Inspection Reports for Secora Rehabilitation of Cascadia
10435 SE Cora Street, Portland, OR 97266, OR, 97266
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
25.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
278% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Aug 12, 2025
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 1, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging the facility failed to provide timely access to medical records for Resident 801 upon oral or written request.
Findings
The facility failed to ensure access to medical records within the required timeframe for Resident 801, resulting in delayed release of requested records over approximately four months. The facility acknowledged omissions and delays in providing requested billing documentation and medical records to the resident and the resident's attorney.
Complaint Details
The complaint was substantiated, involving Resident 801 whose attorney requested medical records on 4/21/25 but did not receive complete records until 7/29/25. Resident 801 also requested records on 7/24/25 and had not received them by the time of the inspection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure access to medical records upon oral or written request within the required timeframe for Resident 801. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Follow-up requests: 8
Days delay: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Acknowledged omissions and delays in providing requested medical records. |
| Staff 10 | Business Office Manager | Acknowledged receiving calls from Resident 801's attorney but did not follow up due to being too busy. |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 4
Aug 1, 2025
Visit Reason
The facility failed to timely provide requested medical records to Resident 801 and failed to comply with medical record request policies. Other deficiencies included failure to ensure residents' rights to access records, and compliance with state administrative rules.
Findings
The facility failed to timely provide requested medical records to Resident 801 and failed to comply with medical record request policies. Other deficiencies included failure to ensure residents' rights to access records, and compliance with state administrative rules.
Deficiencies (4)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0573 - Right to Access/Purchase Copies of Records |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Jun 4, 2025
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Deficiencies: 1
Mar 28, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration policies following a significant medication error involving Resident 35, who did not receive prescribed anticoagulant medication leading to stroke-like symptoms.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically for Resident 35 who missed doses of Rivaroxaban on three consecutive days. This failure resulted in the resident developing stroke-like symptoms and requiring hospital transfer. Staff responsible for the error were identified and terminated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer prescribed Rivaroxaban medication to Resident 35 on 4/14/24, 4/15/24, and 4/16/24, resulting in stroke-like symptoms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 6
Residents affected: 1
Missed medication doses: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 29 | Former Administrator | Completed facility investigation of medication error |
| Staff 30 | LPN | Failed to administer medication to Resident 35 and did not notify staff or providers; terminated due to incident |
| Staff 31 | RN, Former DNS | Sent Resident 35 to hospital emergency department and acknowledged Staff 30's failure |
| Staff 4 | DNS | Reported on medication error and failure to follow protocol |
Inspection Report
Annual Inspection
Deficiencies: 12
Mar 28, 2025
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements across multiple areas including medication administration, advance directives, environment, activities, pressure ulcer care, staffing, behavioral health, food safety, and staff training.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to assist residents in formulating advance directives, unclean environment due to dirty floor vents, inadequate shower assistance for dependent residents, failure to implement activity care plans, incomplete pressure ulcer assessments and care, inaccurate nurse staffing postings, failure to provide necessary behavioral health care and comprehensive care plans, dishwasher temperatures below required sanitization levels, incomplete CNA annual performance reviews, and insufficient CNA in-service training hours.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Potential for minimal harm: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure residents were assessed for safe self-administration of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist residents to formulate an advance directive. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean and homelike environment due to dirty air intake floor vents. | Level of Harm - Potential for minimal harm |
| Failed to ensure dependent residents received showers as scheduled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an activity care plan and include residents in activities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pressure injury wounds were comprehensively assessed and care plans followed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure CNAs received annual performance reviews. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Direct Care Staff Daily Report postings were accurate. | Level of Harm - Potential for minimal harm |
| Failed to provide necessary behavioral health care and develop comprehensive behavioral health care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dishwasher temperatures met minimum sanitization requirements. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were fully informed and understood binding arbitration agreements. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure CNA staff received 12 hours of annual in-service training. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days with inaccurate nurse staffing postings: 13
Annual training hours for Staff 9 (CNA): 7.5
Annual training hours for Staff 18 (CNA): 1.5
Dishwasher water temperature: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 11 | CMA | Stated self-administration medication assessment needed before allowing resident to self-administer medications |
| Staff 10 | CNA | Confirmed medications should not be left at bedside and observed medications within resident's reach |
| Staff 4 | DNS (Director of Nursing Services) | Confirmed resident was not assessed to safely self-medicate and expected showers twice a week |
| Staff 5 | Social Services Director | Discussed advance directives with resident but no follow-up occurred |
| Staff 7 | Activities Director | Failed to invite resident to group activities and acknowledged struggling with non-verbal residents |
| Staff 6 | LPN-Care Manager | Stated residents should receive at least two showers a week and CNA staff should make-up missed showers |
| Staff 8 | RN | Found pressure injury and contacted hospice |
| Staff 12 | CNA | Acknowledged not off-loading resident's heel and described resident's behavioral outbursts |
| Staff 13 | CNA | Acknowledged not off-loading resident's heel and described resident's behavioral outbursts |
| Staff 20 | Human Resources | Confirmed CNA staff had not received annual performance review |
| Staff 23 | Staffing Coordinator | Verified nurse staffing reports were inaccurate or incomplete |
| Staff 26 | Dietary Manager | Confirmed dishwasher water temperature did not meet minimum requirements |
| Staff 2 | Administrator-In-Training | Confirmed arbitration agreements had inaccurate rescind timeframe |
| Staff 3 | Clinical Resource | Provided list of CNA annual training hours |
| Staff 10 | CNA | Observed resident's heels not offloaded and described resident's behavioral symptoms |
| Staff 4 | Director of Nursing Services | Expected staff to follow care plans and monitor behavioral health |
| Staff 5 | Social Service Director | Stated no behavior monitoring or care plan interventions for resident's behavioral symptoms |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 17
Mar 28, 2025
Visit Reason
Multiple deficiencies including failure to assess residents for safe self-administration of medications, failure to assist residents with advance directives, failure to maintain a clean environment, failure to provide adequate ADL care, failure to implement activity care plans, failure to prevent and treat pressure ulcers, failure to provide annual CNA performance reviews, failure to post accurate nurse staffing information, failure to provide behavioral health services, failure to prevent medication errors, failure to maintain sanitary food procurement and preparation, failure to inform residents about binding arbitration agreements, and failure to provide required in-service training for nurse aides.
Findings
Multiple deficiencies including failure to assess residents for safe self-administration of medications, failure to assist residents with advance directives, failure to maintain a clean environment, failure to provide adequate ADL care, failure to implement activity care plans, failure to prevent and treat pressure ulcers, failure to provide annual CNA performance reviews, failure to post accurate nurse staffing information, failure to provide behavioral health services, failure to prevent medication errors, failure to maintain sanitary food procurement and preparation, failure to inform residents about binding arbitration agreements, and failure to provide required in-service training for nurse aides.
Deficiencies (17)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0554 - Resident Self-Admin Meds-Clinically Approp |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir |
| F0584 - Safe/Clean/Comfortable/Homelike Environment |
| F0677 - ADL Care Provided for Dependent Residents |
| F0679 - Activities Meet Interest/Needs Each Resident |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service |
| F0732 - Posted Nurse Staffing Information |
| F0740 - Behavioral Health Services |
| F0760 - Residents are Free of Significant Med Errors |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| F0847 - Entering into Binding Arbitration Agreements |
| F0947 - Required In-Service Training for Nurse Aides |
| M0000 - Initial Comments |
| M0143 - Employees: Criminal Record Checks |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Mar 7, 2025
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Feb 26, 2025
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 19, 2024
Visit Reason
The inspection was conducted following complaints regarding improper use of physical restraints on a resident and failure to provide timely pain management medication to another resident.
Findings
The facility failed to ensure residents were free from physical restraints, specifically tying a gait belt to a wheelchair for Resident 7, and failed to provide timely pain medication (morphine) to Resident 3, resulting in increased risk of mistreatment and unmanaged pain.
Complaint Details
The investigation was complaint-driven, focusing on allegations of improper restraint use on Resident 7 and failure to provide pain medication to Resident 3. Resident 7 was found to have a gait belt tied to the wheelchair, and Resident 3 did not receive morphine on 10/24/23 due to medication unavailability and lack of alternative dispensing efforts. Staff 11 was suspended for the restraint incident. The complaint was substantiated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents were free from physical restraints, specifically tying a gait belt to Resident 7's wheelchair. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely pain management medication (morphine) to Resident 3 as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for restraint review: 3
Residents sampled for abuse review: 3
Date of morphine administration delay: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 11 | Certified Nursing Assistant (CNA) | Tied Resident 7's gait belt to wheelchair, suspended after investigation |
| Staff 3 | Resident Care Manager (RCM) | Observed restraint on Resident 7 and confirmed findings |
| Staff 4 | Resident Care Manager (RCM) | Administered morphine to Resident 3 and confirmed medication delay |
| Staff 5 | Licensed Practical Nurse (LPN) | Completed resident assessments and explained medication dispensing procedures |
| Staff 1 | Administrator | Advised of investigative findings |
| Staff 2 | Director of Nursing Services (DNS) | Advised of investigative findings |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 5
Sep 19, 2024
Visit Reason
Deficiencies included failure to ensure residents were free from physical restraints and failure to provide adequate pain management. Some deficiencies were corrected upon revisit while others remained uncorrected.
Findings
Deficiencies included failure to ensure residents were free from physical restraints and failure to provide adequate pain management. Some deficiencies were corrected upon revisit while others remained uncorrected.
Deficiencies (5)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0604 - Right to be Free from Physical Restraints |
| F0697 - Pain Management |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Aug 2, 2024
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Apr 30, 2024
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Capacity: 53
Deficiencies: 1
Mar 11, 2024
Visit Reason
The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.
Findings
The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.
Deficiencies (1)
| Description |
|---|
| F0884 - Reporting - National Health Safety Network |
Inspection Report
Annual Inspection
Deficiencies: 15
Nov 17, 2023
Visit Reason
The inspection was conducted as part of a comprehensive annual survey of Secora Rehabilitation of Cascadia to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs related to lighting, failure to provide requested menus, lack of privacy for resident council meetings, failure to post survey results, incomplete advance directive assistance, unclean environment and equipment, incomplete background checks for new hires, inaccurate resident assessments, incomplete care plans, inadequate discharge planning and summaries, unmet ADL needs, safety hazards accessible to residents, failure to prevent feeding tube complications, and lack of physician orders for respiratory care equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Potential for minimal harm: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure resident needs and preferences related to lighting were accommodated for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a menu as requested for 1 sampled resident, placing resident at risk for decreased food intake and lack of choices. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a private space for resident council meetings, placing residents at risk for unaddressed concerns. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post notice of availability of previous year's survey results in prominent areas of the facility. | Level of Harm - Potential for minimal harm |
| Failed to assist residents with formulating advance directives for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a clean and homelike environment, including unclean wheelchairs and facility maintenance issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement abuse policy and procedure to screen new hires for background checks for 5 staff members. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess weight gain and vision for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a person-centered care plan for 1 sampled resident related to accident prevention. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement discharge planning for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate grooming and toenail care for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain physician order and develop care plan for use of oral suction machine for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing person-centered activities program for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow up timely on pharmacist recommendations for unnecessary medications for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Staff affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Acknowledged multiple deficiencies including lighting, menu provision, privacy, environment, discharge planning, activities, and safety hazards |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged deficiencies in assessments, care plans, discharge planning, grooming, respiratory care, and pharmacist follow-up |
| Staff 3 | Human Resources | Acknowledged failure to complete criminal background checks for new hires |
| Staff 9 | Activities Director | Provided information on activities program and acknowledged gaps in one-to-one visits |
| Staff 10 | Social Services Director | Acknowledged deficiencies in advance directive assistance, discharge planning, and safety supervision |
| Staff 15 | Certified Nursing Assistant (CNA) | Provided information on menu delivery, shaving assistance, and resident preferences |
| Staff 16 | Licensed Practical Nurse (LPN) | Acknowledged deficiencies in menu delivery, shaving assistance, and respiratory care orders |
| Staff 20 | MDS Coordinator | Acknowledged inaccurate resident assessments |
Inspection Report
Annual Inspection
Deficiencies: 18
Nov 17, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident care, safety, activities, and medication management.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs related to lighting, failure to provide menus upon request, lack of privacy for resident council meetings, failure to post survey results, incomplete advance directive assistance, unclean environment and wheelchairs, incomplete background checks for new hires, inaccurate resident assessments, incomplete and inaccurate care plans, inadequate discharge planning and summaries, unmet ADL needs including grooming and shaving, failure to provide adequate activities, unsafe access to hazardous items, failure to prevent feeding tube complications, and lack of physician orders for respiratory care equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Level of Harm - Potential for minimal harm: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to ensure resident needs and preferences related to lighting were accommodated for 3 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a menu as requested for 1 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post notice of the availability of the previous year's survey results in prominent areas for 1 of 1 facility reviewed. | Level of Harm - Potential for minimal harm |
| Failed to assist residents with formulating an advance directive for 3 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a clean and homelike environment including clean wheelchairs and maintenance of facility environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement abuse policy and procedure to screen new hires for 5 of 5 staff reviewed for background checks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess weight gain and vision for 2 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a person-centered care plan for 1 of 1 sampled resident reviewed for accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure comprehensive, person-centered care plans were revised for 2 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure discharge planning was developed and implemented for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate grooming and toenail care for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete documentation of shaving refusals or care plan reflecting personal hygiene preferences for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safety hazards were not accessible in a resident bathroom for 2 halls reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent complications of tube feeding for 1 of 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a physician order and develop a care plan for the use of an oral suction machine for 1 of 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow up timely on pharmacist recommendations for 1 of 5 sampled residents reviewed for unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Acknowledged findings on lighting, menu provision, privacy, environment, discharge planning, activities, safety hazards |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged findings on wheelchair cleanliness, inaccurate assessments, care plan revisions, discharge planning, grooming, shaving, oral suction machine, pharmacist follow-up |
| Staff 3 | Human Resources | Acknowledged missing criminal background checks for new hires |
| Staff 9 | Activities Director | Provided information on activities program and acknowledged gaps in one-to-one visits |
| Staff 10 | Social Services Director | Acknowledged missing advance directive assistance, discharge planning, and safety concerns |
| Staff 14 | CNA | Observed care plan noncompliance for fall mat |
| Staff 15 | CNA | Provided information on menu delivery, shaving, and resident preferences |
| Staff 16 | LPN | Provided information on menu delivery, shaving, and oral suction machine use |
| Staff 20 | MDS Coordinator | Acknowledged inaccurate weight and vision assessments |
| Staff 21 | CNA | Provided information on wheelchair cleaning |
| Staff 22 | Housekeeping | Acknowledged dirty floor vents and lack of housekeeping manager |
| Staff 4 | CNA | Provided information on resident shaving and activity participation |
| Staff 11 | Agency CNA | Reported no instruction to deliver menus |
| Staff 17 | Dietary Manager | Provided information on menu posting and delivery |
| Staff 7 | Maintenance Director | Acknowledged lighting cord extension issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration for residents.
Findings
The facility failed to provide medication as ordered for 1 of 3 sampled residents reviewed for medication administration, specifically Resident 3 who did not receive a scheduled Stelara injection on 5/25/23, resulting in potential increased abdominal pain risk.
Complaint Details
The visit was complaint-related, confirming that Resident 3 did not receive a Stelara injection as scheduled on 5/25/23 and no follow-up on the missed medication was done until early July when it was discovered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide medication as ordered for Resident 3, missing a scheduled Stelara injection on 5/25/23. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for medication administration: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 7 | LPN | Reported Stelara was not administered on 5/25/23 due to medication being on order from pharmacy |
| Staff 3 | RNCM | Confirmed Resident 3 did not receive Stelara injection on 5/25/23 and no follow-up was done |
Inspection Report
Routine
Deficiencies: 12
Oct 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, advance directives, environment, resident transfers, activities, medication orders, mobility, respiratory care, staffing, nutrition, food sanitation, and waste disposal.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to discuss advance directives with residents, poor maintenance of the building environment, inadequate preparation for resident transfers, failure to include residents in activities, failure to follow physician orders for medications and splint use, improper maintenance of respiratory equipment, insufficient RN staffing coverage, failure to provide adaptive dining equipment, potential contamination risk from the ice machine, and improper garbage disposal.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure residents were assessed for safe self-administration of medications for 3 sampled residents, resulting in medications being left unattended at bedside without proper assessment, physician orders, or lock box. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain, request, and review copies of advance directives or discuss advance directives with residents for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain the building in good repair for 3 resident rooms and 1 main lobby area, including broken window blinds, ripped chairs, and dirty flooring. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document evidence of sufficient preparation and orientation for safe and orderly transfer of 1 resident to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to invite and include 1 resident to activities events, resulting in risk for social isolation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders were followed for notification of high blood sugars for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders for splint devices were implemented for 1 resident, with discrepancies in orders and care plans and inconsistent splint use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure respiratory equipment was properly maintained for 1 resident, including dirty nasal cannula and missing humidifier bottle despite orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to use the services of a registered nurse for eight consecutive hours per day for 16 of 30 days reviewed for staffing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement appropriate adaptive dining equipment (scoop plate) for 1 resident, resulting in difficulty eating and food spillage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent potential contamination of the ice machine due to lack of an air gap between the sewage system and the drain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure waste was properly contained and garbage storage areas maintained in a sanitary condition, with discarded items and food remnants outside the kitchen door. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days with no RN coverage: 16
Blood sugar readings not reported: 4
Residents affected: 3
Residents affected: 2
Resident rooms with building deficiencies: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing (DNS) | Notified of medication self-administration findings, transfer preparation deficiency, RN staffing coverage issue, and activity inclusion findings |
| Staff 3 | RN Care Manager (RNCM) | Reported medication self-administration process, confirmed lack of physician notification for blood sugars, acknowledged splint order discrepancies, and respiratory care expectations |
| Staff 4 | Licensed Practical Nurse (LPN) | Reported medication administration policies, confirmed blood sugar testing without physician notification |
| Staff 5 | Licensed Practical Nurse (LPN) | Observed medication administration, respiratory care deficiencies, and provided statements on Resident 38 and Resident 15 care |
| Staff 8 | Social Services | Confirmed advance directive procedures and lack of discussion with residents |
| Staff 10 | Certified Nursing Assistant (CNA) | Reported Resident 35's medication storage habits |
| Staff 12 | Registered Nurse (RN) | Administered medication to Resident 39 and discovered pills in resident's hands |
| Staff 13 | Certified Nursing Assistant/Resident Assistant (CNA/RA) | Responsible for Resident 15 splint application and Resident 38 care |
| Staff 14 | Certified Nursing Assistant (CNA) | Responsible for Resident 38 care and meal preparation assistance |
| Staff 15 | Activity Director | Invited residents to activities, did not invite Resident 38 to live singer/piano event |
| Staff 16 | Certified Nursing Assistant (CNA) | Responsible for encouraging Resident 15 to wear splint |
| Staff 17 | Registered Nurse (RN) | Failed to complete respiratory equipment maintenance tasks on two Sundays |
| Staff 1 | Administrator | Verified environmental deficiencies, acknowledged garbage disposal issues, and ice machine contamination risk |
| Staff 7 | Kitchen Manager | Acknowledged diet slip requirements and garbage disposal practices |
| Staff 9 | Maintenance Director | Reported plans to dispose of discarded items outside kitchen door |
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