Mt Angel Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mt Angel Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 19, 2024

  Based on interview and record review the facility failed to prevent an avoidable fall related to fall safety for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of bed and sustained a right shoulder fracture. Findings include: Resident 1 was admitted to the facility in 7/2024 with diagnoses including quadriplegia (paralysis that affects all a person's limbs and body from the neck down) and a Stage 4 (full thickness skin loss) pressure injury. The Admission MDS dated [DATE], revealed Resident 1 was cognitively intact. A care plan dated 7/25/24, revealed Resident 1 was limited in performing ADLs and was encouraged to perform as much of her/his ADLs as their condition allowed. […]

• Actual harm, isolatedF600Apr 3, 2024

  Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 2 sampled residents (#1) reviewed for sexual abuse. This resulted in Resident 1 experiencing psychosocial harm and increased distress. Findings include: Resident 1 was admitted to the facility in 3/2024 with diagnoses including dementia, mood disturbance, anxiety and developmental disorder of speech and language. A 3/22/24 Cognitive Loss and Dementia CAA revealed Resident 1 required one-step cueing for tasks, time to process cues and communication, and 24-hour supervision for safety. Resident 1 required a floor alarm because the resident did not remember to use the call light. […]

• Actual harm, isolatedF686Aug 2, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were appropriately assessed, monitored and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed residents at risk for inaccurate wound assessments and worsening wounds. Resident 18 had a coccyx wound that worsened from Stage 2 to Stage 4. Findings include: 1. Resident 18 was admitted to the facility in 2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/22 initial assessment of Resident 18's Stage 2 sacral pressure injury indicated the wound was 1.2 cm in length and 0.6 cm in width, with epithelial tissue (thin protective layer), well-defined edges, no drainage, no odor and the skin surrounding the wound was dark purple or rusty discoloration. […]

• Actual harm, isolatedF689Aug 2, 2022

  Based on interview and record review it was determined the facility failed to re-evaluate a resident injury after the resident reported additional symptoms for 1 of 4 sampled residents (#3) reviewed for accidents. Resident 3 experienced pain from an undiagnosed leg fracture. Findings include: Resident 3 admitted to the facility in 2016 with diagnoses including right leg fracture, stroke and diabetes. A 1/13/22 Progress Note revealed Resident 3 was found on the floor by staff in the early morning. Resident 3 used the commode without calling for assistance and when attempting to get back in her/his recliner slipped down to the floor and landed on her/his buttocks. […]

• No harm, potential for more than minimal, widespreadF842Sep 22, 2023

  Based on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure resident records were accurate for 1 of 1 facility and for 1 of 2 sampled residents (#466) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate medical records. Findings include: 1. A review of the facility's undated Safeguarding Resident Identifiable Information policy indicated the facility was to adhere to HIPAA (Health Insurance Portability and Accountability Act) compliant practices by placing any printed material with residents' personal or medical information in a secure disposal container to be shredded. […]