Life Care Center of Sandpoint

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to provide respiratory care for 1 of 2 residents (Resident #8) reviewed for respiratory care. This deficient practice created the potential for harm if respiratory care was not provided. Findings Include:Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dissection of thoracoabdominal aorta (a severe medical emergency characterized by a tear in the inner lining of the aorta, the main artery that carries blood from the heart through the chest and abdomen), asthma, and dementia. On 7/24/25 at 2:23 PM, it was observed with the RCM, Resident #8's humidifier reservoir was empty, his nebulizer tubing was not stored correctly, and his oxygen tubing was not dated. On 7/24/25 at 2:25 PM, the RCM stated oxygen tubing was replaced weekly, and should have been dated when it was changed. She also stated she was not sure when the humidifier reservoir had last been changed, but it was supposed to be monitored…

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 post dialysis assessments were completed and accurate. This was true for 1 of 2 residents (Resident #15) who received dialysis. This created the potential for Resident #15 for adverse outcomes such as blood loss and infection from the access site. Findings include:The facility's policy revised 3/18/20, documented the facility should provide immediate monitoring and documentation of the status of resident's access site upon return from the dialysis treatment to observe for bleeding or other complications such as redness or edema. Obtain vital signs of resident upon return from dialysis and complete the Pre/Post dialysis Communication Form.Resident #15 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Wegener's Granulomatosis (swelling also called inflammation of small blood vessels, mainly affecting the blood vessels in the nose, sinuses throat,…

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 protected from significant medication errors. This was true for 3 of 7 residents (#9, #15, and #81) reviewed for medication errors. This deficient practice created the potential for harm if residents received the wrong dosage of medications. Findings include:The online Nursing 2025 Drug Handbook accessed on 7/30/25, stated the eight rights of medication administration were: - Right drug - Right patient - Right dose - Right time - Right route - Right reason - Right response - Right documentation 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including fracture of right femur, pain and cognitive communication deficit. Resident #9’s record documented a physician's order for Oxycodone (an opioid pain medication) with the following instructions: -Oxycodone 2.5 mg every 4 hours as needed for pain rated at (3-6/10) -Oxycodone 5 mg every 4 hours as needed for severe pain rated 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 pharmacy labels matched the physician's order. This was true for 1 of 8 residents (Resident #15) whose medications administration was observed. This failure created the potential for harm should Resident #15 be administered the wrong dose of her medications. Findings include:On 7/24/25 at 7:39 AM, LPN #1 was observed as she administered one tablet of Sevelamer Carbonate to Resident #15. The Sevelamer Carbonate pharmacy label documented Sevelamer Carbonate 800 mgs two tablets before meals and at bedtime LPN #1 stated the physician's order was changed to administer one tablet of Sevelamer Carbonate to Resident #15. LPN #1 stated the label on the bottle should have been changed to match the physician's order.On 7/24/25 at 10:29 AM, the DON stated Resident #15's Sevelamer Carbonate order came from the dialysis center and Yes the label should have been changed to match the physician's order.

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 accurate clinical records were maintained for each resident. This was true for 1 of 18 residents (Resident #42) whose record was reviewed. This deficient practice created the potential for Resident #42 to experience harm if she received inappropriate care and/or treatment. Findings include:The State Operations Manual Appendix PP issued 4/25/25 documented the facility must maintain medical records of each resident that are complete and accurate.Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness) and diabetesA physician's order included the following:- Insulin Glargine 100 units/ml, inject 30 units subcutaneously one time a day for diabetes, ordered 12/9/24.- Insulin Glargine 100 units/ml, inject 5 units subcutaneously at bedtime for diabetes, ordered 12/9/24.-If blood…

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, facility job description review, and staff interview, it was determined the facility failed to ensure there was a qualified dietary manager. This failed practice created the potential to negatively affect all residents in the facility who ate food which was prepared in the facility's kitchen. Findings include: The facility's Food Service Director - Certified Dietary Manager Job Description, dated 5/1716, stated the Education, Experience, and Licensure/Certifications as: must have completed a CDM or State-approved course in food services; must have a current certification as a Certified Dietary Manager in applicable state; must maintain an active certification in good standing throughout employment; must have one year experience in post-acute food service; and must have a minimum two years' supervisory experience. During an interview on 7/9/24 at 11:22 AM, DM stated she completed the coursework for certification but had not scheduled a time to take the test. During an interview on 7/9/24 at 2:40 PM, the Administrator stated the DM moved from the position of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer an over-the-counter supplement medication. This was true for 1 of 1 resident (Resident # 32) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication. Findings include: The facility's policy titled Self-administration of Medications, revised 8/29/23 stated .Each resident has the right to self-administer medications after the Interdisciplinary Team has assessed the resident and determined the resident can safely complete the task .If a resident expresses a desire to self-administer medications the DON, Interdisciplinary Team and resident physician must be notified before allowing the resident to self-administer the medication .This request will be documented in the Interdisciplinary Notes of the resident's 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, record review, and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 17 residents (Resident #24) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, Chronic Obstructive Pulmonary Disease (COPD - a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), hearing loss, and hemiplegia and paraplegia (weakness and paralysis on one side of the body) following a stroke. Quarterly MDS assessments, dated 3/11/24 and 6/10/24, documented Resident #24 had adequate hearing and clear speech. Resident #24's care plan, initiation date 2/15/23, included a focus for a communication problem related to Resident #24's chronic hearing…

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, the facility failed to ensure a resident was provided toileting assistant and incontinence care. This was true for 1 of 1resident (Resident #44) reviewed for activities of daily living. This failure had the potential to lead to urinary tract infections, skin rashes, skin infections, pressure sores or increased incontinence. Findings include: The facility's policy titled Activities of Daily Living (ADLs), revised 2/12/24, stated, Residents will receive assistance as needed to complete activities of daily living (ADLs).A resident who is unable to carry out activities of daily living receives the necessary services to maintain .grooming and personal .hygiene. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), scoliosis (curvature of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 3 residents (Resident #41) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day. Findings include: The facility's policy titled, Care of the Cognitively Impaired (Dementia Care), reviewed 8/22/23, stated, The facility will provide dementia treatment and services . Utilizing individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's wellbeing. The facility's policy titled, Person Centered Care Plan, reviewed 8/26/23, stated, The facility will…

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, review of a facility risk management report, and resident staff interview, it was determined the facility failed to ensure a resident's care plan was followed to prevent accidents. This was true for 1 of 4 residents (Resident #24) reviewed for accidents. This resulted in the potential for more than minimal harm to Resident #24 when she was transfered and sustained increased pain to her left knee due to lack of adequate supervision during a transfer. Findings include: Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke, pain in left knee, and chronic pain syndrome. A quarterly MDS assessment, dated 10/21/23, documented Resident #24 required two person staff assistance for transfers. A quarterly MDS assessment, dated 6/10/24, documented Resident #24 was cognitively intact. Resident #24's care plan for activities of daily living, 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 observation, policy review, record review, and resident and staff interview, the facility failed to ensure a resident's food preference was accommodated. This was true for 1 of 2 residents (Resident #21) reviewed for dietary preferences. This deficient practice created the potential for harm if residents experienced dissatisfaction, hunger and/or weight loss from not having meal preferences accommodated. Findings include: The facility's policy titled Food Procurement, Diets, Menus, and Production, dated 12/2021, stated, Residents' preferences are followed to the extent possible in order to promote food acceptance; facility will provide as available, food to accommodates resident allergies, intolerances, and preferences. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses, including aftercare following surgery for a shoulder joint prosthesis. An admission MDS assessment, dated 6/24/24, documented Resident #21 was cognitively intact. During an interview on 7/8/24 at 11:11 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.

Based on observation, policy review, review of the 2017 FDA Food Code, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices. This failed practice placed 19 of 19 residents (#3, #4, #18, #20, #29, #37, #38, #42, #43, #49, #50, #67, #68, #69, #74, #77, #80, #81, #85, #187, #191, and #192) who ate snacks or foods from the unit refrigerators and the 72 other residents who ate food from the refrigerators, at risk for adverse health outcomes. This failed practice increased residents' risk of developing food borne illnesses. Findings include: The 2017 FDA Food Code, Chapter 3, Part 3-5, Limitation of Growth of Organisms of Public Health Concern, subpart 3-501.12 Time/Temperature Control for Safety Food, Slacking, documented, (A) Under refrigeration that maintains the food temperature at 5 C (41 F [Fahrenheit]) or less . On 3/28/19 at 5:21 PM, the long-term unit refrigerator was observed with food items such as thickened juice containers with use by dates of 3/3/19. There was also multiple butters and containers of half 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 ensure resident care plans included their code status. This was true for 8 of 8 residents (#29, #42, #43, #67, #68, #69, #74, and #85) reviewed for care plan revision. This deficient practice had the potential for harm if resident wishes for end of life care were not honored. Findings include: A facility policy, dated 6/8/10, documented a DNR order is incorporated into the resident's care plan. This policy was not followed. a. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and diabetes. The physician orders and POST for Resident #42 documented her code status was Full Code (cardiopulmonary resuscitation). Resident #42's care plan documented advance directives were in effect. The care plan did not include her specific code status. b. Resident #67 was admitted to the facility on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents were provided assistance with bathing and toileting consistent with their needs. This was true for 4 of 9 residents (#20, #38, #74, and #81) reviewed for bathing. This practice created the potential for harm if the lack of assistance for personal hygiene and toileting led residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, or otherwise compromise their physical and/or sense of psychosocial well-being. Findings include: The facility's Activities of Daily Living policy, dated 12/11/18, documented residents received assistance, as needed with ADLs. 1. Resident #74 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included pain, heart disease, fractured wrist, dementia, muscle weakness, and osteoporosis (fragile bones). A quarterly MDS assessment, dated 2/28/19, documented Resident #74 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, staff interview, resident interview, review of nurse staffing information, review of daily assignment sheets, policy review, review of resident appointment schedules, review of Resident Council Meeting Minutes, and review of the Facility Assessment, it was determined the facility failed to ensure sufficient numbers of staff were provided to meet the supervision, bathing, nutrition and hydration, and nursing oversight needs of residents. This deficient practice directly impacted 13 of 18 residents (#4, #20, #35, #38, #34, #39, #43, #46, #49, #50, #64, #74, and #81) reviewed for sufficient staffing and had the potential to negatively impact the other 78 residents residing in the facility. The deficient practice placed residents a) at risk of isolation, embarrassment, and health declines due to lack of consistent baths/showers and b) at risk of falls due to lack of supervision . Findings include: The facility's staffing policy, undated, documented the facility maintains adequate staffing on…

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

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented for hand hygiene during perineal care (peri-care) and wound care, equipment cleaning, and care of urinary catheters and reservoir (urine collection bag). This was true for 4 of 19 residents (#20, #37, #45, #56, #74) reviewed for infection prevention practices. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The facility's Infection Control Plan, revised on 3/2017, documented the facility followed the hand hygiene program according to the CDC hand hygiene guidelines. The CDC website, accessed on 4/3/19, documented hand hygiene should be performed as follows: * Before eating * Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed) * After contact with blood, body fluids or excretions, mucous membranes,…

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' records included a copy of the residents' advance directive or there was documentation of their decision not to formulate an advance directive. This was true for 3 of 12 residents (#37, #38, and #74) reviewed for advance directive information. This failed practice created the potential for harm should the resident's wishes not be followed due to lack of direction and documentation in their record. Findings include: The facility's Advance Directive policy, undated, documented the following: * At admission, the facility's admissions director or designee would determine the need and knowledge of an advance directive with the resident and/or family. * If the resident chose to execute an advance directive, the interdisciplinary team assisted the resident to prepare an advance directive through discussions and receipt of the Advance Directive policy. * If an advance directive was executed, social…

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 a resident was provided personal privacy during a physical assessment. This was true for 1 of 22 residents (Resident #81) reviewed for privacy. This practice created the potential for psychosocial harm if residents experienced a lack of self-esteem and embarrassment due to disregard of personal privacy, and confidentiality during a physical assessment. Findings include: Resident #81 was admitted to the facility on [DATE], with multiple diagnoses including palliative care, malignant neoplasm of the lung (a form of cancer of the lung), chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing) and anxiety disorder. She also received hospice services. On 3/26/19 at 9:31 AM, the Hospice RN was observed sitting in front of Resident #81 in the dining room with Resident #56 and #74. The Hospice RN completed blood glucose testing, blood pressure, pulse, removed Resident #81's shoes…

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 safe, clean, homelike environment. This was true for 2 of 22 residents (#43 and #191) whose environment was observed. This deficient practice created the potential for harm if residents were embarrassed by odors and dirty equipment and/or felt the lack of cleanliness was unacceptable, disrespectful, or undignified. Findings include: The facility's Scope of Services policy, revised 7/20/16, documented the facility provided an environment that was safe, comfortable, aesthetically pleasing, and physically conducive to meet the needs of all residents. 1. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses that included ribs and right clavicle fractures and multiple sclerosis (a potentially disabling disease of the brain and spinal cord). A quarterly MDS, dated [DATE], documented Resident #43 was incontinent of bowel and bladder and required extensive…

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 information was provided to the receiving hospital for emergent situations for 2 of 3 residents (#3 and #49) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive disease of the nervous system that affects movement). She was readmitted from the hospital on 3/7/19, for care related to the surgical repair of a left hip fracture. A discharge MDS assessment, dated 3/4/19, documented Resident #3 was discharged to a hospital. On 3/4/19 at 3:24 PM, a nursing progress note documented Resident #3 had a fall at 8:00 AM while trying to get out of bed. A new order was received to transport Resident #3 to the hospital, and her family was informed. Resident #3's record did not include documentation…

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, review of admission agreement paperwork, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 3 of 3 residents (#3, #49, and #287) reviewed for transfers. This deficient practice 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 Resident admission Agreement documented if a more immediate transfer or discharge is required due to urgent medical need a notice of transfer was given to the resident or their representative as much in advance as is practicable. 1. Resident #3 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease. She was readmitted from the hospital on 3/7/19, for care related to the surgical repair of a left hip fracture. A discharge MDS assessment, dated 3/4/19, documented Resident #3 was discharged to a hospital. On 3/4/19 at 3:24 PM, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 3 of 3 residents (#3, #49, and #287) who were reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold/Reservation of Room policy, revised 11/28/16, documented the following: * Bed-hold policies were provided and explained to the resident upon admission and before each temporary absence. * Before the resident transfers to a hospital, the facility provided written information to the resident or resident representative that specifies: a. The duration of the state bed-hold policy, if any, during which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, hospice and facility agreement review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included delineation of care and responsibilities between hospice/palliative care agency and facility services. This was true for 1 of 1 resident (Resident #81) reviewed for hospice services. This failure created the potential for harm if residents were to receive inadequate or inappropriate care which negatively impacted the resident's quality of end-of-life care. Findings include: A hospice and facility agreement, dated 12/22/08, documented the hospice provider and the facility communicated with each other verbally weekly or at each hospice patient visit to ensure the needs of each hospice patient were addressed and met 24 hours a day. It further documented, this communication would be included in the patient's record. The contract was silent related to coordination and communication of palliative care services. Resident #81 was admitted…

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, policy review, and Activity Calendar review, it was determined the facility failed to ensure there was a variety of activities scheduled to meet the needs of residents with cognitive impairment. This was true for 1 of 2 residents (Resident #74) reviewed for activities. This created the potential for residents to become bored and foster an increase in negative behaviors when not provided with meaningful engaging activities. Findings include: The facility's activity policy, undated, documented residents' activities should be meaningful and individualized according to their needs. The March 2019 Activity Calendar documented activities occurred seven days a week. The Activity Calendar documented the following activities: * Music activities: noon music, during the lunch hour, 7 days during the month and a music activity not during the lunch hour 4 days during the month. * Religious activities: 5 days during the month. * 1:1 activities: 21 days during the month. Resident #74 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure adequate supervision was provided. This was true for 1 of 6 residents (Resident #74) reviewed for accidents and supervision. This failure had the potential for harm if residents sustained injuries from accidents and incidents. Findings include: Resident #74 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included pain, heart disease, fractured wrist, dementia, muscle weakness, and osteoporosis (fragile bones). Resident #74's care plan area addressing her ADL's, dated 7/21/17, documented Resident #74 required the assistance of one staff with bed mobility and toileting. The care plan documented Resident #74 was able to self-propel her wheelchair and she had back-up brakes on her wheelchair. A quarterly MDS assessment, dated 2/28/19, documented Resident #74 had severe cognitive impairment and required extensive assistance of one staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents were consistently provided adequate nutritional and hydration interventions. This was true for 2 of 4 residents (#20 and #74) reviewed for weight loss and hydration concerns. This failure created the potential for harm if residents became dehydrated and they experienced unplanned weight loss. Findings include: The facility's Hydration and Nutrition policy, dated 11/26/18, documented adequate nutrition and hydration were offered to residents. The policy documented fluids were available to residents at all times. The policy documented residents were positioned properly at meals and snacks and assistance was provided as needed. 1. Resident #20 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included diarrhea, vitamin D deficiency, and anorexia. Resident #20's care plan area addressing nutrition, dated 7/15/13, documented she required one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders, and failed to ensure staff changed, dated, and stored residents' oxygen tubing per facility policy. This was true for 2 of 2 residents (#38 and #46) reviewed for oxygen therapy. This failure created the potential for harm if residents' respiratory needs were not met, and from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen tubing. Findings include: The facility's oxygen policy, dated 12/3/19, documented the following: * The oxygen supplies were changed weekly and when visibly soiled, then labeled with the resident's name and dated when supplies were changed. * Regardless of water level, the humidifier aerosol bottles were dated and changed every 7 days. * Oxygen respiratory supplies were stored in a bag labeled with the resident's name when not in use. 1. Resident #38 was admitted 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.