La Grande Post Acute Rehab

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure kitchen equipment was clean and sanitary, and dishes were adequately cleaned for 1 of 1 kitchen reviewed. This placed residents at risk of illness and contaminated food.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive and periodically follow up on preferences for 2 of 2 sampled residents (#s 7 and 19) reviewed for advance directives.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents with Serious Mental Illness (SMI) diagnoses had PASRR (pre-admission screening/resident review) level II referrals for 1 of 1 resident (# 5) reviewed for PASRR level II screening. This placed residents at risk for unmet mental health needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and service related to hospice and comfort care and follow physician orders for 2 of 6 sampled residents (#s17 and 33) reviewed for change of condition and medications. This placed residents at risk for unmanaged symptoms, decreased comfort during end-of-life care and adverse side effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 1 sampled residents (#33) reviewed for catheter care. This placed residents at risk for inadequate catheter management and related complications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure recommendations from dialysis were followed up on and ensure residents' medications were scheduled to avoid missed doses for 1 of 1 sampled resident (#7) reviewed for dialysis. This placed residents at risk for delayed treatment.

Inspectors wroteF699: Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 1 sampled resident (#5) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary hypoglycemic medications for 1 of 5 sampled residents (#3) reviewed for unnecessary medications. This placed residents at risk for complications related to low blood sugars.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were complete and accurately documented for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for inaccurate health records.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement antibiotic stewardship practices for 1 of 1 sampled resident (#5) reviewed for antibiotics. This placed residents at risk for adverse medication effects, inappropriate antibiotic use and potential for development of antibiotic resistance.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure appropriate catheter care and treatment was provided in accordance with professional standards of care for 1 of 3 sampled residents (#3) reviewed for catheters. This placed residents at risk for improper catheter care.

Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 (#1) sampled residents reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement the plan of care for 1 of 3 sampled residents (#2) reviewed for care plans. This placed residents at risk of abuse.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain hygienic conditions in the facility's walk-in freezer and failed to store food in a hygienic manner in the freezer and dry storage rooms to maintain freshness and prevent the spread of food-borne illness in 1 of 1 kitchen reviewed for food storage. This placed residents at risk of food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a system of accurate reconciliation to account for controlled drugs for 1 of 2 sampled medications carts reviewed for medication storage. This placed residents at risk for misappropriation and misplacement of controlled drugs.

Inspectors wroteStaBased on observation, interview and record review it was determined the facility failed to ensure drugs and biologicals were secure for 1 of 1 treatment cart and stored under proper temperatures for 1 of 1 medication refrigerator reviewed for medication storage. This placed residents at risk for misappropriation and reduced medication efficacy.

Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents (#s 7 and 10) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accommodate residents with wheelchair arm rests in safe and proper cleanable order for 1 of 2 sampled residents (#86) reviewed for environment. This placed residents at risk for lack of a clean, safe homelike environment and personal equipment in disrepair.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow bowel care physician orders for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for constipation care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facilities reviewed for infection control. This placed residents at risk for unnecessary and/or prolonged use of antibiotic medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a clean, homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an environment that was not homelike.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consent was obtained prior to administering psychotropic medications to residents for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for being uninformed about their medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications for 1 of 7 sampled residents (#10) reviewed for medication administration. This placed residents at risk for unsafe medication administration.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive assessment in activites for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unidentified care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 5 sampled residents (#11) reviewed for unnecessary medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unmet psychosocial needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 residents (#22) reviewed for accidents. This placed the residents at risk for potential accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to identify, assess and monitor weight loss for 1 of 4 sampled residents (#11) reviewed for nutrition. This placed residents at risk for unidentified weight changes.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained and used as ordered for 1 of 2 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for discomfort.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure safe and secure storage of medicated powder for 1 of 2 sampled residents (#15) reviewed for skin conditions. This placed residents at risk for receiving incorrect medication and treatment.

Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control practices during medication administration for 4 of 5 sampled residents (#s 10, 17, 23 and 131) observed for medication administration. This placed residents at risk for spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure reisdent rooms were designed and equipped for adequate privacy for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for lack of priviacy and dignity.