Pilot Butte Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pilot Butte Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 9, 2024

  Based on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This failure was determined to be an immediate jeopardy situation due to the facility failed to follow the Resident 1's care plan and provide adequate supervision, which resulted in Resident 1's elopement from the facility. Findings include: Resident 1 admitted to the facility on ,d+[DATE] for a 5-day respite stay with diagnoses including Alzheimer's Disease, dementia, anxiety disorder and restlessness. On 9/5/24 at 11:53 AM, Witness 1 (Family) stated on 8/15/24 she was notified Resident 1 was found in the middle of a roundabout, confused and carrying a teddy bear by a local law enforcement officer. […]

• Actual harm, isolatedF686Feb 25, 2023

  Based on observation, interview and record review it was determined the facility failed to follow physician orders and provide care and services to promote the healing of pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a facility acquired unstageable pressure ulcer. Findings include: Resident 1 was admitted to the facility in 2017 with diagnoses including paraplegia (paralysis of the lower body) and a Stage IV (a deep wound that reaches bone, ligaments or muscles) pressure ulcer of the sacral region (region between the bottom on the spine and the tailbone). a. A 9/7/21 physician order indicated to float Resident 1's heels and apply soft boots to both lower extremities at all times. […]

• No harm, potential for more than minimal, widespreadF658Feb 25, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure professional standards were followed related to proper infection control techniques for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Registered Nurses: * Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards: * Be accountable for individual RN actions, maintain competency in one's RN practice role and ensure unsafe nursing practices are addressed immediately. 1. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2023

  Based on observation, interview and record review the facility failed to utilize hygienic practices when handling food, ensure temperature logs were completed for the dishwasher and ensure a cleaning schedule was followed for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include: 1. On 2/20/23 at 8:19 AM Staff 28 (Cook) was in the kitchen at the steam table without a hairnet in place. Staff 28 stated she just got back from break and did not replace her hairnet. On 2/22/23 at 11:10 AM Staff 28 was observed preparing for lunch in the kitchen without a hairnet in place. On 2/22/23 at 11:39 AM Staff 26 (Dietary Manager) entered the kitchen, put on gloves and began to dish out cake. Staff 26 was asked if he washed his hands and he stated he did not. […]

• No harm, potential for more than minimal, widespreadF880Feb 25, 2023

  1. Based on observation, interview and record review it was determined the facility failed to follow proper infection control practices for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: a. Resident 1 was admitted to the facility in 2022 with diagnoses including paraplegia (paralysis of the lower body). On 2/23/23 at 3:04 PM Staff 12 (RN) was observed to perform a dressing change on Resident 1. […]