Highland House Nursing & Rehabilitation Center

and one liter of soda, which was empty on her/his bedside table next to the bed.

The resident was

6/12/24 at 8:23 AM Staff 17 (CNA) and at 10:48 AM Staff 6 (CNA) stated Resident 33 was

her/his meals at the facility and ordered fast food in addition.

Staff 17 stated the resident drank one in a half liters of soda almost daily and freqently requested snacks.

On 6/12/24 at 11:16 AM Resident 33 stated she/he was a diabetic and liked to eat whatever she/he wanted. Resident 33 stated she/he had fast food delivered often.

On 6/12/24 at 7:28 PM, Staff 18 (LPN) and on 6/13/24 at 9:35 AM, Staff 21 (LPN) stated Resident 33 was non-compliant with her/his diabetic diet.

The resident blood sugars consistently ranged in upper 200s to 300s.

Staff 18 and Staff 21 stated the resident ordered pizza three to four times weekly, consumed excessive soda pop and indulged in multiple unhealthy snacks.

Staff 18 and Staff 21 stated education was provided, and when residents were non-compliant, a risk and benefts form should be completed.

Staff 18 and Staff 21 acknowledged a risk and benefits was not completed for Resident 33.

On 6/13/24 at 10:16 AM and 11:10 AM, Staff 2 (DNS), Staff 27 (LPN and Unit Manager) and Staff 30 (LPN Unit Manager) stated Resident 33 was non-compliant with her/his diabetic diet and expected staff to educate, inform the physician and complete a risk and benefits form with Resident 33.

Staff 2, Staff 27 and Staff 30 acknowledged the form was not completed.

• Resident 335 admitted to the facility on 6/2024 with diagnoses including dementia.

A 6/11/24 review of Resident 335's orders revealed a 6/7/24 order for quetiapine fumarate (an antipsychotic medication) and a 6/7/24 order for sertraline (an antidepressant medication).

A 6/11/24 review of Resident 335's medical record revealed no evidence of a consent for quetiapine fumarate and sertraline.

A 6/11/24 review of Resident 335's June 2024 MAR revealed she/he had taken quetiapine fumarate and sertraline on 6/8/24, 6/9/24 and 6/10/24.

On 6/13/24 at 3:25 PM Staff 27 (LPN Unit Manager) stated Resident 335's son had not signed the consent for quetiapine fumarate and sertraline yet.

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

(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

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 facility working.

Staff 36 confirmed unauthorized people had access to the resident records in her office when she was not in the office.

On 6/14/24 at 12:37 PM Staff 1 (Administrator) confirmed he expected resident records to be secured with no access to unauthorized individuals.

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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

treatment.

use of a physical restraint for 1 of 1 sampled resident (#57) reviewed for restraints.

This placed

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 bed with a scoop mattress (A concave-shaped bed that prevents users from rolling off and falling.) There was no documentation in Resident 64's clinical record to indicate the resident's scoop mattress was assessed for a potential physical restraint.

In an interview on 6/14/24 at 10:32 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated it would be expected for an evaluation to be completed for the use of a scoop mattress.

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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

every 12 months.

comprehensively assess residents related to behaviors for 1 of 2 sampled residents (#25) reviewed

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 present behaviors included swearing at people, clashing with her/his roommate as they both will mimic and yell at each other, pick at and smear feces, resist care by shouting and hitting staff.

On 6/13/24 at 3:29 PM Staff 42 (CNA) stated Resident 25 continued to often pull feces from her/his body and smeared on her/himself, resist care by hitting and pulling on staff, yelling, swinging and swearing at others.

On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 acknowledged they expected resident assessments to be comprehensive and behaviors were expected to be assessed accurately.

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

Director of Clinical) stated they would look into why a significant change MDS was not completed. No

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

Screening and Resident Review) evaluation (evaluation for individuals with a mental disorder or

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 AM Staff 36 (Social Services Director) stated she was aware of Resident 25's mental health diagnoses and challenging behaviors.

She confirmed Resident 25 did not have a Level ll PASARR evaluation or referral for an evaluation completed.

On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of a completed Level ll PASARR and an effective system for referrals was needed.

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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

Resident 25's 5/6/24 Annual MDS assessed her/him with moderately impaired cognition.

On 6/11/24 at 8:26 AM Witness 5 stated he did not know if there was a change in staff, but we use to have quarterly care conference meetings and that seems like it's not happening any longer.

Witness 5 could not recall the last time he contributed to Resident 25's care planning process or participated in a care conference meeting.

No evidence was found in Resident 25's medical record to indicate options for alternate care conference meeting times, the reason for lack of resident representative participation, or steps taken to facilitate participation. No care conference meeting occurred between 1/17/24 to 6/11/24.

On 6/14/24 at 10:38 AM Staff 36 (Social Service Director) stated she was responsible to schedule a care conference meeting for care planning in conjunction with each resident's comprehensive and quarterly MDS assessments.

Staff 36 acknowledged it was six months since Resident 25's last care conference meeting, she contacted her/his representative the day prior to the care conference meeting and did not reattempt care conference meetings for resident representatives who were unable to attend.

On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged they expected care conference meeting to be held in conjunction with the Quarterly and Annual MDS assessments and resident representatives were expected to be involved if the resident was not able to advocate for themselves.

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

schizophrenia.

as an admitting diagnosis which was created on 10/17/23.

On 6/14/24 at 9:35 AM Resident 16 stated she/he could not remember when she/he was diagnosed with schizophrenia, but she/he was no longer taking the medication for it and whoever diagnosed her/him stated it would not be for long.

On 6/14/24 at 10:12 AM Staff 37 (CNA) stated she never observed Resident 16 hallucinate or have delusions.

Staff 37 stated at times she/he would report a CNA did not assist her/him when they had.

In an interview on 6/14/24 at 10:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) Staff 1 stated Resident 16 previous caregiver stated Resident 16 was diagnosed with schizophrenia.

Staff 1 also stated Resident 16 had symptoms for a long time and behaviors for an extended period.

Staff 1 stated they would investigate additional history. No additional information was provided.

385149 06/14/2024

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

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.

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

use of regular socks.

fall mat lay on the floor beside it.

The bedside table was out of reach, and no bedside commode was

On 6/12/24 at 9:12 AM Resident 57 was in bed with the bed against the wall and no fall mat on the floor.

The bedside commode was up against the wall by the door, away from the bed. At 12:06 PM Resident 57 was observed self-transferring from her/his wheelchair to the bed on her/his own. At 12:08 PM, Resident 57 mentioned not knowing what the sign on the bedside table said.

On 6/13/24, at 5:41 AM and 8:03 AM Resident 57 was in bed with the bedside commode positioned next to the wall near the door not near the bed. A walker was placed beside the bed, while the wheelchair was approximately five feet away from the bed. At 12:25 PM the bed was rearranged, with the head of the bed now against the wall instead of the side.

At 6/13/24 at 9:33 AM Staff 40 stated on 6/6/24, she witnessed Resident 57 attempting to get up from bed, grabbing the walker, and moving toward the bathroom. Resident 57 fell with upper body on the bed and lower body on the floor.

Staff 40 yelled for assistance.

Staff 41 (RN) arrived and questioned Staff 37 (CNA) about the absence of the bedside commode and fall mat near Resident 57's bed.

In an interview on 6/14/24 at 10:19 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated would expect staff to follow the care plan.

• Resident 63 was admitted to the facility in 2024 with diagnoses including falls and anxiety.

An 4/29/24 care plan indicated Resident 63 required a bedside commode for toileting.

The 5/13/24, 5/22/24, and 5/29/24 Fall incident reports concluded Resident 63 fell while attempting to self-transfer in the bathroom.

On 6/13/24 at 9:42 AM an observation of Resident 63's room revealed no bedside commode.

Staff 44 (CNA) confirmed that a bedside commode would be helpful to prevent falls.

On 6/13/24 at 11:01 AM Staff 59 (Resident Care Manager-LPN) acknowledged the care plan was not followed.

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

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.

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

for respiratory care.

This placed residents at risk for unsanitary conditions and lack of monitoring.

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 nurse could initiate oxygen but needed to obtain orders from a physician for continued use.

On 6/11/24 02:33 PM Staff 2 (DNS) verified there were no oxygen orders in the resident's clinical record.

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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

give her/him time to calm down;

responding: making verbal threats;

-Resident preferred the approach from facility personnel when he/she felt upset, stressed, or overwhelmed: talk calmly or walk away; -Staff to avoid and resist re-traumatizing her/him with thoughtful approaches to care.

No evidence was found in Resident 25's health record related to the development and implementation of individualized interventions, for assessed triggers of trauma which may re-traumatize the resident or identify ways to mitigate or decrease the effect of the trigger on the resident.

On 6/14/24 at 10:38 AM Staff 36 (Social Service Director) stated she was aware of Resident 25's behaviors.

Staff 36 was unaware of specific behaviors Resident 25 exhibited related to PTSD or what triggered the PTSD.

Staff 36 stated to her knowledge the triggers were not assessed or care planned for individual residents.

On 6/14/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the need for residents to have triggers identified for a PTSD diagnosis to prevent re-traumatization.

Staff 2 acknowledged the resident care plans were expected to be resident centered for the individual.

385149 06/14/2024

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

According to the 6/2024 MAR the facility documented the new orders for Resident 63 to rinse her/his mouth with water following use of Symbicort on 6/5/24.

On 6/14/24 at 11:43 AM Staff 2 (DNS) confirmed the pharmacy recommendations were not implemented timely.

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

opportunities.

This placed residents at risk for ineffective medication regimen.

Findings include:

• 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 currently ordered to be applied to both knees.

• Resident 10 was admitted to the facility in 2024 with a diagnosis of low thyroid levels.

Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily.

A 5/23/24 order revealed Resident 10 was to be administered levothyroxine once a day.

There were no directions to give the mediation with or without food.

On 6/13/24 at 7:58 AM Staff 12 (CMA) was observed to administer Resident 10 her/his thyroid medication. Resident 10 was observed in her/his room with her/his breakfast consumed.

On 6/13/24 at 8:05 AM Staff 12 stated the nurses reported it did not matter if the thyroid medication was administered before or after meals.

On 6/13/24 at 8:21 AM Staff 41 (RN) stated the night shift staff usually administered the thyroid medication before breakfast on an empty stomach.

On 6/13/24 at 8:29 AM Staff 2 (DNS) stated thyroid medication should be given without food unless the resident could not tolerate the medication on an empty stomach.

385149 06/14/2024

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

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.

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

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 documented in the resident 86's record and the 10/7/23 UA results did not indicate antibiotics should be administered.

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.

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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.

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

47001

4. Resident 21 was admitted to the facility on [DATE] with diagnoses including cervical vertebra (neck) fracture.

A 4/5/24 Comprehensive MDS Assessment was signed completed on 4/10/24.

On 6/11/24 at 8:34 AM Resident 21 stated she/he did not recall if she/he had a care conference since admission.

A 6/11/24 medical record review revealed Resident 21 had a care conference on 4/4/24, the day after admission, and no other care conferences were located in the resident's record.

On 6/12/24 Staff 36 (Social Service Director) stated new admissions have care conferences within three days of admission, before discharge, within in 14 days of admission if the resident is staying longer than 20 days and then every 90 days.

On 6/12/24 at 1:49 PM Staff 27 (LPN Unit Manager) stated new admissions have care conferences within three days after admission, as needed and every 90 days.

On 6/14/24 at 11:53 AM Staff 1 (Administrator) acknowledged new admissions need to have a care conference completed within seven days after completing the Comprehensive MDS Assessment.

5. Resident 49 was admitted to the facility on [DATE] with diagnoses including left rib fracture.

A 5/11/24 Comprehensive MDS Assessment was signed completed on 5/21/24.

On 6/10/24 at 1:32 PM Witness 8 (Resident Representative) stated she was unaware if Resident 49 had a care conference since admission.

On 6/12/24 Staff 36 (Social Service Director) stated new admissions have care conferences within three days of admission, before discharge, within in 14 days of admission if the resident is staying longer then 20 days and than every 90 days.

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