MILTON FREEWATER HEALTH & REHABILITATION CENTER
For profit - Corporation
70 Beds
EMPRES OPERATED BY EVERGREEN
Data: November 2025
Trust Grade
40/100
#64 of 127 in OR
Photo by Milton Freewater Health and Rehabilitation Center
Photo by Milton Freewater Health and Rehabilitation Center
Photo by Milton Freewater Health and Rehabilitation Center
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Milton Freewater Health & Rehabilitation Center has received a Trust Grade of D, indicating below-average performance with some concerns. It ranks #64 out of 127 facilities in Oregon, placing it in the bottom half, but is the top choice among three facilities in Umatilla County. The facility is showing signs of improvement, reducing issues from eight in 2024 to four in 2025, but still recorded serious incidents, including a resident who experienced internal bleeding due to improper transfer assistance. Staffing is a strong point, with a perfect rating of 5/5 stars and a turnover rate of 42%, which is better than the state average. Notably, there have been no fines assessed, which is a positive sign, and the center has more registered nurse coverage than 93% of other facilities in Oregon, ensuring a higher level of oversight in patient care. However, the center has faced issues such as failing to notify families promptly about COVID-19 cases and insufficient nursing staff to meet residents' needs at times.
- Trust Score
- D
- In Oregon
- #64/127
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near Oregon's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Oregon facilities.
- Skilled Nurses ✓ Good
- Each resident gets 63 minutes of Registered Nurse (RN) attention daily — more than 97% of Oregon nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Top 50%
Review needed
8 → 4 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 4 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 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: 42%
Near Oregon avg (46%)
Typical for the industry
Chain: EMPRES OPERATED BY EVERGREEN
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 actual harm
Aug 2025
4 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
Based on interview and record review, it was determined the facility failed to follow care planned interventions related to transfers for 1 of 3 sampled residents (#13) reviewed for safety. As a resul...
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Based on interview and record review, it was determined the facility failed to follow care planned interventions related to transfers for 1 of 3 sampled residents (#13) reviewed for safety. As a result, Resident 13 experienced an injury of unknown origin and internal bleeding, which required hospitalization and a blood transfusion. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 received an injury of unknown origin on her/his chest area and the resident experienced significant bruising and swelling at the chest area. On 8/5/25 at 5:14 PM, Witness 1 (Complainant) stated paramedics were called to the facility on 7/29/25, where the facility reported Resident 13's hemoglobin level was low and the resident was lethargic. Witness 1 was told the resident was involved in a Hoyer accident on 7/24/25 and sustained bruising on her/his arm. Witness 1 stated no other information was provided by staff. When Resident 13 arrived at the ED, Witness 1 stated he observed the resident had significant bruising across her/his chest, upper abdomen and back, the bruises on the resident's upper abdominal area were black, dark purple and blue and wrapped around to the resident's back. Witness 1 stated the injuries looked like an injury where someone was hit by a car.if there's any sort of trauma and someone's on a blood thinner, she/he needed to go out when it happened. You don't know what's going on internally, she/he could have had significant injury to her/his organs. On 8/6/25 at 8:45 AM, Witness 2 (Complainant) stated nursing staff at the facility observed Resident 13 on 7/26/25 after the day shift nurse came on and received report from the NOC nurse. Witness 2 stated the nurses observed the resident's left breast area to be swollen almost four times the size the area normally was, the whole area was black and blue and bruising was observed down to mid rib on the resident's back. The resident appeared to be in severe pain, so the day shift nurse immediately asked another nurse (Staff 4 - RN) to examine Resident 13. Staff 4 examined the resident's injuries, stated the resident looked as if she/he had fallen and should be sent out. Witness 2 stated Staff 2 (DNS) and Staff 3 (RNCM) were notified, examined Resident 13 but decided not to send her/him to the hospital. Witness 2 stated the resident was given ice packs for the swelling and scheduled pain medication. Witness 2 later learned Resident 13's blood test/lab results indicated Resident 13's hemoglobin and hematocrit counts were at critically low levels, requiring hospitalization and blood transfusions. On 8/6/25 at 11:45 AM, Staff 11 (CNA) stated she provided care for Resident 13 several times. She stated the resident was totally dependent for everything and had been care planned as a two person Hoyer transfer for about two weeks. Prior to that, staff used a sit to stand lift for the resident. Staff 11 stated she had worked the day shift on 7/24/25 and assisted Resident 13 to get up and dressed for breakfast. She recalled she and another CNA used the Hoyer because the resident appeared weak and in pain. She stated the resident did not have any injuries that morning and was certain because she had changed the resident's shirt.On 8/6/25 at 12:31 PM, Staff 4 (RN) stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's left breast area and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the size of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. Staff 4 stated at that point, Staff 1, Staff 2 and Staff 3 took it from there. On 8/6/25 at 3:06 PM, Staff 13 (CNA) stated on 7/24/25 she assisted Staff 14 with transferring Resident 13 using the sit to stand a little before 5:00 PM. She recalled the resident was placed in the sit to stand, the straps were on, the resident's feet were positioned correctly and the resident grabbed the bar. Staff 13 and Staff 14 stood Resident 13 up and the resident stated shit loudly, which was unusual for the resident. Staff 13 stated she noticed the resident was already tired when they transferred her but did not notice anything else. On 8/6/25 at 4:17 PM Staff 5 (LPN) confirmed she worked the evening shift on 7/24/25. She stated she wasn't made aware of the resident's injury until the CNAs told her the resident was transferred into her/his chair and to bed when they noticed the significant bruising. Staff 5 stated the CNAs stated the resident stated ouch when she/he was getting ready for dinner and later was seen leaning to the left side. She stated the bruise was already a deep, dark color, the whole left side flank from [her/his] armpit to the belly button and around to the back, almost to the spine. The breast was huge, hard and had and dark blue bruise. Staff 5 stated she decided to use the hoyer to put the resident in bed, turned her/him to the right side and used ice for the injury. She stated the injury was reported to NOC shift who passed it on to day shift on 7/25/25. Efforts to contact Staff 14 on 8/6/25 and 8/7/25 were unsuccessful. On 8/7/25 at 10:45 AM, Staff 1 (Administrator) stated on 7/25/24 he, Staff 2 and the CNAs re-enacted what happened and they thought the harness in the sit to stand might have caught the resident's left breast when she/he was transferred for dinner and the injury was exacerbated by the blood thinner. On 8/7/25 at 10:45 AM, Staff 2 stated when she examined Resident 13 on 7/25/25, the bleeding had spread below the resident's breast area. She and Staff 3 examined the resident and did not feel the resident sustained a deep tissue injury. A 7/25/24 at 9:23 AM progress note written by Staff 3 stated reported that during sit to stand transfer last evening that the resident called out in pain. On exam no injury was noted at that time, night RN was notified. On RN exam this am the resident was noted to have large area of bruising, swelling and discomfort to left breast extending under left arm/lateral chest. The note further stated the facility provider was notified and the recommendation was to discontinue the anticoagulant and use ice packs on the affected area. No nursing notes were written on 7/26/25; notes from 7/27/25 through 7/29/25 revealed the swelling to the affected area continued, the resident was painful and nursing staff continued to hold the anticoagulant and apply ice packs. No provider notes were observed in the resident's chart during the time frame. On 7/29/25 at 2:06 PM, a nursing note revealed the facility was contacted by laboratory staff, who informed staff the resident's hematocrit (the percentage of red blood cells in a blood sample) and hemoglobin (proteins in red blood cells that carry oxygen throughout the body) levels were critically low. The facility's provider was contacted and recommended the resident be sent to the ED. Hospital ED records dated 7/29/25 diagnosed Resident 13 with acute blood loss anemia from left side torso hematoma/contusion exacerbated by anticoagulant use for secondary stroke prevention with possible splenic infarct (a condition in which blood flow supply to the spleen is compromised and can cause tissue death in the spleen). Two units of PRBC (packed red blood cells) were ordered and transfused. Resident 13 was discharged from the hospital on 7/31/25 and returned to the facility. She/he was observed on 8/6/25 at 11:33 AM but was not interviewed due to her/his cognitive status. A large green colored bruise was observed on the resident's left upper arm area. On 8/7/25 at 10:45 AM, Staff 1, Staff 2 and Staff 3 were informed of the findings of staff not following Resident 13's care plan for transferring a resident with a Hoyer lift instead of a sit to stand.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse for 1 of 4 sampled residents (#11) reviewed for abuse. This placed resi...
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Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse for 1 of 4 sampled residents (#11) reviewed for abuse. This placed residents at risk for abuse and psychosocial harm. Findings include: The facility's Abuse Policy, updated in 3/2025, defined abuse as the willful infliction of injury with resulting physical harm, pain or mental anguish. Physical abuse was defined as hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing and shoving.Resident 10 admitted to the facility in 2018 with diagnoses including stroke and dysphagia (inability to swallow). Resident 10's MDS Quarterly dated 11/7/24 revealed a BIMS score of 99, indicating the assessment could not be completed. Resident 10's Care Plan revised on 12/29/24, revealed she/he had verbal and physical aggression toward others and behaviors such as pulling or knocking things off walls and counters and unsafe behaviors during mealtime. Care plan interventions included providing distractions, to monitor and cue the resident at all times during meals. Resident 11 admitted to the facility in 2023 with diagnoses including hypertension and atrial fibrillation (an irregular, fast heartbeat).Resident 11's MDS Quarterly dated 8/23/24 revealed a BIMS score of 14, indicating no cognitive impairment. The MDS indicated Resident 11 had no behavioral issues. On 9/23/24, the State Survey Agency (SSA) received a FRI which indicated on 9/22/24, Resident 10 grabbed a beverage bottle from Resident 11's cup holder and threw it at Resident 11. The bottle struck Resident 11 in the face, hit the resident's eyeglasses and she/he sustained a small cut on the bridge of her/his nose. The report indicated all staff were in resident rooms providing care to other residents. On 8/6/25 at 2:53 PM, Staff 12 (CNA) stated she remembered Resident 10 and Resident 11 had several altercations because Resident 10 accused Resident 11 of stealing her/his wallet and wanted to fight. She stated the incidents went from bad to worse and at some point Resident 10 was placed on one on one supervision but did not recall when that occurred. She recalled Resident 10 assaulted people, tried to run over staff's toes, turned hall lights off and on and threw things. On 8/7/25 at 9:08 AM, Staff 15 (RN) stated Resident 10 was aggressive, knocked pictures and objects off the walls, cursed at residents and was sexually inappropriate with staff. She stated she witnessed interactions between Resident 10 and Resident 11 where they cursed and threatened each other. She stated after the 9/22/24 incident, Resident 10 was placed on one on one supervision. Residents 10 and 11 were not interviewed due to their discharge from the facility. A risk management report was initiated by nursing staff on 9/22/24 which noted Resident 11 was observed to have a cut on her/his nose and first aid was provided. Review of Resident 10's nursing notes from 6/2024 through 9/2024 revealed she/he initiated several incidents with Resident 11 and other residents at the facility, including throwing punches at Resident 11 and staff. No physical harm to residents was determined in each of the incidents. On 8/7/25 at 11:05 AM, Staff 1 (Administrator) confirmed the incident occurred on 9/22/24.
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 report an injury of unknown origin to the appropriate State agency within state mandated timelines for 1 of 3 sampled resi...
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Based on interview and record review it was determined the facility failed to report an injury of unknown origin to the appropriate State agency within state mandated timelines for 1 of 3 sampled residents (#13) reviewed for accidents and falls. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a Hoyer sling. On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 had received an injury of unknown origin on her/his chest area and the resident experienced significant bruising, swelling at the chest area and was not sent to the hospital for several days after the injuries were apparent.NO FRI's were received by the SSA regarding the injury. On 8/6/25 at 12:31 PM, Staff 4 (RN) stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's chest area, and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the side of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. At that point Staff 4 stated he went to his office and sent a note to Staff 1 (Administrator) and Staff 2 (DNS) because he thought the injury should be reported. Staff 4 stated at that point Staff 1, Staff 2 and Staff 3 (RNCM) took it from there. On 8/7/25 at 10:45 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (RCM) were notified of the findings they did not report Resident 13's injury of unknown origin to the SSA.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined the facility failed to respond to a change of condition related to anticoagulant use for 1 of 3 sampled residents (#13) reviewed for change of c...
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Based on interview and record review, it was determined the facility failed to respond to a change of condition related to anticoagulant use for 1 of 3 sampled residents (#13) reviewed for change of condition. This placed residents at risk for adverse side effects of anticoagulant use. Findings include: According to Drugs.com https://www.drugs.com/, serious side effects of anticoagulant medication include bleeding, with common adverse reactions including anemia, hemorrhage, and nausea.Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). The care plan also indicated the resident received an anticoagulant (blood thinner) for her/his anemia. On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 had received an injury of unknown origin on her/his chest area and the resident experienced significant bruising, swelling at the chest area and was not sent to the hospital for several days after the injuries were apparent. Both complainants stated the resident was on anticoagulant medication (blood thinner) and should have been sent to the hospital immediately after the significant bruising was discovered. On 8/5/25 at 5:14 PM, Witness 1 (Complainant) stated paramedics were called to the facility on 7/29/25 and the facility reported Resident 13's hemoglobin level was low and the resident was lethargic. Witness 1 was told the resident was involved in a Hoyer accident on 7/24/25 and sustained bruising on her/his arm. Witness 1 stated no other information was provided by staff. When Resident 13 arrived at the ED, Witness 1 stated he observed the resident had significant bruising across her/his chest, upper abdomen and back, the bruises on the resident's upper abdominal area were black, dark purple and blue and wrapped around to the resident's back. Witness 1 stated the injuries looked like an injury where someone was hit by a car.if there's any sort of trauma and someone's on a blood thinner, she/he needed to go out when it happened. You don't know what's going on internally, she/he could have had significant injury to her/his organs. On 8/6/25 at 8:45 AM, Witness 2 (Complainant) stated nursing staff at the facility observed Resident 13 on 7/26/25 immediately after the day shift nurse came on and received report from the NOC nurse. Witness 2 stated the nurses observed the resident's left breast area to be swollen almost four times the size the area normally was, the whole area was black and blue and bruised down to mid rib on the resident's back. The resident appeared to be in severe pain, so the day shift nurse immediately asked another nurse (Staff 4 - RN) to examine Resident 13. Staff 4 examined the resident's injuries, stated the resident looked as if she/he had fallen and should be sent out. Witness 2 stated Staff 2 (DNS) and Staff 3 (RNCM) were immediately notified, examined Resident 13 but decided not to send her/him to the hospital. Witness 2 stated the resident was given ice packs for the swelling and scheduled pain medication. Witness 2 later learned Resident 13's blood test results revealed critical levels, requiring hospitalization and blood transfusions. On 8/6/25 at 12:31 PM, Staff 4 stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's chest area, and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the size of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. Staff 4 then saw Staff 1 (Administrator) and told Staff 1 he thought Resident 13 should be sent out due to the resident's bruising and pain. Staff 4 stated at that point Staff 1, Staff 2 and Staff 3 took it from there.On 8/6/25 at 4:17 PM. Staff 5 (LPN) confirmed she worked the evening shift on 7/24/25. She stated she wasn't made aware of the resident's injury until the CNAs told her the resident was transferred into her/his chair and to bed when they noticed the significant bruising. Staff 5 stated the CNAs stated the resident stated ouch when she/he was getting ready for dinner and later was seen leaning to the left side. She stated the bruise was already a deep, dark color, the whole left side flank from her/his armpit to the belly button and around to the back, almost to the spine. The breast was huge, hard and had a dark blue bruise. Staff 5 stated I should have sent [her/him] out when she observed the resident's injury. On 8/7/25 at 10:45 AM, Staff 2 (DNS) stated when she examined Resident 13 on 7/25/25, the bleeding had spread below the resident's breast area. She and Staff 3 examined the resident and did not feel the resident sustained a deep tissue injury.A 7/25/25 at 9:23 AM progress note written by Staff 3 stated reported that during sit to stand transfer last evening that the resident called out in pain. On exam no injury was noted at that time, night RN was notified. On RN exam this am the resident was noted to have large area of bruising, swelling and discomfort to left breast extending under left arm/lateral chest. The note further stated the facility provider was notified and the recommendation was to discontinue the anticoagulant and use ice packs on the affected area. The facility provided documentation those orders were followed. There was no documented evidence in Resident 13's nursing notes the injury was monitored or assessed on 7/26/25.On 7/28/25 at 11:18 AM an order was input for a comprehensive metabolic panel (CMP) test to be completed due to the resident's infection at the site of an IV line in her/his arm. No nursing notes were observed to contain any further communication with the facility provider until 7/29/25.On 7/29/25 at 2:06 PM, a nursing note revealed the facility was contacted by laboratory staff, who informed staff the resident's hematocrit (the percentage of red blood cells in a blood sample) and hemoglobin (proteins in red blood cells that carry oxygen throughout the body) levels were critically low. The facility's provider was contacted and recommended the resident be sent to the ED.Hospital ED records dated 7/29/25 diagnosed Resident 13 with acute blood loss anemia from left side torso hematoma/contusion exacerbated by anticoagulant use for secondary stroke prevention with possible splenic infarct (a condition in which blood flow supply to the spleen is compromised and can cause tissue death in the spleen). Two units of PRBC (packed red blood cells) were ordered and transfused. On 8/7/25 at 10:45 AM, Staff 1, Staff 2 and Staff 3 were informed of the findings of staff not responding to a resident's change of condition related to anticoagulant use.
Jun 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were given the right to participate in the development of their person-centered care plan for 1 of 1 samp...
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Based on interview and record review it was determined the facility failed to ensure residents were given the right to participate in the development of their person-centered care plan for 1 of 1 sampled resident (#2) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include:
Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls.
A review of Resident 2's health record revealed Resident 2 had not had a care conference completed since 11/9/23.
A review of Resident 2's care plan revealed on 2/7/24, 3/5/24, 3/6/24 and 5/10/24, Resident 2's care plan was updated.
On 6/23/24 at 12:36 PM, 6/24/24 at 11:55 AM, and 6/26/24 at 9:09 AM, Resident 2 stated with dissatisfaction, her/his most recent care conference was sometime last year. Resident 2 stated it was important for her/him to be involved in her/his care planning process and other residents participated regularly in care conferences so she/he did not understand why she/he had not had a care conference since last year.
On 6/25/24 at 9:14 AM, Staff 8 (SSD) stated, due to changes in staff, it was difficult to get a team together in order to conduct care conferences. Staff 8 confirmed Resident 2 did not have a care conference since 11/9/23 and she expected residents to be offered care conferences at least quarterly. Staff 8 stated Resident 2 always participated in her/his care conferences and one should have been scheduled since 11/9/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 3 sampled residents (#s 7 and 17)...
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Based on interview and record review it was determined the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 3 sampled residents (#s 7 and 17) reviewed for abuse. This placed residents at risk for abuse. Findings include:
1. Resident 7 was admitted to the facility in 6/2018, with diagnoses including dementia with behavior disturbances.
Resident 7's 9/1/23 Care Plan indicated she/he had physical and verbal aggressive behaviors with instructions to intervene if this behavior escalated.
Resident 17 was admitted to the facility in 3/2023, with diagnoses including hemiplegia (limited motor control of one side of the body).
A 9/21/23 BIMs indicated Resident 17 had normal cognitive function.
Resident 17 exhibited physical and verbal aggressive behaviors as indicated by her/his 9/1/23 care plan. Interventions included to intervene when the resident displayed these behaviors.
On 11/3/23 a FRI was received by the State Survey Agency (SSA) which reported Resident 7 disturbed Resident 17's personal item which resulted in Resident 17 punching Resident 7. Immediate intervention was required to separate Resident 7 and Resident 17.
The incident investigation from 11/3/23 included Resident 17 stating we were both hitting each other at first and then I hit him, I punched him in the face so he would stop.
A 11/3/23 Progress Note stated Resident 17 and Resident 7 were witnessed by Staff 19 (RN) hitting each other.
On 6/26/24 at 10:33 AM, Resident 17 stated she/he hit [Resident 7] in the face so [she/he] would stop bothering me and my things. [Resident 7] kept doing it. I figured if I kept hitting [Resident 7], they would stop.
On 6/27/24 at 11:45 AM, Staff 19 stated she witnessed Resident 17 and Resident 7 yelling at each other and striking each other on 11/3/23.
On 6/27/24 at 10:12 AM, Staff 2 (DNS) stated Resident 7 knew exactly how to push Resident 17 buttons which resulted in both residents hitting each other. Staff 2 confirmed Resident 7 and Resident 17 were involved in an incident of physical abuse on 11/3/23.
2. Resident 7 was admitted to the facility in 6/2018, with diagnoses including dementia with behavior disturbances.
Resident 7's 9/1/23 Care Plan indicated she/he had physical and verbal aggressive behaviors with instructions to intervene if this behavior escalated.
Resident 17 was admitted to the facility in 3/2023 with diagnoses including hemiplegia (limited motor control of one side of the body).
A 9/21/23 BIMs indicated Resident 17 had normal cognitive function.
Resident 17 exhibited physical and verbal aggressive behaviors as indicated by her/his 9/1/23 care plan. Interventions included to intervene when the resident displayed these behaviors.
On 11/6/23 a FRI was received by the State Survey Agency (SSA) which reported Resident 7 had disturbed Resident 17's personal item which resulted in Resident 17 approaching Resident 7, yelling at Resident 7 and attempting to strike Resident 7.
The incident investigation included Resident 17 stating, I looked and saw [Resident 7] sitting at my doorway. I yelled at [her/him] to leave my stuff alone and hurried over. I do not deny, I stood up from my wheelchair and hit [Resident 7] on the right side of [her/his] face.
On 6/24/24 at 1:06 PM, Staff 4 (CNA) stated she did not recall the specific dates of the incidents she had witnessed, but stated she witnessed Resident 7 and Resident 17 striking each other on 3 separate incidents during 2023.
On 6/27/24 at 9:48 AM, Staff 18 (Housekeeping Manager) stated on 11/6/23 she heard an argument in the hallway and witnessed Resident 7 and Resident 17 yelling at each other, pushing each other and throwing punches at each other. Staff 18 stated immediate intervention was required to separate Resident 7 and Resident 17.
On 6/27/24 at 10:12 AM, Staff 2 (DNS) stated Resident 7 knew exactly how to push Resident 17 buttons which resulted in both residents hitting each other. Staff 2 confirmed Resident 7 and Resident 17 were involved in an incident of physical abuse on 11/6/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to accurately assess residents for falls for 1 of 1 sampled resident (#6) reviewed for falls. This placed residents at risk f...
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Based on interview and record review it was determined the facility failed to accurately assess residents for falls for 1 of 1 sampled resident (#6) reviewed for falls. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include:
Resident 6 was admitted to the facility in 10/2023 with diagnoses including dementia.
The 3/28/24 Quarterly MDS indicated Resident 6 had one fall with major injury since her/his prior MDS assessment on 1/3/24.
On 6/24/24 at 2:57 PM Staff 2 (DNS) stated Resident 6 had no falls since her/his prior MDS assessment on 1/3/24 and the resident's 3/28/24 Quarterly MDS, fall section, was inaccurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 26 was admitted to the facility on [DATE], with diagnoses including depression.
Review of the medical record reveale...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 26 was admitted to the facility on [DATE], with diagnoses including depression.
Review of the medical record revealed Resident 26 was not provided with a written summary of her/his basline care plan.
On 6/25/24 at 1:54 PM, Staff 3 (Divisional Director of Clinical Operations) verified there was no documentation to indicate the baseline care plan was discussed with Resident 26 or a written summary was offered. Staff 3 further indicated there was no system in place to provide a baseline care plan to residents and their representatives.
Based on interview and record review it was determined that facility failed to develop and provide a summary of the baseline care plan for 3 of 8 sampled residents (#s 25, 26 and 180) reviewed for pain, nutrition and ADLs. This placed residents at risk for being uninformed of their plan of care. Findings include:
1. Resident 25 was admitted to the facility in 5/2024, with diagnoses including dementia without behavioral disturbances.
Review of the Resident 25's health record indicated no evidence the facility provided a written summary of the baseline care plan to the resident or their representative.
During an interview with Staff 2 (DNS) on 6/27/24 at 4:23 PM, she stated she did not know if a summary of the baseline care plan was provided to the resident.
2. Resident 180 was admitted to the facility in 6/2024, with diagnoses including compression fracture (occurs when one or more bones in the spine weaken and crumple).
Review of Resident 180's health record indicated that a baseline care plan was not developed within 48 hours of admission and did not include resident centered pain interventions. There was no evidence the baseline care plan was provided to the resident.
Interview with Staff 2 (DNS) on 6/27/24 at 4:23 PM, she stated the baseline care plan should be completed with 48 hours and did not know if a summary of the baseline care plan was provided to with the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#2) reviewed for vision. This placed residents at ri...
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Based on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#2) reviewed for vision. This placed residents at risk for impaired vision. Finding include:
Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls.
A 12/6/23 Physician Order indicated Resident 6 was referred for an eye examination due to visual changes and double vision.
The 5/1/24 Quarterly MDS indicated Resident 2 had no impaired cognitive functioning and the resident wore glasses.
A review of Resident 2's heath record revealed no evidence an eye examination was discussed with the resident, scheduled or completed.
Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 4:30 PM revealed Resident 2 was not wearing glasses.
On 6/23/24 at 12:40 PM, Resident 2 stated she/he was supposed to wear glasses and asked for glasses several months ago but nobody followed up.
On 6/27/24 at 10:50 AM, Staff 2 (DNS) confirmed there was no evidence in Resident 2's health record that an eye examination was discussed with Resident 2 or completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 provide appropriate treatment and ser...
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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 provide appropriate treatment and services to maintain and prevent a potential decrease in mobility for 1 of 2 sampled residents (#5) reviewed for rehabilitation services. This placed residents at risk for loss of mobility. Findings include:
Resident 5 was admitted to the facility in 12/2022 with age-related debility (weakness).
Resident 5's 6/14/24 PT Discharge Summary indicated the resident was discharged from PT services on 6/14/24.
Resident 5's current Walk Daily Program task indicated Resident 5 was to be walked by CNA staff from her/his room to the nursing station and back using a front wheeled walker every day before lunch.
A review of Resident 5's health record revealed no evidence the resident was walked by staff from her/his room to the nursing station and back on any days since Resident 5 was discharged from PT services.
Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed no observations of Resident 5 being walked by staff.
On 6/23/24 at 1:28 PM, Resident 5 stated she/he was discharged from PT services earlier this month and was supposed to walk everyday with staff. Resident 5 stated she/he had not walked for at least the past two weeks. Resident 5 stated it was very important for her/him to keep up with her/his walking or she/he would lose her/his walking abilities and become weak.
On 6/25/24 at 10:00 AM, Staff 11 (PTA) stated Resident 5 was discharged from PT services on 6/14/24 and was supposed to be walked by staff everyday. Staff 11 stated Resident 5 had not been walked since her/his discharge from PT services.
On 6/25/24 at 11:00 AM and 6/26/24 at 8:52 AM, Staff 12 (CNA) and Staff 7 (CNA) stated no CNAs walked Resident 5. Staff 7 stated she saw Resident 5's Walk Daily Program on the resident's [NAME] (a care plan that gives a brief overview of the resident's care needs) but she did not have time to walk Resident 5 given the number of residents assigned to her.
On 6/26/24 at 1:19 PM, Staff 2 (DNS) stated CNAs were expected to complete Resident 5's Walk Daily Program and acknowledged Resident 5's Walk Daily Program was not being completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 6 and 10) reviewed for unnecessary medications. This placed ...
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Based on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 6 and 10) reviewed for unnecessary medications. This placed residents at risk for inaccurate treatment. Findings include:
1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone).
Resident 6's 10/3/23 Physician Order indicated the resident was to receive levothyroxine (medication to treat hypothyroidism) one time a day to be given alone before breakfast.
Resident 6's 5/2024 MAR revealed no documentation the resident's levothyroxine was administered on 5/6 and 5/30.
On 6/26/24 at 1:53 PM, Staff 2 (DNS) stated the same nurse worked on 5/6/24 and 5/30/24 and the nurse administered Resident 6's levothyroxine on both days but did not document that he administered the medication because he was distracted during change of shift.
2. Resident 10 was admitted to the facility in 8/2021 with diagnoses including stomach ulcer.
Resident 10's 12/28/22 Physician Order indicated the resident was to receive Protonix (a medication to treat stomach ulcers) one time a day, 30 minutes before meals.
Resident 10's 5/2024 MAR revealed no documentation the resident's Protonix was administered on 5/6 and 5/30.
On 6/27/24 at 11:00 AM, Staff 2 (DNS) stated the same nurse worked on 5/6/24 and 5/30/24 and the nurse administered Resident 10's Protonix on both days but did not document that he administered the medication because he was distracted during change of shift.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet reside...
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Based on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include:
On 6/23/24 the facility had a census of 26 residents. On 6/27/24, Staff 2 (DNS) provided a list of residents who:
-Required two-person mechanical lift transfers: 13;
-Required one or two-person extensive or total assistance for bathing: 21;
-Required one or two-person extensive or total assistance for toileting: 18;
-Required one or two-person extensive or total assistance for dressing: 22;
-Required two person assistance at all times for all care: 3;
-Had behavioral healthcare needs which required monitoring: 19;
-Were at risk for elopement: 5.
Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed multiple times when no CNA staff were visualized in the hallways for up to 30 minutes.
On 6/23/24 at 12:34 PM, Resident 2 stated there were staffing issues on evening and night shift. Resident 2 stated, at times, there was only one nurse and one CNA scheduled which resulted in long call light response times.
On 6/23/24 at 1:35 PM, Resident 27 stated the facility was often short staffed, especially at night. Resident 27 stated recently it took staff so long to answer her/his call light, she/he began crying. Resident 27 stated she/he was incontinent and often waited up to 30 minutes to have her/his brief changed. Resident 27 stated she/he no longer used the call light because the wait was so long and she/he got up by herself/himself even though she/he was not supposed to.
On 6/23/24 at 2:16 PM, Resident 10 stated evening and night shift staffing was not good. Resident 10 stated she/he waited up to 30 minutes for her/his call light to be answered, at times.
On 6/23/24 at 3:13 PM, Resident 26 stated she/he did not typically require pain medication but on this date she/he had pain and requested pain medication. Resident 26 stated it took one hour and five minutes before pain medication was administered.
On 6/24/24 at 1:33 PM, Witness 1 (Complainant) reported staffing was a consistent problem for a long time. Witness 1 stated there were times when only one nurse and one CNA worked the entire facility. Witness 1 stated the facility continued to admit residents even though they were unable to properly staff CNAs to meet the residents' needs.
On 6/24/24 at 2:08 PM, Staff 4 (CNA) stated the facility recently had rough times regarding staffing. Staff 4 stated when the facility was short CNA staff, call lights were not answered timely, CNAs were unable to complete all of the residents' care and showers did not get completed. Staff 4 stated all shifts were impacted by a lack of staffing but evening and night shift were impacted the most.
On 6/25/24 at 9:32 AM, Staff 10 (CMA) stated medications were administered to residents late. Staff 10 indicated it was hard to get medications administered to all residents timely as ordered.
On 6/25/24 at 9:48 PM, Staff 5 (CNA) stated the facility had high acuity residents including many residents with dementia. Staff 5 stated nearly one-half of the residents required two person assistance for transfers using a mechanical lift and three residents required two person care at all times. Staff 5 stated there was one resident who was aggressive and could not be properly monitored when staffing was low and the resident wandered into everyone's room and started fights. Staff 5 stated some shifts were one to two CNAs short which resulted in an increase in falls and residents being upset due to long call light response times. Staff 5 stated at times she was assigned 13 to 14 residents which was a very heavy load.
On 6/26/24 at 12:25 PM, Staff 9 (CMA) stated the morning medications were not all administered timely due to staffing.
On 6/26/24 at 2:14 PM, Staff 2 (DNS) stated there were concerns with low staffing and low staffing could be mentally draining for staff. Staff 2 stated staff felt stressed there won't be enough staff. Staff 2 acknowledged there were multiple shifts that lacked adequate CNA coverage.
On 6/26/24 at 4:45 PM, Staff 1 (Administrator) stated the facility was not doing well with staffing and acknowledged there were multiple shifts that lacked adequate CNA coverage.
Apr 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to complete quarterly care conferences and include residents and their representatives in their care planning process for 1 o...
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Based on interview and record review it was determined the facility failed to complete quarterly care conferences and include residents and their representatives in their care planning process for 1 of 3 sampled residents (#22) reviewed for behaviors. This placed residents and their representatives at risk for not making their care needs and health care decisions known. Findings include:
Resident 22 was admitted to the facility in 9/2022 with diagnoses including dementia and anxiety.
Review of Resident 22's medical record revealed the resident's last care conference was completed on 11/10/22. There was no indication a care conference was held between 12/2022 and 4/2023.
On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 22 and her/his representative did not have a care conference since November of 2022. She stated a busy workload and time constraints caused her to fall behind on scheduling and completing resident care conferences.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure misappropriation of medications for 2 of 2 sampled residents (#s 12 and 13) reviewed for misappropriat...
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Based on observation, interview and record review it was determined the facility failed to ensure misappropriation of medications for 2 of 2 sampled residents (#s 12 and 13) reviewed for misappropriation. This placed residents at risk for lack of medications. Findings include:
Resident 12 was admitted to the facility in 2021 with diagnoses including diabetes.
Resident 13 was admitted to the facility in 2020 with diagnoses including an irregular heart beat.
Resident 3 was admitted to the facility in 2019 with diagnoses including diabetes and a history of blood clots.
Review of a 2/24/23 FRI and associated investigation revealed on 2/24/23 the facility identified Resident 3 did not have her/his apixaban (blood thinner) or metformin (treats diabetes) available in the medication cart. Residents with the same medications and dosages were identified. The pharmacy ran a report and the facility determined Resident 12 was short one metformin and Resident 13 was short one apixaban. The facility provided Resident 12 and Resident 13 a full 30 day supply of medications and ordered Resident 3 her/his medications on a stat [urgent] delivery. It was determined Staff 13 (CMA) used Resident 12's metformin and Resident's 13's apixaban for Resident 3.
Resident 3's, 12's and 13's 2/2023 MARs revealed there were no missed medication administrations.
On 4/4/23 at 7:52 AM Staff 13 stated on one occasion she borrowed medications from other residents when Resident 3 ran out of her/his medications. She did not recall who she borrowed the medications from but stated it was the same medication with the same dosage. Staff 13 also stated it only happened on one day. Staff 13 stated the facility provided education on how to order medications. Staff 13 was able to verbalize the facility medication re-ordering process.
On 4/4/23 at 10:18 AM Staff 1 (Interim Administrator) stated during a routine Quality Assurance (QA) audit they discovered Resident 3's apixaban and metformin were not available in the medication cart, but the resident was still administered the medication. During the investigation it was determined Staff 13 was the staff involved with the misappropriation. Staff 1 indicated Staff 13 did not recall from whom she borrowed the medication. The facility worked with the pharmacy to determine who was on the same medications, when the medications were last filled and how many doses should have been used to date. It was determined one of Resident 12's metformin was missing and one of Resident 13's apixaban was missing. Resident 12 and 13 were reimbursed a 30 day supply of the medication. Staff 1 stated education was provided to all staff who administered medication and routine medications were now on auto-refill. Continued education will be provided to staff at all staff meetings on abuse which includes misappropriation. Staff 1 stated the facility will continue to check the medication carts as part of the QA process on a quarterly basis.
During medication administration observation residents had medications available.
On 3/3/23, the Past Noncompliance was corrected when the facility completed an investigation of Resident 3's lack of available metformin and apixaban. The Plan of Correction included: 1. Staff education on Medication Cart Organization Technique, Pharmacy Delivery, Medication Re-ordering and Rights of Medication Administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure assessments accurately reflected the residents' status for 2 of 5 sampled residents (#s 21 and 22) reviewed for unn...
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Based on interview and record review it was determined the facility failed to ensure assessments accurately reflected the residents' status for 2 of 5 sampled residents (#s 21 and 22) reviewed for unnecessary medications. This placed residents at risk for inaccurate assessments. Findings include:
1. Resident 21 was admitted to the facility in 9/2022 with diagnoses including depression and vascular dementia.
Resident 21's 3/3/23 quarterly MDS indicated the resident received an anticoagulant medication (Section N: Medications - N0410 Medication Received) and received antipsychotic medications on a routine basis (Section N: Medications - N0450 Antipsychotic Medication Review).
Review of Resident 21's medical record revealed the resident did not have orders for and did not receive an anticoagulant medication or an antipsychotic medication.
On 4/6/23 at 10:02 AM Staff 4 (MDS Coordinator/RNCM) verified Resident 21 did not have orders for and did not receive an anticoagulant medication or antipsychotic medication and confirmed the resident's 3/3/23 quarterly MDS was inaccurately coded.
2. Resident 22 was admitted to the facility in 9/2022 with diagnoses including dementia and chronic obstructive pulmonary disease.
Resident 22's 1/21/23 significant change MDS indicated the resident received an anticoagulant medication (Section N: Medications - N0410 Medication Received).
Review of Resident 22's medical record revealed the resident did not have orders for and did not receive an anticoagulant medication.
On 4/7/23 at 11:15 AM Staff 4 (MDS Coordinator/RNCM) verified Resident 22 did not have orders for and did not receive an anticoagulant medication and confirmed the resident's 1/21/23 significant change MDS was inaccurately coded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a copy of a baseline care plan was provided to a resident for 1 of 3 sampled residents (#25) reviewed for dental se...
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Based on interview and record review it was determined the facility failed to ensure a copy of a baseline care plan was provided to a resident for 1 of 3 sampled residents (#25) reviewed for dental services. This placed residents at risk for being uninformed about their care plans. Findings include:
Resident 25 was admitted to the facility 3/9/23 with diagnoses including UTI.
Resident 25's 3/14/23 MDS indicated she/he was cognitively intact.
Review of the resident's record revealed no evidence Resident 25 was provided a copy of her/his baseline care plan.
On 4/3/23 at 12:16 PM Resident 25 stated the facility did not review the care plan with her/him.
On 4/5/23 at 1:18 PM Staff 4 (MDS Coordinator/RNCM) stated the facility was to review baseline care plans with residents and provide a copy. If the resident declined a copy it was documented in the resident's record. A request was made to Staff 4 to provide documentation to verify Resident 25's baseline care plan was offered. 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
3. Resident 228 was admitted to the facility in 4/2021 with diagnoses including a traumatic subdural hemorrhage (bleeding between the brain and the skull caused by a head injury).
A review of Resident...
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3. Resident 228 was admitted to the facility in 4/2021 with diagnoses including a traumatic subdural hemorrhage (bleeding between the brain and the skull caused by a head injury).
A review of Resident 228's nursing progress notes revealed she/he arrived at the facility wearing a heart monitor on her/his chest.
Staff 12 (RN) reported in a 4/23/21 nursing progress note there were no orders for Resident 228's heart monitor.
No evidence was found in Resident 228's clinical record to indicate nursing staff contacted the hospital to obtain orders for the heart monitor or provided care related to the heart monitor during her/his stay at the facility.
On 4/6/23 at 11:44 AM Staff 4 (MDS Coordinator/RNCM) acknowledged Resident 228 did not have signed orders for a heart monitor when she/he was admitted to the facility. She stated it was her expectation the nursing staff would follow up with the hospital for orders because without it, we don't know what to do.
2. Resident 128 was admitted to the facility in 11/2022 with diagnoses including Parkinson's disease and dementia.
Review of Resident 128's bowel care monitoring sheets for 12/2022 and 1/2023 indicated the resident went multiple times without a documented bowel movement (BM) for 3 or more days:
-12/2/22 to 12/7/22 (six days) , 12/17/22 to 12/21/22 (five days) and 12/23/22 to 12/29/22 (seven days).
-1/7/23 to 1/14/23 (eight days), 1/16/23 to 1/23/23 (eight days) and 1/25/23 to 1/30/23 (six days).
Resident 128's 12/2022 and 1/2023 MARs revealed two separate PRN orders for a bisacodyl suppository for constipation. One as needed for constipation if no results from milk of magnesia (MOM) administer per MD order on next shift, during
waking hours only and another every 24 hours as needed for constipation. It was documented Resident 128 received the bisacodyl suppository on the following days:
-For 12/2022, on 12/21/22 (Ineffective), 12/26/22 (Unknown) and 12/28/22 (Effective).
-For 1/2023, on 1/11/23 (Ineffective), 1/13/23 (Ineffective) and 1/30/23 (Unknown).
There were five times when the resident went three or more days without a bowel movement and no bowel care protocol was implemented to address Resident 128's constipation:
-12/2/22 to 12/7/22 (six days),
-12/17/22 to 12/20/22 (four days)
-1/7/23 to 1/10/23 (four days)
-1/16/23 to 1/23/23 (eight days)
-1/25/23 to 1/29/23 (five days)
There was no documentation of any indication of pain including abdominal pain or other concerns from Resident 128.
A 1/25/23 physician note revealed Staff 8 (Medical Director) examined the resident. There were no acute signs of distress and no concerns were found with the resident's gastrointestinal system.
On 4/5/23 at 10:50 AM, Staff 7 (RN) was unable to recall if Resident 128 had any bowel or constipation issues. If the resident did, she/he would be placed on the bowel care protocol list which would initiate the administration of the facility bowel protocol that consisted of the bisacodyl suppository and would be documented on resident's MAR. She could not recall the resident having any complaints of pain including abdominal pain.
On 4/6/23 at 10:42 AM, Staff 4 (MDS Coordinator/RNCM) stated Resident 128 had been identified as needing bowel care a few times but she was not aware of any follow up. Staff 4 reviewed the resident's 12/2022 and 1/2023 MARs and verified the bowel care protocol and physician orders were not documented as being followed. She was not aware of any complaints of abdominal pain or general pain for the resident. Overall, Staff 4 reported the resident was pleasant and interacted with others.
On 4/7/23 at 10:19 AM, Staff 8 (Medical Director) acknowledged completing an examination of Resident 128 and to his recollection nothing stood out. Staff 8 was not aware of any constipation issues or of any pain including abdominal pain for the resident.
Based on interview and record review it was determined the facility failed to provide and/or assess residents' need for bowel care and identify and provide care for a heart monitor for 3 of 7 sampled residents (#s 13, 128 and 228) reviewed for medications, change of condition and medical devices. This placed residents at risk for constipation and not receiving prescribed treatments. Findings include:
1. Resident 13 was re-admitted to the facility in 2022 with diagnoses including repair of a hip fracture.
Review of a 2/17/23 quarterly MDS revealed Resident 13 was moderately cognitively impaired and required extensive assistance from two staff for toileting and transfers.
Review of the resident's 3/2023 and 4/2023 bowel report revealed Resident 13 had a bowel movement on 3/22/23. Resident 13 did not have another bowel movement until 3/27/23, five days later. The resident's next documented bowel movement after 3/27/23 was on 4/4/23, eight days later.
Review of the resident's 3/2023 MAR revealed the resident was to be administered Senna (laxative) PRN constipation and/or polyethylene glycol (laxative) PRN. The 3/2023 and 4/2023 MAR revealed bowel care was not provided to Resident 13 between 3/22/23 and 3/27/23 or between 3/27/23 and 4/4/23.
An undated bowel care form revealed staff were to document information including the date of a resident's last bowel movement, bowel assessments were to be documented every shift if a resident did not have a bowel movement for four days and/or after interventions were provided, and if the physician was notified a resident did not have a bowel movement in more than four days. The form revealed Resident 13 had a bowel movement on 3/27/23. A hand written note indicated the resident reported she/he had a bowel movement on 3/29/23 and the resident reported the bowel movement to the CNA. The form did not have a bowel assessment for Resident 13.
Resident 13's 3/2023 and 4/2023 Progress Notes revealed from 3/22/23 through 4/4/23 there was no assessment of the resident's bowel status or the need for bowel care .
On 4/5/23 at 12:40 PM Staff 13 (CMA) stated a resident was to be administered bowel care if they did not have a bowel movement after the third day. It was tracked on a bowel sheet. If a resident refused bowel care the nurse was notified and the medication refusal was documented on the MAR.
On 4/5/23 at 1:02 PM Staff 7 (RN) stated residents were to have bowel care if they did not have a bowel movement for three days. The nurse was to do an assessment of the resident's abdomen and document in the resident's record.
On 4/5/23 at 1:09 PM Staff 4 (MDS Coordinator/RNCM) stated Resident 13's mentation and health varied from month to month and at times was able to walk by her/himself and could possibly go to the bathroom independently. Staff 4 acknowledged the bowel sheet had a note indicating the resident reported she/he had a bowel movement between 3/22/23 and 3/27/23 and there should have been an assessment of the resident's status in the progress notes. A request was made to Staff 4 to provide documentation of bowel assessments and/or medications that were provided to the resident between 3/22/23 and 3/27/23 and between 3/27/23 and 4/4/23. 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure medications were ordered timely for 1 of 1 sampled resident (#3) reviewed for medication refills. This placed resid...
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Based on interview and record review it was determined the facility failed to ensure medications were ordered timely for 1 of 1 sampled resident (#3) reviewed for medication refills. This placed residents at risk for ineffective medication regimen. Findings include:
Resident 3 was admitted to the facility in 2019 with diagnoses including diabetes and a history of blood clots.
A 2/24/23 FRI and associated investigation revealed on 2/24/23 the facility identified Resident 3 did not have her/his apixaban (blood thinner) or metformin (treats diabetes) available in the medication cart.
Resident 3's 2/2023 MARs revealed there were no missed medication administrations.
On 4/4/23 at 7:52 AM Staff 13 (CMA) stated on one occasion she borrowed medications from other residents when Resident 3 ran out of medications. She did not recall who she borrowed the medications from but stated it was the same medication and the the same dosage.
On 4/4/23 at 10:18 AM Staff 1 (Interim Administrator) stated during a routine Quality Assurance (QA) audit they found Resident 3's apixaban and metformin were not available in the medication cart. Staff 1 stated education was provided to all staff who administered medication and now routine medications were auto-refilled. Staff 1 stated the facility will continue to check the medication carts as part of the QA process on a quarterly basis to ensure all residents have prescribed medications on hand.
During medication administration observation residents' medications were available.
On 3/3/23, the Past Noncompliance was corrected when the facility completed an investigation of Resident 3's lack of available metformin and apaxiban. The Plan of Correction included: 1. Staff education on Medication Cart Organization Technique, Pharmacy Delivery, Medication Re-ordering and Rights of Medication Administration.
Refer to F602 for additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#1) reviewed ...
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Based on interview and record review it was determined the facility failed to withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for low blood pressure. Findings include:
Resident 1 was admitted to the facility in 7/2013 with diagnoses including hypertension (high blood pressure).
Physician orders from 10/18/22 for metoprolol tartrate stated Give 12.5 mg orally two times a day related to essential hypertension. Hold for [systolic blood pressure (SBP; upper blood pressure measurement)] <110.
Review of Resident 1's MAR from 3/2023 revealed she/he received metoprolol tartrate outside of physician ordered parameters of SBP on:
- 3/5/23 morning administration. SBP was 104.
- 3/5/23 evening administration. SBP was 104.
- 3/15/23 evening administration. SBP was 102.
- 3/24/23 evening administration. SBP was 102.
- 3/25/23 morning administration. SBP was 102.
- 3/30/23 evening administration. SBP was 102.
On 4/5/23 at 5:05 PM Staff 7 (RN) confirmed metoprolol tartrate was given to Resident 1 outside of physician ordered parameters on the listed dates and administration times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#2) reviewed for dental care needs. This placed residen...
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Based on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#2) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include:
Resident 2 was admitted to the facility in 8/2021 with diagnoses including stroke.
On 4/3/23 at 4:15 PM Resident 2 was observed to have several damaged lower teeth which appeared jagged and dark. She/he reported, My lower teeth are gone mostly. Last time I saw a dentist was three years ago.
Resident 2's current signed physician orders (dated 2/10/23) provided for her/him to have a consult and treatment for dental work as indicated.
Resident 2's most recent comprehensive MDS assessment and CAAs (dated 6/16/22) indicated no obvious or likely cavities or broken natural teeth. The CAA worksheet revealed the resident's cognitive deficit contributed to her/his dental problems. The assessment did not provide for the inclusion of dental care in her/his care plan.
On 4/6/23 at 9:13 AM Staff 15 (CNA) reported she assisted Resident 2 with oral care on several occasions. She reported Resident 2 complained of gum pain when she/he brushed her/his teeth. Staff 15 stated she notified the nurse a few times but did not recall which nurse.
On 4/6/23 at 9:54 AM Staff 7 (RN) reported she was unaware Resident 2 had any specific dental issues and she/he had not said anything about the need to see a dentist.
On 4/6/23 at 11:13 AM Staff 4 (MDS Coordinator/RNCM) stated, Oral care in long term care is horrible or null. She acknowledged she was responsible for completing comprehensive annual MDS assessments and she was not working in the facility when Resident 2's annual assessment was completed. She stated she expected resident dental needs to be reported to her so she could refer them for dental work.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
2. Resident 10 was admitted to the facility in 11/2017 with diagnoses including stroke.
Review of Resident 10's medical record revealed her/his 2/9/23 Care Conference document was incomplete. The only...
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2. Resident 10 was admitted to the facility in 11/2017 with diagnoses including stroke.
Review of Resident 10's medical record revealed her/his 2/9/23 Care Conference document was incomplete. The only section completed was for activities.
On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 10's 2/9/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 2/9/23 Care Conference document.
3. Resident 20 was admitted to the facility in 6/2022 with diagnoses including depression.
Review of Resident 20's medical record revealed her/his 2/16/23 Care Conference document was incomplete. The only section completed was for activities.
On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 20's 2/16/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 2/16/23 Care Conference document.
4. Resident 21 was admitted to the facility in 9/2022 with diagnoses including depression.
Review of Resident 21's medical record revealed her/his 3/10/23 Care Conference document was incomplete. The document was missing information on social services, therapy and discharge.
On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 21's 3/10/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 3/10/23 Care Conference document.
Based on interview and record review it was determined the facility failed to ensure care conferences were documented for 4 of 7 sampled residents (#s 10, 13, 20 and 21) reviewed for behaviors, unnecessary medications, care planning and nutrition. This placed residents at risk for incomplete records. Findings include:
1. Resident 13 was admitted to the facility in 2020 with diagnoses including chronic lung disease.
A 2/16/23 Care Conference Form revealed the resident's weight was filled out and the resident's activity status was addressed. The sections of the form to indicate if the resident or resident's responsible party attended or was invited, who attended from the facility and if there were any identified concerns from the resident or responsible party were blank. The nursing summary, dietary summary, social services summary, therapy summary and follow up sections were also blank.
On 4/6/23 at 10:31 AM Staff 6 (Social Services) stated the resident's care conference was done but she did not yet transcribe all the notes into the resident's record.
Jan 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure staff performed appropriate PP...
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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 staff performed appropriate PPE use or adequate hand hygiene for 1 of 2 halls observed. This placed residents at risk for infection. Findings include:
The Centers for Disease Control and Prevention (CDC) website section titled, Hand Hygiene in Healthcare Settings indicated healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water immediately after touching a patient and the patient's immediate environment. Healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with CDC recommendations.
The January 2023 Oregon Health Authority updated rule for health care facilities directed consistent masking by health care providers . Masks act as source control if the provider has COVID-19 and provide a protective effect if a patient has COVID-19 . Health care personnel must wear a face covering when entering, exiting and a face mask while they are in a health care setting in accordance with the requirements.
On 1/23/23 at 1:24 PM Staff 3 (RNCM) was observed to remove a foot rest from a resident's wheelchair across from the nursing station. Staff 3 walked to resident room [ROOM NUMBER] where she was observed to touch a green plastic bag and clothing in the resident's closet. Staff 3 closed the closet door, exited the resident's room and walked to the nursing station and touched the counter with no hand hygiene observed.
On 1/23/23 at 3:17 PM Staff 7 (CNA) was observed at the nursing station with his face mask under his chin, and talking to Staff 10 (RN) within six feet of each other
On 1/23/23 at 3:41 PM Staff 2 (DNS) and Staff 3 were observed in the DNS' office with no face masks and within six feet of each other.
On 1/23/23 at 3:44 PM Staff 7 was observed to walk into resident room [ROOM NUMBER] and assisted the resident with dialing her/his phone. Staff 7 walked out of the room, touched a doorknob across from nursing station, with no hand hygiene observed after he touched the residents' phone.
During an interview on 1/24/23 at 5:07 PM Staff 7 stated hand hygiene was to be performed after he touched a resident or their belongings. Staff 7 acknowledged he was directed to wear the face mask while in facility and should not wear it under his chin at the nursing station.
On 1/25/23 at 9:16 AM Staff 9 (CNA) was observed with her face mask under her chin, wiped her nose, pulled the face mask up over her nose and touch the medication cart with no hand hygiene performed.
On 1/25/23 at 12:26 PM Staff 3 stated staff were expected to wear face masks, except while eating, in the facility at all times. Staff 3 stated staff were expected to perform hand hygiene after contact with a resident or their belongings.
On 1/25/23 at 1:00 PM Staff 1 (Executive Director) was informed of staff's lack of hand hygiene after handling items within each of the resident's immediate environment and lack of proper face mask use. Staff 1 stated she expected staff to perform hand hygiene after resident contact and face masks were to be worn as directed while in the facility.
Nov 2022
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure bathing was provided for 1 of 3 sampled residents (#1) reviewed for ADL's. This placed residents at ri...
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Based on observation, interview and record review it was determined the facility failed to ensure bathing was provided for 1 of 3 sampled residents (#1) reviewed for ADL's. This placed residents at risk for lack of personal hygiene. Findings include:
Resident 1 admitted to the facility in 8/2021 with diagnoses including arthritis and hypertension.
The 9/8/22 Quarterly MDS assessed Resident 1 with a BIMS score of 12 (mildly impaired cognition) and as needing extensive physical assist from staff for personal hygiene, which included bathing.
Resident 1's 11/2022 care plan instructed staff to provide a shower two times weekly.
Record review of the bathing records from 10/1/22 to 10/31/22 revealed Resident 1 was provided a shower on 10/8/22 and 10/18/22. Resident 1 received bed baths on 10/11/22, 10/15/22, 10/22/22 and 10/29/22. No refusals were documented.
On 10/31/22 at 2:33 PM Resident 1 was observed in her/his bed, appeared well groomed with no foul odor. Resident 1 stated the facility was often short staffed and she/he does not always receive a shower as scheduled.
Between 10/31/22 at 2:25 PM and 11/1/22 at 11:00 AM interviews with Staff 3 (CNA), Staff 4 (CNA) and Staff 5 (CNA) were conducted and revealed staff were not always able to provide resident showers as care planned.
On 11/1/22 at 12:45 PM Staff 1 (Executive Director) and Staff 2 (DNS) acknowledged Resident 1's bathing record. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to staff an RN for 8 consecutive hours per day 7 days per week for 7 out of 61 days reviewed for staffing. This placed reside...
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Based on interview and record review it was determined the facility failed to staff an RN for 8 consecutive hours per day 7 days per week for 7 out of 61 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include:
A review of the Direct Care Staff Daily Reports from 9/1/22 through 10/31/22 revealed seven days without eight consecutive hours of RN coverage on any shift in a 24-hour period on the following days:
- 9/9/22.
- 9/26/22.
- 9/28/22.
- 10/3/22.
- 10/4/22.
- 10/5/22.
- 10/26/22.
On 11/1/22 at 12:45 PM Staff 1 (Executive Director) acknowledged days with no RN on the floor for any shift during a 24-hour period. No additional information was provided.
Feb 2022
8 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to identify, assess and treat an injury ...
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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 identify, assess and treat an injury of unknown origin and failed to follow physician orders for 2 of 4 sampled residents (#126 and 11) reviewed for skin conditions and nutrition. This placed residents at risk for untreated and worsening skin impairments and unidentified weight loss. Findings include:
1. Resident 126 was admitted to the facility in 1/2018 with diagnoses including Parkinson's Disease.
Resident 126's 11/2021 Significant Change MDS indicated the resident was cognitively impaired and had no skin issues.
On 2/1/22 at 10:25 AM Resident 126 was observed in the facility's common area near the nursing station. Resident 126 had a dark purple bruise which covered the top of her/his left hand. Within the bruised area, there were two scabs, each approximately two centimeters in length.
Resident 126's care plan, last revised 5/13/21, directed staff to complete a skin inspection daily with cares, observe for impairments and report to the nurse. The care plan indicated Resident 126 had fragile skin, a history of skin tears and was at risk for skin issues.
Resident 126's 1/2022 physician orders directed staff to complete a weekly skin audit every Wednesday evening and document YES for new skin impairment and NO for no new impairment.
Review of Resident 126's 1/2022 TAR revealed a checkmark and staff initials every Wednesday for the skin audit and lacked the corresponding YES or NO documentation.
Review of Resident 126's health record revealed no evidence the left hand skin impairment was identified, assessed or treated.
On 2/2/22 at 1:25 PM Staff 21 (CNA) stated she noticed the bruise and scabs on Resident 126's left hand but was unsure how or when it happened.
On 2/2/22 at 1:36 PM Staff 3 (RN) stated she was not aware of any skin issues on Resident 126.
On 2/2/22 at 1:53 PM Staff 22 (Divisional Director of Clinical Operations) observed Resident 126's left hand bruise and scabs. Staff 22 was notified there was no documentation related to the skin impairment. At 3:18 PM, Staff 22 confirmed there was no documentation in the resident's health record to indicate the skin impairment was identified, assessed and treated. Staff 22 acknowledged Resident 126's care plan indicated the resident had fragile skin and daily skin inspections were expected.
2. Resident 11 admitted to the facility on 12/2021 with diagnoses including Alzheimer's Disease, morbid (severe) obesity and pneumonia.
Resident 11's 12/3/21 Physician Order directed the facility to provide weekly weights every Friday for four weeks and one time a day every 30 day(s). The order was discontinued on 1/31/22 with reason of discharge from facility.
Record review of Resident 11's 12/2021 TAR revealed weight were taken on 12/10/21 and 12/24/21.
Record review of the Weights and Vitals Summary task for 12/2021 revealed weight taken on 12/3/21, 12/10/21, 12/17/21, and 12/24/21.
The 1/2022 TAR revealed the physician order for weekly weights one time a day every Friday for four weeks, start 12/10/21 to 1/31/22. No weights were documented on the TAR for 1/2022.
Record review on 2/4/22 revealed the Weights and Vitals Summary task for 1/2022 revealed weight were taken on 1/7/22. No other weights were recorded for 1/2022.
On 2/7/22 Staff 2 (DNS) confirmed Resisdent 11's physician order for weights taken [NAME] Friday and daily for first 30 days. She stated she expected staff to follow physician orders to take weights of residents. No other documentation was provided for Resident 11's weights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to provide appropriate treatment of a pressure ulcer for 1 of 1 sampled resident (#11) reviewed for pressure ul...
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Based on observation, interview, and record review it was determined the facility failed to provide appropriate treatment of a pressure ulcer for 1 of 1 sampled resident (#11) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:
Resident 11 was admitted to the facility in 12/2021 with diagnoses including post femoral fracture (leg fracture), Alzheimer's Disease, and pressure ulcer of sacral region (buttock).
The 12/3/21 to 1/17/22 Physician's Order instructed the following related to the pressure ulcer to buttock:
- . change pink foam bandages as needed related to pressure ulcer of sacral region .
Review of the 12/2021 and 1/2022 TAR revealed the pink foam bandage change to the buttock, was provided on 1/3/22.
The 1/10/22 Physician Order instructed the following related to the pressure ulcer on the buttock:
- Cleanse with normal saline, pat dry, apply Santyl (medication to remove dead tissue and heal wounds) to areas of slough, cover with foam dressing, change daily and PRN .
Review of the 1/2022 TAR revealed care was provided as instructed daily to the buttock from 1/10/22 to discharge.
Review of 12/2021 and 1/2022 Skin/Wound Progress Notes, Daily Skilled and Weekly Skin Evaluations revealed the following:
-12/10/21: Buttock wound has unchanged;
-12/17/21: Buttock wound worsening;
-12/25/21: Buttock wound worsening, MD to be notified;
- review reveled no evidence the physician was contacted;
-1/8/22: Buttock wound worsening, facility spoke with Staff 20 (Physician Assistant) and to start new order for Santyl;
-1/10/22: Physician order for Santyl treatment;
-1/11/22: Buttock wound worse, spoke with family, air mattress in place, turned side to side every two hours, change plan of care to not sit up daily for meals in wheelchair;
-1/12/22: Buttock improving;
-1/13/22: Buttock improving;
-1/16/22: Buttock worsening;
- review revealed no additional documentation of wound care treatments, interventions, or a wound care consult when identified the wound to worsen;
-1/21/22: Sent to hospital.
The 1/21/22 hospital notes by Witness 2 (Medical Doctor) indicated Resident 11 was admitted with significant dementia, multiple other comorbid medical conditions and had a sacral pressure ulcer which was infected. She/he was not septic or showed any signs of necrotizing fasciitis (acute disease, inflammation of muscle or organs). Witness 2 wrote Resident 11's sacral wound was highly unlikely to heal, and she/he was likely to have recurrent pressure ulcers due to health condition.
Resident 11 returned to the facility on 1/31/22.
Observations were made of Resident 11 with air mattress, turned positions and nutritional supplements on 2/2/22, 2/3/22 and 2/4/22, between the hours of 10:04 AM to 3:28 PM.
On 2/4/22 at 9:14 AM, observation was made of the sacral wound and dressing change. Staff 2 (DNS/RN), and Staff 3 (RN) were observed to perform the dressing change according to physician orders with no concerns.
In an interview on 2/7/22 at 12:08 PM, Staff 2 reported she measured, assessed, changed the foam dressing for Resident 11's wound weekly and reported changes to the physician. Staff 2 reported the wound was improving. She identified interventions to the plan of care such as protein shakes, Santyl treatment and to limit time up in wheelchair. Staff 2 identified significant worsening to the buttock wound after an extended time up in a wheelchair to an orthopedic visit. Staff 2 stated Resident 11's wheelchair cushion for the 1/13/22 appointment was in place. Staff 2 stated she contacted the physician as needed and assessed the non-pharmacalogical interventions as improving the wound. Staff 2 stated she utilized multiple areas within the health record inconsistently for documenting, tracking pressure ulcers in the facility and she was able to track the wound progression in her head.
On 2/8/22 at 11:57 AM, Staff 22 (Divisional Director of Operations/RN) provided Resident 11's wound care sheets the facility provided to the corporate office weekly. Staff 22 confirmed the facility was working on a system to consistently track wounds more clearly. Staff 22 stated the facility contacted Resident 11's physician, changed orders and the plan of care interventions prior to sending her/him to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to communicate a new area of pain and a...
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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 communicate a new area of pain and a pain intervention implemented for 1 of 3 sampled residents (#5) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include:
Resident 5 was admitted to the facility in 8/2021 with a diagnosis including non-operable pelvic fracture and osteoarthritis.
Resident 5's Care Plan dated 8/13/21 for pain indicated the resident had acute pain due to pelvic fracture. Staff were to anticipate the resident's needs for pain relief and respond immediately to any complaint of pain.
Resident 5's admission MDS dated [DATE] indicated the resident was cognitively intact. The Pain CAA dated 8/26/21 described severe pain with movement which interfered with her/his ability to sleep and her/his ability to perform daily activities.
A physical therapy encounter note dated 1/31/22 stated Resident 5 reported pain in right back/ribcage area. Biofreeze (pain relief gel) was applied and Resident 5 reported a decrease in pain.
In an interview on 2/1/22 at 10:34 AM Resident 5 stated she/he experienced new right side muscle pain due to coughing. Resident 5 pointed to the area and grimaced in pain. Resident 5 received Biofreeze to the painful area during physical therapy but was unable to get nursing staff to provide the Biofreeze.
In an interview on 2/3/22 at 12:46 PM, Staff 16 (CMA) stated Resident 5 had pain in her/his left hip and knees. Staff 16 stated she was unaware of any new areas of pain.
In an interview on 2/3/22 at 12:43 PM, Staff 8 (Director of Rehab/therapist) stated Resident 5 reported her/his ribs/back area hurt because of coughing. Staff 8 stated she applied Biofreeze and Resident 5 reported it was helpful. Staff 8 stated she did not inform nursing staff of the new area of pain or request an order for nursing to apply the Biofreeze.
In interviews on 2/4/22 at 11:10 AM and on 2/7/22 at 12:46, Staff 2 (DNS) stated she expected therapy staff to report when residents had new pain and any treatment provided for pain relief. Staff 2 confirmed nursing staff was unaware of Resident 5's new pain and the intervention used.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 adequate indication and clini...
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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 adequate indication and clinical rationale for the use of an antipsychotic (mind altering) medication for 1 of 5 sampled residents (#16) whose medications were reviewed. This placed residents at risk for receiving unnecessary psychotropic medications and experiencing adverse side effects. Findings include:
Resident 16 admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, and cerebrovascular accident (stroke).
Resident 16's admission Nursing Evaluation, signed complete by Staff 3 (RN) on 12/23/21 behavioral section indicated she/he was cooperative, and no other behaviors were documented.
A 12/25/21 Progress note indicated Resident 16 was upset and belligerent this evening when Staff 2 (DNS/RN) attempted to give a shot. The information was passed on to the night shift to try to administer the shot.
A 12/27/21 Progress note revealed Resident 16 had very sexually inappropriate behaviors with the female staff. Initiated cares in pairs and male staff to care for resident this evening shift.
The Progress note on 12/28/21 at 1:22 PM, by Staff 4 (RN) indicated Resident 16 was seen by the Staff 19 (Physician) today via telehealth (video conference) and new orders were received for quetiapine (antipsychotic) 25 mg for sexual behaviors.
A Physician Order for Resident 16 on 12/28/21 at 1145 AM for quetiapine fumarate tablet, give 25 mg by mouth one time only for sexual behavior toward staff for one day.
A Physician Order for Resident 16 on 12/29/21 at 8:00 AM for quetiapine fumarate tablet, give 25 mg by mouth one time a day for sexual behavior toward staff.
A Physician Order for Resident 16 on 1/5/22 at 8:00 AM for quetiapine fumarate tablet, give 25 mg by mouth one time a day for Dementia with behavioral disturbance.
Review of Resdent 16's health record revealed no behavior monitor in place prior to the intiation of the quetiapine.
Record review of the 12/28/21 admission MDS revealed Resident 16's BIMS score of 10 (8-12 moderately impaired). During the seven day look back period, physical and verbal behavior occurred one to three times. No other behaviors were indicated and no psychiatric/mood disorders were identified. The CAA indicated Resident 16 exhibited inappropriate sexual behaviors with no description or details of the behavior.
Record review revealed no other documentation on behaviors, non-pharmaceutical interventions or indication for use of an antipsychotic medication prior to 12/28/21.
Observations between 2/2/22 to 2/4/22 between 9:44 AM to 3:29 PM of Resident 16 in her/his room, pleasantly engaged with staff and own diversional activities.
On 2/7/22 Staff 5 (SSD) stated Resident 16 did not have a prior history of inappropriate sexual behaviors prior to admission to facility. Staff 5 recalled one incident of reported inappropriate verbal sexual behavior directed at staff prior to 12/28/21. Staff 5 was unable to provide evidence of non-pharmacological approaches, indicators for use of an antipsychotic prior to the start of the 12/28/21 quetiapine.
On 2/8/22 at 12:37 PM, Staff 22 (Regional Director of Clinical Operations) acknowledged she would expect interventions and documented indications for use prior to administration of an antipsychotic medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain medications timely to ensure the provision ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain medications timely to ensure the provision of routine medications for 5 of 6 sampled residents (#s 4, 23, 10, 16, and 21) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include.
1. Resident 4 was admitted to the facility in 4/2019 with diagnoses including nutritional anemia (iron-deficiency).
Resident 4's 1/2022 physician orders included an order for ferrous sulfate (iron) tablet 325 mg, one tablet two times a day every other day related to nutritional anemia.
Resident 4's 1/2022 MAR revealed OO marked on the following days for a total of 11 missed doses of iron:
- 1/4/22 day shift
- 1/6/22 day and evening shift
- 1/8/22 day shift
- 1/10/22 day and evening shift
- 1/12/22 day and evening shift
- 1/14/22 day shift
- 1/16/22 day and evening shift
On 2/4/22 at 8:46 AM Staff 16 (CMA) stated if OO was marked on the MAR, it indicated the medication was on order. Staff 16 stated a back up supply of over-the-counter medications such as iron were usually kept in the cabinet in the medication room. If there was not a back up supply, she notified Staff 1 (Executive Director) or Staff 2 (DNS) so the medication could be obtained from the local store. Staff 16 stated if the medication was unavailable longer than three or four days, she reminded Staff 1 or Staff 2 the medication was needed.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the findings of this investigation. Staff 22 stated there should not be missed doses of prescribed medications.
2. Resident 23 was admitted to the facility in 8/2021 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic kidney disease.
Resident 23's 1/2022 and 2/2022 physician orders included the following orders:
- Torsemide (a diuretic medication used to reduce extra fluid in the body) tablet 10 mg, one tablet one time a day for diuretic;
- Cholecalciferol capsule 2000 units one time a day for vitamin D3 deficiency.
Resident 23's 1/2022 and 2/2022 MARs revealed OO marked on the following days for a total of three missed doses of Torsemide:
- 1/7/22
- 2/3/22
- 2/4/22
Resident 23's 1/2022 MAR revealed OO marked on the following days for a total of seven missed doses of cholecalciferol:
- 1/10/22
- 1/11/22
- 1/12/22
- 1/13/22
- 1/14/22
- 1/16/22
- 1/17/22
On 2/4/22 at 8:46 AM Staff 16 (CMA) stated if OO was marked on the MAR, it indicated the medication was on order. Staff 16 stated she ordered residents' prescription medications from the pharmacy as needed when the supply was getting low.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the findings of this investigation. Staff 22 stated there should not be missed doses of prescribed medications.
3. Resident 10 was admitted to the facility in 4/2019 with diagnoses including Major Depressive Disorder, diabetes, and hypertension.
Resident 10's 1/2022 physician orders included the following orders:
- Bupropion 150 mg tablet 24 hour extended release one time a day related to Major Depressive Disorder;
- Cholecalciferol tablet 1000 units one time a day for vitamin D3 deficiency;
- Ferrous Sulfate (iron) 325 mg tablet one time every other day related to Anemia;
- Metoprolol Succinate 12.5 mg tablet extended release one time per day related to hypertension (heart);
- Zoloft 50 mg tablet one time per day related to Major Depressive Disorder;
- Potassium Chloride 10 mEq (one thousandth) tablet one time per day related to Hypokalemia (low potassium);
- Apixaban 5 mg tablet give two times per day related to venous thrombosis (blood clot) and embolism (blood clot or air bubble);
- Bactrim 800 - 1600 mg tablet two times per day, 1/9/22 to 1/26/22, related to cellulitis (skin infection);
- Fexofenadine 180 mg tablet one time a day related to Allergic Rhinitis.
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of two missed doses of Bupropion:
- 1/10/22
- 1/11/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of seven missed doses of cholecalciferol:
- 1/10/22
- 1/11/22
- 1/12/22
- 1/13/22
- 1/14/22
- 1/16/22
- 1/17/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of nine missed doses of ferrous sulfate:
- 1/3/22
- 1/5/22
- 1/7/22
- 1/9/22
- 1/11/22
- 1/13/22
- 1/15/22
- 1/17/22
- 1/23/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of three missed doses of Metoprolol Succinate:
- 1/3/22
- 1/4/22
- 1/5/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of one missed dose of Zoloft:
- 1/5/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of two missed doses of potassium:
- 1/6/22
- 1/7/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of three missed doses of Apixaban:
- 1/6/22 day shift
- 1/7/22 day shift
- 1/22/22 day shift
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of 10 missed doses of Bactrim:
- 1/21/22 evening shift
- 1/22/22 day and evening shift
- 1/23/22 day and evening shift
- 1/24/22 day and evening shift
- 1/25/22 day and evening shift
- 1/26/22 day shift
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of 15 missed doses of Fexofenadine;
- 1/4/22, 1/5/22, 1/6/22, 1/7/22, 1/8/22, 1/9/22, 1/10/22, 1/11/22, 1/12/22, 1/13/22, 1/15/22, 1/16/22, 1/17/22
- 1/29/22
- 1/30/22
On 2/4/22 at 8:46 AM Staff 16 (CMA) stated if OO was marked on the MAR, it indicated the medication was on order. Staff 16 stated she ordered residents' prescription medications from the pharmacy as needed when the supply was getting low.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the findings of this investigation. Staff 22 stated there should not be missed doses of prescribed medications.
4. Resident 16 admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, and cerebrovascular accident (stroke).
Resident 10's 1/2022 physician orders included the following order:
- Quetiapine Fumarate 25 mg tablet one time a day for dementia with behaviors.
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of one missed dose of quetiapine fumarate;
- 1/29/22
On 2/4/22 at 8:46 AM Staff 16 (CMA) stated if OO was marked on the MAR, it indicated the medication was on order. Staff 16 stated she ordered residents' prescription medications from the pharmacy as needed when the supply was getting low.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the findings of this investigation. Staff 22 stated there should not be missed doses of prescribed medications.
5. Resident 21 was admitted to the facility in 4/2019 with diagnoses including Major Depressive Disorder, diabetes, and chronic pain.
Resident 21's 1/2022 physician orders included the following orders:
- Duloxetine capsule 60 mg delayed release one time a day related to Major Depressive Disorder;
- Ferrous Sulfate 325 mg tablet one time every other day related to Anemia;
- Flomax 0.4 mg capsule one time a day for BPH (blood pressure heartrate);
- Furosemide 20 mg tablet one time a day related to edema (fluid retention);
- Lidocaine 4% patch applied to neck and back topically one time a day related to Chronic Pain Syndrome;
- Metformin 850 mg tablet one time a day related to Type Two Diabetes Mellitus;
- Potassium Chloride 10 mEq (one thousandth) tablet one time per day related to use of diuretics;
- Apixaban 5 mg tablet give two times per day related to atrial fibrillation (heart);
- Guaifenesin 600 mg tablet extended release two times per day related to mucus.
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of one missed dose of Duloxetine:
- 1/14/22
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of nine missed doses of ferrous sulfate:
- 1/3/22
- 1/5/22
- 1/7/22
- 1/9/22
- 1/11/22
- 1/13/22
- 1/15/22
- 1/17/22
- 1/23/22
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of 10 missed doses of Flomax:
- 1/4/22
- 1/5/22
- 1/19/22, 1/20/22, 1/21/22, 1/22/22, 1/23/22, 1/24/22, 1/25/22, 1/26/22.
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of one missed dose of Furosemide:
- 1/10/22
Resident 10's 1/2022 MAR revealed OO marked on the following days for a total of seven missed doses of Lidocaine patch:
- 1/15/22
- 1/16/22
- 1/17/22
- 1/26/22
- 1/27/22
- 1/29/22
- 1/31/22
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of two missed doses of potassium:
- 1/4/22
- 1/5/22
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of one missed dose of Apixaban:
- 1/8/22 day shift
Resident 21's 1/2022 MAR revealed OO marked on the following days for a total of 15 missed doses of Guaifenesin:
- 1/12/22 day and evening shift
- 1/13/22 day and evening shift
- 1/14/22 day and evening shift
- 1/15/22 day and evening shift
- 1/16/22 day and evening shift
- 1/17/22 day and evening shift
- 1/18/22 evening shift
- 1/28/22 evening shift
- 1/29/22 evening shift.
On 2/4/22 at 8:46 AM Staff 16 (CMA) stated if OO was marked on the MAR, it indicated the medication was on order. Staff 16 stated she ordered residents' prescription medications from the pharmacy as needed when the supply was getting low.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the findings of this investigation. Staff 22 stated there should not be missed doses of prescribed medications.
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 ensure a medication pass error rate of less than 5%. There were four errors in 29 opportunities resulting in ...
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Based on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were four errors in 29 opportunities resulting in a 13.79% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include:
Resident 23 was admitted to the facility in 8/2021 with diagnoses including chronic obstructive pulmonary disease (COPD).
Resident 23's 2/2022 physician orders included the following orders:
- Advair HFA Aerosol 115-21 MCG/ACT, inhale two puffs two times a day related to COPD. Rinse mouth after use;
- Calcium tablet 500 mg, give two tablets by mouth two times a day for hypocalcemia;
- Flonase Suspension 50 MCG/ACT, one spray in both nostrils one time a day for allergic rhinitis;
- Potassium Chloride tablet extended release, 40 mEq two times a day for supplement.
On 2/4/22 at 8:22 AM Staff 16 (CMA) was observed to prepare and administer Resident 23's medications and the following errors occurred:
- Staff 16 did not instruct or assist Resident 23 to rinse her/his mouth with water after inhalation of Advair HFA Aerosol;
- Staff 16 did not dispense or administer the calcium tablets;
- Staff 16 administered two sprays of Flonase Suspension in both nostrils;
- Staff 16 dispensed and administered only 20 mEq Potassium Chloride.
On 2/4/22 at 10:23 AM Resident 23's medication orders were reviewed with Staff 16 and Staff 16 acknowledged the medication errors.
On 2/8/22 at 12:37 PM Staff 22 (Divisional Director of Clinical Operations) was notified of the medication errors. No further information was provided.
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 ensure proper personal protective equipment (PPE), store and handle utensils in a sanitary manner in 1 of 1 ...
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Based on observation, interview, and record review it was determined the facility failed to ensure proper personal protective equipment (PPE), store and handle utensils in a sanitary manner in 1 of 1 kitchen. This placed the residents at risk for cross contamination and illness. Findings include:
1. During the 2/7/22 at 4:19 PM observation of kitchen meal service, Staff 11 (Dietary Manager) was observed to push a wheeled cart, with trays of eating utensils on the top rack, through the north door which led to the assisted living facility dining area.
On 2/7/22 at 5:14 PM, Staff 11 was observed to receive the wheeled cart through the door from the assisted living staff. Staff 11 took the trays of eating utensils off the wheeled cart and placed them next to the steam table where the meal trays were prepared for service.
In an interview on 2/7/22 at 5:15 PM, Staff 11 acknowledged the eating utensils were placed next to the steam table for resident use. Staff 11 acknowledged she did not know if the eating utensils were contaminated in the assisted living dining area. Staff 11 promptly removed the eating utensils.
On 2/7/22 at 5:29 PM, Staff 11 confirmed she would expect eating utensils sanitized after they were in a public area and before service to a resident.
2. During the 2/7/22 at 4:19 PM kitchen meal service, observation was made in the kitchen of a table with three chairs, directly under an air vent from ceiling and within six feet of the steam table. Below the steam table were open shelves which contained open boxes of condiment packets such as ketchup, mustard, peanut butter, jelly, soy sauce and salt and pepper. On top of the table was an open can of soda pop, two cups, personal keys with a lanyard, ink pen, white napkins, and a cell phone. On the chair closest to the steam table hung a gray sweat shirt.
On 2/7/22 at 5:12 PM, Staff 12 (Dietary Aide) confirmed the kitchen staff take off their face masks, face shields and use the table as a break area.
On 2/7/22 at 5:29 PM, Staff 11 (Dietary Manager) confirmed the kitchen staff use the table in the kitchen as a break area when tray line is not in process and remove their face masks and face shields. Staff 11 acknowledged the condiments and steam tray line were within six feet and should remain free of possible contamination.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a sus...
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Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection. This placed residents at risk for not being informed of the facility's COVID-19 outbreak status. Findings include:
On 2/7/22 at 2:45 PM Staff 1 (Executive Director) provided a COVID-19 infection notification letter, dated 11/15/21. The letter included notification of a positive case of COVID-19 and mitigating actions taken by staff.
On 2/7/22 at 2:49 PM Staff 1 stated after the occurrence of a suspected or confirmed COVID-19 infection, she drafted a notification letter. Staff 1 stated the receptionist mailed copies of the letter out to resident representatives and families and stated a letter was passed out to each resident in the facility. Staff 1 could not confirm the residents, the resident representatives and resident families were notified by 5:00 PM the next calendar day after a single occurrence and could not confirm the facility provided timely cumulative updates. Staff 1 stated there was no documented evidence the notifications occurred as required.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Oregon facilities.
- • 42% turnover. Below Oregon's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 32 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Milton Freewater Health & Rehabilitation Center's CMS Rating?
CMS assigns MILTON FREEWATER HEALTH & REHABILITATION 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 Milton Freewater Health & Rehabilitation Center Staffed?
CMS rates MILTON FREEWATER HEALTH & REHABILITATION CENTER's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 42%, compared to the Oregon average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Milton Freewater Health & Rehabilitation Center?
State health inspectors documented 32 deficiencies at MILTON FREEWATER HEALTH & REHABILITATION CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 31 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Milton Freewater Health & Rehabilitation Center?
MILTON FREEWATER HEALTH & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EMPRES OPERATED BY EVERGREEN, a chain that manages multiple nursing homes. With 70 certified beds and approximately 30 residents (about 43% occupancy), it is a smaller facility located in MILTON FREEWATER, Oregon.
How Does Milton Freewater Health & Rehabilitation Center Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, MILTON FREEWATER HEALTH & REHABILITATION CENTER's overall rating (3 stars) matches the state average, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Milton Freewater Health & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Milton Freewater Health & Rehabilitation Center Safe?
Based on CMS inspection data, MILTON FREEWATER HEALTH & REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oregon. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Milton Freewater Health & Rehabilitation Center Stick Around?
MILTON FREEWATER HEALTH & REHABILITATION CENTER has a staff turnover rate of 42%, 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 Milton Freewater Health & Rehabilitation Center Ever Fined?
MILTON FREEWATER HEALTH & REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Milton Freewater Health & Rehabilitation Center on Any Federal Watch List?
MILTON FREEWATER HEALTH & REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.