TIGARD REHABILITATION AND CARE
For profit - Limited Liability company
112 Beds
SAPPHIRE HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
3/100
#123 of 127 in OR
Photo by Spencer Ross
Photo by Spencer Ross
Photo by Lord Gnat
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Tigard Rehabilitation and Care has received a Trust Grade of F, indicating poor performance with significant concerns about the quality of care. Ranking #123 out of 127 facilities in Oregon places them in the bottom half, and they are last among the nine nursing homes in Washington County. Unfortunately, the facility is worsening, with reported issues increasing from 3 in 2024 to 8 in 2025. Staffing is a relative strength, with a low turnover rate of 0%, but they have concerning RN coverage, which is less than 90% of other Oregon facilities, suggesting limited oversight. The facility has accumulated fines of $54,945, higher than 75% of Oregon facilities, indicating recurring compliance issues. Specific incidents include a critical failure to properly disinfect medical equipment, which exposed residents to potential infections, and a lack of monitoring for food storage temperatures, risking foodborne illnesses. Overall, while staffing may be stable, the facility's serious deficiencies raise red flags for families considering care for their loved ones.
- Trust Score
- F
- In Oregon
- #123/127
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $54,945 in fines. Higher than 84% of Oregon facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for Oregon. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 46 deficiencies on record. Higher than average. Multiple issues found across inspections.
3/100
Bottom 4%
Review needed
3 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Oregon average (3.0)
Significant quality concerns identified by CMS
Federal Fines: $54,945
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: SAPPHIRE HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 46 deficiencies on record
1 life-threatening
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk ...
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Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 5 admitted to the facility in 2011 with diagnoses including anxiety, mood and personality disorder. The 7/20/23 Care Plan indicated Resident 5 had behaviors of refusing cares, refusing all wound cares and other cares including bathing and hygiene tasks. Resident 5 was not easily directed and interventions by staff escalated the resident's agitation. Resident 5 had history of being verbally and physically aggressive toward staff. Interventions included: to not argue with the resident and to discontinue attempts to treat if she/he became agitated and reapproach later. A 1/6/25 Facility Reported Incident indicated the following:- - On 1/4/25 Resident 5 told Staff 21 (RN) to go to Hell when attempting to complete wound care. Staff 21 was heard by CNA Staff reply to Resident 5, I'm already in Hell. You're Satan's bitch, aren't you? Staff 21 also threatened to call the police on Resident 5 for assault because the resident grabbed the collar of Staff 21's isolation gown. - - Staff 19's (CNA) witness statement indicated she and Staff 20 (CNA) went to provide a brief change to Resident 5. Staff 19 indicated Resident 5 was not accepting cares, but they were able to start changing the resident's brief. Staff 21 came into the room to complete wound care. Resident 5 became upset because of the brand of cream being used. Resident 5 became agitated and grabbed Staff 21's gown, tore it and told her to Go to Hell. Staff 21 was heard replying, I'm already there and you're Satan's bitch. Staff 21 stated she was going to call the police and press charges on Resident 5 for assault. - - Staff 20's witness statement indicated she and Staff 19 went to change Resident 5's brief and Staff 21 also went into the room to complete wound care. Resident 5 did not want to be changed and was not calming down. Staff 21 informed her and Staff 19, it was fine, keep changing [her/him]. Resident 5 was upset about the cream being used and both Resident 5 and Staff 21 were yelling back and forth at each other. - - Staff 21 indicated Resident 5 was calling her names and told her to go to Hell. Staff 21 told the resident wound care had to be done, and she/he needed to be changed, the resident continued to yell. Staff 21 indicated Resident 5 grabbed her and she told the resident she could report her/him. Staff 21 indicated she stated she was in Hell but did not recall saying anything else. - - Resident 5 indicated she/he told Staff 21 to get out and Staff 21 told her/him she was going to call them to take her/him away. Resident 5 was unable to recall any other statements made by Staff 21. - - The investigation indicated Resident 5's care plan was not followed related to staff not discontinuing attempts to treat and provide care when the resident became agitated. No psychosocial harm was found, and Staff 21 was terminated. Abuse was unable to be ruled out related to the verbal abuse toward Resident 5. On 7/10/25 at 11:07 AM Resident 5 was unable to recall the incident that occurred between her/him and Staff 21. On 7/10/25 at 1:10 PM Staff 19 stated she and Staff 20 went into Resident 5's room with Staff 21 to change the resident's brief and complete wound care. Staff 19 stated they were all wearing gowns due to the resident being on Enhanced Barriers Precautions. Staff 19 stated Resident 5 lashed out and grabbed Staff 21's gown and told her to go to Hell. Staff 19 stated Staff 21 told the resident that she was already there, and she/he was Satan's bitch. Staff 19 stated they were able to change the resident, but she/he continued to lash out and Staff 21 threatened to call the police on the resident for assaulting staff. Staff 19 stated Resident 5 had a history of being resistive to care. Staff 19 stated when Resident 5 was being resistive to cares staff were to leave the room, reassess and reapproach. Staff 19 stated Staff 21 told her and Staff 20 to keep going with providing the brief change and to not worry about it even though Resident 5 was resistive.On 7/10/25 at 12:14 PM Staff 20 stated Resident 5 had known behaviors of refusing cares. Staff 20 stated her, and Staff 19 went into Resident 5's room to change her/his brief and Staff 21 was also in the room to complete wound care. Staff 20 stated Resident 5 was not complying with care and refusing to be changed. Staff 20 stated Staff 21 told her and Staff 19 to go ahead and change the resident even though she/he was freaking out and told them to get out. Staff 20 stated both Staff 21 and Resident 5 were yelling at each other. Staff 20 stated she heard Staff 21 telling Resident 5 she/he was Satan's bitch. Staff 20 stated when Resident 5 was resistive to cares, staff were to walk away and reapproach. On 7/10/25 at 12:57 PM Staff 21 stated Resident 5 was hateful and on 1/4/25 Resident 5 was calling her names, trying to hit and kick her and told her to go to Hell. Staff 21 stated she told Resident 5 that she was already there and then proceeded to say something under her breath. Staff 21 stated CNA staff overheard her and reported it. Staff 21 stated she did not argue about what she reportedly said. Staff 21 further stated she was directed by Staff 15 (Former DNS) to force brief changes at least once a day which triggered the resident's behaviors.On 7/14/25 at 11:45 AM Staff 15 stated on 1/4/25 Staff 21 attempted to complete a treatment on Resident 5. Resident 5 was noncompliant, and verbiage was said by Staff 21. Staff 15 denied having any conversations with Staff 21 to force brief changes on Resident 5. Staff 15 stated staff were to encourage cares to be completed and if Resident 5 continued to refuse then to reapproach at a later time. On 7/10/25 at 1:30 PM Staff 1 (Administrator) acknowledged the 1/4/25 incident between Staff 21 and Resident 5 resulted in abuse. No further information was provided.
Jan 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavio...
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Based on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care. Findings include:
Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.
A 10/12/24 admission MDS revealed Resident 52's preferred language was Spanish and she/he needed an interpreter to communicate with health care staff.
A 10/28/24 care plan revealed Resident 52 spoke Spanish.
A review of the medical record revealed the following English language documents were issued to and signed by Resident 52:
- 10/14/24 Portable Orders for Life-Sustaining Treatment (POLST),
- 10/22/24 Notice of Medicare Non-Coverage,
- 10/29/24 Notice of Medicare Non-Coverage,
- 1/9/25 SNF Discharge Instructions/Recapitulation of Stay.
On 1/14/25 at 11:52 AM Witness 2 (Complainant) stated she visited with Resident 52 and she/he complained the facility provided documents to her/him in English only and requested she translated documents to Resident 52.
Unable to interview Resident 52 due to her/his phone being disconnected.
On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 spoke Spanish with very little English.
On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated Resident 52 had variable English skills and required a translator for communication. Staff 18 did not know if Resident 52 read English and stated she/he needed her/his Notice of Medicare Non-Coverage to be issued in Spanish.
On 1/15/25 at 2:40 PM Staff 19 (LPN) confirmed Resident 52 spoke Spanish with very little English.
On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 spoke Spanish and the facility failed to provide documents to her/him in a language she/he could understand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This place...
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Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include:
A facility Mail and Electronic Communication policy, revised in 2017, stated, Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).
During the resident council meeting on 1/14/25 at 2:00 PM residents stated their mail was not delivered to them on Saturdays.
On 1/15/25 at 10:04 AM Staff 20 (Activities Director) stated mail was delivered Monday through Friday only. Staff 20 stated mail delivered to the facility on Saturdays was not given to resdients until the next Monday morning.
On 1/15/25 at 11:31 AM Staff 1 (Administrator) stated resident mail was to be delivered to the residents on the same day it was delivered to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed res...
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Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed residents at risk for unmet needs. Findings include:
Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.
An 10/16/24 Utilization Review assessment revealed Resident 52 had chronic suicidal ideation comments.
An 10/26/24 Progress Note revealed Resident 52 yelled and swung at staff, was combatiative, and refused to have her/his vitals done.
A 11/5/24 Progress Note with a licensed clinical social worker revealed Resident 52 was referred to her by the facility for a depressed mood. Resident 52 expressed feeling depressed following recent medical complications and loss of independence, had depressed mood, sadness, feelings of helplessness, difficulties concentrating, and some irritability. Resident 52 expressed recent suicidal ideation with no intent or plan.
A review of Resident 52's medical record revealed no monitoring for mood or behaviors.
A review of Resident 52's comprehensive care plan revealed nothing related to mood, history of suicidal ideation, adjustment, or behaviors.
On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 was in a weird slump for a bit when asked about her/his mood.
On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated she was unaware of any mood issues for Resident 52.
On 1/15/25 at 10:46 AM Staff 21 (CNA) stated Resident 52 complained about not having family support and expressed wanting to die.
On 1/15/25 at 2:40 PM Staff 19 (LPN) stated Resident 52 expressed being tired of being sick and wanted to be done with life. Staff 19 referred her/him to Staff 18.
On 1/16/25 at 12:42 PM Staff 4 (LPN Resident Care Manager) stated Resident 52 had a chronic low mood and had suicidal ideation without a plan or active suicidal behaviors. Staff 4 stated Resident 52 was seen by a licensed clinical social worker for her/his mood issues.
On 1/17/25 at 7:32 AM Staff 18 stated Resident 52 had passive suicidal ideation and saw mental health support in the facility but that was about adjustment issues and not related to any suicidal behaviors. Staff 18 stated she did not feel Resident 52 had actual suicidal ideation or mood issues so she did not do a care plan related to it.
On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 had mood and behavior issues and she expected those issues to be addressed in her/his care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at r...
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Based on interview and record review it was determined the facility failed to provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings Include:
Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes.
An 10/5/24 hospital progress note revealed Resident 52 had a a right foot ulcer.
An 10/8/24 Clinical admission revealed a right lateral (outer edge) foot diabetic foot ulcer was identified.
Daily Skilled Evaluations completed 10/9/24 through 10/18/24, 10/20/24 through 11/1/24, 11/4/24, and 11/5/24, identified Resident 52's right lateral foot diabetic ulcer was not evaluated.
10/14/24, 10/17/24, 10/25/24, 11/1/24, and 11/19/24 Physician Progress Notes revealed no information related to Resident 52's right lateral foot diabetic ulcer.
A 11/21/24 Skin Check assessment revealed Resident 52 was identified to also have a venous ulcer (a chronic wound that occurs when blood pools in the veins of the legs, damaging the skin and causing an open sore) on the left front lower leg and a venous ulcer on the left shin; both were indicated to have been identified on admission.
A 11/26/24 Progress Note revealed Resident 52 had newly identified wounds to her/his left lower extremity, right foot, and buttocks. New wound orders were requested.
A 11/26/24 Skin Integrity Issue investigation revealed Resident 52 had a wound noted on 10/8/24 but there were no orders for treatment. Staff 6 (Assistant DNS) completed a skin assessment of Resident 52 and discovered two additional wounds to her/his left lower leg and one pressure wound. Resident 52 stated the wound to the left leg was present for years. Orders for wound care were requested and obtained at that time for the four wounds.
On 11/27/24 physician orders were received for wound care to Resident 52's wounds.
On 1/16/25 at 11:10 AM Staff 6 stated she was aware of Resident 52's wounds. Staff 6 stated the facility identified Resident 52 had a wound on her/his right foot at the 10/8/24 admission, but orders for treatment were not obtained until 11/27/24. Staff 6 reviewed the 11/21/24 Skin Check assessment and confirmed the left front lateral lower leg wound and left shin venous ulcer wounds were identified as present on admission and Resident 52 stated the wounds were there for a long time. Staff 6 stated the facility failed to provide treatment for these wounds until 11/27/24.
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
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents were assessed after weight loss w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents were assessed after weight loss was identified for 1 of 3 sampled residents (# 34) reviewed for nutrition. This placed residents at risk continued weight loss. Findings include:
Resident 34 admitted to the facility on [DATE] with diagnoses including malnutrition and type 1 diabetes.
The 8/13/24 Care Plan indicated Resident 34 had a nutritional problem related to ongoing malnutrition and weight loss since admit. The goal was for Resident 34's weight to be within acceptable parameters set by the RD and Interdisciplinary team. Interventions included distant supervision, high protein foods and supplements.
Review of Resident 34's Weight Summary report indicated the following:
- 6/25/24 weight of 200.6 pounds.
- 7/10/24 through 9/4/24 weight averaging 205.5 pounds.
- 9/16/24 no weight taken.
- On 9/23/24 Resident 34's weight was 174.6 pounds (32.5-pound weight loss).
On 9/26/24 a progress note indicated the identified weight of 174.6 pounds and a reweigh was requested.
Review of the Weight Summary Report indicated Resident 34 was not weighed again until 10/7/24 with a weight of 175.2 pounds (two weeks after the 9/26/24 reweigh request).
Review of Resident 34's medical record indicated no new nutritional interventions were implemented between 9/26/24 and 10/7/24.
Review of Resident 34's progress notes indicated she/he was sent to the hospital on [DATE] related to diabetes and returned to the facility on [DATE].
A 10/15/24 nutritional progress note indicated a reweigh was previously requested. Resident 34 was due for review by the Nutritional at Risk (NAR) group but left to the hospital and would be reviewed in NAR upon return.
Review of NAR Assessments indicated no review of Resident 34 was completed between 9/26/24 (first identified weight loss) and 10/14/24 (two and a half weeks later) when the resident discharged to the hospital. The first noted NAR assessment was completed on 10/22/24 (three days after readmission to the facility).
Observations made from 1/13/25 through 1/15/25 revealed Resident 34 was able to feed himself with adaptive equipment. Resident 34 was observed to eat 100% of her/his meals.
On 1/16/25 at 9:39 AM and 3:22 PM Staff 13 (RD) stated she reviewed the weight report weekly and determined who needed to be further assessed for being at risk for weight loss. Staff 13 stated a re-weigh request was to be completed by the following morning to determine accuracy. Staff 13 stated a resident was to be reviewed in NAR within a week of being identified for weight loss. Staff 13 acknowledged Resident 34's re-weigh recommendation was not completed timely, and Resident 34 was not reviewed in NAR until 10/22/24 resulting in a delay in nutritional interventions.
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 F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for st...
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Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include:
On 1/14/25 at 1:30 PM Staff 2 (DNS) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA). No performance reviews were provided.
On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged no performance reviews were completed for the identified CNA staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food stor...
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Based on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses.
A review of the facility policy Refrigerator and Freezer policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee.
On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25.
On 1/14/25 at 1:09 PM Staff 16 (Dietary Manager) stated he was not aware of the process for monitoring the resident foods refrigerator utilized by the care team. He stated he had taken the temperature of the refrigerator on 1/10/25 when he placed the log on the front of the refrigerator.
On 1/15/25 at 9:59 AM foods were observed with no dates or names in both compartments of the resident refrigerator in the dining room. Staff 17 (CNA) stated she was not sure what the policy was for labeling and dating foods. The resident snack refrigerator behind the nurses station was also observed. The temperature log only had one recorded temperature, dated 1/14/15.
In an interview on 1/16/25 at 1:00 PM Staff 16 acknowledged refrigerator temperatures were to be monitored and recorded daily, and refrigerator food was to be labeled and dated.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect....
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Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect. This placed residents at risk for a decrease in their quality of life.
Resident 2 admitted to the facility in 11/2023, with diagnoses including hyperlipidemia (a condition caused by high levels of fat in the blood).
Resident 1 admitted to the facility in 2/2024, with diagnoses including chronic systolic heart failure.
A 7/17/24 Facility Reported Incident indicated Resident 1 was observed having a verbal altercation with Resident 2 in the facility parking lot. It was reported the altercation began after Resident 2 requested Resident 1 to return a spare wheelchair that Resident 1 had borrowed. Resident 1 during the verbal altercation was observed spitting in Resident 2's face before staff intervened and separated both residents.
A 7/17/24 witness statement by Staff 3 (Medical Records Director) and Staff 4 (ADNS) indicated Resident 1 spat in the face of Resident 2 during the resident's verbal altercation.
On 10/1/24 at 3:23 PM Resident 2 stated Resident 1 had spit in her/his face during the argument. Resident 2 stated she/he felt offended and disrespected and it was emotionally difficult for her/him. Resident 2 confirmed she/he had not been abused by Resident 1 during the altercation. Resident 2 stated she/he declined a physical assessment be conducted by staff and had not been injured during the altercation between Resident 1.
On 10/2/24 at 12:13 PM Resident 1 denied spitting in Resident 2's face but confirmed she/he had gotten in her/his face during the verbal altercation as she/he was pissed off.
On 10/2/24 at 12:42 PM Staff 3 indicated that she witnessed Resident 1 talking aggressively regarding Resident 2's wheelchair. Staff 3 stated that during the altercation, Resident 1 was witnessed spitting in the face of Resident 2. Staff 3 stepped in and separated both parties and escorted Resident 2 back to her/his room for clinical assessment. Staff 3 stated Resident 2 had declined assessment due to no injuries being sustained during the incident.
On 10/2/24 at 12:52 PM Staff 4 stated she observed Resident 1 yelling in the face of Resident 2. Staff 4 stated Resident 1 was upset with Resident 2 when she/he asked for a wheelchair that Resident 1 had borrowed. Staff 4 confirmed that during the incident, Resident 1 was witnessed spitting in the face of Resident 2. Staff 4 stated she assisted Staff 3 in separating both residents and stayed with Resident 1 outside while she/he calmed down. Staff 3 stated both residents were placed on safety monitoring and confirmed no additional incidents occurred.
On 10/10/24 at 12:55 PM Staff 2 (DNS) and Staff 4 (ADNS) confirmed findings and provided no additional information.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This plac...
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Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential repeat sexual abuse incidents. Findings include:
Resident 1 was admitted to the facility in 11/2023, with diagnoses including severe sepsis and post-traumatic stress disorder.
A 11/8/23 admission MDS Assessment, Section C: Cognitive Patterns, identified Resident 1 with severe cognitive impairment.
Resident 1's 11/17/23 Care Plan identified the resident with a history of trauma related to domestic violence with interventions, including maintaining personal space boundaries and announcing self before approaching.
Resident 2 was admitted to the facility in 8/2023, with diagnoses including encephalopathy and dementia with behavioral disturbance.
An 11/24/23 Quarterly MDS Assessment, Section C: Cognitive Patterns, identified Resident 2 with severe cognitive impairment.
Resident 2's 8/18/23 Care Plan identified the resident with inappropriate sexual behavior related to touching and kissing other residents.
A 4/29/24 Facility Reported Incident revealed Resident 2 was found with her/his hand down Resident 1's brief while she/he was asleep. Resident 2 was reported to have been removed from the room after and was transferred to a different hallway soon after the incident. Tigard police were notified on the morning of 4/30/24 who identified Resident 1 with a history of engaging in inappropriate sexual behaviors.
On 5/2/24 at 12:59 PM, Resident 2 stated she/he went to visit Resident 1 on 4/29/24 but did not recall touching Resident 1 during their visit.
On 5/2/24 at 1:24 PM, Staff 3 (CMA) stated she witnessed Resident 2 with her/his hand inside the front of Resident 1's brief towards the resident's genitals exposing her/his right hip and buttocks.
A review of facility progress notes and risk management report indicated Resident 2 was discovered in Resident 1's room on the evening of 4/29/24 and placed her/his hand down Resident 1's brief while she/he was asleep. Facility immediately placed Resident 2 on the opposite side of the facility.
On 5/2/24 at 2:08 PM, Staff 5 (Receptionist) stated Resident 2 had been placed on a one on one monitoring schedule to assure resident safety and prevent further occurrence of sexually inappropriate behaviors.
Observation of Resident 2 from 5/2/24 to 5/3/24 revealed the resident with an assigned one on one staff member.
On 5/3/24 at 11:25 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2 placed her/his hand down the front of Resident 1's brief while she/he was sleeping in her/his room. Staff 2 stated Resident 2 was placed with a one on one staff member indefinitely.
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed re...
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Based on interview and record review it was determined the facility failed to treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include:
Resident 8 admitted to the facility in 5/2023, with diagnosis including diabetes.
Resident 8's 10/10/23 physican orders instructed staff to clean the right toe diabetic wound with wound cleanser, apply a thin layer of AD (ointment) to the wound and periwound, and to secure the wound with bordered foam. The dressing was to be changed three times per week and as needed.
Resident 8's October 2023 TAR revealed no wound care was done between 10/11/23 through 10/27/23.
On 4/10/24 at 11:15 AM, Staff 2 (DNS) verified wound treatments were not completed from 10/11/23 through 10/27/23.
Dec 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for s...
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Based on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for safety and coordination of care. Findings include:
Resident 2 was admitted to the facility in 2023 with diagnoses including schizoaffective disorder and stimulant abuse.
An 11/1/23 admission MDS identified Resident 2 had no cognitive impairment.
Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself.
An 11/27/23 Nursing Care Note identified Resident 2 was unarousable while care staff attempted to provide catheter care. Resident 2's head was positioned in a downward angle. Care staff contacted emergency care services and resident 2 was noted to have refused to be transferred to the hospital.
An 11/28/23 Provider Note indicated after the emergency event, Resident 2 tested positive for illegal substances.
On 12/4/23 at 10:17 AM Staff 3 (RCM) confirmed resident 2 tested positive for illegal substances per physician order.
On 12/4/23 at 10:51 AM Staff 6 (CNA) revealed Resident 2 had a lighter in her/his room.
On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substanc...
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Based on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substances for 1 of 1 sampled resident (#2) reviewed for behavioral emotional health. This placed residents at risk for a decline in mood and potential risk for reduced quality of life. Findings include:
Resident 2 was admitted to the facility in 10/2023 with diagnoses including schizoaffective disorder and stimulant abuse.
Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself.
Resident 2's 11/1/23 Care Plan identified the facility was to provide Resident 2 with continued resources related to drug addiction counseling.
On 12/4/23 at 12:19 PM Staff 4 (SSD) stated Resident 2 declined the offer of drug support services and counseling. Staff 4 indicated these services were offered and documented in Resident 2's clinical record. Staff 4 confirmed no additional drug addiction services or resources were provided to Resident 2.
A review of Resident 2's clinical record revealed no attempts or continued resources were provided to Resident 2 for drug addiction resources and services.
On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.
Aug 2023
15 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to offer the resident the opportunity to participate ...
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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 offer the resident the opportunity to participate in the care planning process for 1 of 4 sampled residents (#19) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include:
Resident 19 admitted to the facility on [DATE] with diagnoses including anxiety disorder.
On 8/7/23 at 10:11 AM Resident 19 stated she/he would like to attend her/his care conference and did not recall attending one in the past.
On 8/8/23 Resident 19's medical record was reviewed and revealed no care conferences were completed since she/he admitted to the facility.
On 8/8/23 at 11:03 AM Staff 3 (Social Services Director) acknowledged Resident 19 did not have a care conference completed since she/he admitted to the facility on [DATE].
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an Advance Directives for 1 of 3 s...
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Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an Advance Directives for 1 of 3 sampled residents (#14) reviewed for Advanced Directives. This placed residents at risk for not having their health care preferences honored. Findings include:
A record review on 8/7/23 revealed no advance directive or documentation to indicate Resident 14 was informed of or provided written information concerning their right to formulate an advance directive.
On 8/9/23 at 2:33 PM Resident 14 stated she/he completed an Advance Directive during her/his hospital stay prior to admission.
On 8/10/23 at 11:34 AM Staff 3 (Social Services) stated the facility provided an Advanced Directive form to Resident 14 upon admission. Staff 3 (Social Services) confirmed the facility did not follow up to ensure a copy of the Advance Directive was obtained and placed in the medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide NOMNC (Notice of Medicare Non Coverage) and SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-c...
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Based on interview and record review it was determined the facility failed to provide NOMNC (Notice of Medicare Non Coverage) and SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 2 of 3 sampled residents (#s 247 and 248) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include:
Resident 247 admitted to the facility with Medicare Part A services on 1/19/23. The last day of coverage for skilled services was 2/13/23. Resident 247 remained in facility. A review of the medical record revealed no evidence a NOMNC was provided to Resident 247 when skilled services ended.
Resident 248 admitted to the facility with Medicare Part A services on 1/20/23. The last day of coverage for skilled services was 3/3/23. The resident remained in the facility until 5/5/23. A review of the medical record revealed no evidence SNF ABN was provided to Resident 248 when skilled services ended.
On 8/8/23 at 11:57 AM Staff 3 (Social Services Director) was unable to find the required beneficiary forms for Resident 247 and Resident 248 in their records.
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 follow and implement physician orders and provide bowel medication in a timely manner for 2 of 6 sampled residents (#s 26 ...
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Based on interview and record review it was determined the facility failed to follow and implement physician orders and provide bowel medication in a timely manner for 2 of 6 sampled residents (#s 26 and 43) reviewed for medications and tube feeding. This placed residents at risk for medical complications from constipation and adverse side effects of medications. Findings include:
The facility's undated Bowel Care Protocol indicated if a resident did not have a BM (bowel movement) in 72 hours a licensed nurse was to perform an abdominal assessment and offer Miralax (a laxative) in eight ounces of liquid. It was okay to use the Miralax on top of existing Miralax order, if it existed. If there were no results in 24 hours they were to notify the physician. For any resident on narcotics, request an order for scheduled or PRN stool softeners or Miralax.
1. Resident 26 admitted to the facility on 8/2022 with diagnoses including dementia and depression.
a. Resident 26's Physician Order Report signed by the physician on 7/28/23 revealed an order for Miralax powder. Staff were to administer 17 grams mixed in four to eight ounces of fluid and drink daily for bowel care at 6:00 AM and 10:00 AM.
Resident 26's BM log from 7/19/23 through 8/8/23 revealed the following:
-7/19/23 through 7/24/23 (six days) Resident 26 did not have a BM.
-7/29/23 through 8/3/23 (six days) Resident 26 did not have a BM.
A review of the resident's clinical record from 7/19/23 through 8/8/23 revealed no documentation bowel care was implemented or the resident was assessed for constipation.
On 8/9/23 at 1:24 PM Staff 26 (LPN) stated she was not sure if Resident 26 struggled with BMs, and the facility had standing orders for bowel care protocol but was not sure what the bowel protocol was.
On 8/10/23 at 6:55 PM Staff 31 (Agency/LPN) stated she thought Resident 26 struggled at times with BM's. Staff 31 stated she received a bowel care list from the night shift nurse for residents who had not had a BM in three days and the CMAs administered bowel care protocol. Staff 31 stated each resident had their own bowel protocol.
b. Resident 26's Physician Order signed by the physician on 7/20/23 directed staff to administer naproxen (pain medication) two times daily.
A review of Resident 26's 7/2023 MAR revealed she/he did not receive her/his naproxen from 7/21/23 through 7/27/23 (six days) because the medication was not available.
On 8/11/23 at 10:16 AM Staff 2 (Resident Care Manager/LPN) stated staff were expected to implement and follow the bowel care protocol. Staff 2 acknowledged there was no evidence to indicate bowel protocol was implemented. Staff 2 acknowledged Resident 26 did not receive her/his naproxen for six days. Staff 2 stated naproxen was an OTC (over the counter) medication and staff were expected to report to Staff 32 (Business Office Manager) when supplies were low because he was in charge of ordering medications.
2. Resident 43 admitted to the facility on 7/2023 with diagnoses including stroke and chronic pain syndrome.
Resident 43's Physician Order signed by the physician on 7/17/23 directed staff to administer whey protein powder 12 grams enterally two times daily for additional caloric intake.
A review of Resident 43's MAR revealed she/he did not receive whey protein on 7/17/23, 7/18/23 and 7/19/23 in the AM and on 7/22/23, 7/23/23 and 7/25/23 in the PM because the whey protein was not available.
Resident 43's Physician Order signed by the physician on 7/18/23 directed staff to administer atorvastatin (a blood pressure) medication and duloxetine (anti-depressant) medication one tablet daily.
A review of Resident 43's MAR revealed she/he did not receive her/his atorvastatin on 7/18/23 or her/his duloxetine on 7/18/23 and 7/19/23 because the medications were not available.
On 8/9/23 at 1:24 PM Staff 26 (LPN) acknowledged Resident 43 missed her/his atorvastatin and duloxetine because she/he was a new admission and the pharmacy did not have the medications available due to a cut off time. Staff 26 stated she attempted to pull the duloxetine from the omnicell (automated medication dispenser) but it was not the correct dosage. Staff 26 further stated the whey protein was ordered through the pharmacy but the facility supplied the whey protein and did not have any in stock so she placed an order.
On 8/11/23 at 10:16 AM Staff 2 (Resident Care Manager/LPN) acknowledged Resident 43 did not receive her/his atorvastatin on 7/18/23, duloxetine on 7/18/23 and 7/19/23 or the whey protein. Staff 2 stated there was a miscommunication between the pharmacy regarding Resident 43's medications and the pharmacy never received the fax regarding the atorvastatin and duloxetine medications. Staff 2 stated the whey protein was an OTC (over the counter) supply and staff were expected to report to Staff 32 (Business Office Manager) when supplies were needed or low because he was in charge of ordering medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 elopement interventions were i...
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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 elopement interventions were in place for 1 of 3 sampled residents (#26) reviewed for accidents. This placed residents at risk for lack of supervision and increased elopement risk. Findings include:
Resident 26 admitted to the facility in 8/2022 with diagnoses including dementia and depression.
A review of Resident 26's clinical record from 4/11/23 through 7/13/23 revealed the resident wandered throughout the halls and facility with the use of her/his walker, entered other residents rooms and at times, was difficult to redirect.
Resident 26's Physician Order Report signed by the physician on 7/13/23 revealed the resident was an elopement risk with a start date of 6/5/23 and her/his elopement precautions was to make sure the resident had her/his name band on at all times and staff were to document her/his whereabouts and if the resident was exhibiting exit seeking behavior.
A review of Resident 26's 7/2023 and 8/2023 TARs revealed she/he had six out of 64 instances where she/he had exit seeking behaviors.
Resident 26's Comprehensive Care Plan dated 7/14/23 and revised on 7/28/23 revealed Resident 26 was an elopement risk with a history of attempts to leave the facility unattended, wandered aimlessly and had impaired safety awareness. Staff were directed to add daily outdoor time to Resident 26's treatment plan to decrease her/his elopement risk. Staff were to encourage supervision/escort for all outings and family was in agreement. Identify pattern of wandering: Is wondering purposeful, aimless or escapist? Is resident looking for something. Staff were to redirect the resident if attempts to exit the facility independently.
A Brief Interview For Mental status dated 7/18/23 indicated Resident 26's cognitive status was moderately impaired with a score of eight out of 15 points.
An Elopement Incident Report dated 7/22/23 revealed the following:
-At approximately 2:00 PM Staff 31 (Agency/LPN) came out of a residents room and a CNA reported Resident 26 was missing.
-All staff searched inside and outside the building on all halls but could not locate Resident 26.
-Staff reported at approximately 2:15 PM to Staff 31 that Resident 26 was located at the [NAME] approximately 700 feet away from the facility and had used her/his motorized wheelchair.
-The resident returned to the facility and indicated it was just a nice day and wanted to get out and she/he stated I just wanted to keep everyone on their toes and laughed.
-Resident 26 was not injured and educated regarding her/his safety.
-Facility management changed the exit door code and abuse and neglect was ruled.
A Progress Note dated 7/31/23 at 9:55 AM revealed Staff 1 (Administrator) observed Resident 26 walk out of the front door with her/his walker and Staff 1 stopped and redirected the resident back into the building. Resident 26 was frustrated and stated this is discrimination. At 4:10 PM Staff 1 observed Resident 26 attempt to type in the code at the front door and Staff 1 approached the resident and asked what she/he was doing? The resident stated she/he wanted some fresh air and wanted to go right now. Staff 1 stated she would sit with her/him out back and Resident 26 agreed.
Random observations from 8/7/23 through 8/10/23 revealed Resident 26 wandered throughout the building with the use of her/his walker or her/his motorized wheelchair. On 8/10/23 at approximately 1:00 PM Resident 26 was at the front entrance of the facility and pushed on the locked door in an attempt to leave the building and staff redirected Resident 26 back to her/his room.
On 8/9/23 at 1:24 PM Staff 26 (LPN) stated Resident 26 was an elopement risk and wandered in the hallways often. Staff 26 stated she was not present when Resident 26 left the building but Staff 1 changed the code to the front entrance and Resident 26 had not attempted to leave the facility since the 7/22/23 incident. Staff 26 was unaware if the resident was wearing a wrist band.
On 8/10/23 at 11:02 AM Staff 30 (Agency/CNA) stated she was not aware Resident 26 was a elopement risk and did not believe the resident had a wrist band on.
On 8/10/23 at 11:18 AM Staff 29 (CNA) stated she was assigned to Resident 26 on 7/22/23 when she/he left the facility during the day and went to the [NAME]. Staff 29 stated she went to check on Resident 26 and could not find her/him. Staff 29 stated she was not sure how the resident left the facility. Staff 29 stated she alerted Staff 31 (Agency/LPN) and all staff searched the entire building inside and out. Staff 29 stated another staff located Resident 26 at the [NAME] store (which was across the street) and the resident was brought back to the facility. The resident was gone approximately 40 minutes. Staff 29 stated Resident 26 was an elopement risk and had witnessed exit seeking behaviors such as pushing buttons on the front door or standing at the front of the exit door but had never left the building unsupervised. Staff 29 stated Resident 26 did not have a wrist band with her/his name on it.
On 8/10/23 at 11:57 AM Staff 27 (CNA) stated she worked on 7/22/23 and thought another resident or visitor let Resident 26 out of the facility and was found by Staff 24 (RN) at the [NAME]. Staff 27 stated she had not witnessed Resident 26 show exit seeking behaviors but she/he wandered in the halls and asked staff have you seen my son. Staff 27 stated she did not recall if the resident had a wrist band with her/his name on it or that she/he was an elopement risk.
On 8/10/23 at 12:19 PM Staff 24 stated she was on her break on 7/22/23 outside and Resident 26 was outside on her/his own and was not supposed to be without supervision. Staff 24 stated she brought her/him back from the [NAME] but was not sure how she/he got out of the facility. Staff 24 stated Resident 26 was fine, no injuries and used her/his motorized scooter to get to the [NAME]. Staff 24 stated Resident 26 was an elopement risk and wandered throughout the facility but had not witnessed any attempts to leave the facility. Staff 24 stated she was unsure if the resident had a wrist band.
On 8/10/23 at 6:55 PM Staff 31 (Agency/LPN) stated she worked on 7/22/23 when Resident 26 left the building and Staff 29 alerted her that Resident 26 could not be located. Staff 31 stated all staff searched inside and outside of the facility and Staff 24 found the resident at the [NAME] and brought her/him back to the facility. Staff 31 stated she assessed Resident 26 and asked what she/he was doing and her/his response was I was bored and wanted to get out of here and keep staff on there toes. Staff 31 stated she was not sure how the resident got out of the facility but she/he could have possibly known the code. Staff 31 stated the resident was an elopement risk and staff were expected to document her/his behaviors in the TARs. Staff 31 stated she was unaware if the resident had a wrist band.
On 8/11/23 at 10:45 AM Staff 1 and Staff 21 (DNS) stated they were notified of Resident 26's elopement the morning of 7/23/23. Staff 1 stated all the doors to the facility were locked and she changed the code access to get in and out of the building. Staff 1 and Staff 21 indicated staff were expected to keep eyes on and redirect Resident 26 if she/he showed exit seeking behaviors. Staff 1 and Staff 21 stated they did not utilize a wander guard and were not aware of the elopement precaution: Make sure resident has name on band at all times and acknowledged staff were also unaware Resident 26 did not have a name or wrist band on at all times. Staff 1 and Staff 21 acknowledge that not all staff were aware Resident 26 was an elopement risk.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 14 admitted to the facility in 6/2023 with diagnoses including stroke.
On [DATE] at 2:33 PM Resident 14 stated she/h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 14 admitted to the facility in 6/2023 with diagnoses including stroke.
On [DATE] at 2:33 PM Resident 14 stated she/he used a bedside commode and had regular bowel movements.
On [DATE] a review of Resident 14's bowel records revealed documentation for bowel movements were not accurately recorded on the following dates: [DATE] through [DATE] (eight days), 7/28, 7/29, [DATE] through [DATE] (three days), [DATE], [DATE] and [DATE] (three days).
A review of Resident 14's medical record revealed no other bowel documentation was found.
On [DATE] at 2:55 PM Staff 2 (Resident Care Manager/LPN) acknowledged bowel records for Resident 14 were inaccurate for [DATE] through [DATE]; [DATE],[DATE], [DATE] through [DATE], [DATE], [DATE] and [DATE]. Staff 2 stated Resident 14 used the bathroom and required one-person assistance for toileting and CNAs were expected to document when Resident 14 had a bowel movement.
Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 3 of 6 sampled residents (#s 7, 14 and 44) reviewed for medications and death. This placed residents at risk for inaccurate medical records. Findings include:
1. Resident 44 admitted to the facility on [DATE] with diagnoses including heart failure, chronic pulmonary disease and diabetes.
A review of Resident 44's [DATE] admission orders revealed she/he was coded a DNR (Do Not Resuscitate) and no CPR (Cardiopulmonary Resuscitation) was to be initiated.
A signed copy of Resident 44's [DATE] POLST (Physician Orders for Life-Sustaining Treatment) revealed she/he was a [Full Code] and to initiate CPR.
A [DATE], [DATE] and [DATE] Late Nursing Note entry indicated Resident 44's code status: DNAR - No CPR. Do Not Attempt Resuscitation (allow natural death).
A [DATE] Nursing Noted indicated Staff 25 (LPN) around 2200 hours found Resident 44 unresponsive with no pulse or respirations. After finding full code in resident's profile, CPR was immediately started.
On [DATE] at 11:00 AM Staff 1 (Administrator) and Staff 21 (DNS) stated Resident 44 was a Full Code and CPR was initiated per Resident 44's [DATE] POLST which was located at the nurses station. Staff 1 and Staff 21 acknowledged Resident 44's medical records were inaccurate and staff were expected to document accurate information into each resident's medical record regarding POLST status.
2. Resident 7 admitted to the facility on 9/2022 with diagnoses including peripheral vascular disease (lack of blood flow to the extremties) and bilateral below the knee amputation.
Resident 7's Annual MDS dated [DATE] revealed her/his BIMS score was 15 which indicated she/he was cognitively intact.
A review of Resident 7's bowel records from [DATE] through [DATE] revealed Resident 7 did not have a BM (bowel movement) from [DATE] through [DATE] (five days). No evidence was found in Resident 7's medical record that bowel protocol was implemented.
On [DATE] at 8:18 AM Staff 27 (CNA) stated Resident 7 used the bedside commode or a bed pan. Staff 27 stated Resident 7 did not struggle with constipation and had regular BMs and staff were expected to document in Resident 7's medical record when she/he had a BM.
On [DATE] at 11:02 AM Staff 30 (CNA) and at 11:18 AM Staff 29 (CNA) stated Resident 7 was able to toilet herself/himself onto the bedside commode or used a bed pan. Staff 30 and Staff 29 stated Resident 7 had regular BMs and would report a concern if she/he was constipated. Staff 30 and Staff 29 stated they were to document BMs in Resident 7's medical record.
On [DATE] at 1:56 PM Staff 2 (Resident Care Manager/LPN) stated Resident 7 was able to state her/his needs and would alert staff if she/he was constipated. Staff 2 stated she expected staff to document or ask Resident 7 if she/he had a BM and document the response into Resident 7's medical record. Staff 2 acknowledge Resident 7's BM records were inaccurate.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility failed to maintain a safe environment for 1 of 1 courtyard areas reviewed for environment. This placed residents at risk for accidents...
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Based on observation and interview it was determined the facility failed to maintain a safe environment for 1 of 1 courtyard areas reviewed for environment. This placed residents at risk for accidents. Findings include
Observations from 8/8/23 through 8/10/23 revealed no safety warnings or other cautionary measures in place for a broken and raised section (two to three inches) of a pathway in the courtyard.
On 8/8/23 at 12:23 PM Resident 15 was observed in her/his wheelchair in the courtyard. The resident had difficulty navigating the broken section of the pathway. The resident was unable to crossover the broken pathway and appeared to be stuck.
On 8/9/23 at 10:03 AM Resident 15 stated that she/he went outside daily and regularly got stuck on the broken section of the pathway. She/he then stated staff would usually notice or Resident 15 would use her/his cell phone to call for help.
On 8/9/23 at 10:48 AM Staff 5 (Maintenance Director) stated he was aware of the broken section of the pathway in the courtyard. He further stated he had only been at the facility approximately one month and was trying to address several identified concerns.
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
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 the medication error rate was less than 5%. There were 28 medication administration opportunities with...
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Based on observation, interview and record review it was determined the facility failed to ensure the medication error rate was less than 5%. There were 28 medication administration opportunities with 8 errors resulting in an error rate of 28%. This placed residents at risk for adverse medication side effects. Findings include:
The undated facility policy for care of tube feeding (gastrostomy) indicated the following:
5.e. Medications will be administered by gravity. If problems with gravity and administration occur, a very small amount of pressure with the syringe to attempt flow and then remaining administration will be by gravity, unless otherwise noted by the physician.
Resident 9 admitted to the facility in 2023 with diagnoses including stroke.
The 7/27/23 Physician Order indicated Resident 9 was to receive the following medications:
-acetaminophen 500 mg 2 tabs via gastric tube TID;
-docusate sodium (laxative) 100 mg via gastric tube BID;
-ezetimibe (cholesterol medication) 10 mg via gastric tube once daily;
-ferrous sulfate (supplement) 325/65 mg via gastric tube once daily;
-folic acid (supplement) 1 mg via gastric tube once daily;
-polyethylene glycol (laxative) 3350/17 gm via gastric tube once daily;
-Konvomep (antiulcer medication) oral suspension 2/84 mg/ml 20 ml via gastric tube TID;
-sennosides syrup (laxative) 8.8 mg/5 ml give 5 ml via gastric tube once daily.
On 8/9/23 at 9:32 AM Staff 10 (LPN) was observed to administer the following medications:
-acetaminophen 500 mg 2 tabs pushed quickly into the feeding tube with syringe and plunger.
-docusate sodium 100 mg pushed quickly into the feeding tube with syringe and plunger.
-ezetimibe 10 mg pushed quickly into the feeding tube with syringe and plunger.
-ferrous sulfate 325/65 mg pushed quickly into the feeding tube with syringe and plunger.
-folic acid 1 mg pushed quickly into the feeding tube with syringe and plunger.
-polyethylene glycol 3350/17 gm pushed quickly into the feeding tube with syringe and plunger.
-Konvomep oral suspension 2/84 mg/ml TID 20 ml pushed quickly into the feeding tube with syringe and plunger.
-sennosides syrup 8.8 mg/5 ml give 5 ml pushed quickly into the feeding tube with syringe and plunger.
On 8/9/23 at 9:32 AM and 1:26 PM Staff 10 acknowledged she pushed each of Resident 9's medications quickly into the feeding tube with the syringe and plunger instead of letting the medications flow by gravity.
On 8/9/23 at 1:42 PM Staff 21 (DNS) stated the expectation was for staff to individually separate all gastric tube medications, and allow them to flow by gravity and complete flushes in between.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to ensure hot food was served at preferable temperatures for 1 of 1 lunch meal reviewed for food concerns. This ...
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Based on observation, interview and record review it was determined the facility failed to ensure hot food was served at preferable temperatures for 1 of 1 lunch meal reviewed for food concerns. This placed residents at risk for inadequate food temperatures. Findings include:
On 8/7/23 interviews with Residents 39 and 297 revealed meals were often served cold. When meals were received, the hot foods were usually cold and had to be warmed up.
A review of Resident Council minutes from 4/2023 through 7/2023 revealed cold food was an ongoing concern. The Resident Council minutes did not document actions taken to address the cold food.
On 8/9/23 a lunch meal test tray was requested by the survey team. During the lunch meal service a total of 49 minutes passed between the first meal tray being placed in the first meal cart to when the survey team received the lunch meal test tray. The lunch meal consisted of roasted pork loin and broccoli. Both items were determined to be lukewarm in temperature.
On 8/9/23 at 1:33 PM Staff 8 (Activities Director) stated cold food was an ongoing concern that was brought up in the Resident Council meetings she facilitated. She stated the only response she received from the Dietary Department was to encourage residents to eat in the main dining room which was right next to the kitchen. Staff 8 stated this was not always possible during outbreaks of infectious disease such as COVID-19.
On 8/9/23 at 2:09 PM Staff 6 (Dietary Manager) was informed of food temperatures being lukewarm for the lunch meal test tray. He stated he was aware of resident complaints of cold food and acknowledged this was an ongoing challenge. When asked what was done to address the concern , Staff 6 replied residents were encouraged to eat in the main dining room. Staff 6 stated he was working on a plan to address the cold food concern.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered for 1 of 1 facility garbage areas reviewed for sanitation. This placed reside...
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Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered for 1 of 1 facility garbage areas reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include:
Observations of the facility garbage dumpster were made on 8/7/23 and 8/9/23 through 8/11/23. The garbage dumpster was located outside of the facility kitchen. The garbage dumpster was left open despite having covers. A strong odor was noticeable from the open trash dumpster. From 8/9/23 to 8/11/23 there were multiple bags of trash inside the dumpster.
On 8/9/23 at 2:09 PM the observations of the uncovered garbage dumpster were shared with Staff 6 (Dietary Manager). Staff 6 stated he was unaware the garbage dumpster was uncovered.
On 8/10/23 at 10:05 AM Staff 1(Administrator) was informed of and shown the uncovered garbage dumpster. She stated she was not aware the garbage dumpster was to be covered at all times.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (...
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Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include:
On 8/8/23 a review of the facility's staff training records revealed the following:
-Staff 11 (CNA), hired 3/27/23 had no documentation they completed 12 hours of in-service training.
-Staff 12 (CNA), hired 6/15/22 had no documentation they completed 12 hours of in-service training.
-Staff 13 (CNA), hired 10/14/22 had no documentation they completed 12 hours of in-service training.
-Staff 14 (CNA), hired 1/5/23 had no documentation they completed 12 hours of in-service training.
-Staff 15 (CNA), hired 2/1/23 had no documentation they completed 12 hours of in-service training.
On 8/8/23 at 9:06 AM Staff 16 (Clinical Operations Education Director) confirmed the facility was unable to provide documentation to verify any in-service trainings were completed over the last 12 months nor did they have a system to track required 12-hour minimum annual training hours.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outc...
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Based on interview and record review it was determined the facility failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 1 of 1 CNA (#12) reviewed for annual nurse aide training performance. This placed residents at risk for lack of care by competent staff. Findings include:
On 8/8/23 a review of the facility's staff training records for CNAs employed over one year revealed the following:
-Staff 12 (CNA), hired 6/15/22, had no performance review and no documentation of regular in-service training.
On 8/10/23 at 1:02 PM Staff 16 (Clinical Operations Education Director) confirmed the facility did not have a system in place to conduct annual nurse aide training performance reviews for Staff 12.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview it was determined that the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed res...
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Based on observation and interview it was determined that the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness. Findings include:
1. Observations from 8/9/23 at 9:53 AM through 8/10/23 at 9:40 AM revealed the ceiling of the kitchen had three round uncovered air vents (approximately 12 inches in diameter) which all had surrounding areas which were blackened colored, jagged, had hanging loose debris and were blowing air over the food prep area and serving areas. On 8/9/23 air was observed blowing over the food service area during the lunch meal service.
On 8/9/23 at 2:09 PM Staff 6 (Dietary Manager) stated the missing vent covers were being cleaned and painted.
2. On 8/9/23 between 11:49 AM and 12:30 PM during lunch meal service observations Staff 7 (Cook) did not change her gloves or conduct hand hygiene after touching multiple surfaces in the kitchen, including the food prep areas and utensils. Staff 7 used the same gloved hand to handle rolls and sandwiches to put on plates served to residents.
On 8/9/23 at 2:09 PM the observations of Staff 7 were discussed with Staff 6. No additional information was provided.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to have the Medical Director or designee attend the QAA (quality assessment and assurance) committee for 2 of 3 quarters revi...
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Based on interview and record review it was determined the facility failed to have the Medical Director or designee attend the QAA (quality assessment and assurance) committee for 2 of 3 quarters reviewed for QAA. This placed residents at risk of not receiving care and services for optimal resident outcomes. Findings include:
Documentation of QAA meeting minutes were requested from 1/2023 through 8/2023 and the only documentation provided was the sign in sheets from 4/2023 and 8/2023 which revealed the Medical Director attended on 4/21/23 but did not attend on 8/8/23. No other documentation was provided.
On 8/11/23 at 12:01 PM Staff 1 (Administrator) and Staff 21 (DNS) stated they held monthly QAA meetings and all major department supervisors attended. Staff 1 and Staff 21 stated the Medical Director did not attend the Quarterly QAA meetings on a regular basis but was highly encouraged to attend. Staff 1 stated she could not find any documentation from 1/2023 through 3/2023 the Medical Director attended the quarterly QAA meetings.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
1. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth a...
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1. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include:
Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.
A review of the current Facility Assessment revealed no evidence a risk assessment had been completed and there was no information referring to a facility policy or procedure to prevent the growth and spread of water-borne pathogens in the facility's main water system.
On 8/10/23 at 2:00 PM Staff 5 (Maintenance Director) and on 8/11/23 at 9:08 AM Staff 1 (Administrator) confirmed the facility did not have a prevention plan, policy or system in place for the prevention of a spread of water-borne pathogens, such as Legionella, in the facility's main water system.
2. Based on observation and interview it was determined the facility failed to follow CDC (Centers for Disease Control and Prevention) Infection Control Guidelines related to PPE usage for 1 of 2 sampled residents (#31) reviewed for infection control. This placed residents at risk for potential infection and cross contamination. Findings include:
The CDC's 7/12/22 implementation of Nursing Home PPE guidelines for Infection Control included PPE was to be properly discarded before exiting a patient's room to prevent the spread of pathogens.
On 8/8/23 Resident 31 was sent to the hospital and returned to the facility the same day with a diagnosis of COVID-19 infection. She/he was placed in a private room on the 100 hall which had no other residents at the time.
Observations on 8/8/23 outside of Resident 31's room revealed a plastic storage bin with PPE and a small garbage bin. Signage posted on the resident's door stated the resident was on transmission based precautions.
On 8/8/23 Resident 17 was temporarily moved to a private room on the 100 hall due to not getting with her/his roommate.
On 8/9/23 at 12:42 PM the small garbage bin outside of Resident 31's room was observed to contain used PPE.
The facility's 9/6/22 Policy and Procedure for Transmission-Based Precautions directed staff to dispose of PPE before leaving the resident's room.
On 8/11/23 at 8:55 AM Staff 21 (DNS) acknowledged the small garbage bin outside of Resident 31's room should only contain plastic wrappers from the new PPE. Staff 21 stated all used PPE should be disposed of before leaving the resident's room.
May 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 sampled residents (#4) reviewed for abu...
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Based on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 sampled residents (#4) reviewed for abuse. This placed residents at risk for psychosocial trauma. Findings include:
Resident 4 admitted to the facility in 2022 with diagnoses including dementia.
Resident 5 admitted to the facility in 2022 with diagnoses including dementia.
A 11/13/22 Event Report indicated Resident 5 touched Resident 4's breasts without consent when the two residents were talking in the hallway. The incident was witnessed by Staff 10 (CNA).
A facility investigation document dated 11/14/22 indicated Resident 5 acknowledged touching Resident 4's breasts. Resident 4 indicated she/he did not want to be touched by Resident 5.
On 5/12/23 at 11:01 AM Resident 4 stated Resident 5 touched her/his breasts one time and she/he did not like it. Resident 4 stated she did not cry or lose sleep about it but wanted to smack Resident 5.
On 5/12/23 at 12:21 PM Staff 12 (SS) indicated Resident 4 was monitored after the incident but had no change from baseline behaviors.
On 5/16/23 at 1:30 PM Staff 10 stated she witnessed Resident 5 touch Resident 4's breasts and she separated the residents.
On 5/18/23 at 3:05 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged this incident occurred.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 3 sampled residents (#4) reviewed for allegations of abuse. ...
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Based on interview and record review it was determined the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 3 sampled residents (#4) reviewed for allegations of abuse. This placed residents at risk for psychosocial harm. Findings include:
The facility's Abuse Prevention Policy and Procedures, updated 5/7/14, included the following:
As soon as a report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse. The investigation will include at a minimum the following steps:
- Identification of the parties involved
- Identification of witnesses
- Interviews of all the parties involved, including the resident (if interviewable).
Resident 4 admitted to the facility in 2022 with diagnoses including dementia.
Resident 6 admitted to the facility in 2022 with diagnoses including dementia.
A 2/19/23 Event Report indicated Resident 4 reported to Staff 12 (Agency LN) that Resident 6 touched her/his breasts without consent. No witnesses were identified and no witness statements were included. The report indicated Resident 6 did not remember the incident, but did not include an interview with Resident 6. The investigation did not include statements from other staff members.
On 5/17/23 at 3:05 PM Staff 12 stated she did not witness the incident. Staff 12 stated she thought another resident witnessed the incident, but did not recall which resident that was.
During interviews on 5/16/23 and 5/17/23 Staff 2 (DNS) stated there was no additional investigative information to provide regarding this incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 provide bowel medication in a timely manner for 1 of 3 sampled residents (#7) reviewed for bowel care. This placed residen...
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Based on interview and record review it was determined the facility failed to provide bowel medication in a timely manner for 1 of 3 sampled residents (#7) reviewed for bowel care. This placed residents at risk for medical complications from constipation including bowel impaction. Findings include:
Resident 7 admitted to the facility in 2023 with diagnoses including acute pain.
Resident 7's 3/2023 MAR included the use of oxycodone (narcotic pain medication).
Resident 7's care plan did not include information related to the risks of using narcotic medication, including constipation.
Resident 7's bowel records from 3/2023 indicated she/he had a bowel movement on 3/18/23 and did not have another bowel movement until 3/25/23 (one week later).
A review of Resident 7's clinical record revealed no indication the resident was offered bowel medication until 3/24/23 (six days after the resident's last bowel movement).
On 5/12/23 at 2:03 PM Staff 4 (LPN) stated Resident 7 had consistent issues with constipation. Staff 4 stated nurses were to offer bowel medication if a resident did not have a bowel movement for three days.
On 5/16/23 at 1:45 PM Staff 3 (LPN Resident Care Manager) acknowledged there was no evidence to indicate Resident 7 was offered bowel medication until six days after her/his previous bowel movement. Staff 3 indicated staff were to offer bowel medication three days after a resident's previous bowel movement. Staff 3 was not able to identify a rationale for not offering bowel medication to Resident 7 and stated she expected nurses to document in the clinical record if a medication was offered and refused.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide necessary respiratory care and services including maintaining a policy and procedure for emergency respiratory car...
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Based on interview and record review it was determined the facility failed to provide necessary respiratory care and services including maintaining a policy and procedure for emergency respiratory care and services; completing thorough respiratory assessments; maintenance of equipment and supplies for tracheostomies for 1 of 2 sampled residents (#1) reviewed for tracheostomy (a surgical opening into the windpipe to provide an airway to the lungs). This placed residents at risk for impaired breathing. Findings include:
The facility's May 2023 Facility Assessment indicated the facility was able to accept residents who had tracheostomies.
The facility's 2001 MED-PASS Tracheostomy Care policy revised 8/2013 did not include:
1. Emergency care including staff training and competency for implementation of emergency interventions,
2. Procedures to follow in the event of adverse reactions to respiratory treatments or interventions,
3. Respiratory assessments including who could conduct each aspect of the assessment, what was contained in an assessment, when and how it was conducted, and documented,
4. Maintenance of equipment,
5. Infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and the use of humidifiers.
Resident 1 was admitted to the facility in 4/2023 with diagnoses including: Acute Respiratory Failure with Hypoxia (breathing problems with low oxygen) and a tracheostomy.
Progress Notes from 4/2023 through 5/2023 indicated Resident 1 was alert and oriented and able to make her/his needs known. Resident 1 was discharged to the hospital on 5/1/23.
Resident 1's admission Orders stated: Mist to trach (tracheostomy) every shift. Titrate according to amount and consistency of secretions. Suction per resident need.
On 4/29/23 at 3:26 PM Staff 6 (RN) noted in Resident 1's Progress Note the inner cannula was changed to one the facility had on-hand, but the new cannula was missing a cap (plug for the trach used so residents can talk and breathe through their nose/mouth instead of through the opening in their neck).
On 4/29/23 at 7:01 PM Staff 7 (LPN) noted in the Progress Notes Resident 1 had shortness of breath and difficulty breathing following suctioning which was due to the lack of a cap for the cannula. The physician was notified and supplemental oxygen was ordered.
On 4/30/23 at 5:53 AM, a Progress Note by Staff 13 (LPN) indicated a trach cap was obtained at the beginning of night shift.
Attempts to contact Staff 13 from 5/15/23 through 5/17/23 were unsuccessful.
On 5/15/23 at 9:36 AM Staff 5 (LPN) stated when she cared for Resident 1, the suction machine in Resident 1's room did not work. Staff 3 (LPN Resident Care Manager) was notified and found a different suction machine.
On 5/15/23 at 9:51 AM Staff 7 (LPN) stated she worked with Resident 1 and changed the inner cannula to the tracheostomy. She stated it was problematic replacing the new inner cannula because the original cannula had a cap and the replacement did not have a cap. She stated the facility did not have the correct size cannula. She stated she told Staff 2 (DNS) about the lack of a cannula cap and one was obtained later from another facility.
In an interview on 5/15/23 at 10:15 AM Staff 6 (RN) stated she could not recall if she auscultated (listened with stethoscope) Resident 1's lungs.
A review of Resident 1's Treatment Records from 4/2023 through 5/2023 did not reveal an assessment of the resident's respiratory status before and after suctioning.
Resident 1's Treatment Records from 4/2023 through 5/2023 indicated Staff 13 (LPN) did not document Resident 1's respiratory status.
On 5/12/23 at 2:02 PM Staff 2 (DNS) stated the facility should have had trach supplies ready for Resident 1. Staff 2 stated she expected the nurses to have a base knowledge of tracheostomy care, including what to assess and document, which was taught in nursing school.
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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure nursing staff had appropriate competencies and skill sets related to tracheostomy care for 1 of 2 sampled residents...
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Based on interview and record review it was determined the facility failed to ensure nursing staff had appropriate competencies and skill sets related to tracheostomy care for 1 of 2 sampled residents (#1) reviewed for tracheostomy (a surgical opening into the windpipe to provide an airway to the lungs). This placed residents at risk for complications of a tracheostomy. Findings include:
The facility's May 2023 Facility Assessment indicated the facility was able to accept residents with tracheostomies.
The facility's training records indicated four day shift nurses were verbally educated on tracheostomy care between 2/2023 and 4/2023. No other competency documentation was provided.
Resident 1 was admitted to the facility 4/2023 with diagnoses including: Acute Respiratory Failure with Hypoxia (breathing problems with low oxygen) and a tracheostomy.
Progress Notes from 4/2023 through 5/2023 indicated Resident 1 was alert and oriented and able to make her/his needs known.
On 5/12/23 at 11:57 AM Staff 4 (LPN) stated he was uncomfortable taking care of Resident 1 and requested additional training on tracheostomy care when he was assigned to work with Resident 1.
Staff 4 stated he requested Staff 3 (LPN Resident Care Manager) accompany him and walk him through suctioning of the tracheostomy.
On 5/12/23 at 12:19 PM Staff 3 stated some of the nurses had tracheostomy experience in the past, but nothing recent. She stated some of the RNs could take care of a resident with a tracheostomy. She stated the dayshift nurses were more experienced, she was not sure about the expertise of night shift nurses.
On 5/12/23 at 2:02 PM Staff 2 (DNS) stated some of the nurses mentioned they did not feel confident in their skills for tracheostomy care and wanted a refresher course when Resident 1 was admitted . Staff 3 and Staff 2 in-serviced two nurses who were working on the day Resident 1 was admitted .
On 5/15/23 at 9:39 AM Staff 5 (LPN) stated she was called in to attend a training on trach care because the facility admitted a resident with a tracheostomy. Staff 5 stated after the in-service she requested additional training because she had not taken care of a resident with a tracheostomy.
On 5/12/23 at 2:02 PM Staff 2 (DNS) stated she expected the nurses to have a base knowledge of tracheostomy care, including what to assess and document, which was taught in nursing school. Staff 2 was unable to produce tracheostomy competency records for the nurses.
See F695.
Jun 2022
12 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to properly disinfect a glucometer between resident uses for 1 of 2 sampled residents (#107) reviewed for CBG mo...
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Based on observation, interview and record review it was determined the facility failed to properly disinfect a glucometer between resident uses for 1 of 2 sampled residents (#107) reviewed for CBG monitoring. This failure, which was determined to be immediate jeopardy, placed Residents 156, 2, 104 and 155 at risk for viral hepatitis C infection. Findings include:
On 6/10/22 at 12:38 PM Staff 3 (RN) used a glucometer (a device used to check CBG levels from a blood sample) from the treatment cart to check Resident 107's CBG. Staff 3 then wiped the front of the glucometer with an alcohol wipe and placed the glucometer in the front center of the top drawer of the treatment cart.
On 6/10/22 at 1:00 PM Staff 3 removed the same glucometer from the treatment cart and prepared to enter Resident 156's room to check the resident's CBG. The Surveyor stopped Staff 3 from entering the room and asked her what the facility's policy and procedure was for disinfecting glucometers. Staff 3 stated she did not know. At the Surveyors request, Staff 3 then asked Staff 2 (DNS) what the correct procedure was for disinfecting glucometers between use. Staff 2 stated there were disinfectant wipes on the treatment cart for disinfecting the glucometers. The surveyor, Staff 2 and Staff 3 returned to the cart and verified the disinfectant wipes were available on the treatment cart. Staff 2 was asked to provide a list of residents who have CBGs checked and if any of them had a bloodborne infection. Staff 2 was requested by the Surveyor to cease all resident CBG checks at this time. Staff 2 immediately removed all seven used glucometers from the two treatment carts for disposal. Staff 2 then brought six brand new unused glucometers from storage for individual resident use. Staff 2 stated the glucometers would be labeled for each resident and stored in separate bags.
On 6/10/22 at 1:45 PM The facility provided a list of all residents in the facility who had their CBG's checked. The list indicated Resident 107 had viral hepatitis C.
On 6/10/22 at 2:39 PM Staff 1 (Administrator) was notified of the immediate jeopardy situation and was provided with a copy of the immediate jeopardy template. An immediate plan of correction was requested.
On 6/10/22 at 4:03 PM Staff 1 and Staff 2 (DNS) provided a copy of the glucometer manufacturers disinfection instructions, demonstrated the manufacturers recommended disinfection cleaning wipes were available in the facility and the wipes were labeled with the correct contact time. Staff 2 provided copies of licensed nurse in-servicing materials related to glucometer disinfecting and a roster which indicted licensed nurse staff currently in the facility competed the education.
On 6/10/22 at 4:11 PM Staff 1 submitted an acceptable plan of correction which included the following:
Immediate:
- All CBG's stopped, nurses in the building trained on policy and proper protocol as well as demonstrating competency, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times.
- All open CBG machines have been pulled and discarded. New individualized CBG machines have been assigned to each resident and labeled with their name and placed in individualized bag.
- RNCM has assumed charge roll of the floor and is educating RN while working side by side.
- Documentation to be provided showing the germicidal product meets manufacturer's requirements for disinfection of CBG machine.
Ongoing:
- Resident physicians notified and obtained orders for bloodborne pathogen testing.
- Blood draws ordered for residents who received CBG testing.
- All remaining nurses to be trained before next working shift on proper protocol on CBG process, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times.
Systemic Changes:
- Germicidal product to be clearly labeled with dwell time.
- DNS/RNCM or designee will perform CBG competencies all current licensed nurses employed and will conduct CBG competency for all new hires prior to end of orientation period.
Monitoring:
- DNS/RNCM or designee, to complete random weekly checks on 50% of residents receiving CBG testing to ensure compliance with correct CBG administration as well as monitoring of technique and ensuring correct cleaning protocols are being followed, corrections as needed.
- DNS/RNCM or designee to report findings at Monthly QAPI.
On 6/10/22 at 4:17 PM Staff 1 was notified the immediacy was removed and resident CBG testing could resume.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident had the right to refuse medications for 1 of 3 sampled residents (#2) reviewed for unnecessary medicatio...
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Based on interview and record review it was determined the facility failed to ensure a resident had the right to refuse medications for 1 of 3 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk of not having the right to refuse. Findings include:
Resident 2 was admitted to the facility in 2022 with diagnoses including stroke.
Resident 2's 6/2022 MAR included the order Ok to disguise medications in food due to medication refusals.
On 6/10/22 at 10:52 AM Staff 2 (DNS) stated the order did not allow Resident 2 the right to refuse. Staff 2 stated she would discontinue the order immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
2. Resident 156 admitted to the facility in 5/2022 with diagnoses including a stroke.
On 6/8/22 at 3:13 PM the resident stated she/he completed an advance directive while in the hospital and it was se...
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2. Resident 156 admitted to the facility in 5/2022 with diagnoses including a stroke.
On 6/8/22 at 3:13 PM the resident stated she/he completed an advance directive while in the hospital and it was sent to the current facility with the rest of her/his paperwork.
No advance directive was found in the facility's electronic health record for Resident 156.
On 6/9/22 at 1:20 PM Staff 1 (Administrator) verified there was no advanced directive in the resident's medical record.
Based on interview and record review it was determined the facility failed to obtain copies of advance directives for 2 of 4 sampled residents (#s 105 and 156) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include:
1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke.
The 5/20/22 admission Agreement indicated Resident 105 completed an advance directive.
There was no advance directive located in Resident 105's medical record.
On 6/9/22 at 1:20 PM Staff 1 (Administrator) confirmed there was no advance directive in Resident 105's medical record and the family had not been contacted to provide a copy.
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 provide a written summary of the baseline care plan for 2 of 2 sampled residents (#s 106 and 107) reviewed for new admissi...
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Based on interview and record review it was determined the facility failed to provide a written summary of the baseline care plan for 2 of 2 sampled residents (#s 106 and 107) reviewed for new admissions. This placed residents at risk of being uninformed of their plan of care. Findings include:
1. Resident 106 was admitted to the facility in 5/2022 with diagnosis including multiple sclerosis and urinary tract infection.
The 5/21/22 admission MDS revealed Resident 106 had intact cognition.
On 6/14/22 at 1:50 PM Resident 106 was shown her/his baseline care plan and stated she/he did not recall reviewing her/his baseline care plan and did not receive a copy of it.
On 6/14/22 at 1:17 PM Staff 2 (Interim DNS) and Staff 19 (RNCM) stated the facility had no formal process to review the baseline care plan or to provide copies of the baseline care plan to residents or their representatives.
2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including diabetes, heart failure and chronic kidney disease.
The 5/27/22 admission MDS revealed Resident 107 had intact cognition.
On 6/14/22 at 1:51 PM Resident 107 was shown her/his baseline care plan and stated she/he never saw the baseline care plan before and did not receive a copy of it.
On 6/14/22 at 1:17 PM Staff 2 and Staff 19 stated the facility had no formal process to review the baseline care plan or to provide copies of the baseline care plan to residents or their representatives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
3. Resident 156 was admitted in 5/2022 with diagnoses including stroke.
A review of the resident's medical record on 6/14/22 revealed no comprehenensive care plan was developed.
On 6/16/22 at 10:54 ...
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3. Resident 156 was admitted in 5/2022 with diagnoses including stroke.
A review of the resident's medical record on 6/14/22 revealed no comprehenensive care plan was developed.
On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the care plan was not developed in the appropriate amount of time.
Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 3 of 7 sampled residents (#s 105, 107 and 156) reviewed for activities and unnecessary medications. This placed residents at risk for unmet needs. Findings include:
1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke.
Resident 105's 5/27/22 admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, keep up with the news, do things in groups of people, do their favorite activities, go outside to get fresh air when the weather was good and to participate in religious services or practices.
Resident 105's current activity care plan included the following interventions: facility RA/CNA will walk with the resident in the mornings and the social service director or activity director will walk with Resident 105 in the afternoons. Resident 105's care plan did not include activities identified in her/his admission MDS.
In an interview on 6/14/22 at 2:27 PM Staff 2 (Interim DNS) reviewed Resident 105's activity care plan and stated Resident 105 did not walk, she would expect the care plan to reflect the resident's interests and the care plan should have included the identifed activities from the MDS.
2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder.
Resident 107's 5/27/22 admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do their favorite activities and go outside to get fresh air when the weather is good.
Resident 107's 6/2/22 Activity Assessment identified the resident's activity preferences as crafts, music, walking/wheeling outdoors, watching TV, talking or conversing, cooking, dining out, movies, needlework, painting, quilting and radio.
Resident 107's 6/9/22 current activity care plan directed staff to provide the resident with coloring pages/books and colored pencils and encourage the resident to request in-room activities they enjoy. Resident 107's care plan did not include other activities identified in her/his admission MDS or Activity Assessment.
In an interview on 6/14/22 at 2:27 PM Staff 2 reviewed Resident 107's activity care plan and stated preferences identifed on the resident's admission MDS and Activity Assessment were not included on the care plan and she expected the care plan to be personalized and include those preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and needs for residents for 2 of 2 s...
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Based on observation, interview, and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and needs for residents for 2 of 2 sampled residents (#s 105 and 107) reviewed for activities. This placed residents at risk for a lack of psychosocial well-being. Findings include:
The facility's Group Programs and Activities Calendar policy, last revised 6/2018, indicated large and small group activities were available in the facility and an activities calendar was completed and maintained in a high-visibility, high traffic area to inform residents, families and staff of the activity opportunities available.
1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke.
Random observations from 6/8/22 through 6/15/22 between the hours of 8:00 AM and 4:00 PM revealed Resident 105 was in bed with the room dark; occasionally the TV was on. No other activities were observed. The activity calendar in the main hallway was blank with the exception of payday and Father's Day listed.
Resident 105's 5/27/22 admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, keep up with the news, do things in groups of people, do their favorite activities, go outside to get fresh air when the weather was good and to participate in religious services or practices.
On 6/9/22 at 2:32 PM and 6/14/22 at 8:36 AM Staff 20 (Activities/Social Services Director) stated she was recently hired as the Activities Director and there was currently no functioning activity program. Staff 20 stated she had no process in place to set up activities and there was no interim activity staff to conduct the program or assist her while she was being trained.
On 6/10/22 at 11:07 AM, 11:51 AM and 6/13/22 at 10:59 AM Staff 11 (CNA), Staff 15 (CNA) and Staff 5 (CNA) reported the facility did not currently have an activities program.
On 6/14/22 at 11:45 AM Staff 1 (Adminstrator) reported the facility did not have an activities program and Staff 20 would be trained as the activity director once payment was made for the activity training course.
2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder.
Resident 107's 5/27/22 admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do their favorite activities and go outside to get fresh air when the weather is good.
Resident 107's 6/2/22 Activity Assessment identified the resident's activity preferences as crafts, music, walking/wheeling outdoors, watching TV, talking or conversing, cooking, dining out, movies, needlework, painting, quilting and radio.
Random observations from 6/8/22 through 6/15/22 between the hours of 8:00 AM and 4:00 PM revealed Resident 107 was in her/his room, at times coloring pages from a coloring book and occasionally watching TV. No other activities were observed. The activity calendar in the main hallway was blank with the exception of payday and Father's Day listed.
On 6/8/22 at 11:28 AM, 6/13/22 at 8:52 AM, 6/14/22 at 10:48 AM and 6/15/22 at 8:20 AM Resident 107 reported that no activities occurred in the facility during the week or on the weekends. Resident 107 stated she/he was given coloring pages and colored pencils, had colored many pages, was tired of coloring and wanted to do something different. Resident 107 stated a few weeks ago she/he was given a stack of old magazines which she/he read at least twice and had no further interest in reading them again. Resident 107 stated she/he loved crafts and bingo and asked to have a visit with her/his dog but that did not happened. Resident 107 reported she/he just sat in her/his room all day and stated they just dump you off and leave you here.
On 6/9/22 at 2:32 PM and 6/14/22 at 8:36 AM Staff 20 (Activities/Social Services Director) stated she was recently hired as the Activities Director and there was currently no functioning activity program. Staff 20 stated she had no process in place to set up activities and there was no interim activity staff to conduct the program or assist her while she was being trained.
On 6/10/22 at 11:07 AM, 11:51 AM and 6/13/22 at 10:59 AM Staff 11 (CNA), Staff 15 (CNA) and Staff 5 (CNA) reported the facility did not currently have an activities program.
On 6/14/22 at 11:45 AM Staff 1 (Adminstrator) reported the facility did not have an activities program and Staff 20 would be trained as the activity director once payment was made for the activity training course.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 3 of 7 residents (#s 106, 107 and 156) reviewed ...
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Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 3 of 7 residents (#s 106, 107 and 156) reviewed for medication administration. The facility's medication administration error rate was 35%. This placed residents at risk for adverse medication consequences. Findings include:
1. Resident 106 was admitted to the facility in 2022 with diagnoses including stroke.
Resident 106's current physician's orders included the following medications that were ordered to be administered between 6:00 AM and 10:00 AM:
- aspirin (pain reliever and blood thinner)
- vitamin D3 (supplement)
- fludrocortisone (steroid)
- levetiracetam (anticonvulsant)
- magnesium oxide (supplement)
- polyethylene glycol (stool softener)
Resident 106's current physician's orders included the medication Eliquis (anticoagulant) that was ordered to be administered at 8:00 AM.
On 6/13/22 at 12:01 PM Staff 6 (RN) was observed to administer Resident 106's aspirin, vitamin D3, fludrocortisone, levetiracetam, magnesium oxide, polyethylene glycol and Eliquis.
On 6/13/22 at 1:39 PM Staff 2 (DNS) stated medications should be administered within 1 hour of their ordered administration times.
2. Resident 107 was admitted to the facility in 2022 with diagnoses including diabetes.
Resident 107's current physician's orders included insulin aspart 10 units (injectable medication for treating high blood sugar).
On 6/14/22 at 11:42 AM Staff 17 (Agency RN) administered insulin aspart to Resident 107 using an insulin pen. Staff 17 did not prime the pen first to remove air from the needle. Staff 17 confirmed she did not prime the pen and stated she did not prime the pen because she did not see any air in it. The Surveyor suggested Staff 17 check the insulin pen manufacturers instructions, which she did not do.
On 6/14/22 at 12:15 PM Staff 19 (RNCM) confirmed the correct procedure was to prime the insulin pen prior to administering the insulin.
3. Resident 156 was admitted to the facility in 2022 with diagnoses including diabetes.
Resident 156's current physician's orders included insulin aspart per sliding scale (injectable medication for treating high blood sugar).
On 6/14/22 at 11:52 AM Staff 17 (Agency RN) administered insulin aspart to Resident 156 using an insulin pen. Staff 17 did not prime the pen first to remove air from the needle. Staff 17 confirmed she did not prime the pen and stated she did not prime the pen because she did not see any air in it. The Surveyor again suggested Staff 17 check the insulin pen manufacturers instructions, which she did not do.
On 6/14/22 at 12:15 PM Staff 19 (RNCM) confirmed the correct procedure was to prime the insulin pen prior to administering the insulin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide education regarding the benefits and potential side effects associated with receiving the pneumococcal vaccination...
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Based on interview and record review it was determined the facility failed to provide education regarding the benefits and potential side effects associated with receiving the pneumococcal vaccination for 3 of 5 sampled residents (#s 3, 155 and 156) reviewed for vaccinations. This placed residents at risk of not being aware of healthcare options. Findings include:
1. Resident 3 was admitted in 5/2022 with diagnoses including one-sided weakness.
There was no documentation of her/him receiving information from the facility regarding the benefits and potential side effects related to the pneumococcal vaccine or if the resident had received the pneumococcal vaccine.
On 6/14/22 at 12:16 PM Staff 2 (Interim DNS) stated she was unaware of Resident 3's pneumococcal vaccination status and had not discussed this with the resident.
2. Resident 155 was admitted in 6/2022 with diagnoses including chronic kidney disease.
There was no documentation of the facility staff offering her/him the pneumococcal vaccines or providing information related to their benefits and potential side effects.
On 6/14/22 at 10:27 AM Resident 155 stated she/he just got over pneumonia and the facility staff did not discuss the vaccine with her/him.
On 6/14/22 at 12:19 PM, Staff 2 (Interim DNS) confirmed she had not discussed or offered the pneumococcal vaccine with Resident 155.
3. Resident 156 admitted to the facility in 5/2022 with diagnoses including a stroke.
The resident stated the facility staff had not asked if she/he had received the pneumococcal vaccine previously and had not provided information regarding the pneumococcal vaccine, its benefits, or potential side effects with her/him.
There was no documentation in the resident's medical record of the resident receiving the pneumococcal vaccine or education related to the benefits or potential side effects.
On 6/14/22 at 12:19 PM, Staff 2 (Interim DNS) stated she had not discussed or offered the pneumococcal vaccine with Resident 156.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide education regarding the benefits, risks, and potential side effects associated, and failed to provide the opportun...
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Based on interview and record review it was determined the facility failed to provide education regarding the benefits, risks, and potential side effects associated, and failed to provide the opportunity to accept or decline COVID-19 vaccinations for 2 of 5 sampled residents (#s 3 and 157) reviewed for vaccinations. This placed residents at risk for making uninformed healthcare decisions. Findings include:
1. Resident 3 was admitted in 5/2022.
There was no documentation of her/him receiving information from the facility regarding the benefits and potential side effects related to the COVID-19 vaccine.
On 6/15/22 at 1:07 PM Staff 2 (Interim DNS) confirmed she did not yet offer the COVID-19 vaccine to the resident or provide her/him with education related to the risks, benefits, and potential side effects associated with receiving the vaccine.
2. Resident 157 was admitted in 5/2022 with diagnoses including diabetes.
No evidence was found in the facility's electronic health record indicating Resident 157's COVID-19 vaccination status.
On 6/15/22 at 10:14 AM Resident 157 reported the facility did not discuss a COVID-19 vaccination with her/him. She/he stated she/he received both doses plus one booster of the vaccine prior to admission and that she/he kept a vaccination card with her/his personal belongings.
On 6/15/22 at 1:05 PM, Staff 2 (Interim DNS) stated she did not document any communication with Resident 157 related to her/his COVID-19 vaccination status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
3. Resident 156 was admitted in 5/2022 with diagnoses including stroke.
a. The 6/2022 MAR indicated an order for metformin to be administered twice daily to address the symptoms associated with diabe...
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3. Resident 156 was admitted in 5/2022 with diagnoses including stroke.
a. The 6/2022 MAR indicated an order for metformin to be administered twice daily to address the symptoms associated with diabetic polyneuropathy. The MAR indicated the morning dose on 6/2/22 was not administered due to other.
No additional information was located in the resident's clinical record to indicate a rationale for not providing the medication.
On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the medication should have been administered.
b. The 6/2022 MAR indicated Resident 156 had an order for pantoprazole to be administered twice daily before meals to address GI distress. The MAR indicated the morning dose on 6/2/22 was not administered due to other.
No additional information was located in the resident's clinical record to indicate a rationale for not providing the medication.
On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the medication should have been administered. She reported there should be documentation from the nurse clarifying the reason the dose was not administered.
4. Resident 157 was admitted to the facility in 5/2022 with diagnoses including diabetes.
The 6/2022 MAR indicated Resident 157 had an order for omeprazole to be administered once each day. The MAR indicated she/he received one dose in the morning and one dose in the evening on 6/3/22.
On 6/15/22 at 3:39 PM Staff 19 (RNCM) confirmed the medication error and reported the order was revised after the morning dose on 6/3/22 to allow for evening administration of the medication. She reported when an order was updated, the previous administration on that day was no longer visible to the administering nurse.
2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder.
a. A 5/20/22 physician's order indicated Resident 107 was prescribed insulin aspart U-100 units solution; subcutaneously at meals; 100 unit/ML per sliding scale as follows:
-If blood sugar is 141 to 180, give 1 unit.
-If blood sugar is 181 to 220, give 2 units.
-If blood sugar is 221 to 260, give 2 units.
-If blood sugar is 261 to 300, give 3 units.
-If blood sugar is 301 to 340, give 3 units.
-If blood sugar is 341 to 380, give 4 units.
-If blood sugar is 381 to 420, give 4 units.
-If blood sugar is greater than 420, give 5 units.
-If blood sugar is greater than 420, call MD.
A review of Resident 107's 5/2022 and 6/2022 MARs revealed Resident 107 was not administered insulin aspart U-100 at breakfast (8:00 AM) on 5/23/22 and 5/26/22.
A 5/23/22 comment note on Resident 107's MAR indicated Resident 107's blood sugar was not checked prior to breakfast and a 5/26/22 comment note indicated the resident's insulin was not administered due to Resident 107's blood sugar being 175.
On 6/13/22 at 3:15 PM Staff 19 (RNCM) reviewed Resident 107's 5/23/22 and 5/26/22 insulin MAR and progress notes and stated the resident was not administered insulin as prescribed by the physician.
b. A 5/20/22 physician's order indicated Resident 107 was prescribed ferrous gluconate 324 mg, once a day.
A review of Resident 107's 5/2022 and 6/2022 MARs revealed Resident 107 received ferrous gluconate, 324 mg, twice on 6/3/22.
On 6/13/22 at 3:15 PM Staff 19 (RNCM) reviewed Resident 107's 6/3/22 ferrous gluconate MAR and stated the resident incorrectly received two doses of ferrous gluconate 6/3/22.
On 6/14/22 at 2:42 PM Staff 2 (Interim DNS) was provided with the findings of this investigation and acknowledged the medications were not administered according to physician's orders.
Based on interview and record review it was determined the facility failed to follow physician's orders for medication administration for 4 of 5 sampled residents (#s 2, 107, 156 and 157) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include:
1.Resident 2 was admitted to the facility in 2022 with diagnoses including constipation.
Resident 2's Physician Order Report signed my the physician on 5/2/22 revealed orders for the following PRN bowel care medications:
- Milk of Magnesia, to be administered if the resident did not have a bowel movement for three days.
- Senna, to be administered first on day three with no bowel movement.
Resident 2's 5/10/22 through 6/10/22 bowel record revealed the following date ranges when the resident did not have a bowel movement:
- 5/18/22 through 5/20/22.
- 6/3/22 through 6/5/22.
Resident 2's 5/2022 and 6/2022 MARs revealed the ordered Milk of Magnesia and senna were not administered when the resident did not have a bowel movement for three days.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to ass...
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Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to assure resident safety and maintain highest practicable physical, mental, and psychosocial well-being of each resident for 13 of 13 staff (#s 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include:
The facility's Competency of Nursing Staff policy, last revised 5/2019, indicated the following:
1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by the State law.
2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:
a. participate in a facility-specific, competency based development and training program: and
b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.
On 6/13/22 at 12:15 PM, nursing staff training requirements were reviewed to ensure licensed nursing staff had the specific competencies and skills sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care.
On 6/10/22 at 12:58 PM Staff 1 (Administrator) reported when new staff were hired, they completed a packet of orientation materials and then were assigned to the floor with an experienced nursing staff member until they were sure the staff member was capable of performing all tasks. Staff 1 reported the experienced staff member provided him with feedback and, based on the feedback, it was determined if the newly hired staff member was competent to perform their job duties. Staff 1 reported they did not utilize any type of formal competency measures or checklists. Staff 1 stated he was not aware of any routine competencies being completed with current staff.
On 6/10/22 at 11:03 AM, 6/13/22 at 8:30 AM and 6/13/22 at 10:49 AM Staff 11 (CNA), Staff 6 (RN) and Staff 5 (CNA) reported they did not remember being assessed for competencies to perform their job duties.
On 6/13/22 at 12:15 PM Staff 1 and Staff 2 (Interim DNS) were asked to provide documentation of all licensed nursing staff including documentation indicating all staff were able to exhibit competencies required for their job duties.
On 6/13/22 at 1:27 PM Staff 1 stated they were unable to provide any documentation indicating nursing staff displayed specific competencies, skill sets and techniques necessary to care for residents.
Refer to F759 and F880.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) and failed to complete nu...
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Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) and failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 10 of 10 CNAs (#s 5, 7, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include:
A review of the facility's staff training records for CNAs employed over one year revealed the following:
-Staff 5 (CNA), hired 1/7/21, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 7 (CNA), hired 11/1/20, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 9 (CNA), hired 12/2/20, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 10 (CNA), hired 8/17/20, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 11 (CNA), hired 7/11/17, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 12 (CNA), hired 5/8/12, had no performance review and no documentation they completed 12 hours of in-service training
-Staff 13 (CNA), hired 10/14/09, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 14 (CNA), hired 6/7/12, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 15 (CNA), hired 1/16/21, had no performance review and no documentation they completed 12 hours of in-service training.
-Staff 16 (CNA), hired 9/4/20, had no performance review and no documentation they completed 12 hours of in-service training.
On 6/13/22 at 1:27 PM, Staff 1 (Administrator) acknowledged the facility did not have a system in place to track nurse aide in-service training hours and did not complete annual performance reviews.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), $54,945 in fines. Review inspection reports carefully.
- • 46 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $54,945 in fines. Extremely high, among the most fined facilities in Oregon. Major compliance failures.
- • Grade F (3/100). 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 Tigard Rehabilitation And Care's CMS Rating?
CMS assigns TIGARD REHABILITATION AND CARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Tigard Rehabilitation And Care Staffed?
CMS rates TIGARD REHABILITATION AND CARE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Tigard Rehabilitation And Care?
State health inspectors documented 46 deficiencies at TIGARD REHABILITATION AND CARE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 45 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Tigard Rehabilitation And Care?
TIGARD REHABILITATION AND CARE 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 SAPPHIRE HEALTH SERVICES, a chain that manages multiple nursing homes. With 112 certified beds and approximately 57 residents (about 51% occupancy), it is a mid-sized facility located in TIGARD, Oregon.
How Does Tigard Rehabilitation And Care Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, TIGARD REHABILITATION AND CARE's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Tigard Rehabilitation And Care?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Tigard Rehabilitation And Care Safe?
Based on CMS inspection data, TIGARD REHABILITATION AND CARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oregon. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Tigard Rehabilitation And Care Stick Around?
TIGARD REHABILITATION AND CARE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Tigard Rehabilitation And Care Ever Fined?
TIGARD REHABILITATION AND CARE has been fined $54,945 across 1 penalty action. This is above the Oregon average of $33,628. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Tigard Rehabilitation And Care on Any Federal Watch List?
TIGARD REHABILITATION AND CARE 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.