of low thyroid levels.
Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily.
A 5/23/24 order revealed Resident 10 was to be administered levothyroxine once a day. There were no directions to give the mediation with or without food.
On 6/13/24 at 7:58 AM Staff 12 (CMA) was observed to administer Resident 10 her/his thyroid medication. Resident 10 was observed in her/his room with her/his breakfast consumed.
On 6/13/24 at 8:05 AM Staff 12 stated the nurses reported it did not matter if the thyroid medication was administered before or after meals.
On 6/13/24 at 8:21 AM Staff 41 (RN) stated the night shift staff usually administered the thyroid medication before breakfast on an empty stomach.
On 6/13/24 at 8:29 AM Staff 2 (DNS) stated thyroid medication should be given without food unless the resident could not tolerate the medication on an empty stomach.
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 F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected ...
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Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 3, 5, and 6) reviewed training. This placed residents at risk for lack of competent staff. Findings include:
A review of the facility's staff training records revealed the following:
-Staff 3 (CNA), hired 1/26/06 completed 10 hours of documented training from 1/25/23 through 1/25/24.
-Staff 5 (CNA), hired 4/7/10, completed six hours of documented training from 4/27/23 through 4/27/24.
-Staff 6 (CNA), hired 3/28/16, completed 10 hours of documented training from 3/28/23 through 3/28/24.
In an interview on 6/14/24 at 10:23 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated it was expected the staff complete the 12 hours of annual training.
Mar 2023
20 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
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#34) ...
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Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#34) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include:
The facility's Right to Self-Administer Medications policy, dated 7/2018, indicated the following:
-If a resident requested to self-administer medications it was the responsibility of the interdisciplinary team (IDT) to determine if it was safe before the resident exercises the right. A resident may self-administer medications after the IDT determined which medications may be self-administered.
-Appropriate documentation of the determinations would be documented in the resident's medical record and care plan.
Resident 34 was admitted to the facility in 9/2021 with diagnoses including psoriasis (a skin disease marked by red, itchy, scaly patches) and mild cognitive impairment.
A 3/2/23 physician order indicated nursing staff were to apply Triamcinolone Acetonide External Cream (steroid cream to treat psoriasis) to both of Resident 34's upper arms, topically, two times a day for rash until 3/12/23.
Observations on 3/8/23 at 8:27 AM revealed Resident 34 had unsecured Triamcinolone Acetonide External Cream in a clear medication cup on her/his bedside table. Resident 34 stated some nurses allowed her/him to keep the medication at the bedside and other nurses did not.
On 3/8/23 at 8:32 AM Staff 18 (LPN/Unit Manager) observed a plastic medication cup of white cream at Resident 34's bedside and confirmed the resident's topical steroid cream was unsecured on the bedside table. Staff 18 reported there was no physician order allowing Resident 34 to have the medication at the bedside and no medication self-administration evaluation was in the resident's health record.
An observation on 3/9/23 at 9:14 AM revealed Resident 34, again, had unsecured Triamcinoline Acetonide External Cream in a clear medication cup on her/his bedside nightstand. Resident 34 stated a nurse removed some medications from her/his bedside nightstand drawer the previous evening because she/he was not supposed to have medications at her/his bedside but left the medication for psoriasis. Resident 34 reported she/he did not know what medications were removed from her/his nightstand.
Resident 34's health record did not include evidence the resident was assessed for safe self-administration of medications and there were no physician orders allowing Resident 34 to have medications at the bedside.
On 3/9/23 at 10:01 AM Staff 3 (DNS) stated in order for residents to have medications left at their bedside, physician orders and a medication self-administration evaluation were required.
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 protect the resident's right to be free from sexual abuse by Witness 3 (Alledged Perpetrator/Medical Transportation Drive...
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Based on interview and record review, it was determined the facility failed to protect the resident's right to be free from sexual abuse by Witness 3 (Alledged Perpetrator/Medical Transportation Driver) for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse. Findings include:
The facility's abuse policy, revised 11/2017, defined sexual abuse as any form of nonconsensual sexual contact, including but not limited to unwanted or inappropriate touching .in the form of touching of the sexual or intimate parts .This protection extended to abuse by staff, consultants, contractors, volunteers, students and visitors.
Resident 54 was admitted to the facility in 12/2022 with diagnoses including major depression.
Resident 54's 12/19/22 admission MDS indicated a BIMS score of 15 (cognitively intact).
A FRI was submitted to the state agency on 2/12/23 which revealed the following: On Sunday 2/12/23 Witness 3 signed into the facility's visitor log and went to visit Resident 54 in her/his room. Resident 54 stated Witness 3 entered her/his room, began to rub her/his shoulders, Resident 54 was unsure who this visitor was until he stated [his name], your driver from earlier this week. Witness 3 stated he knew Resident 54 had an upcoming appointment on 2/25/23 and that she/he should request him as the driver so he could make sure they had a good time. Resident 54 stated Staff 8 (CNA) entered her/his room and Witness 3 left the room. Staff 8 closed the door and Resident 54 then informed Staff 8 of a prior incident with Witness 3 which occured on 2/9/23. Witness 3 was the driver from her/his appointment on 2/9/23 and took her/him back to her/his room. Witness 3 then began to massage her/his shoulders, told her/him it would relax her/him, then proceeded to grope her/his right breast and squeezed. Resident 54 stated she/he felt extremely uncomfortable. A staff member came into the room and Witness 3 left the room. Resident 54 did not tell anyone of the 2/9/23 incident until 2/12/23.
A Grievance form was completed by Resident 54 on 2/12/23. On 2/9/23 she/he was escorted back to her/his room by the transportation driver (Witness 3), as she/he waited for the CNA to put her/him back to bed, the driver rubbed her/his shoulders. She/he felt very uncomfortable and then he touched her/his breast. On 2/12/23 Witness 3 came close to her/him, began to rub her/his shoulders and asked if she/he knew who he was and it was the driver from her/his medical appointment on Thursday.
On 3/8/23 at 9:22 AM Resident 54 repeated the same information reguarding the 2/9/23 and 2/12/23 instances of sexual abuse by Witness 3. Resident 54 stated she/he had not seen Witness 3 since 2/12/23 and was told he could not come into the facility, which made her/him feel safe. She/he stated the incidents were disturbing but I was ok, I'm strong.
On 3/8/23 at 12:22 PM Staff 1 (Administrator) confirmed the incidents and findings of sexual abuse from the facility investigation. Staff 1 took steps to prevent further contact from Witness 3, trespassed Witness 3 from the property to prevent any future contact and notified the transportation company. 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
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 complete a thorough investigation of an allegation of abuse for 1 of 3 sampled residents (#54) reviewed for abuse. This pl...
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Based on interview and record review it was determined the facility failed to complete a thorough investigation of an allegation of abuse for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations. Findings include:
The 10/2005 Oregon Nursing Facility Abuse Reporting and Investigation Guide for Providers specified a thorough investigation is a systematic collection of information that describes and explains an incident or series of incidents. The investigation seeks to determine if abuse occurred, how the incident occurred, and how to prevent further occurrences. Critical component(s) of any investigation include the timely initiation of the investigation and the thoroughness of the investigation. The evidence data should be accurate and appropriate to include testimonial, documented, pictorial and physical evidence as applicable to come to a conclusion and it is important that conclusions not be reached without adequate information. Each investigation must seek to answer who, what, where, when, why and how, through interviews, comprehensive record review and observations. Interviews may include but are not limited to: reported victim(s), reported perpetrator(s), CNA(s), staff in immediate area or who provided services, roommate(s), visitors and/or family.
The facility's 11/2017 Abuse Prevention Program Policy & Procedure specified the following:
- Identify and assess all possible incidents of abuse.
- Investigations of an allegation of sexual abuse would start with a determination of whether the sexual activity was consensual or not; take into consideration the cognitive ability of the resident to consent.
Resident 54 was admitted to the facility in 12/2022 with diagnoses including major depression.
Resident 54's 12/19/22 admission MDS indicated BIMS score of 15 (cognitively intact).
A 2/12/23 facility Investigation Summary, completed by Staff 1 (Administrator) specified the following on 2/12/23:
- Description: Medical transport driver rubbed [Resident 54] shoulders, squeezed breast, returned to facility to rub shoulder in resident's room and proposition for future rides;
- Event Details: Alleged sexual abuse;
- Location: Resident Room;
- Name of person reporting: [Staff 8 (CNA)];
- Name of alleged perpetrator: [Witness 3, Medical Transport Driver];
- Witnesses statements: none
- Resident interview: Completed, in summary.
Resident 54 completed a Grievance form on 2/12/23 with a statement which revealed a prior event took place on 2/8/23 (which occured on 2/9/23) after her/his medical appointment.
No additional interviews with staff, residents, visitors, the alleged perpetrator or other potential witnesses were included in the FRI submitted to the State Agency or the Investigation Summary.
On 3/9/23 at 2:11 PM Staff 1 (Administrator) acknowledged no further documentation was available for the investigation of Resident 54's report of sexual abuse on 2/12/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview and record review was determined the facility failed to ensure assessments accurately reflected the residents' status for 1 of 9 sampled residents (#30) reviewed for ADLs. This plac...
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Based on interview and record review was determined the facility failed to ensure assessments accurately reflected the residents' status for 1 of 9 sampled residents (#30) reviewed for ADLs. This placed residents at risk for inaccurate assessments. Findings include:
Resident 30 admitted to the facility in 12/2019 with diagnoses which included heart failure and arthritis.
Resident 30's 1/6/23 Annual MDS indicated she/he had a BIMS of 15 (cognitively intact). The MDS indicated she/he required extensive assistance with toilet use.
Resident 30's 1/2023 care plan indicated Resident 30 was independent with toilet use.
On 3/9/23 at 1:19 PM Staff 31 (CNA) stated Resident 30 was independent with toilet use and required very little assistance.
On 3/9/23 at 1:31 PM Staff 32 (LPN/Unit Manager) confirmed Resident 30 was independent with toilet use and the Annual MDS was coded inaccurately for extensive assistance for toilet use.
On 3/9/23 at 1:37 PM Staff 3 (DNS) acknowledged she expected the MDS was coded accurately to reflect the Resident 30's needs for toiliting
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 F0658
(Tag F0658)
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 Staff 11 (Former Staff/RN) adhered to profe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure Staff 11 (Former Staff/RN) adhered to professional standards for medication administration. This placed residents at risk for adverse side effects of medication and hospitalization. Findings include:
Resident 167 admitted to the facility on [DATE] with diagnoses including diabetes, atrial fibrillation and stroke. Resident 167 discharged on 6/6/22.
The 5/26/22 admission MDS indicated Resident 167 was cognitively intact.
According to mayoclinic.org a regular resting heart rate is 60-100 beats per minute.
Resident 167's 6/2022 MARs indicated she/he received the following morning medications on 6/5/22:
-Aspirin 81 mg (antiplatelet medication)
-Breo Ellipta Aerosol powder (bronchodilator medication)
-Combivent Respimat aerosol solution (bronchodilator medication)
-Eplerenone 25 mg (antihypertensive medication)
-Lasix 40 mg (diuretic medication)
-lisinopril 10 mg (antihypertensive medication)
-Pacerone 100 mg (antiarrhythmic medication)
-potassium chloride ER 20 mEQ (supplement medication)
-Metformin 1000 mg (antidiabetic medication)
-metoprolol 25 mg (antihypertensive medication)
A 6/6/22 written statement from Staff 11 (Former Staff/RN) indicated the following:
On 6/5/22 while I was working on the Quartz wing approximately 0830 [AM] I accidentally gave [Resident 167] the wrong medication. I had pre-poured [her/his] meds and gave [her/him] [Resident 168's] medication by mistake. [Resident 167] took the meds and then asked me where [her/his] meds were? I immediately double checked and brought [her/his] meds. Staff 11 indicated she should have notified the physician and DON [Director of Nursing] of the incorrect medication administration.
Resident 168's 6/2022 MARs indicated she/he received the following morning medications (which were given to Resident 167):
-Tricor 48 mg (cholesterol medication)
-Eliquis 5 mg (anticoagulant medication)
-Keppra 750 mg (anticonvulsant medication)
-topiramate 200 mg (anticonvulsant medication)
-amoxicillin 500 mg (antibiotic medication)
-calcium/vitamin d 500/200 mg-unit 2 tabs (supplement)
A 6/6/22 written statement by Staff 14 (Former Staff/LPN) indicated the following:
-Resident [167] brought to my attention at around 9pm when [she/he] approach[ed] me at the med cart asking for the list of medications [she/he] was given so [she/he] could take it to [her/his] doctor in the morning. I had been told in report that [she/he] was given a vitamin in error. When [she/he] asked about the medications [she/he] had been given I said you mean the vitamin? [She/he] said that was no vitamin. I have been complaining of feeling weird all day. [Staff 12 (Former Staff/CNA)] followed [her/him] to [her/his] room and took vitals. No report of anything out of range. I was walking that way when [Staff 12] was passing me in the hall and [Staff 12] said [Resident 167] was given a seizure medication. I then went looking at medications and found [Resident 168] had seizure medications on that wing. I then went to find my coworker [Staff 13 (Former Staff/LPN)] and explained what I had found. She came and took a look at all of the medications I suspected [Resident 167] had been given. We talked with the patient and decided this was a matter that needed to be reported. Resident stated she/he was given the wrong medications and said that the cup [left in her/his room]. This is the same resident I had suspected it was. Resident stated that [she/he] had felt like [she/he] was given psychedelic medications. [Resident 167] said [she/he] had been reporting this all day. [Resident 167] felt like [she/he] was being ignored. [Resident 167] also thought that I was the one that was trying to cover up the error. [Resident 167] also believed that I was the nurse that gave her/him the wrong medication. On call doctor was called. On call provider [Nurse Practitioner] said that [Resident 167] would feel groggy and that [her/his] symptoms would be just how she/he explained with these sort of medications. Call was made by [Staff 13] to DNS with no answer. Administrator was called by [Staff 13]. [Vital signs] were taken every half hour for the remainder of the shift. CBG's were also monitored. Resident refused to go to the hospital. Residents [heart rate] was 41 and [her/his] CBG was 89. [She/he] was given orange juice and assessment of lungs and circulation were done. Resident appeared calm and stable. [Resident 167] said that [she/he] was past all the weird feelings. Spoke with resident for quite some time to make sure [she/he] was comfortable. Asked resident if [she/he] would like me to call [her/his spouse] and [she/he] stated that [the spouse] was here earlier and already knew.
-On the bottom of the written statement a note was attached that indicated the medications given to Resident 167 included amoxicillin 500 mg; calcium/vitamin d 500/200; Eliquis 5 mg; Keppra 750 mg; topiramate 200 mg and Tricor 48 mg.
-On the bottom of the written statement a set of vital signs were hand written as follows:
[6/5/22] 11:00 PM CBG 89 [6/6/22] 3:00 AM CBG 107; 131/69; oxygen saturation 91%; pulse 41; respirations 18; temperature 98.6.
A 6/10/22 written statement by Staff 12 (Former Staff/CNA) indicated the following:
-[Staff 11] stated she gave a patient the wrong medication, I asked what it was, she replied well [she/he] won't be having any seizures. Later that night the patient [Resident 167] asked [Staff 14] the nurse to document that [she/he] received the wrong medication. I told [Staff 14] what [Staff 11] had said to me about the patient won't be having any seizures. This all happened 6/5/22.
Interviews with staff revealed the following:
-On 3/9/23 at 10:34 AM Staff 13 (Former Staff/LPN) stated Staff 11 gave Resident 168's medication to Resident 167 on 6/5/22. Staff 13 stated Resident 167 came to the medication cart and reported she/he had hallucinations and was concerned because she/he got the wrong medications. Staff 13 stated she and Staff 14 interviewed Resident 167 and the resident saved the medication cup that had Resident 168's name on it. Staff 13 stated the provider was notified and Resident 167 refused to go to the hospital. Staff 13 stated she was concerned for the resident because of her/his heart condition and past heart surgery. Staff 13 stated they reached out to Staff 11 and she did not call back.
-On 3/9/23 at 11:28 AM Staff 14 stated she worked from 6/5/22 6:00 PM until 6/6/22 6:00 AM. Staff 14 stated Staff 11 (Former Staff/LPN) was going off shift on 6/5/22 at 6:00 PM and told her she accidentally gave someone someone else's vitamin. Staff 14 stated Staff 11 did not go into detail or do an incident report. Staff 14 stated she was passing bedtime medications when Resident 167 approached the medication cart and stated all day she/he felt light headed and dizzy like she/he was going to pass out and she/he had a medication cup with Resident 168's name on it. Staff 14 stated she worked with Staff 13 to figure out the situation and reported it to the provider. Staff 14 acknowledged her statement indicated Resident 168's heart rate was 41 which was low. Staff 14 stated the provider was notified and the resident refused to go to the hospital.
-On 3/9/23 at 4:16 PM Staff 11 stated Resident 167 was alert and oriented and told her she/he got the wrong medications on 6/5/22. Staff 11 was asked if she gave Resident 168's medications to Resident 167, she declined to answer. Staff 11 was asked if Resident 167 had a medication cup with Resident 168's name on it in her/his room, she declined to answer. Staff 11 was asked if Resident 167 had any symptoms after reporting she/he received the wrong medications, Staff 11 stated Resident 167 felt different so we took vitals and watched [her/him] really close. Staff 11 was asked if the medication error was reported, she stated the resident's spouse knew, two CNAs knew and it was reported to Staff 14 who was the oncoming nurse. Staff 11 was asked what the response was from Staff 14, Staff 11 declined to answer. Staff 11 was asked if she told Staff 12 that Resident 167 would not be having seizures that evening, Staff 11 declined to answer. Staff 11 stated Resident 167 did not complain of hallucinations that day. Resident 168's medications were reviewed with Staff 11, she stated she did not remember what the medications were. Staff 11 stated Staff 15 (Former Staff/DNS) asked her to write a statement and she emailed her statement to Staff 15 the day after it happened on 6/6/22.
On 3/9/23 at 5:16 PM Staff 15 (Former Staff/DNS) stated she remembered the incident regarding Resident 167 receiving the wrong medication on 6/5/22. Staff 15 stated Staff 11 casually told the nurse she gave the wrong medication. Staff 15 stated she completed the investigation and Staff 11 did not deny giving Resident 167 the wrong medications. Staff 15 stated Staff 11 did not take ownership of the error and instead told a CNA the patient won't have a seizure. Staff 15 stated Staff 11 did not come back in the building after working on 6/5/22 and was let go.
On 3/10/23 at 9:23 AM Staff 1 (Administrator) acknowledged on 6/5/22 Staff 11 gave Resident 168's morning medications to Resident 167 and the medications included: calcium / vitamin d tablet 500-200 mg two tabs, Tricor 48 mg, Eliquis 5 mg, Keppra 750 mg, amoxicillin 500 mg and topiramate 200 mg and acknowledged this increased Resident 167's risk of bleeding. Staff 1 stated he reached out to Staff 11 several times and she did not notify staff about the medication error.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide bathing assistance to dependent residents for 2 of 7 sampled residents (#s 4 and 18) reviewed for ADLs. This place...
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Based on interview and record review it was determined the facility failed to provide bathing assistance to dependent residents for 2 of 7 sampled residents (#s 4 and 18) reviewed for ADLs. This placed residents at risk for lack of hygiene. Finding include:
1. Resident 18 was admitted to the facility in 10/2022 with diagnoses including end stage renal disease and for an infection to her/his dialysis chest catheter.
Resident 18's 1/27/23 Quarterly MDS revealed she/he had a BIMS score of 12 (moderate cognitive impairment) and was totally dependent on two staff for physical assistance with showers.
A review of the 30-day shower log revealed Resident 18 received a sponge bath on 2/17/23. Resident 18's shower days were on Monday and Friday, which were also her/his dialysis days. There was no evidence in Resident 18's health record to indicate she/he was provided with a shower between 2/18/23 and 3/7/23.
On 3/7/23 at 8:55 AM Resident 18 stated she/he had not received a shower in two weeks and let multiple staff members know she/he did not receive a shower.
On 3/7/23 at 3:34 PM Staff 23 (CNA) stated Resident 18 refused a shower in the past, but did not recall the date, or know if it was on a dialysis day or not. Staff 23 stated she did not offer to give a shower on another day; she went by the schedule.
On 3/9/23 at 8:45 AM Staff 24 (LPN) stated Resident 18 recently moved rooms and switched dialysis days which possibly led to her/him not receiving a shower.
On 3/9/23 at 1:51 PM Staff 3 (DNS) stated it was her expectation the nurse would check that all residents received their showers. Staff 3 acknowledged Resident 18 did not receive a shower on the identified dates.
2. Resident 4 admitted to the facility in 2009 with diagnoses including need for assistance with personal care.
The 2/10/21 care plan indicated Resident 4 was dependent with bathing.
A 4/7/22 hospice note indicated Resident 4 reported she/he was waiting for her/his shower. CNA staff reported Resident 4's room was no longer on the shower schedule and the resident's last shower was on 3/31/22 [6 days prior]. The hospice note indicated to please shower the [resident] twice a week.
Review of the April 2022 ADL report for bathing indicated Resident 4 was to receive a shower twice a week, Tuesday and Friday. The shower record indicated the following:
- 4/1/22, 4/4/22 and 4/6/22 were marked as activity did not occur. The resident was not marked as receiving a shower until 4/8/22 (7 days later).
- 4/13/22 and 4/15/22 were marked as activity did not occur. The resident was not marked as receiving a shower until 4/18/22 (5 days later).
- 4/22/22 and 4/25/22 were marked as activity did not occur. The resident was not marked as receiving a shower until 4/27/22 (5 days later).
On 4/8/22 Witness 1 (Complainant) indicated on 4/4/22 the facility was short staffed, and Resident 4 was unable to receive a shower. Witness 1 indicated the resident was visited on 4/5/22 and Resident 4 indicated she/he had not showered. Witness 1 indicated the resident's hair was visibly greasy.
On 3/7/23 at 12:58 PM Staff 4 (CNA) stated she often was the CNA for Resident 4 and provided her/his showers. Staff 4 stated she marked activity did not occur on the ADL report for Resident 4's showers for 4/2022. Staff 4 stated sometimes they were short staffed, and she marked on the shower sheet the shower did not occur during those instances.
On 3/9/23 at 8:35 AM Staff 3 (DNS) confirmed Resident 4 did not receive a shower 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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to provide routine diabetic foot care for 2 of 2 sampled residents (#s 10 and 34) reviewed for foot care. This p...
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Based on observation, interview and record review it was determined the facility failed to provide routine diabetic foot care for 2 of 2 sampled residents (#s 10 and 34) reviewed for foot care. This placed residents at risk for pain. Findings include:
The facility's Quality of Care Foot Care policy, dated 8/2018, indicated the following:
-To provide the resident with foot care, including treatment to prevent complications from diabetes, peripheral vascular disease or immobility that is consistent with professional standards of practice.
-Treatment includes preventive care to minimize podiatric complications in residents with diabetes and circulatory disorders.
-Residents with complicating disease processes will be referred to qualified professionals for foot care.
1. Resident 10 was admitted to the facility in 12/2022 with diagnoses including diabetes.
On 3/6/23 at 3:36 PM Resident 10 reported her/his toenails were long and uncomfortable and asked to have her/his toenails trimmed but nobody had done so since her/his admission. Resident 10 was observed to have several long, dark colored, thick toenails on each foot.
A review of Resident 10's health record did not include evidence the resident received diabetic foot care including toenail trimming since her/his admission.
On 3/7/23 at 12:33 PM and 12:54 PM Staff 20 (CNA) and Staff 7 (CNA) reported licensed nursing staff completed nail care for diabetic residents.
On 3/7/23 at 12:49 PM Staff 19 (Agency LPN) stated there was no documentation in Resident 10's health record regarding toenail care and he never trimmed Resident 10's toenails. He observed Resident 10's toenails and Resident 10 reported her/his nails were nasty, too long and hurt. Staff 19 stated there were toenails on both feet that were long and needed to be cut and he would cut the toenails that could be done and would make a referral to the podiatrist for additional diabetic foot care.
On 3/9/23 at 10:01 AM Staff 3 (DNS) reported she expected diabetic residents to have regular foot care including toenail trimming.
2. Resident 34 was admitted to the facility in 9/2021 with diagnoses including diabetes and nail fungus.
On 3/6/23 at 4:38 PM Resident 34 reported she/he was concerned regarding her/his toenails. Resident 34 stated every time she/he had a shower she/he asked to have her/his toenails trimmed but staff never did. Resident 34 stated staff told her/him they were going to refer her/him to a podiatrist but so far that did not happen. Resident 34's toenails were observed to be thick, yellow and the toenails on the great toes were long and curved.
A review of Resident 34's health record did not include evidence the resident received diabetic foot care including toenail trimming.
On 3/7/23 at 12:33 PM and 12:54 PM Staff 20 (CNA) and Staff 7 (CNA) reported licensed nursing staff completed nail care for diabetic residents.
On 3/7/23 at 12:45 PM Staff 19 (Agency LPN) stated there was no documentation in Resident 34's health record regarding toenail care and he never trimmed Resident 34's toenails. Staff 19 stated he would cut Resident 34's toenails as best as he could and would make a referral to the podiatrist for additional diabetic foot care.
On 3/9/23 at 10:01 AM Staff 3 (DNS) reported she expected diabetic residents to have regular foot care including toenail trimming.
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, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#30) reviewed for respirato...
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Based on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#30) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include:
Resident 30 was admitted to the facility in 9/2022 with diagnoses including heart failure.
Resident 30's 1/6/23 Annual MDS indicated the resident used supplemental oxygen.
Resident 30's health record included a 3/2023 physician order for the following:
- Change oxygen tubing, humidification bottle and clean filter every night shift, every Monday for comfort. Oxygen on one to four liters per nasal cannula to keep O2 sats above 90%;
- Document O2 sats and liters per minute every day and night shift for comfort.
On 3/6/23 at 2:57 PM Resident 30 was lying in bed in her/his room and receiving oxygen which was produced and delivered from an oxygen concentrator. A humidifier bottle was attached to the concentrator and contained no fluid. A nasal cannula and tubing was attached to the oxygen concentrator and placed in Resident 30's nose. Resident 30 stated her/his mouth and lips often were dry from the oxygen and the staff did not fill the humidifier bottle.
Observations on 3/8/23 at 9:01 AM and 1:36 PM, and 3/9/23 at 11:45 AM, revealed no fluid in the humidifier bottle attached to the oxygen concentrator while Resident 30 used the oxygen.
On 3/9/23 at 1:25 PM Staff 17 (LPN) stated Resident 30 used oxygen to maintain her/his oxygen saturation and for comfort at nighttime only. Staff 17 stated the resident was to ensure the humidifier bottle was filled with water. Staff 17 did not fill water for the oxygen concentrator.
On 3/9/23 at 1:37 PM Staff 32 (LPN/Unit Manger) stated Resident 30 used oxygen for respiratory maintenance. Staff 32 stated there was an order for the nurses to fill the humidifier bottle every Monday. Staff 32 stated she expected the task to be completed as ordered by the charge nurse on duty.
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 interview and record review it was determined the facility failed to ensure residents received dialysis services consistent with the care plan for 1 of 1 sampled residents (#18) reviewed for ...
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Based on interview and record review it was determined the facility failed to ensure residents received dialysis services consistent with the care plan for 1 of 1 sampled residents (#18) reviewed for dialysis. This placed residents at risk for potential complications in dialysis care and treatment. Findings include:
Resident 18 was admitted to the facility in 10/2022 with diagnoses including end stage renal disease and dialysis.
The 11/13/22 care plan revealed the following:
-Focus: needs hemodialysis related to end stage renal failure;
-Goal: will have no signs or symptoms of complications from dialysis through the review date;
-Interventions: check and change dressing daily at access site, document. Monitor vital signs, notify MD of significant abnormalities. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth or drainage.
The 3/2023 TAR indicated: Complete the dialysis post-assessment form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review and follow up as indicated. Call Dialysis center if not returned with resident. Staff 17 stated she did not complete the Post-Dialysis Communication because the dialysis center did not provide the information.
Review of the Nursing Post-Dialysis communication sheets from 11/14/22 to 3/7/23 revealed they were not completed since 2/14/23.
On 3/7/23 at 2:46 PM Staff 17 (LPN) stated she filled out Resident 18's Pre-Dialysis communication and sent it with Resident 18 to dialysis. The dialysis center was supposed to fill out the Post-Dialysis communication and send it back with Resident 18, but the dialysis center did not fill it out. Staff 18 stated there was a task on the resident's TAR for the nurse to check-off when residents returned from dialysis with paperwork. Staff 18 stated she did not assess Resident 18 when she/he returned from dialysis.
On 3/9/23 at 8:37 AM Resident 18 stated she/he did not recall the last time the nursing staff took her/his vitals or weight when she/he returned from dialysis.
On 3/9/23 at 1:47 PM Staff 3 (DNS) confirmed the Post-Dialysis communication was not completed since 2/14/23, post-dialysis assessments were missing and it was her expectation that nurses completed an assessment when Resident 18 returned from dialysis.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to identify potential trauma and monitor psychosocial...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to identify potential trauma and monitor psychosocial distress for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for unmet psychosocial needs. Findings include:
Resident 54 admitted to the facility in 12/2022 with diagnoses which included major depression.
Resident 54's [DATE] admission MDS indicated she/he had a BIMS of 15 (cognitively intact).
A [DATE] facility investigation indicated Resident 54 was sexually abused by Witness 3 (Medical Transportaion Driver).
On [DATE] an investigation was initiated, and sexual abuse was substantiated by Staff 1 (Administrator). Staff 1's report revealed Staff 30 (LPN) placed Resident 54 on alert for psychosocial distress.
A [DATE] at 5:18 PM a progress note revealed Resident 54 reported she/he felt worried, she/he was not in distress and staff would continue to monitor.
A [DATE] at 3:58 PM a progress note revealed Resident 54 was in good spirits with no signs of emotional distress were observed or expressed complaints of distress.
Record review revealed no other documented observations, monitoring or assessments for psychosocial distress or needs after Resident 54's substantiated allegation of abuse.
On [DATE] at 9:22 AM Resident 54 stated the incident with Witness 3 was disturbing and stated It was a long hard day but I was ok, I'm strong. Resident 54 reported she/he got a little depressed because her/his mother died the following Saturday and she/he was pretty upset with everything that happened that week. She/he also reported it concerned her/him when she/he had another appointment soon after the abuse from Witness 3 and she/he had to trust the new male driver alone. She/he reached out to an old friend who was a grief counselor and asked a CNA about the possibly to have a priest visit her/him. She/he stated the CNA planned to assist, if they could.
On [DATE] at 1:57 PM Staff 2 (Assistant Administrator) confirmed no other alert charting or assessing for psychosocial distress or trauma occured after [DATE] for Resident 54.
On [DATE] at 9:33 AM Staff 16 (Social Services Director) confirmed she was Resident 54's Social Service Director. When asked about the [DATE] incident, Staff 16 stated there was some issue with a driver, I did not document anything because Staff 1 documented. Staff 16 acknowledged no psychosocial alert charting, assessments or services were provided for Resident 54's mental health. Staff 16 thought someone might have asked the resident if she/he wanted to see a psychiatrist, but she was unsure and could not provide any further information.
On [DATE] at 9:25 AM Staff 1 (Administrator) acknowledged the abuse occurred and no further documentation was for Resident 54's monitoring or assesment for trauma or potential psychosocial needs.
Refer to F600
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 F0760
(Tag F0760)
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 were free from significant medica...
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**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 were free from significant medication errors for 1 of 8 sampled residents (#167) reviewed for medication. This placed residents at risk for adverse side effects of medication and hospitalization. Findings include:
Resident 167 admitted to the facility on [DATE] with diagnoses including diabetes, atrial fibrillation and stroke. Resident 167 discharged on 6/6/22.
The 5/26/22 admission MDS indicated Resident 167 was cognitively intact.
Resident 167's 6/2022 MARs indicated she/he received the following morning medications on 6/5/22:
-Aspirin 81 mg (antiplatelet medication)
-Breo Ellipta Aerosol powder (bronchodilator medication)
-Combivent Respimat aerosol solution (bronchodilator medication)
-Eplerenone 25 mg (antihypertensive medication)
-Lasix 40 mg (diuretic medication)
-lisinopril 10 mg (antihypertensive medication)
-Pacerone 100 mg (antiarrhythmic medication)
-potassium chloride ER 20 mEQ (supplement medication)
-Metformin 1000 mg (antidiabetic medication)
-metoprolol 25 mg (antihypertensive medication)
A 6/6/22 written statement from Staff 11 (Former Staff/RN) indicated the following:
On 6/5/22 while I was working on the Quartz wing approximately 0830 [AM] I accidentally gave [Resident 167] the wrong medication. I had pre-poured [her/his] meds and gave [her/him] [Resident 168's] medication by mistake. [Resident 167] took the meds and then asked me where [her/his] meds were? I immediately double checked and brought [her/his] meds.Staff 11 indicated she should have notified the physician and the DON [Director of Nursing] of the incorrect medication administration.
Resident 168's 6/2022 MARs indicated she/he received the following morning medications (which were given to Resident 167):
-Tricor 48 mg (cholesterol medication)
-Eliquis 5 mg (anticoagulant medication)
-Keppra 750 mg (anticonvulsant medication)
-topiramate 200 mg (anticonvulsant medication)
-amoxicillin 500 mg (antibiotic medication)
-calcium/vitamin d 500/200 mg-unit 2 tabs (supplement)
A 6/6/22 written statement by Staff 14 (Former Staff/LPN) indicated she was informed Resident 167 received a vitamin in error but Resident 167 approached her around 9:00 PM, told her she/he was not given a vitamin and informed Staff 14 she/he had complained of feeling weird all day. Staff 12 (Former staff/CNA) told Staff 14 Resident 167 had received another resident's seizure medication. Staff 14 investigated the situation and discovered Resident 167 was administered Resident 168's medication. Staff 14 notified Staff 13 (Former Staff/LPN) of the situation, Resident 167 was interviewed and stated she/he was given another resident's medications, felt that [she/he] was given psychedelic medications, had reported this throughout the day and felt ignored. The on-call provider was notified and indicated Resident 167's symptoms would be just how she/he explained with these sort of medications. Resident was closely monitored and refused to be transferred to the hospital for evaluation and treatment. Resident 167's heart rate was 41. The written statement indicated the medications given to Resident 167 included: amoxicillin 500 mg; calcium/vitamin d 500/200; Eliquis 5 mg; Keppra 750 mg; topiramate 200 mg and Tricor 48 mg.
A 6/10/22 written statement by Staff 12 (Former Staff/CNA) indicated the following:
-[Staff 11 stated she gave a patient the wrong medication, I asked what it was, she replied well [she/he] won't be having any seizures. Later that night the patient [Resident 167] asked [Staff 14] the nurse to document that [she/he] received the wrong medication. I told [Staff 14] what [Staff 11] had said to me about the patient won't be having any seizures. This all happened 6/5/22.
Interviews with staff revealed the following:
-On 3/9/23 at 10:34 AM Staff 13 (Former Staff/LPN) stated Staff 11 gave Resident 168's medication to Resident 167 on 6/5/22. Staff 13 stated Resident 167 came to the medication cart and reported she/he had hallucinations and was concerned because she/he got the wrong medications. Staff 13 stated she/he and Staff 14 interviewed Resident 167 and the resident saved the medication cup that had Resident 168's name on it. Staff 13 stated she was concerned for the resident because of her/his heart condition and past heart surgery.
-On 3/9/23 at 11:28 AM Staff 14 stated she worked from 6/5/22 6:00 PM until 6/6/22 6:00 AM. Staff 14 stated Staff 11 was going off shift on 6/5/22 at 6:00 PM and told her she accidentally gave someone someone else's vitamin. Staff 14 stated Staff 11 did not go into detail or do an incident report. Staff 14 stated she was passing bedtime medications when Resident 167 approached the medication cart and stated she/he felt light headed and dizzy like she/he was going to pass out all day and she/he had a medication cup with Resident 168's name on it. Staff 14 stated she and Staff 13 investigated the situation and reported the medication error to Resident 167's provider.
-On 3/9/23 at 4:16 PM Staff 11 stated Resident 167 was alert and oriented and told her she/he got the wrong medications on 6/5/22. Staff 11 was asked if she gave Resident 168's medications to Resident 167, she declined to answer. Staff 11 was asked if Resident 167 had a medication cup with Resident 168's name on it in her/his room, she declined to answer. Staff 11 was asked if Resident 167 had any symptoms after reporting she/he received the wrong medications, Staff 11 stated Resident 167 stated she/he felt different so we took vitals and watched [her/him] really close. Staff 11 was asked if the medication error was reported, she stated the resident's spouse knew, two CNAs knew and it was reported to Staff 14 who was the oncoming nurse. Staff 11 was asked what the response was from Staff 14, Staff 11 declined to answer. Staff 11 was asked if she told Staff 12 that Resident 167 would not be having seizures that evening, Staff 11 declined to answer. Staff 11 stated Resident 167 did not complain of hallucinations that day. Resident 168's medications were reviewed with Staff 11, she stated she did not remember what the medications were. Staff 11 stated Staff 15 (Former Staff/DNS) asked her to write a statement and she emailed her statement to Staff 15 the day after it happened on 6/6/22.
On 3/9/23 at 5:16 PM Staff 15 stated she remembered the incident regarding Resident 167. Staff 15 stated Staff 11 casually told the nurse she gave the wrong medication on 6/5/22. Staff 15 stated Resident 167 reported the error to the oncoming nurse. Staff 15 stated she completed the investigation and Staff 11 did not deny giving Resident 167 the wrong medications. Staff 15 stated Staff 11 did not take ownership of the error and instead told a CNA the patient won't have a seizure. Staff 15 stated Staff 11 did not come back in the building after working on 6/5/22 and was let go.
On 3/10/23 at 9:23 AM Staff 1 (Administrator) acknowledged on 6/5/22 Staff 11 gave Resident 168's morning medications to Resident 167 on 6/5/22 and included the following medications: calcium / vitamin d tablet 500-200 mg two tabs, Tricor 48 mg, Eliquis 5 mg, Keppra 750 mg, amoxicillin 500 mg and topiramate 200 mg and acknowledged this increased Resident 167's risk of bleeding.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined the facility failed to store treatment supplies in locked compartments for 1 of 1 treatment cart on 500 hall observed. This placed residents at ris...
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Based on observation and interview it was determined the facility failed to store treatment supplies in locked compartments for 1 of 1 treatment cart on 500 hall observed. This placed residents at risk for accidents. Findings include:
On 3/6/23 at 4:24 PM an unlocked treatment cart was observed on the 500 hall.
Between 3/6/23 at 4:24 PM and 4:40 PM one resident and seven staff were observed to pass near the unlocked treatment cart.
On 3/6/23 at 4:41 PM Staff 30 (LPN) was located at the nurses station and brought to the treatment cart. She confirmed the cart was unlocked and stated the cart should have been locked. Staff 30 confirmed needles, medications and treatment supplies were in the unlocked cart.
On 3/7/23 at 8:24 AM an unlocked treatment cart was observed on the 500 hall.
Between 3/7/23 at 8:24 AM and 8:40 AM six staff and two visitors passed near the unlocked treatment cart.
On 3/7/23 at 8:40 AM the surveyor was not able to find the nurse responsible for the unlocked treatment cart. Staff 33 (CMA) confirmed the treatment cart was unlocked.
On 3/10/23 at 9:55 AM Staff 3 (DNS) acknowledged the treatment carts were reported by Staff 30 as being left unlocked on 3/6/23 and 3/7/23. Staff 3 expected the treatment carts to be locked when staff were not with the cart.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure staff wore and used PPE correctly for 1 of 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure staff wore and used PPE correctly for 1 of 1 COVID unit reviewed for infection control. This placed residents and staff at risk for respiratory illnesses and infections. Findings include:
On 3/8/23 at 8:46 AM Staff 26 (CNA) was observed to retrieve a tray of food from room [ROOM NUMBER]. Staff 26 retrieved a spoon from the medication cart and handed it to Staff 35 (CNA) who was in a COVID isolation room, then answered the call light in room [ROOM NUMBER]. Staff 26 then walked to assist a resident in room [ROOM NUMBER]B who was on aerosol precautions. Staff 26 did not perform any hand hygiene during the observation period. At 9:00 AM Staff 26 stated she should have performed hand hygiene before entering and exiting the room and in between each resident contact.
On 3/9/23 at 8:40 AM Staff 27 (CNA) was observed walking in the COVID unit hallway with a N95 face mask on her chin and goggles on top her head. She stated she was going on break, walked into the staff room to retrieve personal items then proceeded to walk further down the hallway before donning the N95 and goggles while in the COVID unit.
On 3/9/23 at 8:45 AM Staff 24 (LPN) stated Staff 27 should have kept her N95 and goggles on while on the COVID floor and will talk to her when she returns from break about proper PPE use.
On 1/9/23 at 1:59 PM Staff 3 (DNS) stated it was her expectation that staff on all halls, COVID or not, followed correct PPE use and proper hand hygiene.
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 F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to obtain copies and provide assistance to residents who expressed interest in formulating an advance directive for 3 of 7 sa...
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Based on interview and record review it was determined the facility failed to obtain copies and provide assistance to residents who expressed interest in formulating an advance directive for 3 of 7 sampled residents (#s 6, 18, and 32) reviewed for advance directives. This placed residents at risk for not having their healthcare decisions honored. Findings include:
1. Resident 6 was admitted to the facility in 12/2019 with diagnoses including heart disease.
Resident 6's 12/7/22 Annual MDS revealed she/he had a BIMS of 15 (cognitively intact).
A 2/8/23 Interdisciplinary Note revealed advance directive education was provided to Resident 6.
On 3/7/23 at 10:39 AM Staff 3 (DNS) was unable to locate an advance directive for Resident 6.
On 3/7/23 at 1:03 PM Staff 16 (Social Services Director) stated she was not familiar with an advance directive and thought the Physician Orders for Life Sustaining Treatment (POLST) was the same thing. Staff 16 confirmed she did not review advance directives with residents.
On 3/8/23 at 10:33 AM Resident 6 stated she/he would fill out one out (advanced directive) if one was provided.
2. Resident 18 was admitted to the facility in 10/2022 with diagnoses including end stage renal disease and for an infection to her/his dialysis chest catheter.
Resident 18's 1/27/23 Quarterly MDS revealed she/he had a BIMS of 12 (moderate cognitive impairment).
A 10/28/22 care plan revealed Resident 18 had an advance directive in the medical record.
.
A 1/27/23 social services quarterly evaluation for Resident 18 indicated the resident did not have an advance directive.
On 3/7/23 at 9:46 AM Resident 18 stated she/he did not know what an advance directive was but if education was provided, she/he would have filled one out.
On 3/7/23 at 10:39 AM Staff 3 (DNS) was unable to locate an advance directive for Resident 18.
On 3/7/23 at 1:03 PM Staff 16 (Social Services Director) stated she was not familiar with an advance directive and thought the Physician Orders for Life Sustaining Treatment (POLST) was the same thing. Staff 16 confirmed she did not review advance directives with residents.
3. Resident 32 was re-admitted to the facility on 12/2022with diagnoses including seizures.
Resident 32's 2/9/23 Quarterly MDS revealed she/he had a BIMS of 10 (moderate cognitive impairment).
A 2/9/23 Social Services Quarterly Evaluation for Resident 32 indicated the resident had an advanced directive.
On 3/7/23 at 10:39 AM Staff 3 (DNS) was unable to locate an advance directive for Resident 32.
On 3/7/23 at 1:03 PM Staff 16 (Social Services Director) stated she was not familiar with an advance directive and thought the Physician Orders for Life Sustaining Treatment (POLST) was the same thing. Staff 16 confirmed she did not review advance directives with residents.
On 3/7/23 at 2:47 PM Resident 32 stated she/he did not recall receiving any information about an advance directive.
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** 2. On 3/6/23 at 1:53 PM Resident 32's windowsill was observed to have four nails sticking up along the length of the windowsill ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/6/23 at 1:53 PM Resident 32's windowsill was observed to have four nails sticking up along the length of the windowsill and a portion of the wood was detached from the window frame.
On 3/8/23 at 1:41 PM Staff 22 (Maintenance Director) stated he was not aware of the nails and windowsill in disrepair. Staff 22 stated the staff did not report the nails or the windowsill to him nor did he notice the windowsill in disrepair during his monthly rounds.
3. On 3/6/23 at 1:38 PM room [ROOM NUMBER] was observed to have visible gouges along the wall with exposed sheet rock next to the head of the bed.
On 3/8/23 at 1:53 PM Staff 22 (Maintenance Director) acknowledged he was aware of the wall in room [ROOM NUMBER] needing repair however due to the recent change in facility ownership, there was no budget for repairs.
On 3/9/23 at 3:00 PM Staff 2 (Assistant Administrator) stated the facility did not have the budget to make any repairs due to the change in ownership.
Based on observation and interview it was determined the facility failed to provide a homelike environment for 3 of 5 halls (200, 300 and 400 hall) reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include:
1. On 3/6/23 at 4:41 PM the window in room [ROOM NUMBER] was observed to be very dirty and difficult to see through. There was a black substance built-up along the bottom left corner and the base of the window.
On 3/8/23 at 1:45 PM and 3/9/23 at 2:44 PM Staff 22 (Maintenance Director) confirmed the window was very dirty and reported the window had to be replaced because the dirt was on the inside of the glass (double paned window) and could not be washed.
On 3/9/23 at 1:39 PM Staff 2 (Assistant Administrator) was informed of the findings of the investigation. No additional information was provided.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 34 was admitted to the facility in 9/2021 with diagnoses including diabetes and mild cognitive impairment.
A 10/5/21...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 34 was admitted to the facility in 9/2021 with diagnoses including diabetes and mild cognitive impairment.
A 10/5/21 physician order indicated Resident 34 was prescribed TED hose (stockings designed to reduce blood clots in the lower legs) to be applied to both lower legs in the morning for edema. The resident was to wear them 12 hours on and 12 hours off.
Observations from 3/6/23 through 3/9/23 between the hours of 8:30 AM and 5:00 PM revealed Resident 34 was not wearing TED hose and no TED hose were located in the resident's room.
A review of Resident 34's progress notes revealed on 2/4/23, 2/18/23, 3/3/23 and 3/4/23 entries were made by licensed nursing staff indicating the facility had no TED hose available in the resident's size.
The 3/2023 TED hose TAR indicated there were dates left blank, dates marked 9 (see progress notes) and dates marked 2 (refused).
On 3/6/23 at 4:38 PM Resident 34 stated she/he was concerned because she/he was supposed to have TED hose on everyday and TED hose were never put on.
On 3/8/23 at 9:37 AM Staff 7 (CNA) stated Resident 34 was to have TED hose on every day but did not because the facility did not have her/his size for at least the past month.
On 3/8/23 at 10:19 AM Staff 18 (LPN Unit Manager) and surveyor observed boxes of TED hose in the supply room and only small and medium TED hose were found.
On 3/8/23 at 10:24 AM Resident 34 was observed speaking to Staff 18. Resident 34 stated she/he did not have TED hose for at least the past two to three months and there were problems with communication because she/he told several people about the lack of TED hose. Staff 18 stated she expected staff to go to the supply room and get the correct size and if the correct size was not available then staff were to notify Staff 5 (Staffing Coordinator) so she could place an order.
On 3/8/23 at 10:35 AM Staff 5 stated she was unaware there were no TED hose that fit Resident 34 in the supply room but she had large and extra large TED hose in boxes in the basement.
On 3/9/23 at 9:10 AM the supply room was observed to still have only small and medium sized TED hose.
On 3/9/23 at 9:18 AM Staff 7 stated the night CNA put on Resident 34's new TED hose but they were too small and the resident requested they be taken off. Staff 7 stated the resident required extra large TED hose and she was sure there were no extra large TED hose in the supply room. Resident 34 confirmed the TED hose were too small and hurt her/his legs so she/he asked to have them removed.
On 3/9/23 at 10:01 AM Staff 3 (DNS) stated she expected nursing staff to follow physician orders regarding Resident 34's TED hose. She further stated she expected the facility to have the proper size to fit Resident 34 and it was important staff put on the correct size because the wrong size could cause damage.
Based on observation interview and record review it was determined the facility failed to ensure physician orders and bowel protocols were followed for 4 of 16 sampled residents (#s 15, 34 and 166) reviewed for medications, ADLs and respiratory care. This placed residents at risk for adverse health consequences. Findings include:
1. Resident 15 admitted to the facility in 2/2023 with diagnoses including lumbar fracture.
The facility's undated Bowel Protocol indicated after day 3 of no bowel movement to give milk of magnesia (laxative) 30 ml PO or give 10 mg bisacodyl (laxative) PO.
The 2/15/23 admission MDS indicated Resident 15 was cognitively intact.
On 3/6/23 at 3:41 PM Resident 15 stated she/he had not had a bowel movement in a week.
On 3/7/23 at 12:00 PM bowel documentation was reviewed and indicated Resident 15's last bowel movement was on 3/1/23. The electronic health record was reviewed including MARs and progress notes. There was no indication Resident 15 was offered milk of magnesia or bisacodyl. There was no indication the resident had complications due to not having a bowel movement.
On 3/7/23 at 12:41 PM and 1:06 PM Staff 3 (DNS) acknowledged Resident 15's last bowel movement was on 3/1/23 and the resident was not offered bowel medications on 3/5/23 or after per the bowel protocol.
2. Resident 166 admitted to the facility on [DATE] with diagnoses including helicobacter pylori (stomach infection).
The 2/19/22 hospital physician orders indicated Resident 166 was to receive doxycyline (antibiotic medication) BID for seven days for helicobacter pylori.
The 2/2022 MARs indicated Resident 166 did not receive doxycycline on evening shift of 2/19/22 and on day and evening shift of 2/20/22.
Resident 166 was hospitalized on [DATE] at 1:45 AM but there was no indication it was a direct result of not receiving doxycycline.
On 3/9/23 at 8:35 AM Staff 3 (DNS) acknowledged Resident 166 did not receive doxycycline as ordered and missed three doses from 2/19/22 through 2/20/22.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 5 halls (100, 200, 300 and 400) reviewed for staffing. Thi...
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Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 5 halls (100, 200, 300 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include:
On 3/6/23 and 3/10/23 the facility provided lists of residents who:
-Required assistance or were dependent with eating: 31
-Required a mechanical lift with transfers: 16
-Required one or two-person assistance with dressing: 61
-Required one or two-person assistance or dependent with toileting: 58
- Required one or two-person assistance with bathing: 40
-Were fully dependent on staff for bathing: 20
-Wandered: 1
-Received therapy services: 39
On 3/6/23 the facility had 7 residents and in 4/2022 the facility had 6 residents approved for the bariatric rate.
A review of the Direct Care Staff Daily Reports from 2/1/23 through 3/5/23 and 4/1/22 through 4/30/22 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts:
- 4/1/22
- 4/3/22
- 4/9/22
- 4/11/22
- 4/14/22
- 4/15/22
- 4/16/22
- 4/17/22
- 4/19/22
- 4/20/22
- 4/24/22
- 4/25/22
- 4/26/22
- 4/28/22
- 4/29/22
- 4/30/22
- 2/1/23
- 2/4/23
- 2/6/23
- 2/10/23
- 2/14/23
- 2/17/23
- 2/22/23
- 2/28/23
- 3/4/23
Interviews with residents revealed the following concerns:
- On 4/8/22 a concern was reported indicating Resident 4 did not receive a shower due to not having enough staff.
- On 3/6/23 at 4:34 PM Resident 22 stated she/he had to wait up to 45 minutes for assistance from staff.
- On 3/7/23 at 8:55 AM Resident 18 stated there was not enough staff on 3/3/23 and she/he had to wait until 9-9:30 PM to be put into bed. Resident 18 stated she/he did not received a shower for two weeks. Resident 18 also stated therapy was short staffed and she/he only received 15 minutes, which was not enough for her/him to get stronger to discharge.
Interviews with staff revealed the following concerns:
- On 3/7/23 at 8:58 AM Staff 25 (Therapy Manager Assistant) stated they had one physical therapist working between two buildings and there was not enough therapy staff to cover all the residents.
- On 3/7/23 at 12:05 PM Staff 9 (CNA) stated when there was only one CNA for a hall, and residents did not receive showers. Staff 9 stated this occurred once or twice a month.
- On 3/7/23 at 12:58 PM Staff 4 (CNA) and Staff 6 (CNA) stated sometimes residents were not able to be given showers due to being short staffed. Staff 4 stated she marked NA on resident shower records because she was too busy and was unable to provide a shower. Staff 4 stated sometimes residents had to wait until the following day for a shower if they had time.
- On 3/9/23 at 10:44 AM Staff 28 (Therapy) stated she was overwhelmed. Staff 28 stated she saw 20 residents per day for the past three weeks and there was no end in sight. Staff 28 stated she worked with residents for 15 to 25 minutes. Staff 28 stated some residents would have benefited from more time but it was difficult to see everyone and provide quality of care. Staff 28 stated she ran from one resident to another.
On 3/7/23 at 10:19 AM and 3:00 PM Staff 2 (Assistant Administrator) and Staff 5 (Staffing Coordinator) acknowledged the failure to meet the state minimum bariatric CNA staffing ratios for the identified dates and on 3/10/23 at 9:40 AM Staff 1 (Administrator) stated he was aware of staffing issues and acknowledged the issues indicated.
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 F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 7, 8, 9 and 10) reviewed for s...
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Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include:
On 3/7/23 at 2:30 PM Staff 2 (Assistant Administrator) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA).
On 3/7/23 at 2:37 PM Staff 2 provided written documentation indicating the facility did not require performance reviews to be completed. Staff 2 confirmed no performance reviews were completed for the identified CNA staff.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 10 of 33 days reviewed for staffing. This placed residents at...
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Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 10 of 33 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include:
Review of the 2/1/23 through 3/5/23 Direct Care Staff Daily Reports indicated the following days when required information was missing or incorrect on the daily postings:
-2/12/23
-2/13/23
-2/15/23
-2/19/23
-2/20/23
-2/25/23
-2/26/23
-3/1/23
-3/5/23
On 3/10/23 at 8:45 AM Staff 2 (Assistant Administrator) acknowledged the missing and/or inaccurate information for the identified dates.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen refrigerator ...
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Based on observation, interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen refrigerator reviewed for sanitary food storage. This placed residents at risk for exposure to harmful bacteria, reduced nutritive value and stale food products. Findings include:
The facility's Food and Nutrition Services Food Safety policy, dated 7/2018, indicated the following regarding refrigerated foods:
-Food, including leftovers, will be labeled and dated in the refrigerator.
On 3/6/23 at 12:06 PM during the initial tour of the facility's kitchen, the walk-in refrigerator was observed to contain the following improperly stored items and unsanitary conditions:
-One package of turkey-pastrami dated 2/17/23;
-One round, plastic container of egg salad-undated;
-Two apple juice and two orange juice canisters-undated;
-Five large pastry bags of white whipped cream and one large pastry bag of chocolate whipped cream-undated;
-Three Styrofoam bowls of chocolate pudding-undated;
-One Styrofoam bowl of cottage cheese-undated;
-One sandwich wrapped in plastic wrap-undated;
-11 green peppers soft and soggy to the touch.
On 3/6/23 at 12:25 PM Staff 21 (Dietary Manager) confirmed the identified foods were undated and stated all of the food in the refrigerator should be dated and the packaged turkey-pastrami should have been discarded. Staff 21 acknowledged the green peppers were soft and soggy and needed to be thrown away.
Feb 2022
10 deficiencies
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 interview and record review it was determined the facility failed to update care plans related to smoking status and resident preferences for 1 of 5 sampled residents (#29) reviewed for medic...
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Based on interview and record review it was determined the facility failed to update care plans related to smoking status and resident preferences for 1 of 5 sampled residents (#29) reviewed for medications findings include:
Resident 29 was admitted to the facility in 11/2018 with diagnoses including heart failure, depression and anxiety.
The resident's care plan initiated on 6/6/21 indicated a goal of no significant weight loss of 5% in 30 days or 10% in 180 days.
A Comprehensive Plan Solution dated 12/22/21 indicated the resident was very happy with her/his 60-pound weight loss.
On 1/26/22 at 2:15 PM Resident 29 stated her/his goal was to continue to lose weight until she/he reached her/his desired weight.
On 1/31/22 at 11:28 AM Staff 8 (Unit Manager) confirmed Resident 29's care plan did not reflect her/his goal of weight loss.
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 interview and record review it was determined the facility failed to follow orders related to insulin for 1 of 5 sampled residents (#47) reviewed for medications. This placed residents at ris...
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Based on interview and record review it was determined the facility failed to follow orders related to insulin for 1 of 5 sampled residents (#47) reviewed for medications. This placed residents at risk for diabetic complications. Findings include:
Resident 47 admitted to the facility 12/2021 with diagnoses including type 2 diabetes with kidney complication.
A 12/3/21 physician's order indicated the resident was to receive 30 units of Lantus (an insulin injected without regard to food intake that reaches the bloodstream several hours after injection to lower glucose levels for 24 hours) everyday at bedtime. The order did not include any parameters to hold the insulin.
A review of the resident's 12/3/21 through 12/6/21 TAR revealed the following related to Lantus administration:
*12/4 - insulin was held because the resident's CBG was 91 and she/he did not want a snack.
*12/5 - insulin was held because the resident did not want to eat a snack. No CBG was documented.
Between 12/6/21 and 12/17/21 Resident 47 was out of the facility.
A 12/17/21 physician's order indicated Resident 47 was to receive 70 units of Lantus every morning. The order did not include any parameters to hold the insulin.
A review of the resident's 12/17/21 through 12/31/21 TAR revealed the following related to Lantus administration:
*12/17 - insulin held due to a CBG of 104.
*12/19 - insulin held due to a CBG of 139 and the resident did not want a snack.
*12/21 - not administered due to vitals outside of parameters. There was no additional documentation or CBG documented.
*12/29 - no documentation was completed.
*12/31 - not administered due to vitals outside of parameters. There was no additional documentation or CBG documented.
A review of the resident's 1/2022 TAR revealed the following related to Lantus administration:
*1/3/21 - not administered due to vitals outside of parameters. The accompanying documentation indicated the resident's CBG was 92 and Staff 12 (RN) would administer the Lantus at lunch if CBG is higher. There was no documentation in the resident's health record to indicate the CBG was re-checked that day.
*1/15 - not administered due to vitals outside of parameters. The CBG was documented as 94.
1/21 - not administered due to vitals outside of parameters. The CBG was documented as 89.
*1/4, 1/15 and 1/21 - not administered due to vitals outside of parameters however there was no documentation to explain which parameters this referred. There was also no documentation of the resident's CBG level.
*1/5, 1/12, 1/19, 1/24 and 1/25 - no documentation was completed. The dates were left blank.
*1/26 - N/A. There was no documentation related to this entry found in the record.
A review of Resident 47's chart did not reveal any documentation to indicate the provider was notified for any of the 19 days the resident did not receive her/his insulin.
On 2/1/22 at 12:39 PM Staff 3 (DNS) stated she expected staff to administer the insulin as ordered. She confirmed there were no parameters to hold the insulin. Staff 3 stated if staff felt the insulin should be held they were expected to contact the provider. She further stated if the insulin was held there should be documentation in the resident's chart to explain why.
CONCERN
(D)
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 ensure there was a signed agreement and ongoing communication and collaboration with the dialysis provider fo...
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Based on observation, interview and record review it was determined the facility failed to ensure there was a signed agreement and ongoing communication and collaboration with the dialysis provider for 1 of 1 sampled resident (#8) reviewed for dialysis. This placed residents at risk for complications related to dialysis. Findings include:
Resident 8 was admitted to the facility in 10/2021 with diagnoses including end-stage kidney disease.
On 1/24/22 after entering the facility at approximately 11:00 AM, the survey team requested documentation of contracts with dialysis providers.
On 1/24/11 at 2:55 PM Staff 3 (DNS) indicated there was no contract with a dialysis provider and she contacted Staff 1 (Administrator) who was not aware a contract was required. Staff 3 stated she would contact the dialysis center for further information.
According to Resident 8's medical record she/he had a central venous catheter (CVC) dialysis access site (a long intravenous line placed under the skin into a large central vein). Resident 8 received treatments three times weekly at a local dialysis provider on Monday, Wednesday and Friday.
On 1/26/22 at 1:25 PM Resident 8's CVC access site was observed on her/his right upper chest with a dressing that was clean, dry and intact. Resident 8 stated no one should touch the dressing except dialysis staff.
On 1/27/22 at 11:10 AM Resident 8 stated she/he took papers with her/him to dialysis. Resident 8 indicated the papers frequently were not ready when she/he left the facility for dialysis.
On 1/27/22 dialysis pre and post treatment assessments were requested from Administration. At 4:30 PM the following documentation was provided:
*12/8/21 - Facility Dialysis Post Assessment: The assessment identified Resident 8's access site as an AV (arteriovenous dialysis access site) Fistula/Shunt and documented a strong thrill (gentle vibration) and the presence of a sound known as a Bruit (swishing noise) via stethoscope. Resident 8 did not have an AV access site,
*1/17/22 - Facility Dialysis Pre Assessment (complete) and
*1/19/22 - Facility Dialysis Pre Assessment (incomplete, included only Resident 8's vital signs).
On 1/27/22 at 1:45 PM Staff 9 (Unit Manager) stated the resident should have pre & post dialysis paperwork that included vital signs, appearance of the access site, the resident's weight, level of cognition and whether they had anything to eat. Staff 9 indicated the dialysis center did not usually send the information back.
On 1/31/22 additional Pre and Post Assessments from the facility and the dialysis center were provided to surveyors, including:
*Copies of Facility and Dialysis Pre and Post Assessments for 1/26/22, 1/28/22 and 1/31/22 and
*Copies of Dialysis Post Treatment Assessments for: 1/5/22, 1/7/22, 1/10/22, 1/12/22, 1/14/22, 1/17/22, 1/19/22, 1/21/22 and 1/24/22 had a fax header on the top indicated the assessments were faxed to the facility at the same time on 1/28/22.
On 2/1/22 at 11:14 AM Staff 3 and the surveyor discussed the lack of consistent documentation of communication between the facility and the dialysis center. Staff 3 indicated she was not aware of the lack of a contract with the dialysis center.
On 2/2/22 at 11:39 AM Staff 3 emailed the surveyor additional Dialysis Post Treatment Assessments for the following dates: 12/3/21, 12/6/21, 12/8/21, 12/10/21 and 12/13/21. The fax header on the top indicated the assessments were faxed to the facility from the dialysis center on 2/2/22 at 8:31 AM.
The facility failed to ensure a contract was in place with the dialysis provider where Resident 8 received her/his services. Additionally the facility lacked a system to coordinate the exchange of communication between the facility and the dialysis center including maintaining current information in the resident's record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed adequately monitor resident medications for 1 of 5 sampled residents (#107) reviewed for medications. This placed residents a...
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Based on interview and record review it was determined the facility failed adequately monitor resident medications for 1 of 5 sampled residents (#107) reviewed for medications. This placed residents at risk for medication side effects. Findings include:
Resident 107 was admitted to the facility in 2022 with diagnoses including a fall with a fracture.
The resident's medical record revealed she/he received Eliquis (anticoagulant) twice daily for treatment of atrial fibrillation (irregular heartbeat).
Resident 107's 1/2022 Medication Monitors included no signs and symptoms related to the use of an anticoagulant medication for staff administering medications.
On 2/1/22 at 11:44 AM the lack of monitoring related to Resident 107's use of an anticoagulant was reviewed with Staff 3 (DNS) and no additional information was provided.
CONCERN
(D)
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 ensure residents received adequate psychotropic medication monitoring for 1 of 5 sampled residents (#47) reviewed for medi...
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Based on interview and record review it was determined the facility failed to ensure residents received adequate psychotropic medication monitoring for 1 of 5 sampled residents (#47) reviewed for medications. This placed residents at risk for adverse side effects and unnecessary use of medication. Findings include:
Resident 47 admitted to the facility in 12/2021 with diagnoses including major depressive disorder.
A 12/21/21 physician order indicated the resident was to receive 100 mg of Sertraline (an antidepressant) daily.
The 12/28/21 care plan revealed the resident used an antidepressant medication and staff should monitor her/him for side effects and effectiveness every shift.
A review of Resident 47's 12/2021 and 1/2022 Monitors revealed no monitoring related to the antidepressant.
On 2/1/22 at 12:39 PM Staff 3 (DNS) confirmed there was no monitoring in place to monitor for side effects or the effectiveness of the antidepressant.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
On 1/28/22 at 7:58 AM Staff 18 (LPN) documented she administered Resident 52 artificial tears and fluticasone nasal spray, however she was not observed to administer the medications. Resident 52 refus...
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On 1/28/22 at 7:58 AM Staff 18 (LPN) documented she administered Resident 52 artificial tears and fluticasone nasal spray, however she was not observed to administer the medications. Resident 52 refused her/his Miralax and Staff 18 did not update the administration record to indicate the refusal.
On 2/1/22 at 3:25 PM the medication errors were reviewed with Staff 3 (DNS).
Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than five percent. There were 4 errors out of 27 opportunities resulting in a medication administration error rate of 14.81 percent. This placed residents at risk for unsafe medication administration practices. Findings include:
On 1/28/22 at 7:57 AM Staff 24 (CMA) assisted Resident 37 with administration of an oral inhaler. Instructions included with the medication indicated to rinse mouth with water after use, do not swallow. Staff 24 was not observed to assist Resident 37 with rinsing her/his mouth or direct her/him to do so after inhalation of the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to allow residents to have visitors for 5 of 10 sampled residents (#s 1, 23, 25, 26 and 41) reviewed for advance...
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Based on observation, interview and record review it was determined the facility failed to allow residents to have visitors for 5 of 10 sampled residents (#s 1, 23, 25, 26 and 41) reviewed for advance directives, choices and pain. This placed residents at risk for psychosocial decline. Findings include:
A 11/2021 CMS memo allowing all nursing facility residents visitations, QSO-20-39-NH, revealed .during an outbreak investigation, visitors must still be allowed in the facility.
Resident 1 admitted to the facility in 4/2019 with diagnoses including depression.
Resident 23 admitted to the facility in 5/20/21 with diagnoses including anxiety, bipolar disorder, post traumatic stress disorder and depression.
Resident 25 admitted to the facility in 2/2021 with diagnoses including paraplegia and anxiety.
Resident 26 admitted to the facility in 12/2021 with diagnoses including depression.
Resident 41 admitted to the facility in 12/2019 with diagnoses including depression.
Between 1/24/22 and 1/31/22 observations of Resident 1 revealed her/him to frequently sit in the front common room of the facility and stare out the window.
A review of a 1/24/22 Facility Letter sent to residents, representatives and families indicated due to three staff testing positive for Covid-19, visitors were excluded from the building except in certain, very limited circumstances.
On 1/25/22 at 9:47 AM Staff 12 (RN) reported no visitors were allowed inside to see residents due to Covid-19. She stated visitors were not allowed inside for quite some time. Staff 12 reported window visits were allowed.
On 1/25/22 at 10:51 AM Staff 3 (DNS) reported there were new guidelines related to visitation that were just sent out and the facility followed those guidelines. Staff 3 provided the surveyor with the 11/2021 CMS Memo and the 1/24/22 Facility Letter to residents and representatives.
On 1/25/22 at 11:02 AM Witness 1 (Family Member) reported the facility did not allow her to visit Resident 1 aside from through a closed window.
On 1/25/22 at 11:17 AM Resident 25 reported she/he was not able to have visitors since Covid-19 began. The resident stated friends came from out of town to visit on her/his birthday in 12/2021 and they were told they could only visit through the window.
On 1/25/22 at 11:41 AM Resident 23 reported her/his spouse was not allowed to visit inside the facility since the beginning of 2020. The resident reported it was very difficult emotionally.
On 1/26/22 at 12:53 PM Staff 14 (CNA) reported visitors were not allowed in the facility for a long time. She stated visits were provided through the window.
On 1/26/22 at 1:28 PM Staff 15 (CNA) stated she was told by administration that residents could not have visitors inside the facility.
On 1/26/22 at 4:39 PM Resident 41 reported staff told her/him family was not allowed to visit inside the facility and were not allowed since the beginning of 2020. The resident stated it was difficult and she/he felt like a prisoner trapped in her/his room.
On 1/26/22 at 4:46 PM Staff 16 (Screener) reported indoor visits were not allowed.
On 1/27/22 at 9:47 AM Staff 17 (CNA) reported there were no indoor visits for awhile and it was still not allowed. She reported she noticed increased depression in many of the residents over the last year.
On 1/27/22 at 10:04 AM Staff 18 (LPN) reported residents could not have visitors inside; they could only have window visits.
On 1/27/22 at 9:47 AM Resident 26 reported she/he was not allowed to have any indoor visitors. The resident stated she/he was told they could go outside if she/he wanted to visit. Resident 26 reported she/he did not visit outside because it was too cold.
On 1/27/22 at 1:55 PM Staff 20 (CNA) reported she was told visitors were not allowed inside since she began work at the facility (approximately four months).
On 1/28/22 at 9:47 AM Staff 21 (Screener) stated the facility did not allow visits inside. She reported window visits were offered with the windows closed and using phones.
On 1/28/22 at 10:28 AM Staff 22 (CNA) reported residents were able to have window visits with the window closed. She stated most residents did not have a phone to talk with their visitors so staff often loaned their personal cell phones to residents. Staff 22 stated there were no visitors inside the facility for almost two years. She reported she was never made aware residents could have visitors inside.
On 1/31/22 at 2:13 PM Staff 7 (Infection Preventionist) reported he was not aware of the 9/17/20 CMS Memo until recently and confirmed the facility did not offer indoor visits in accordance with the guidance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to provide activities on a routine basis for 1 of 1 sampled resident (#1) reviewed for choices and 1 of 1 facili...
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Based on observation, interview and record review it was determined the facility failed to provide activities on a routine basis for 1 of 1 sampled resident (#1) reviewed for choices and 1 of 1 facility reviewed for activities. This placed residents at risk for boredom and psychosocial decline. Findings include:
Resident 1 admitted to the facility in 4/2019 with diagnoses including depression.
A 9/17/20 Center for Medicare and Medicaid Services Memo indicated communal activities could occur in facilities with the use of masks and social distancing.
From 1/26/22 through 2/1/22 Resident 1 was frequently observed sitting in the front lobby of the facility staring out the window. No facility provided activities were observed.
On 1/27/22 at 9:47 AM Staff 17 (CNA) reported many residents seemed more depressed over the past year. She stated they were not allowed to do the activities they normally enjoyed such as watch football in the den together. Staff 17 stated the activities offered were not good. She reported the units were provided coloring and crossword pages but most of the residents were not able to do them. Staff 17 reported since 3/2020 the facility did not offer much for activities. She said the only group activity they offered was bingo with walkie talkies once in a while. Staff 17 reported Staff 23 (Recreation Assistant) brought coffee to the unit and visited the residents one-to-one sometimes but not a whole lot else.
On 1/27/22 at 4:16 PM Staff 20 (CNA) reported the facility offered bingo over walkie talkies, nail care or one-on-one activities but there were no small group activities.
On 1/28/22 at 10:28 AM Staff 22 (CNA) reported Resident 1 wandered around the facility and stared out the window because she/he was bored. She stated there was nothing for the residents to do. Staff 22 reported Resident 1 was a smoker and the smoking schedule was the only thing she/he looked forward to. She stated the only activity she has observed was the 2:00 PM bingo which did not occur regularly. Staff 22 reported the Activity Calendar was not accurate and most activities on the calendar did not actually occur. She stated she was told by the administration all activities needed to be one-to-one only due to Covid-19. Staff 22 said many residents questioned why they should get up in the morning because there was nothing to do anyway and they were in a routine of staying in their rooms all day.
On 1/28/22 at 11:45 AM Staff 6 (RN) stated the activities listed on the Activity Calendar were not accurate due to Covid-19.
On 1/31/22 the Activity Calendar posted throughout the facility indicated Exercise was scheduled for 1:30 PM.
On 1/31/22 at 1:33 PM Staff 23 (Recreation Assistant) reported she was going to do exercise with one resident in the resident's room. She stated she was not able to provide small group activities and therefore could only do exercise as a one-to-one activity.
On 2/1/22 at 9:44 AM Staff 10 (Activity Director) reported activities were difficult to offer due to restrictions related to Covid-19. She stated the residents could do bingo over walkie talkies, have one-to-one visits and packets with word searches, coloring pages and crafts were provided on the units for residents to have. Staff 10 reported she offered small group activities with distancing and masking for a small amount of time however once there was staff or residents who tested positive for Covid-19 those activities stopped.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure accurate records and documentation related to medications, behaviors and smoking for 4 of 6 sampled residents (#s 6...
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Based on interview and record review it was determined the facility failed to ensure accurate records and documentation related to medications, behaviors and smoking for 4 of 6 sampled residents (#s 6, 24, 47 and 107) reviewed for hospice and medications. This placed residents at risk for inaccurate medical records and inappropriate care. Findings include:
1. Resident 6 admitted to the facility in 3/2020 with diagnoses including stroke.
In 7/2021 the resident admitted to hospice services and her/his daily medications were discontinued, including an anticoagulant (a blood thinner).
A review of Resident 6's Monitors dated 8/2021 through 1/2022 revealed monitoring for adverse reactions to the anticoagulant medication continued to occur twice a day.
On 2/1/22 at 12:34 PM Staff 3 (DNS) confirmed documentation of the anticoagulant monitoring continued for six months after the medication was stopped. She stated she expected the nurses to identify the resident no longer received the anticoagulant and to remove the monitoring.
2. Resident 24 admitted to the facility in 11/2020 with diagnoses including alcohol abuse and nicotine dependence.
A signed smoking contract from 4/2021 revealed the resident was a high risk smoker and required supervision. A more recent smoking contract was not found in the resident's record.
A review of Smoking Screens revealed the following:
*4/29/21 - The resident required supervision with smoking.
*7/8/21 - The resident did not follow the facility's smoking policy and refused to smoke at scheduled times. She/he was found with smoking materials in her/his room multiple times and had a history of unsafe smoking. Resident 24 was unsafe to smoke independently.
*8/16/21 - The resident required supervision with smoking.
The resident's revised 8/29/21 care plan revealed she/he smoked and required supervision with smoking.
On 1/27/22 at 9:56 AM Resident 24 was observed coming up the parking lot of the facility in her/his electric wheelchair smoking a cigarette.
On 1/27/22 at 11:41 AM and again at 1:55 PM Resident 24 was observed sitting on the corner of the street and the entrance to the facility in her/his electric wheelchair smoking cigarettes.
On 1/27/22 at 10:04 AM Staff 12 (LPN) reported the resident was independent with smoking. She stated the resident was not allowed to keep smoking materials in her/his room and staff checked the room each shift. Staff 12 reported Resident 24 obtained her/his cigarettes and lighter from nursing staff and returned them when she/he returned.
On 1/31/22 at 2:08 PM Staff 7 (Infection Preventionist) reported the resident was independent with smoking. He stated the resident was safe to smoke.
On 2/1/22 at 12:36 PM Staff 3 (DNS) reported Resident 24 was never a supervised smoker and the smoking screens were inaccurate. She stated she expected the smoking screens to be done quarterly and they were not completed.
3. Resident 47 admitted to the facility in 6/2020 with diagnoses including cholecystitis (gallbladder inflammation).
A 12/3/21 physician's order indicated the resident had a new cholecystostomy drain (a tube to drain fluids from the gallbladder). The order instructed staff to empty the collection bulb when full and as needed, at least once daily.
A review of the 12/2021 Treatment Administration Record (TAR) did not reveal any instructions related to the cholecystostomy drain.
A review of the 1/2022 TAR revealed an entry for the drain care was put into place on 1/26/22. The instructions indicated staff were to cleanse around the opening, cover with a split gauze every other day and as needed for dislodgement.
A 1/27/22 Progress Note revealed Resident 47 had the drain removed.
According to the TAR, staff documented drain care was done on 1/30/22, three days after the drain was removed.
On 2/1/22 at 9:37 AM Staff 13 (LPN) reported when the resident had the drain, she checked it every shift. She stated there should have been a section on the TAR to document the output and dressing change. Staff 13 stated the resident no longer had the drain, however there was now an area on the TAR to document the drain care. She reported she needed to contact the provider to get an order to discontinue the drain care.
On 2/1/22 at 10:30 AM Resident 47 reported staff took care of her/his drain every day when she/he had it in place. The resident reported she/he no longer had the drain.
On 2/1/22 at 12:39 PM Staff 3 (DNS) reported the resident did have a drain and confirmed the drain care and monitoring was not on the TAR. She stated it was corrected on 1/26/22. Staff 3 was informed the resident had the drain removed on 1/27/22 yet the TAR entry was still in place and staff documented drain care when it was no longer in place. She stated it was unacceptable for staff to document care which could not have been done.
4. Resident 107 was admitted to the facility in 2022 with diagnoses including a fall with a fracture.
According to her/his medical record Resident 107 was prescribed trazodone (antidepressant/sedative) for use as a sleep aid. The resident had no diagnosis of depression or behaviors associated with depression.
The resident's 1/2022 Medication Monitor revealed staff were monitoring Resident 107 for behaviors and documentation of behavioral interventions related to her/his use of an antidepressant.
On 2/1/22 at 11:44 AM Staff 3 (DNS) acknowledged the trazodone was not used to treat depression for Resident 107 and there was no reason to monitor for behaviors or document interventions.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview it was determined the facility failed to ensure 1 of 1 ice machine was plumbed correctly to prevent the backflow of contaminated matter into the ice machine. This pl...
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Based on observation and interview it was determined the facility failed to ensure 1 of 1 ice machine was plumbed correctly to prevent the backflow of contaminated matter into the ice machine. This placed residents at risk for foodborne illness. Findings include:
According to the 2013 FDA Food Code 5-402.11: . a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
During an initial tour of the kitchen on 1/24/22 at 11:43 AM, the facility ice machine was observed to have a drain pipe coming from the back panel that extended along the floor approximately six feet where it entered the wall. The drain pipe was plumbed in a way that did not include an air gap between the end of the pipe and where it drained to prevent the potential backflow of contaminated matter.
On 1/24/22 at 11:45 AM Staff 11 (Dietary Manager) and the surveyor observed the drain pipe from the ice machine and Staff 11 acknowledged the plumbing did not include an air gap as required. Staff 11 stated the ice machine was changed recently and they did not think about checking for the air gap.
On 1/24/22 at 3:23 PM Staff 11 stated she talked with Staff 1 (Administrator) and maintenance and they had a temporary plan ready to put in place. Staff 11 further stated she ordered a supply of ice for use until the ice machine had the proper plumbing.
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $36,852 in fines, Payment denial on record. Review inspection reports carefully.
- • 65 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $36,852 in fines. Higher than 94% of Oregon facilities, suggesting repeated compliance issues.
- • Grade F (33/100). Below average facility with significant concerns.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Highland House Nursing & Rehabilitation Center's CMS Rating?
CMS assigns HIGHLAND HOUSE NURSING & REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Highland House Nursing & Rehabilitation Center Staffed?
CMS rates HIGHLAND HOUSE NURSING & REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 54%, compared to the Oregon average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Highland House Nursing & Rehabilitation Center?
State health inspectors documented 65 deficiencies at HIGHLAND HOUSE NURSING & REHABILITATION CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 64 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Highland House Nursing & Rehabilitation Center?
HIGHLAND HOUSE NURSING & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VOLARE HEALTH, a chain that manages multiple nursing homes. With 119 certified beds and approximately 87 residents (about 73% occupancy), it is a mid-sized facility located in GRANTS PASS, Oregon.
How Does Highland House Nursing & Rehabilitation Center Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, HIGHLAND HOUSE NURSING & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Highland House Nursing & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Highland House Nursing & Rehabilitation Center Safe?
Based on CMS inspection data, HIGHLAND HOUSE NURSING & REHABILITATION CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Oregon. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Highland House Nursing & Rehabilitation Center Stick Around?
HIGHLAND HOUSE NURSING & REHABILITATION CENTER has a staff turnover rate of 54%, which is 8 percentage points above the Oregon average of 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 Highland House Nursing & Rehabilitation Center Ever Fined?
HIGHLAND HOUSE NURSING & REHABILITATION CENTER has been fined $36,852 across 1 penalty action. The Oregon average is $33,447. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Highland House Nursing & Rehabilitation Center on Any Federal Watch List?
HIGHLAND HOUSE NURSING & REHABILITATION 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.