Gresham Post Acute Care And Rehabilitation

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 2 of 3 sampled residents (#s 10 and 68) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include:1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. Resident 10's 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact, and the resident did not require the use of oxygen services. A review of Resident 10's health record revealed no current physician order for ongoing oxygen use unless the oxygen level dropped below 92% On 12/15/25 at 12:41 PM Resident 10 was observed with an oxygen nasal cannula (tube with two prongs that fit in the nostrils to deliver supplemental oxygen) in her/his left nostril and connected to an oxygen concentrator (medical device that provides concentrated oxygen). On 12/17/25 at 9:54 AM Staff 5 (LPN) stated residents needed a physician order for the ongoing use of oxygen and they were expected to be…

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 resident received trauma informed care for 1 of 1 sampled residents (# 55) reviewed for behavioral and emotional care needs. This placed resident at risk for re-traumatization. Findings Include:The facility's undated Trauma Informed Care and Culturally Competent Care policy revealed the resident assessment process involved an in-depth evaluation of trauma-related symptoms and the identification of triggers. The policy revealed the facility's process involved the development of an individualized care plan to address past trauma, and to identify and decrease exposure to triggers that may re-traumatize the resident.Resident 55 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD) and sleep terrors.Resident 55's 9/11/25 Social Service History, Trauma, and Substance Use Disorder (SUD) Assessment indicated no trauma history.Resident 55's 9/16/25 admission Minimum Data Set (MDS) indicated…

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 conduct a safety assessment and obtain orders prior to initiating the use of bed rails for 1 of 2 sampled resident (#18) reviewed for bed rails. This placed residents at risk for potential accidents and/or injuries. Findings include: Resident 18 was admitted to the facility in 10/2025 with diagnoses including osteoporosis (condition which bones become weak and brittle) and muscle weakness.The admission MDS Assessment 10/28/25 indicated Resident 18 required substantial assistance for bed mobility and transfer out of bed.Resident 18's current Care Plan did not include the use of bed rails, and no evidence was found in the resident's clinical record an evaluation was completed for the use of bed rails. On 12/15/25 at 12:42 PM Resident 18 was observed in bed with bilateral quarter rails in the upright position.On 12/16/25 at 3:13 PM Staff 13 (CNA) stated she was aware Resident 18 had bilateral bed rails in place on her/his bed. Staff 13 was unable to locate an order or care plan supporting the use…

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 address pharmacy recommendations for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for adverse outcomes associated with medication administration. Findings include:Resident 3 was admitted to the facility in 11/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS, a progressive and fatal neurological disorder that causes weakness, paralysis and respiratory failure). Resident 3's 11/10/25 Pharmacist's admission Medication Regimen Review revealed the following recommendations: -Rivaroxaban (an anticoagulant medication that reduces the blood's clotting ability and places people at increased risk of bleeding) should be administered with food to increase its efficacy.-The resident should be monitored for signs and symptoms of bleeding due to her/his use of rivaroxaban. Resident 3's 12/1/25 Pharmacist's Medication Regimen Review recommended give with evening meal be added to the resident's physician orders for the rivaroxaban and/or adjust the medication'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 observations, interviews, and record review it was determined the facility failed to ensure the medication error rate was less than five percent for 2 of 29 attempts. This placed residents at risk for adverse side effects related to medication errors. Finding include:Resident 62 was admitted to the facility in 2/2025 with a diagnosis of heart failure.A review of physician orders revealed a 12/16/25 order for potassium chloride oral packet 20 MEQ give 2 packets twice a day and torsemide 100 mg, give 0.5 tablet twice a day.On 12/17/25 at 8:28 AM, Staff 34 (CMA) was observed to administer torsemide 100 mg and potassium chloride 20 MEQ, 1 packet.On 12/17/25 at 9:42 AM, Staff 34 confirmed Resident 34 had orders to administer torsemide 50 mg and potassium chloride 20 MEQ two packets. Staff 34 stated she was unaware the order changed and acknowledged she administered the wrong dose of torsemide and potassium chloride.On 12/19/25 at 8:45 AM, Staff 2 (DNS) stated staff are expected to administer medications per physician orders.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review it was determined the facility failed to ensure medications were not expired for 1 of 4 medication carts and 1 of 2 medication room. This placed residents at risk for decreased efficiency of medications. Finding include:On [DATE] at 9:56 AM, an expired bottle of vitamin B 12 was observed in the 100-hall medication cart. Staff 35 (CMA) confirmed the bottle of vitamin B 12 expired in 8/2025.On [DATE] at 1:29 PM two undated open vials of Tubersol were observed in the 200-hall medication room. Staff 3 (LPN Resident Care Manager) stated Tubersol was good for 30 days after opening. Staff 3 confirmed there was no open date on either open vial of Tubersol and stated there was no indication when the vials were open.On [DATE] at 1:41 PM, Staff 2 (DNS) stated medications must be destroyed when expired. Staff 2 stated Tubersol was good for 30 days after the vial was open and confirmed the two opened, undated vials of Tubersol had no indication of an open date and were 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 follow infection control standards for 1 of 5 sampled resident (#68) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:Resident 68 admitted to the facility in 10/2019 with diagnoses including congestive heart failure and dysphagia (difficulty swallowing foods or liquids).The 9/14/25 Quarterly MDS indicated Resident 68 had severe cognitive impairment.Resident 68's physician order dated 1/7/25 revealed she/he required oxygen as needed.On 12/17/25 at 8:57 AM Resident 68's oxygen cannula and tubing were observed on the floor next to her/his bed.On 12/17/25 at 9:04 AM Staff 12 (RN) was observed to provide care for Resident 68. After the provision of care, Staff 12 was observed to pick up the resident's nasal cannula and oxygen tubing from the floor. Staff 12 wiped the nasal cannula with an alcohol wipe and placed the nasal cannula and tubing on the resident's bed.On 12/17/25 at 9:12PM Staff 12 stated when 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 administer anti-seizure medication according to physician orders for 1 of 3 sampled residents (# 1) reviewed for medications. This placed residents at risk for adverse medication side effects and increased episodes of seizures. Findings include:Resident 1 admitted to the facility on 9/2025, with diagnoses including seizures and respiratory failure. A 9/22/25 Physician Order noted felbamate (an anti-seizure medication) was to be administered twice a day for seizures. A 9/24/25 Progress Note noted staff were working on obtaining Resident 1's anti-seizure medication and that there were complications with receiving the medication, which as not delivered until 9/25/25. Resident 1's 9/2025 MAR indicated the resident's felbamate medication was not administered until 9/25/25 (three days, and five doses after the order date of 9/22/25). On 10/22/25 at 8:56 AM, Staff 3 (Resident Care Manager) stated orders were not reviewed and staff missed the nurses struggle to obtain the medication from the pharmacy. Staff 3 also…

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 staff wore appropriate hair restraints during meal preparation for 1 of 1 kitchen reviewed for sanitation and properly stored and labeled food for 2 of 2 resident refrigerators reviewed for storage. This placed residents at risk for unsanitary food and cross contamination. 1. Resident 4 admitted to the facility in 12/2022 with diagnoses including osteomyelitis (bone infection) and malnutrition. A 7/28/24 Annual MDS revealed Resident 4 was cognitively intact. On 8/28/24 at 10:44 AM Resident 4's personal refrigerator was observed to contain three covered cups of milk not labeled or dated, three plastic facility containers of chocolate pudding dated 7/19/24, 8/1/24 and 8/3/24, one facility container of vanilla pudding dated 8/17/24, one facility container of butterscotch pudding dated 8/3/24 and one small container of ranch dip not labeled or dated. On 8/28/24 at 10:50 AM Resident 4 stated no one in the facility checked the temperatures or expiration dates for her/his refrigerator. On 8/28/24 at 11:14 AM…

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 received 12 hours of annual in-service training for 4 of 5 randomly selected staff members (#s 19, 20, 21 and 22) reviewed for evidence of in-service training. This placed residents at risk for a lack of quality care. Findings include: On 8/29/24 at 1:06 PM Staff 24 (Human Resources) provided a list of training hours for nurse aid staff which revealed the following: -Staff 19 (CNA): 1.1 annual training hours; -Staff 20 (CNA): 0 annual training hours; -Staff 21 (CNA): 0 annual training hours and -Staff 22 (CNA): 0 annual training hours. On 8/29/24 at 1:10 PM Staff 24 acknowledged Staff 19, Staff 20, Staff 21 and Staff 22 did not complete the required 12 hours of annual in-service training. On 8/30/24 at 10:51 AM Staff 1 (Administrator) acknowledged CNA staff were required to have 12 hours of annual in-service training and stated the facility needed to develop a tracking system for monitoring the hours.

Based on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 3 of 5 sampled residents (#s 14, 26, and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: 1. Resident 66 was admitted to the facility in 7/2024 with diagnoses including major depressive disorder. Resident 66's 7/20/24 Physician Order indicated the resident was prescribed citalopram hydrobromide (antidepressant medication) to be taken each morning related to major depressive disorder. Resident 66's 8/2024 MAR revealed the resident received citalopram hydrobromide, daily. Review of Resident 66's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks and benefits of citalopram hydrobromide and no evidence the resident consented to receive the medication until 8/27/24. On 8/28/24 at 2:23 PM Staff 7 (LPN-Care Manager)…

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 transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options, rights and lack of advocacy from the Ombudsman Office. Findings include: 1. Resident 44 was admitted to the facility in 11/2022 with diagnoses including chronic respiratory failure (a condition resulting in the inability to effectively exchange carbon dioxide and oxygen in the body) and quadriplegia (paralysis that effects the torso and all four limbs). A review of Resident 44's health record revealed she/he was transferred to the hospital on 3/19/24, 6/19/24 and 7/15/24. No evidence was found in Resident 44's health record to indicate a transfer notice with appeal rights was provided in writing to her/him upon transfer to the hospital or that…

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 residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 44 was admitted to the facility in 11/2022 with diagnoses including chronic respiratory failure (a condition resulting in the inability to effectively exchange carbon dioxide and oxygen in the body) and quadriplegia (paralysis that effects the torso and all four limbs). A review of Resident 44's health record revealed she/he was discharged to the hospital on 3/19/24, 6/19/24 and 7/15/24. No evidence was found in Resident 4's health record to indicate written notice of the facility's bed hold policy was provided to Resident 44 when she/he was transferred to the hospital on 3/19/24, 6/19/24 or 7/15/24. On 8/27/24 at 2:30 PM Staff 26 (Social Service Director) stated she 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 record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for inaccurate assessment and care. Findings include: Resident 33 was readmitted in 10/2023 with diagnoses including generalized anxiety disorder and major depressive disorder-recurrent. A 3/13/24 physician's note (internal medicine) identified the resident reported significant anxiety and depression with psychiatric treatment in the past. Resident 33 did not recall the use of antipsychotic medication. The physician suggested a diagnosis of schizoaffective disorder (a chronic mental health disorder characterized by symptoms of both schizophrenia and mood disorder) but it was unclear if the resident met the diagnostic criteria. Further consultation with a colleague was planned. On 3/14/24, a diagnosis of schizoaffective disorder, depressive type was entered in the medical record. According to the record, the diagnosis was made by…

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 baseline care plan was sufficient to meet the needs of a resident admitted with a pressure injury for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. This placed residents at risk for a delay in treatment. Findings include: Resident 173 was admitted to the facility in 8/2024 with diagnoses including recent onset of paralysis of the lower extremities and a documented history of pressure injury to the sacrum that occurred during hospitalization. A Hospital History and Physical dated 8/16/24 indicated Resident 173 had a new pressure injury to sacrum (area above the tailbone) found on 8/14/24. The wound was described as an intact, discolored DTI (deep tissue Injury). Treatment included protective ointment, a foam dressing, frequent repositioning and pressure reduction. Documentation on the facility Clinical admission Form dated 8/21/24 did not identify the presence of the wound on the resident's sacrum. Resident 173's Initial Care Plan dated 8/22/24 did not identify the presence of 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 observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 3 of 7 sampled residents (#s 19, 66 and 67) reviewed for accidents, care plans and nutrition. This placed residents at risk for unmet needs. Findings include: 1. Resident 19 admitted to the facility in 11/2017 with diagnoses including dysphagia (difficulty swallowing) and epilepsy (seizure disorder). A Care Plan initiated on 3/3/21 revealed Resident 19 used bilateral fall mats related to risk of injury from seizure activity and was to be shaved daily. A 8/16/24 Quarterly MDS revealed Resident 19 had severe cognitive impairment. Observations on 8/28/24 from 8:00 AM to 3:00 PM revealed Resident 19 did not have bilateral fall mats in place in her/his room while the resident was in bed and she/he had facial hair growth that was a quarter to half an inch long. On 8/28/24 at 12:29 PM Staff 5 (CNA) stated Resident 19 was to have bilateral fall mats in place at all times. Staff 5 also stated he did not shave 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure 1 of 1 Nurse Practitioner's (Former Staff 34) diagnostic practices were confined to his specified clinical discipline. This placed residents at risk for diagnosis by unqualified staff. Findings include: According to OAR [PHONE NUMBER], Nurse Practitioner Scope of Practice: (7)The nurse practitioner is responsible for recognizing limits of knowledge and experience, and for resolving situations beyond his/her nurse practitioner expertise by consulting with or referring clients to other health care providers. (8)The nurse practitioner will only provide health care services within the nurse practitioner's scope of practice for which he/she is educationally prepared and for which competency has been established and maintained. Educational preparation includes academic coursework, workshops or seminars, provided both theory and clinical experience are included. (9)The scope of practice as previously defined is incorporated into 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 maintain oxygen equipment for 1 of 1 sampled resident (#5) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure. Findings include: Resident 5 was admitted to the facility in 6/2024 with diagnoses including chronic obstructive pulmonary disease (chronic lung disease that causes breathing difficulty). The 6/7/24 admission MDS indicated Resident 5 was cognitively intact. The 6/3/24 physician order revealed the resident used continuous oxygen and to clean the oxygen concentrator and filter every Tuesday NOC (night) shift. Observations on 8/26/24 at 11:26 AM revealed Resident 5's oxygen concentrator was covered in dust and the external filter had a thick gray layer of dust. On 8/26/24 at 11:28 AM Resident 5 stated she/he did not recall staff cleaning the concentrator or filter the whole time she/he has been in the facility. The 6/2024 TAR revealed no documentation for 6/4/24, 6/11/24, 6/18/24 or 6/28/24 to indicate NOC shift staff cleaned Resident 5's 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 interview and record review it was determined the facility failed to identify clinical indications for the use of an antipsychotic medication for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for the unnecessary use of psychotropic medication. Findings include: Resident 33 was readmitted in 10/2023 with diagnoses including cancer, generalized anxiety disorder and major depressive disorder-recurrent. The Behavior Monitor for Resident 33 tracked behaviors of: Withdrawal, difficulty sleeping, a history of accusations, easily overwhelmed, irritability and tangential. The 2/2024 Behavior Monitor identified two episodes of difficulty sleeping during the month and no behaviors/concerns were identified in progress notes. A 2/29/24 nurse practitioner visit described Resident 33's behavior as appropriate, with an open attitude, anxious mood, clear speech and concrete thought process. The resident's focus during the visit was her/his pain which was all the time, anxiety and insomnia. A GAD (Generalized Anxiety Disorder) scale 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 provide timely incontinence care for 1 of 1 resident (# 5) reviewed for incontinence care. This placed residents at risk for unmet care needs. Findings include: Resident 5 was admitted to the facility in 8/2023 with diagnoses including brain damage. Resident 5's 8/31/23 care plan included Resident 5 required two person total assist with incontinence care. Bowel Movement Documentation from 9/2023 indicated Resident 5 received incontinence care and incontinence care checks three times on 9/1/23 and twice on 9/2/23. On 10/26/23 at 1:59 PM and 2:34 PM, Staff 19 (CNA) and Staff 20 (CNA) stated incontinence checks were suppose to be performed every two hours but they were usually only able to perform incontinence checks twice during an eight hour shift. Staff 19 stated CNAs document whenever a resident's brief is checked regardless of if it needed to be changed. On 10/27/23 at 10:42 AM Staff 17 (RCM) stated the expectation was to have incontinent residents checked every two hours. Staff 17 confirmed it 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 ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 19, 20, 22 and 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 5/17/23 indicated the following employees had not received their annual performance evaluations: -Staff 19 (CNA), hire date 4/4/18; last performance evaluation was completed on 8/26/21. -Staff 20 (CNA), hire date 6/17/17; last performance evaluation was completed on 6/11/21. -Staff 22 (CNA), hire date 3/10/21; no performance evaluation was completed. -Staff 23 (CNA), hire date 5/31/10; last performance evaluation was completed on 8/25/21. On 5/17/23 at 3:05 PM Staff 17 (Human Resource Manager) confirmed annual performance reviews for the identified staff were not completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to protect residents' rights to make personal care decisions for 1 of 3 sampled residents (#267) reviewed for choices. This placed residents at risk for lack of personal care decisions for resident choices. Findings include: Resident 267 admitted to the facility in 10/2022 with diagnoses including metabolic encephalopathy (a medical problem in the brain caused by a blood imbalance) and diabetes mellitus. Resident 267's admission MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The facility's Resident Rights policy, revised 2/2021 stated Employees shall treat all residents with kindness, respect and dignity and residents have the right of self determination. Resident 267's care plan dated 11/16/22 indicated the resident was resistant to ADL care at times due to pain. Interventions were to negotiate a time with the resident to provide care, leave the resident's room and return five to ten minutes later 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 provide written information to residents concerning the right to formulate an advance directive for 1 of 3 sampled residents (#9) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Resident 9 was admitted to the facility in 2023 with diagnoses including acute kidney failure and chronic kidney disease. A 4/2023 admission MDS indicated Resident 9 was cognitively intact. The 4/20/23 Care Plan indicated: Resident states that the orders on the POLST reflect their advance directive wishes and they do not wish to fill out the Advance Directive form. On 5/15/23 at 12:23 PM Witness 1 (Family) stated the facility had not asked Resident 9 if she/had an advance directive or if one could have been obtained. On 5/16/23 at 8:20 AM Resident 9 stated she/he had an advance directive through her/his physician's office and the facility had not asked if she/he had an advance directive or if she/he would like to fill one out. Resident 9's clinical…

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 a Notice of Medicare Non-coverage to 1 of 3 sampled residents (#118) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 118 was admitted to the facility on [DATE] with diagnoses including leg fracture. Resident 118's Clinical Census (reviewed on 5/18/23) indicated the resident's last covered day of Medicare Part A services (skilled services including therapy) was 1/13/23. On 5/18/23 at 3:07 PM Staff 1 stated Resident 118 was not provided with a Notice of Medicare Non Coverage prior to discharge, but a notice should have been provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#56) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: The facility's 6/2018 Activity Programs policy and procedure specified the following: -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. -Activities are documented in the resident's medical record. Resident 56 was admitted to the facility in 1/2023 with diagnoses including depression, anxiety and respiratory failure. Resident 56's 1/16/23 admission MDS indicated the resident was cognitively intact. Her/his activity preferences indicated it was important or very…

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 physician's orders for 3 of 6 sampled residents (#s 4, 9 and 319) reviewed for medication administration, bowel care and daily weights. This placed residents at risk for adverse medical consequences. Findings include: 1. Resident 319 was admitted to the facility in 2023 with diagnoses including fracture. Resident 319's 5/2023 physician's orders revealed an order for calcium carbonate-vitamin D3 600 mg-12.5 mcg every morning after a meal. Resident 319's 5/2023 MAR revealed the medication was charted as having been administered from 5/5/2023 through 5/17/23, including by Staff 35 (CMA) on 5/17/23. On 5/18/23 at 9:36 AM Staff 35 was observed administering medications to Resident 319. She stated she could not administer the resident's ordered calcium carbonate-vitamin D3 600 mg-12.5 mcg because the medication was not available. Staff 35 stated she would notify Staff 3 (LPN) to either obtain the medication or adjust the dose. Staff 35 stated the ordered dosage was not on the medication cart…

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 accurately assess a pressure ulcer and provide ordered pressure ulcer wound care for 3 of 6 sampled residents (#s 4, 32 and 168) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: 1. Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. a. On 5/16/23 at 10:42 AM Resident 32 stated the facility did not perform her/his pressure ulcer wound care on 5/12/23. Resident 32's 5/2023 physician's orders revealed wound care instructions for the resident's left buttock pressure wound including wound vac (A device which creates negative pressure on a wound to help the wound heal) settings. Resident 32's 5/9/23 Skin & Wound Evaluation revealed the resident had a Stage 4 (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone) pressure wound over the left trochanter (bony prominence near the end of the thigh bone).…

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 nail care for 1 of 2 sampled residents (# 41) reviewed for nail care. This placed residents at risk for inadequate foot care. Findings include: Resident 41 was admitted to the facility in 7/2022 with diagnoses including type 2 diabetes. Physician orders from 7/8/22 stated Resident 41 was to receive podiatry (foot and toenail) services as needed. On 5/17/23 at 9:44 AM Resident 41 reported she/he had not received toe nail care for a few months. Resident 41's big toe nails were observed to be extended one inch, half an inch thick, yellow, crusted and excessively curved. All other toenails were also extended half an inch, a quarter of an inch thick, yellow, crusted and excessively curved. On 5/17/23 at 10:02 AM Staff 3 (LPN/Resident Care Manager) reported Resident 41 had requested to receive nail care during her/his last care conference on 4/12/23. Staff 3 stated Staff 32 (Social Services) was responsible for setting up nail care services for Resident 41. On 5/17/23 at 10:12 AM Staff 32…

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 urinary catheter care as ordered for 1 of 3 sampled residents (#32) reviewed for urinary catheters. This placed residents at risk for UTI. Findings include: Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. Resident 32's 5/2023 physician's orders revealed the resident's suprapubic catheter (a tube inserted through the abdominal wall into the bladder to drain urine) was ordered to be changed monthly. Resident 32's 5/2023 TAR revealed on 5/13/23 the resident's suprapubic catheter was not changed and was documented as 7 for Resident temporarily not available. A review of the resident's clinical record revealed no Progress Notes to indicate why the catheter was not changed or rescheduled. On 5/17/23 at 12:23 PM Staff 2 (DNS) verified the resident's catheter was not changed as ordered. No additional information was provided.

Based on interview and record review it was determined the facility failed to assess residents after dialysis for 1 of 1 sampled resident (#18) reviewed for dialysis. This placed residents at risk for complications related to dialysis. Findings include: Resident 18 was admitted to the facility in 2022 with diagnoses including end-stage kidney disease. Resident 18's 4/6/23 Cognitive Patterns MDS BIMS score was 4 which indicated the resident was severely cognitively impaired. Resident 18's Care Plan initiated on 12/28/22 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility. A review of Resident 18's clinical record revealed six Dialysis Communication Reports (a document designed to share information between the facility and the dialysis clinic and to document pre and post dialysis assessments of the resident by both the facility and the dialysis clinic). Of the six reports, three were from 1/2023, one from 2/2023 and two were undated. None of the six included 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 ensure an RN was available for at least eight consecutive hours per day seven days per week for 4 of 44 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed on 4/1, 4/2, 4/7 and 5/14 there was no RN coverage for eight consecutive hours. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#56) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 56 was admitted to the facility in 1/2023 with diagnoses including muscular dystrophy (a genetic disorder causing progressive muscular weakness) and respiratory failure. A review of Resident 56's 4/1/23 through 5/17/23 MAR indicated an order for Senna-Ducusate Sodium (a laxative and stool softener) which was administered every morning and at bedtime for bowel health. The order indicated to hold the medication if Resident 56 had diarrhea. The MAR indicated Resident 56 was administered Senna twice daily and there were no instances when the medication was held. A review of Resident 56's Bowel Elimination Flowsheets from 4/18/23 through 5/17/23 indicated Resident 56 had loose stools/diarrhea on the following dates: 4/21, 4/22, 4/24, 4/25, 4/26, 4/28, 4/30, 5/1, 5/2, 5/3, 5/5, 5/6, 5/7, 5/8,…

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 and medications in locked compartments for 1 of 2 treatment carts randomly observed. This placed residents at risk for medication diversion and accidents. Findings include: The facility's 11/2020 Storage of Medications Policy noted: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts were not to be left unattended. On 5/15/23 at 12:58 PM an unlocked treatment cart was observed near the nurse's station on Hall 100. Staff were observed to walk by the cart but did not lock the cart. There were no residents in the area. On 5/15/23 at 1:00 PM Staff 4 (LPN) stated the treatment cart contained different items used for treatments including insulin and resident prescription medications including Coumadin (drug used to prevent blood clots), lanthanum carbonate (drug used to lower high blood phosphate levels for individuals on dialysis), sevelamer (a drug…

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 received specialized rehabilitative services (OT services) at the frequency needed for donning/doffing splints for 1 of 2 sampled residents (#2) reviewed for therapy. Findings include: Resident 2 was admitted to the facility in 6/2022 with diagnoses including multiple sclerosis (progressive neurological diseases affecting the brain and spinal cord) and functional quadriplegia (complete immobility). A 6/2/22 physician order requested an OT evaluation and treatment. Resident 2's 3/12/23 Quarterly MDS indicated the resident had limited functional mobility due to impairments on both sides of her/his upper and lower extremities. Resident 2's 3/13/23 through 6/10/23 OT Recertification, Progress Report (most recent progress report dated 4/21/23) and Updated Therapy Plan indicated the following: -Caregivers will demonstrate good understanding of orthotic wearing schedule and donning/doffing protocol in order to reduce long term risk for contractures/skin breakdown. Caregivers not yet…

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 accurately document in the medical record for 2 of 5 sampled residents (#'s 27 and 168) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical records and unmet treatment needs. Findings include: 1. Resident 168 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure. The resident discharged on 4/23/23. a. The 4/19/23 admission Nurse Database (nursing assessment) indicated Resident 168 had a right iliac crest blister. The 4/19/23 Skin and Wound Assessment revealed an undiagnosed wound which measured 8.29 cm by 4.55 cm. The assessment indicated current treatment included wound cleanser and a foam dressing. The accompanied picture of Resident 168's buttocks revealed two Stage II (partial thickness skin loss) pressure ulcers with red skin surrounding and between the two wounds. A review of the 4/2023 TARs revealed no scheduled treatments for the two wounds. A PRN order for house…

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.