North Bend Post Acute

In the surveyor’s words

From the most serious findings on record at North Bend Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 12, 2023

  Based on observation, interview, and record review the facility failed to ensure 1 of 1 resident (Resident 43) reviewed for bowel management, 1 of 1 resident (Resident 4) reviewed for Diabetes (unstable blood sugar levels) management, and 1 of 4 residents (Residents 41) reviewed for non-pressure skin management received necessary care and services in accordance with professional standards of practice for quality of care. Resident 43 experienced harm when they were administered a daily laxative incongruent with prescribing provider order, did not receive antidiarrheal medications for prolonged diarrhea, did not have a stool sample obtained for laboratory evaluation or specialized diet initiated per standing orders which resulted in daily watery stools with increased, persistent discomfort… […]

• Actual harm, isolatedF600Oct 4, 2023

  Based on interview and record review, the facility failed to consistently implement care planned safety interventions for 2 of 3 residents (Residents 1 & 9) who exhibited aggressive behaviors to ensure the care planned behaviors did not escalate to verbal, physical or psychological abuse for 4 of 4 residents (Resident 7, 12, 2, 10), and the facility failed to protect 3 of 3 residents (Resident 6, 7, & 8) from potential abuse when they did not immediately remove (Staff E) from providing care to all residents after allegations of abuse and neglected were reported. […]

• Actual harm, isolatedF689Oct 4, 2023

  Based on interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents for resident-to-resident altercations and falls for 4 of 4 (Residents 1, 3, 9, 15) residents reviewed for accidents, hazards, and supervision. The lack of supervision and implementation of safety measures to prevent resident-to-resident altercations allowed Resident 1 and Resident 9 to initiate verbal and physical altercations with multiple residents and caused physical harm to one resident (Resident 2) when they were slapped in the forearm. […]

• Actual harm, isolatedF699Oct 4, 2023

  Based on observation, interview and record review, the facility failed to ensure that resident's who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying, monitoring, or treating past experiences of Post-Traumatic Stress Disorder (PTSD - a disorder that develop when a person had experienced or witnessed a scary, shocking, terrifying, or dangerous event) for 3 of 3 residents (Residents 13, 12, & 14) reviewed for mood and behavior. […]

• Actual harm, isolatedF684Apr 28, 2023

  Based on observation, interview, and record review the facility failed to obtain Physician Orders (PO) for wound care to include assessment, monitoring, and treatment, and to notify the physician timely of changes in wound condition for 3 of 3 residents (Resident 1, 2, and 3) reviewed for surgical incision wounds. This failure resulted in harm to Resident 1 who experienced bleeding and a surgical incision dehiscence (a separation of the wound edges) and to clarify conflicting wound care POs for Resident 3 related to removal of sutures which resulted in a delay of treatment for 7 days, and placed all other residents at risk of delayed wound care, increased pain, and diminished quality of life. […]