Highland House Nursing & Rehabilitation Center

(injury/decline/room, etc.) that affect the resident.

interview and record review the facility failed to notify a resident's representative of a fall for 1 of 2

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 fall out of bed on 12/23/22 and acknowledged Witness 1 was not notified of the incident.

On 6/13/24 at 11:01 AM Staff 2 (DNS) stated Witness 1 was the emergency contact and should have been notified about Resident 89's unwitnessed fall on 12/23/22.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

with people in the hallway and carts going up and down the hallway by the resident.

At 6/10/24 at 2:20 PM Resident 90 confirmed the 7/6/23 complaint with concerns of loud noises at night while she/he stayed in the facility.

On 6/11/24 at 5:51 AM a cart with full plastic bags was wheeled down the 300 hall with a squeaky wheel.

Another staff member rolling two yellow garbage pails down the 300 hall could be observed and heard while standing in the 200 hallway. At 6:09 AM staff was heard talking loudly at the nurses' station.

On 6/13/24 at 5:56 AM, a cart was heard rolling loudly by the nurse's station. At 6:02 AM Staff 16 (CNA) was observed wheeling to large garbage cans loudly down the 200 hall and entered the soiled linens room the sound of the cans was loud.

Staff 16 stated residents did complain of the loud noise of the garbage cans. As well as other noises during the night such as residents yelling, coughing, or having their TV up too loud.

Staff 16 stated she had brought up the noisy garbage cans wheels up to management, but she had not heard anything back for a possible change.

In an interview on 6/14/24 at 10:30 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated they would expect noise levels to be quiet during sleeping hours and for staff to be quiet during shift change from night shift to day shift.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

related to Staff 32 and Resident 87.

On 6/12/24 at 10:57 AM Staff 45 (Former Staffing) stated she had to move Staff 32 from multiple units due to residents' reports of mistreatment.

Staff 45 stated management was aware of the issue but did not address the concerns.

Staff 45 stated Resident 87 filed a complaint about Staff 32.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

witness the incident.

She also recalled Resident 30 was placed on 1:1 (one staff monitors one

On 6/11/24 at 5:19 PM Staff 47 (CNA) stated she heard on night shift Resident 30 hit Resident 20.

On 6/12/24 at 8:51 AM Staff 44 (CNA) stated at the end of 11/2023 Resident 20 was cleaning the rails in the hall. Resident 30 hit Resident 20 when Resident 20 was within reach.

Staff 44 stated the incident was reported to a nurse, but she did not recall the nurse.

On 6/12/24 at 3:38 PM Staff 1 (Administrator) stated it was his expectation for staff to report resident to resident incidents. He was not aware of an incident when Resident 30 hit Resident 20.

• Resident 91 was admitted to the facility in 8/2022 with diagnoses including intervertebral disc

displacement of the spine.

An 8/19/22 MDS assessed Resident 91 as moderately cognitively impaired.

A Grievance Form dated 3/19/23 alleged three CNAs were rude and short with Resident 91 and one CNA pushed Resident 91 causing pain.

The Grievance Summary Report was completed by Staff 24 (former Administrator), and indicated interviews were completed with the CNA who wrote the grievance, the RN who spoke with Resident 91 and with Resident 91. In the Greivance Summary Report, Resident 91 alleged two CNAs were rude to him and said he was, too heavy. No other interviews were provided and the was no evidence the allegation of one of the CNAs pushed Resident 91 resulting in pain was addressed. In the Grievance Summary Report indicated Resident 91's concern was resolved, and she/he was not harmed and was happy knowing Staff 23 (former agency CNA) was not returning to the facility.

On 6/12/24 at 2:44 PM Staff 25 (former DNS) stated she did not recall the incident with Resident 91, but stated it was her understanding Staff 23's contract was canceled due to poor attendance and a poor attitude.

On 6/13/24 at 10:24 AM Staff 23 denied the allegation.

Staff 23 stated the facility canceled her contract on 3/21/23 without interviewing her.

On 6/13/24 at 11:15 AM Staff 24 stated she did not recall the incident with Resident 91.

On 6/13/24 at 2:01 PM Staff 22 (former Staffing Coordinator) stated she was not involved in the decision to cancel Staff 23's contract.

Staff 22 stated she had never received a complaint about Staff 23, and she was an, excellent CMA who did not call in.

On 6/14/24 at 11:48 AM Staff 1 (Administrator) acknowledged he was unable to evidence the allegation of abuse from Resident 91 was investigated or reported to the State.

Staff 1 stated he would have, handled it differently.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

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 pointed at her/him and were laughing. Resident 65 stated she/he informed Staff 4 (Assistant Social Worker) about the concern. Resident 65 stated she/he no longer completed grievances because the staff did not reprimand staff. Resident 65 stated she/he requested the CNAs who laughed at her/him no longer provide her/him care.

On 9/5/24 at 7:41 AM Staff 4 stated she was never accused of being rude or disrespectful to a resident, she worked with all the residents in the facility, and was never asked not to work with any of the residents.

On 9/5/24 at 8:32 AM Staff 3 (Regional Director of Clinical) confirmed an investigation should have been completed.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

validate the baseline care plan was completed within 72 hours of admission.

Staff 30 stated Resident

On 6/11/24 at 1:25 PM Resident 335 was observed transferring her/himself form the chair to the bed.

On 6/11/24 at 1:36 PM Resident 335 was observed ambulating in her/his room without pants on, a CNA assisted Resident 335.

On 6/11/24 at 3:51 PM Staff 42 (CNA) stated she did not know Resident 335 and as far as she knew, Resident 335 was not at risk for falls.

On 6/13/24 at 3:25 PM Staff 27 stated Resident 335 had a diagnosis of dementia and was taking psychotropic medications.

Staff 27 acknowledged Resident 335 should have, but did not, have a baseline care plan for the dementia diagnoses or for the the psychotropic medications.

On 6/14/24 at 11:54 AM Staff 2 (DNS) stated he expected the baseline care plan to be in place within 48 hours of admission, and the baseline care plan should include fall risk, psychotropic medications and dementia diagnosis.

Staff acknowledged Resident 335's baseline care plan was not completed within 48 hours of admission.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

Review of the resident's record revealed there were no results for a urine sample for the 12/11/23 orders.

On 6/11/24 at 1:37 PM a request was made to Staff 2 (DNS) to provide results from the 12/11/23 physician order UA. No additional information was provided.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

night and stated she/he had not had any pain medications since admission.

admission at 11:45 AM and during the night on 6/14/24 but did not receive any pain medications until

On 6/14/24 at 9:48 AM Staff 7 (CNA) stated she worked with Resident 339 during the night of 6/13/24 through 6/14/24.

Staff 7 stated Resident 339 requested pain medications during the night and she informed the nurse.

A review of Resident 339's 6/2024 MAR revealed Resident 339 had not received her/his pain medications until 6/14/24 at 8:09 AM.

On 6/14/24 at 11:10 AM Staff 2 (DNS) stated the emergency medication kit had Resident 339's pain medications. At 11:55 AM Staff 2 stated every nurse had access to the emergency medication kit and Resident 339 should have received her/his pain medications when she/he requested it.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

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.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

life.

transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis.

This placed residents

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 did not get dialysis treatment on 12/11/23 due to lack of transportation.

Witness 10 stated if a resident resided in a nursing facility the facility was to assist the resident to and from the dialysis unit.

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Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526

dementia care and abuse prevention.

to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected

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.

Review of the resident's record revealed there were no results for a urine sample for the 12/11/23 orders.

On 6/11/24 at 1:37 PM a request was made to Staff 2 (DNS) to provide results from the 12/11/23 physician order UA. No additional information was provided.

385149

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 385149 B.

Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue Grants Pass, OR 97526