Cherry Ridge of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident observation, and staff interviews, it was determined the facility failed to implement a comprehensive, person centered care plan as written. This was true for 1 of 12 residents (Resident #32) whose record was reviewed for care plan implementation. This failure created the potential for Resident #32 to develop pressure injuries and adverse outcomes when his heels were not offloaded as directed by his care plan. Findings include: Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's care plan, revised 6/18/21, directed staff to offload Resident #32's heels or use Prevalon boots when in bed, as he allowed.On 7/9/26 at 11:22 AM, Resident #32 was observed in bed without Prevalon boots in place.On 7/9/26 at 11:23 AM, LPN #2 stated Resident #32 should have his boots on. LPN #2 lifted the blanket and observed Resident #32's legs resting on a pillow. When asked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interviews, it was determined the facility failed to ensure resident's medications were administered according to professional standards of practice. This was true for 1 of 1 resident (Resident #30) whose medication was reviewed and true for 1 of 3 residents (Resident #9) whose medication administration was observed. This failed practice created the potential for Resident #30 to receive improper treatment, skin irritation, allergic reaction, or other adverse outcomes and created the potential for Resident #9 to not receive the full dose of their prescribed eye drops. Findings include: 1. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and adult failure to thrive. On 7/7/26 at 10:58 AM, CNA #2 was observed assisting Resident #30 with activities of daily living (ADLs). CNA #2 stated Resident #30 had redness to her lower abdomen and under her breasts. CNA #2 stated she assisted Resident #30 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 record review, resident observation, and staff interviews, it was determined the facility failed to ensure podiatry treatment orders and care plan interventions were implemented as written. This was true for 1 of 1 resident (Resident #32) reviewed for podiatry services. This failure created the potential for untreated foot conditions, discomfort, and deterioration of skin integrity due to the lack of required podiatry services. Findings include:Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's care plan, initiated 4/11/24, directed staff to provide podiatry evaluation and treatment as needed.On 7/9/26 at 11:25 AM, LPN #2 removed Resident #32's socks and stated his toenails needed to be trimmed. When describing the toenails, LPN #2 stated they were chunky, yellow, and irregular.On 7/9/26 at 11:34 AM, LPN #2 stated Resident #32 was on the podiatry list to be seen every three months.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, resident observation, and staff interview, it was determined the facility failed to ensure proper monitoring was conducted to identify potential catheter associated urinary tract infections. This was true for 1 of 3 residents (Resident #32) reviewed for catheter care. This failure created the potential for undetected signs of infection if Resident #32 was not monitored for appropriate symptoms. Findings include:Resident #32 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's physician order, dated 2/14/25, directed staff to monitor, record, and report to the provider signs and symptoms of catheter associated urinary tract infection, including: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in…

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 and staff interviews it was determined the facility failed to ensure an oxygen concentrator was removed from the resident's room after the physician discontinued the resident's oxygen order. This was true for 1 of 1 resident (Resident #12) whose oxygen concentrator was observed. This deficient practice created the potential for harm if the resident attempted to use the oxygen equipment without a valid physician order. Findings include:The facility's Oxygen Administration, Safety, Storage & Maintenance policy revised 10/10/25, documented the facility would administer, store, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practitioner orders. If oxygen therapy was discontinued, discard all disposable components, replace filters as specified by the manufacturer, and disinfect the exterior surfaces of the oxygen equipment in accordance with the Instructions for Use.Resident #12 was admitted to the facility on [DATE] and readmitted…

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 medications were administered with an appropriate clinical indication. This was true for 1 of 5 residents (Resident #23) reviewed for unnecessary medications. The lack of an appropriate indication created the potential for improper medication administration and use of medication without a clearly defined clinical need. Findings include:Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including COPD, anxiety, and PTSD.Resident #23's care plan, revised 3/2/26, documented: give medications as ordered by physician.A review of Resident #23's physician orders documented the following order:- Morphine Sulfate 20 mg/mL, give 0.25 mL by mouth every 6 hours as needed for severe pain related to chronic obstructive pulmonary disease, initiated on 7/7/26.On 7/9/26 at 2:45 PM, the CNO stated she did not know what the appropriate indication for the morphine order should be.

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 food was served at palatable temperatures as required. This was true for 1 of 1 resident (Resident #31) reviewed for food quality. This failure created the potential for reduced enjoyment of meals and decreased dietary intake when food was not served at acceptable temperatures. Findings include: Resident #31 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, gastro esophageal reflux, and chronic kidney disease.On 7/7/26 at 3:16 PM, Resident #31 stated the hot food is always cold. She stated she generally eats in the dining room and that most of the time it is a problem. Resident #31 stated she normally does not ask for her food to be reheated because cold food is normal in the facility.On 7/9/26 at 7:46 AM, a request for a breakfast tray was made to the kitchen.On 7/9/26 at 8:12 AM, the tray was delivered by the CM. Food temperatures were taken and documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined the facility failed to ensure a physician order was clarified regarding its clinical indication and medication dosage. This was true for 2 of 2 residents (#1 and #12) whose records were reviewed. This deficient practice resulted in inaccurate documentation within the resident's medical record. Findings include: The facility's Documentation of Resident Health Status Needs & Services, revised 9/1/25, documented that the resident's medical record should be accurate, objective and clinically relevant. 1. Resident #12 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including morbid (severe) obesity with alveolar hypoventilation, and diabetes. A physician order dated 6/4/26 documented Resident #12 was to receive the following medications: -Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 units/ml (insulin glargine), inject 120 units subcutaneously one time a day related to morbid obesity with alveolar…

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 interviews it was determined the facility failed to consider caregiver/support person availability, capacity, and capability to perform required care as part of the identification of discharge needs. This was true for 1 of 3 residents (Resident #1) reviewed for the facility's transfer and discharge process. This deficient practice created the potential for harm when Resident #1 was transported to a homeless shelter that was unable to provide the required level of care. Findings include: The facility's Discharge or Transfer policy revised 8/30/25, documented upon transfer of a resident, information necessary to meet the resident's needs should be provided.Resident #1 was readmitted to the facility on [DATE] with chronic kidney disease, morbid obesity (BMI 70), muscle weakness, difficulty walking, and anxiety/adjustment disorders.A Discharge MDS assessment dated [DATE], documented Resident #1 was cognitively intact and required supervision/touching assistance for eating,…

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, CMS SOM Appendix PP, policy review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written. This was true for 1 of 3 residents (Resident #1) whose care plans were reviewed in the sample. This deficient practice created the risk of adverse outcomes if residents comprehensive care plans did not reflect the care necessary for each resident. Findings include:The CMS SOM, Appendix PP dated 7/23/25, documented each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs.A Resident Assessment (RAI) & Comprehensive Care Plans Policy and Procedure, revised 9/3/25, documented under section 4a: The Interdisciplinary team (IDT) will develop a comprehensive, person-centered care plan within 7 days of the completion of the comprehensive assessment.Resident #1 was initially admitted to 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, CMS SOM Appendix PP, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 3 residents (Resident #1) whose care plans were reviewed in the sample. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:The CMS SOM, Appendix PP, dated 7/23/25, documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.A Resident Assessment (RAI) & Comprehensive Care Plans Policy and Procedure, revised on 9/3/25, documented under section 4b: The Care Plan will reflect: Discharge Planning Goals. Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic 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 observation and staff interview it was determined the facility failed to ensure medications available for residents were labeled and dated. This was true for 1 of 2 medication carts inspected. This failure created the potential to receive expired medication with decreased efficacy. Findings include:On [DATE] at 9:03 AM, during a medication cart inspection the following medication was located with no open date or date of discard: Erythromycin ophthalmic ointment 5 milligram Trelegy Ellipta inhaler 62.5 microgramOn [DATE] at 09:06 AM, LPN #1 stated she was not sure how long the ophthalmic ointment was good for. She also stated both medications should have been labeled with the open date.

Based on observation, record review, resident and staff interview, it was determined the facility failed to provide a pest-free environment and an effective pest control program. This deficient practice created the potential for facility residents (#3, #4, #6, #7, #12, #13, #16, #19, #24, #25, #26, #27, #28, #29, and #39) to experience pest infestation if measures were not taken to eradicate and contain common household pests like flies. Findings include:The facility's Resident Environment policy, revised 11/28/19, documented the facility will provide a homelike environment that is similar to that of a private home/ The facility's Pest Control policy, revised 10/18/23, documented routine inspections are conducted periodically at the facility for evidence of pests. Insect or pest sightings are reported to the housekeeping/maintenance supervisor. From 8/4/25 through 8/7/25, the following was observed:On 8/4/25 at 8:05 AM, a full fly trap was found hanging outside the facility on a nearby fence, two additional full fly traps were observed around the exterior fence of the facility.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.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure food was stored appropriately, dated, and not contaminated by ice, and the kitchen was clean and free of pests. These deficiencies had the potential to affect the 31 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 3-303.12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. On 8/4/25 at 8:20 AM, and on 8/7/25 at 11:15 AM, freezer icicles were observed in the vegetable and dough freezer stuck to the back of the fridge. Ice was stuck to the shelves containing boxes of food, opened and unopened, with ice dripping down through the shelves onto additional boxes of opened and unopened food. On 8/7/25 at 11:17 AM, the Dietary Manager…

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, observation, and staff interview, it was determined the facility failed to implement effective infection control practices during medication administration and shower room sanitation. This failure created the potential to affect all residents who reside in the facility due to risk for cross-contamination and adverse outcomes. Findings include:1. On 8/6/25 at 9:57 AM, during an inspection of Shower room [ROOM NUMBER] with the Director of Maintenance, the following environmental concerns were observed:The shower floor, specifically the area where residents stand during bathing, lacked grout between the tiles. Black mold-like substances were visible along the bottom edges of the shower walls.An adhesive trim affixed to the lower portion of the shower walls was peeling away. Upon closer inspection, the underside of the peeling adhesive trim also showed the presence of black mold-like material extending along the edge of the wall.On 8/6/25 at 9:57 AM, the Director of Maintenance stated 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 review of The Long-Term Care Agency reporting portal, facility's incident report, record review and staff interview it was determined the facility failed to conduct a thorough investigation into an allegation of abuse. This was true for 1 of 3 residents (Resident #7) whose record was reviewed for Abuse and Neglect. This failure created the potential for undetected harm due to incomplete investigative procedures. Findings include:Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia, auditory hallucinations, and chronic pain syndrome.On review of The Long-Term Care Agency reporting portal an incident dated 1/3/25 was reported. The incident documented Dietary Aide #1 and Dietary Aide #2 provided Resident #7 with THC (tetrahydrocannabinol) gummies; a psychoactive substance derived from cannabis. On review of the facility's incidents and accidents, a report initiated on 1/3/25 was located documenting the following investigation:On 1/3/25, the previous CEO 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents Minimum Data Set assessment included correct information. This was true for 1 of 3 residents (Resident #6) whose records were reviewed for accuracy of assessments. This deficient practice had the potential for negative consequences if residents were not 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.Resident # 6 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependance. Resident #6's admission MDS Assessment, dated 10/21/24, documented under A1500 in Section A, no for the question, Is 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 refer residents with a diagnosed mental disorder to the appropriate state-designated authority for an evaluation and determination. This was true for 3 of 3 residents (#5, #6, and #8), reviewed for PASRR level I evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, Alzheimer’s disease, and depression. The Change in Status MDS Assessment, dated 6/30/25, did not document Resident #5 had a PASRR level II. Resident #5’s PASRR level 1, dated 1/15/24, did not include documentation of Resident #5's depressive disorder, although it did document Resident #5 was taking Trazadone (an antidepressant) 50 milligrams at bedtime. On 8/6/25 at 5:15 PM, the Social Services Director…

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 and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate with hours posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:From 8/4/25 through 8/6/25 it was observed the nurse staffing information did not include the number of hours worked per shift for registered nurses, licensed practical nurses, and certified nursing assistants.On 8/6/25 at 10:30 AM, the Staffing Coordinator stated the hours worked for nursing staff were not posted for the number of covered positions on the daily staff postings. The hours should have been posted.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record review, and staff interview it was determined the facility failed to ensure significant medication errors were prevented. This was true for 3 of 3 residents (#2, #3, and #17) whose records were reviewed for significant medication errors. These findings created the potential for increased pain and adverse outcomes when medication was not administered according to the resident's physician order. Findings include:The facility’s Medication Errors policy, revised on 8/1/23, documented the following: A medication error is observed or identified when the observation or administration of drugs are not in accordance with: Prescriber’s Orders Manufacture’s specification regarding the preparation and administration of the drug or biological. Accepted professional standards and principles that apply to the professional providing services. 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain, absence of left hip joint, and flexion deformity 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.

Based on record review and staff interview, the facility failed to provide a minimum of 12 hours of in-service education per year for 2 of 3 CNAs (Certified Nursing Assistants; #1 and #2) reviewed for sufficient and competent CNA staffing. This deficient practice placed residents at risk of receiving care from staff who were not adequately trained to meet residents' needs. Findings include:A review of CNA staff records documented CNA #1 and CNA #2 had been employed at the facility for over 12-months. On 8/6/25 at 4:15 PM, a review of CNA #1's training records did not document completed hours for the previous 12-month annual evaluation period for 2024/2025.On 8/6/25 at 4:25 PM, a review of CNA #2's training records did not document completed hours for the previous 12-month annual evaluation period for 2024/2025.On 8/7/25 at 8:35 AM, the CEO stated the facility was unable to produce any records that CNA #1 and CNA #2 had the required annual 12-hours of training for the evaluation period of 2024/2025.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a RN was on-site 8 consecutive hours a day, 7 days a week to provide care and treatment to the residents. This is true for 5 of 21 days reviewed for sufficient staffing. This failure created the potential for harm if routine and /or emergency nursing needs were unmet and had the potential to affect all 33 residents in the facility. Findings include: The facility's Sufficient Qualified Nurse Staffing policy and procedure, released 11/28/17, documented the facility use the service of an RN for at least eight consecutive hours a day, 7 days a week. A Three-Week Nursing Schedule dated 7/28/24 - 8/17/24 documented there was no RN on-site for 8 consecutive hours on the following dates: 7/28/24, 8/2/24, 8/4/24, 8/9/24, and 8/11/24. On 8/22/24 at 3:00 PM, the DON stated she and another RN take turns being on-call and come in as needed when an RN is not available for a shift in a 24-hour day. The DON stated she was not aware a RN was required to be on-site 8 consecutive hours, 7 days 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 policy review and staff interview, it was determined the facility failed to ensure residents were provided with clean equipment to obtain vital signs and perform transfers. This deficient practice created the potential for residents to experience psychosocial harm if unclean equipment was used for their care. Findings include: The facility's Resident's Environment policy and procedure, revised 11/28/19, documented the residents are to have a safe, clean, comfortable, and homelike environments provided that allows the resident to receive treatment and supports daily living safely. 1. On 8/19/24 at 12:40 PM and on 08/20/24 at 10:24 AM the following equipment was observed: - Two Hoyer lifts were visibly dusty. Their bases were observed to have clear dried brown substance on them. Thick white or gray type of material was observed wrapped around the wheels. One of the Hoyer lift control wands for electric lifting was smeared with a light brown substance. - Three mobile blood pressure machines were noticeably dusty on reading screen, top, legs, and bases. One of the BP cuff 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 observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 7 residents (Resident's #24, #26, and #29) observed during dining in the facility. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: The facility's Dining Policy, revised 9/10/20, states the dining environment should enhance the quality of life of their residents by providing a pleasant atmosphere, including when the resident would like to eat, and having enough staff to serve the residents during mealtime. On 8/19/24 the following was observed: - At 12:10 PM, Resident #24 was sitting at a table by himself in the back corner. Resident #26 and Resident #29 were sitting at the end of the main table with two additional residents seated at the table with them. - At 12:25 PM, the facility staff began serving residents their meals. - At 12:31 PM, the tray cart was removed from the dining room. Resident #24, #26, and #29 had not been served their meal 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, policy review, and staff interview, it was determined the facility failed to ensure resident records were provided to the hospital upon transfer. This was true for 1 of 2 residents (Resident #16) reviewed for hospital transfers. This deficient practice created the potential for harm if Resident #16 was not treated in a timely manner due to lack of information provided upon transfer. Findings include: The facility's Transfer and Discharge policy and procedure, revised 10/15/22, documented upon transfer of a resident the following information should be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advanced directive information; d. Special instructions and /or precautions for ongoing care, as appropriate; e. The resident's comprehensive care plan goals; and f. All information necessary to meet the resident's needs. Resident #16 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.

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 medication was administered according to professional standards of practice. This was true for 1 of 5 residents (Resident #31) observed during medication administration. This created the potential for Resident #31 to develop a yeast infection when she did not rinse her mouth with water after taking her medication. Findings include: The Drugs website accessed on 8/27/24 stated to rinse your mouth well with water after taking fluticasone propionate (corticosteroid) to decrease the risk of a mouth infection. Spit out the water you rinsed with (do not swallow). Resident #31 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body tissue). Resident #31 physician's order included fluticasone propionate inhalation 2 puffs inhale orally two times a day related to moderate persistent asthma. On 8/21/24 at 8:09 AM LPN #1 handed…

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 professional standards of practice was followed for 1 of 13 residents (Resident #32) reviewed for standards of practice. Resident #32's care plan was not followed as directed. This deficient practice created a potential for harm to Resident #32 if care and services were not delivered according to her care plan. Findings include: The facility's Care Plan policy, revised 10/15/22, states that care plans are developed for a resident's specific condition, to include specific, measureable objectives, to meet the resident's needs as identified by their assessment, and response to the interventions or change in the resident's condition. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and morbid obesity. Resident #32's care plan, dated 3/11/24, directed staff to monitor/document/report to the physician as needed the following signs/symptoms: Edema, weight…

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 taking antipsychotic medications received an abnormal involuntary movement scale (AIMS) evaluation. This is true for 2 of 5 residents (Resident's #5 and #16) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents receiving antipsychotic medications were not monitored for adverse side effects. Findings include: The American Psychiatric Association (APA) website, accessed on 8/28/24, recommended that all patients taking an antipsychotic medication should be screened for tardive dyskinesia (a movement disorder that causes sudden, uncontrollable movements in the face and body) every six months. 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including traumatic subdural hemorrhage (a serious medical condition that occurs when blood collects between the skull and the surface of the brain), diabetes, and schizoaffective…

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.