Caldwell Care of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure services provided met accepted professional standards of clinical practice This was true for 2 of 6 residents (#47 and #56) who were observed during medication administration and for 1 of 1 resident (Resident #3) who received hemodialysis services. These failures placed Resident's #47 and #56 at risk for harm when their medications were not administered appropriately, and placed Resident #3 at risk for harm when staff took his blood pressure on the arm with his hemodialysis access. Findings include: 1. Lippincott's Nursing 2026 webpage titled, Protecting a Hemodialysis Fistula; Clinical Do's and Don'ts, accessed 3/4/26, documented, do not take blood pressure readings on the access arm as it could contribute to clotting in the fistula, and do not put any excessive pressure on the access arm. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal (kidney) disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, it was determined the facility failed to implement and follow resident centered comprehensive care plan interventions and physician ordered treatments for 3 of 16 residents (Residents #9, #47, and #64) reviewed for quality of care. The facility failed to apply physician ordered interventions for Resident #47, failed to implement fall prevention interventions for Resident #64, and failed to complete reassessment of blood pressures for Resident #9. These failures created the potential for harm when required care plan interventions, treatments, and reassessments were not carried out. Findings include:1. Resident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care. A review of Resident #64's care plan, revised 3/19/26, documented she required one person assistance for ambulation and transfers. The care plan also directed staff to monitor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to prevent a fall when a fall intervention was not updated in the resident's care plan. This was true for 1 of 5 residents (Resident #5) reviewed for accident prevention. This deficient practice created the potential for harm when Resident #5 fell from her wheelchair when she was left unsupervised in the dining room. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.On 12/1/25, a fall investigation report documented Resident #5 fell from her wheelchair while unattended in the dining room. The IDT investigation documented, to avoid future falls, Resident #5 was always to be supervised while in the dining room.On 1/26/26, a fall investigation report documented Resident #5 fell from her wheelchair on 1/23/26 when a staff member left her in the dining room unsupervised.A review of Resident #5's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, pharmacy review, and staff interview, it was determined the facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for 1 of 5 residents (Resident #38) reviewed for psychoactive medication monitoring. This created the potential for side effects to go undetected when the facility did not complete a current AIMS (an abnormal involuntary movement scale) or DISCUS (dyskinesia identification system condensed user scale) assessment as recommended by the consulting pharmacist. Findings include:Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury.Resident #38's care plan directed staff to monitor and report side effects and adverse reactions related to psychoactive medications.A physician order dated 7/22/25 documented:Seroquel (an antipsychotic medication) 300 mg by mouth once daily for traumatic brain injury.A pharmacy review dated 1/26/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents receiving anticonvulsant medications were monitored for potential side effects as required by their comprehensive person-centered care plans. This was true for 2 of 5 residents (#34 and #41) whose records were reviewed for unnecessary medications. This failure created the potential for harm if side effects were undetected. Findings include:1. Resident #34 was admitted on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.Resident #34's record included a physician order for Depakote (an anticonvulsant) sprinkles delayed release capsule 250 mg by mouth three times a day for alcohol dependence.Resident #34's care plan revised 8/6/25, directed staff to monitor, notify the provider and document side effects for anticonvulsants such as:Over-sedation or lethargyRestless agitationIncreased confusion or poor concentrationMental status changeVisual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined the facility failed to ensure expired medications were removed from the medication storage room and not available for administration to residents. This was true for 1 of 1 medication room observed. This failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy. Findings include:On 3/4/26 at 1:14 PM, during the inspection of the Medication Storage Room with the ADON, five acetaminophen suppositories which expired on 10/2025 were found inside the refrigerator. The ADON stated the acetaminophen suppositories were expired and should not be kept in the refrigerator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure its Antibiotic Stewardship practices were followed by initiating antibiotic therapy without obtaining culture and sensitivity results to guide appropriate treatment. This was true for 1 of 1 residents (Resident #64) reviewed for antibiotic stewardship. This failure created the potential for inappropriate antibiotic use and development of antibiotic resistant organisms. Findings include:The facility's Antibiotic Stewardship Policy, revised 8/10/25, documented the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program to ensure appropriate antibiotic usage, promote therapeutic and cost effective care, and reduce the likelihood of developing multi drug resistant organisms. The policy also documented the facility utilizes McGeer's Criteria to validate infections and routinely reviews culture and sensitivity reports as part of infection surveillance.The Revised McGeer's Criteria…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 consecutive hours per day, 7 days a week. This was true for 1 of 38 days reviewed for RN staffing coverage. The failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all residents living in the facility. Findings include: Licensed Nurse time punches for 9/1/24 to 10/8/24, documented the facility did not have an RN on duty for 8 consecutive hours on 9/1/24. On 10/10/24 at 5:15 PM, the CRN and DON stated on 9/1/24, the RN was covered by an LPN and confirmed there was not an RN for 8 consecutive hours that day.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect the 59 residents who received meals in the dining room and eat snacks that had been stored in the snack refrigerators. This placed residents at risk for the potential for consuming contaminated and spoiled foods, and adverse health outcomes related to food-borne illnesses. Findings include: Review of the Idaho Food Code, revised February 2021, stated,. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Facility Food and Supply Storage policy dated 11/28/17, documented, For food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure 2 of 5 resident's (#32 and #47) records reviewed for oxygen use had complete orders, and 2 of 2 residents (#5 and #47) were using oxygen per physician orders. This created the potential for residents to experience harm, respiratory difficulties, and adverse outcomes. Findings include: Facility Oxygen Therapy policy, revised 8/4/23, directed staff to verify physician orders prior to initiating oxygen therapy. 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including panic disorder and dementia. On 10/8/24 at 2:34 PM, it was observed Resident #5 had been transferred into bed without his oxygen nasal cannula in place. On 10/8/24 at 3:01 PM, CNA #4 stated Resident #5 should be using the oxygen at all times, but CNA #3 had forgot to put it back on him. A physician's order, dated 8/4/23, for oxygen at 2 liters per minute, via nasal cannula, to help maintain Resident #5 adequate oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure residents received a written notice prior to a change in their room for 1 of 1 resident (Resident #110) who was reviewed for a room change. This resulted in a lack of information being provided to a resident necessary to make an informed decision. Findings include: Resident #110 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD (lung diseases that block airflow and make it difficult to breathe), and diabetes. Resident #110's record included documentation that on 1/3/24, she was transferred from her single-bed room to a 4-bed room. Resident #110's record did not include documentation she was provided with written notice prior to the room change. During an interview on 10/11/24 at 9:30 AM, the CRN reviewed Resident #110's record and confirmed there was no documentation to confirm Resident #110 had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment. This was true for 1 of 3 shower rooms observed. This deficient practice created the potential for diminished quality of life for all residents that use the east shower room. Findings include: On 10/8/24 at 9:22 AM, observed paint peeling away from the ceiling in various areas in the east shower room. On 10/8/24 at 9:25 AM, CNA #2 stated she noticed the paint had started peeling a few months ago. The facility maintenance work orders were reviewed for the last 6 months. There was no work order for the peeling paint found. On 10/8/24 at 3:30 PM, the Maintenance Director stated he was not aware of the paint peeling in the east hall shower room and that it needed to be fixed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse. This was true for 1 of 6 residents (Resident #32) reviewed for abuse. This failure placed all residents at risk of ongoing abuse, potential physical, and psychosocial harm. Findings include: Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including, hemiplegia (paralysis of one side of the body) and end stage renal disease (a chronic kidney disease that has reached its final, permanent stage). Resident #111 was admitted to the facility on [DATE] with multiple diagnoses including dementia and hypertension. A facility reported incident investigation, initiated 3/9/24, documented Resident #111 walked up behind Resident #32 and put him in a choke hold, stating he was going to kill him. Resident #111 was pulled away from Resident #32 by nursing staff. Resident #32 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 4 residents (Resident #110) reviewed for hospitalizations. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed at the facility within a specified time. Findings include: Resident #110 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD (lung diseases that block airflow and make it difficult to breathe), and diabetes. Resident #110's record included documentation she was transferred to the hospital on 1/21/24, for evaluation and treatment of worsening respiratory symptoms. Her record did not include documentation she was provided with a bed-hold notice. During an interview on 10/11/24 at 10:24 AM, the DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 2 of 4 residents (#42 and #46) reviewed for Pre-admission Screening and Resident Review (PASARR) level 2 evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Pre-admission Screening and Resident Review policy, dated 11/28/17, documents positive level 1 PASARR's (a major mental illness has been identified) are forwarded to the state-designated authority for a level 2 PASARR evaluation. The State Operation Manual, Appendix PP revised on 8/8/24, documents if a PASARR level 1 identifies a major mental illness, an in-depth evaluation, known as a PASARR level 2 evaluation is completed by the state-designated authority, which must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR), was completed within the required timeframe for 2 of 4 residents (#42 and #46) reviewed for PASARR screenings. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: The facility's Pre-admission Screening and Resident Review policy, dated 11/28/17, documented a PASARR level 1 will be completed prior to admission and is included in the required paperwork from the referring agency, hospital, or physician. The State Operation Manual, Appendix PP revised on 8/8/24, documents all applicants to Medicaid-certified nursing facilities are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level 1 and should be completed prior to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a comprehensive person-centered care plan related to a fall intervention of 30-minute checks for 1 of 22 Residents (#52). This deficient practice had the potential to affect residents health and wellbeing. Findings include: Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease (a progressive brain disorder that causes movement problems, stiffness, and other issues) and bipolar disorder. Resident #52's care plan documented 30-minute checks due to a fall on 6/9/24. Resident #52's Interdisciplinary Team progress note dated 6/15/24, documented, The plan is to have Resident #52 be on 30-min checks at all times for increased safety. Resident #52's CNA task [NAME], dated 6/18/24, directed CNA staff to perform 30-minute checks for safety and falls. Resident #52's medical record did not document 30-minute checks were performed. On 10/10/24 at 2:50 PM, the DON stated the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to follow standard of practice during resident transfers for 1 of 2 residents (Resident #8), and follow a comprehensive person-centered care plan to maintain resident body weight for 1 of 22 residents (Resident #26). This deficient practice created the potential for harm or adverse outcomes. Findings include: Facility Resident Mobility - Safety policy, revised 4/16/24, documented, Gait belts are used with resident requiring hands-on assistance unless contraindicated, for the primary purpose of staff and resident safety. Gait belts are considered part of a direct care staff's uniform. 1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder (a serious mental health condition that involves a persistent low mood and a loss of interest in activities that were once enjoyable) and dementia. Resident #8's care plan revised 4/27/23, stated Transfer: Limited/Extensive assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined the facility failed to ensure all residents had access to their call lights while in their beds. This issue was observed in 1 of 22 resident's (Resident #5) observed for call light access. This failure had the potential for harm if residents were not able to summon staff assistance by activating the call light. Findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including panic disorder and dementia. Resident #5's care plan initiated 3/17/23, directed staff to keep his call light button within reach. On 10/8/24 at 2:34 PM, Resident #5 was observed in his bed without the call light button which was across the room, on his dresser. On 10/8/24 at 2:36 PM, Resident #5 stated he had been yelling for help because he was in pain but no one heard him. On 10/8/24 at 2:48 PM, CNA #3 stated she forgot to give Resident #5 his call light. On 10/10/24 at 10:53, the DON stated staff should ensure all residents have access to their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide safe shower floors for all residents that use the east shower room. This deficient practice had the potential to cause harm due to slips or falls and distress for residents that use the east side shower. Findings include: Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes. On 10/7/24 at 2:38 PM, Resident #51 stated the shower floor had been very slippery and he had almost fallen in the shower room because the floor anti-slip pads were missing. On 10/8/24 at 9:22 AM, observed the non-slip strips had peeled up and were missing in the east hall shower room. On 10/8/24 at 9:28 AM, CNA #2 stated the non-slip strips had peeled up about two months ago and a work order was submitted but nothing had been done yet. On 10/8/24 at 3:30 PM, the Maintenance Director stated the missing shower floor non-slip strips needed to be replaced. A facility work order #2674 (for the non-slip strips) in the east hall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and policy review, it was determined the facility failed to ensure staff disposed of controlled medications consistent with the facility's policies to prevent possible diversion. This was true for 2 of 2 licensed nurses (RN #1 and LPN #2) interviewed during medication cart inspection. This had the potential to negatively impact each of the 79 residents residing in the facility. This failed practice created the potential for harm if controlled medications were diverted and residents did not receive the medications as ordered. Findings include: The facility's policy for Management and Destruction of Controlled Substances, dated 11/28/17, documented two licensed nurses destroyed the controlled medications by rendering the controlled medications irretrievable by using the following example: Zorbitol plus, Drug Buster, Bleach, Drug Shedder. The facility's policy for Medication Management, dated 11/28/17, documented licensed nurses were to follow appropriate procedures for the destruction and disposal of controlled, cytotoxic (toxic to cells), and non-controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, staff interview, and review of the facility's guidelines, the facility failed to ensure the tubing for respiratory equipment included the date it was last changed. This was true for 4 of 6 residents (#5, #32, #35, and #51) reviewed for oxygen therapy. This placed residents at risk of respiratory infections due to the growth of pathogens (organisms that cause illness) in the tubing of respiratory equipment. Findings include: The facility's Respiratory Equipment Change and Cleaning Guidelines, dated 7/6/18, documented the nasal cannula, weekly .label and date the cannula when changed. This policy was not followed. Examples include: a. Resident #5's record documented the resident had multiple diagnoses including sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Resident #5's Quarterly MDS Assessment, dated 9/25/19, documented she required oxygen therapy. Resident #5's Physician's Orders, dated 9/24/19, documented an order for oxygen at 3L/Min (liters per minute) via nasal cannula (in the nostrils)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, it was determined the facility failed to ensure rooms with multiple residents had at least 80 square feet space per resident. This was true for 3 of 32 resident rooms (rooms 111, 112 and 114) which did not meet the requirement of 80 square feet per resident. This was true for 6 of 6 residents (#15, #17, #18, #24, #35 and #51) whose rooms did not have 80 square feet of living space. This failure created the potential for residents to experience a loss of well-being due to lack of living space. Findings include: *Resident #35 and Resident #51 were in room [ROOM NUMBER], which had 78.6 square feet per resident. *Resident #18 and Resident #24 were in room [ROOM NUMBER], which had 79.0 square feet per resident. *Resident #15 and Resident #17 were in room [ROOM NUMBER], which had 79.5 square feet per resident. On 10/18/19 at 1:15 PM, Resident #15, #17, #18, #24, and #51 said they liked their rooms. The furniture in the rooms was observed to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the use of oxygen. This was true for 1 of 6 residents (Resident #47) whose comprehensive care plans were reviewed. This deficient practice created the potential for Resident #47 to receive inadequate care or treatment due to missing information in her care plan. Findings include: Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including generalized anxiety disorder. An Annual MDS Assessment, dated 9/28/19, documented Resident #47 received oxygen therapy. A physician's order, dated 9/24/19, included an order for oxygen at 2 liters per minute via nasal cannula continuously. Resident #47's care plan did not document her use of oxygen. On 10/15/19 at 3:00 PM, Resident #47 was observed in bed, receiving oxygen at 2 liters per minute via nasal cannula. On 10/17/19 at 10:28 AM, RN #1 said Resident #47's care plan did not address her use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 26 medications (11.5%) which affected 1 of 2 residents (Resident #45) whose medication administration was observed during medication pass. This failure created the potential for subtherapeutic effect when Resident #45's Mucinex (an expectorant, helps loosen congestion) was crushed, not administered as ordered, and she was not instructed to rinse her mouth after receiving the inhaled medications. Findings include: 1. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Resident #45's October 2019 recapitulated physician's order included Breo Ellipta Aerosol Powder Breath Activated (an inhaler taken orally containing corticosteroid) 100-25 mcg/inh (microgram per inhalation), one puff one time a day for COPD. The order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, it was determined the facility failed to ensure staff performed proper hand hygiene during resident cares. This was true for 1 of 15 resident (Resident #30) observed during resident cares. The deficient practice placed residents at risk of infection from cross-contamination. Findings include: The facility's policy and procedure for Hand Hygiene/Handwashing, dated 11/28/17, directed staff to perform hand hygiene when moving from a contaminated body site to a clean body site during patient care, when removing gloves, intermittently after removing gloves, between contact with patients, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and heart failure. A Quarterly MDS Assessment, dated 9/24/19, documented Resident #30 required the assistance of one to two persons for ADL. A physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and received information and education consistent with the current Center for Disease Control (CDC) recommendations. This was true for 1 of 5 residents (#20) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia. Findings include: The CDC website, accessed on 10/22/19, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar13®, and PPSV 23 or Pneumovax23®) for all adults 65 years or older: * For those who have already received 1 or more doses of PPSV23, or those with unclear documentation of the type of pneumococcal vaccine received: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. * Administer a second dose of PPSV23 at least 1 year after PCV13 and at least 5 years…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.