Coeur d Alene Health of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS- standardized assessment tool used in nursing facilities to assess residents' health and functional status) assessments included correct information. This was true for 3 of 18 residents (#11, #20, and #44) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #11 was initially admitted to the facility on [DATE], with multiple diagnoses including depression, delusional disorder, and dementia. Resident #11's…

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, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 3 of 18 residents (Resident #60, #64, #182) whose care plans were reviewed. This placed residents at risk for adverse outcomes when care plans were not revised to reflect their updated needs. Findings include: The facility's Care Plan policy, revised on 10/15/22, documented a qualified person would monitor the resident's condition and effectiveness of the care plan interventions and revise the care plan quarterly, annually, and with a significant change in condition. 1. Resident #60 was readmitted to the facility on [DATE], with multiple diagnoses including congestive heart failure and chest pain. A hospital Discharge summary, dated [DATE], documented Resident #60 was seen for an exacerbation for acute congestive heart failure. Resident # 60's Care Plan, dated 11/9/24, did not include revision or…

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 bathing was provided to residents who required assistance. This was true for 1 of 6 residents, (Resident #60) whose records were reviewed for bathing. This failure had the potential for embarrassment and compromised skin integrity due to lack of hygiene. Findings include: Resident #60 was admitted on [DATE], with multiple diagnoses including generalized muscle weakness, difficulty walking, and need for assistance with personal care. The facility's shower schedule, undated, documented Resident #60 was scheduled to receive a shower on Wednesday and Saturday evenings. Resident #60's care plan, revised on 11/4/24, documented he required assistance with bathing. The care plan also documented if he refused to bathe, the licensed nurse should be notified. Resident #60's bathing record from February-March 2025 was reviewed documenting the following: -2/1/25-2/16/25, no documentation a shower was offered or refused -2/17/25, a…

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 quality care was provided to 1 of 18 residents whose bowel records were reviewed. This was true for Resident #49 when his physician orders were not followed placing him at increased risk for harm. Findings include: Resident #49 was admitted on [DATE] with multiple diagnoses including quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function), respirator dependence, and a personal history of constipation and gastrointestinal hemorrhage. Resident #49's record documented the following physician orders, dated 5/21/24: -Milk of Magnesia (MOM) Suspension 1200 MG/15 ML, Give 30 ML orally as needed for no bowel movement (BM) for two (2) days. Give 1 dose. If no results within 24 hours, see Dulcolax Suppository order. -Dulcolax Suppository 10 MG, Insert 1 suppository rectally as needed for bowel care. Give if no results from MOM. If no results in 24 hours, see Fleet Enema order. -Fleet…

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, resident interview, staff interview, and record review, it was determined the facility failed to ensure residents are free from pain. This was true for 1 of 2 residents, (Resident #60) whose records were reviewed for pain management. This failure placed Resident #60 at risk of psychosocial harm and functional decline related to unrelieved pain, and not being offered effective pain management. Findings include: Resident #60 was readmitted to the facility on [DATE], after a short hospital stay, with multiple diagnoses including malignant neoplasm of the stomach (stomach cancer) and cognitive communication deficit. On 3/17/25 at 8:18 AM, Resident #60 was observed lying on his bed with no sheets on his right-side verbalizing 9 out of 10 abdominal pain and guarding his abdomen. When asked, Resident #60 stated he had already asked for pain medication. On 3/17/25 at 8:20 AM, LPN #3 entered the room and asked Resident #60 how he was feeling. Resident #60 verbalized having 8 out of 10 abdominal…

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 record review and staff interview, it was determined the facility failed to ensure a registered nurse (RN) was on-site for 8 consecutive hours a day, 7 days a week, to provide care to the residents. This was true for 2 of 21 days reviewed for sufficient staffing. This failure placed all residents at risk for harm if their routine and/or emergency needs could not be met without the care of a registered nurse. Findings include: The nursing staff hours worked were reviewed from 2/23/25-3/15/25. This review documented the facility did not provide 8 consecutive hours of registered nurse coverage on 2/24/25 and 3/3/25. On 3/20/25 at 1:22 PM, the Administrator confirmed those two dates did not have an RN on-site for 8 consecutive hours.

Based on observation, record review, and staff interview it was determined the facility failed to ensure nurse staffing data was completed accurately, posted daily, and the records were maintained for a minimum of 18 months. This failed practice had the potential to affect the 76 residents residing in the facility, their representatives, and any visitors who would like to review staffing data and census information. Findings include: The facility's daily nurse staffing data posting records were reviewed for 10/1/24-3/20/25 and documented the following: Missing dates: October 2024: 9, 12, 13, 19, 20, 26, 27 November 2024: 2. 3. 9, 10, 16, 17, 23, 24, 30 December 2024: 1, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31 January 2025 : 1, 5, 11, 12, 18, 19, 25, 26 February 2025: 1, 2, 8, 9, 15, 16, 22, 23, 27 March 2025: 1, 2, 8, 9, 15 Incomplete data: October: 4, 17 December: 24 January: 2, 3, 4, 20, 21 February: 6, 7, 13, 14, 18 On 3/16/25 at 12:45 PM, the facility's daily nurse staffing data posting was observed. The data posting was…

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, policy review, United States Food and Drug Administration (FDA) food code review, and staff interview, it was determined the facility failed to ensure sanitation of nutrition rooms and equipment. This failure had the potential to affect all residents who consumed food or ice from the nutrition rooms and increased the risk for transmission of food born illnesses. Findings include: The facility's Sanitizing Stationary Food Service Equipment and Food Contact Surfaces policy, dated 1/1/18, documented the facility will provide proper cleaning and sanitation of food service equipment to minimize the growth of microorganisms that may result in food contamination. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) In equipment such as ice bins and beverages, dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverages and syrup…

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, policy review, resident interview, food test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 4 of 4 residents (#1, #9, #19 and #35) reviewed for food concerns, and had the potential to affect all residents in the facility who ate food from the kitchen. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's policy for Food: Quality and Palatability, dated 9/2017, documented: * Food was prepared by methods that conserve nutritive value, flavor, and appearance. * Food was palatable, attractive, and served at a safe and appetizing temperature. * Food and liquids/beverages were prepared in a manner, form, and texture that met the needs of the residents. The facility's policy for Food Preparation, dated 11/28/17, documented food was prepared by methods that conserve nutritive value, flavor and appearance. The documented procedures included: * Food was stored, prepared, and held by methods…

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 record review, policy review, review of the Facility Assessment, and staff interview, it was determined the facility failed to ensure the Facility Assessment identified how staffing levels and competencies met resident needs. This had the potential to affect all residents residing in the facility, and created the potential for harm if the facility did not have sufficient and competent staff to provide the necessary care and services for the residents. Findings include: 1. The facility's policy for Facility Assessment, dated 11/28/17, documented the facility evaluated its resident population and identified the resources needed to provide the necessary care for its residents competently during both day-to-day operations and emergencies. The procedure components included an assessment that addressed or included the following: * The staff competencies that were necessary to provide the level and types of care needed for the resident population. * All personnel, including managers, staff (both employees and those who provided services under contract), and volunteers, as well as…

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, policy review, and staff interview, it was determined the facility failed to ensure: a) clean laundry was covered appropriately when transported throughout the facility which had the potential to affect all residents in the facility b) Staff performed hand hygiene in between contact with residents in the dining room which was true for 4 residents (#31, #32, #36, and #42) who were observed in the main dining room and required assistance with their meals. These deficient practices created the potential for harm if residents experienced infections from cross contamination. Findings include: 1. The facility's policy for Work Practices - Linen and Laundry, dated 11/28/17, documented that clean linen was to be delivered on a covered cart to resident areas. This policy was not followed. On 1/22/20 at 8:36 AM, a laundry cart with residents' personal laundry was observed being rolled down a unit corridor, and it was partially covered as clothing was delivered to residents' rooms. A sheet was resting on top of the hangers along the length of the cart, and it was hanging…

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 received information and assistance to exercise their rights to formulate an advance directive. This was true for 3 of 8 residents (#19, #23, and #100) whose records were reviewed for advance directives. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include: The State Operations Manual, Appendix PP, defined an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment for POST-Physician Orders for Scope of Treatment) paradigm form is a form designed to improve patient care by creating a portable medical 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, and staff interview, it was determined the facility failed to ensure blood pressure medications were held when the resident's pulse was outside of ordered parameters. This was true for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse effects from blood pressure medications. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (weakness and paralysis) after a stroke, hypertension (high blood pressure), and Type 2 diabetes mellitus. Resident #9's physician orders documented the following: * Carvedilol (medication to lower blood pressure) 25 mg twice a day for hypertension. Hold if systolic blood pressure (top number of blood pressure reading) is less than 100 or if heart rate is less than 60, dated 10/29/19. * Lisinopril (medication to lower blood pressure) 20 mg once a day for hypertension. Hold if…

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, policy review, and facility training documentation, it was determined the facility failed to ensure each CNA completed the required hours of yearly education. This was true for 3 of 3 CNAs (Staff A, B, and C), who worked at the facility for 1 year or longer. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for 53 of 53 residents living in the facility. Findings include: The facility's policy for In-service Education/Training, dated 11/28/19, documented an employee performance review was completed, and regular in-service education was provided based on the outcome of the review. In-service education maintains the continuing competence of the employee in their job performance. Procedures included the following: * Education and in-service training were provided to assist in maintaining the continuing competence and knowledge of the staff, and education would meet the State/Federal mandatory 12-Hour continuing education requirements. * Ongoing education was provided at regular intervals on topics to maintain…

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 pertinent information was provided to the receiving facility when a resident was transferred to the hospital. This was true for 1 of 1 resident (Resident #36) who was reviewed for transfer to the hospital. This deficient practice had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the information provided to the receiving provider included the following: * Contact information of the practitioner responsible for the resident's care. * Contact information of the resident's representative. * Advance directive information. * Special instructions and/or precautions for ongoing care. * The resident's comprehensive care plan goals. * All information needed to meet the resident's needs, including but not limited to the resident's status,…

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 a written notice of transfer was provided to the resident and the State Long Term Care ombudsman when a resident was transferred to the hospital. This was true for 1 of 1 resident (Resident #36) who was reviewed for transfer to the hospital. This deficient practice had the potential to cause harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the facility provided a notice of transfer as soon as practicable, and the written notice contained the following: * The reason for the transfer/discharge. * The effective date of the transfer. * The location of where the resident was being transferred. * A statement that the resident had the right to appeal the transfer. * The contact information of the state long term care ombudsman. * If applicable, the contact information of…

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 a bed hold notice was provided to the resident and/or their representative when a resident was transferred to the hospital. This was true for 1 of 1 resident (Resident #36) who was reviewed for transfer to the hospital. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented at the time of a resident's discharge, the facility provided a written notice of bed hold policy that specified the duration of the bed hold readmission criteria after the bed hold period ended. This policy was not followed. Resident #36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including anemia (a low number of red blood cells), gastrointestinal hemorrhage…

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 and resident interview, and record review, it was determined the facility failed to ensure a resident's bed safety assessments were documented accurately. This was true for 1 of 1 resident (Resident #35) whose bed safety assessments were reviewed. This failure created the potential for harm if residents received an injury due to inaccurate resident assessments. Findings include: Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including severe obesity, difficulty in walking, and muscle weakness. Resident #35's Bed Safety Evaluation, dated 12/4/19 at 11:26 AM, documented the recommendation for side rail use was No Side Rails. Resident #35's Bed Safety Evaluation, dated 12/18/19 at 9:50 AM, documented mobility bars to assist with independent bed mobility, and the recommendation for side rail use was Side Rail Elimination. The assessment also documented a grab bar to allow improved bed mobility, and new bed rail to allow for independent bed mobility. On…

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 resident and staff interview, it was determined the facility failed to ensure care conferences were held regularly and included the resident when possible. This was true for 2 of 14 residents (#9 and #35) whose care plans were reviewed. This failure created the potential for inappropriate care and services which did not meet the resident's current needs. Findings include: The facility's policy for Care Plans, dated 11/28/19, documented the following: * Care conference meetings were scheduled upon admission, quarterly, and with a change of condition. * The facility provided sufficient advanced notice of the meeting and scheduled the meetings to accommodate the resident's representative. * If the resident and/or their representative were not able to participate in the care conference meeting, an explanation was documented in the resident's record. This policy was not followed. 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including…

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, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' hygiene and grooming were appropriately maintained. This was true for 1 of 14 residents (Resident #28) who were reviewed for ADLs. This failure had the potential to cause psychosocial distress if residents experienced embarrassment, isolation, decreased sense of self-worth, and/or decreased sense of well-being. Findings include: The facility's policy for Activities of Daily Living, dated 2/28/19, documented assistance was provided to residents who required extensive or total assistance with nutrition, grooming, oral hygiene, toileting, and other personal cares. The facility's policy for Quality of Life, dated 11/28/19, documented the following: * The facility provided appropriate treatment and services to maintain or improve residents' ADLs. * The facility provided the necessary services to maintain good nutrition, grooming, oral, and personal hygiene for residents who…

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 consistently provided adequate nutritional interventions to prevent significant unplanned weight loss. This was true for 1 of 1 resident (Resident #27) who was reviewed for weight loss. This failure created the potential for harm if residents experienced a loss in functional ADLs due to muscle loss and/or weakness. Findings include: The facility's Nutrition Care Policy - Identifying Nutrition Problems, Responding to Significant Change, dated 11/28/17, documented the following: * The registered dietitian (RD) identified residents needing further monitoring/evaluation, including those having a significant undesirable weight loss or gain. * Notify and consult with the physician regarding residents' current nutritional status or significant change in nutritional status. This policy was not followed. Resident #27 was initially admitted to the facility on [DATE] and readmitted on [DATE], 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, staff and resident interview, and record review, it was determined the facility failed to ensure a resident was appropriately assessed and a physician's order was obtained prior to installing side rails. This was true for 1 of 1 resident (Resident #35) who was reviewed for side rails. This created the potential for harm from entrapment or injury related to the use of side rails. Findings include: The facility's policy for Restraints, dated 3/31/18, documented if a side rail was used, the facility ensured correct installation, use, and maintenance of the side rails, including a physician's order with rationale, and assessing the resident for risk of entrapment prior to installing the side rails. This policy was not followed. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including severe obesity, difficulty in walking, and muscle weakness. A Bed Safety Evaluation, dated 12/4/19 at 11:26 AM, documented Resident #35 was determined to be unsafe in bed and the…

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 were monitored appropriately while receiving anti-diabetic medications. This was true for 1 of 5 residents (Resident #101) reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse reactions due to a lack of appropriate monitoring. Findings include: Resident #101 was admitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus with diabetic neuropathy (nerve damage). Resident #101's physician orders documented the following: * Blood sugar checks as needed (PRN) to rule out hyper or hypoglycemia, dated 1/19/20. * Hypoglycemia protocol: if able to take by mouth, follow the 15/15 rule- administer 15 grams of fast acting carbohydrate and recheck BG in 15 minutes. If still less than 70, administer another 15 grams of fast acting carbohydrate and recheck second BG in 15 minutes. If not above 70, administer another 15 grams of…

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 hospice documentation included a physician statement of terminal illness. This was true for 1 of 1 resident (Resident #7) reviewed for hospice care. This failure created the potential for harm if residents received inappropriate hospice care. Findings include: The facility's policy for Hospice, dated 1/28/17, documented a written physician certification the individual was terminally ill must be completed. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior), dysphagia (swallowing difficulties), and history of stroke. A Hospice Referral Order, dated 3/5/19 and signed by the physician, documented that in the event Resident #7 had an event of acute decline, staff were to make an emergent admission referral for hospice services. No physician…

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.