Avista Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1) Ensure the resident's right to formulate an Advanced Directive for one resident (Resident #3) and 2) Ensure that a resident was competent to sign an advance directive/Code Status for one resident (Resident #43), of 3 reviewed for Advance Directives, resulting in the potential for the residents' lack of informed knowledge related to options for code status and miscommunication of code status. Findings Include: Resident #3: Record review revealed Resident #3 was most recently admitted on [DATE] with diagnoses which included diabetes mellites, chronic respiratory failure, bipolar disorder, anxiety, chronic kidney disease (CKD), Bardet-Biedl syndrome (BBS- rare genetic disorder characterized by obesity, kidney abnormalities, and vision loss), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate assistance with toileting and bathing. A review of 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, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (Resident #43) of 23 residents reviewed, resulting in Resident #43 lacking Care Plan interventions related to wandering into other residents' rooms. Findings Include: Resident #43: A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of a myocardial infarction (heart attack), weakness right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15, and the resident needed some assistance with care. On 6/22/2026 at 1:55 PM, Resident #43 was observed lying in another residents' bed (Resident #7) across the hall from Resident #43's room.…

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 The facility failed to provide adequate supervision, and develop, enact and evaluate interventions for repeated wandering into other residents' rooms for one resident (Resident #43). Findings include: Resident #43: A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of a myocardial infarction (heart attack), weakness right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15, and the resident needed some assistance with care. On 6/22/2026 at 1:55 PM, Resident #43 was observed lying in another resident's bed (Resident #7) in the wrong room (across the hall from Resident #43's room). Resident #7 was very upset when he found Resident #43 lying in his bed. He told 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.

Based on interview and record review the facility failed to ensure that nurses completed yearly competencies and training for one nurse (Nurse A) of 1 nurse reviewed for education and competencies. Findings Include: On 06/25/2026 at 9:30 AM, Regional Human Resources/HR Director T was interviewed about staff education. She said the completed education documents were stored in the staff files in the HR office. A yearly competency was requested to be reviewed for Nurse A. On 6/25/2026 at 11:29 AM, the HR Director T was interviewed, and she said she did not have a competency evaluation for Nurse A. A review of the Facility Assessment dated March 2026 identified the following: Training, Competencies- Annual and on hire, in person and Show me. On 6/25/2026 at 2:40 PM, the Administrator was interviewed about the absence of a competency for Nurse A and said the staff were looking into it.

Based on observation, interview and record review the facility failed to ensure clinical staff postings were accurately completed for several days in 2025 and 2026, resulting in several missed days and incomplete documents. Findings Include: On 6/24/2026 at 10:20 AM, the Director of Nursing was interviewed and staffing documents were requested. She said the facility Scheduler kept the documents in her office. A record review of the daily posted nurse staffing data sheets from June 2025 to June 2026 indicated there were several days that the documents were missing: 5/21/2026 and 6/16/2026. In addition, there were 2 documents for 5/29/2026 and none for 5/30/2026. There was also a staffing document dated January but did not include a day or year. There were several days with missing information on the form including 12/30/2025; the RN Total Scheduled Hours for the 7:00 AM to 7:00 PM shift was blank and the RN hours Actual Hours Worked was blank. The Total Number of Staff for RNs was listed as 0. On 6/25/2026 at 2:20 PM, the Administrator was interviewed about the daily posted nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the drug/medication regimen reviews were completed, dated and in the medical record monthly, for 3 residents (Resident #8, Resident #12 and Resident #84) of five residents reviewed for medications, resulting in the potential for each resident to receive unnecessary medications and develop adverse effects. Findings Include: Medication Regimen Review Resident #8: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #8 was admitted to the facility on [DATE] with diagnoses: Dementia, Pulmonary hypertension, diabetes, history of falls, back pain, history of a stroke, auditory hallucinations, depression, peripheral vascular disease, cataracts, and hypertension. The MDS assessment dated [DATE] had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 9/15 and the resident needed some assistance with care. On 6/23/2026 at 2:38 PM, a review of the electronic medical record/emr identified 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 observation, interview and record review, the facility failed to ensure that the communication process was implemented, and documentation was readily available reflecting coordination of a resident's care, for one resident (Resident #13) of one resident reviewed for hospice services. Findings include:Resident #13 (R13):A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R13 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF / decreased ability of heart to pump blood), atherosclerotic heart disease (ASHD / hardening of arteries), chronic obstructive pulmonary disease (COPD/ progressive lung disease), diabetes mellitus (DM), stage 2 chronic kidney disease (CKD) and history of falls. A record review of Orders revealed R13 was admitted to hospice services on 05/11/2026. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 06/22/2026 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 interview and record review, the facility failed to ensure that 4 of 5 Certified Nursing Assistants (CNA), reviewed for the mandatory 12 hours of yearly training, had the required training. Findings Include: On 06/25/2026 at 9:30 AM, Regional Human Resources/HR Director T was interviewed about staff education. She said the completed education documents were stored in the staff files in the HR office and the 12 hour Certified Nursing Assistant/CNA training was able to be downloaded from the training cite on the computer. At that time the HR Director T was asked to see the 12 hour CNA training for 4 CNA's I, V, X, and Y. The HR Director was not able to locate the proof of training. On 6/25/2026 at 11:29 AM, the HR Director T was interviewed and she provided several pages of training documents for CNA X equaling 10.91 hours. She also provided 75 minutes/1 hour 15 minutes of training for CNA I. She said there was no additional training for CNA's Y and V and that was all of the information she could locate. Only CNA X had training on Abuse Neglect and Dementia Care. On 6/25/2026…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY based on interview and record review, the facility staff failed to follow and update timely a fall care plan for one resident (Resident #101) resulting in missed interventions necessary for care and services not being care planned with a likelihood of unmet care needs. Findings include: Resident #101:Record review of Resident #101's fall incident report dated 4/2/2026 at 6:00AM revealed that the aide requested nursing assistance in the weight room across from the therapy office. Upon arrival the writer noticed resident alert and oriented laying up against the wall in the weight room. Aide reported resident lost his footing on the weight scale as resident was assisted back to his wheelchair. Aide stated resident did not (hit) his head. This writer assessed resident for bruising & injuries, none noted. Resident reported he lost his step on his weaker side as the aide was assisting him back in his wheelchair. There was no mention of resident footwear at the time of the incident. Incident report noted no witness…

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, the facility failed to prevent a fall/accident and ensure that a left foot Ankle Foot Orthosis (AFO) device and gait belt were applied prior to standing for one resident (Resident #101) of 4 sampled residents, resulting a fall with likelihood for repeat falls, pain and serious injury. Findings include: Resident #101:Record review of Resident #101's fall incident report dated 4/2/2026 at 6:00AM revealed that the aide requested nurse assistance in the weight room across from the therapy office. Upon arrival the writer (Nurse) noticed resident #101 was alert and oriented laying up against the wall in the weight room. Aide reported resident lost his footing on the weight scale as resident was assisted back to his wheelchair. Aide stated resident did not (hit) his head. This writer assessed resident for bruising & injuries, none noted. Resident reported he lost his step on his weaker side as the aide was assisting him back in his wheelchair. There was no mention 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, interview and record review the facility failed to 1). Maintain food service equipment (steam table lids, food trays, plate warmers and refrigerator, 2) Ensure kitchen cookware was sanitary and dry; and 3). Maintain the walk- in freezer to be free of ice/snow buildup, resulting in an increased potential for cross-contamination and foodborne illness for all residents who consume meals from the kitchen. Findings include: On 5/13/2025 at approximately 10:00 AM, a kitchen tour was completed in the presence of Dietary Manager Q and the following was observed: Refrigerator: - At the bottom corner of right door, the seal was observed to be ripped/flapping. - There were crumbled food particles in the bottom right-side corner of the door. - The outside bottom of the refrigerator had streaks/smears and Manager Q explained when they attempted to wipe it off it would not come off. A dampened towel was requested and upon wiping the soiled area the streak marks were easily removed. Trays/Plate Warmer: - Seven trays (located next to the juice machine) were jagged on the edge.…

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, interview and record review, the facility failed to store and discard medications for 4 of 4 medication carts reviewed, resulting in a lack of dating of multi-dose medications, opened and undated medications, and the potential for residents to receive medications with altered efficiency. Findings include: Record review of the facility 'Storage of Medications' policy dated 8/2024, revealed medications and biological's are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Section III: Expiration dating- 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic . blood sugar testing solutions and strips require an expiration date shorter than the manufacture's expiration date once opened to ensure medication purity and potency. Observation and interview on 05/13/25 at 09:22 AM with Registered Nurse (RN) D 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, interview and record review, the facility failed to 1) Ensure that one resident's (Resident #38), who was on isolation precautions, room was free of soiled linen, 2) Ensure two residents (Residents #15, Resident #64) of 2 residents observed for wound care were free of cross-contamination, and 3) Ensure that kitchen staff wore hair nets properly (covering all hair) and that no artificial finger nails were allowed on kitchen staff while preparing foods, resulting in the potential for cross contamination, resident illness, and increased risk for infection during wound care. Findings Include: During the initial tour of the facility kitchen, Dietary Manager Q was had a hair net on, however on the right and left side of her face were long tendrils of hair that were not covered by the hair net. Dietary Manger Q also had long artificial nails at the time. During an interview done on 5/13/25 at 10:00 a.m., Dietary Manager Q stated I just got my hair done; no we are not supposed to have fake nails.…

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, the facility failed to assess, monitor and document wound care timely for two residents (Resident #46, Resident #337) of three residents reviewed for wound care, resulting in missed treatments with the likelihood of worsening wounds. Findings include: Resident #337: On 5/13/25, at 9:30 AM, Resident #337 was in their room. They had an occlusive dressing over their left elbow that was dated 5-8. CNA S entered the room and was asked what date they read on the elbow dressing and CNA S stated, it says 5/8. On 5/13/25, at 11:35 AM, a record review of Resident #337 electronic medical record revealed an admission on [DATE] with diagnoses that included Aphasia, Hypertension and Stroke. Resident #337 required assistance with Activities of Daily Living. A review of Treatment Administration Record 5/1/2025 - 5/31/2025 revealed cleanse left antecubital skin tear with wound cleanser pat dry apply nonstick dressing wrap with kerlix daily and prn until healed one time a day 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, interview and record review, the facility failed to 1) Implement one resident's (Resident #17) preventive pressure ulcer measure (air mattress), and 2) Prevent an erosion to the penis area for one resident (Resident #74) of 4 residents reviewed for pressure ulcers, resulting in the potential for pressure ulcer development, increased discomfort and pain with hospitalization. Findings include: Resident #74: During an observation and interview on 05/15/25 at 09:11 AM, Licensed Practical Nurse (LPN) B went to Resident #74's room with the state surveyor for a penal erosion observation and measurements. In catheter observations the Resident #74 had on a regular catheter bag today left over from last night. Urinary catheter with secure device noted to be taunt from penis head to left thigh. Resident #74 had the large overnight catheter bag run down the left leg and it crossed to the right pant leg at the bottom of the pants. LPN B walked into the room and applied gown and gloves; no hand sanitizer…

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 the facility failed to ensure one resident's (Resident #24) trapeze (bed mobility device) was within reach out of five residents reviewed for assistive devices. Findings Include: Resident #24: On 5/13/2025 at approximately 2:20 PM, Resident #24 was laying in bed and her trapeze was not hanging in a place that was accessible to her as it was flipped over the stabilization bar its connected too. Resident #24 was asked if she was able to reach the trapeze and she stated she was unable to and attempted to reach for it but was unable to access it. On 5/14/2025 at 10:55 AM, Resident #24 was observed sleeping peacefully in bed. Her trapeze was not accessible to the resident as it was flipped over the bar. On 5/14/2025 at approximately 11:30 AM, a review was conducted of Resident#24's records and it revealed she admitted to the facility on [DATE] with diagnoses the included, Diabetes, Dementia, Atrial Fibrillation and Hypertension. Further review yielded the following:…

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, the facility failed to ensure that one resident (Resident #25) of 2 residents observed had their dry nebulizer mask stored in a storage bag when not in use, resulting in the potential for cross contamination with respiratory infection, and increased antibiotic usage. Findings Include: Resident #25: Review of the Face Sheet, care plans dated 2/25 through 4/25, orders and electronic medication admission record/EMAR dated 4/25 and 5/25, revealed Resident #25 was [AGE] years old, admitted to the facility on [DATE], alert with a Guardian in place, and required staff assistance with all Activities of Daily Living. The residents' diagnosis included, chronic heart and lung disease, Alzheimer's Disease, weakness, acute on chronic respiratory failure with hypoxia, Myocardial Infarction, Anxiety Disorder, Adjustment Disorder, Depression, and cerebral aneurysm. Review of the residents' Physician orders dated 2/25, stated Albuterol Sulfate Inhalation Nebulization Solution…

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, interview, and record review the facility failed to maintain cold holding refrigeration temperatures of potentially hazardous food in the kitchen resulting in an increased potential for foodborne illness, potentially affecting the facility's total census of 79 residents who receive meal services. Findings include: On 6/4/24 at 11:47 AM, while observing lunch being plated from the kitchen's steam table, the surveyor observed the two door reach-in cooler located between the juice and coffee stations with both doors in the fully opened position. At this time the surveyor inquired with Dietary Manager, staff E, on if this was a normal practice during meal service to which they replied, yes. On 6/4/24 at 1:10 PM, upon review of the contents in the two door reach-in cooler the surveyor asked staff E, if they could take a temperature of the remaining portion of milk from the days lunch service to which they stated, of course. On 6/4/24 at 1:12 PM, temperature verification from staff E's thermometer probe revealed a temperature of 55 degrees F. At this time 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.

Based on observation, interview and record review, the facility failed to act upon grievances reported in Resident Council meetings and provide responses to grievances as reported during Resident Council with the potential to affect all residents that attend the council meetings, resulting in, unresolved resident concerns and a decreased quality of life. Findings Include: During Resident Council on June 4,2024 at 3:30 PM, the four residents in attendance were asked if their concerns voiced in the meetings were followed up on and resolution/update provided at the next scheduled meeting. The attendees reported staff will ask generalized questions regarding if their issues have been resolved but there is no other discussion past issues or how the facility will resolve them. On 6/5/2024 at approximately 9:00 AM, a review was completed of Resident Council Notes from June 2023 to May 2024. While residents voice their concerns in resident council the notes did not specify the issues with that specific discipline. Furthermore, there was not a response documented to the residents' concerns…

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.

This Citation pertains to Intake Number MI000144366. Based on observation, interview and record review, the facility failed to that ensure residents' food choices were honored, food was palatable (with temperature maintained), and an adequate amount of food was offered to one resident (Resident #47), and 4 of 4 residents in the Resident Council Meeting on 06/04/24 at 3:20 PM, resulting in anger, frustration and verbalizations of being hungry. Findings Include: Observation done on 6/3/24 at the noon meal revealed chili, a salad and beverages were served in the main dining room. The facility menu dated 6/3/24, revealed lunch was to include Texas toast. The resident's were not offered any toast, bread nor crackers to go with the chili. During an interview done on 6/3/24 at 1:50 p.m., Dietary Manager E stated (food company name given) makes our menu's; we follow the menu. They (resident's) didn't have bread or crackers today, it wasn't on the menu. The cook must of overlooked the toast today (Texas toast). We are getting tablets to take resident's orders. The Dietary Aide or the Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessment and documentation of incompetency prior to enacting a Durable Power of Attorney (DPOA) and accurate documentation of advance directive forms for one resident (Resident #28) of two residents reviewed for Advance Directives, resulting in DPOA enactment prior to incompetency determination, medical decisions being made for the resident without legal documentation of determination of incompetency, including consent for psychoactive medications and the likelihood for the resident's care wishes to not be followed. Findings include: Resident #28: Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty swallowing), osteoporosis, failure to thrive, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to maximum assistance 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, interview and record review, the facility failed to ensure that hygiene care was provided to two residents (Resident #23 and Resident #28) of four residents reviewed, resulting in a lack of comprehensive documentation and provision of daily care, long, visible facial hair on a female resident, and the likelihood for feelings of psychosocial distress utilizing the reasonable person concept. Findings include: Resident #28: On 6/3/24 at 1:40 PM, Resident #28 was observed sitting in a wheelchair in their room with a food tray in front of them on an overbed table. The Resident was female and had multiple, visible, thick colored hairs on their chin. An interview was attempted to be completed at this time. When spoke to, Resident #28 was pleasantly confused and did not consistently provide appropriate responses to questions when asked. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty…

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, the facility failed to implement and operationalize a comprehensive Restorative Nursing program to ensure appropriate assessment, services, and treatment to maintain or improve Range of Motion (ROM) for two residents (Resident #36 and Resident #44) of two residents reviewed, resulting in a lack of ongoing and accurate assessment and documentation of Range of Motion (ROM) and contractures, a lack of implementation of Restorative Nursing services and residents with known contractures and limitations in ROM, and the likelihood for further decline in ROM, functional decline, and avoidable pain. Findings include: Resident #36: On 6/3/24 at 11:05 AM, Resident #36 was observed sitting in a wheelchair in their room. The Resident's right arm was bent at the elbow with their hand in a fist. Their arm was bent upwards and positioned against their chest. The wheelchair had one leg rest on the right side and the Resident's right foot was positioned on the leg rest. Their…

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, the facility failed to implement and operationalize policies and procedures to ensure adequate staff training, equipment monitoring, prevention, reporting, investigation, and a thorough analysis of accidents for one resident (Resident #44) of four residents reviewed for falls, resulting in a lack of reporting, thorough investigation, comprehensive procedures to prevent accidents, Resident #44 experiencing a fractured tibia and fibula bones (both bones in lower leg) necessitating emergency medical treatment, unnecessary pain, and the likelihood for decline in overall functioning and health status. Findings include: Resident #44: On 6/3/24 at 10:19 AM, Resident #44 was not in their room. A raised edge mattress was present on the Resident's bed and multiple splints/braces were observed on top of the Resident's closet. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which…

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, the facility failed to ensure assessment, maintenance and care of an indwelling urinary catheter, per professional standards of practice, for one resident (Resident #39), and failed to complete treatment of a Urinary Tract Infection (UTI) for one resident (Resident#18) of four residents reviewed, resulting in an indwelling urinary catheter being maintained in an unsanitary manner, a lack of a urinary catheter securement device, delayed, and incomplete antibiotic therapy with the likelihood of ongoing UTI's with continued and increased Multi-Drug Resistant Organisms (MDRO- infections caused by microorganisms that are resistant to treatment), difficulty in treatment, and a decline in overall health. Resident #18: On 6/04/24, at 9:19 AM, During infection control task, the line listings were reviewed which revealed Resident #18 had been treated for a urinary tract infection (UTI) on 4/24/2024. On 6/4/2024, at 1:30 PM, a record review of Resident #18's electronic…

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, the facility failed to ensure Peripherally Inserted Central Catheter (PICC line - catheter inserted in the body through the arm that extends to the heart and is utilized for long term administration of intravenous [IV] medications) care was provided, per professional standards of practice and health care provider's order, for one resident (Resident #37) of one resident reviewed, resulting in a lack of dressing change completion, a lack of sterile technique during dressing change, resident verbalizations of concerns related to a lack of care, and the likelihood for infection and alteration in overall health status. Findings include: Resident #37: On 6/3/24 at 11:04 AM, Resident #37 was observed in their room, laying in bed. An IV pole with an empty bag of Meropenem (IV antibiotic medication) was present in the room. The medication bag was labeled for administration to Resident #37 but did not include the date/time the medication was hung and the IV tubing was 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.