Life Care Center of Coeur d'Alene

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility did not ensure residents assessments were accurately documented. This was true for 2 of 3 residents (#4 and #39) reviewed for MDS accuracy. This failure resulted in inaccurate transmission of assessment data, as Resident #4's MDS assessment documented the use of physical restraints, and Resident #39 did have a PASRR level II. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including anxiety, depression, and a need for assistance with personal care. A review of Resident #4's Quarterly MDS assessment dated [DATE] documented in Section P0100 (Physical Restraints) Resident #4 used restraints when in a chair or in bed, and the restraints were used less than daily. On 3/20/26 at 8:47 AM, the DON confirmed that Resident #4's Quarterly MDS assessment was coded inaccurately regarding the use of physical restraints. 2. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses…

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, policy review, and staff interviews, it was determined the facility failed to provide a PASRR level II to the designated state agency. This was true for 1 of 2 residents (Resident #79) whose record was reviewed for PASRR documentation. This deficient practice created the potential for harm if Resident #79's coordination of care was not completed between the facility and the designated state agency, with interventions appropriately documented in Resident #79's care plan. Findings include:Resident #79 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, anxiety, and depression.A PASRR level I, dated 3/27/25, documented Resident #79 did not document he have PTSD or an anxiety disorder.On 3/18/26 at 9:34 AM, the SSD stated Resident #79 should have had a corrected PASRR level I completed along with a PASRR level II, as Resident #79 had diagnoses of PTSD and anxiety.

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 revise residents care plans and to provide care conferences. This was true for 4 of 18 residents (#10, #69, #79, and #91) whose care plans were reviewed. This deficient practice created the potential for harm if resident's care plans were not updated to direct staff with appropriate care interventions for Resident #10, Resident #69, and Resident #91, and a potential for harm for Resident #79 when quarterly care conferences were not completed with the resident and/or their representative. Findings include: The facility's Comprehensive Care Plan and Revisions policy, reviewed 8/29/25, documented care plans should be reviewed and revised when changes occur to update the plan of care to reflect the change in care delivery. 1. Resident #10 was admitted on [DATE] with multiple diagnoses including heart disease, difficulty walking, abnormal posture, and kyphosis (an exaggerated, forward-rounding curvature of the upper…

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 interviews, it was determined the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan. This was true for 2 of 18 residents (#55 and #103) reviewed for standards of practice.Resident #55 had a wrong route of administration on two medication orders.Resident #103's vitals signs were not checked prior to administration of her anti-hypertensive medication.These failed practices created the potential for these residents to experience adverse effects when their medications were not administered according to physician's orders. Findings include:1. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including hypertension and acute pancreatitis. The National Library of Medicine web page titled Metoprolol accessed on 3/25/26, documented blood pressure and heart rate should be measured at rest, during exercise, and before and…

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 resident was provided quality treatment and care in accordance with professional standards of practice related to timely physician response. This was true for 1 of 18 residents (Resident #98) whose record was reviewed for quality of care. This deficient practice created the potential for harm due to delayed medical intervention when Resident #98 experienced a change of condition. Findings include: The National Library of Medicine website accessed on 3/25/26, defined standard of care as the benchmark that determines whether professional obligations to patients have been met.Resident #98 was admitted to the facility on [DATE] with multiple diagnoses including urinary tract infection, diabetes, heart failure, and chronic kidney disease.A nursing progress note, dated 4/15/25 at 12:42 AM, documented an SBAR (Situation, Background, Assessment, Recommendation) note was sent to Resident #98's physician, identifying Resident #98…

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, review of records, and interviews, it was determined the facility failed to ensure residents received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was true for 1 of 1 residents (Resident #9) reviewed for range of motion services. This failure created the potential for Resident #9 to experience a further decrease in mobility and function due to his refusals to participate in the restorative nursing program and to wear his right hand grip orthotic were not addressed accordingly. Findings include:The facility's Restorative Nursing policy reviewed 9/18/25, documented the following:Restorative Nursing Functions can be within one of the following categories: Range of Motion (Active and Passive), Splint or brace assistance, bed mobility, transfers etc.Communicate the restorative care plan and care directives to other members of the interdisciplinary team.The licensed nurse will conduct an evaluation on a routine basis 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.

Based on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 1 of 1 residents (Resident #1) reviewed for physician orders. When the facility failed to administer insulin as ordered and administered an incorrect dose of morphine, creating the potential for uncontrolled blood sugars and overmedication. Findings include: 1.Resident #1 was admitted to the facility with multiple diagnoses, including diabetes, severe protein calorie malnutrition, and a need for assistance with personal care.a)A review of Resident #1's diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition.A physician's order dated 2/2/26 directed staff to administer Insulin Aspart Injection Solution 100 units/mL sliding scale as follows:0-150 = 0 units151-200 = 2 units201-250 = 4 units251-300 = 6 units301-350 = 6 units351-999 = 6 units If greater than 351, give 6 units and notify the provider.A review of Resident #1's MAR dated 2/2/26-3/18/26…

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 did not ensure hospice documentation was complete and available in the resident's medical record. This was true for 1 of 1 residents (Resident #1) reviewed for hospice services. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification. Findings include:Resident #1 was admitted to the facility with multiple diagnoses, including diabetes, severe protein calorie malnutrition, and a need for assistance with personal care.A review of Resident #1's hospice care plan, revised [DATE], documented he was receiving hospice services and had a Do Not Resuscitate (DNR) code status.A review of Resident #1's medical record showed no documentation of:A current hospice plan of care.A current terminal diagnosis certification.Both of which are required to initiate and maintain hospice services.On [DATE] at 4:03 PM, the surveyor requested…

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 interview and job description review, the facility failed to ensure a qualified director of food and nutrition services was in place to oversee the dietary department with the potential to effect 82 census residents. Findings include: Review of the Food Service Director Job Description, date 09/28/22, indicated that the position required a minimum course of study in food safety before October 1,2023 (e.g., Serv Safe Food Manager Certification). During an interview on 10/01/24 at 11:18 AM, the Dietary Manager (DM) stated that he had been employed at the facility for one and a half years. The DM stated that he was not certified and did not have any Serv-Safe courses completed. The DM stated that he worked six months straight without a day off and had no time to do any training. During an interview on 10/01/24 at 11:45 AM, the Registered Dietitian (RD) stated that she was in the facility two days a week and was aware the DM was not certified. The RD stated that the DM needed to be certified so he could understand how to run the kitchen for long-term residents. The RD 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.

Based on observation, interview, and job description review, the facility failed to ensure there was sufficient staff with the appropriate competencies and training to carry out the functions of the dietary department. This failure had the potential to affect the ability of the dietary staff to safely and effectively carry out the functions of the food and nutrition service for 81 of 82 residents consuming food. Findings include: Review of the Food Service Job Description, dated 09/28/22, indicated that specific requirements of the position required that the manager must effectively conduct educational programs . Must be knowledgeable of food service practices and procedures as well as the laws, regulations, and guidelines governing food service functions in the post-acute care facility . Must be able to collaborate and work with the Registered Dietician . Must be able to ensure the patient's physician ordered diets are prepared and served accurately at meals and snacks. Review of the undated dietary schedule provided by the Dietary Manager (DM) revealed that there were two…

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, interviews, and policy review, the facility failed to ensure food was not stored on the floor in the freezer and in the dry storage area, a dirty ice machine was cleaned, and proper handling of food and dishware on the tray line. These failures had the potential to increase the prevalence and spread of foodborne illness and infection for all 82 census residents. Findings include: Review of the facility's policy titled, Sanitation and Maintenance, dated 04/30/24, revealed that The Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state, and local requirements. During an observation of the kitchen and interview on 09/30/24 at 10:09 AM accompanied by Cook1, there was a black mold-like substance observed on the plastic lining inside the ice machine. The cleaning schedule revealed the ice machine had been cleaned on 07/16/24. Cook1 stated that the ice machine was cleaned every six months and looked like it needed to be cleaned again.…

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, interview, and policy review, the facility failed to serve residents consecutively while seated at five of the seven tables (one, two, three, four, and seven) observed during meal service which included one of one resident (Resident (R) 48) reviewed for dignity during meal service of 29 sample resident. This had the potential to affect meal satisfaction for the 17 residents eating meals in the dining room. Findings include: Review of the facility's policy titled, Resident Dining Services, dated 04/30/24, indicated that Residents seated together are served in consecutive order so they can eat at the same time. During a lunch meal observation on 10/02/24 at 11:37 AM, the following was observed: -Meals served at 11:37 AM for one resident at table one and one resident at table two, -Meals served at 11:39 AM, for one resident at table three and one resident at table four, -Meals served at 11:40 AM for one resident back to table three and one resident at table five, -Meals served at 11:41 AM for one resident back to table two, one resident at table six, and one…

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, interview, and policy review, the facility failed to ensure that two out of four residents (Resident (R) 140 and R18) reviewed for abuse were free from sexual abuse from R139 as he was observed placing R140's hand on top of his genitals and on another occasion was observed placing his hand on R18's groin of 29 sample residents. The failure to protect R140 and R18 from R139 resulted in the potential for more than minimal phsychosocial harm from unwanted sexual contact. Findings include: Review of the facility's policy titled, Abuse-Prevention, dated 07/18/23 and provided by the facility, revealed It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation . Procedure 1. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse . Review of the facility's policy titled,…

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, record review, interview, and policy review, the facility failed to ensure the medication error rate of less than 5% by having a medication error rate of 7.69% for the 26 medication administration opportunities observed for two of five residents (Resident (R) 58 and R78) of 29 sample residents. The facility's failure to administer medications as ordered and placed residents who received medications at risk for medication errors. Findings include: Review of the facility's policy titled, Medication Administration via Enteral Access Devise, revised 08/08/23, directs staff under Medication Administration General Considerations 5. Administer each medication separately . 1. Review of R58's undated Admissions tab of the electronic medical record (EMR) revealed an admission date of 02/02/23. Review of the October 2024 Orders tab of the EMR revealed an order for Lantus Solostar insulin 25 units to be administered at 8:00 AM each day. During an observation on 10/01/24 at 9:59 AM, Registered Nurse (RN) 1 administered the Lantus Solostar. During an interview on 10/01/24 at…

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, interview, and policy review, the facility failed to ensure one of three residents (Resident (R) 40) reviewed for insulin use had a medical record that was accurate regarding the treatment of high and low blood sugar (BS) levels of 29 sample residents. This failure created the potential for inadequate treatment of R40's diabetes. Findings include: Review of the facility's policy titled, Authentication of All Record Entries, dated 02/29/24 and provided by the facility, revealed Anyone documenting in the medical record should be credentialed and/or have the authority and right to document. Individuals must be trained and competent in the fundamental documentation practices of the facility and legal documentation standards. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/24 in the electronic medical record (EMR) under the MDS tab, revealed R40 was admitted to the facility on [DATE] with diagnosis which included diabetes mellitus. R40 had 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.

Based on observation, record review, interview, and Centers for Disease Control (CDC) guidance, the facility failed to implement proper infection control procedures for one of four residents (Resident (R) 78) reviewed for infection control of 29 sample residents. R78 required enhanced barrier precautions (EBP) due to having an invasive device such as a feeding tube or catheter. This failure had the potential to increase the risk of infection. Findings include: Review of the Centers for Disease Control reference titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 07/12/22 and located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, required the use of gowns during high contact resident care acuities including the accessing of medical devises, which include percutaneous endoscopic gastric (PEG) tubes which were used for medication administration. 1. Review of R78's Census tab of the electronic medical record (EMR) revealed an admission date of 08/01/24. Review…

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 resident and staff interview, it was determined the facility failed to ensure a resident's bed rails were installed on his bed per his preference and physician order to aid him in repositioning and mobility. This was true for 1 of 1 resident (Resident #50) reviewed for residents' rights. This deficient practice had the potential to cause harm if the Resident #50 experienced decreased mobility and weakness from not having bed rails to assist him with repositioning. Findings include: Resident #50 was admitted to the facility on [DATE] and re-admitted following a hospital stay on 3/27/23, with multiple diagnoses including paraplegia (paralysis of his lower limbs below his navel) and a Stage 4 pressure ulcer to his right buttock. A Stage 4 pressure ulcer is a deep wound that exposes muscle, bone, or tendon. Resident #50's record included a physician order, initiated on 11/9/22, for full side rails to both sides of the bed to aid in bed mobility and repositioning. Resident…

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 residents' received information and assistance to exercise their rights to formulate an Advance Directive and this was documented in their record. This was true for 3 of 18 residents (#5, #10, and #18) whose records were reviewed. This failed practice created the potential for harm or adverse outcome if the resident's wishes were not followed or documented regarding their advance care planning. Findings include: The State Operations Manual, Appendix PP, defines 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 (or POST) paradigm form is a form designed to improve patient care by creating a portable medical order form that…

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 and resident representative interview, it was determined the facility failed to ensure notification of a medication dosage change to the legal guardian for 1 of 2 residents (Resident #10) reviewed for notification of changes. This deficient practice placed Resident #10 at risk due to lack of information shared and the resident's right to be informed. Findings include: The facility policy for Changes in Resident's Condition or Status, dated 8/18/22, stated, This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. This policy was not followed. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain injury (TBI), cognitive impairment, and aphasia (inability to communicate verbally). Resident #10 had a legal guardian to advocate for him and make decisions on his behalf. A Psychotropic Medication Meeting Note from 1/19/23…

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 information was provided to the receiving facility for 2 of 3 residents (#51 and #60) reviewed for transfer to the hospital. This deficient practice had the potential to cause harm if the residents were not treated appropriately or in a timely manner due to a lack of information. Findings include: The facility's policy for Transfers and Discharges, dated 5/12/23, stated the facility would ensure the transfer or discharge was documented in the resident's medical record, and appropriate information was communicated to the receiving health care institution or provider. This policy was not followed. 1. Resident #60 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and an unstageable sacral (the bottom of the spine and tailbone) pressure ulcer. An unstagable pressure ulcer is full thickness skin and tissue loss. A nurse's note, dated 5/22/23 at 3:45 PM, documented the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and record review, it was determined the facility failed to ensure bathing was provided to residents. This was true for 2 of 11 residents (#56, and #277) reviewed for bathing. This failure had the potential for residents to experience embarrassment and compromised skin integrity due to lack of hygiene. Findings include: 1. Resident #56 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses which included quadriplegia (paralysis of all four limbs). An annual MDS assessment, dated 4/10/23, documented Resident #56 required total assistance for bathing. Resident #56's care plan, revised on 4/25/23, documented Resident #56 required extensive 2 person assistance with bathing. Resident #56 was interviewed on 6/12/23 at 10:43 AM. Resident #56 stated it had been a while since he had a shower. When asked if he had made the staff aware of his needs, he stated yes, RN #2 was informed. Resident #56's shower record, dated 5/1/23 to 6/15/23, documented 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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents received treatment for constipation as ordered by the physician for 1 of 18 residents (Residents #6) who were reviewed. Findings include: The facility's Bowel Protocol, undated, included the following: Bowel Protocol: 4-6 ounces of prune juice or 1 ounce of fruit butter (a natural laxative made of applesauce, prune juice, and bran) for no bowel movement for 2 days, no abdominal pain; Milk of Magnesia 30 ml daily as needed for no bowel movement for 3 days; Dulcolax suppository 10 mg as needed daily if no results from Milk of magnesia; Fleet enema as needed if no results from suppository. This protocol was not followed. Resident #6, was admitted to the facility on [DATE], with diagnoses that included dementia, and fracture of the left shoulder. Resident #6's MAR, dated 5/1/23 through 6/14/23, documented she received Norco (an opioid) three times daily routinely for pain related to fracture of 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, policy review, and resident and staff interview, it was determined the facility failed to ensure a resident's urinary catheter needs were met in accordance with professional standards of nursing practice. This was true for 1 of 7 residents (#60) reviewed for urinary catheters. This failed practice created the potential for resident's to experience urinary tract infections (UTI's) due to lack of proper catheter care. Findings include: The CDC website accessed on 6/21/23, under Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2009, documented proper urinary catheter maintenance techniques, including cleansing the meatal (the open area in a male's penis where the urine comes out) surface during daily bathing or showering. The facility's Indwelling Urinary Catheter Management policy, revised 8/22/22, directed staff to provide catheter care to residents in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident'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, and staff interview, it was determined the facility failed to ensure nutritional assistance services were provided. This was true for 1 of 12 residents (Resident #13) reviewed for nutrition assistance. This had the potential for undetected weight loss and nutritional deficits when the facility failed to assist with nutritional needs. Findings include: Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including the need for assistance with personal care. A quarterly MDS assessment, dated 4/6/23, documented Resident #13 required supervision with encouragement or cueing with meals. An Occupational Therapy evaluation, dated 6/7/23, was completed for wheelchair safety. Resident #13 was not evaluated for self-feeding or nutritional assistance. Resident #13's care plan, revised on 6/12/23, directed staff to assist her with meals as needed. The care plan did not specify when Resident #13 may need assistance. On 6/12/23 at 12:09 PM, Resident #13 was observed…

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 provide oxygen therapy as oredered by the physician and assess resident oxygen needs. This was true for 1 of 6 residents (Resident #56) reviewed for oxygen therapy. This failure placed residents at risk for decline related to shortness of breath due to low oxygen saturation. Findings include: The Cleveland Clinic website, accessed on 6/22/23, stated for most people, a normal oxygen saturation level (the measure of how much oxygen is traveling through the body) is between 95% and 100%. It also stated with lung disease, oxygen levels may be lower. Resident #56 was readmitted to the facility on [DATE], with multiple diagnoses including respiratory failure (the lungs failure to either oxygenate and/or eliminate carbon dioxide). An annual MDS assessment dated [DATE], documented, Resident #56 required oxygen therapy. Resident #56's record included a physician order, dated 6/2/23, continuous oxygen use at 1-3 liters per…

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 post-dialysis assessments were completed. This was true for 2 of 3 residents (#44 and #47) who were reviewed for dialysis. This failure created the potential for harm if dialysis residents experienced complications and/or compromised medical status. Findings include: The facility's policy for Dialysis, dated 4/24/19, stated residents receiving dialysis will receive consistent care pre- and post-dialysis. The policy stated post-dialysis, staff were to obtain vital signs upon return and the Pre/Post Dialysis Communication form was to be completed. The policy also stated to document in the clinical nursing record the completion of dialysis treatment, order changes, condition of the dialysis access site, any complaints from the resident, and whether the physician was notified. This policy was not followed. Resident records did not include documentation of post-dialysis monitoring. Examples include: 1. Resident…

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 Nursing Assistants performed tasks which they had the knowledge, skills, and competencies. This was true for 1 of 6 NAs (#1) observed in the facility. This had the potential for adverse effects to residents medical and physical status. Findings include: On 6/14/23 at 12:10 PM, Resident #56 was observed in the dining room and asked NA #1 to check his oxygen flow rate on his portable oxygen concentrator. NA #1 stated the oxygen liter flow was at 2 liters. Resident #56 requested for NA #1 to increase his oxygen flow rate to 2.5 liters. NA #1 increased the oxygen liter flow to 2.5 liters. No observation of nurse assessment or physician order verification was observed. On 6/15/22 at 10:22 AM, the SDC stated changing oxygen liter flow was not within the scope of practice of the NA. On 6/16/23 at 9:09AM, the IP stated, NAs were not allowed to change the resident's oxygen flow rate. The IP stated NA #1 should have notified Resident #56's nurse of his request to increase his oxygen flow rate 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.

Based on observation and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices for refrigerated foods. These failed practices placed the residents who resided in, and dined in the facility, at risk of adverse health outcomes. Findings include: On 6/12/23 at 9:00 AM, during a brief kitchen tour with the Kitchen Manager, the following was observed in the walk-in refrigerator: - Small green salad in a plastic bowl which was covered with plastic wrap and a sticker dated 6/7/23. - Fruit salad in a plastic bowl which was covered with plastic wrap and a sticker dated 6/6/23. - Lunchmeat in a sealable plastic bag with no date. - Shredded cheese in the original manufacturer bag with an expiration date of 6/5/23. - Cucumbers with a use by date of 6/11/23. - Large mayonnaise container with an expiration date of 4/19/23 - Large plastic container of honey mustard sauce with an expiration date of 3/16/23. - Large container of pickled beets with an expiration date of 6/10/23. - Large container of dill pickles with an expiration date 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 observation, policy review, and staff interview, it was determined the facility failed to ensure infection control measures were implemented appropriately for 1 of 2 residents (Resident #50) observed during a wound dressing change. These failures resulted in the potential for the introduction of infection due to cross contamination. Findings include: The facility's skills evaluation, titled Wound Care/Treatment Clean Dressing Change, undated, stated the following process for wound care: - Clean hands-hand hygiene-hand washing or hand sanitizer per policy. - Prepare a clean dry work area. Clean bedside table or tray if needed with disinfectant solution to prepare work surface. Utilize impervious barrier, i.e., drape or liner if needed. - Prepare dressing items. If dressings need cut, precut with clean scissors (clean before and after with alcohol prep for 60 seconds). Open packages and cut tape. - Clean hands-hand hygiene-hand washing or hand sanitizer per policy. Apply clean gloves. - Gently remove 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.