Pilot Butte Rehabilitation Center

Based on interview and record review it was determined the facility failed to report allegations of neglect and abuse timely for 3 of 4 sampled residents (#s 21, 47, and 51) reviewed for abuse and neglect. This placed residents at risk for neglect and abuse. Findings include:1. Resident 21 was admitted to the facility 8/25/25 with diagnoses including pelvic fracture. On 9/15/25 at 3:52 PM, Resident 21 stated she/he reported an allegation of abuse by Staff 33 (RN) and Staff 34 (CNA) that occurred on 9/7/25. The resident alleged an RN, and a CNA gave her/him a suppository against her/his will. Resident 21 also alleged Staff 34 forcefully placed her hand on the resident's hip to hold her/him down. Resident 21 stated she/he spoke to Staff 2 (DNS) and Staff 1 (Administrator) about the incident and wanted to file a grievance. The facility reported the alleged abuse to the State Agency on 9/16/25. On 9/16/25 at 7:53 AM, Staff 2 stated she and Staff 1 spoke with the resident and the staff involved when they learned of the incident 9/8/25. Staff 2 stated she did not take further action. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital and notify the Ombudsman for 1 of 2 sampled residents (# 6) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:Resident 6 was admitted to the facility in 1/2025 with diagnoses including kidney failure.A review of Resident 6's clinical record revealed she/he was transferred to the hospital on [DATE]. No evidence was found in the clinical record to indicate a written notice of the facility's bed hold policy was provided to the resident or her/his representative. No documentation was found indicating the Ombudsman was notified of the transfer.On 9/18/25 at 8:47 AM, Staff 11 (Regional Director of Clinical Operations) and Staff 14 (Assistant Director of Nursing Services) verified a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to follow physician orders and failed to monitor a resident for a change of condition for 3 of 5 sampled residents (#s 2, 5, and 8) reviewed for medications. This placed residents at risk for unmet care needs. Findings include:1. Resident 2 was admitted to the facility in 9/2022 with a diagnosis of heart disease. Per Mayo Clinic: Hypokalemia (low potassium) symptoms of irregular heart rhythms were the most worrisome complication of very low potassium levels, particularly in people who have heart disease Resident 2's 8/11/25 Basic Metabolic Panel results revealed her/his potassium level was 2.7 (normal range 3.4-4.9). Resident 2's Progress Notes revealed:-On 8/11/25 Resident 2 was seen by her/his physician at the medical clinic and laboratory samples were obtained. -On 8/12/25 her/his physician called the facility with orders to transport Resident 2 to the local emergency department due to a critically low potassium level. The note indicated Resident 2 refused to be transported to the hospital due to the cost…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to maintain comfortable temperature levels for 1 of 2 (Pine Meadow Hall) halls observed for environment. This placed residents at risk for uncomfortable temperatures. Findings include: Resident 26 admitted to the facility in 2024 with diagnoses including ALS (a nervous system disease). On 5/28/24 at 10:17 AM Resident 26 stated her/his room and the hall were too cold and made her/his body hurt. Resident 26 stated she/he reported this to management and nursing staff, but nothing was done to resolve the temperature issue. On 5/30/24 at 10:39 AM Staff 15 (CNA) and Staff 16 (CNA) stated Pine Meadow Hall was cold and residents complained about it. Multiple random observations from 5/28/24 through 5/31/24 revealed Resident 26's room and Pine Meadow Hall were cold. The thermostat for the hall was set to 68 degrees. On 5/30/24 at 1:04 PM Staff 14 (Maintenance Director) stated he tested the temperature in residents' rooms but did not document the results or complete audits. Staff 14 stated he was aware of Resident 26's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide therapeutic diets to 3 of 4 (#s 2, 23, and 28) sampled residents reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and diabetes. A 5/24/24 Summary of Care Document for Resident 2 included discharge orders for a diabetic diet. On 5/29/24 at 2:53 PM Staff 4 (Dietary Manager) stated residents who required diabetic diets were individually interviewed to determine what level of diet compliance each resident wanted and Resident 2's preferences were added to her/his meal ticket to reflect her/his requests. Staff 4 acknowledged there were no prescribed recipes used or portion control guideline for staff preparing meals to follow for therapeutic diets including residents who required a diabetic diet. On 5/29/24 at 3:50 PM Staff 13 (RD) acknowledged the facility approved therapeutic diets, which included a diabetic diet, should be printed and followed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive, and at an appetizing temperature for 1 of 1 kitchen and 3 of 4 sampled residents (#s 9, 11 and 23) reviewed for food quality. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 9 admitted to the facility in 2023 with diagnoses including cancer. An 10/10/23 Significant Change MDS indicated the resident was cognitively intact. On 5/28/24 at 11:23 AM Resident 9 stated the food was always cold and the meat was chewy. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the food was not hot and the meat was hard. 2. Resident 23 admitted to the facility in 2024 with a diagnosis of malnutrition. A 2/2/24 admission MDS indicated Resident 23 was cognitively intact. On 5/29/24 at 1:03 PM Resident 23's lunch had raw hamburger in the taco casserole. On 5/29/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to ensure beard restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk for contaminated food. Findings include: A review of the facility's policy Dietary Dress Code dated 1/2024 revealed beards must be clean, well-groomed and must be completely covered with a beard covering. On 5/28/24 at 8:10 AM Staff 4 (Dietary Manager) and Staff 26 (Cook) were observed preparing food in the kitchen without beard restraints. Staff 4 indicated he was not aware staff had to wear beard coverings. On 5/29/24 at 12:01 PM Staff 13 (RD) acknowledged staff were to wear beard restraints while working in the kitchen.

Based on interview, and record review it was determined the facility failed to obtain consent to administer medication for 1 of 5 (#16) sampled residents reviewed for unnecessary medications. This placed residents at risk for uninformed care. Findings include: Resident 16 admitted to the facility in 12/2019 with diagnoses including dementia, restlessness and agitation. A review of Resident 16's Physician Orders revealed an 4/11/24 order for buspirone (a medication in the anxiolytic drug class used to treat anxiety). A review of Resident 16's medical record revealed an 4/11/24 signed consent for buspirone listed as an antidepressant medication. The consent went over the risks and benefits for an antidepressant medication. On 5/30/24 at 4:03 PM Staff 2 (DNS) stated buspirone was an anxiolytic medication, not an antidepressant medication. Staff 2 acknowledged Resident 16 and her/his representative were not given informed consent for buspirone.

Based on interview and record review it was determined the facility failed to evaluate a resident's choice for bathing for 1 of 1 sampled resident (#18) reviewed for choices. This place residents at risk for lack of honored choices. Findings include: Resident 18 admitted to the facility in 2023 with diagnoses including stroke and anxiety. The 3/4/24 Quarterly MDS indicated Resident 18 required partial to moderate assistance for bathing and was cognitively intact. A 11/29/24 care plan indicated to provide Residents 18's bathing according to his/her preferences two times a week. The Task: Shower form for Resident 18 indicated the following: -On 5/1/24 at 9:30 PM the resident refused her/his shower. -On 5/4/24 at 8:30 PM the resident refused her/his shower. -On 5/11/24 at 9:54 PM the resident refused her/his shower. On 5/28/24 at 9:23 AM Resident 18 stated she/he refused showers because staff offered showers at night when she/he wanted to be in bed. Resident 18 stated she was told by CNAs her/his showers were scheduled at night. Resident 18 requested a different time for bathing and no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure advance directive information was provided to residents for 3 of 4 sampled residents (#s 11, 34, and 40) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored. Findings include: 1. Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. An 4/6/24 quarterly MDS revealed Resident 11 had impaired cognition. An 4/11/24 Care Conference form indicated Resident 11 had an advance directive. On 5/29/24 at 10:01 AM Staff 9 (Social Service Director) stated if the Care Conference form indicated the resident had an advance directive, a copy was to be in the resident's clinical record. On 5/29/24 at 2:18 PM Staff 2 (DNS) stated Resident 11 did not have an advance directive. Staff 2 also stated there was no documentation to indicate Resident 11 or her/his representative were provided information regarding advance directives. On 5/29/24 at 2:50 PM Witness 3 (Family) and Witness 4 (Family) stated the facility did not provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide an Advanced Beneficiary Notice for 1 of 3 (#5) sampled residents reviewed for Beneficiary Notification. This placed residents at risk for financial loss. Findings include: Resident 5 admitted to the facility in 8/2016 with diagnoses including respiratory failure. Resident 5 had a skilled Medicare stay from 1/10/23 through 1/19/23. Resident 5 remained in the facility after 1/19/23 on Medicaid. A review of Resident 5's medical record revealed no evidence of an Advanced Beneficiary Notice (ABN) issued to her/him after his Medicare stay. On 5/31/24 at 9:08 AM Staff 3 (Regional Nurse Consultant) acknowledged Resident 5 was not issued an ABN upon payor change from Medicare to Medicaid on 1/19/23.

Based on interview and record review it was the determined the facility failed to prevent abuse for 3 of 3 (#s 14, 21, and 31) sampled residents reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnosis including stroke. A 3/5/24 Quarterly MDS revealed Resident 14 was cognitively intact. A 3/27/24 revised care plan indicated Resident 14 was incontinent of bowel and required one staff to assist with bowel care. A 5/14/24 Alleged Abuse investigation for Resident 14 indicated a CNA reported an allegation of abuse because Resident 14 was questioned why she/he no longer had Staff 23 (former Agency CNA) provide her/his care. Resident 14 stated Staff 23 completed her/his personal care and wiped her/him roughly stating Staff 23 tried to stick a wipe and her finger up her/his butt. Resident 14 told Staff 23 she was rough during care. Resident 14 indicated Staff 23 continued to provide rough care, became upset and told her/him not to tell her how to complete her job. On 5/28/24 at 1:33 PM Resident 14 confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to revise care plans for 2 of 5 sampled residents (#s 2 and 34) reviewed for unnecessary medications. This placed residents at risk for lack of appropriate care. Findings include: 1. Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and stroke. A 5/24/24 hospital Discharge Summary indicated Resident 2 admitted to the hospital due to a hematoma (pool of mostly clotted blood) in her/his chest wall while on an oral anticoagulant. Resident 2's discharge medications included no anticoagulant medication. A 5/24/24 revised care plan indicated to provide interventions, monitor and prevent bleeding for Resident 2 due to the use of her/his anticoagulant medication. On 5/31/24 at 9:22 AM Staff 5 (Resident Care Manager) stated the orders for Resident 2 were not checked twice as expected when Resident 2's anticoagulant medication was discontinued. Staff 5 acknowledged Resident 2's care plan was not revised. 2. Resident 34 admitted to the facility in 2024 with a diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 2 sampled residents (#s 7 and 9) reviewed for accidents and hospice. This placed residents at risk for unmet care needs. Findings include: Resident 9 admitted to the facility in 2017 with diagnoses including end of life care and restless leg syndrome. An 10/10/23 Cognitive Loss CAA revealed Resident 9 stated rest, repositioning and medications were helpful to address her/his pain relief and discomfort. The 11/2/23 physician order indicated Resident 9 was to receive Benztropine (restless leg medication) every evening at bedtime. A review of Resident 9's clinical record for 5/2023 revealed Resident 9 missed eight doses of her/his Benztropine. On 5/28/24 at 8:20 AM Resident 9 stated she/he went without the medication she needed for her/his restless leg syndrome for eight days. On 5/29/23 at 3:38 PM Staff 2 (DNS) acknowledged the resident missed eight doses of her/his medication. 2. Resident 7 admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to scheduled an audiology exam for 1 of 1 sampled resident (#22) reviewed for communication needs. This placed residents at risk for unmet needs. Findings include: Resident 22 admitted to the facility in 4/2023 with diagnoses including a stroke. A 1/24/24 Provider Progress Note revealed Resident 22 requested to see a hearing doctor. An 4/27/24 MDS revealed Resident 22 was cognitively intact. On 5/28/24 at 9:48 AM Resident 22 stated she/he was hard of hearing and was recommended hearing aids at a doctor's appointment approximately eight months ago. On 5/29/24 at 12:21 PM Staff 9 (Social Service Director) stated Resident 22 should have had a hearing appointment set up but was unable to locate the information. A 5/29/24 Progress Note revealed Resident 22's son was called to confirm or schedule a yearly hearing exam for Resident 22. On 5/31/24 at 8:06 AM Staff 5 (RN Resident Care Manager) stated she was aware Resident 22 was hard of hearing and acknowledged Resident 22 did not see a hearing doctor.

Based on observation, interview and record review it was determined the facility failed to accurately assess pressure wounds and follow physician orders for 2 of 3 sampled residents (#s 4 and 19) reviewed for pressure ulcers. This placed resident at risk for worsening wounds. Findings include: 1. Resident 4 admitted to the facility in 2023 with diagnoses including stroke and aphasia (speech or language deficit due to brain injury). A 12/9/23 physician order indicated to float Resident 4's heels while in bed, apply skin prep to her/his heels each shift and ensure a foam boot was applied to her/his right heel at all times. The 4/19/24 Quarterly MDS indicated Resident 4 had a Stage 4 (deep wound that may impact muscles, ligaments, and bone) pressure ulcer to the heel. The 5/2024 TAR indicated on each shift through 5/29/24 Resident 4's heels were floated while in bed, skin prep was applied to her/his heels each shift and a foam boot was applied to her/his right heel at all times. The 5/22/24 revised care plan indicated to administer treatments as ordered and encourage Resident 4 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision for 1 of 2 sampled residents (#33) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 22 admitted to the facility in 4/2024 with diagnoses including a stroke. An 4/5/24 MDS revealed Resident 33 had moderate cognitive impairment. A 5/15/24 Elopement Evaluation revealed Resident 33 was a moderate risk for elopement. A 5/29/24 review of Resident 33's care plan revealed no evidence of an elopement care plan. Resident 33 was observed during random observations from 5/28/24 through 5/31/24 to ambulate with a walker up and down the hallways, through the dining room, front lobby and occasionally resident rooms throughout the day. On 5/30/24 at 1:54 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 33 was at risk for elopement but was not care planned at risk for elopement.

Based on interview and record review it was determine the facility failed to implement orders and consistently monitor a dialysis (a procedure to remove excess waste products and fluid from the blood) access site for 1 of 1 sampled resident (#2) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and stroke. A 3/4/24 admission MDS indicated Resident 2 received dialysis. A 5/20/24 RD Nutrition Assessment indicated Resident 2 required an early breakfast and late lunch on dialysis days and to avoid high phosphorus and potassium food options at meals. A 5/21/24 Nursing Note indicated receipt of a new diet order for Resident 2 to avoid high phosphorus and potassium foods. A 5/24/24 revised care plan indicated to assess Resident 2's dialysis shunt for bruit (whooshing) and thrill (vibration) daily and provide diet according to orders. The 5/2024 TAR indicated no post-dialysis monitoring of bruit, thrill or pressure site dressing. On 5/28/24 at 2:09…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident was assisted with discharge planning arrangements for 1 of 1 sampled resident (#11) reviewed for care planning. This placed residents at risk for increased anxiety. Findings include: Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. Resident 11's clinical record revealed her/his home was six miles from the facility. A 12/8/23 Quarterly MDS revealed Resident 11 was able to answer questions but had moderate cognitive issues. A 1/10/24 Care Conference form revealed Witness 3 (Family) and Witness 4 (Family) attended the care conference. The form indicated Witness 3 and Witness 4 requested they be notified before Resident 11 was discharged to ensure they had things set up for the resident's care. The form indicated Resident 11 wanted to go home. Concerns related to the resident's discharge were the resident's mental status and weakness. The form did not indicate what needed to be set up at the resident's home to ensure it was ready for her/his care. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure non-pharmacological interventions were provided prior to PRN antianxiety medication administration for 1 of 5 sampled residents (#37). This placed residents at risk for sedation. Findings include: Resident 37 admitted to the facility in 2024 with a diagnosis of dementia. Resident 37's Care Plan was updated on 3/12/24 to indicate the resident was at risk for side affects of Ativan (antianxiety medication). A 5/2024 MAR revealed Resident 37 was to be administered Ativan PRN. The resident was administered Ativan 53 times. Only one time the medication was documented as not effective. 5/2024 progress note revealed Resident 37 had anxiety and PRN Ativan was administered. The Ativan was frequently administered at the same time as oxycodone (narcotic pain medication), therefore it was indeterminate if a decrease in the resident's pain level would have decreased her/his anxiety. The Progress notes did not describe how Resident 37's anxiety presented or what specific interventions were provided to decrease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure orders for a hypertensive medication were implemented for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for abnormal heart rhythms. Findings include: Resident 2 admitted to the facility in 2024 with diagnoses including high blood pressure and end stage kidney disease. A 5/13/24 revised care plan indicated Resident 2 had altered cardiovascular status, to monitor vital signs, provide medications per physician order and report any abnormalities. A 5/24/24 hospital Discharge Summary indicated to continue Resident 2's metoprolol succinate (medication to control abnormal heart rhythms). The 5/2024 MAR indicated Resident 2's metoprolol succinate was last administered by the facility on 5/21/24. On 5/31/24 at 9:22 AM Staff 5 (Resident Care Manager) stated the orders for Resident 2 were not checked twice as expected when Resident 2 returned from the hospital (on 5/24/24). Staff 5 acknowledged Resident 2's metoprolol succinate was not administered as ordered.

Based on observation, interview and record review it was determined the facility failed to honor resident food preferences for 2 of 4 (#s 22 and 28) sampled residents reviewed for food. This placed residents at risk for unmet needs. Findings include: 1. Resident 22 admitted to the facility in 4/2023 with diagnoses including diabetes. An 4/27/24 MDS revealed Resident 22 was cognitively intact. On 5/28/24 at 9:49 AM Resident 22 stated she/he frequently did not get what was requested when her/his meal was delivered. Resident 22 stated for breakfast she/he received scrambled eggs, an English muffin and cold cereal with no milk. Resident 22 requested milk for her/his cereal but was informed there was no milk available. On 5/29/24 at 12:03 PM Resident 22 stated she/he requested scrambled eggs for breakfast, but instead received a pancake, fruit and raisin bran. On 5/29/24 at 12:53 PM Resident 22 stated she/he requested a ham and cheese sandwich, a salad and Jello for lunch, but instead she/he received chicken casserole. On 5/29/24 at 11:47 AM Staff 4 (Dietary Manager) stated if a resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide immunizations to 1 of 5 sampled residents (#21) reviewed for immunizations. This placed residents at risk for infections. Findings include: Resident 21 was admitted to the facility in 8/2023 with diagnoses including chronic respiratory failure. A review of Resident 21's immunizations revealed she/he was not offered a Prevnar 20 vaccine, but was eligible to receive the Prevnar 20 vaccine. On 5/30/24 at 2:44 PM Staff 2 (DNS) acknowledged Resident 21 was eligible for a Prevnar 20 vaccine and it was not offered to her/him.

Based on interview and record review it was determined the facility failed to report to the State Agency an unwitnessed fall with serious bodily injury for 1 of 3 sampled residents (#101) reviewed for accidents. This placed residents at risk for additional accidents and potential abuse. Findings Include: Resident 101 was admitted to the facility in 8/2023, with diagnoses including hip fracture, history of falls, and dementia with cognitive decline. An Incident Report dated 8/31/23 indicated a nurse was called to Resident 101's room because of a fall. The resident was found lying in bed with a skin tear above the left eye and another on the right elbow. There were no witnesses listed. The nurse found bruising and excess fluid when she assessed the elbow. The resident was sent out to the hospital. A 9/1/23 at 3:20 PM, Alert Progress Note indicated Resident 101 was on alert charting due to multiple recent falls. The most recent fall was on 8/31/23 and resulted in a fractured elbow requiring surgery and a laceration above the eye. A review of the medical record for Resident 101 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to thoroughly investigate an unwitnessed fall with a major injury and rule out potential abuse or neglect for 1 of 3 sampled residents (#101) reviewed for falls. This placed resident at risk for additional falls and potential abuse. Findings include: Resident 101 was admitted to the facility in 8/2023, with diagnoses including hip fracture and repeated falls. Resident 101's care plan revised on 9/25/23, indicated the resident was at risk for falls, had a history of falls prior to admission and had multiple recurrent falls while at the facility despite fall interventions in place. An Incident Report dated 8/31/23, indicated a nurse was called to Resident 101's room because of a fall. The resident was found lying in bed with a skin tear above the left eye and another on the right elbow. The resident said she/he could not extend the arm all the way. The resident did not remember hitting her/his head but stated she/he must have since there was a skin tear to her/his left eyebrow. There were no witnesses listed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Resident 103 was admitted to the facility in 7/2022 with diagnoses including neck fracture and a history of falls. A Facility Reported Incident Form dated 8/16/22 indicated on 8/15/22 at 8:06 PM a CNA found Resident 103 on the floor in her/his bathroom. The nurse who arrived to assess the resident indicated the toilet was not attached to the floor. The toilet was on its side with a four wheel dolly beside it. No signs were placed on the resident's door or the bathroom door to not use the toilet. No evening staff members were notified the toilet was not secured to the floor. A written statement dated 8/15/22 by the facility Maintenance Director indicated the maintenance department was notified the toilet in Resident 103's bathroom was very loose because the floor mounting screws were stripped. He pulled the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 professional standards were followed related to proper infection control techniques for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Registered Nurses: * Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards: * Be accountable for individual RN actions, maintain competency in one's RN practice role and ensure unsafe nursing practices are addressed immediately. 1. Resident 1 was admitted to the facility in 2017 with diagnoses including paraplegia (paralysis of the lower body). On 2/23/23 at 3:04 PM Staff 12 (RN) was observed to perform a dressing change on Resident 1. Staff 12 donned clean gloves, removed the dirty dressing from the wound, and then proceeded to clean the wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to utilize hygienic practices when handling food, ensure temperature logs were completed for the dishwasher and ensure a cleaning schedule was followed for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include: 1. On 2/20/23 at 8:19 AM Staff 28 (Cook) was in the kitchen at the steam table without a hairnet in place. Staff 28 stated she just got back from break and did not replace her hairnet. On 2/22/23 at 11:10 AM Staff 28 was observed preparing for lunch in the kitchen without a hairnet in place. On 2/22/23 at 11:39 AM Staff 26 (Dietary Manager) entered the kitchen, put on gloves and began to dish out cake. Staff 26 was asked if he washed his hands and he stated he did not. On 2/22/23 at 11:47 AM Staff 30 (Dietary aide) began to assist in preparing trays for meal service while wearing a dirty apron from the dish room. Staff 30 stated he did not know if it was okay to wear the apron. Staff 26 told Staff 30 he needed to remove the apron. On 2/22/23 at 12:06 PM Staff 27 (Cook)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to follow proper infection control practices for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: a. Resident 1 was admitted to the facility in 2022 with diagnoses including paraplegia (paralysis of the lower body). On 2/23/23 at 3:04 PM Staff 12 (RN) was observed to perform a dressing change on Resident 1. Staff 12 donned clean gloves, removed the dirty dressing from the wound, did not change her gloves and proceeded to clean the wound and open clean dressings with dirty gloves. On 2/23/23 at 3:10 PM Staff 12 acknowledged she did not change her dirty gloves before cleaning the wound and opening new dressing packages. b. Resident 19 was admitted to the facility in 2023 with diagnoses including leg fracture and diabetes. On 2/22/23 at 8:14 AM Staff 12 (RN) was observed to perform a CBG check on Resident 19 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure appropriate COVID-19 testing was conducted for staff during a COVID-19 outbreak for 1 of 1 facility reviewed for infection control. This place residents a risk for COVID-19 infections. Findings include: Facility staff reported as of 1/14/23 they had a COVID-19 outbreak in the facility. The facility's COVID-19 Testing Requirements policies and procedures included the following: * Facilities were required to test residents and staff in a manner consistent with current standards of practice for Covid-19. * Outbreak: Upon identification of a single case of Covid-19 infection in any staff or residents, the testing should begin immediately, but not earlier than 24 hours after the exposure, if known. * Broad-based testing: testing is recommended immediately and, if negative, again 48 hours after the first negative test and, if negative, and again 48 hours after the second negative test. This will typically be at day 1, day 3, and day 5. If additional Covid-19 positive individuals were identified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to provide a safe, functional and sanitary environment for 1 of 1 laundry rooms reviewed for infection control. This placed residents at risk for contaminated laundry and staff at risk for injury. Finding include: On 2/24/23 at 1:25 PM an observation was conducted of the laundry area of the facility. A washer and dryer were in place for residents' personal laundry. There was a black hose from the back of the washing machine to the center of the room by the floor by the drain. In the center of the room was a trough drain for the commercial washer located in the same room. The commercial washer drain was covered with a piece of plywood cut to fit the drain with a small open area to allow the black hose from the residents' washing machine to drain into the trough. The black hose did not reach inside the drain and water could be seen draining from the hose wetting the wood floor cover for the drain, and the wood drain cover, which was part of the room's floor, was saturated with water such that it was falling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure resident representatives were notified of a change of condition for 1 of 1 sampled resident (#9) reviewed for notification of change. This placed residents and resident representatives at risk for lack of information. Findings include: Resident 9 was admitted to the facility in 2023 with diagnoses including dementia. Resident 9's face sheet revealed Witness 2 (Family Member) was her/his responsible party, medical power of attorney, and emergency contact. A 1/23/23 admission MDS revealed Resident 9 had a BIMS of 7 which indicated severe cognitive impairment. A 2/18/23 Progress Note revealed Resident 9 choked on hot chocolate which resulted in facility staff performing the Heimlich Maneuver on her/him. There was no documentation Witness 2 was notified. On 2/23/23 at 4:49 PM Witness 2 stated he was not notified of Resident 9's choking episode but expected to be notified. On 2/23/23 at 5:45 PM Staff 19 (LPN) indicated she was present for Resident 9's choking incident and did not recall Witness 2 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to revise care plans related to fluid restrictions and medical devices for 2 of 2 sampled residents (#s 13 and 184) reviewed for dialysis and care planning. This placed residents at risk for lack of adequate care. Findings include: 1. Resident 184 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease (kidney failure) and heart failure. A 2/17/23 physician order indicated Resident 184 was limited to 1200 ml of fluids each day. The 2/20/23 revised care plan did not include information related to Resident 184's fluid restriction. On 2/22/23 at 11:09 AM Staff 8 (Resident Care Manager) stated she often did not see orders directly entered into the system by the physician and offsite staff currently assisted with care plan updates. Staff 8 acknowledged Resident 184's care plan related to fluid restrictions was not updated timely. 2. Resident 13 was admitted to the facility in 2019 with diagnoses including breast cancer. A care plan revised 11/23/22 indicated Resident 13 wore…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 qualified staff assessed wounds for 2 of 2 LPNs reviewed for wound care. This placed residents at risk for receiving inadequate treatment. Findings include: The Oregon State Board of Nursing Scope of Practice Standards for Licenses Practical Nurses, Oregon Administrative Rules [PHONE NUMBER] and [PHONE NUMBER] outlined the following: -The Primary Legal Differences Between RN and LPN Practice: The RN uses broad knowledge to determine (1) what data is appropriate to the client's health status based on data collected by the RN or other team members (2) synthesizes the data to determine reasoned conclusions (nursing diagnosis) (3) develops and authors the plan of care (4) supervises the implementation of the plan (5) modifies the plan as information regarding the client's condition changes. The LPN uses basic knowledge to determine (1) the client's status at the time of intervention (2) implements the plan of care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#232) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 232 was admitted to the facility in 2021 with diagnoses including pelvic fracture. On 2/21/23 at 4:32 PM Witness 3 (Complainant) stated Resident 232 was not showered or provided with a bed bath for many days while in the facilty. The 8/2021 Documentation Survey Report revealed Resident 232 did not receive a bed bath or a shower from 8/5/21 through 8/10/21 (six days) and 8/13/21 through 8/20/21 (eight days). On 2/22/23 at 2:04 PM Staff 14 (CNA) stated there were times showers were missed or not offered. On 2/23/23 at 8:36 AM Staff 8 (Resident Care Manager) reviewed Resident 232's shower records and confirmed a shower or bed bath was not documented as completed. Staff 8 also stated this was during a COVID-19 outbreak and there was a plastic wall which separated the shower from the residents in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to obtain physician orders for 1 of 1 sampled resident (#233) reviewed for catheters. This placed residents at risk for unmet care needs. Findings include: Resident 233 was admitted to the facility in 2023 with diagnoses including retention of urine. On 2/20/23 at 10:16 AM Resident 233 stated the facilty staff were to use an external catheter on her/him but the facility did not have the correct size. A review of Resident 233's Physician Orders revealed no orders for an external catheter. A review of Resident 233's Progress Notes revealed Resident 233 had an external catheter in place on 2/17/23 and 2/23/23. A review of Resident 233's Urinary Continence tasks revealed an external catheter was documented as in place on 2/18/23 and 2/23/23. On 2/23/23 at 4:10 PM Staff 12 (RN) stated Resident 233 used an external catheter. On 2/23/23 at 5:45 PM Staff 19 (LPN) stated Resident 233 tried an external catheter, however the facility did not have the correct size. On 2/24/23 at 8:45 AM Staff 9 (LPN) stated Resident 233…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 appropriate foot care was provided for residents with compromised mobility for 1 of 1 sampled resident (#2) reviewed for ADLs. This placed resident at risk for unmet foot care needs. Finding include: Resident 2 admitted to the facility in 2020 with diagnoses including stoke with paralysis on the right side and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The [NAME] (CNA directions for resident care) in place for 2/2023 indicated staff were to apply lotion to both feet and legs twice daily. On 2/22/23 at 1:26 PM Resident 2 was observed in her/his room. The resident's feet were observed and found to be very dry with flaky skin which flew into the air when her/his socks were removed. The big toe of the left foot laid over the next toe and had reddened areas of skin between the two toes where the toes pressed against each other. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined the facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of proper treatment and care by competent staff. Findings include: The new hire paperwork for Staff 12 (RN) was reviewed. Staff 12 did not complete a Skilled Nursing New Hire Checklist which included orientation to the Needle Stick Protocol. On 2/21/23 at 8:14 AM Staff 12 was observed to use a blood glucose monitor to test an unidentified resident in the dining room at a table with multiple residents present. Staff 12 indicated the facility allowed this practice. On 2/24/23 at 3:29 PM Staff 3 (DNS) was asked about the nursing staff training for new hires and staff to ensure nursing staff were able to to demonstrate competency and skills. Staff 3 acknowledged the facility had no method to verify that the skills of nursing staff were reviewed prior to 1/2023 and she was in the process to remedy the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.