Highland House Nursing & Rehabilitation Center

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 residents did not have cigarettes and lighters in their rooms and a fall investigation was thoroughly completed for 3 of 10 sampled residents (#1, 11, and 110) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 1 was admitted to the facility in 7/2024 with diagnoses including chronic obstructive pulmonary (lung) disease and epilepsy (brain disorder characterized by seizures). The 2/2025 facility Resident Smoking Policy and Procedure revealed ignition sources were not permitted in resident rooms. Lighters belonging to independent smokers were required to be stored in an assigned smoking locker. The 4/9/25 Nursing Smoking Screen revealed Resident 1 smoked more than 10 times daily and was able to light her/his own cigarettes. The 7/25/25 Annual MDS revealed Resident 1 had a BIMS of 15 (cognitively intact), used her/his wheelchair independently, and was a smoker. 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 that the facility failed to implement nutritional interventions to prevent weight loss for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for continued weight loss. Findings include: Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. a. Resident 40's 6/16/25 Nutritional Evaluation revealed the dietary manager was to evaluate Resident 40 for fortified food, if the resident would accept any of the typical offerings. Resident 40's clinical record revealed a diet order for fortified meals was initiated on 8/3/25. On 12/3/25 at 11:20 AM Staff 37 (District Dietary Manager) stated if a RD wrote orders for a fortified diet the dietary staff implemented the order. The RD would send an email to the dietary staff or would directly add the fortified meal into the resident's dietary orders. Staff 37 stated if a RD recommended a fortified diet but did not write an order, the dietary manager would not communicate with the resident, and the Resident Care Manager would need…

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 sufficient respiratory services for 1 of 3 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include:Resident 11 was admitted to the facility in 4/2024 with diagnoses including stroke and respiratory failure. The 5/24/23 facility Transportation Agreement revealed all vehicles were to be staffed and equipped in accordance with the minimum requirements of federal, state, and local laws and regulations. The 7/4/25 Quarterly MDS revealed Resident 11 required oxygen therapy. The 7/2025 TAR indicated Resident 11 required three liters of oxygen per minute via a nasal canula (a plastic tubing in the nose), staff were to monitor the resident for shortness of breath and maintain oxygen saturation (the amount of oxygen traveling through the blood) at or above 90%. A 7/2/25 signed Transportation Request Form indicated Resident 11 had appointments for labs and imaging on 7/7/25, she/he required a companion, and yes was marked for oxygen.…

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 behavior health services were provided for 3 of 5 sampled residents (#s 9, 19, and 36) reviewed for behavioral-emotional health and hospice. This placed residents at risk for unresolved emotional needs. Findings include:1. Resident 9 was admitted to the facility in 4/2025 with a diagnosis of kidney disease. Resident 9's 8/13/25 Quarterly MDS revealed she/he was moderately cognitively impaired. Resident 9's 8/19/25 Initial Assessment by Witness 7 (Psychologist) revealed Resident 9 had anxiety, memory issues, fear of relocation, and had thoughts of embarrassment due to her/his current health and living situation. Resident 9 denied depression but alluded to the presence of depression. Witness 7 indicated Resident 9's behavioral health needs included emotional support and anxiety management. The plan included a referral to psychiatry to manage medication, low dose antianxiety medications, and regular therapy. Resident 9's clinical record did not reveal a referral to psychiatry or therapy…

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 received thickened liquids as ordered for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for aspiration. Findings include: Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. Resident 40's 9/16/21 Dietary Order Details revealed she/he was to receive mildly thickened liquids. Resident 40's 9/21/25 Progress Notes revealed Staff 29 (LPN) notified Residents 40's medical provider that she/he aspirated during a meal. Resident 40's provider ordered a chest x-ray. Resident 40's 9/21/25 communication form to Resident 40's medical provider revealed she/he aspirated at lunch while drinking Ensure which was not thickened. The form included a handwritten note by Resident 40's medical provider dated 9/23/25 which revealed Resident 40's chest x-ray was negative. On 10/1/25 at 7:19 AM Staff 29 verified a CNA provided Resident 40 a supplemental drink which was not thickened, Resident 40 aspirated, and she notified her/his physician.…

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 residents were treated with respect and dignity for 1 of 6 sampled residents (#12) reviewed for abuse. This placed residents at risk for being treated with a lack of respect and dignity. Findings include: Resident 12 admitted to the facility in 11/2024, with diagnoses including Parkinson's Disease. Resident 12 was on Hospice Services and passed away on 3/9/25. The 2/17/25 facility investigation revealed several staff attempted to assist Resident 12 to sit down in her/his wheelchair. Resident 12 displayed agitation, which included spitting on the ground and toward staff members. Staff 6 (CNA) flicked the resident on the back of her/his hand and stated, If you're going to be mean to me, I'm going to be mean to you. The resident experienced no negative outcome as a result of the interaction. The 2/18/25 Progress Note indicated Resident 11 was combative with staff and Hospice was notified of her/his behavioral changes. The 2/19/25 Progress Note indicated Resident 12 had possible psychosocial distress…

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 accurately assess facility acquired pressure ulcers for 1 of 3 sampled residents (#11) reviewed for skin conditions. This placed residents at risk for unassessed and worsening pressure ulcers. Findings include: The National Pressure Injury Advisory Panel defined shearing as a pressure injury when tissue layers moved over the top of each other, and a Stage 3 pressure ulcer as a full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle are not exposed and some slough (dead tissue often appearing as a yellow, tan, or white fibrous material) may be present but does not obscure the depth of tissue loss. Resident 11 was admitted to the facility in 1/2025, with diagnoses including intestinal bypass and failure to thrive. The resident discharged on 2/10/25. The 1/9/25 Nursing admission Evaluation revealed Resident 11 had a red coccyx upon admission. The 1/11/2025 admission MDS indicated Resident 11 was at risk for pressure ulcers and had no pressure ulcers. The 2/5/25 Wound…

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 evaluate a potential unavoidable accident of a feeding tube being dislodged to prevent recurrence for 1 of 3 sampled residents (#11) reviewed for safety. This placed residents at risk for dislodged feeding tubes. Findings include: Resident 11 admitted to the facility in 1/2025, with diagnoses including failure to thrive and malnutrition. Resident 11's 1/9/25 Hospital Records revealed a J-tube (feeding tube inserted into stomach or small intestine) was surgically placed. The 1/11/25 admission MDS revealed Resident 11 had a J-tube for enteral feedings (nutritional support). The 2/10/25 Progress Note indicated Staff 7 (CNA) transported Resident 11 to the shower room and when she removed the blanket, the J-tube dislodged and fell out. Staff 7 indicated the J-tube was intact when she placed a bath blanket over her/him in preparation to go to the shower room. The note further revealed an order was received to transfer the resident to the hospital for the J-tube replacement. Review of Resident 11's medical record…

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 residents were free from significant medication errors for 1 of 4 sampled residents (#13) reviewed for medications. This placed residents at risk for respiratory distress. Findings include: Resident 13 admitted to the facility in 3/2025, with diagnoses including failure to thrive. Resident 13 was on hospice services. Resident 13's 3/20/25 Progress Note indicated she/he was seen by a hospice nurse and the resident's methadone order was increased to 7.5 mg twice daily. Resident 13's 3/20/25 Hospice Order instructed staff to discontinue the previous order for methadone liquid 5 mg twice daily and to increase the methadone liquid 10 mg/ml to 7.5 ml to equal 7.5 mg by mouth every 12 hours for pain management (7.5 ml equaled 75 mg). The 3/2025 MAR indicated Resident 13 was administered 7.5 ml (75 mg) of Methadone on 3/20/25 at 8:00 PM by Staff 10 (CMA). Resident 13's 3/21/25 Hospice Orders included orders for Naloxone HCL nasal spray 4 mg one dose now (medication to reverse narcotic medication effects)…

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 residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This placed residents at risk for unwanted sexual abuse. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including altered mental status. Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia. Resident 3 was admitted to the facility in 1/2024 with diagnoses including dementia. Review of a progress note dated 7/22/24 at 8:50 PM revealed Resident 1 was observed with her/his hand down the front of Resident 2's pants. The residents were separated and the administrator was notified. Review of a physician note dated 7/25/24 at 1:26 PM revealed Resident 1 was caught with her/his hands down the pants of a female resident and in bed with her/his roommate. Resident 1 was placed in a private room and had 1:1 supervision by facility staff. Resident 1 was alert and oriented to place only during the physician visit. Review of a facility…

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 residents were treated with dignity and respect for 4 of 15 sampled residents (Witness 2 and Resident #s 51, 65, and 95) reviewed for dignity and abuse. This placed residents at risk for depression. Findings include: 1. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer. A 3/20/24 Quarterly MDS revealed Resident 51 was cognitively intact. On 6/10/24 at 12:27 PM Resident 51 stated staff did not treat her/him with respect. During this interview Staff 4 (CNA) entered Resident 51's room. Resident 51 informed Staff 4 she/he was having a conversation. Staff 4 stated she could pick up the resident's lunch try even if Resident 51 was talking. After Staff 4 left the room, Resident 51 stated she/he did not feel the staff treated her/him with respect. On 6/10/24 at 1:30 PM Staff 4 stated she entered Resident 51's room because the resident's call light was activated. Staff 4 acknowledged Resident 51 stated she/he was in a conversation but Staff 4 stated she could provide resident care…

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 ensure a resident's wheelchair, residents' walls and floors were in good repair and failed to provide comfortable sound levels for 5 of 13 sampled residents (#s 20, 29, 51, 90, and 137) reviewed for environment. This placed residents at risk for skin tears and unhomelike conditions. Findings include: 1. Resident 20 was admitted to the facility in 2021 with a diagnosis including heart disease. On 6/10/24 at 2:30 PM a bathroom tile was observed to be missing on Resident 23's bathroom floor in front of the toilet. There was also a patched area on the bathroom wall with no paint to cover the caulking. The patch was approximately two feet wide and two feet long. On 6/12/24 at 2:13 PM Staff 2 (Administrator) observed the missing tile and the patched wall. On 6/12/24 at 2:48 PM Staff 46 (Maintenance) stated rooms were patched and then were painted when the residents were not in the room. Patching was a priority and not painting. 2. Resident 29 was admitted to the facility in 2017 with diagnosis of stroke. On…

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 a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 6 of 14 sampled residents (#s 8, 83, 84, 86, 87, and 90) reviewed for abuse and dignity. This placed residents at risk for unaddressed concerns and grievances. Findings include: 1. Resident 8 was admitted to the facility in 4/2024 with diagnoses including a fracture of the right leg. A 6/6/24 Grievance Form revealed Resident 8 had a concern related to a male CNA providing persona care after she/he had requested a female CNA and the male CNA made Resident 8 feel uncomfortable after he requested to change her gown. A 6/7/24 grievance resolution reveled an investigation related to a male CNA requesting to change Resident 8's gown, no evidence of addressing Resident 8's concern related to a male CNA providing personal care. On 6/10/24 at 12:11 PM Resident 8 stated a male CNA came in during the night to provide personal care. Resident 8 stated she/he told the…

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 revise and update a care plan intervention for 6 of 11 sampled residents (#s 16, 19, 21, 25, 49 and 51) reviewed for medications care planning, dental and respiratory. This placed residents at risk for unmet of care needs. Findings include: 1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression. A 10/17/23 Nursing Note revealed the provider add the diagnosis of schizophrenia to Resident 16's dignosis list. Resident 16 is prescribed aripiprazole (an antipsychotic medicine that is used to treat schizophrenia)for this condition. A 10/25/23 Psych Consultants report revealed Resident 16 was seen from a facility referral and Resident 16 stated My mind is straight. Resident 16 then stated she/he saw black bugs flying in her/his room and saw them crawling on the window blinds. Resident 16 stated people think she/he was seeing things, but she/he knows they are there. Resident 16 was diagnosed with…

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 monitor for 5 of 14 sampled residents (#s 16, 33, 51, 133, and 134) reviewed for medications, antibiotics, dialysis, and edema. This placed residents at risk for adverse side effects and constipation. Findings include: 1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression. a. A 5/2024 MAR instructed staff to administer metoprolol tartrate (to treat high blood pressure) every 12 hours for heart health and to hold the medication if Resident 16's blood pressure was below 100/60 or heart rate was below 60. On the following days and shifts Resident 16's blood pressure was not within physician ordered parameters and she/he was administered metoprolol: 5/2/24 day shift, 5/4/24 day shift, 5/7/24 evening shift, 5/8/24 evening shift, 5/9/24 day shift, 5/10/24 evening shift, 5/15/24 evening shift, 5/16/24 day shift, 5/17/24 evening shift, 5/18/24 evening shift, 5/19/24 evening shift, 5/23/24 evening shift, 5/26/24 evening shift, and 5/28/24…

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 post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports (DCSDR) from 5/9/24 through 6/9/24 revealed no census documented on 6/5/24 day and evening shift, 6/6/24 evening shift, or 6/8/24 night shift. On 6/11/24 at 5:25 AM the DCSDR was observed posted by the nurses station. The night shift was blank for resident census, number of staff and hours worked. On 6/12/24 at 8:02 AM the DCSDR was observed to have 6/11/24 posted. No census was documented for evening shift or night shift. At 9:17 AM the 6/12/24 DCSDR was posted with no census documented on the day shift. In an interview on 6/14/24 at 10:22 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) reported it was expected to have an accurate DCSDR posted within one hour of a shift change.

3. Resident 51 was admitted to the facility in 2023 with a diagnosis of Cancer. A 4/30/24 Pharmacy report recommended Resident 51's ferrous sulfate (supplement) should be discontinued because the resident's iron level was normal and docusate (treats constipation) because it was not an effective medication. A 6/2024 MAR revealed Resident 51 continued to be administered ferrous sulfate and docusate. On 6/11/24 at 2:33 PM a request was made to Staff 2 (DNS) to provide documentation Resident 51's physician declined 4/31/24 pharmacy recommendations. No additional information was provided. Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 4 of 6 sampled residents (#s 16, 33, 63, and 51) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression. a. A 10/28/23 Recommendation Summary for Medical Director and DON indicated Resident 16 required a gradual dose reduction assessment.…

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 it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for ineffective medication regimen. Findings include: 1. Resident 34 was admitted to the facility in 2019 with a diagnosis of chronic pain. A 10/3/23 Order revealed staff were to apply an external pain patch to both knees. A 4/4/24 quarterly MDS revealed Resident 34 was cognitively intact. On 6/11/24 at 8:21 AM Staff 56 (CMA) was observed to apply a medicated pain patch to Resident 34's right arm and right leg. On 6/12/24 at 8:18 AM Resident 34 stated she/he only used the patch on the right arm and leg and did not require it on the left knee. On 6/12/24 08:20 AM Staff 56 stated she applied the patch only in the locations Resident 34 preferred. On 6/12/24 at 9:19 AM Staff 30 (LPN Resident Care Manager) stated if a resident did not want the patch applied to the location ordered the order should be clarified. Staff 30 stated the patch was…

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 have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 3, 5, and 6) reviewed training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 3 (CNA), hired 1/26/06 completed 10 hours of documented training from 1/25/23 through 1/25/24. -Staff 5 (CNA), hired 4/7/10, completed six hours of documented training from 4/27/23 through 4/27/24. -Staff 6 (CNA), hired 3/28/16, completed 10 hours of documented training from 3/28/23 through 3/28/24. In an interview on 6/14/24 at 10:23 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated it was expected the staff complete the 12 hours of annual training.

Based on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risk and benefits for the use of an antipsychotic medication and the risk and benefits of not following a prescribed diet for 3 of 6 sampled residents (#s 16, 33, and 335) reviewed for medications and diet. This placed residents' and resident responsible parties at risk for lack of informed consent and decision making. Findings include: 1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression. A 3/2023 MAR instructed staff to administer aripiprazole (an antipsychotic medication treat depression and schizophrenia) one time a day related to schizophrenia with a start date of 3/3/23. There was no documentation found in Resident 16's clinical record to show she/he had a diagnosis of schizophrenia. Resident 16's 5/17/23 Antispychotic Medication Informed Consent indicated she/he had a physician order for aripiprazole for depression and anxiety, and the resident experienced inconsolable fear and crying. An…

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 the facility failed to notify a resident's representative of a fall for 1 of 2 sampled residents (#89) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents. Findings include: Resident 89 was admitted to the facility in 12/2022 with diagnoses including a fractured leg and pelvis. The MDS dated [DATE] revealed Resident 89 had a BIMS score of nine, which indicated the resident had moderate cognitive impairment. Resident 89's undated admission Record revealed Witness 1 (Family Member) was Resident 89's emergency contact. On 6/5/24 at 12:48 PM Witness 1 stated Resident 89 fell out of bed at the facility two days after her/his admission. Witness 1 stated Resident 89 informed Witness 1 of the fall, but was unsure how the resident had fallen out of bed. Witness 1 was upset because facility staff did not notify her of the incident or potential injuries. On 6/12/24 at 4:00 PM Staff 21 (LPN) stated Resident 89 had an unwitnessed…

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 privacy and confidentiality of resident records in 1 of 1 Social Services office. This placed residents at risk for lack of privacy and confidentiality. Findings include: On 6/14/24 at 10:18 AM Staff 36's (Social Services Director) office door was observed open with no staff present. The left computer monitor screen was visible with a resident's electronic health record and the right computer monitor screen was open and accessible email. The office was observed to contain with many papers with residents names and information which included transportation forms, State of Oregon letters to residents, completed discharge checklists, completed requests to transfer and individual resident care conference information. On 6/14/24 from 10:18 AM to 10:38 AM multiple staff and residents were observed in the area of Staff 36's office and were able to access the resident records. On 6/14/24 at 10:38 AM Staff 36 stated she left her office door open while she was in the facility to let people know she was in the…

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 assess the use of a physical restraint for 1 of 1 sampled resident (#57) reviewed for restraints. This placed residents at risk for potential abuse or neglect. Findings include: Resident 64 was admitted to the facility in 2023 with diagnosis of brain damage and anxiety. A 9/26/23 Fall Risk Evaluation indicated Resident 64 experienced multiple falls in the past three months. Resident 64 exhibited balance issues while standing and had a seizure disorder. Resident 64 was at risk for falls. A 10/14/23 care plan indicated Resident 64 experienced decreased mobility and was at risk for falls. Interventions included a fall mat to the right side of the bed, anticipate her/his needs, bed against the wall and to ensure commonly used items were in reach. A 4/5/24 MDS assessed Resident 64 with no physical restraints in place and had no falls since the resident's last MDS assessment. Resident 64 was rarely understood. On 6/12/24 at 9:13 AM, and on 6/13/24 5:42 AM, and at 8:05 am Resident 64 was observed in…

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 report a resident to resident altercation for 2 of 11 sampled residents (#s 20 and 91 ) reviewed for abuse. This placed residents at risk for ongoing abuse. 1. Resident 20 was admitted to the facility in 2020 with a diagnosis of heart disease. A 12/16/23 Annual MDS revealed Resident 20 was cognitively impaired. Resident 20's Care Plan initiated 12/10/21 revealed Resident 20 propelled in a wheelchair. Review of Resident 20's clinical record revealed there were no resident to resident altercations identified in 11/2023. Resident 30 was admitted to the facility in 2020 with a diagnosis of seizures. Resident 30's Care Plan initiated in 2020 revealed Resident 30 was physically aggressive towards others due to a head injury. Staff were to intervene if the resident showed agitation to prevent escalated behaviors. A 12/20/23 Psychotropic Medication Review revealed Resident 30 had aggressive behavior. Review of Resident 30's clinical record revealed in 11/2023 she/he was not in a resident to resident…

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 investigate for abuse for 1 of 6 sampled residents (#65) reviewed for dignity and respect. This placed residents at risk for abuse. Findings include: Resident 65 admitted to the facility in 2/2024 with diagnoses including kidney failure. An 8/15/24 care plan revealed Resident 65 had a history of trauma. Interventions included staff were to avoid re-traumatizing the resident with thoughtful approaches to care and avoid being rude to Resident 65. An 8/23/24 Social Services Note indicated Resident 65 stated she/he had issues with Staff 4 (CNA), Staff 5 (CNA), and Staff 6 (CNA). Resident 65 stated they were rude and refused to provide her/him a shower and they did not listen to the residents. Resident 65 stated they needed to listen to the residents during resident care, and she/he did not want Staff 4 and Staff 6 in her/his room. No documentation was found in Resident 65's clinical record an investigation was completed for alleged abuse. On 9/4/24 at 12:38 PM Resident 65 stated two CNAs were talking, they…

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 comprehensively assess residents related to behaviors for 1 of 2 sampled residents (#25) reviewed for behavioral health assessments. This placed residents at risk for unassessed behavioral emotional healthcare needs and services. Findings include: Resident 25 admitted to the facility in 2017 with a diagnoses including Schizoaffective Disorder (mental health and mood condition). Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition. Resident 25 was assessed with no behaviors exhibited. On 6/12/24 at 10:43 AM Resident 25 was observed to sit in the hallway, repetitively grab and abruptly move her/his coffee cup, talk to her/himself and stated fuck you to a staff who walked past her/him. On 6/13/24 at 9:08 AM Resident 25 was observed to sit in the hallway, push and pull her/his bedside table, talk to her/himself and said fuck you to Staff 2 (DNS) as he attempted to give a Resident 25 a high-five greeting. On 6/13/24 at 10:21 AM Staff 6 (CNA) stated Resident 25's…

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 document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 2 sampled residents (#57) reviewed for change of condition. This placed residents at risk for unassessed needs. Findings include: Resident 57 was admitted to the facility in 2023 with diagnoses including stroke. A 11/13/23 admission MDS indicated the following: -Cognitively intact. -No depression concerns. -Set up or clean-up assistance for upper body dressing. -Supervision or touching assistance for personal hygiene. -Occasional bladder incontinence. -No falls since admission, but a history of falling in the last month. A 5/15/24 Quarterly MDS revealed the following: -Moderately impaired. -Feeling down and depressed two to six days in the seven-day look back period. -Partial moderate assistance for upper body dressing. -Substantial to maximal assistance for personal hygiene. -Frequent bladder incontinence. -Two or more falls since prior assessment. -Hypoglycemic (low blood sugars). The 5/29/24 care plan…

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 residents were referred to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation (evaluation for individuals with a mental disorder or intellectual disability) for 1 of 1 sampled resident (#25) reviewed for PASARR's. This placed residents at risk for not receiving specialized mental health services. Findings include: Resident 25 admitted to the facility in 2017 with diagnoses including schizoaffective disorder (serious mental condition with breakdowns in thoughts, emotions, and behaviors), bipolar disorder (extreme mood swings) and Post-Traumatic Stress Disorder (mental condition with intense emotional and/or physical reaction). Resident 25's 5/6/24 Annual MDS indicated she/he was not considered to have a serious mental illness and therefore no Level ll PASARR was completed. A review of Resident 25's Electronic Health Record revealed there was no Level Il PASARR referral or evaluation completed. In an interview on 6/14/24 at 10:38…

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 ensure a baseline care plan was developed for 2 of 12 sampled resident (#s 134 and 335) reviewed for dialysis, accidents, and medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 134 was admitted to the facility 12/2/23 with a diagnosis of kidney disease. A 12/2/24 hospital After Visit Summary revealed Resident 134 was to receive dialysis three times a week and her/his first scheduled treatment was 12/4/23. Review of Resident 134's baseline care plan revealed there was no information related to when she/he was scheduled for dialysis or the type and location of Resident 134's dialysis access. On 6/11/24 at 2:06 PM Staff 30 (LPN Resident Care Manager) stated a base line care plan was developed by the nurse who did the initial admission paperwork and by the resident care managers as they reviewed the resident's hospital paperwork. Staff 30 acknowledged a baseline care plan for dialysis was not…

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 staff failed to follow professional standards of practice for a diagnosed mental disorder for 1 of 6 (#16) sampled residents reviewed for medications. Findings include: Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression. A 2/21/23 hospital History and Physical revealed Resident 16 was seen for right hip pain after sustaining a fall. A review of past medical history revealed no diagnosis of schizophrenia. Resident was on the medication aripiprazole (an antipsychotic medication used to treat depression and schizophrenia) and escitalopram (an antidepressant to treat depression and anxiety). A psychiatric evaluation revealed mood, behavior, thought content and judgement were normal. A 3/2023 MAR instructed Staff to administer aripiprazole one time a day for schizophrenia. A 3/6/23 admission MDS indicated Resident 16 was cognitively intact with no hallucinations, delusions or behaviors exhibited during the seven day look back period. The assessment also indicated Resident 16…

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 a resident had glasses for 1 of 3 sampled residents (#20) reviewed for communication-sensory. This placed residents at risk for unmet vision needs. Findings include: Resident 20 was admitted to the facility in 2021 with a diagnosis of dementia. A 3/17/23 quarterly MDS indicated Resident 20 had adequate vision with corrective lenses. On 6/10/24 at 12:36 PM Witness 3 (Spouse) stated Resident 20 liked to read and wore glasses, but the glasses were broken. On 6/10/24 at 1:46 PM Resident 20 was observed to read and she/he did not wear glasses. Staff 52 stated Resident 20's glasses were broken for some time. On 6/12/24 at 2:36 PM Staff 53 (CNA) stated Resident 20's lens was missing since at least 12/2023. On 6/12/24 at 2:23 PM Staff 36 (Social Service Director) stated on 6/11/23 she just found an unsigned note on her desk reporting one of Resident 20's lens was broken. Staff 36 was not aware of of the issue and Resident 20 did not have any scheduled vision appointments.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 3 of 6 sampled residents (#51, 57 and 63) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer. An Unwitnessed Fall investigation dated 3/14/24 revealed on 3/14/24 Resident 51 slipped out of bed. Interventions to prevent future falls included staff readjusted the mattress to ensure it was centered on the bed frame and nonslip material was to be applied under the mattress. A care plan updated 3/14/24 revealed to prevent falls Resident 51 was to have nonslip material applied to the bed mattress to ensure the mattress did not slip. A 3/20/24 quarterly MDS revealed Resident 51 was cognitively intact. On 6/10/24 at 12:25 PM Resident 51 stated her/his mattress did not fit the bed frame and caused her/him to fall. Resident 51 also stated staff did not provide her/him with a new mattress. On 6/11/24 at 4:51 PM with…

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 nutritional supplements were provided for 1 of 3 sampled residents (#19) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 19 was admitted to the facility in 2018 with a diagnosis of diabetes. A 2/1/24 Nutritional Screen indicated Resident 19 was to be provided a diabetic nutritional supplement BID to prevent weight loss. An 4/2024 MAR revealed Resident 19 received a supplement BID through 4/7/24 and was out of the facility through 4/16/24. Resident 19's supplement was not restarted after 4/16/24. An 4/20/24 Nutritional Screen revealed Resident 19 was assessed and the plan was to continue with the current plan and to monitor the resident for weight loss. On 6/13/24 at 9:18 AM Staff 30 (LPN Resident Care Manager) stated the resident was hospitalized in 4/2024 and acknowledged the resident's supplement was not restarted upon readmission to the facility.

Based on observation, interview, and record review, it was determined the facility failed to obtain orders for oxygen and clean a resident's oxygen equipment for 1 of 1 sampled resident (#51) reviewed for respiratory care. This placed residents at risk for unsanitary conditions and lack of monitoring. Findings include: Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer. On 6/10/24 at 12:39 PM Resident 51 was observed to wear a nasal canula (device to administer oxygen through the nose). The back of Resident 51's oxygen concentrator (machine which takes air from the surroundings, extracts oxygen and filters it into purified oxygen) was observed to have a thick layer of dust over the vent. Resident 51's clinical record did not contain orders for oxygen. On 6/11/24 at 2:25 PM with Staff 55 (LPN) Resident 51's concentrator was observed to have a thick layer of dust on the vents. Staff 55 stated she was new to the facility but the equipment was to be cleaned weekly and the amount of dust on the vents indicated it was not cleaned for a long time. Staff 55 stated a…

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 ensure pain medications were available for 2 of 3 sampled residents (#85, and 339) reviewed for pain. This placed residents at risk for increased pain. Findings include: 1. Resident 85 was admitted to the facility in 2023 with diagnoses including arm and leg fractures. A 11/17/23 Pain Assessment revealed Resident 85 did not have pain at the time of the assessment but reported pain interfered with her/his sleep and social activities. A 11/22/23 admission MDS revealed Resident 85 reported constant pain for the last five days. A 11/2023 MAR and associated progress notes revealed the following: -Resident 85 was to be administered oxycodone every four hours while awake. From 11/24/23 through 11/27/23 Resident 85 was not administered the medication six times. -From 11/27/23 Percocet was to be administered every four hours. Notes indicated the medication was not available. -No additional medications were added for pain relief. Resident 85's…

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 ensure a resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and account for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 sampled residents (#25) reviewed for Behavioral-Emotional. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: Resident 25 admitted to the facility in 2017 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction). Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition and a PTSD diagnosis. Resident 25's 6/11/24 SS (social service) Post-Traumatic Checklist assessed her/him to experience anger outbursts, difficulty concentrating, unable to answer complicated questions and was irritable. Interventions for the…

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 transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis. This placed residents at risk for worsening kidney function. Findings include: Resident 134 was admitted to the facility in 2023 with a diagnosis of kidney disease. 12/2/23 hospital orders revealed Resident 134 was to receive dialysis at a dialysis center on Mondays, Wednesdays, and Fridays. On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency the facility did not follow up with transportation for Resident 134 and On 12/11/23 (Monday) she/he missed a dialysis treatment. On 6/10/24 at 6:56 PM Staff 43 stated the facility was aware Resident 134 required transportation to the dialysis unit, the paperwork was submitted, but they did not transport the resident. On 6/20/24 via e-mail, Staff 2 (DNS) indicated Resident 134 did not go to dialysis. No additional information was provided for the rationale Resident 134 did not attend dialysis. On 6/21/24 Witness 10 (Dialysis RN) verified Resident 134…

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 follow infection control standards for 1 of 5 halls (200 hall) reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 6/14/24 at 10:08 AM, Staff 37 (CNA) was observed carrying dirty linens down the 200 hall and entering the soiled linen room. Staff 37 acknowledged not having bags in her pocket and was aware that linens should be placed in a bag before transport. In an interview on 6/14/24 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the expectation of staff were to place dirty linen in a bag for transport from resident room to soiled linen room.

Based on interview and record review it was determined the facility failed to ensure a resident was not administered an antibiotic without indication for 1 of 3 sampled residents (#86) reviewed for UTI. This placed residents at risk for drug resistant infections. Findings include: Resident 86 was admitted to the facility in 2023 with a diagnosis of UTI. A 10/7/23 Progress Note revealed Resident 86 had increased confusion. The physician was notified and Resident 86 was sent to the hospital for evaluation, treatment, and returned on 10/8/23. Resident 86's urine culture results dated 10/7/23 revealed there was a mixed growth of skin and or genital organisms indicating an improper collection. The form revealed a new sample was to be submitted if clinically indicated. A 10/2023 MAR revealed Resident 86 was administered antibiotics from 10/10/23 through 10/16/23 for an UTI. On 6/14/24 at 9:29 AM Staff 2(DNS) stated 72 hours after an antibiotic was started the facility staff were to review the test results to ensure an antibiotic was indicated. Staff 2 stated a 72 hour review was not…

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 copies and provide assistance to residents who expressed interest in formulating an advance directive for 3 of 7 sampled residents (#s 6, 18, and 32) reviewed for advance directives. This placed residents at risk for not having their healthcare decisions honored. Findings include: 1. Resident 6 was admitted to the facility in 12/2019 with diagnoses including heart disease. Resident 6's 12/7/22 Annual MDS revealed she/he had a BIMS of 15 (cognitively intact). A 2/8/23 Interdisciplinary Note revealed advance directive education was provided to Resident 6. On 3/7/23 at 10:39 AM Staff 3 (DNS) was unable to locate an advance directive for Resident 6. On 3/7/23 at 1:03 PM Staff 16 (Social Services Director) stated she was not familiar with an advance directive and thought the Physician Orders for Life Sustaining Treatment (POLST) was the same thing. Staff 16 confirmed she did not review advance directives with residents. On 3/8/23 at 10:33 AM Resident 6 stated she/he would fill out one out (advanced…

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 and interview it was determined the facility failed to provide a homelike environment for 3 of 5 halls (200, 300 and 400 hall) reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include: 1. On 3/6/23 at 4:41 PM the window in room [ROOM NUMBER] was observed to be very dirty and difficult to see through. There was a black substance built-up along the bottom left corner and the base of the window. On 3/8/23 at 1:45 PM and 3/9/23 at 2:44 PM Staff 22 (Maintenance Director) confirmed the window was very dirty and reported the window had to be replaced because the dirt was on the inside of the glass (double paned window) and could not be washed. On 3/9/23 at 1:39 PM Staff 2 (Assistant Administrator) was informed of the findings of the investigation. No additional information was provided. 2. On 3/6/23 at 1:53 PM Resident 32's windowsill was observed to have four nails sticking up along the length of the windowsill and a portion of the wood was…

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 physician orders and bowel protocols were followed for 4 of 16 sampled residents (#s 15, 34 and 166) reviewed for medications, ADLs and respiratory care. This placed residents at risk for adverse health consequences. Findings include: 1. Resident 15 admitted to the facility in 2/2023 with diagnoses including lumbar fracture. The facility's undated Bowel Protocol indicated after day 3 of no bowel movement to give milk of magnesia (laxative) 30 ml PO or give 10 mg bisacodyl (laxative) PO. The 2/15/23 admission MDS indicated Resident 15 was cognitively intact. On 3/6/23 at 3:41 PM Resident 15 stated she/he had not had a bowel movement in a week. On 3/7/23 at 12:00 PM bowel documentation was reviewed and indicated Resident 15's last bowel movement was on 3/1/23. The electronic health record was reviewed including MARs and progress notes. There was no indication Resident 15 was offered milk of magnesia or bisacodyl. There…

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 sufficient staffing to meet resident care needs for 4 of 5 halls (100, 200, 300 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 3/6/23 and 3/10/23 the facility provided lists of residents who: -Required assistance or were dependent with eating: 31 -Required a mechanical lift with transfers: 16 -Required one or two-person assistance with dressing: 61 -Required one or two-person assistance or dependent with toileting: 58 - Required one or two-person assistance with bathing: 40 -Were fully dependent on staff for bathing: 20 -Wandered: 1 -Received therapy services: 39 On 3/6/23 the facility had 7 residents and in 4/2022 the facility had 6 residents approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 2/1/23 through 3/5/23 and 4/1/22 through 4/30/22 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts: - 4/1/22 - 4/3/22 - 4/9/22 - 4/11/22 -…

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 CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 3/7/23 at 2:30 PM Staff 2 (Assistant Administrator) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA). On 3/7/23 at 2:37 PM Staff 2 provided written documentation indicating the facility did not require performance reviews to be completed. Staff 2 confirmed no performance reviews were completed for the identified CNA staff.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 10 of 33 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 2/1/23 through 3/5/23 Direct Care Staff Daily Reports indicated the following days when required information was missing or incorrect on the daily postings: -2/12/23 -2/13/23 -2/15/23 -2/19/23 -2/20/23 -2/25/23 -2/26/23 -3/1/23 -3/5/23 On 3/10/23 at 8:45 AM Staff 2 (Assistant Administrator) acknowledged the missing and/or inaccurate information for the identified dates.

Based on observation, interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen refrigerator reviewed for sanitary food storage. This placed residents at risk for exposure to harmful bacteria, reduced nutritive value and stale food products. Findings include: The facility's Food and Nutrition Services Food Safety policy, dated 7/2018, indicated the following regarding refrigerated foods: -Food, including leftovers, will be labeled and dated in the refrigerator. On 3/6/23 at 12:06 PM during the initial tour of the facility's kitchen, the walk-in refrigerator was observed to contain the following improperly stored items and unsanitary conditions: -One package of turkey-pastrami dated 2/17/23; -One round, plastic container of egg salad-undated; -Two apple juice and two orange juice canisters-undated; -Five large pastry bags of white whipped cream and one large pastry bag of chocolate whipped cream-undated; -Three Styrofoam bowls of chocolate pudding-undated; -One Styrofoam bowl of…

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 residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#34) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: The facility's Right to Self-Administer Medications policy, dated 7/2018, indicated the following: -If a resident requested to self-administer medications it was the responsibility of the interdisciplinary team (IDT) to determine if it was safe before the resident exercises the right. A resident may self-administer medications after the IDT determined which medications may be self-administered. -Appropriate documentation of the determinations would be documented in the resident's medical record and care plan. Resident 34 was admitted to the facility in 9/2021 with diagnoses including psoriasis (a skin disease marked by red, itchy, scaly patches) and mild cognitive impairment. A 3/2/23 physician order indicated nursing staff were to apply Triamcinolone…

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 protect the resident's right to be free from sexual abuse by Witness 3 (Alledged Perpetrator/Medical Transportation Driver) for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's abuse policy, revised 11/2017, defined sexual abuse as any form of nonconsensual sexual contact, including but not limited to unwanted or inappropriate touching .in the form of touching of the sexual or intimate parts .This protection extended to abuse by staff, consultants, contractors, volunteers, students and visitors. Resident 54 was admitted to the facility in 12/2022 with diagnoses including major depression. Resident 54's 12/19/22 admission MDS indicated a BIMS score of 15 (cognitively intact). A FRI was submitted to the state agency on 2/12/23 which revealed the following: On Sunday 2/12/23 Witness 3 signed into the facility's visitor log and went to visit Resident 54 in her/his room. Resident 54 stated Witness 3 entered her/his room, began to rub…

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 complete a thorough investigation of an allegation of abuse for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations. Findings include: The 10/2005 Oregon Nursing Facility Abuse Reporting and Investigation Guide for Providers specified a thorough investigation is a systematic collection of information that describes and explains an incident or series of incidents. The investigation seeks to determine if abuse occurred, how the incident occurred, and how to prevent further occurrences. Critical component(s) of any investigation include the timely initiation of the investigation and the thoroughness of the investigation. The evidence data should be accurate and appropriate to include testimonial, documented, pictorial and physical evidence as applicable to come to a conclusion and it is important that conclusions not be reached without adequate information. Each investigation must seek to answer who, what, where, when, why and how, through…

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 was determined the facility failed to ensure assessments accurately reflected the residents' status for 1 of 9 sampled residents (#30) reviewed for ADLs. This placed residents at risk for inaccurate assessments. Findings include: Resident 30 admitted to the facility in 12/2019 with diagnoses which included heart failure and arthritis. Resident 30's 1/6/23 Annual MDS indicated she/he had a BIMS of 15 (cognitively intact). The MDS indicated she/he required extensive assistance with toilet use. Resident 30's 1/2023 care plan indicated Resident 30 was independent with toilet use. On 3/9/23 at 1:19 PM Staff 31 (CNA) stated Resident 30 was independent with toilet use and required very little assistance. On 3/9/23 at 1:31 PM Staff 32 (LPN/Unit Manager) confirmed Resident 30 was independent with toilet use and the Annual MDS was coded inaccurately for extensive assistance for toilet use. On 3/9/23 at 1:37 PM Staff 3 (DNS) acknowledged she expected the MDS was coded accurately to reflect the Resident 30's needs for toiliting

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure Staff 11 (Former Staff/RN) adhered to professional standards for medication administration. This placed residents at risk for adverse side effects of medication and hospitalization. Findings include: Resident 167 admitted to the facility on [DATE] with diagnoses including diabetes, atrial fibrillation and stroke. Resident 167 discharged on 6/6/22. The 5/26/22 admission MDS indicated Resident 167 was cognitively intact. According to mayoclinic.org a regular resting heart rate is 60-100 beats per minute. Resident 167's 6/2022 MARs indicated she/he received the following morning medications on 6/5/22: -Aspirin 81 mg (antiplatelet medication) -Breo Ellipta Aerosol powder (bronchodilator medication) -Combivent Respimat aerosol solution (bronchodilator medication) -Eplerenone 25 mg (antihypertensive medication) -Lasix 40 mg (diuretic medication) -lisinopril 10 mg (antihypertensive medication) -Pacerone 100 mg (antiarrhythmic…

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 bathing assistance to dependent residents for 2 of 7 sampled residents (#s 4 and 18) reviewed for ADLs. This placed residents at risk for lack of hygiene. Finding include: 1. Resident 18 was admitted to the facility in 10/2022 with diagnoses including end stage renal disease and for an infection to her/his dialysis chest catheter. Resident 18's 1/27/23 Quarterly MDS revealed she/he had a BIMS score of 12 (moderate cognitive impairment) and was totally dependent on two staff for physical assistance with showers. A review of the 30-day shower log revealed Resident 18 received a sponge bath on 2/17/23. Resident 18's shower days were on Monday and Friday, which were also her/his dialysis days. There was no evidence in Resident 18's health record to indicate she/he was provided with a shower between 2/18/23 and 3/7/23. On 3/7/23 at 8:55 AM Resident 18 stated she/he had not received a shower in two weeks and let multiple staff members know she/he did not receive a shower. On 3/7/23 at 3:34 PM Staff 23…

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 routine diabetic foot care for 2 of 2 sampled residents (#s 10 and 34) reviewed for foot care. This placed residents at risk for pain. Findings include: The facility's Quality of Care Foot Care policy, dated 8/2018, indicated the following: -To provide the resident with foot care, including treatment to prevent complications from diabetes, peripheral vascular disease or immobility that is consistent with professional standards of practice. -Treatment includes preventive care to minimize podiatric complications in residents with diabetes and circulatory disorders. -Residents with complicating disease processes will be referred to qualified professionals for foot care. 1. Resident 10 was admitted to the facility in 12/2022 with diagnoses including diabetes. On 3/6/23 at 3:36 PM Resident 10 reported her/his toenails were long and uncomfortable and asked to have her/his toenails trimmed but nobody had done so since her/his admission. Resident 10 was observed to have several long, dark…

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 respiratory equipment was properly maintained for 1 of 1 sampled resident (#30) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include: Resident 30 was admitted to the facility in 9/2022 with diagnoses including heart failure. Resident 30's 1/6/23 Annual MDS indicated the resident used supplemental oxygen. Resident 30's health record included a 3/2023 physician order for the following: - Change oxygen tubing, humidification bottle and clean filter every night shift, every Monday for comfort. Oxygen on one to four liters per nasal cannula to keep O2 sats above 90%; - Document O2 sats and liters per minute every day and night shift for comfort. On 3/6/23 at 2:57 PM Resident 30 was lying in bed in her/his room and receiving oxygen which was produced and delivered from an oxygen concentrator. A humidifier bottle was attached to the concentrator and contained no fluid. A nasal cannula and tubing was attached to the oxygen concentrator and placed in…

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 residents received dialysis services consistent with the care plan for 1 of 1 sampled residents (#18) reviewed for dialysis. This placed residents at risk for potential complications in dialysis care and treatment. Findings include: Resident 18 was admitted to the facility in 10/2022 with diagnoses including end stage renal disease and dialysis. The 11/13/22 care plan revealed the following: -Focus: needs hemodialysis related to end stage renal failure; -Goal: will have no signs or symptoms of complications from dialysis through the review date; -Interventions: check and change dressing daily at access site, document. Monitor vital signs, notify MD of significant abnormalities. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth or drainage. The 3/2023 TAR indicated: Complete the dialysis post-assessment form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review…

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 identify potential trauma and monitor psychosocial distress for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for unmet psychosocial needs. Findings include: Resident 54 admitted to the facility in 12/2022 with diagnoses which included major depression. Resident 54's [DATE] admission MDS indicated she/he had a BIMS of 15 (cognitively intact). A [DATE] facility investigation indicated Resident 54 was sexually abused by Witness 3 (Medical Transportaion Driver). On [DATE] an investigation was initiated, and sexual abuse was substantiated by Staff 1 (Administrator). Staff 1's report revealed Staff 30 (LPN) placed Resident 54 on alert for psychosocial distress. A [DATE] at 5:18 PM a progress note revealed Resident 54 reported she/he felt worried, she/he was not in distress and staff would continue to monitor. A [DATE] at 3:58 PM a progress note revealed Resident 54 was in good spirits with no signs of…

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 ensure residents were free from significant medication errors for 1 of 8 sampled residents (#167) reviewed for medication. This placed residents at risk for adverse side effects of medication and hospitalization. Findings include: Resident 167 admitted to the facility on [DATE] with diagnoses including diabetes, atrial fibrillation and stroke. Resident 167 discharged on 6/6/22. The 5/26/22 admission MDS indicated Resident 167 was cognitively intact. Resident 167's 6/2022 MARs indicated she/he received the following morning medications on 6/5/22: -Aspirin 81 mg (antiplatelet medication) -Breo Ellipta Aerosol powder (bronchodilator medication) -Combivent Respimat aerosol solution (bronchodilator medication) -Eplerenone 25 mg (antihypertensive medication) -Lasix 40 mg (diuretic medication) -lisinopril 10 mg (antihypertensive medication) -Pacerone 100 mg (antiarrhythmic medication) -potassium chloride ER 20 mEQ (supplement medication)…

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 store treatment supplies in locked compartments for 1 of 1 treatment cart on 500 hall observed. This placed residents at risk for accidents. Findings include: On 3/6/23 at 4:24 PM an unlocked treatment cart was observed on the 500 hall. Between 3/6/23 at 4:24 PM and 4:40 PM one resident and seven staff were observed to pass near the unlocked treatment cart. On 3/6/23 at 4:41 PM Staff 30 (LPN) was located at the nurses station and brought to the treatment cart. She confirmed the cart was unlocked and stated the cart should have been locked. Staff 30 confirmed needles, medications and treatment supplies were in the unlocked cart. On 3/7/23 at 8:24 AM an unlocked treatment cart was observed on the 500 hall. Between 3/7/23 at 8:24 AM and 8:40 AM six staff and two visitors passed near the unlocked treatment cart. On 3/7/23 at 8:40 AM the surveyor was not able to find the nurse responsible for the unlocked treatment cart. Staff 33 (CMA) confirmed the treatment cart was unlocked. On 3/10/23 at 9:55 AM Staff 3 (DNS)…

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 and interview it was determined the facility failed to ensure staff wore and used PPE correctly for 1 of 1 COVID unit reviewed for infection control. This placed residents and staff at risk for respiratory illnesses and infections. Findings include: On 3/8/23 at 8:46 AM Staff 26 (CNA) was observed to retrieve a tray of food from room [ROOM NUMBER]. Staff 26 retrieved a spoon from the medication cart and handed it to Staff 35 (CNA) who was in a COVID isolation room, then answered the call light in room [ROOM NUMBER]. Staff 26 then walked to assist a resident in room [ROOM NUMBER]B who was on aerosol precautions. Staff 26 did not perform any hand hygiene during the observation period. At 9:00 AM Staff 26 stated she should have performed hand hygiene before entering and exiting the room and in between each resident contact. On 3/9/23 at 8:40 AM Staff 27 (CNA) was observed walking in the COVID unit hallway with a N95 face mask on her chin and goggles on top her head. She stated she was going on…

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.