Teton Healthcare of Cascadia

Based on observations, record review, and staff interviews it was determined the facility failed to ensure medications were not expired and were secure and inaccessible to unauthorized staff and residents. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy and potential for harm to a resident if they obtain medications which were left unattended and unsecured by staff. Findings include: The facility's policy, Medication Storage & Labeling, dated 10/13/25, documented.Procedure 2. Storage Requirements a. General Medications: i. Store in locked compartments (cabinets, carts, medication rooms), ii. Maintain clean, sanitary conditions: prevent contamination.5. Disposal a. Expired or discontinued medications must be removed promptly and disposed of per facility policy and DEA guidelines to prevent diversion. On 3/2/26 at 8:50 AM, observed in the Medication Storage room with LPN #1 present the following:Three bottles of Rena Vite 100 tablets with a manufacturer printed expiration date of 1/2026Two bottles…

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 the FDA Food Code, policy review, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled, cooking equipment was free of encrustation, and the floors were properly cleaned and sanitized. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination of food and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code 2022, 3-501.17 documented, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The FDA Food Code 2022, 4-601.11, documented, Equipment, Food-Contact Surfaces,…

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 infection control prevention practices were maintained to provide a safe and sanitary environment during medication administration. This was true for 1 of 4 residents (Resident #60) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include:The facility's policy, Medication Administration, revision date, 12/18/21, 9/10/25, documented.Procedure 9. a. Remove medication from the storage receptacle (container, bottle, or blister pack) without directly touching the medication.Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that restricts airflow causing breathing difficulty) and diabetes.Resident #60's physician orders documented fifteen morning medications for resident including Colace 100 mg - 1 soft gel capsule by mouth.On 3/4/26 at 8:30 AM,…

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 residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility who are transferred with Hoyer lift equipment. This deficient practice created the potential for harm from cross contamination due to equipment not being cleaned between use. Findings include:The facility Work Practices Cleaning policy dated 1/1/18, documented multiple use resident care items are properly cleaned/disinfected between each resident use. Resident care items may include but is not limited to resident lifts.The following areas were observed: - On 8/14/25 at 7:55 AM, observed in room [ROOM NUMBER], a sticky substance on the over the bed table and a dry black substance on commode. - On 8/14/25 at 8:25 AM, observed in room [ROOM NUMBER], next to Resident #89’s bed and by the bathroom door a trash can with soiled briefs in it. On 8/14/25 at 8:30 AM, CNA #4 stated the garbage…

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's care plans were revised to reflect current needs and interventions. This was true for 1 of 3 residents (Resident #5) 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 Accidents and Supervision to Prevent Accidents policy dated 10/15/22, documented under falls, development of a person-center plan of care by the interdisciplinary team can evaluate potential use of therapy, devices, environmental adjusts, review of medications, and treatment of other impacting factors may reduce the number of outcome severity of falls. If fall occurs, manage the fall, then determine root-cause analysis to assist with updates to the fall prevention plan. When reviewing root-cause, evaluate all the causal factors leading to the resident fall as the(y)…

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 stored appropriately; this was true for 1 of 18 resident's rooms inspected (Resident #1). This failure created the potential for adverse effects if residents self-administered medications inappropriately or did not take their medications. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and hypertension.On 8/14/25 at 8:44 AM, observed on Resident #1's bedside table a medication cup with a purple substance with multi-colored specks and a spoon in it.On 8/14/25 at 8:48 AM, RN #1 stated Resident #1 did not have an order to self-administer medications, she did not have it documented in her care plan to self-administer medication so she should not have left the medications in her room.On 8/14/25 at 11:38 AM, the DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment, when staff did not follow proper enhanced barrier precautions protocol. These failures had the potential to impact 1 of 5 residents (Resident #70) observed with EBP signs on their room doors, placing them all at risk for cross-contamination and infection. Findings include:Resident #70 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis (inflammation of the bladder) and dysphagia (difficulty or pain with swallowing). On 8/14/25 at 7:36 AM, observed CNA #2 had not donned a gown or gloves when she assisted Resident #70 with a transfer from her bed into her wheelchair and then into the shower room where she assisted her with a shower. Resident #70 was on EBP with a sign on her door that documented for staff to wear gown and gloves when assisting with transfers and showering. On 8/14/25 at 7:40 AM, CNA #2…

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 a) the kitchen equipment and environment was maintained and clean, and b) food was served in a safe and sanitary manner. These deficiencies placed all residents who consumed food prepared by the facility at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. The FDA Food Code Section 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 74 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified and b) residents were injured due to unsafe areas in the facility. Findings include: The facility's Resident's Environment policy, revision date 11/28/19, documented: - The facility would provide a safe, clean, comfortable, and homelike environment. - Housekeeping and maintenance services would provide services to maintain a sanitary, orderly, and comfortable interior. The following areas were observed: - On 12/16/24 at 9:54 AM, observed in room [ROOM NUMBER], the baseboard by the shower stall was loose and sticking out from the wall. On 12/16/24 at 10:01…

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' Minimum Data Set (MDS) had correct assessment information. This was true for 3 of 5 residents (#27, #41, and #52) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/2024, documents if a PASRR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes. 1. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including depression, bipolar disease, and schizophrenia. Resident #27's record documented a PASARR level II, dated 10/12/18, was completed. Resident #27's Significant Change MDS, section A1500, dated 2/20/23, documented no, he did not have a completed PASARR…

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 interview, it was determined the facility failed to develop and implement comprehensive person-centered care plans. This was true for 4 of 18 residents (#33, #34, #220, and #226) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plans. Findings include: The facility's Care Plans policy revision date 10/15/22, documented the facility develops and implements a comprehensive person-center care plan for each resident, consistent with the residents' rights and include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. 1. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including fractured pelvis and need for assistance with personal care. On 12/16/24 at 3:06 PM, Resident #33 stated she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 3 of 74 residents (#1, #33, and #226) whose care plans were reviewed. This placed residents at 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 facility's Care Plan policy, revision date 10/15/22, documented the team of qualified persons monitor the resident's condition and effectiveness of the care plan interventions and revises the care plan quarterly, annually, with a significant change assessment or more frequently as needed with input by the resident and/or the representative, to the extent possible based on the following: a. Achieving the desired outcome. b. Resident failure or inability to comply with or participate in a program to attain or maintain the highest practicable level 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 observation and resident and staff interview, it was determined the facility failed to ensure resident meals were palatable and maintained correct temperatures. This failed practice affected 3 residents (#15, #45, and #226) and had the potential to negatively affect all residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code, states hot food will be maintained at 135 degrees F or above and cold foods will be maintained at 41 degrees F or below. On 12/16/24 at 10:00 AM, resident #15 stated the food is cold and the cream of wheat is one big lump most days. On 12/16/24 at 12:58 PM, resident #226 stated the food is barely warm and soggy. On 12/16/24 at 3:15 PM, resident #45 stated the food is cold. On 12/20/24 at 8:20 AM, a tray from the last meal cart delivered on the 200 hall was tested for palatability and serving temperature with the following results: - Gravy = 120 degrees F - Scrambled eggs = 115 degrees F On 12/20/24 at 10:30 AM, the DM stated the temperature for the gravy and the scrambled eggs should be at 135 degrees F.

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 prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Hand Hygiene Policy revision date 2/11/22, documented staff are to assist residents to wash their hands after toileting, when leaving their room, prior to eating or entering the dining room, and when soiled and/or potentially soiled. ABHR may be used as directed. The facility's Resident's Environment policy, revision date 11/28/19, documented the facility would provide a safe, clean, comfortable, and homelike environment. The following were observed for hand hygiene: a) On 12/16/24 at 7:52 AM, Resident #3's meal tray was served to him in his room by the IP nurse. Resident #3 was not offered or encouraged to perform hand hygiene before eating. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to provide the Advance Beneficiary Notice (CMS-10055 form) for 2 of 2 residents (#60 and #62) and Notice of Medicare Non-Coverage (NOMNC) (CMS- 10123 form) for 1 of 1 resident (Resident #232) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include: 1. Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including left femur fracture and traumatic brain injury. A Skilled Nursing Facility Beneficiary Notification Review documented Resident #60's Medicare A benefit ended on 11/20/24 and she continue to stay in the facility. Resident #60's record did not include an Advance Beneficiary Notice (ABN). 2. Resident #62 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, staff interview, and policy review, it was determined the facility failed to ensure resident's privacy was maintained during cares, treatment information was protected, and residents had unrestricted access to review mail in a timely manner. This was true for 1 of 4 medication carts, 1 of 18 residents (Resident #53) reviewed for privacy and confidentiality, and all residents who receive mail at the facility. This deficient practice placed residents at risk of embarrassment, loss of control over their personal information, diminished quality of life, and psychosocial distress. Findings include: The facility's Resident Rights policy, dated 10/15/22, documented the facility would take measures to ensure that each resident has the right to personal privacy. 1. On 12/16/24 at 8:00 AM, observed on hall 400, a computer on top of the medication cart opened to resident information, the medication cart keys were in the lock, and the cart was unlocked. On 12/16/24 at 8:02 AM, RN #1 stated she should…

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 resident's hospital discharge instructions were reviewed upon readmission to the facility to assure physician orders were in place to meet their medical needs. This was true for 1 of 1 resident (Resident #53) whose records were reviewed. This failure placed Resident #53 at risk of delayed care and assessments for a foley catheter. Findings include: Resident #53 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis (inflammation of bone caused by infection) of the right ankle and foot and diabetes. Resident #53's discharge Physician Orders & Plan of Care from the hospital dated 9/18/24, documented in the Physician Order section, bladder train and discontinue foley when able. Resident #53's Admissions MDS, dated [DATE], documented under Section H, Yes for indwelling catheter. On 12/19/24, a review of Resident #53's physician orders did not document an order for her to have a foley catheter,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. This was true for 1 of 3 residents (Resident #1) reviewed for restorative nursing services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include: The facility's Quality of Life policy, revision date 10/15/22, documented the facility provides the appropriate treatment and services to maintain or improve his/her ability to carry out activities of daily living and their abilities do not diminish unless circumstances of the individual's clinical condition demonstrate such decline was unavoidable. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of the lower end of the left Tibia (shin bone) and need for assistance with personal…

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, and record review, it was determined the facility failed to notify the physician with resident's significant weight loss. This was true for 3 out of 18 residents (#34, #59 and #62) whose medical records were reviewed. This deficient practice had the potential to cause cognitive and functional decline. Findings include: 1. Resident #34 was admitted to the facility on [DATE], with multiple diagnoses including dementia and kidney failure. Resident #34's record documented on 11/13/24, he weighed 167 pounds. On 11/28/24, Resident #34 weighed 151 pounds which was a -9.58% weight loss. Resident #34's care plan directed staff to notify MD for weight change. On 12/20/24 at 10:43 AM, the CRN stated, the physician should have been notified of Resident #34's weight loss. 2. Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including kidney failure and nutritional deficiency. Resident #59's record documented on 9/7/24, he weighed 199.2…

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

Based on staff interview and review of employee personal files, it was determined the facility failed to provide a minimum of 12 hours of in-service education per year for 1 of 2 CNAs (CNA #1), failed to ensure each CNA's performance was evaluated at least once every 12 months and annual evaluations were performed for 2 of 2 CNAs (CNA #1 and #4) whose personnel records were reviewed for sufficient and competent staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility. Findings include: The following were reviewed for 12 hours of in-service education: 1. On 12/20/24 at 9:45 AM, review of CNA #1's employee file documented her hire date was 2/1/22. Review of CNA #1's Employee in-service hours, documented she had 6 hours for 2022-2023. CNA #1 had no documented in-service training hours for 2023-2024. On 12/20/24 at 10:04 AM, the HR/Payroll coordinator stated CNA #1 had not completed her training and should have. The following were reviewed for annual performance reviews: 1. On 12/20/24 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.

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 12/16/24 at 7:13 AM, observed the Daily Staffing form dated 12/14/24. On 12/16/24 at 7:22 AM, the Administrator stated the Daily Staffing form should have been changed every morning.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to ensure the medical necessity for psychotropic medication administration. This was true for 1 of 3 residents (Resident #40) reviewed for psychotropic medication administration. This failure created the potential for negative side effects related to receiving psychotropic medications that are not necessary. Findings include: The facility's Psychoactive Drug Use policy revision date 10/15/22, documented psychoactive drugs are used only when necessary to treat a specific condition. Resident #40 was initially admitted on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia and dysphagia (difficulty swallowing). Resident #40's Acknowledgement of Psychoactive Medication Use form for Risperdal (antipsychotic used to treat schizophrenia, bipolar, and autism spectrum disorder) dated 12/28/22, did not document the medical symptom treated/basis for use. A Pharmacy Medication Regimen Review form dated 7/27/23,…

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.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately and properly labeled; this was true for 3 of 74 residents (#1, #50, and #223) rooms inspected and 1 of 4 medication carts observed. This failure created the potential for adverse effects if residents self-administered medications inappropriately or receive the wrong medication due to improper labeling. Findings include: The facility's Medication Management policy revision date 10/15/22, documented: - medications are labeled in accordance with facility requirements, State and Federal regulations. - medications are provided in packaging to facilitate proper storage and administration of the medication using the agreed upon distribution system. The following was observed for medication in resident rooms: a) On 12/16/24 at 10:36 AM, observed in Resident #1's bathroom, another resident's tube of Calcipotriene ointment 0.005% (a prescription ointment to treat psoriasis). On 12/16/24 at 10:41 AM, the MDS Coordinator #2…

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 records review and interviews, it was determined the facility failed to ensure resident food intolerances and preferences were accommodated. This was true for 1 of 1 resident (Resident #229). This had the potential for adverse health effects and possible harm to residents with food intolerances or allergies. Findings include: Resident #229 was admitted to the facility on [DATE] with multiple diagnoses including surgical aftercare, lactose intolerance, and gluten sensitivity. On 12/16/24 at 1:24 PM, Resident #229 stated her family had to bring her food in over the weekend because she needed a gluten and lactose free diet and the facility kept serving her gluten and lactose type foods. When she complained the facility brought her a grilled cheese sandwich. The menu for 12/14/24 included the following; - Breakfast - Coffee Cake, Cinnamon Baked Apple Slices, Fried Egg, Sausage Links, - Lunch - Ham & Cheese Croissant Sandwich, Shredded Lettuce/tomato, Barley Beef Vegetable Stew, Peanut Butter Oatmeal Cookie,…

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 resident and staff interview, it was determined the facility failed to ensure a resident had a quarterly interdisciplinary care plan review that included participation of the physician or non-physician practitioner, a registered nurse, a nurse aide, or a member of the food and nutrition staff. This was true for 1 of 15 residents (Resident #17) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan. Findings include: The facility's care plan policy, revised 11/29/19, stated: Care conference meetings are scheduled on admission, quarterly, and with change of condition. The facility provides sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident's representative (such as conducting the meeting in-person, via conference call, or video conferencing), and planning enough time for information…

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.