Cascadia of Nampa

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 residents received respiratory services consistent with physician's order and/or their care plan. This was true for 1 of 3 residents (Resident #1) reviewed for oxygen use. This deficient practice created the potential for harm if Resident #1's respiratory needs were not met. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and overactive bladder.A physician's order dated 11/30/25, documented Resident #1 was to receive oxygen 1 liter per minute per nasal cannula to maintain her oxygen saturation greater than 90% every shiftA care plan initiated 5/27/25, documented Resident #1 was to receive oxygen as ordered by the physician.Resident #1 was observed without using her oxygen via nasal cannula on:12/2/25 at 9:11 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 policy review, review of McGeer's Criteria Surveillance for Infection, and staff interviews, it was determined the facility failed to ensure antibiotic stewardship was implemented and residents had appropriate clinical indications for the use of antibiotic. This was true for 1 of 1 resident (Resident #1) whose record was reviewed for antibiotic use. This deficient practice created the potential for Resident #1 to receive unnecessary treatment for a suspected urinary tract infection and/or develop multi-drug-resistant organism. Findings include:The facility's Antibiotic Stewardship policy revised 10/15/22, documented the facility focused on improving antibiotic use through an Antibiotic Stewardship program to ensure appropriate antibiotic usage are in place, to promote therapeutic and cost-effective care for the residents, and ultimately reduce the likelihood of developing multi-drug-resistant organism. The policy also documented the facility utilized McGeer's criteria to validate the infection, 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.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This created the potential for insect and pest infestation of the facility's premises and had the potential to adversely affect all 90 residents residing in the facility. Findings include: The facility's Pest Control policy, dated 10/18/23, documented routine inspections were conducted at the facility for evidence of pests. The policy documented staff were to keep the facility grounds free of trash and brush and to keep the dumpster area clean and the lid closed. On 6/18/24 at 10:20 AM, with the Dietary Manager the area in the parking lot behind the kitchen where the trash dumpster was located was observed. One dumpster used to contain the facility trash and recycling material was open and the lid was flipped back exposing boxes and bags of trash. During an interview on 6/18/24 at 10:20 AM, the Dietary Manager stated, The dumpster should be closed and not left open.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents' rights for self-determination was honored. This was true for 3 of 3 residents (#5, #35, and #49) reviewed for choices. This deficient practice had the potential for Resident #5, #35, and #49 to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for having the television (TV) on in the dining room during meals was not accommodated. Findings include: Review of the facility document, Resident Rights 2017, documented .The Resident has the right to make choices about the aspects of his/her life in the facility that are significant to the resident . - Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including spina bifida (a condition that occurs when the spine and spinal cord do not form properly which can range from being mild to causing serious disabilities) and muscle weakness. An…

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 a fall prevention intervention was implemented following a fall. This was true for 1 of 3 residents (Resident #10) whose records were reviewed. This had the potential for harm if the resident sustained an injury from a fall. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, dated 10/15/22, documented .The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistance devices to each resident to prevent avoidable accidents . Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including abnormalities of gait and mobility. A fall risk evaluation, dated 8/8/23, documented Resident #10 was a fall risk. A quarterly MDS assessment, dated 8/10/23, documented Resident #10 was moderately cognitively impaired. The assessment further documented she required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review and staff interview, it was determined the facility failed to ensure residents were offered a pneumococcal vaccine they were eligible to receive. This was true for 2 of 5 residents (#31 and #52) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 3/15/23, located at https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, included recommendations for pneumococcal vaccinations for all adults 65 years or older as follows: - For those who have never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV20 or PCV15. - For those who have previously received PCV13 at any age and PPSV23 at less than [AGE] years of age, the CDC recommends receiving PCV20 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure the dishwasher was maintained at an appropriate rinse temperature to ensure the dishes and utensils were sanitized, and failed to ensure food was placed on and held at a safe temperature on the steam table. These deficient practices placed the 79 of 79 residents who resided in the facility (each consumed food prepared by the facility) at risk of contracting foodborne illnesses. Findings include: 1. On 1/30/19 at 11:13 AM, FSE (Food Service Employee) #1 ran pots, pans, and utensils through the dishwasher. The rinse temperature of the dishwasher reached 173 degrees Fahrenheit (F) when she ran the pots/pans through the dishwasher, and 169 degrees (F) when she ran the rack of silverware through the dishwasher. She continued using the dishwasher even though the rinse temperature did not reach 180 degrees (F). On 1/30/19 at 11:15 AM, FSE #1 said she had not checked the water temperature and did not know what temperature the rinse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, policy review, review of meeting minutes, and record review, it was determined the facility failed to provide guidance to assist the Resident Council group with agenda items to address and discuss facility policies/rules, concerns and grievances, and requests that resulted from the group meetings, and failed to act promptly to resolve and respond to requests from the group meetings. This was true for 13 of 13 (#3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53) residents who attended the Resident Group Meeting. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Findings include: Review of the facility's 11/28/17 policy, Resident & Family Group Meetings, indicated the facility was to, Respect their residents' right to organize and participate in resident/family groups in the facility. Definition .…

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 5. Resident #43 was admitted to the facility on [DATE], with multiple diagnosis including type II diabetes and cerebrovascular (related to blood vessels of the brain) disease. Resident #43's POST, dated 12/18/18, documented a code status of Full Code. The POST section for Advance Directives to identify a Living Will was blank. Resident #43's care conference note, dated 12/27/18, documented the Advance Directive was reviewed and continued. On 1/30/19 at 10:41 AM, Resident #43 said he had a living will. On 1/30/19 at 4:12 PM, Resident #43's spouse said she was unsure if a copy of the living had been provided to the facility, and said she had a copy of the living will in the car, if the facility needed it. On 1/31/19 at 10:04 AM, the Social Worker said she knew Resident #43 had a living will, and did not see a copy of it in his chart. 4. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction…

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, review of meeting minutes, and resident, family member, and staff interview, it was determined the facility failed to ensure grievances were responded to, investigated, and prompt corrective action taken to resolve the grievances. This was true for 4 of 21 residents (#1, #24, #41, and #64) reviewed for grievances and 13 of 13 residents (#3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53) who participated in the Resident Group Interview. This failure created the potential for harm if residents' grievances, both verbal and written, were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Complaints and Grievances policy and procedure, dated 11/28/17, documented an individual had the right to voice grievances to the facility or other agency or entity that hears grievances without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, family, and staff interview and record review, it was determined the facility failed to ensure care plans were reviewed and/or revised, and failed to ensure residents and/or resident representatives were involved in the development of the care plan for 9 of 22 residents (Residents #1, #7, #14, #15, #32, #54, #64, #267, and #318) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate care due to inaccurate information on their care plan and should residents' input not be considered on the care plan. Findings include: 1. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, abnormal posture, multiple sclerosis (degenerative neurological disorder), and hereditary spastic paraplegia (progressive weakness and stiffness of the legs). Resident #32's quarterly MDS assessment, dated 10/29/18, documented she was cognitively intact. She required extensive assistance from staff for bed mobility,…

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 4. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #7's admission MDS assessment, dated 6/28/18, documented she was cognitively intact, family involvement in discussions about her care was very important, and she required the assistance of one person for bathing. Resident #7's care plan, dated 1/6/19, directed staff to provide Resident #7 with one shower a week. Resident #7's bathing/shower flowsheets and nurses' progress notes, dated 10/1/18 through 1/26/19, documented missing shower entries. The flowsheets documented if Resident #7 refused, to please call her daughter and notify social services. Showers should have been provided for Resident #7 on Sundays and Thursdays. Resident #7 did not receive baths/showers as follows: * Documentation from 10/6/18 - 10/14/18 included: - On 10/6/18 shower - On 10/10/18 not applicable - On 10/14/18 shower Resident #7 did not…

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 2. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including difficulty in walking, generalized muscle weakness, history of falls, and unspecified dementia without behavioral disturbances. Resident #1's admission MDS, dated [DATE], and quarterly MDS, dated [DATE], documented he had severe cognitive impairment. He required extensive assistance of staff for bed mobility, transfers, dressing, personal hygiene, and toileting, was totally dependent on staff for bathing, and required limited assistance to walk in room and eat. He was not steady or able to balance with transfers. Resident #1's care plan for falls, revised on 12/24/18, documented he was at risk for falls due to having actual falls with no injuries and due to having dementia with poor safety awareness, poor balance, confusion, vision/hearing problems, and having an unsteady gait. The interventions on the plan of care included neurological assessment checks per policy and procedure. Resident #1's Post Fall Investigation report,…

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 #1 was admitted to the facility on [DATE], with multiple diagnoses including a history of falls, difficulty walking, muscle weakness, and dementia without behavioral disturbances. Resident #1's admission MDS assessment and the quarterly MDS assessment, dated 09/20/18 and 12/20/18, respectively, documented he was severely cognitively impaired, required extensive assistance of staff for bed mobility, transfers, dressing, and toileting; and required limited assistance to walk in his room and eat; and he was not steady or able to balance with transfers. Resident #1's care plan, revised on 12/24/18, directed staff that he was at risk for falls due to actual falls with no injuries and due to dementia with poor safety awareness, poor balance, poor communication/comprehension, confusion, incontinence, vision/hearing problems, and unsteady gait. Resident #1's Incident Reports, dated 9/16/18 at 6:30 AM, 9/29/18 at 12:40 PM, 11/26/18 at 11:25 PM, 12/8/18 at 3:00 AM, and on 12/21/18 at 11:40 PM, documented he…

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 interview, and record review, it was determined the facility failed to ensure 2 of 2 residents (#15 and #168) reviewed for self-administration of medications were clinically appropriate to do so prior to allowing them to self-administer medications. This had the potential for harm should the residents administer medications contrary to physician orders. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses, including major depressive disorder, insomnia, anxiety disorder, and bipolar disorder. Resident #15's quarterly MDS assessment, dated 12/4/18, documented he was cognitively intact, did not exhibit behaviors, and required supervision for bed mobility, transfers, walking in his room and the corridor, locomotion, dressing, and eating, and required limited assistance with toilet use. On 1/30/19 at 2:25 PM, Resident #15 had a baggie with a prescription cream inside the bag on his overbed table. The pharmacy label on the cream…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and resident and staff interviews, it was determined the facility failed to ensure a resident's physician and representative were notified of significant changes in the resident's clinical condition in a timely manner. This was true for 1 of 3 residents (Resident #319) reviewed for notification of changes. This failure created the potential for harm when the facility failed to immediately notify Resident #319's physician and family member of his decreased level of consciousness. Findings include: The facility's policy for Resident Change of Condition, dated 11/28/17, documented the following: * When a potentially life-threatening condition is recognized, the nurse should relay the information to the health care provider. * Changes of condition may include a change in functional status, new or increased confusion, deteriorating mobility, falls, changes in behavior, and potentially life threatening conditions related to a change in the resident's chronic disease state and…

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

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure the residents' living environment was homelike. This was true for 4 of 22 residents (#16, #24, #29, and #41) reviewed for homelike environment. This failure created the potential for diminished quality of life and psychosocial harm for those residents with room wall damage. Findings include: The facility's General Environmental Condition policy and procedure, dated 11/28/17, documented a comfortable environment was provided for residents, staff and the public. Plant operation and maintenance services were provided to maintain the inside and outside of the building, as necessary (e.g., painting, building repair such as handrails, flooring, plumbing, electrical, yard work, etc.). On 1/28/19 at 10:55 AM, Resident #16's room was observed with 4 inch by 4 inch wall damage above the baseboard on the west wall, and 12 inch by 12 inch wall damage on the south wall. Resident #16 stated he could not avoid hitting the wall with his wheelchair and the other wall damage was done…

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

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the required documentation was completed when a resident was transferred to the hospital. This was true for 1 of 3 residents (#318) reviewed for transfer or discharge, and had the potential for harm if the required documentation was not obtained from the physician and the pertinent information made available to the receiving facility. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Information provided to the receiving facility should include, at a minimum, contact information of the responsible medical practitioner and the resident's representative, Advance Directive information, special instructions and/or precautions for ongoing care, the resident's care plan goals, and all information necessary to meet the resident's needs . A Progress Note, dated 1/27/19 at 3:11 AM, documented Resident #318 was transferred to the emergency room per MD verbal order at 1:30 AM due to increased blood in her 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.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a notice of transfer was provided in writing to a resident and/or her representative when she was transferred to the hospital. This was true for 1 of 3 residents (#318) reviewed for transfer or discharge, and had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Contents of the written notice would include the reason for transfer/discharge, the effective date, the location of where the resident is being transferred/discharged , the contact information for the state ombudsman, and the contact information for the agency responsible for protection and advocacy of those who are developmentally disabled or mentally ill. A Progress Note, dated 1/27/19 at 3:11 AM, documented Resident #318 was transferred to the emergency room at 1:30 AM due to increased blood in her Foley catheter, worsening flank pain, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to complete a comprehensive assessment when a resident experienced a significant change in health and functional status. This was true for 1 of 1 resident (#65) reviewed for hospice. This had the potential for harm if facility staff did not recognize changes in the resident's health status and needs. Findings include: The facility's Resident Assessment policy, dated 11/28/17, documented a significant change assessment should be completed within 14 days after the facility determines or should have determined there has been a significant change in the resident's physical or mental condition. Resident #65 was admitted to the facility on [DATE] with multiple diagnoses, including dementia. Resident #65's admission MDS assessment, dated 11/2/18, documented he did not have hospice services. There were no other comprehensive MDS assessments found in Resident #65's clinical record. Resident #65's progress note, dated…

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 develop and implement comprehensive resident-centered care plans to include code status and assistance with eating. This was true for 2 of 21 residents (#40 and #43) who were reviewed for care plans. This failure created the potential for harm if residents received inappropriate or inadequate care, and if their resuscitation code status wishes were not honored. Findings include: The facility's care plan policy, dated 11/28/17, documented comprehensive person-centered care plans would be developed for each resident to attain or maintain residents highest practicable physical, mental, and psychosocial well-being. 1. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses, including aphasia (loss of ability to understand or express speech, caused by brain damage), muscle weakness, dysphagia (difficulty swallowing), and dementia. Resident #40's admission MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in ROM (range of motion). This was true for 1 of 5 residents (#38) reviewed for treatment and services related to ROM. This deficient practice placed residents at risk of experiencing a decrease in mobility and function due to lack of active ROM (AROM) or passive ROM (PROM) services. Findings include: The facility's Range of Motion policy and procedure, dated 11/28/17, documented staff were to provide care and treatment to help residents reach and maintain his/her highest level of range of motion as a maintenance program or as a preventative measure to reduce the risk of or prevent avoidable decline. Resident #38 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses which included diabetes mellitus, muscle weakness, and difficulty walking. A quarterly MDS assessment, dated 10/25/18,…

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 staff interview, policy review, and record review, it was determined the facility failed to ensure the bowel protocol was followed and implemented for 1 of 2 residents (#267) reviewed for bowel and bladder care. This had the potential to place residents at risk for fecal impaction. Findings include: The facility's Bowel Care Protocol, updated on June 2018, stated CNAs were to document each shift residents' number of bowel movement or lack of bowel movement, bowel consistency, and size of bowel movement. When a resident did not have documented bowel movement in the last 48 hours, the night nurse was responsible to ensure the physician's orders included approval to follow the Bowel Care Protocol or other bowel regime orders. Resident #267 was admitted to the facility on [DATE], with multiple diagnoses which included depression and hypertension. Resident #267's January 2019 Physician Order summary included the following: * Milk of Magnesia (MOM) suspension 1200 mg/15 ml if no bowel movement for 2 days. *…

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 staff interview and record review, it was determined the facility failed to ensure residents' weights were monitored in accordance with their nutritional assessment and plan of care. This was true for 1 of of 8 residents (#44) reviewed for weight loss. This failure created the potential for harm if Resident #44 experience further weight loss and interventions were not in place in timely manner. Findings include: The facility's Weight Measurement policy and procedure, dated 11/28/17, directed staff to weigh residents at least monthly and as needed. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus, dysphagia (difficulty swallowing), gastroparesis (stomach cannot empty itself of food in a normal fashion). A quarterly MDS assessment, dated 11/3/18, documented Resident #44 was cognitively impaired and she required extensive assistance of 2 staff members for activities of daily living. A Nutritional care plan, revised on 11/6/18, documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, observation, and interviews with staff and a resident, it was determined the facility failed to ensure a physician's order was in place prior to a resident receiving oxygen therapy. This was true for 1 of 1 resident (#318) reviewed for oxygen. This failure created the potential for harm if residents received oxygen inconsistent with physician orders. Findings include: The facility's policy and procedure for Oxygen Therapy, dated 11/14/17, documented staff were to verify the physician's order prior to initiating oxygen. Resident #318 was admitted to the facility on [DATE] with multiple diagnoses, including chronic heart disease, pulmonary hypertension, and acute respiratory failure with hypoxia (low oxygen level). On 1/28/19 at 11:20 AM, Resident #318 was in her room and had oxygen in place by nasal cannula at 2.5 liters per minute. On 1/29/19 at 3:32 PM, Resident #318 was in her room and had oxygen in place by nasal cannula at 1.5 liters per minute. A physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and interviews with staff and a resident's family member, it was determined the facility failed to ensure that prior to the placement of bed rails, residents were thoroughly assessed for the risk of entrapment and a consent was in place. This was true for 1 of 4 residents (#54) reviewed for bed rail use, and created the potential for harm from entrapment or injury related to the use of bed rails. Findings include: The facility's policy for Restraints, dated 11/28/17, documented prior to use of bed rails, the facility would assess the resident for risk of entrapment, review the risks and benefits of bed rails with the resident or their representative, and obtain informed consent prior to installing the bed rails. Resident #54 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke) affecting the right side, and difficulty walking. On 1/28/19 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.