Pendleton Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Pendleton Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Jun 17, 2022

  Based on clinical record review, facility documentation, facility policy, and interviews, for one (1) of three (3) residents for reviewed for allegations of abuse, (Resident #1), the facility failed to implement their abuse policy following an allegation of abuse, the Nurse Aide was allowed to work on another unit taking care of other residents although the policy directed to suspend immediately. In addition, the same NA returned to work following the facilities investigation despite an active police investigation with pending charges including abuse against an elderly person. As a result, Immediate Jeopardy was identified on 5/26/22. The facility submitted an immediate action plan that addressed failures to follow the abuse policy. […]

• Actual harm, isolatedF760Mar 30, 2021

  Based on clinical record review, facility documentation review and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed to ensure a resident was free from a significant medication error that resulted in a hospitalization and a surgical procedure. The findings include: Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 3/19/2021 and updated 3/20/2021 directed to administer [MEDICATION(S)] 40 milligrams (mg) daily for 14 days for [CONDITION(S)] (DVT) prophylaxis and then to resume Resident #1's home dose of [MEDICATION(S)]. The report further identified Resident #1's oxygen level was 94%. […]

• No harm, potential for more than minimal, patternF761Dec 1, 2022

  Based on observations and interviews, the facility failed to ensure medications were stored in a safe manner. The findings include: 1. Observations on 11/30/2022 at 10:05 AM identified the nurse's station on 2B identified 24 cards of medications left unattended on the nurse's station desk without the presence of a licensed staff. Further observation identified there was no barriers preventing access to the nurse's station desk area and no residents were noted near the nurse's station where the medication cards were left unattended. On 11/30/2022 at 10:10 AM (five minutes later) RN#2 came to the nursing station and sat down at the desk in front of the 24 medication cards. […]

• No harm, potential for more than minimal, patternF812Dec 1, 2022

  Based on observations of the kitchen, review of policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent the spread of infection. The findings included: An observation of the kitchen on 11/28/22 at 10:20 AM identified the following: 1. Moderate amount gray matter buildup on knife holder. 2. Large amount of brown and gray matter buildup on the top of the utensil rack. 3. Moderate amount of dried brown spillage, green and orange crumb like debris, concentrated around the legs of the counters 4 bag ties under the food prep counter across from stove and center counter. 4. […]

• No harm, potential for more than minimal, patternF921Dec 1, 2022

  Based on environmental observations and interviews for 6 of 7 residents reviewed for environment for (Residents # 2, # 4 and # 8, # 30 # 47 and # 63) bathrooms., the facility failed to maintain residents personal care items in a safe, sanitary, manner. The findings included: An in-service report titled Monthly N.A. Meeting dated 8/14/2022 identified under N.A. Responsibilities notes bedpans should be kept in a bag in the bathroom, labeled and not on the toilet or on the bathroom floor and basins should be labeled and placed in the bedside table of the resident it belongs to. Observations on 11/28/2022 at 10:30 AM of Residents #4 and #8 bathroom identified a urine leg bag without a label, draped over a towel rail with a small amount of urine within public view. […]