REGENCY HERMISTON NURSING & REHAB CENTER
For profit - Corporation
105 Beds
REGENCY PACIFIC MANAGEMENT
Data: November 2025
Trust Grade
40/100
#67 of 127 in OR
Photo by Regency Hermiston
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Regency Hermiston Nursing & Rehab Center has received a Trust Grade of D, indicating below-average performance with some significant concerns. It ranks #67 out of 127 facilities in Oregon, placing it in the bottom half, but it is #2 of 3 in Umatilla County, meaning there is only one local option that is better. The facility is worsening in quality, having increased from 1 issue in 2024 to 8 in 2025, which raises alarms about care standards. Staffing is rated at 4 out of 5 stars, with a turnover rate of 45%, which is slightly better than the state average, suggesting that staff members tend to stay longer and have familiarity with the residents. However, the facility has incurred $59,777 in fines, which is concerning and indicates repeated compliance problems; this is higher than 80% of other Oregon facilities. While the nursing home has average RN coverage, there have been serious incidents, such as a resident who required a mechanical lift for transfers being placed at risk when the lift malfunctioned, resulting in staff needing to catch the resident to prevent a fall. Additionally, another resident experienced physical abuse, which the facility failed to adequately protect against, leading to pain and fear for that resident. There are also concerns regarding food safety and cleanliness, with staff not adhering to proper food handling protocols. Overall, while there are some strengths in staffing, the weaknesses in care quality and safety raise important questions for families considering this facility.
- Trust Score
- D
- In Oregon
- #67/127
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 45% turnover. Near Oregon's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $59,777 in fines. Higher than 79% of Oregon facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Oregon. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 48%
Review needed
1 → 8 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below Oregon average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Oregon average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 45%
Near Oregon avg (46%)
Typical for the industry
Federal Fines: $59,777
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: REGENCY PACIFIC MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
2 actual harm
Apr 2025
8 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual and physical abuse by other residents for 4 of 5 sampled...
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Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual and physical abuse by other residents for 4 of 5 sampled residents (#s 12, 29, 128 and 279) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include:
Review of the facility's revised 10/2022 Abuse/Neglect/Misappropriation/Exploitation Policy and Procedures revealed the purpose of the policy was to define how the facility will prevent, identify, report and investigate abuse. Sexual abuse was defined as any form of non-consensual contact including unwanted or inappropriate touching. The facility must evaluate whether the resident has the capacity to consent to sexual activity. Physical abuse included hitting, slapping, pinching, striking with an object and shoving.
1. Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance.
Resident 12's 7/6/24 Quarterly MDS revealed, Resident 12 had a BIMS score of 3, which indicated the resident had severe cognitive impairment.
Resident 22 admitted to the facility in 2019 with diagnoses including schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), sexual disorders and depression.
Resident 22's 9/15/24 Quarterly MDS revealed, Resident 22 had a BIMS score of 4, which indicated the resident had severe cognitive impairment.
A 9/19/24 at 1:00 PM Alleged Abuse incident report written by Staff 2 (DNS) revealed Staff 19 (CNA) observed Resident 22 in Resident 12's room. Resident 22 sat in her/his wheelchair at Resident 12's bed side. Staff 19 saw Resident 22's hands on Resident 12's breasts and over her/his clothing. The residents were immediately separated and neither recalled the incident minutes later.
A 9/19/24 at 1:34 PM Progress note revealed Staff 4 (Resident Care Manager/LPN) spoke with Resident 12 related to Resident 22's physical contact with her/him and she/he could not recall anyone coming into her/his room.
On 4/7/25 at 11:55 AM Resident 12 was observed in her/his room in bed coloring. Resident 12 was able to state some needs, but she/he was not able to recall ever being abused or touched by another resident.
On 4/7/25 at 6:49 PM Staff 19 stated when staff walked down the facility hallways, they always looked into resident's room to ensure residents were safe. Staff 19 stated she recalled when she walked past and looked into Resident 12's room she observed Resident 12 in bed while Resident 22 sat in her/his wheelchair at the head of Resident 12's bed. Resident 22's hands were grabbing and touching all over Resident 12's breasts. Staff 19 removed Resident 22 from Resident 12's room and told management staff.
On 4/9/25 at 11:15 AM Staff 4 confirmed she wrote the 9/19/24 at 1:34 PM progress note and she interviewed Resident 12 after the incident. Staff 4 stated Resident 12 was on alert charting, did not recall the physical abuse and did not experience any changes in behavior after the incident.
On 4/9/25 at 11:27 AM Staff 2 confirmed she wrote the 9/19/24 at 1:00 PM Alleged Abuse incident report for Resident 12 and Resident 22. Staff 2 confirmed Staff 19 reported she witnessed Resident 22 with her/his hands on Resident 12's breast and the facility investigation confirmed abuse. Staff 2 acknowledged both residents were assessed as severely cognitively impaired, both were often confused and neither resident recalled the incident after it occurred.
2. Resident 29 was admitted to the facility in 3/2022 with diagnoses including personality disorder (long-term pattern of thoughts, feelings, and behaviors that are unhealthy) and anxiety.
Resident 29's 8/29/23 Annual MDS revealed she/he had moderate cognitive impairment and was able to understand others.
Resident 128 was admitted to the facility in 6/2024 with diagnoses including dementia and anxiety.
Resident 128's 6/9/24 admission MDS revealed she/he had moderate cognitive impairment.
The facility's incident investigation completed on 11/29/24 by Staff 18 (Former Administrator in Training) indicated Resident 128 struck Resident 29 twice as the resident moved past her/him. Resident 29 grabbed Resident 128's right forearm with both hands, shook her/him and stated, Don't hit me. Staff intervened and separated the residents. Staff 17 (CNA) witnessed Resident 29 and Resident 128 strike each other and assisted in separating them.
On 4/10/25 at 8:25 AM Staff 17 stated both residents had a history of hitting other residents.
On 4/10/25 at 8:55 AM Resident 29 stated she/he did not remember the incident.
On 4/11/25 at 11:04 AM Staff 2 (DNS) acknowledged the physical interaction between Resident 29 and Resident 128. Staff 2 stated both residents were monitored and kept at a distance to prevent this type of incident from occurring.
3. Resident 279 was admitted to the facility in 8/2019 with diagnoses including heart attack and a fracture of the left tibia (broken shin).
Resident 279's 8/29/23 Annual MDS revealed she/he had moderate cognitive impairment, had adequate hearing and was able to understand others.
Resident 29 was admitted to the facility 3/2022 with diagnoses including type 2 diabetes mellitus and heart disease.
Resident 29's 7/7/23 Quarterly MDS revealed she/he had moderate cognitive impairment, had adequate hearing and was able to understand others.
The facility's incident investigation completed on 10/5/23 by Staff 1 (Administrator) indicated Resident 279 entered Resident 29's room on 10/5/23 and did not leave when Resident 29 asked her/him to leave. Staff 16 (LPN) witnessed Resident 29 hit Resident 279's arm and then separated the residents.
On 4/9/25 at 9:16 AM Resident 29 stated she/he did not remember the reported incident but stated facility staff placed a stop sign across her/his door to discourage other residents from coming in.
On 4/10/25 at 8:10 AM and 4/17/25 at 12:14 PM Staff 16 stated he heard Resident 29 yelling in her/his room on 10/5/23. Staff 16 stated he went to Resident 29's room to investigate and observed Resident 29 hit Resident 279's arm.
On 4/10/25 at 9:43 AM Staff 2 (DNS) stated she considered abuse to include willful hitting or physical contact between residents. Staff 2 confirmed the incident occurred on 10/5/23, revealing Resident 29 hit Resident 279 because Resident 29 did not want Resident 279 in her/his room. Staff 2 stated Resident 29 should not have hit Resident 279 and emphasized it was the facility's responsibility to protect residents from abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to develop comprehensive care plans for 1 of 1 sampled resident (#40) reviewed for vision. This placed resident...
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Based on observation, interview, and record review it was determined the facility failed to develop comprehensive care plans for 1 of 1 sampled resident (#40) reviewed for vision. This placed resident at risk for lack of visual care needs. Findings include:
Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance.
Resident 12's 1/6/25 Quarterly MDS revealed the resident had vision impairment and her/his BIMS score was 5 which indicated a severe cognitive impairment. The resident's required substantial/maximal assistance with a helper completing more than half of the effort.
On 4/7/25 at 11:55 AM Resident 12 was observed without eyeglasses, in bed coloring. Resident 12 stated she/he was worried about her/his eyeglasses and said they were missing. The surveyor looked around on Resident 12's bed and bedside table and no eyeglasses were visible.
Resident 12 was observed to not have worn eyeglasses on the following dates and times:
-4/7/25 at 10:28 AM and 11:55 AM;
-4/8/25 at 8:08 AM, 9:26 AM, 12:39 PM and 2:23 PM;
-4/9/25 at 7:41 AM.
Record review of Resident 12's care plan revealed no indication she/he wore eyeglasses or that staff were to assist her/him with eyeglasses.
On 4/9/25 at 8:52 AM Staff 9 (CNA) stated they obtained information to care for Resident 12 from her/his care plan. Staff 9 stated they were not sure if Resident 12 had prescription eyeglasses but the resident did wear eyeglasses when she/he colored.
On 4/9/25 at 8:58 AM Staff 20 (CNA) stated they obtained information to care for Resident 12 from the care plan. Staff 20 stated Resident 12 wore eyeglasses to see better especially when she/he colored and did puzzles.
On 4/9/25 at 11:15 AM Staff 4 (Resident Care Manager/LPN) stated she was aware Resident 12 wore eyeglasses sometimes. Staff 4 confirmed Resident 12 required staff assistance to complete many ADLs, staff needed to assist the resident with her/his eyeglasses and often needed assistance to find the eyeglasses to wear. Staff 4 confirmed the care plan did not include information about eyeglasses.
On 4/9/25 at 11:27 AM Staff 2 (DNS) stated she expected Resident 12's care plan to include direction for staff to assist her/him with eyeglasses as needed or requested by the resident.
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
2. Resident 40 admitted to the facility in 2022 with diagnoses including Type 2 Diabetes (body's trouble with blood sugars) and vascular disease (body's circulatory system).
Resident 40's 2/26/25 Quar...
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2. Resident 40 admitted to the facility in 2022 with diagnoses including Type 2 Diabetes (body's trouble with blood sugars) and vascular disease (body's circulatory system).
Resident 40's 2/26/25 Quarterly MDS revealed Resident 40 had a BIMS score of 10 which indicated moderate cognitive impairment. The resident was dependent on staff to complete personal hygiene
Review of Resident 40's health care record revealed the following:
-From 3/12/25 through 4/8/25 indicated the resident received assistance from staff with personal hygiene daily.
-From 3/13/25 through 4/9/25 no evidence was found indicating whether the resident was offered or refused assistance to trim chin hair.
On 4/8/25 at 9:23 AM Resident 12 used her/his left hand, rubbed her/his chin, pulled the hairs together into a point and stated she/he wanted the chin hairs cut.
Resident 12 was observed with long chin hairs, about two inches long, on the following dates and times:
-4/8/25 at 9:23 AM and 2:20 PM;
-4/9/25 at 7:45 AM and 5:12 PM.
On 4/10/25 at 4:13 PM Staff 10 (CNA) acknowledged Resident 40 required assistance with her/his ADLs. Staff 10 stated they were aware of Resident 40's long chin hairs and the resident asked several times in the past to get them cut.
On 4/10/25 at 4:16 PM Staff 4 (Resident Care Manager/LPN) stated she was aware of Resident 12's long chin hairs. She expected staff to offer Resident 12 to shave her/his chin hairs PRN, at least two times a week during bathing and if she/he refused it should be documented as refused in her/his medical record.
Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 4 sampled residents (#s 11 and 40) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include:
1. Resident 11 admitted to the facility in 12/2024 with diagnoses including weakness and kidney disease.
A 4/4/25 quarterly MDS revealed Resident 11 had a BIMS score of three which indicated severe cognitive impairment and was dependent on staff for grooming.
A review of Resident 11's 3/13/25 through 4/10/25 health record revealed CNA staff documented grooming was completed daily, a shower was provided six times, and the resident refused a shower two times.
Random observations from 4/7/25 through 4/11/25 revealed Resident 11 had long white hairs hanging approximately two inches from her/his chin in multiple locations.
On 4/10/25 at 2:42 PM, Staff 28 (CNA) stated she was not sure if Resident 11 had long chin hairs. She stated grooming for residents occurred at least twice a day and included shaving. She stated shaving was offered to residents during showers but was not sure if Resident 11 was offered during her/his showers.
On 4/10/25 at 2:50 PM, Staff 4 (Resident Care Manager/LPN) stated she did not know Resident 11 had long chin hairs and acknowledged it was not proper ADL care. She stated the expectation was for residents to be offered shaving twice daily, with showers, and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to follow physician orders for skin assessments and monitoring for 2 of 2 residents (#s 27 and 40) reviewed for ...
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Based on observation, interview and record review it was determined the facility failed to follow physician orders for skin assessments and monitoring for 2 of 2 residents (#s 27 and 40) reviewed for non-pressure skin conditions. This placed residents at risk for delayed treatment and skin breakdown. Findings include:
The facility's revised 4/2018 Skin at Risk Program Overview Policy indicated the Skin at Risk Program was based on the nursing process and included identification of residents at risk for skin breakdown, care plan developed to prevent skin breakdown, implementation of care plan interventions, to evaluate and monitor interventions for skin.
1. Resident 27 admitted to the facility in 2019 with diagnoses chronic pain and depression.
Resident 27's physician order, start date on 10/21/23, directed staff to check her/his skin and indicate if a new condition was present. If a new condition was present staff were to document a progress note and initiate a skin documentation form.
Resident 27's 2/25/25 Quarterly MDS revealed the resident had a BIMS score of 11 which indicated a moderate cognitive impairment.
On 4/7/25 at 11:13 AM Resident 27 was observed with a bruise about the size of a quarter on her/his right upper forearm. Resident 27 stated she/he did not know where the bruise came from.
Resident 27 was observed with the bruise on her/his right upper forearm on the following dates and times:
-4/8/25 at 3:28 PM;
-4/9/25 at 7:41 AM, 4:00 PM, 5:18 PM;
-4/10/25 at 9:50 AM and 12:15 PM.
Review of Resident 27's health record reveal no indication an assessment, monitoring or progress note were completed for any bruise.
On 4/10/25 at 4:26 PM Staff 4 (Resident Care Manager/LPN) confirmed Resident 27 had a bruise to her/his right upper forearm. Staff 4 confirmed Resident 27's health record had no information regarding the bruise and she expected staff to provide appropriate documentation when a new skin condition occurred.
On 4/11/25 at 11:39 AM Staff 2 (DNS) acknowledged Resident 27's bruise was not assessed, monitored or documented. She stated she expected staff to assess, monitor and document any new skin condition.
2. Resident 40 admitted to the facility in 2022 with diagnoses including Type 2 Diabetes (body's trouble with blood sugars) and vascular disease (body's circulatory system).
Resident 40's physician order, start date on 10/19/23, directed staff to check her/his skin and indicate if a new condition was present. If a new condition was present staff were to document a progress note and initiate a skin documentation form.
Resident 40's 2/26/25 Quarterly MDS revealed the resident had a BIMS score of 10 which indicated moderate cognitive impairment.
On 4/8/25 at 9:58 AM Resident 40 was observed in bed with her/his feet sticking out from under the sheet. Resident 40's left foot was discolored with hues of blue and green and the ankle towards the calf was covered in a white mesh wrap with scabs visible under it.
A review of Resident 40's health record revealed no indication an assessment, monitoring or progress note were completed for her/his left foot scabbing and discoloration.
On 4/10/25 at 4:16 PM Staff 4 (Resident Care Manager/LPN) stated Resident 40 had scabs on her/his left foot from scratching her/himself and the discoloration of the foot was from an infection. Resident 4 acknowledged she was not able to find any documentation for Resident 40's left foot.
On 4/11/25 at 11:29 AM Staff 2 (DNS) stated she expected Resident 40's left foot to be assessed, monitored and documented. Staff 2 was unable to provide any additional information.
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 accurate communication occurred between the facility and the dialysis provider, ensure the residents c...
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Based on observation, interview and record review it was determined the facility failed to ensure accurate communication occurred between the facility and the dialysis provider, ensure the residents care plan and physician orders were followed for fluid restriction for 1 of 1 sampled resident (#69) reviewed for dialysis. This paced residents at risk for lack of communication with the dialysis center and fluid overload. Findings include:
Resident 69 admitted to the facility in 3/2025 with diagnoses including heart failure and ESRD (end stage kidney disease).
The facility's Dialysis Policy revised on 3/2024 indicated the following:
-Licensed nurses were to complete the Pre and Post-dialysis assessments with each dialysis visit.
-The licensed nurse are to ensure the Dialysis Communication form were completed and special instructions/orders were implemented.
a. A 3/3/25 physician order indicated staff were to follow the dialysis flow sheet protocol every day shift every Tuesday, Thursday and Saturday.
A review of the Dialysis Communication form revealed the following:
The 3/4/25, 3/25/25, and 4/1/25 revealed:
The post dialysis section had no documentation related to vitals, dialysis cite assessment and condition, pertinent information, nurse signature and date or time.
The 3/8/25, 3/11/25, 3/13/25, 4/5/25 and 4/8/25 Dialysis Communication forms did not include the following:
The post dialysis section had no documentation related to vitals, dialysis cite assessment and condition, pertinent information, no nurse signature and date or time.
No documentation was found in the resident's clinical record to indicate staff completed the Dialysis Communication forms or notified the dialysis center.
On 4/9/25 at 9:49 AM Witness 1 (Dialysis RN) stated the facility was required to complete the Pre-dialysis section prior to sending Resident 69 to dialysis; however, there had been instances when the facility did not send the form or the form was sent incomplete. Witness 1 stated it was important the forms were complete because the information was used to determine the type of care the resident received during dialysis treatment.
On 4/9/25 at 11:27 AM Staff 23 (LPN) stated nurses were expected to fill the Pre and Post Dialysis Communication form before and after Resident 69 went to dialysis and staff were to ensure the Dialysis Center Report was completed by the dialysis center. Staff 23 further stated it was the nurse's responsibility to ensure the forms were complete.
On 4/9/25 at 11:53 PM Staff 22 (Resident Care Manager/LPN) stated nurses were expected to complete the Dialysis Communication forms and send with the resident to dialysis. Staff 22 stated staff were expected to ensure the Post Dialysis Assessment forms were completed after the resident returned from dialysis. Staff 22 reviewed the residents Dialysis Communication forms dated 3/4/25, 3/8/25, 3/11/25, 3/13/25, 3/25/25, 4/1/25, 4/5/25 and 4/8/25 and confirmed they were incomplete and was an ongoing problem.
On 4/10/25 at 11:46 AM Staff 2 (DNS) and Staff 3 (Assistant DNS) confirmed nurses were expected to complete the Dialysis Communication forms and send with the resident to dialysis. Staff were expected to ensure the Post Dialysis Assessment forms were completed after the resident returned from dialysis. Staff 2 reviewed the residents Dialysis Communication forms dated 3/4/25, 3/8/25, 3/11/25, 3/13/25, 3/25/25, 4/1/25, 4/5/25 and 4/8/25 and confirmed they were incomplete. Staff 2 further stated the facility had not provided staff training related to dialysis.
b. The 3/3/25 care plan indicated Resident 69 had acute edema (swelling caused by excess fluid trapped in the body's tissue) to her/his lower extremities. Staff to monitor and report any issues related to fluid overload to the nurse and physician. Staff not to leave a pitcher of water at Resident 69's bedside.
The 3/4/25, 3/6/25 and 3/27/25 Dialysis Communication form instructed staff to limit Resident 69's fluid to 16 ounces a day.
A 3/27/25 physician order indicated Resident 69 required a 1000 ml fluid restriction. The order instructed kitchen staff to provide 700 ml. The nursing staff was to provide 120 ml during the morning, evening shift and night shift was to provide 60 ml. The order instructed staff to notify the Resident Care Manager, DNS and provider each shift when the resident did not adhere to the ordered fluid restriction.
The 3/29/25 Dialysis Communication form indicated Resident 69 required 1000 ml fluid restriction.
The 3/2025 LNAR (Licensed Nurse Administration Record) related to fluid intake revealed Resident 69 consumed the following:
Morning shift
3/31/25 950 ml
Evening shift
3/29/25 480 ml
3/30/25 460 ml
3/31/25 240 ml
Night shift
3/29/25 480 ml
3/31/25 1200 ml total
No documentation was found in the resident's clinical record to indicate staff notified the Resident Care Manager, DNS or provider related to the resident not adhering to fluid restrictions. There was no evidence found to indicate an assessment was completed or staff were monitoring Resident 69's fluid overload.
A 4/1/25 nursing note created by Staff 22 (Resident Care Manager/LPN) indicated Resident 69 required a additional dialysis appointment due to fluid overload.
A 4/1/25 nursing note indicated staff posted a sign in Resident 69's room related to appropriate fluids for a renal diet.
The 4/2025 LNAR fluid intake revealed Resident 69 consumed the following:
Morning shift
4/1/25 360 ml
4/2/25 960 ml
4/3/25 480 ml
4/4/25 480 ml
4/5/25 240 ml
4/6/25 240 ml
4/7/25 240 ml
4/8/25 240 ml
Evening shift
4/1/25 240 ml
4/4/25 640 ml
4/5/25 480 ml
4/6/25 180 ml
4/7/25 460 ml
Night shift
4/1/25 120 ml
4/2/25 120 ml
4/3/25 120 ml
On 4/7/25 at 10:27 AM Resident 69 was observed in her/his room. The resident stated she/he attended dialysis three days a week but sometimes went more often due to fluid overload. Resident 69 stated she/he was on 1000 ml fluid restrictions. Multiple beverages were observed on the resident's bedside table, including a 600 ml cup of ice water. The resident stated she/he always kept a pitcher of ice water at her/his bedside and after the ice melted, would ask staff to refill it. No sign was posted in the resident's room to indicate she/he was on a fluid restriction.
A 4/8/25 nursing note indicated Resident 69 returned from dialysis and needed to return to dialysis the following day due to fluid overload.
A 4/9/25 physician order instructed staff to apply compression socks in the AM and remove them in the PM related to ESRD.
On 4/8/25 at 9:05 AM Staff 24 (CNA) stated the resident went to dialysis three days a week but was unsure if the resident was on a fluid restriction. Staff 24 stated she would bring the resident water whenever she/he requested.
On 4/8/25 at 2:33 PM Staff 25 (Lead CNA) stated Resident 69 attended dialysis three days per week and when she/he returned from dialysis she provided her/him 240 ml of fluid and an additional 240 ml at dinner. Staff 25 stated she did not monitor the resident legs for swelling and did not know if she/he was supposed to wear compression stockings (socks that apply gentle pressure to legs and ankles to help reduce swelling). Staff 25 stated she believed the resident was on an 1800 ml fluid restriction.
On 4/8/25 at 4:30 PM Staff 26 (CNA) stated Resident 69 attended dialysis three days a week. Staff 26 stated she was not aware if the resident was on fluid restrictions or the specific amount of fluids the resident was permitted to consumed during the shift. Staff 26 stated if the resident requested fluids during her shift, she would provide fluids to the resident and document the amount consumed.
On 4/8/25 at 4:28 PM Resident 69 stated she/he attended dialysis in the morning and had to have 2.7 liters of fluid removed. The resident further reported she/he was scheduled to return to dialysis the following day due to fluid overload. Resident 69 stated she/he did not have compressions socks on to help with the swelling. Resident 69 further stated she/he had a significant amount of fluid removed over the past few days. The following fluids were observed on the resident's bedside table:
-one almost empty 120 ml cup of water
-120 ml cup of fluid;
-120 ml cup of fluid approximately half drank and;
-600 ml cup of ice water with approximately 500 ml remaining.
On 4/9/25 at 8:18 AM Resident 69 stated she/he had a shower but staff did not put on her/his sock or shoes. The resident's feet were observed to be red and swollen. The resident stated she/he did not have any socks in her/his room. Resident 69's breakfast tray had the following fluids:
-600 ml pitcher of water;
-120 ml apple juice;
-Two 120 ml cups of water and;
-8 oz of silk (soy) milk.
On 4/9/25 at 11:27 AM Staff 23 (LPN) stated Resident 69 received dialysis three days a week. The resident was on 1000 ml fluid restriction, and staff were instructed not to leave a water pitcher on her/his bedside table. Staff 23 observed a 600 ml water cup on the resident's bedside table and noted there was no sign in the resident's room regarding her/his fluid restriction. Staff 23 acknowledged the picture of water on Resident 69's bedside table.
On 4/9/25 at 11:53 PM Staff 22 (Resident Care Manager/LPN) indicated Resident 69 developed edema. Staff 22 stated nurses were expected to assess and monitor the resident's edema, but was unable to provide documentation indicating the resident was assessed or monitored. Staff 22 confirmed the resident's care plan indicated staff were not to leave water at the resident's bedside and acknowledged staff did not follow the care plan. Staff 22 reviewed the resident physician orders which instructed staff to notify the physician, DNS and Resident Care Manager per shift if the resident did not adhere to fluid restrictions.
The following fluids were observed on the resident's bedside table:
-800 ml cup ice water
-120 ml cup of juice
On 4/10/25 at 11:46 AM Staff 2 (DNS) reviewed the resident's physician orders and confirmed staff were not notifying the physician when the resident did not adhere to fluid restrictions. Staff 2 confirmed staff were not following fluid restrictions and did not monitor the resident's edema.
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 observation, interview and record review it was determined the facility failed to maintain a medication administration error rate of less than five percent. There were 4 errors in 29 opportun...
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Based on observation, interview and record review it was determined the facility failed to maintain a medication administration error rate of less than five percent. There were 4 errors in 29 opportunities resulting in a 13.79 percent error rate. This placed residents at risk for adverse medication side effects. Findings include:
1. Resident 3 admitted to the facility in 11/2019 with diagnoses including seizures and multiple sclerosis.
A 2/22/2025 quarterly MDS revealed Resident 3 had a BIMS score of three which indicated the resident had severe cognitive impairment.
Resident 3's 2/2025 provider orders indicated Metoprolol Tartrate 25mg (a blood pressure medication) was to be given as 12.5mg twice daily with instructions to hold the medication for systolic blood pressure (top number in a blood pressure reading) below 110. Resident 3's provider orders indicated potassium chloride extended release 20meq (a supplement) was to be given one time a day with instructions to swallow whole, do not crush or chew, and do not allow to dissolve in the mouth.
During an observation of medication administration for the 200-hall on 4/9/25 at 8:30 AM, Staff 11 (CMA) administered Metoprolol 12.5mg to Resident 3 after their blood pressure was recorded as 102/61. Staff 11 placed a potassium chloride 20meq tablet in a cup and poured a small amount of water on the pill which caused it to dissolve prior to administering it to Resident 3.
A 4/9/25 review of Resident 3's health record revealed no indication the potassium chloride was ordered to be dissolved in water prior to administration.
On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated the expectation for administering blood pressure medications was for staff to take the blood pressure reading prior to administration and not administer the medication if the reading was outside the ordered parameters. She stated Resident 3's potassium chloride order did not indicate the pill was to be dissolved prior to administration.
On 4/11/25 at 9:37 AM, Staff 22 (LPN Registered Care Manager) stated dissolving potassium chloride in water prior to administration was not the correct method and Resident 3's order for potassium chloride had no indication for it to be dissolved prior to administration.
2. Resident 16 admitted to the facility in 4/2023 with diagnoses including diabetes and difficulty breathing.
A 1/31/2025 quarterly MDS revealed Resident 16 had a BIMS score of 15 which indicated the resident was cognitively intact.
During an observation of medication administration for the 500-hall on 4/9/25 at 9:08 AM, Staff 17 (CMA) noticed a small round brown pill on Resident 16's bedside table while administering medications and discarded it in the resident's trashcan. She stated she did not know what pill it was or when it was given to the resident.
On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated the expectation for unidentified medications found in resident's rooms was for staff to bring the medication to a nurse or management for identification and destruction in the drug buster (liquid in a jug used to dissolve medications).
On 4/11/25 at 9:37 AM, Staff 22 (LPN Resident Care Manager) stated the expectation for unidentified medications found in resident's rooms was for staff to bring her the pill for identification and destruction.
3. Resident 30 admitted to the facility in 12/2024 with diagnoses including right leg fracture and diabetes.
A 4/2/2025 comprehensive MDS revealed Resident 30 had a BIMS score of 14 which indicated the resident was cognitively intact.
During an observation of medication administration for the 400-hall with Staff 30 (LPN) on 4/9/25 at 5:35 PM, a tube of Orajel (gel medication for tooth pain) was observed on Resident 30's bedside table.
A 4/9/25 review of Resident 30's health record revealed no provider order for Orajel, and no self-administration assessment for Orajel.
On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated she was not aware of the Orajel in Resident 30's room. She stated the expectation for an over-the-counter medication at a resident's bedside was for an order to be placed and a self-administration assessment to be completed prior to the resident having the medication at their bedside.
On 4/11/25 at 9:37 AM, Staff 22 (LPN Resident Care Manager) stated she was not aware Resident 30 had Orajel at their bedside. She stated an over-the-counter medication at a resident's bedside required a provider's order and a self-administration assessment prior to the resident having the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to ensure resident medications were not expired for 2 of 2 medication storage rooms and 2 of 3 medication carts ...
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Based on observation, interview and record review it was determined the facility failed to ensure resident medications were not expired for 2 of 2 medication storage rooms and 2 of 3 medication carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include:
The facility Medication Storage In The Facility policy, revised July 2021, indicated expiration dates on all medications were to be checked prior to administration, no expired medications were to be administered, and all expired medications were to be removed from the active supply and destroyed in the facility.
During an observation of the 400-hall medication cart on 4/8/25 at 3:52 PM, the following were found:
- One bottle of Geri Dryl 25mg tablets with an expiration date of 9/2024.
- One bottle of ASA 81mg tablets with an expiration date of 8/2024.
- One bottle of calcium 500mg + D 500mg tablets with an expiration date of 12/2024.
- One bottle of melatonin 1mg tablets with an expiration date of 3/2025.
- One bottle of acid reducer 10mg tablets with an expiration date of 3/2025.
- One bottle of calcium 600mg +D3 10mcg tablets with an expiration date of 2/2025.
- One bottle of Rena Vite tablets with an expiration date of 12/2023.
- One bottle of ocular vitamin tablets with an expiration date of 1/2025.
- One bottle of zinc 50mg tablets with an expiration date of 3/2025.
- One bottle of calcium 600mg +D 5mcg tablets with an expiration date of 8/2024.
- Two bottles of ASA 325mg tablets with an expiration date of 12/2024.
- One bottle of prenatal vitamin tablets with an expiration date of 9/2024.
- One bottle of ferrous gluconate 240mg tablets with an expiration date of 2/2025.
- One bottle of acetaminophen 500mg/15ml liquid with an expiration date of 1/2025.
- One box of Pepto Bismol chewable tablets with an expiration date of 3/2025.
- Two bottles of Multi Vite liquid with an expiration date of 1/2025.
- One bottle of pink bismuth 525mg/30ml liquid with an expiration date of 2/2025.
- One bottle of flaxseed 1,000mg tablets with an expiration date of 1/2025.
On 4/8/25 at 4:12 PM, Staff 29 (CMA) stated the expectation for expired medications was they would be removed from the cart and destroyed.
During an observation of the 500-hall cart on 4/8/25 at 4:17 PM, the following were found:
- One bottle of Levetiracetam 100mg/ml liquid with an expiration date of 4/1/2025.
- One bottle of acid reducer 10mg tablets with an expiration date of 3/2025.
On 4/8/25 at 4:25 PM, Staff 3 (Assistant Director of Nursing) stated the expectation for expired medications was for them to be removed from the cart and discarded.
During an observation of the 200/300/400-hall medication storage room on 4/8/25 at 4:35 PM, the following were found:
- One bottle of acid reducer 10mg tablets with an expiration date of 3/2025.
- Three bottles of ASA 325mg tablets with an expiration date of 12/2024.
- Two bottles of ferrous gluconate 27mg tablets with an expiration date of 2/2025.
- One bottle of ASA 325mg tablets with an expiration date of 2/2024.
On 4/8/2025 at 4:47 PM, Staff 2 (DNS) stated the expectation for expired medications was for them to be destroyed and reordered.
During an observation of the 100/500-hall medication storage room on 4/8/25 at 4:52 PM, the following were found:
- Eight bottles of ASA 325mg tablets with an expiration date of 12/2024.
- One bottle of ASA 325mg tablets with an expiration date of 2/2024.
- Two bottles of ASA 325mg tablets with an expiration date of 4/2024.
- One bottle of acid reducer 10mg tablets with an expiration date of 3/2025.
- One bottle of Dakin's solution with an expiration date of 11/2023.
- One tube of Ayr saline nasal gel with an expiration date of 1/2025.
On 4/8/25 at 5:16 PM, Staff 2 (DNS) stated the expectation for expired medications was for them to be destroyed and reordered.
CONCERN
(E)
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 a manner to prevent spoilage in 1 of 1 kitchen reviewed for sanitary practices. This placed res...
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Based on observation, interview and record review it was determined the facility failed to store food in a manner to prevent spoilage in 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for foodborne illness. Findings include:
The facility's Food Safety and Sanitation Policy and Procedure dated 2023 indicates:
-All time and temperature control for safety foods should be labeled, covered and dated when stored; and
-Perishable foods should be used prior to the use by date on the package.
On 4/7/25 at 10:06 AM during a tour of the facility's Kitchen, the following was observed in the walk-in refrigerator:
-a plastic container labeled, chicken noodle - use by 4/5;
-a plastic container labeled, rice prep - use by 4/6;
-a one-quart container of sauerkraut labeled, expires 4/4; and
-two unlabeled and undated trays containing multiple prepared beverage cups: 28 cups of milk and 6 cups of apple juice.
On 4/7/25 at 10:06 AM Staff 5 (Dietary Manager) acknowledged the items should not be in the refrigerator past their use by dates and should be thrown away. Staff 5 stated she expected trays of beverages to be labeled at the time they were placed in the refrigerator to avoid any confusion and maintain their freshness.
On 4/7/25 at 10:28 AM an undiscernible and unlabeled piece of meat was observed wrapped in plastic on a shelf in the walk-in freezer. The meat was dark brown and had layers of ice under the plastic wrapping. Staff 5 acknowledged the item, stated it looked like a ham with freezer burn. Staff 5 stated she expected items to be thrown away before they reached that stage so the residents were served fresh meals.
On 4/11/25 at 11:41 AM Staff 2 (DNS) stated she expected foods to be discarded in timely manner to ensure food safety and prevent food-borne illness. She also stated she expected food in freezer to be free from freezer burn.
Jun 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
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure narcotics were administered according to physician's orders for 1 of 4 sampled residents (#1) reviewed for medicati...
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Based on interview and record review it was determined the facility failed to ensure narcotics were administered according to physician's orders for 1 of 4 sampled residents (#1) reviewed for medication errors. This placed residents at risk for adverse medication consequences. Findings include:
On 3/21/24 a concern was received by the State Survey Agency (SSA) which alleged Resident 1 was given an additional dose of the narcotic Oxycodone.
Resident 1 was admitted to the facility in 2022, with diagnoses including a fractured leg and dementia.
Resident 1's 3/2024 signed physician orders revealed she/he was to be administered an Oxycodone 5 mg tablet by mouth every eight hours for pain.
A review of Resident 1's 3/2024 MAR revealed on 3/20/24 Resident 1 was given Oxycodone 5 mg at 6:00 AM, 2:00 PM and 10:00 PM.
On 3/20/24 at 9:00 PM, Staff 9 (CMA) and Staff 10 (CMA/CNA) counted the narcotics for Resident 1 and discovered there was a missing Oxycodone tablet. Staff 9 stated she had accidentally given Resident 1 an extra dose of 5 mg Oxycodone. Staff 9 and Staff 10 informed the charge nurse, a medication error form was filled out and Resident 1 was closely monitored.
On 6/4/24 at 9:20 AM, Staff 9 stated on 3/20/24 she accidentally gave Resident 1 two 5 mg tablets of Oxycodone instead of one 5 mg tablet of Oxycodone per the MAR and physician order.
On 6/4/24 at 3:17 PM, Staff 2 (DNS) acknowledged Staff 9 did not follow the physicians' orders for Resident 1's Oxycodone administration. Staff 2 stated she expected staff to follow physician orders when administering medications.
Nov 2023
12 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 18 was admitted to the facility with diagnoses including hemiplegia (limited or no ability to move a side of the bod...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 18 was admitted to the facility with diagnoses including hemiplegia (limited or no ability to move a side of the body).
Resident 18's 10/2023 Care Plan included the use of a mechanical lift for all transfers.
On [DATE] at 3:34 PM Staff 16 (CNA) stated the mechanical lifts were difficult to use and dangerous. Staff 16 stated after the resident was raised in the air, the wheels lock and it is very difficult to push the mechanical lift for repositioning . I've had residents swing so much when we are trying to move them in it that I've had to catch the resident to prevent them from falling.
On [DATE] at 7:03 PM Staff 3 (CNA) stated Resident 18 experienced a malfunctioning mechanical lift when she/he was transferred from a wheelchair to her/his bed in 10/2023. Staff 3 stated Resident 18 was being supported by the mechanical lift when it gave out and Staff 36 (CNA) was required to catch the resident who was halfway out of the mechanical lift sling, six inches from the floor.
On [DATE] at 7:09 PM Staff 36 (CNA) stated she assisted Staff 3 when the mechanical lift malfunctioned. Staff 36 stated Resident 18 was being transferred with a mechanical lift when the lock disengaged and the mechanical lift collapsed which dropped Resident 18 towards the ground. Staff 36 stated she had to catch Resident 18 to prevent her/him from striking the ground. Staff 36 recalled Resident 18 having been afraid after the incident and stated Resident 18 has had a continued fear of mechanical lift transfers since.
On [DATE] at 7:13 PM Resident 18 stated she/he experienced a near injury as a result of a faulty mechanical lift. Resident 18 reported the mechanical lift gave out and she/he was dropped from being fully raised to being six inches from the floor. Resident 18 stated they were not even touching it when the drop happened so it wasn't user error. Resident 18 stated she/he has felt afraid during transfers since she/he was nearly dropped to the floor. Resident 18 stated I don't feel [mechanical lifts] are safe for anyone. Still when they use [a mechanical lift] I wonder: Is it going to fall? Is it going to happen again? I am afraid it will happen again every time they use one.
On [DATE] at 10:16 AM Staff 2 (DNS) stated she was unaware of the incident with Resident 18 but confirmed unsafe mechanical lifts should not be used for any transfers.
On [DATE] 2:29 PM Staff 1 (Administrator) stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11 (Maintenance Director), there was nothing wrong with them. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly.
3. Resident 4 was admitted to the facility with diagnoses including obesity and difficulty walking.
Resident 4's 10/2023 Care Plan included the use of a mechanical lift for all transfers.
On [DATE] at 3:34 PM Staff 16 (CNA) stated the mechanical lifts were difficult to use and dangerous. Staff 16 stated after the resident was raised in the air, the wheels lock and it is very difficult to push the [mechanical lift] for repositioning . I've had residents swing so much when we are trying to move them in it that I've had to catch the resident to prevent them from falling.
On [DATE] at 3:38 PM Resident 4 was observed receiving mechanical lift transfer assistance from Staff 16 (CNA) and Staff 3 (CNA). After Resident 4 was raised out of her/his wheelchair, Staff 16 and Staff 3 began to attempt to reposition the mechanical lift. The movements made were jerky and the resident began swinging back and forth while supported with the mechanical lift sling. Staff 16 and Staff 3 both were required to bend over and move the bottom portion of the mechanical lift when the wheels became stuck on the flat, smooth and unobstructed ground.
On [DATE] at 3:45 PM Resident 4 stated the observed transfer was consistent with previous mechanical lift transfers. Resident 4 stated she/he did not feel safe with the use of the facility's mechanical lifts because the wheels often jammed and staff had to make adjustments to the mechanical lift for it to move, rather than focusing on the resident.
On [DATE] at 10:16 AM Staff 2 (DNS) stated mechanical lifts should not require staff to bend over to allow for wheel movement. Staff 2 confirmed a mechanical lift requiring this practice should no be used.
On [DATE] 2:29 PM Staff 1 (Administrator) stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11 (Maintenance Director), there was nothing wrong with them. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly.
Based on observation, interview, and record review it was determined the facility failed to ensure the environment remained free from accident hazards related to mechanical lift transfers for 3 of 3 sampled residents (#s 4, 15 and 18) reviewed for accidents. This failure resulted in Resident 15 sustaining a hip fracture which required surgical intervention. Findings include:
Resident 15 was admitted to the facility in 2018 with diagnoses including pain in her/his lower legs.
Resident 15's [DATE] Annual MDS indicated the resident had no cognitive impairment. Resident 15 required the assistance of two-persons using a mechanical lift for transfers.
An [DATE] 7:21 AM Fall Investigation revealed Resident 15 fell during a mechanical lift transfer because staff were unable to turn the mechanical lift which resulted in the mechanical lift tipping over and the resident landing on her/his right side. Resident 15 complained of pain to her/his right leg and shoulder and was sent to the hospital. A witness statement indicated multiple staff complained the wheels on the mechanical lift were getting stuck, nothing had been done and the lift was unsafe. The investigation concluded that the staff were in error and education and competencies would be completed.
An [DATE] Hospital Discharge Summary revealed Resident 15 was admitted to the hospital on [DATE] for surgical intervention of a right hip fracture which was sustained after the resident was dropped from a mechanical lift.
On [DATE] at 1:51 PM Staff 2 (DNS) was requested to provide mechanical lift education and competencies for the following staff on duty [DATE]: Staff 5 (RN), Staff 6 (CNA), Staff 7 (CNA), Staff 8 (CNA), Staff 12 (CNA), Staff 20 (CNA), Staff 21 (CNA), Staff 22 (CNA) and Staff 23 (CNA). The following competencies were provided:
-Staff 6 completed on [DATE];
-Staff 7 completed on [DATE] and
-Staff 23 completed on [DATE].
Staff 2 was unable to provide education and competencies for the remaining requested staff.
The [DATE] through [DATE] monthly maintenance reports were provided for one of the five mechanical lifts. There was no additional evidence provided that monthly maintenance was completed on the additional four mechanical lifts.
On [DATE] at 12:58 PM a mechanical lift was observed outside of Staff 11's (Maintenance Director) office. The wheels on the mechanical lift did not turn properly. When the mechanical lift was pushed it did not steer or turn in the direction being pushed.
On [DATE] at 3:24 PM Resident 15 stated staff were getting her/him up using the pumperoo type mechanical lift when part of the mechanical lift broke which caused her/him to fall. Resident 15 stated she/he injured her/his chest and broke her/his leg.
On [DATE] at 4:11 PM Staff 4 (CNA) stated on [DATE], she and Staff 10 were getting Resident 15 up for breakfast. Staff 4 stated as she attempted to drive the mechanical lift the wheels became jammed. Staff 4 stated the mechanical lift could only move with the front wheels, the lift was not budging and with the momentum and the weight of the resident, the lift tipped over and Resident 15 fell onto the floor. Staff 4 stated the mechanical lift was taken off of the floor but the administration and maintenance said there was nothing wrong with the mechanical lift.
On [DATE] at 4:35 PM Staff 10 (CNA) stated the mechanical lifts were wobbly and jiggly, the wheels got stuck and were difficult to turn. Staff 10 stated on [DATE] she attempted to transfer Resident 15 with Staff 4 (CNA). Staff 10 stated Staff 4 turned the mechanical lift, the legs and back wheels became stuck and the lift immediately stopped moving. Staff 10 stated Staff 4 tried to get the mechanical lift to move but the mechanical lift tipped over and Resident 15 fell to the ground.
On [DATE] at 12:06 PM Staff 7 (CNA) stated the mechanical lifts did not always work. Staff 7 stated she brought her concerns to Staff 1 (Administrator) and Staff 11 and they just blame it on us.
On [DATE] at 12:58 PM Staff 5 (RN) stated she told management on several occasions that the mechanical lifts were not operating properly and someone was going to get hurt. Staff 5 stated in 8/2023, Resident 15 fell from the mechanical lift because the lift was not working properly and tipped over. Staff 5 stated earlier today, she attempted a mechanical lift transfer of a resident with Staff 12 (CNA) assisting and the mechanical lift nearly tipped over. Staff 5 stated as she took the mechanical lift down the hallway it would barely roll. She placed the lift outside of Staff 11's office. Staff 5 stated the batteries needed to operate the mechanical lifts were always dead or died in the middle of a transfer despite being on the battery charger all day.
On [DATE] at 1:10 PM Staff 12 (CNA) stated often the wheels on the mechanical lifts did not move properly and got stuck.
On [DATE] at 7:03 PM Staff 3 (CNA) stated the mechanical lifts were horrible. Staff 3 stated frequently there were mechanical lifts out of commission. Staff 3 stated the mechanical lifts were hard to push, difficult to steer and barely turned.
On [DATE] at 7:09 PM Staff 17 (CNA) stated the wheels on three of the mechanical lifts got stuck and the legs did not move well. Staff 17 stated in the past, the pump mechanical lift locked at the top and the lift collapsed. Staff 17 stated at least one mechanical lift needed to be serviced every week.
On [DATE] at 6:39 AM Staff 5 stated two malfunctioning mechanical lifts were taken off of the floor and new ones replaced them.
On [DATE] 2:29 PM Staff 1 stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11, there was nothing wrong with them. Staff 1 stated Staff 11 was unable to recreate the issues. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly.
On [DATE] 11:09 AM Witness 2 (Resident Advocate) reported she discussed concerns regarding the mechanical lifts with Staff 1 over a year ago and felt the concerns were minimized and there was no follow through. In addition, Witness 1 stated when concerns were brought forward to Staff 1, Staff 1 tended to minimize or say there was no problem thus concerns were usually not addressed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 2 sampled residents (#40) reviewed for dignity. This placed residents at risk for lac...
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Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 2 sampled residents (#40) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include:
Resident 40 was admitted to the facility in 2021 with diagnoses including stroke.
A review of Resident 40's 9/27/23 Annual MDS Assessment revealed she/he had moderate cognitive impairment.
Resident 40's Care Plan revised on 10/8/21 revealed she/he required extensive assistance from one staff member twice a week and as necessary to complete bathing tasks.
Resident 37 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy.
A review of Resident 37's 10/7/23 Quarterly MDS Assessment revealed she/he had moderate cognitive impairment.
On 11/14/23 at 1:42 PM Resident 40 was observed in a shower chair and partially covered by a bath blanket while Staff 17 (CNA) transported her/him to the 400 hall shower room. Resident 40's left buttock and left leg were completely exposed.
On 11/14/23 at 1:44 PM Resident 37 was observed sitting in her/his wheelchair near the 400 hall shower room. She/he stated, Did you see that? That man was completely naked and they just rolled him down the hall naked for his shower. Resident 37 stated residents are frequently transported to and from the shower without being completely covered. She/he stated she/he thought it was not right to be transported naked.
On 11/14/23 at 2:13 PM Staff 17 stated she did not notice Resident 40's buttock and leg were uncovered when she prepared her/him for her/his shower. She stated, Maybe I should have made sure [she/he] was more covered.
On 11/16/23 at 11:57 AM Staff 18 (RN) stated CNAs and shower aides prepared residents for showers in the shower room or in the residents' rooms. She stated staff members were expected to make sure residents were completely covered while going between their rooms and the shower room.
On 11/17/23 at 11:57 AM Staff 2 (DNS) stated when going to and from the shower room she expected residents to be covered completely for everyone's dignity and privacy.
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 assess a resident for safe self-administration of medication for 1 of 2 sampled residents (#41) reviewed for ...
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Based on observation, interview and record review it was determined the facility failed to assess a resident for safe self-administration of medication for 1 of 2 sampled residents (#41) reviewed for medication self-administration. This placed residents at risk for unsafe medication administration. Findings include:
Resident 41 was admitted to the facility in 2022 with diagnoses including asthma.
A Physician Order from 3/17/23 instructed Resident 41 to inhale 2 puffs of albuterol 90 mcg for shortness of breath. The order included instructions the medication was to be administered by a clinician.
On 11/13/23 at 3:38 PM an albuterol inhaler was observed on the residents bedside table. Resident 41 stated she/he had been assessed and approved to use the inhaler independently.
On 11/15/23 at 8:43 AM Staff 32 (RNCM) stated a resident must have physician orders and an assessment for safety with self-administration of any medication. Review of Resident 41's orders with Staff 32 revealed Resident 41's albuterol medication was to be administered by a clinician and should not be left in her/his room. Staff 32 also confirmed a self-administration assessment was not performed on Resident 41 regarding self-administration of albuterol. Upon visit of Resident 41's room, Staff 32 confirmed Resident 41 had an albuterol inhaler by her/his bedside and removed the inhaler from Resident 41's room.
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 oxygen was administered as ordered for 1 of 1 sampled resident (#31) reviewed for respiratory care. Th...
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Based on observation, interview and record review it was determined the facility failed to ensure oxygen was administered as ordered for 1 of 1 sampled resident (#31) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and discomfort. Findings include:
Resident 31 was admitted to the facility in 2021 with diagnoses including chronic respiratory failure with hypoxia (an absence of enough oxygen), pneumonia and chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe).
The facility's 6/2023 Oxygen Administration Policy indicated the following:
-It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until order can be obtained.
Resident 31's 8/12/21 Physician Order indicated the resident received two liters of oxygen per minute (LPM) via nasal cannula (a medical device to provide supplemental oxygen therapy to people with low oxygen levels).
An 8/22/23 Annual MDS indicated Resident 31 received oxygen therapy.
An observation on 11/16/23 at 10:59 AM revealed Resident 31's oxygen flow was set at three LPM.
On 11/16/23 at 3:46 PM Staff 5 (RN) observed Resident 31's oxygen flow rate was set to three LPM and Staff 5 stated the oxygen flow rate was supposed to be at two LPM. Staff 5 confirmed any increase in oxygen rate required a physician order.
On 11/17/23 at 10:44 AM DNS Staff 2 (DNS) acknowledged the resident was supposed to receive two LPM and three LPM was not according physician order. Staff 2 stated she expected physician orders to be followed.
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 F0575
(Tag F0575)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies was posted and available to residents for 1 of 1 facility observed f...
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Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies was posted and available to residents for 1 of 1 facility observed for required postings. This failure placed residents at risk for lack of information about how to file a complaint. Findings include:
Review of the facility's required postings on 11/16/23 revealed a poster with State agency information on reporting a complaint was not posted in the facility.
On 11/16/23 at 10:16 AM Staff 2 (DNS) stated the facility previously had a poster up with contact information for the pertinent State agencies, but the poster was removed a week ago. Staff 2 acknowledged no contact information for the pertinent State agencies was currently posted.
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 F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility failed to ensure survey results were readily accessible for 1 of 1 facility reviewed for resident rights. This placed residents and th...
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Based on observation and interview it was determined the facility failed to ensure survey results were readily accessible for 1 of 1 facility reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include:
On 11/14/23 at 10:30 AM a binder containing the facility's survey results was observed lying flat on the counter adjacent to a closed roll-up window on the south side of the building. The binder was oriented away from the room and the label of the binder was not visible when observed from wheelchair height. A sign was observed on the outside of the door which read, PUBLIC ACCESS TO FACILITY IS LOCATED ON THE [north] SIDE OF THE BUILDING.
On 11/14/23 at 10:33 AM Staff 9 (Activities Director) stated the south side of the building was the facility's back door. She stated the main entrance was located on the north side of building and residents and guests entered and exited through the north side doors.
On 11/17/23 at 11:05 AM Staff 5 (RN) reported she knew the binder existed but did not know where it was. She stated I don't think residents even know about it, to be honest.
On 11/17/23 at 11:50 AM Staff 1 (Administrator) confirmed the current location of the survey binder and stated That's where it's always been. From COVID this side was locked and was not a public entrance. He stated nursing stations are the most central locations where residents would be more likely to find the binder.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility ...
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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 maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include:
Observations of the facility's general environment and residents' rooms from 11/13/23 through 11/17/23 identified the following issues:
-The 100 hall shower room was missing the threshold from the shower room to the hallway and was not cleanable. The tiles in the shower stall were worn down and chipped. The flooring was discolored. The overhead light was dirty and had a cracked plastic covering.
-The skilled floor dining room had black marks along the wall under the window and black shoe prints on the wall near the sink.
-room [ROOM NUMBER] had gouges in the wall above the bed and along the wall next to the bathroom. The heater was also gouged and had areas of missing paint.
-room [ROOM NUMBER]'s bathroom light covering had come off and was on the floor by the toilet. In the corner of the room, the wall had gouges approximately five feet long. The wall under the window had numerous black markings. The wall edges where the corner of the wall met were gouged and needed repair.
-room [ROOM NUMBER] had long dark marks on the wall entering the room, dark marks above the bed and along the wall near the head of the bed. The bathroom wall had several areas that needed repair.
-room [ROOM NUMBER]'s wall had gouges near the head of the bed, the bathroom door with missing a chunk of wood and was scraped along the bottom of the door. The corner of the wall was gouged and needed repairs.
-room [ROOM NUMBER]'s windows were dirty and hard to see out of. There were gouges near the head of the bed and along the wall, entering the room there were gouges on approximately four feet of the wall. The wall on the right side of the room was gouged and scraped.
-room [ROOM NUMBER] had large black gouges in the floor and the window was dirty and hard to see out of.
-room [ROOM NUMBER]'s window was dirty and hard to see out of. There were long gouges on the wall behind the bed and other walls that needed to be painted. The dresser and closet were scraped up. The bed protector on the wall was broken the entire length of the wall behind the bed.
-room [ROOM NUMBER], when entering the room the wall had long gouges the length of the wall, the wall was scraped by the headboard, the dresser was scraped up, and there was missing plaster on the corner wall that needed to be repaired.
11/17/23 at 9:57 AM Staff 11 (Maintenance Director) acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include:
On 11/13/23 the facility had a census of 72 residents. On 11/15/23 Staff 2 (DNS) provided a list of residents who:
-Required two-person mechanical lift transfers: 24.
-Were considered to be bariatric (obese) with a body mass index over 40: 9.
-Had behavioral healthcare needs: 13.
-Required frequent checks: 3.
-Were determined to be at a high fall risk: 26.
-Were dependent on staff for showers: 57.
-Were dependent on staff for toileting: 44.
-Required one-to-one assistance with eating: 6.
The 1/2023 through 11/2023 Resident Council Meeting notes revealed residents' voiced concerns regarding long call light response times during every Resident Council meeting this year.
Observations from 11/13/23 through 11/16/23 from the hours of 6:30 AM to 9:30 PM revealed the following concerns:
-11/14/23 at 1:40 PM the resident in room [ROOM NUMBER] was yelling help me;
-11/14/23 at 1:48 PM the call light in room [ROOM NUMBER] was activated for 35 minutes and the call light in room [ROOM NUMBER] was activated for 32 minutes;
-11/14/23 at 3:21 PM the call light in room [ROOM NUMBER] was activated for 35 minutes;
-11/15/23 at 10:13 AM the call light in room [ROOM NUMBER] was activated for 30 minutes;
-11/15/23 at 2:50 PM Resident 28, identified to be at a high fall risk, attempted to self-transfer using a transfer pole and was unable to get to a standing position. No staff were observed in the hallway; and
-11/16/23 at 11:16 AM a resident on the 200 hallway was yelling somebody help me.
Interviews with staff revealed the following:
On 11/13/23 at 3:35 PM Staff 16 (CNA) stated she typically was assigned 11 residents on evening shift and reported during the first week of 11/2023, there was a day when she was the only licensed CNA on the unit. Staff 16 stated it was very difficult because she was told she had to get all of the residents up for dinner and then change all of the residents' bedsheets. Staff 16 stated this was an impossible task.
On 11/15/23 at 8:28 AM Staff 4 (CNA) stated staffing on the weekend was awful and Saturdays were consistently short one staff. Staff 4 stated because of low staffing, residents had falls and staff were unable to get residents up for meals because there were so many residents that require two-person mechanical lift transfers. Staff 4 stated the residents often did not get showered or toileted in a timely manner and residents did not receive restorative therapy at times because the restorative aid was pulled to the floor to work as a CNA.
On 11/15/23 at 9:57 AM and 7:26 PM Staff 5 (RN) stated the long-term hallways had very heavy care residents. She stated many residents required two-person mechanical lift transfers, there were several residents with behaviors and it took at least one hour to provide routine care for one resident. Staff 5 reported the facility staffed to the state minimum ratios but that was not adequate based on the needs of the residents. Staff 5 stated the facility was short CNA coverage all the time and there were staff that frequently called in. Staff 5 reported as a result of the facility being short staffed, many residents had skin issues, recently a resident had a choking incident, showers were missed and the CNAs were unable to take breaks and had to stay past their shift in order to get their charting done.
On 11/15/23 at 10:45 AM Staff 6 (CNA) stated the weekends were consistently incredibly short staffed. Staff 6 stated there were many new CNAs and NAs which made it hard for the veterans because the newly hired staff did not get enough training. Staff 6 stated due to low staffing, sometimes residents did not get showered and the CNAs did not take breaks or lunches at times.
On 11/15/23 at 12:06 PM Staff 7 (CNA) stated the facility was typically short staffed. Staff 7 stated when the facility was short staffed the residents did not get showered and they got upset, wondering when they would receive a shower. Staff 7 stated if the facility was staffed over the state minimum ratios then staff got sent home.
On 11/15/23 at 12:17 PM Staff 8 (CNA) stated staffing may look good on paper but there were not enough staff to meet the acuity needs of the residents. Staff 8 stated training of NAs was a big problem because they were not provided adequate training. Staff 8 stated the CNA staff were in a lose/lose situation due to inadequate staffing. Staff 8 stated residents did not get washed properly, their dentures did not get taken out and cleaned at night and skin care was not getting done.
On 11/15/23 at 1:10 PM Staff 12 (CNA) stated in general the facility was short staffed almost every day. Staff 12 stated the new NAs were not adequately trained which took a lot of time from the experienced CNAs. Staff 12 stated when the facility was short staffed residents had to stay up longer than they should, were left in bed for meals, showers were missed and denture/oral care was not completed. Staff 12 stated CNAs had to work longer than their scheduled shift in order to get their charting completed.
On 11/15/23 at 7:03 PM Staff 3 (CNA) stated evening shift CNAs often had 10 to 12 assigned residents. Staff 3 stated the facility had many residents who required two-person mechanical lift transfers which made it hard on the staff. Staff 3 stated often the staff had to bump showers and residents had to sit up in their chairs for long periods of time because staff did not have time to put the residents back to bed.
On 11/16/23 at 10:52 AM Staff 9 (Activities Director) stated she participated in monthly Resident Council meetings and long call light times were a problem brought up by the residents' throughout the entire year.
On 11/16/23 at 1:06 PM Staff 2 stated staffing was determined based on the state minimum staffing ratios. Staff 2 stated staff came to her stating the facility was short staffed and she told them the facility was staffed based on the state minimum staffing ratios so staffing was fine. Staff 2 acknowledged that the facility was supposed to staff according to the acuity needs of the residents but stated they had no acuity tools to use. Staff 2 stated the facility was not completing annual licensed staff competencies and she needed to get those going.
On 11/17/23 at 11:09 AM Witness 2 (Resident Advocate) stated she brought staffing concerns to the attention of Staff 1 (Administrator) and the concerns were minimized. Witness 2 stated during visits in 9/2023 and 10/2023, call light times were over 40 minutes and residents frequently reported call light response times between 30 minutes to one hour. Witness 2 stated staffing issues lead to residents sitting in urine soaked clothing for long periods of time. Witness 2 stated staffing concerns continued to be an ongoing issue with the facility.
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 2 of 5 sampled CNA staff (#s 7 and 31) reviewed for suffici...
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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 2 of 5 sampled CNA staff (#s 7 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include:
On 11/16/23 at 12:10 PM a review of the facility staff training records for CNAs employed over one year revealed the following:
-Staff 7 (CNA), hire date 7/17/22; had no annual performance review documentation on file.
-Staff 31 (CNA), hire date 10/1/21; had no annual performance review documentation on file.
On 11/16/23 at 1:09 PM Staff 2 (DNS) confirmed she was unable to provide annual performance review documentation for Staff 7 and Staff 31.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 3 of 3 facility dumpsters reviewed for sanitation. T...
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Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 3 of 3 facility dumpsters reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include:
On 11/15/23 at 12:06 PM three dumpsters were observed, all with lids open. Two used medical gloves and one wet-wipe were observed around the two south dumpsters.
On 11/16/23 at 9:25 AM three dumpsters were observed, all with lids open. Three used medical gloves were observed on the ground around the outside of the south dumpsters. Two medical gloves were observed on the ground around the outside of the north dumpster.
On 11/16/23 at 10:10 AM the north and south dumpster areas were reviewed with Staff 11 (Maintenance Director). Staff 11 confirmed the dumpster lids were to be closed and used medical equipment was to be in the containers, not on the ground around the containers.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 food was labeled and stored in a manner to minimize spoilage and proper food handling practices were followed to prev...
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Based on observation and interview it was determined the facility failed to ensure food was labeled and stored in a manner to minimize spoilage and proper food handling practices were followed to prevent cross contamination in 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illness and unappetizing meals. Findings include:
1. On 11/13/23 at 10:56 AM the following observations were made regarding dry food storage:
-Three undated containers of pasta;
-One undated container of croutons; and
-One undated container of rice.
On 11/13/23 at 11:13 AM Staff 33 (Cook) stated dry food containers were not dated. When questioned, Staff 33 was unable to say specifically how long they have had the dry foods.
On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) confirmed all food should be dated.
2. On 11/15/23 at 11:39 AM Staff 34 (Cook) was observed preparing and plating lunch with no hairnet.
On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) stated staff were to wear hairnets anytime they were in the kitchen area. Staff 35 confirmed Staff 34 was not wearing a hairnet when preparing and plating food.
3. On 11/15/23 at 11:40 AM the wall directly above the food plating area contained grease and food scraps.
On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) stated staff were to maintain cleanliness of all areas of the kitchen, especially the area surrounding food plating. Staff 35 confirmed the grease and food on the wall was unacceptable.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 randomly sampl...
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Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 randomly sampled CNAs (#s 7, 8, 12, 30 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include:
On 11/16/23 at 12:02 PM the following CNA staff training logs were requested and received from Staff 2 (DNS):
-Staff 7 (CNA): received 0 hours of annual training;
-Staff 8 (CNA): received 0 hours of annual training;
-Staff 12 (CNA): received 0 hours of annual training;
-Staff 30 (CNA): received 0 hours of annual training and
-Staff 31 (CNA): received 0 hours of annual training.
On 11/16/23 at 12:26 PM Staff 2 acknowledged the required 12 hours of annual in-service training was not completed for Staff 7, Staff 8, Staff 12, Staff 30 and Staff 31.
Jul 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by Resident 2 for 1 of 3 sampled residents (#1) reviewed for abuse....
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Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by Resident 2 for 1 of 3 sampled residents (#1) reviewed for abuse. This failure resulted in Resident 1 experiencing pain and fear. Findings include:
The facility's Abuse/Neglect/Misappropriation/Exploitation Policy and Procedure revised 10/2022 revealed the following information:
- It is the policy of this facility to protect residents from mistreatment, neglect, abuse, exploitation, involuntary seclusion and misappropriation of property by implementing procedures designed to prevent, identify, report and investigate potential instances of abuse, neglect and exploitation.
- Physical Abuse - Includes, but is not limited to hitting, slapping, pinching, choking, striking with an object, kicking, shoving, prodding, corporal punishment or the use of chemical or physical restraints unless indicated by the resident's condition.
Resident 1 was admitted to the facility in 2022 with diagnoses including a history of stroke and chronic kidney disease.
Resident 1's 5/2023 Quarterly MDS revealed a BIMS score of 10 (moderate cognitive impairment) and a history of behavioral symptoms not directed toward others (hitting, rummaging and disruptive sounds four to six days per week).
Resident 2 was admitted to the facility in 2022 with diagnoses including diabetes and chronic pain syndrome.
Resident 2's 7/2023 Quarterly MDS indicated a BIMS score of 15 (cognitively intact) and a history of verbal behavior symptoms directed toward others (threatening, screaming or cursing at others on a daily basis).
Resident 1's medical record revealed there was a resident-to-resident incident between her/him and Resident 2 on 4/13/23. Resident 1 was in the hall outside Resident 2's room. Resident 2 became upset because Resident 1 would not stop making noise. The incident was investigated and there were no injuries or abuse found.
Resident 1 was moved to a room in a different hall away from Resident 2's room.
A 7/4/23 progress note revealed Resident 1 was observed by Staff 4 (CMA) in the hall near Resident 2's room. Staff 4 stated Resident 2 yelled get out of here you [expletive] thief and she/he hit Resident 1. Resident 1 stated Resident 2 slapped her/him on the left side of her/his face. The left side of her/his face had a red mark and she/he complained of pain.
A 7/5/23 progress note indicated Resident 1 complained of pain and tenderness to the left side of her/his face.
On 7/10/23 two public complaints were received by the State Agency regarding allegations of physical abuse between two residents. Resident 2 was observed by facility staff to slap Resident 1 in the face.
On 7/12/23 at 4:45 PM Resident 1 was observed in her/his wheelchair in the hall by the nurses station. She/he was alert and interacting with another resident.
On 7/12/23 at 4:50 PM Resident 2 was observed in her/his room sitting by the doorway. Resident 2 declined to talk with the surveyor.
On 7/13/23 at 12:03 PM Staff 3 (LPN) stated Resident 1 was oriented only to self and had behaviors of repetitive crying, moaning and wandering around the facility in her/his wheelchair. Staff 3 stated between April 2023 and July 2023 there were incidents of yelling between Resident 1 and Resident 2. Staff 3 indicated Resident 1 did not cause any harm or problems with other residents. Staff 3 stated Resident 1 reported Resident 2 slapped her/him and pointed to her/his left cheek where it was warm and red. Staff 3 indicated the resident appeared scared and was teary eyed.
On 7/17/23 at 7:00 PM Witness 1 (Complainant) indicated Resident 1 was very scared and her/his left cheek was red and puffy after the incident with Resident 2.
On 7/19/23 at 10:42 PM Staff 5 (LPN) stated Resident 1 did not enter Resident 2's room on 7/4/23 and Resident 2 had a history of aggressive behavior toward Resident 1. Staff 5 revealed Resident 2 displayed aggressive behaviors toward other residents in the past. Staff 5 stated a Stop sign was placed on Resident 2's door as the intervention after her/his incident with Resident 1.
On 7/21/23 at 12:51 PM Staff 1 (Administrator) and Staff 2 (DNS) reviewed the 7/4/23 incident between Resident 1 and Resident 2. Staff 1 stated the incident was not reported as abuse initially and the whole story was not documented.
On 7/28/23 at 1:38 PM Staff 1 and Staff 2 acknowledged the findings related to the 7/4/23 incident. 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported within two hours for 1 of 3 sampled residents (#1) reviewed for allegations of a...
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Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported within two hours for 1 of 3 sampled residents (#1) reviewed for allegations of abuse. This placed residents at risk for unreported abuse. Findings include:
The facility's Abuse/Neglect/Misappropriation/Exploitation policy and procedure, revised 10/2022 indicated:
Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse .
Resident 1 was admitted to the facility in 2022 with diagnoses including a history of stroke and chronic kidney disease.
Resident 1's medical record revealed on 7/4/23 she/he was involved in a resident to resident incident and was slapped in the face by another resident.
On 7/10/23 two public complaints were received by the State Agency regarding allegations of physical abuse between two residents.
On 7/13/23 at 12:03 PM Staff 3 (LPN) acknowledged a FRI was not submitted for the 7/4/23 incident between Resident 1 and Resident 2. Staff 3 stated facility administration and regional staff were contacted and facility staff were directed to talk to Staff 1 (Administrator) prior to sending a FRI to the State Agency.
On 7/19/23 at 10:42 PM Staff 5 (LPN) stated the DNS usually submitted FRIs and was not aware of any training provided to nurses for how to complete the process.
On 7/28/23 at 12:51 PM Staff 1 stated he was not notified of the 7/4/23 incident and it was not originally identified as abuse.
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 thoroughly investigate an allegation of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents ...
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Based on interview and record review it was determined the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include:
The facility's Abuse/Neglect/Misappropriation/Exploitation Policy and Procedure, revised 10/2022, revealed the following:
- All alleged incidents of abuse . are thoroughly investigated in order to determine what occurred and make necessary changes to the provision of care and services to prevent reoccurrences.
- The first phase of the investigation must be completed within 24 hours of knowledge of the incident and should begin as soon as the incident is identified and the alleged victim protected.
- The investigation should end with identification of who was involved in the incident and what, when, where, why and how the incident happened, including the probable or reasonable cause and should allow the [facility] to determine if abuse . occurred.
- The incident investigation must be completed within 5 days of discovery of the incident or injury.
Resident 1 was admitted to the facility in 2022 with diagnoses including a history of stroke and chronic kidney disease.
Resident 2 was admitted to the facility in 2022 with diagnoses including diabetes and chronic pain syndrome.
Resident 1's medical record revealed she/he and Resident 2 were involved in a resident to resident incident on 7/4/23 and Resident 2 slapped her/him in the face.
On 7/10/23 two public complaints were received by the State Agency regarding an allegation of physical abuse when Resident 1 was slapped by Resident 2.
At 4:00 PM on 7/12/23 an investigation for the 7/4/23 resident-to-resident incident was requested from Staff 2 (DNS).
On 7/12/23 at 5:50 PM the surveyor made a second request to Staff 1 (Administrator) and Staff 2 for the 7/4/23 incident investigation. Staff 1 indicated they were not notified of the incident and they were almost finished with the investigation.
On 7/13/23 at 10:00 AM Staff 2 provided the surveyor with a resident-to-resident incident report. The incident report revealed information documented on 7/4/23 when the incident occurred and additional documentation dated 7/12/23. A witness statement by Staff 4 (CMA) dated 7/12/23 was included with the incident report.
The resident-to-resident incident report completed on 7/12/23 was not completed within five working days as required and lacked the following information:
- How each resident was kept safe and monitored following the incident, including to determine what type of medical or emotional support might be necessary.
- Documentation of interviews or witness statements from other staff or residents who were present during the incident.
- Documentation of how abuse was ruled in or out as a result of the incident.
On 7/17/23 at 7:00 PM Staff 4 acknowledged she/he witnessed the 7/4/23 incident and stated there were other staff present also.
On 7/28/23 at 1:38 PM the surveyor discussed the 7/4/23 incident investigation with Staff 1 and Staff 2. Both staff acknowledged the investigation was not completed timely and lacked required information.
Jun 2023
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 abuse for 1 of 3 (#100) sampled residents reviewed for abuse. This placed residents at ris...
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Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 (#100) sampled residents reviewed for abuse. This placed residents at risk for abuse. Findings include:
The facility's Abuse policy, revised 9/2022, stated the facility and staff would prevent, identify, report and investigate allegations of abuse, neglect and exploitation which included physical abuse, defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
Resident 100 admitted to the facility in 6/2021 with diagnoses including anxiety and muscle weakness.
Resident 100's 3/2023 Quarterly MDS revealed a BIMS score of 3 which indicated severe cognitive impairment.
Resident 200 admitted to the facility in 5/2022 with diagnoses including diabetes mellitus and Personality Disorder.
Resident 200's 4/2023 Annual MDS revealed a BIMS score of 13 which indicated no cognitive impairment.
The facility submitted a report to the State Agency which included the following information: On 5/24/23 at 6:25 PM, Resident 100 was seated in her/his wheelchair located outside of Resident 200's room. Resident 200 approached Resident 100 and told her/him to get out of her/his way. Resident 100 attempted to move her/his wheelchair but the brakes were locked and she/he was unable to move. Resident 200 struck Resident 100 in the forehead and Resident 100 struck Resident 200 in the chest. Staff 4 (LPN) was down the hallway and attempted to intervene before Resident 100 was struck but was unable to make it in time. Neither resident had any injuries as a result of the altercation.
On 6/15/23 at 11:09 AM Staff 4 confirmed he witnessed Resident 200 hit Resident 100 in the forehead and Resident 100 hit Resident 200 in the chest. He stated Resident 100 was initally upset but a few minutes later was laughing and joking with staff.
On 6/16/24 at 10:01 AM Staff 8 (Social Services Director) stated she spoke to Resident 200 a couple of days after the incident and Resident 200 confirmed she/he struck Resident 100 because Resident 100 was in the way and should have moved out of the way faster.
Both residents were observed in the faciltiy on 6/15/23 and 6/16/23 with no concerns.
On 6/16/23 at 10:30 AM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the incident occurred.
Jan 2023
2 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to implement care plans for 1 of 3 sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to implement care plans for 1 of 3 sampled residents (#10) reviewed for safety. This placed residents at risk for unmet needs. Findings include:
Resident 10 was admitted to the facility in 12/2021 with diagnoses including fracture of the spine and Parkinson's Disease.
Resident 10's Annual MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment.
Resident 10's care plan, revised 5/17/22, revealed she/he was at risk for falls due to a history of falls and other factors affecting her/his mobility. Interventions implemented were to ensure the resident's call light was within reach, to keep her/his bedside area free of clutter and for staff to anticipate Resident 10's needs.
On 1/12/23 at 9:55 AM Resident 10 was observed lying in bed. She/he stated she/he was supposed to use the call light for assistance but couldn't reach the call light cord, which was observed on the resident's bedside table.
On 1/12/23 at 10:40 AM the call light cord was observed to still remain out of the resident's reach and located on the bedside table. The call light cord was tangled around a phone cord, behind a peanut butter jar at the front of the table and was approximately three feet away from Resident 10, who was lying in bed in the upright position. Resident 10 stated she/he could not see the cord and didn't know where it was.
On 1/12/23 at 10:50 AM Staff 10 (Social Services Director) confirmed Resident 10 was unable to reach the call light.
On 1/19/23 at 11:00 AM Staff 2 (DNS) was advised of the findings of this investigation and provided no further information.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure resident hygiene and ADL care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure resident hygiene and ADL care was provided for 1 of 3 sampled residents (#10) reviewed for personal care. This placed residents at risk for poor hygiene. Findings include:
Resident 10 was admitted to the facility in 12/2021 for diagnoses including fracture of the spine and Parkinson's Disease.
Resident 10's Annual MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Resident 10's preferences for daily activities revealed personal hygiene, including which clothes she/he wanted to wear, was very important to her/him.
Resident 10's care plan, revised 5/17/22, revealed she/he required one-person extensive assistance with dressing and grooming.
On 1/12/23, three observations were made of Resident 10 at 9:55 AM, 10:40 AM and 12:50 PM. Resident 10 was in bed for all observations and wore a blue long sleeved shirt.
On 1/13/23 at 11:00 AM Resident 10 was observed wearing the same shirt she/he wore on 1/12/23. Several food stains were observed on the front of Resident 10's shirt. Resident 10 confirmed her/his shirt had not been changed and food stains were on it. She/he stated she/he wanted the shirt changed and she/he slept in the same shirt.
On 1/13/23 at 11:47 AM Staff 14 (CNA) went in Resident 10's room to provide personal care. She exited Resident 10's room at 12:09 PM, and confirmed Resident 10 was wearing the same shirt from 1/12/23.
On 1/18/23 at 10:07 AM Staff 15 (CNA) stated she worked night shift primarily and Resident 10 preferred to be in a gown or pajamas for bedtime.
On 1/19/23 at 11:00 AM Staff 2 (DNS) was advised of the findings of this investigation and provided no further information.
Nov 2022
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 assess a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#13) reviewed ...
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Based on observation, interview and record review it was determined the facility failed to assess a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#13) reviewed for self-administration of medications. This placed the residents at risk for unsafe medication administration. Findings include:
Resident 13 was admitted to the facility 2021 with diagnoses including diabetes.
The 8/14/22 quarterly MDS indicated the resident was cognitively intact.
A review of Resident 13's clinical record revealed no medication self-administration assessment or physician orders the resident could self-administer medication.
On 11/1/22 at 11:41 AM during a random observation in Resident 13's room, a medicated nasal spray was observed on Resident 13's counter.
On 11/1/22 at 11:41 AM Resident 13 stated she/he used the nasal spray for their runny nose.
On 11/1/22 at 12:10 PM Staff 11 (RN) stated residents can self-administer their medications after a self-administration assessment. An assessment ensures the residents ability to self-administer medications safely. All medications were to be stored in the resident's room in a safe manner. Staff 11 stated she was not aware if Resident 13 had an order to self-administer medications.
On 11/4/22 at 8:25 AM Staff 5 (DNS) stated she expected the nurses to conduct a self-medication assessment on the resident. Staff 5 stated Resident 13 was not assessed to be able to self-administer their medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
2. Resident 13 was admitted to the facility 2021 with diagnoses including diabetes.
The 8/14/22 quarterly MDS indicated the resident was cognitively intact.
The 10/2022 MAR and physician order did no...
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2. Resident 13 was admitted to the facility 2021 with diagnoses including diabetes.
The 8/14/22 quarterly MDS indicated the resident was cognitively intact.
The 10/2022 MAR and physician order did not have an order for a medicated nasal spray.
On 11/1/22 at 11:41 AM during a random observation in Resident 13's room, a medicated nasal spray was observed on Resident 13's counter. Resident 13 stated she/he used the nasal spray for their runny nose.
On 11/1/22 at 12:24 PM Staff 14 (CMA/CNA) stated Resident 13 did not have an order for medicated nasal spray on their medication list. Staff 14 removed the medicated nasal spray out of Resident 13's room.
On 11/2/22 at 11:02 AM Staff 8 (LPN/RCM) stated it was brought to her attention medicated nasal spray was discovered in Resident 13's room. Staff 8 stated there was not a physician's order for the spray and it was removed from the resident's room.
On 11/4/22 at 8:25 AM Staff 5 (DNS) stated the medicated nasal spray medication found in Resident 13's room did not have a physician's order. Staff 5 stated she expected staff to obtain a physician order prior to administration of any medication.
Based on interview and record review it was determined the facility failed to administer medications according to physician's orders for 2 of 5 sampled residents (# 13 and 35) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include:
1. Resident 35 was admitted to the facility in 2022 with diagnoses including heart failure, presence of a pacemaker and hypertension (high blood pressure).
Resident 35's current physician's orders included:
- metoprolol 25 mg evry morning for hypertension. Do not administer the medication if the systolic blood pressure (the top number in a blood pressure reading) was less than 110, the diastolic blood pressure (the bottom number in a blood pressure reading) was less than 60 or if the heart rate was less than 55.
- hydralazine 50 mg for hypertension. Do not administer the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60.
Resident 35's 10/2022 MAR revealed the following:
- The metoprolol was administered to Resident 35 on 10/8/22, 10/9/22, 10/15/22, 10/22/22, 10/23/22 and 10/30/22 when the resident's blood pressure and heart rate were documented as NA.
- The hydralazine was administered to Resident 35 on 10/23/22 when the resident's blood pressure was 114/54.
On 11/2/22 at 2:29 PM Staff 2 (RNCM) verified Resident 35's metoprolol was administered when the blood pressure was documented as NA and the hydralazine was administered outside of physician ordered parameters.
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 observation, interview and record review it was determined the facility failed to implement care planned interventions related to transferring of a resident for 1 of 1 sampled residents (#51)...
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Based on observation, interview and record review it was determined the facility failed to implement care planned interventions related to transferring of a resident for 1 of 1 sampled residents (#51) reviewed for accidents. This placed the resident at risk for falls. Findings include:
Resident 51 was re-admitted to the facility 2022 with diagnoses including left femur fracture, dementia and a colostomy (an opening on the resident's abdomen used to expel waste products).
The 8/2022 Quarterly MDS indicated Resident 51 was severely cognitively impaired; required two staff persons assistance with transfers and one staff person assistance with wheelchair mobility.
Resident 51's care plan dated 6/2022 indicated the resident had a history of falls and the interventions implemented included a two person assist with transfers.
On 11/2/22 at 1:56 PM Staff 13 (CMA/CNA) was observed to assist Resident 51 from the wheelchair to the resident's bed. Staff 13 stated the resident was a one-person extensive assist and the resident could bear weight. The amount of weight was dependent on Resident 51's pain level at the time of transfer.
On 11/4/22 at 8:25 AM Staff 5 (DNS) stated Resident 51's care plan indicated the resident was a two person assist with transfers. Staff 5 stated she expected staff to follow the resident's care plan.
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** Silva, [NAME] L.
Based on observation and interview it was determined the facility failed to follow proper infection control pra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Silva, [NAME] L.
Based on observation and interview it was determined the facility failed to follow proper infection control practices for 1 of 1 staff (# 15) reviewed for infection control. This placed the residents at risk of developing an infection. Findings include:
On 11/2/22 at 11:49 AM Staff 15 (CNA) was observed to assist Resident 13 with sitting up in bed. While assisting the resident, Staff 15 noticed an issue with the residents colostomy bag (on opening on the residents abdomen used to expel waste products). With gloved hands, Staff 15 repositioned the resident's full colostomy bag and stated she needed to get the nurse to look at the residents colostomy bag. Staff 15 assisted the resident back to laying down, doffed (removed) her gloves without performing hand hygiene afterwards, touched the doorknob in the resident's room, walked down the hall and touched the counter at the nurse's station. Staff 15 stated I know I should have washed my hands after doffing (removing) my gloves, but I didn't.
On 11/4/22 at 8:25 AM Staff 5 (DNS) stated she expected staff to perform hand hygiene after resident care and doffing (removing) gloves.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility faileded to ensure the building was clean and kept in good re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility faileded to ensure the building was clean and kept in good repair for 5 of 5 rooms (#s 109, 505, 506, 510, 515) reviewed for environment. This placed residents at risk of living in an unkept and unhomelike environment. Findings include:
On 10/31/22 at 1:14 PM large holes and chipped paint was observed in room [ROOM NUMBER] near Resident 22's bed.
On 10/31/22 at 1:18 PM large gouges and chipped paint was observed on the wall in room [ROOM NUMBER] behind Resident 12's bed.
On 10/31/22 at 1:45 PM holes and chipped paint was observed underneath the soap dispenser in room [ROOM NUMBER].
On 10/31/22 at 4:11 PM large gouges and chipped paint was observed in room [ROOM NUMBER] near Resident 40's bed.
On 10/31/22 at 4:16 PM major damage including large gouges, exposed drywall and exposed pipes were observed in room [ROOM NUMBER] near Resident 23's bed.
On 11/2/22 at 3:35 PM Staff 9 (CNA) stated she reported the wall damage in room [ROOM NUMBER] in August 2022 and continued to report those concerns with no action taken by the facility. Staff 9 stated the damage that was observed on the wall in room [ROOM NUMBER] had only been repaired after the survey team arrived.
On 11/2/22 at 3:53 PM findings were reviewed with Staff 7 (Maintenance Director). Staff 7 acknowledged the findings and stated damage is done to resident walls on a consistent basis, and it was tough to keep up with the repairs.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 45% turnover. Below Oregon's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), $59,777 in fines. Review inspection reports carefully.
- • 32 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $59,777 in fines. Extremely high, among the most fined facilities in Oregon. Major compliance failures.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Regency Hermiston Nursing & Rehab Center's CMS Rating?
CMS assigns REGENCY HERMISTON NURSING & REHAB CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Regency Hermiston Nursing & Rehab Center Staffed?
CMS rates REGENCY HERMISTON NURSING & REHAB CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the Oregon average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Regency Hermiston Nursing & Rehab Center?
State health inspectors documented 32 deficiencies at REGENCY HERMISTON NURSING & REHAB CENTER during 2022 to 2025. These included: 2 that caused actual resident harm and 30 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Regency Hermiston Nursing & Rehab Center?
REGENCY HERMISTON NURSING & REHAB 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 REGENCY PACIFIC MANAGEMENT, a chain that manages multiple nursing homes. With 105 certified beds and approximately 78 residents (about 74% occupancy), it is a mid-sized facility located in HERMISTON, Oregon.
How Does Regency Hermiston Nursing & Rehab Center Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, REGENCY HERMISTON NURSING & REHAB CENTER's overall rating (3 stars) matches the state average, staff turnover (45%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Regency Hermiston Nursing & Rehab Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Regency Hermiston Nursing & Rehab Center Safe?
Based on CMS inspection data, REGENCY HERMISTON NURSING & REHAB CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Regency Hermiston Nursing & Rehab Center Stick Around?
REGENCY HERMISTON NURSING & REHAB CENTER has a staff turnover rate of 45%, which is about average for Oregon nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Regency Hermiston Nursing & Rehab Center Ever Fined?
REGENCY HERMISTON NURSING & REHAB CENTER has been fined $59,777 across 2 penalty actions. This is above the Oregon average of $33,677. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Regency Hermiston Nursing & Rehab Center on Any Federal Watch List?
REGENCY HERMISTON NURSING & REHAB 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.