Highland House

F-F689

4. Resident 133 was admitted to the facility in 2023 with a diagnosis of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Resident 133's 11/2023 MAR revealed staff were to administer an antibiotic every four hours. The MAR revealed the resident did not receive antibiotics on five occasions. Level of Harm - Minimal harm or potential for actual harm Resident 133's 12/2023 MAR revealed staff were to administer an antibiotic every four hours. The MAR revealed the resident was not administered the prescribed antibiotic on three occasions. Residents Affected - Some

On 6/13/24 at 7:41 AM Staff 28 (LPN) stated when a medication was administered staff had to enter yes in

the electronic record and then save the response after the medication was administered. If a resident was not available or refused a medication the response was changed to refused, resident not available or see nurse's note. Staff 28 stated the MAR should not be blank for scheduled medications.

On 6/13/24 at 2:35 PM Staff 2 (DNS) stated he would provide documentation if Resident 133 was not in the facility due to appointments to support the missed antibiotic administration. No additional information was provided.

5. Resident 134 was admitted to the facility in 2023 with a diagnosis of kidney disease.

Progress Notes revealed the following:

-12/9/23 Resident 134 had pain with urination and the resident's physician was notified

A 12/11/23 Provider Note revealed Resident 134 had pain with urination and staff were to obtain a urine sample.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26991 potential for actual harm Based on interview and record review it was determined the facility failed to ensure pain medications were Residents Affected - Few available for 2 of 3 sampled residents (#85, and 339) reviewed for pain. This placed residents at risk for increased pain. Findings include:

1. Resident 85 was admitted to the facility in 2023 with diagnoses including arm and leg fractures.

A 11/17/23 Pain Assessment revealed Resident 85 did not have pain at the time of the assessment but reported pain interfered with her/his sleep and social activities.

A 11/22/23 admission MDS revealed Resident 85 reported constant pain for the last five days.

A 11/2023 MAR and associated progress notes revealed the following:

-Resident 85 was to be administered oxycodone every four hours while awake. From 11/24/23 through 11/27/23 Resident 85 was not administered the medication six times.

-From 11/27/23 Percocet was to be administered every four hours. Notes indicated the medication was not available.

-No additional medications were added for pain relief.

Resident 85's pain levels from 11/24/23 through 11/28/23 ranged from four to nine (pain levels four to six=moderate pain, seven and greater=severe pain).

A 11/27/23 Physical Therapy note revealed Resident 85 reported a pain level of six for her/his leg and a pain level of eight for her/his wrist. Resident 85 reported she/he was frustrated with not having proper pain medications.

Resident 85's clinical record revealed she/he had surgery on 11/29/23 and returned the same day.

On 6/10/24 at 6:56 PM Staff 43 (Former RN) stated Resident 85 was not administered pain medications as prescribed.

On 6/13/24 at 2:01 PM Staff 27 (LPN Resident Care Manager) stated Resident 85 was admitted to the facility for a short period of time. Staff 27 stated she was aware the resident had pain and was scheduled for surgery in late 11/2023. Staff 27 was not aware of pain control issues and staff were able to pull pain medications from the emergency supply if the medications were not available in the medication cart.

On 6/14/24 at 10:00 AM and 12:53 PM Staff 2 (DNS) stated Resident 85 was on multiple pain medications and in 11/2023 there was an oxycodone shortage. A request was made to Staff 2 to provide documentation additional pain medications were added to the resident's pain regimen when the medications were documented as not available. No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 47001

Level of Harm - Minimal harm or 2. Resident 339 admitted to the facility on [DATE REDACTED] at 11:45 AM with diagnoses including left femur (thigh potential for actual harm bone) fracture.

Residents Affected - Few On 6/14/24 at 8:52 AM Witness 9 (Family Member) stated Resident 339 called on 6/13/24 during the night and stated she/he had not had any pain medications since admission.

On 6/14/24 at 9:30 AM Resident 339 stated she/he requested pain medication on 6/13/24 after admission at 11:45 AM and during the night on 6/14/24 but did not receive any pain medications until 8:30 AM on 6/14/24.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 35855 potential for actual harm Based on observation, interview, and record review, it was determined the facility failed to post accurate and Residents Affected - Some complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include:

A review of the Direct Care Staff Daily Reports (DCSDR) from 5/9/24 through 6/9/24 revealed no census documented on 6/5/24 day and evening shift, 6/6/24 evening shift, or 6/8/24 night shift.

On 6/11/24 at 5:25 AM the DCSDR was observed posted by the nurses station. The night shift was blank for resident census, number of staff and hours worked.

On 6/12/24 at 8:02 AM the DCSDR was observed to have 6/11/24 posted. No census was documented for evening shift or night shift. At 9:17 AM the 6/12/24 DCSDR was posted with no census documented on the day shift.

In an interview on 6/14/24 at 10:22 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) reported it was expected to have an accurate DCSDR posted within one hour of a shift change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or 26991 potential for actual harm Based on interview and record review it was determined the facility failed to ensure a resident was Residents Affected - Few transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis. This placed residents at risk for worsening kidney function. Findings include:

Resident 134 was admitted to the facility in 2023 with a diagnosis of kidney disease.

12/2/23 hospital orders revealed Resident 134 was to receive dialysis at a dialysis center on Mondays, Wednesdays, and Fridays.

On 12/12/23 Staff 43 (Former RN) reported to the State Survey Agency the facility did not follow up with transportation for Resident 134 and On 12/11/23 (Monday) she/he missed a dialysis treatment.

On 6/10/24 at 6:56 PM Staff 43 stated the facility was aware Resident 134 required transportation to the dialysis unit, the paperwork was submitted, but they did not transport the resident.

On 6/20/24 via e-mail, Staff 2 (DNS) indicated Resident 134 did not go to dialysis. No additional information was provided for the rationale Resident 134 did not attend dialysis.

On 6/21/24 Witness 10 (Dialysis RN) verified Resident 134 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 385149 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 35855

Residents Affected - Some Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 3, 5, and 6) reviewed training. This placed residents at risk for lack of competent staff. Findings include:

A review of the facility's staff training records revealed the following:

-Staff 3 (CNA), hired 1/26/06 completed 10 hours of documented training from 1/25/23 through 1/25/24.

-Staff 5 (CNA), hired 4/7/10, completed six hours of documented training from 4/27/23 through 4/27/24.

-Staff 6 (CNA), hired 3/28/16, completed 10 hours of documented training from 3/28/23 through 3/28/24.

In an interview on 6/14/24 at 10:23 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated it was expected the staff complete the 12 hours of annual training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 385149