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 34 of 52 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 35 of 52 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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or 26991 potential for actual harm Based on observation, interview and record review it was determined the facility failed to ensure a resident Residents Affected - Few had glasses for 1 of 3 sampled residents (#20) reviewed for communication-sensory. This placed residents at risk for unmet vision needs. Findings include:

Resident 20 was admitted to the facility in 2021 with a diagnosis of dementia.

A 3/17/23 quarterly MDS indicated Resident 20 had adequate vision with corrective lenses.

On 6/10/24 at 12:36 PM Witness 3 (Spouse) stated Resident 20 liked to read and wore glasses, but the glasses were broken.

On 6/10/24 at 1:46 PM Resident 20 was observed to read and she/he did not wear glasses. Staff 52 stated Resident 20's glasses were broken for some time.

On 6/12/24 at 2:36 PM Staff 53 (CNA) stated Resident 20's lens was missing since at least 12/2023.

On 6/12/24 at 2:23 PM Staff 36 (Social Service Director) stated on 6/11/23 she just found an unsigned note

on her desk reporting one of Resident 20's lens was broken. Staff 36 was not aware of of the issue and Resident 20 did not have any scheduled vision appointments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 52 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 26991

Residents Affected - Few Based on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 3 of 6 sampled residents (#51, 57 and 63) reviewed for accidents. This placed residents at risk for accidents. Findings include:

1. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.

An Unwitnessed Fall investigation dated 3/14/24 revealed on 3/14/24 Resident 51 slipped out of bed. Interventions to prevent future falls included staff readjusted the mattress to ensure it was centered on the bed frame and nonslip material was to be applied under the mattress.

A care plan updated 3/14/24 revealed to prevent falls Resident 51 was to have nonslip material applied to

the bed mattress to ensure the mattress did not slip.

A 3/20/24 quarterly MDS revealed Resident 51 was cognitively intact.

On 6/10/24 at 12:25 PM Resident 51 stated her/his mattress did not fit the bed frame and caused her/him to fall. Resident 51 also stated staff did not provide her/him with a new mattress.

On 6/11/24 at 4:51 PM with Resident 51's permission, Staff 53 (CNA) looked under Resident 51's bed and nonslip material was not observed. Resident 51's mattress was also observed to have bed brackets on the bed frame to keep the mattress in place but the mattress was too big and it was positioned on top of the brackets and not within the brackets.

On 6/11/24 at 5:01 PM Staff 1 (Administrator) stated the mattress was too large and would be addressed.

On 6/11/24 at 5:09 PM Staff 2 (DNS) stated the maintenance staff applied brackets to the bed frame to keep

the mattress from slipping off the bed. Staff were to put nonslip material on the edge of the bed frame to prevent the mattress from slipping.

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2. Resident 57 was admitted to the facility in 2023 with diagnoses including stroke.

A 11/22/23 care plan indicated Resident 57 was at risk for falls and a history of falls. Resident 57 exhibited impulsive behavior, often getting up out of bed without using the call light. Interventions included to ambulate Resident 57 during the day and evening, anticipate needs, call light in reach, bedside commode next to the bed and encourage its use, commonly used items in reach and a sign posted to remind Resident 57 to call for assistance before getting out of bed.

A 5/15/24 MDS indicated Resident 57 was moderately impaired required one person supervision with transfers and had two or more falls since prior assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 52 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 0689 A 6/6/24 Witnessed Fall investigation indicated Staff 40 (Housekeeper) observed Resident 57 attempting to transfer to the bathroom without assistance, using a front wheel walker. Resident 57 lost her/his balance and Level of Harm - Minimal harm or fell backwards against the bed. The resident sustained some bruising on mid back, possibly from a previous potential for actual harm fall. At the time Resident 57 had on regular socks and not nonskid socks. Resident 57 was noted to have repeated falls, to be impulsive, and not wait for assistance. The root cause was attributed to poor safety Residents Affected - Few awareness and cognitive impairment exacerbated by the use of regular socks.

On 6/11/24 at 5:35 AM Resident 57 was in her/his bed. The bed was positioned against the wall and a fall mat lay on the floor beside it. The bedside table was out of reach, and no bedside commode was visible. Fall mat intervention was not indicated on the care plan.

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.

49677

3. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 52 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 0692 Provide enough food/fluids to maintain a resident's health.

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 nutritional supplements Residents Affected - Few were provided for 1 of 3 sampled residents (#19) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:

Resident 19 was admitted to the facility in 2018 with a diagnosis of diabetes.

A 2/1/24 Nutritional Screen indicated Resident 19 was to be provided a diabetic nutritional supplement BID to prevent weight loss.

An 4/2024 MAR revealed Resident 19 received a supplement BID through 4/7/24 and was out of the facility through 4/16/24. Resident 19's supplement was not restarted after 4/16/24.

An 4/20/24 Nutritional Screen revealed Resident 19 was assessed and the plan was to continue with the current plan and to monitor the resident for weight loss.

On 6/13/24 at 9:18 AM Staff 30 (LPN Resident Care Manager) stated the resident was hospitalized in 4/2024 and acknowledged the resident's supplement was not restarted upon readmission to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 52 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 26991 potential for actual harm Based on observation, interview, and record review, it was determined the facility failed to obtain orders for Residents Affected - Few oxygen and clean a resident's oxygen equipment for 1 of 1 sampled resident (#51) reviewed for respiratory care. This placed residents at risk for unsanitary conditions and lack of monitoring. Findings include:

Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.

On 6/10/24 at 12:39 PM Resident 51 was observed to wear a nasal canula (device to administer oxygen through the nose). The back of Resident 51's oxygen concentrator (machine which takes air from the surroundings, extracts oxygen and filters it into purified oxygen) was observed to have a thick layer of dust over the vent.

Resident 51's clinical record did not contain orders for oxygen.

On 6/11/24 at 2:25 PM with Staff 55 (LPN) Resident 51's concentrator was observed to have a thick layer of dust on the vents. Staff 55 stated she was new to the facility but the equipment was to be cleaned weekly and the amount of dust on the vents indicated it was not cleaned for a long time. Staff 55 stated a 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 52 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 41 of 52 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 42 of 52 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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or 38140 potential for actual harm Based on interview and record review it was determined the facility failed to ensure a resident who was a Residents Affected - Few trauma survivor received trauma-informed care in accordance with professional standards of practice and account for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 sampled residents (#25) reviewed for Behavioral-Emotional. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include:

Resident 25 admitted to the facility in 2017 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction).

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

Resident 25's 6/11/24 SS (social service) Post-Traumatic Checklist assessed her/him to experience anger outbursts, difficulty concentrating, unable to answer complicated questions and was irritable. Interventions for

the verbal outbursts were to talk calmly or walk away. It was assessed as not helpful to keep talking to her/him. No other interventions or triggers were identified.

Resident 25's SS Psychosocial Evaluation revealed in the section Describe Trauma: any time they may experience anxiety, sensitive to touch or noise or nightmares as the following: she/he does suffer from PTSD r/t [related] to trauma experienced while in the service. No other information was documented.

On 6/13/24 at 10:21 AM Staff 6 (CNA) stated she obtained information to care for Resident 25 from the Kardex (care plan for CNAs), at report to each other during change of shift and I just know [her/him] because I've worked with [her/him] so long. Staff 6 stated Resident 25 experienced behaviors and certain things would set [her/him] off.

On 6/13/24 at 3:29 PM Staff 42 (CNA) stated Resident 25 was often resistive to care and would hit or yell at staff. Staff 42 obtained her information to care for Resident 25 from the Kardex.

Resident 25's 6/13/24 Kardex section for Behavior/Mood directed staff to provide the following:

-Non-Medication Interventions in place routinely;

-Approach in a slow non-threatening manner;

-Remove to a safe environment PRN for increased behavior;

-Remove to a quieter environment PRN to decrease over stimulation;

-Do not force or rush care;

-One on One PRN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 52 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 0699 Resident 25's PTSD care plan directed staff to provide the following:

Level of Harm - Minimal harm or -Avoid continuing to talk to her/him when she/he expressed feeling stressed, upset, or overwhelmed, give potential for actual harm her/him time to calm down;

Residents Affected - Few -Resident expressed feeling stressed, upset, or overwhelmed with the following behaviors or ways of 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 52 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 45 of 52 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 46 of 52 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 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 follow pharmacy recommendations for 4 of 6 sampled residents (#s 16, 33, 63, and 51) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include:

1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.

a. A 10/28/23 Recommendation Summary for Medical Director and DON indicated Resident 16 required a gradual dose reduction assessment. The recommendation proposed lowering the dosage of aripiprazole (antipsychotic medication treat depression and schizophrenia) from 10 milligrams to 7.5 millagrams. The physician did not sign or date the recommendation, or provide a clinical rationale for maintaining the current medication dosage.

A 11/2023 and 12/2023 MARs instructed staff to administer aripiprazole 10 milligrams once a day from 11/7/23 through 12/22/23.

During an interview on 6/14/24 at 10:49 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) expressed the recommendations should be implemented within the month.

b. A 4/28/24 Nursing Recommendations from the pharmacy indicated Resident 16 was taking the antipsychotic aripiprazole. Standards of practice required an assessment for abnormal involuntary movement (AIMs) every six months and was due in 5/2024. A handwritten note next to the recommendation indicated completion, although it lacked a specific date.

No other documentation was found in clinical records the AIMS evaluation was completed in 5/2024.

In an interview on 6/14/24 at 10:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the recommendations should be implemented in the month.

36494

2. Resident 33 was admitted to the facility in 8/2021 with diagnoses including insomnia and anxiety.

The 6/2024 MAR included a 10/18/23 order for temazepam (treats insomnia) one capsule to be administered at bedtime for insomnia.

A 4/26/24 and 5/31/24 pharmacist Consultation Report recommended discontinuation of the temazepam.

The report noted, No change. Resident assessed and was determined regimen is currently at the lowest optimal dose and continues to be beneficial for resident's psychiatric symptoms, outweigh any apparent risk. Discontinue the temazepam or change the temazepam from daily to Monday, Wednesday, Friday and Sunday.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 52 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 0756 The pharmacy recommendation was not signed until 6/11/24 and indicated to see if patient willing to discontinue the temazepm. Level of Harm - Minimal harm or potential for actual harm On 6/12/24 at 1:56 PM Staff 48 (Consultant Pharmacist) stated she completed the monthly pharmacy reviews and she recommended a reduction to Resident 33's temazapen. Staff 48 stated common practice Residents Affected - Some was a 30-day response time when a recommendation was given, but often took 60 days or longer to receive

a response from the physician.

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's temazapen was not followed up on promptly. Staff 2 stated he expected staff to follow up on pharmacy recommendations weekly to prevent oversights or delays.

26991

3. Resident 51 was admitted to the facility in 2023 with a diagnosis of Cancer.

A 4/30/24 Pharmacy report recommended Resident 51's ferrous sulfate (supplement) should be discontinued because the resident's iron level was normal and docusate (treats constipation) because it was not an effective medication.

A 6/2024 MAR revealed Resident 51 continued to be administered ferrous sulfate and docusate.

On 6/11/24 at 2:33 PM a request was made to Staff 2 (DNS) to provide documentation Resident 51's physician declined 4/31/24 pharmacy recommendations. No additional information was provided.

49677

4. Resident 63 was admitted to the facility in 2024 with diagnoses including anxiety and asthma.

A pharmacy review dated 4/29/24 recommended following the use of Symbicort (inhaler medication) Resident 63 was to rinse her/his mouth with water.

The 4/2024 and 5/2024 MARs did not include the order to rinse Resident 63's mouth with water after using Symbicort.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 52 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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 26991 potential for actual harm Based on interview and record review it was it was determined the facility failed to ensure a medication error Residents Affected - Some rate of less than 5%. The facility administration rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for ineffective medication regimen. Findings include:

1. Resident 34 was admitted to the facility in 2019 with a diagnosis of chronic pain.

A 10/3/23 Order revealed staff were to apply an external pain patch to both knees.

A 4/4/24 quarterly MDS revealed Resident 34 was cognitively intact.

On 6/11/24 at 8:21 AM Staff 56 (CMA) was observed to apply a medicated pain patch to Resident 34's right arm and right leg.

On 6/12/24 at 8:18 AM Resident 34 stated she/he only used the patch on the right arm and leg and did not require it on the left knee.

On 6/12/24 08:20 AM Staff 56 stated she applied the patch only in the locations Resident 34 preferred.

On 6/12/24 at 9:19 AM Staff 30 (LPN Resident Care Manager) stated if a resident did not want the patch applied to the location ordered the order should be clarified. Staff 30 stated the patch was currently ordered to be applied to both knees.

2. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 52 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 0880 Provide and implement an infection prevention and control program.

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 follow infection Residents Affected - Few control standards for 1 of 5 halls (200 hall) reviewed for infection control. This placed residents at risk for cross contamination. Findings include:

On 6/14/24 at 10:08 AM, Staff 37 (CNA) was observed carrying dirty linens down the 200 hall and entering

the soiled linen room. Staff 37 acknowledged not having bags in her pocket and was aware that linens should be placed in a bag before transport.

In an interview on 6/14/24 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Director of Clinical) stated the expectation of staff were to place dirty linen in a bag for transport from resident room to soiled linen room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 52 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 0881 Implement a program that monitors antibiotic use.

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 not Residents Affected - Few administered an antibiotic without indication for 1 of 3 sampled residents (#86) reviewed for UTI. This placed residents at risk for drug resistant infections. Findings include:

Resident 86 was admitted to the facility in 2023 with a diagnosis of UTI.

A 10/7/23 Progress Note revealed Resident 86 had increased confusion. The physician was notified and Resident 86 was sent to the hospital for evaluation, treatment, and returned on 10/8/23.

Resident 86's urine culture results dated 10/7/23 revealed there was a mixed growth of skin and or genital organisms indicating an improper collection. The form revealed a new sample was to be submitted if clinically indicated.

A 10/2023 MAR revealed Resident 86 was administered antibiotics from 10/10/23 through 10/16/23 for an UTI.

On 6/14/24 at 9:29 AM Staff 2(DNS) stated 72 hours after an antibiotic was started the facility staff were to

review the test results to ensure an antibiotic was indicated. Staff 2 stated a 72 hour review was not documented in the resident 86's record and the 10/7/23 UA results did not indicate antibiotics should be administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 52 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 52 of 52 385149

F-F695

47001

4. Resident 21 was admitted to the facility on [DATE REDACTED] 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 52 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 0657 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. Level of Harm - Minimal harm or potential for actual harm 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, by day 21. Residents Affected - Some 38140

6. Resident 25 admitted to the facility in 2017 with diagnoses including a stroke.

Resident 25's Quarterly MDS was completed on 11/5/23.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 52 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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 35855 potential for actual harm Based on interview and record review it was determined the facility staff failed to follow professional Residents Affected - Few standards of practice for a diagnosed mental disorder for 1 of 6 (#16) sampled residents reviewed for medications. Findings include:

Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.

A 2/21/23 hospital History and Physical revealed Resident 16 was seen for right hip pain after sustaining a fall. A review of past medical history revealed no diagnosis of schizophrenia. Resident was on the medication aripiprazole (an antipsychotic medication used to treat depression and schizophrenia) and escitalopram (an antidepressant to treat depression and anxiety). A psychiatric evaluation revealed mood, behavior, thought content and judgement were normal.

A 3/2023 MAR instructed Staff to administer aripiprazole one time a day for schizophrenia.

A 3/6/23 Admission MDS indicated Resident 16 was cognitively intact with no hallucinations, delusions or behaviors exhibited during the seven day look back period. The assessment also indicated Resident 16 did not have a diagnosis of schizophrenia. The psychotropic care area indicated Resident was on aripiprazole an antidepressant and escitalopram for depression and anxiety.

A 5/17/23 Antipsychotic Medication Informed consent revealed Resident 16 was physician ordered to take aripiprazole for depression and anxiety. Resident 16 experienced inconsolable fear and crying.

A 9/6/23 Quarterly MDS indicated Resident 16 was cognitively intact with no hallucinations, delusions or behaviors exhibited during the seven day look back period. The assessment also indicated Resident 16 did not have a diagnosis of schizophrenia.

A 9/2023 and 10/2023 Documentation Survey Reports revealed no documented behaviors for Resident 16.

A 10/17/24 Nursing Note revealed the diagnosis of schizophrenia was added. Resident 16 was perscribed aripiprazole for this condition.

A 10/25/23 Psych Consultants revealed Resident 16 was seen from a facility referral and Resident 16 stated My mind is straight. Resident 16 then stated she/he saw black bugs flying in her/his room and saw them crawling on the window blinds. Resident 16 stated people think she/he was seeing things, but she/he knows

they are there. Resident 16 was diagnosed with depression and schizophrenia. Resident 16 denied history of mental health treatment or hallucinations. Resident 16 needed ongoing assessment for mood and cognitive states Resident 16 needed to participate in psychotherapy to address difficulties with paranoia and hallucinations.

A 10/25/23 Lab result indicated Resident 16 had a UTI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 52 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 0658 A 10/30/23 hospital History and Physical revealed Resident 16 was seen for an irregular heart rate which varied from 40 to 200 beats per minute. Past Medical History revealed no diagnosis of schizophrenia. Level of Harm - Minimal harm or Resident 16 was on medications aripiprazole and escitalopram. A psychiatric evaluation revealed mood, potential for actual harm behavior, and thought content were normal.

Residents Affected - Few No documentation was found in Resident 16's clinical records which indicated she/he had a history of schizophrenia.

A Medical Diagnosis report revealed Resident 16 had a diagnosis of schizophrenia with classification 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 52 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 35855 potential for actual harm Based on interview and record review it was determined the facility failed to follow physician orders and Residents Affected - Some monitor for 5 of 14 sampled residents (#s 16, 33, 51, 133, and 134) reviewed for medications, antibiotics, dialysis, and edema. This placed residents at risk for adverse side effects and constipation. Findings include:

1. Resident 16 was admitted to the facility in 2023 with diagnoses including anxiety and depression.

a. A 5/2024 MAR instructed staff to administer metoprolol tartrate (to treat high blood pressure) every 12 hours for heart health and to hold the medication if Resident 16's blood pressure was below 100/60 or heart rate was below 60. On the following days and shifts Resident 16's blood pressure was not within physician ordered parameters and she/he was administered metoprolol: 5/2/24 day shift, 5/4/24 day shift, 5/7/24 evening shift, 5/8/24 evening shift, 5/9/24 day shift, 5/10/24 evening shift, 5/15/24 evening shift, 5/16/24 day shift, 5/17/24 evening shift, 5/18/24 evening shift, 5/19/24 evening shift, 5/23/24 evening shift, 5/26/24 evening shift, and 5/28/24 evening shift.

A 6/2024 MAR instructed staff to administer metoprolol tartrate every 12 hours for heart health and to hold

the medication if Resident 16's blood pressure was below 100/60 or heart rate was below 60. Resident 16's blood pressure was not within physician ordered parameters and she/he was administered metoprolol on the following shifts: 6/2/24 evening shift, 6/3/24 day and evening shift, 6/4/24 day shift, 6/5/24 day shift, 6/8/24 day shift, 6/10/24 day shift, and 6/11/24 evening shift. On evening shift Resident 16 was administered medication when heart rate was below 60 on 6/10/24 and 6/11/24.

A review of Resident 16's Heart Rate report revealed:

Her/his Heart rate was not documented as obtained.

-5/1/24 evening shift.

-5/3/24 evening shift.

-5/5/24 evening shift.

-5/6/24 evening shift.

-5/8/24 day shift.

-5/11/24 day shift.

-5/12/24 evening shift.

-5/14/24 evening shift.

-5/16/24 evening shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 52 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 -5/19/24 day shift.

Level of Harm - Minimal harm or -5/20/24 evening shift. potential for actual harm -5/21/24 evening shift. Residents Affected - Some -5/24/24 evening shift.

-5/26/24 day shift.

-5/27/24 evening shift.

-5/29/24 evening shift.

-5/30/24 evening shift.

-6/1/24 evening shift.

Heart rate below 60 beats per minute.

-6/10/24 at 2:28 PM 59.

-6/11/24 at 2:56 PM 59.

A review of Resident 16's Blood Pressure report revealed:

Her/his blood pressure not documented as obtained.

-5/8/24 day shift.

-5/12/24 evening shift.

-5/16/24 evening shift.

-5/19/24 day shift.

-5/24/24 evening shift.

-5/26/24 day shift

-5/27/24 evening shift.

-5/29/24 evening shift.

-5/31/24 evening shift.

-6/3/24 evening shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 52 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 Her/his blood pressure was documented as below 100/60:

Level of Harm - Minimal harm or -5/2/24 6:21 AM 103/52. potential for actual harm -5/4/24 6:33 AM 98/55. Residents Affected - Some -5/7/24 3:21 PM 107/56.

-5/8/24 3:42 PM 115/56.

-5/9/24 8:42 AM 101/52.

-5/10/24 3:08 PM 116/52.

-5/15/24 3:19 PM 105/55.

-5/16/24 6:55 AM 114/55.

-5/17/24 2:49 PM 105/59.

-5/18/24 2:54 PM 107/57.

-5/19/24 2:35 PM 104/58.

-5/23/24 3:29 PM 101/58.

-5/26/24 3:17 PM 106/47.

-5/28/24 3:28 PM 108/51.

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 if the physician did not specify if one measurement was out of parameter the staff should hold the medication.

b. A 5/2024 MAR instructed staff to administer Furosemide as needed for fluid retention for weight gain of more than two pounds. No medication was administered in 5/2024 no documentation of weights were on the MAR to identify if there was a weight gain.

A review of the Weight Summary report revealed in 5/2024 Resident 16's weight was obtained 12 instances out of 31 opportunities. From 5/4/24 to 5/5/24 Resident went from 152 to 154 a weight gain of two pounds. From 5/25/24 to 5/29/24 Resident 16 went from 150 pounds to 155 pounds a weight gain of five pounds.

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 they would expect daily weights to be completed.

36494

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 52 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 2. Resident 33 was admitted to the facility in 8/2021 with diagnoses including diabetes.

Level of Harm - Minimal harm or A physician order dated 1/16/24, indicated Resident 33 was to receive Senna (a laxative)two tablets two potential for actual harm times daily.

Residents Affected - Some The 5/2024 and 6/2024 MARs indicated Resident 33 did not receive the medication 32 times from 5/1/24 through 6/11/24.

On 6/12/24 at 7:28 PM Staff 18 (LPN) stated Resident 33 refused her/his Senna medication. Staff 18 stated

she recorded refusals in the medical records and after multiple refusals, she would alert the physician. Staff 18 stated she was unsure if she reported Resident 33's refusals.

On 6/13/24 at 10:16 AM Staff 27 (LPN Unit Manager) and Staff 30 (LPN Unit Manager) acknowledged Resident 33 refused her/his Senna medication on multiple occasions. Staff 27 and Staff 30 stated staff were expected to notify the physician after every refusal.

26991

3. Resident 51 was admitted to the facility in 2023 with a diagnosis of cancer.

An Unwitnessed Fall investigation revealed Resident 51 slipped out of bed on 3/14/24. The investigation indicated neurological assessments were initiated.

Progress Notes revealed the following:

-3/14/24 no assessment documented related to a fall

-3/15/24 no assessment related to a fall

-3/16/24 Resident 51 previously fell and reported pain to the wrist and back. Pain medications were effective

-3/18/24 Resident 51 did not have an injury from a previous fall and was able to walk without pain.

Resident 51's clinical record did not contain neurological assessments after the 3/14/24 fall.

On 6/10/24 at 12:25 PM Staff 30 (LPN Resident Care Manager) reviewed Resident 51's chart and acknowledged staff did not monitor the resident after her/his fall.

On 6/11/24 05:09 PM Staff 2 (DNS) stated after a fall staff were to monitor a resident twice a day. A request was made to Staff 2 to provide neurological assessments for Resident 51's fall. No additional information was provided.

Refer to