Eagle Rock Health and Rehabilitation of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to complete a significant change in condition or status assessment MDS within 14 days to accurately reflect the resident's status. This was true for 1 of 1 resident (Resident #4) whose medical record was reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments. Findings include:Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (a long-term, progressive inability of the lungs to oxygenate the blood sufficiently) and dementia.Resident #4's physician order dated 2/19/26, documented End of Life Care: Hospice Services.Resident #4's care plan documented hospice care started 2/19/26.On 3/31/26 at 5:10 PM, the MDS coordinator stated the facility had not completed a significant change in condition or status assessment MDS within 14 days of Resident #4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR I), was completed correctly for 1 of 1 resident (Resident #13) reviewed for Level 1 PASARR screenings. This failure created the potential for harm if residents required, but did not receive specialized services for mental health while residing in the facility. Findings include:The facility's Pre-admission Screening and Resident Review (PASRR) Process dated 8/29/25, documented under Procedure1. Ensure Level I PASRR screening has been completed on potential admissions prior to admission. 2. A negative Level I screen permits admission to proceed and end (the) PASRR process during the initial admission process. 3. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II. 3a. When a Level II PASRR screening is warranted, it should be obtained (as well as determination…

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, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #13) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include:The facility's Comprehensive Care Plan and Conferences policy dated 9/3/25, documented the care plan will reflect the residents' individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes.Resident #13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder and joint replacement surgery aftercare.Resident #13's medical record dated 3/3/26, documented medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 22 residents (#2 and #12) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include. The facility's Resident Care Plan Revisions policy, revision date 9/3/25, documented.updates to the care plan will occur as needed based on the residents' response to interventions or changes in condition. Resident #2 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of the right tibia (lower leg bone) and anxiety. On 3/30/26 at 8:19 AM, Resident #2's physician order dated 3/6/26 - Edema Management Right lower leg: edema, apply Tubi grip on AM, off PM. On 3/30/26 at 11:33 AM, observed Resident #2 sitting 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 record review, policy review, and staff interview it was determined the facility failed to ensure physician orders were followed. This was true for 2 of 3 residents (#3 and #21) reviewed for quality of care. This failed practice placed residents at risk for discomfort and adverse effects, including potential for infection. Findings include:The facility's Standing Order - Bowel Protocol, signed date 12/18/25, documented: -Bowel Protocol Step 1: Senna 8.6mg 3 tablets PO at HS for constipation lasting >72 hours. -Bowel Protocol Step 2: Bisacodyl (Dulcolax) 5mg 3 tablets PO at HS for constipation lasting >96 hours.-Bowel Protocol Step 3: Bisacodyl (Dulcolax) suppository 10mg 1 suppository rectally at 10:00 for continued constipation morning after tablets.-Bowel Protocol Step 4: Fleets enema rectally at 12:00 for continued constipation 2 hours after suppository.-Special instructions: If no BM produced within 2 hours of enema, Call MD for further instruction.The facility's Infusion Therapy Responsibilities…

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 adequate care and treatment was provided to 1 of 1 resident (Resident #59) reviewed for enteral tube use. This created the potential for harm if complications developed from improper medication administration via enteral access device practice. Finding include:The facility's Medication Administration Enteral Assess Device policy, release date 9/16/25, directed staff to follow the general professional standards for safe administration of medications and verify tube placement per facility protocol.Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and dysphagia (difficulty swallowing).Resident #59's physician's order dated 1/21/26, documented Enteral Tube: May Crush meds or use liquid form via tube. Check tube placement via auscultation prior to medication…

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, manufacturer's PAP user manual, interview, and record review, the facility failed to ensure 3 of 4 Residents (#12, #13, and #53) received respiratory services as prescribed by the physician. This created the potential for residents to experience respiratory difficulties and impaired breathing. Findings include:The facility's BiPAP/CPAP Administration policy dated 9/12/25, documented the facility will provide non-invasive ventilation (NIV) using BiPAP or CPAP therapy in accordance with physician orders and professional standards of practice.[NAME] PAP therapy user manual undated, documented under oxygen safety information, when using oxygen with this system, a [NAME] Respironics pressure valve must be placed in-line with the user circuit between the device and the oxygen source. The pressure valve helps to prevent the back flow of oxygen from the user circuit into the device when the unit is off. Failure to use the pressure valve could result in a fire hazard. When using…

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, observation, record review, and interviews, it was determined the facility failed to provide adequate pain management. This was true for 1 of 1 resident (Resident #53) whose medical record was reviewed. This failure created the potential for residents to experience continual pain and distress. Findings include:The facility's Pain Assessment and Management policy dated 9/2/25, documented under Procedure, Pain Management, 2. The facility should address/treat the underlying causes of the pain, to the extent possible, a. developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management.Resident #53 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis of right ankle and foot (serious, often chronic bone infection (usually Staphylococcus aureus) requiring prompt treatment to prevent permanent damage) and lumbar vertebra fracture.Resident #53'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 personnel record review, policy review, facility assessment, resident record review, and staff interviews, it was determined the facility failed to ensure employees were competent to care for resident needs. This was true for 1 of 5 nurses observed for medication administration. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents. Findings include:The facility's Medication Administration policy revision date 9/10/25, stated if parameters are indicated, take (or delegate to appropriate qualified staff to take) vital signs prior to preparing the medication. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Interstitial lung disease (a group of over 200 disorders causing inflammation or scarring in the lung tissue between air sacs, making it difficult to breathe and get oxygen into the bloodstream) and heart failure.On 3/30/26 at 9:35 AM, LPN #2 gave Resident #21 his medication which included his Metoprolol…

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 nurse staffing information was accurate and 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:On 3/30/26 at 4:17 PM, the following dates and times were missing daily staffing sheets or staffing data on the daily staffing sheets. - 5/6/25 No RN or LPN data listed for day and evening shifts - 9/8/25 No RN or LPN data listed for evening shift - 9/19/25 No CNA data listed for day/evening/night shifts - 12/7/25 Daily staffing sheet missing - 12/20/25 Daily staffing sheet missing - 12/21/25 Daily staffing sheet missing - 12/22/25 Only 1 RN for 8 hours listed for evening shift, no licensed nurses scheduled for day or night shifts.On 3/31/26 at 4:00 PM, the Staffing Coordinator stated the missing staffing data and sheets from those dates listed should not have been missing but was.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined the facility failed to ensure residents received prior written rationale regarding room changes. This was true for 1 of 3 residents (Resident #5) whose records were reviewed. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include:Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by persistent airflow limitation and respiratory symptoms such as chronic cough, sputum, shortness of breath, and exacerbations) and diabetes.On 9/15/25 at 8:20 AM, the facility provided resident listing had Resident #5 documented as being in room [ROOM NUMBER]. On 9/15/25 at 8:25 AM, the surveyor found room [ROOM NUMBER] empty and RN#1 stated the resident had been moved to room [ROOM NUMBER] over the weekend. On 9/15/25 at 11:00 AM, Resident #5's medical record had no documentation 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 interview, policy review, and record review, the facility failed to ensure a copy of the residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This was true for 3 of 3 Residents (#9, #17, #23) reviewed for Ombudsman notification. This failed practice had the potential to affect all residents by; 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings include: Review of the facility's Discharge and Transfer policy with revision date 4/17/25, documented a copy of the notice of discharge or tranfer is sent to a representative of the Office of the State Long Term Care (LTC) Ombudsman.notices will be sent monthly.a. Resident #9 was admitted to the facility on [DATE], with multiple…

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, resident and staff interview, it was determined the facility failed to ensure resident meals were prepared and accommodated resident allergies, intolerances, and preferences to meet individual resident needs. This was true for 1 of 3 residents (Resident #5) who were interviewed about food services and had the potential to affect all residents with special dietary needs who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include:The facility's Nutrition policy dated 8/1/23, documented the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment and provides a therapeutic diet that considers the resident's clinical condition, and preferences. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung 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.

Based on observation, record review, and staff interview, it was determined the facility failed to maintain kitchen sanitation and food storage at least 6 inches above the floor. These deficiencies had the potential to affect the 53 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food and food services equipment. Findings include: 1. The Food and Drug Administration (FDA) Food Code Section 3-305.11, documented: (A) Food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. On 2/18/25, at 1:20 PM and 2/20/25 at 3:35 PM, it was observed the kitchen pantry shelves contained food items which were located 4.5 inches above the floor. On 2/20/25 at 3:40 PM, the Culinary Director confirmed the shelves containing food items were only 4.5 inches above the floor. 2. FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented:…

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 3. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness). An admission MDS assessment, dated 3/3/24 documented it was somewhat important for Resident #36 to have books, newspapers, and magazines to read; listen to music he likes; to do things with group of people, and be around animals such as pets. Resident #36's care plan, dated 12/14/24, did not address his preferences for his activities. Resident #36 was observed in his room on 2/18/25 at 4:28 PM. A calendar of activities was observed posted on the wall by the door. Resident #36 stated he was not interested in participating in any of the activities in the facility. Resident #36 was again observed to be in his room on 2/19/25 at 10:12 AM, and on 2/20/25 at 9:27 AM, sitting on his bed. There were no books, newspapers, or magazines observed in his room. On 2/20/25 at 10:51 AM, the CEO reviewed Resident #36's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, 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 17 residents (Resident #8) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include: The CMS SOM, Appendix PP, dated 8/8/24, 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. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar and psychotic disorders. Resident #8's physician orders documented: -Depakote (anticonvulsant to treat bipolar) was discontinued on 6/20/24. -Mirtazapine (antidepressant) was discontinued on 6/20/24. -Lorazepam (antianxiety),…

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 residents received oxygen therapy per physician orders. This was true for 1 of 4 residents (Resident #36) reviewed for oxygen therapy. This deficient practice created the potential for harm if residents' respiratory needs were not met. Findings include: The facility's Oxygen Therapy policy and procedure, revised 8/4/23 directed staff to verify physician's order prior to initiating oxygen therapy. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness). A care plan, initiated 2/26/24, documented Resident #36 used supplemental oxygen related to shortness of breath. The care plan directed staff to administer oxygen via nasal cannula as ordered. A physician assistant's progress notes, dated 2/19/24, documented Resident #36 had oxygen levels greater than…

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, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 2 residents (#42 and #48) reviewed for medication errors. This deficient practice created the potential for harm if residents received the wrong dosage of medications. Findings include: The facility policy for Oral Medication Administration, dated 1/1/18, included the direction for nursing staff to validate the order against the medication packaging, confirm correct dose, correct route, and time/frequency. 1. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including amputation of the left and right great toe, gangrene (a condition where the tissue dies due to lack of blood supply), and disease of the spleen. A Medication Error Report, dated 1/13/25, documented the following: -A photocopy of a prescription, dated 1/7/25, documented oxycodone (a narcotic used to treat pain), 5 mg…

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 physician orders were followed for 1 of 9 residents (Resident #2) whose records were reviewed for quality of care related to following medication and treatment orders. This failure created the potential to adversely affect residents whose care and services were not delivered according to their physician orders. Findings include: Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including olecranon (elbow) fracture, Parkinson's Disease, and acute respiratory failure. Her record documented medication administration discrepancies including an AM medication given in the evening and medications crushed into food without an order. Resident #2's record included 32 Daily Skilled Nursing Notes, between the dates of 7/5/24 through 8/13/24, documented Resident #2's medications were crushed and added to applesauce, pudding, or yogurt when given to her. On 8/12/24 at 12:31 PM, LPN #4 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure medications were reconciled and removed from a medication cart when discontinued for 1 of 3 medication carts observed. This was true for 1 of 19 residents (Resident #105) and created the potential for harm for 19 residents who received medications from the cart due to an increased risk for medication administration errors. Additionally, this failure created an increased risk for medication diversion. Findings include: Resident #105 was admitted to the facility on [DATE], with multiple diagnoses including metabolic acidosis (a buildup of too much acid in the body resulting in kidney failure), diabetes, and hypertension. On 10/29/24 at 3:45 PM, the facility's medication cart for the 200 and 400 halls was inspected with LPN #1 present. LPN #1 was observed to remove a blister pack from the cart and began to prepare a medication disposal kit to destroy the medication. The blister pack contained 31 tablets 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 observation, record review, and staff interview, it was determined the facility failed to ensure medications were labeled correctly for 1 of 3 carts observed. This failure created the potential for harm if the resident who was prescribed the medication (Resident #104) received the wrong dose of his medication. Findings include: Resident #104 was admitted to the facility on [DATE], with multiple diagnoses including left arm fracture, heart failure, hypertension (high blood pressure), and pain. Resident #104's October 2024 MAR documented her prescribed oxycodone (a semi-synthetic opioid used for pain) 5 mg every four hours as needed for pain was discontinued on 10/24/24 and replaced with a new order for oxycodone 5 mg, four times a day (every 6 hours). On 10/29/24 at 3:45 PM, the 300 Hall medication cart was inspected with LPN #1 present. Resident #104's blister pack label for her oxycodone 5 mg stated every 4 hours as needed. The label did not reflect the updated order of four times a day (every 6…

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 resident and staff interview, it was determined the facility failed to ensure physician orders were obtained for supplemental oxygen use for 1 of 15 residents (Resident #16) and failed to ensure staff changed and dated residents' oxygen tubing and humidification bottles per physician orders and facility policy for 2 of 15 residents (#16 and #37) reviewed for oxygen use. These deficient practices placed Resident #16 and Resident #37 at risk for respiratory infections due to growth of pathogens in oxygen humidifiers or tubing, and Resident #16 at risk for respiratory distress from receiving too little or too much oxygen. Findings include: The facility's Oxygen Therapy policy, revised 8/4/23, documented residents received respiratory treatments and monitoring, per physician orders, standards of practice and care plan. The amount, method and duration of oxygen usage and diagnosis were identified on the resident's treatment record per physician orders and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents were offered or received influenza or pneumococcal pneumonia immunizations. This was true for 1 of 5 residents (Resident #16) reviewed for immunizations. This failure placed Resident #16 at risk for harm should he experience illness from contracting pneucoccoal pneumonia or influenza. Findings include: Resident #16 was admitted on [DATE], with multiple diagnoses including heart failure, respiratory failure, and sleep apnea (sleep disorder in which breathing frequently stops and starts). The Facility's Pneumococcal Program policy, revised 2/22/22, and the Influenza Program policy, revised 8/1/23, stated the resident and/or their representative would receive education regarding immunizations for influenza and pneumococcal pneumonia . The policies also stated the resident would be offered and administered the immunizations unless it was medically contraindicated, the resident had already had an immunization for…

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 3 of 3 CNAs (CNA #1, CNA #2, and CNA #3) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained in competencies to meet residents' needs. Findings include: On 1/11/24, the prior year's in-service training was requested for CNA #1, CNA #2, and CNA #3. The facility's Administrator stated that in-service training was not provided since the facility's change of ownership one year ago. He confirmed CNA #1, CNA #2, and CNA #3 had not completed the required 12 in-service hours in the past year.