Mount Ascension Transitional Care Of Cascadia

Based on interview and record review, the facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to the resident or the resident's representative, for 1 (#74) of 15 sampled residents. Findings include:Review of resident #74's electronic medical record showed a discharge date of 12/28/25 to a local hospital. There were no transfer or bed hold notices in resident #74's electronic medical record. Resident #74 did not return to the facility following the transfer on 12/28/25.During an interview on 2/26/26 at 10:12 a.m., staff member X stated residents who transferred to the hospital for urgent evaluation would sign a bed hold and transfer notice form. Staff member X stated the nurse who was transferring the resident to the hospital would fill it out. Staff member X stated she did not know if a form was filled out for resident #74.During an interview on 2/26/26 at 10:21 a.m., staff member Y stated that residents who transferred from the facility signed a transfer notice and a bed hold notice form. Staff member Y stated the 100 wing 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.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed within 48 hours after a resident's admission, to reflect monitoring of high-risk medications used by the resident, for 1 (#79) of 15 sampled residents. Findings include:During an interview on 2/24/26 at 10:04 a.m., resident #79 stated she had just gotten to the facility and already wanted to go home. Resident #79 stated she wanted to speak with the staff about going home.Review of resident #79's February 2026 medication administration record showed an admission date of 2/20/26, and included physician orders for: - . Insulin Glargine Subcutaneous Solution 100 UNIT/ML. Inject 15 unit subcutaneously in the morning for DM (Diabetes Mellitus) ., - . Apixaban Oral Tablet 5 MG. Give 2 tablet by mouth two times a day for anticoagulant for 5 Days -Start Date- 02/20/2026.,- . Apixaban Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for anticoagulant for 85 Days -Start Date- 02/25/2026. [sic]Review of resident #79's baseline care plan, initiated 2/20/26, showed pertinent diagnoses 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 implement a care plan for individualized shower preferences to maintain resident cleanliness and ensure the resident felt their hygiene needs were met, for 1 (#42) of 15 sampled residents. Findings include:During an observation and interview on 2/24/26 at 8:55 a.m., resident #42 was sitting in her recliner. The resident's hair was braided and appeared disheveled with strands of hair hanging on both sides of her face. Resident #42 stated she was upset because she had not received a shower two times a week on Tuesday and Friday. She stated she needed assistance while showering, and the facility staff were too busy to get showers done. Resident #42 stated she did not feel clean when she did not receive her shower two times a week.During an interview on 2/26/26 at 8:35 a.m., staff member N stated the MDS nurse completes resident care plans. Staff member N stated, I think she does all the care plans.During an interview on 2/26/26 at 9:15 a.m., staff member E stated she was not certain who is responsible 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 interview and record review, the facility failed to update a resident care plan based on an individual resident's care needs related to behaviors exhibited, for 1 (#70) of 15 sampled residents. This deficient practice placed resident #70 at risk for unmet needs and or the lack of behavior monitoring to identify changes. Findings include:Review of resident #70's nursing progress notes, dated 1/26/26 at 3:48 p.m., showed: Note Text : CNA alerted this nurse to an occurrence in which rsdt walked behind another female rsdt who was sitting at the dining room table. Rsdt was witnessed rubbing female's shoulders and arms from behind, then bending over and giving the rsdt a kiss on the cheek. Female rsdt not of sufficient cognition to grant consent. Rsdt and female separated, but both still in the common area under supervision. DON and Administrator notified. [sic]During an interview on 2/26/26 at 10:20 a.m., staff member B stated resident #70's care plan should have been updated to include monitoring for recent changes in behavior after a physical incident with another 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 observation, interview, and record review, the facility failed to provide ADL assistance to a resident who required staff assistance with bathing, for 1 (#42) of 15 sampled residents. The deficient practice resulted in a resident feeling unclean. Findings include:During an interview on 2/24/26 at 8:55 a.m., resident #42 stated she had requested a shower twice a week on Tuesday and Friday. Resident #42 stated she very rarely received two showers a week. Resident #42 stated she did not feel clean due to the lack of showers provided.During an interview on 2/26/26 at 8:25 a.m., staff member L stated a bath aide was scheduled later in the morning to complete resident showers. Staff member L stated she tried to get some resident showers completed before the bath aide arrived to begin their shift. She stated that if a resident refused a shower, staff would re-approach the resident later and extend the offer again. Staff member L stated that if a resident refused a shower after a second attempt, she would report the refusal to the nurse, and the resident would sign a shower refusal…

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 provide necessary care and services to promote the highest practicable well-being for range of motion for 1 (#71) of 15 sampled residents. The resident's range of motion limitations affected her ability to complete or participate in ADL care and increased the risk of continued deterioration in range of motion. Findings include: During an observation and interview on 2/24/26 at 8:37 a.m., resident #71 was observed seated in a wheelchair with her left elbow, wrist, and fingers in a flexed position. When resident #71 was asked if she received help with exercising her arm, she stated, No. Resident #71 said her wrist and her hand were numb. Resident #71, using her right hand, moved the hand and wrist, but she could not move them to a straight position. Resident #71 said she would do exercises if they were provided by the facility.Review of resident #71's Minimum Data Set (MDS), with an Assessment Reference Date of 2/21/25, showed under Section GG - Resident #71 had an upper extremity, shoulder, elbow, wrist, 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, interview, and record review, the facility failed to review the risks and benefits of using a mobility bar and failed to obtain safety measurements for mobility bars attached to the bed, for 2 (#s 1 and 71) and failed to obtain informed consent prior to the installation of the mobility bar for 1 (#71) of 15 sampled residents. The failure placed the residents at risk for entrapment. Findings include:During an observation and interview on 2/24/26 at 9:34 a.m., resident #1 said she did use the mobility bar on the side of her bed to steady herself. Resident #1 said she fell out of bed on Sunday (2/22/26) as she got between the head of the bed and the mobility bar. The mobility bar was observed to be in a stationary upright position about 1/3 of the way down the side of the bed.F700 - Side Rails, of the Appendix PP, State Operations Manual, showed, . Examples of bed rails include, but are not limited to: Side rails, bed side rails, and safety rails; and Grab bars and assist bars. 1. Review of resident #1's Post Fall Evaluation, dated 2/23/26 at 6:00 a.m., showed 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 interview and record review the facility failed to provide a medication to meet the needs of 1 (#60) of 15 sampled residents. The failure to provide medication in a timely manner could prolong illness of Covid-19.Review of resident #60's physician note, dated 2/9/26, showed resident #60 had a chronic illness and was being treated with chemotherapy for metastatic cancer.Review of resident #60's nursing progress note, dated 2/21/26, at 5:04 p.m., showed that resident #60 tested positive for COVID-19. The physician ordered Molnupiravir (an oral antiviral medication for treating mild-to-moderate Covid-19 in high-risk, non-hospitalized patients) to treat resident #60's COVID-19.Review of resident #60's nursing progress note, dated 2/22/26, at 5:51 p.m., showed that Molnupiravir (medication) to treat COVID-19 was supposed to be delivered on Monday (2/23/26), in the morning. Review of resident #60's nursing progress note, dated 2/23/26 at 3:52 p.m., showed the Molnupiravir had not been delivered from the pharmacy.Review of resident #60's nursing progress note, dated 2/23/26 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, interview, and record review, the facility failed to label a medication with an open date and failed to dispose of an expired vaccine. This deficient practice had the potential to affect any resident using the identified medications/supplies. Findings include:During an observation on [DATE] at 10:08 a.m., the Floor 2 nursing medication storage room contained the following open and expired medical supplies:- 1 vial Tuberculin solution opened, not dated.- 1 syringe Adacel Tdap vaccine, expiration date [DATE].During an interview on [DATE] at 10:28 a.m., staff member G stated it was the expectation of all nursing staff to check for outdated supplies, but this was the primary responsibility of the night shift nurse. Staff member G stated the Pharmacist also inspected the medication carts and medication storage rooms once a month and removed expired items. Staff member G stated it was the responsibility of the nurse who opened a new stock of a product to write an open date on the bottle/product.…

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 documentation for the education, and the signed consent or declination of the influenza or pneumococcal immunizations by the resident or their responsible party, for 1 (#5) of 5 residents sampled for vaccinations. Findings include:During an interview on 2/26/26 at 10:02 a.m., staff member B stated some residents were behind on their immunizations, to include documentation in their medical record. Staff member B stated she was starting to work on updating immunizations. Staff member B stated she started in the director of nursing and infection preventionist roles in mid-January (2026). Staff member B stated resident #5 should have been offered immunizations when she was admitted in December (2025). Staff member B stated residents new to the facility were offered flu and COVID immunizations, and staff would check the resident's imMTrax (State immunization record system).A request was made on 2/25/26 at 10:50 a.m. for resident #5's consent and declination forms including education for COVID-19, pneumococcal, 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 interview and record review, the facility failed to ensure documentation was completed and maintained to show education was provided to the resident or their representative related to the risks and benefits of the COVID-19 vaccination, for 1 (#5) of 5 sampled residents for vaccinations. Findings include:During an interview on 2/26/26 at 10:02 a.m., staff member B stated it had been identified that some residents were behind on their immunizations, and that included documentation in the medical records. Staff member B stated it was an area of the infection control program she was starting to work on. Staff member B stated that newly admitted residents were offered flu and COVID immunizations, and the residents' imMTrax (State immunization record system) was checked. Staff member B stated that resident #5 should have been offered immunizations when she was admitted in December (2025).Review of resident #5's comprehensive care plan showed an admission date of 12/9/25. The care plan included a problem, initiated 2/23/26, of . enhanced droplet precautions r/t positive COVID-19…

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 staff received facility specific restraint and abuse prevention training prior to providing resident care to keep a resident free from a physical restraints for 1 (#3) of 9 sampled residents. This deficient practice resulted in the resident biting at the placed hand restraints causing their tooth to break. The deficient practice increased the risk of imminent harm related to restraints. The facility identified the failure of staff utilizing physical restraints and addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:Review of a facility reported incident, submitted to the State Survey Agency on 12/28/25 at 6:00 a.m., showed, [Staff member D] restrained our resident [resident #3] . [Employee title] was sent home. [Resident #3] is safe and is being sent to the hospital for a head-to-toe examination. Full investigation to follow.Review of the facility reported incident's investigative findings, submitted to the State Survey Agency 1/2/26,…

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 complete a thorough investigation, take corrective action to ensure the safety of a resident with a known elopement attempt, and maintain documentation of the investigation involving the resident who left the protective oversight of the facility when transported to a dental visit, and he was left unattended, and then left the dental office alone and traveled to a relative's house, approximately two miles away. The resident's location was unknown for approximately one hour, for 1 (#2) of 3 sampled residents for wandering and elopement risk. The facility's failure to address these concerns placed this resident at continued risk of harm. Findings include:During an interview on 1/6/26 at 12:00 p.m., NF3 stated resident #2 had a diagnosis of schizophrenia and would have hallucinations of spirits that would tell him to do things. She stated resident #2 was fairly cognitively intact and able to make certain decisions for himself but could exhibit poor 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 interview, and record review, the facility failed to modify care plan interventions to reduce the risk of elopement, failed to provide routine behavioral monitoring for a resident with a known elopement risk, failed to provide supervision of a resident with a known elopement risk during transport to a medical appointment which resulted in the resident leaving unsupervised, failed to conduct an interdisciplinary investigation of an elopement, and failed to ensure a resident's care plan interventions were updated to prevent the reoccurrence of an elopement for 1 (#2) of 9 sampled residents. The facility's failure to address these concerns placed this resident at a continued risk of elopement and or harm. Findings include:During an interview on 1/6/26 at 12:00 p.m., NF3 stated resident #2 was fairly cognitively intact and able to make certain decisions for himself, but could exhibit poor and impulsive decision-making which made him vulnerable when he left unattended. She said resident #2 did much better…

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 interviews and record reviews, the facility failed to uphold and operationalize policies and procedures related to grievances and take immediate action to prevent further grievances or address abuse and neglect included in grievances. Due to the lack of follow-up, those residents or individuals submitting the grievances had no resolution to their identified concerns, and there was no documentation of facility efforts to resolve the grievances. This deficient practice resulted in many residents or individuals not having concerns addressed, and increased the risk of ongoing nursing care or abuse and neglect concerns. For those grievances submitted, which were not investigated, 4 (#s 1, 2, 4, and 5) of 7 sampled residents were affected, and this was a system breakdown. Findings include:1. Review of resident #1's Progress notes, dated 6/4/25, reflected that resident #1 complained about not being repositioned all night, from the time he was put in bed until the morning. Review of resident #1's Care Plan, dated 6/4/25, reflected that resident #1 had pressure ulcers on her sacrum…

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 interviews and record reviews, the facility failed to identify and report accusations of abuse and/or neglect by staff to The State Survey Agency for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice increased the risk of harm to residents by the accused staff. Findings include:1. Review of resident #1's Progress notes, dated 6/4/25, reflected resident #1 complained about not being repositioned all night, from the time he was put in bed until morning. Review of resident #1, physician note, dated 6/16/25, reflected resident #1's family member voiced a complaint about the lack of medication administration of vaginal cream, which was not being used, and questioned if catheter care was being completed. During an interview on 9/22/25 at 2:01 p.m., staff member A stated there was no State Survey Agency report for the neglect of care, which was related to the lack of assisting a resident with repositioning, the lack of catheter care, or the lack of the use of the vaginal cream, per the reported concerns by resident #1 and a family member on 6/4/25 or 6/16/25.2.…

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

Based on interviews and record reviews, the facility failed to thoroughly investigate alleged violations of abuse or neglect by staff, to prevent further abuse, neglect, or mistreatment from occurring, and take appropriate corrective action, as a result of investigation findings for 3 (#s 1, 4, and 5) of 7 sampled residents. This deficient practice placed residents at risk of harm from further abuse, neglect or mistreatment by staff members accused. Findings include:1. Review of a Grievance, dated 8/3/25, reflected resident #4 voiced a complaint that a staff member hurt him while he was being assisted during care.2. Review of a Grievance, dated 6/16/25, reflected resident #5 complained that a staff member hurt his arm when he was being assisted during a transfer. The resident had a fractured left arm. Record reviews of the grievances for resident #4 or #5 failed to show the events are investigated or reported to the State Survey Agency as potential alleged abuse or neglect. 3. Review of resident #1's Progress notes, dated 6/4/25, reflected resident #1 complained about not being…

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 evaluate and revise a care plan after a resident's elopement for 1 (#8) of 17 sampled residents, and ensure the staff were educated on the care plan. This deficient practice increases the risk for additional elopements as well as injury. Findings include:Review of a facility reported incident report, dated 6/27/25, showed resident #8 left the facility building at 7:00 a.m. on 7/21/25. The resident was found sitting on the ground, 10 feet from the building, with a small abrasion to his knee and a small skin tear on his hand.During an interview on 7/29/25 at 11:33 a.m., staff member C stated she was not sure if there were interventions on care plans at the facility for residents who were a high risk for elopement. Staff member C stated she was not sure how to find out if a resident was at high risk for an elopement, and stated, I'm not sure if they are on the care plan. Staff member C stated she was not sure what a Kardex was. During an interview on 7/30/25 at 9:06 a.m., staff member B stated a resident's care plan should be…

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 licensed nurse failed to follow a provider's order and process it timely for a resident's urine analysis (UA) with reflex culture for 1 (#12) of 17 sampled residents. This deficient practice resulted in a five-day delay in diagnosing a UTI. Findings include:A review of a provider's order for resident #12, which was located in the resident's electronic health record, dated 6/9/25, and signed by NF6, showed: . Attn: [Facility Name] Nursing StaffLab Results and/or New Orders:Orders for urinalysis with reflex to culture. Please collect .A review of a lab report from [Medical Center Name], dated 6/13/25, showed: . Specimen Information Type, Urine . Collected By, 6/23/25 5:16 p.m. Culture, Value: >100,000 CFU/ml Escherichia coli .A review of a provider's document for resident #12, located in the resident's electronic health record, dated 6/16/25, and signed by NF7 and NF6, showed: . Patient does have a UTI. Will treat with Macrobid 100 mg bid x 7 days.During an interview on 7/27/25 at 3:21 p.m., NF6 stated the facility received the order from 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 interview and record review, facility nursing staff failed to identify a change in condition of a resident for 1 (#5) of 17 sampled residents. This deficient practice resulted in an 11-day delay of testing and treatment for a resident who had a UTI. Findings include: A review of a progress note for resident #5, located in the resident's electronic health record in the facility's EHR, dated 6/24/25, and authored by staff member F, showed: Resident has had increased confusion and c/o of burning when voiding. Therapies has noted a decline with walking and strength training and has been becoming verbally abusive to staff at times. [sic] There was no follow-up documentation in resident #5's electronic health record in the facility's EHR, indicating a provider was notified or consulted for the residents change in condition for 11 days. A review of a progress note for resident #5, located in the resident's electronic health record in the facility's EHR, dated 7/5/25, and authored by staff member G, showed: Resident more confused complaining of increase in back pain. VS 130/70 72…

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 interviews and record reviews, the facility failed to have a registered nurse working at least eight consecutive hours a day, seven days a week. This deficient practice increased the risk to all residents at the facility, in the event RN services were required, but an RN was not scheduled and on shift to provide RN services. Findings include: During an interview on 1/13/25 at 3:39 p.m., resident #10 stated, I think the staff try hard, but I don't think there is enough of them. Sometimes it is hard to be seen by a nurse; they are so busy. During an interview on 1/13/25 at 4:05 p.m., resident #24 stated, The facility has had staffing issues for some time. They have hired quite a few recently. Some of the nurses don't seem like they have control of situations during their shifts. Maybe because they are new. A review of the facility's [NAME] report showed the facility failed to have an RN on shift for the following dates: - 7/13/24; 7/14/24; 7/20/24; 7/21/24; 7/27/24; 7/28/24 A review of actual staffing schedules from July 2024 to October 2024 showed the facility did not have…

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 ensure staff practiced appropriate use of personal protective equipment (PPE), during care of residents on enhanced barrier precautions (EBP) on 100 north hall, for 5 (#s 42, 49, 51, 56, and 232) of 30 sampled residents. Findings include: During an observation of the 100 north hall on 1/13/25 at 3:02 p.m., no EBP signs were observed. 1. During an observation on 1/13/25 at 3:40 p.m., resident #56 was observed to have a urinary catheter in place draining clear yellow urine. 2. During an observation on 1/13/25 at 3:55 p.m., resident #51 was observed to have a urinary catheter in place draining clear yellow urine. 3. During an observation on 1/13/25 at 4:12 p.m., resident #42 was observed to have a urinary catheter in place draining clear yellow urine. 4. During an observation on 1/14/25 at 9:15 a.m., resident #49 was observed to have a cholecystostomy tube draining green bile fluid from her right upper abdomen. 5. During an observation and interview on 1/14/25 at 3:24 p.m., resident #232 was observed lying 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 interview and record review, the facility failed to maintain the antibiotic stewardship program to include infection surveillance and monitoring of antibiotic use. This deficient practice increased the risk of a negative outcome for all residents receiving prescribed antibiotics who were at an elevated risk for multi drug-resistant infections. Findings include: During an interview on 1/15/25 at 1:40 p.m., staff member E stated she had been in her role since November 2024. Staff member E stated, I am trying, but I don't have a lot of support, so I just do what I can. Staff member E reported some of the healthcare providers prescribing antibiotics within the facility do not follow McGreer's criteria and sometimes treat with antibiotics based on behavior or symptoms, and added, . but I can't tell the doctors what to do. During a combined interview and record review on 1/15/25 at 2:45 p.m., the facility's infection control log was reviewed and discussed with staff member E for the period of December 1, 2024 through December 31, 2024. The log showed a total of 20 infections for…

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

Based on interview and record review, the facility failed to ensure residents were screened for influenza, pneumonia, and COVID-19 immunizations; and failed to offer or obtain a signed declination for pneumococcal vaccines, for 3 (#s 28, 45 and 232) of 5 residents sampled for immunizations. Findings include: 1. Review of resident #28's vaccination history, not dated, failed to show the resident received an updated pneumococcal vaccine per CDC guidelines, and failed to show a signed declination for the vaccine. His last pneumococcal vaccine (PCV13) was administered in 2000 (year). 2. Review of resident #45's vaccination history, not dated, failed to show administration or a signed declination for pneumococcal vaccine (PCV13, PCV15, PCV21 or PCV23). 3. Review of resident #232's vaccination history, not dated, failed to show administration or a signed declination for pneumococcal vaccine (PCV13, PCV15, PCV21 or PCV23). During an interview on 1/15/25 at 1:45 p.m., staff member E stated she had only been in her role since November 2024. Staff member E stated she did not know she 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.

Based on interview and record review, the facility staff failed to respect a resident's rights by not following up with a request's request to be sent to the emergency room when the resident was not feeling well, and a visitor called the ambulance for the transfer to the acute care setting, for 1 (#11) of 30 sampled residents. Findings include: Review of a Facility-Reported Incident, submitted to the State Survey Agency on 1/1/25, showed resident #11 was not feeling well and requested to go to the hospital, claiming the facility staff refused to send her. Review of resident #11's nursing progress notes, dated 12/30/24 at 12:24 p.m., showed, Resident requested to go to Hospital this AM at approximately 9:30 am. Resident c/o not feeling well. [sic] During an interview on 1/15/25 at 6:24 p.m., staff member M stated, Resident #11 said she wasn't feeling well and wanted to go to the hospital. Her oxygen levels were low. Review of resident #11's nursing progress note entered on 12/30/24 at 3:28 p.m. showed, Ambulance was called by non facility home caregiver. Caregiver did not notify…

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 identify and report an allegation of neglect to the State Survey Agency, within 24 hours of the incident, for 1 (#11) of 30 sampled residents. Findings include: Review of a Facility-Reported Incident, submitted to the State Survey Agency on 1/1/25, showed resident #11 was not feeling well and requested to go to the hospital, claiming the facility staff neglected to send her. Review of resident #11's electronic medical record showed this incident occurred on 12/30/24. During an interview on 1/16/25 at 11:25 a.m., staff member B stated she was aware of the incident that occurred with resident #11 on 12/30/24. During an interview on 1/16/25 at 1:57 p.m., staff member A stated, I do the reporting in Bounds (electronic reporting system) and reported the incident to the state when we determined it might have been a reportable incident. During an interview on 1/16/25 at 2:03 p.m., staff member L stated, We received an anonymous complaint in our complaint portal on our website on 1/1/25. We then reported it to the state; that is…

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 interviews and record reviews, a facility licensed staff member failed to provide services that met professional standards, by failing to monitor a resident's need for oxygen, and monitor the resident's need to transition to an acute care facility, for further assessment, for 1 (#11) of 30 sampled residents. The resident was treated for an illness at the acute care hospital. Findings include: During an interview on 1/13/25 at 4:09 p.m., resident #11 stated, . The facility staff let my issue go on too long before calling the hospital. My companion that day didn't like it and called an ambulance for me since I wasn't feeling well. I already spoke with APS about it, and I don't want to revisit the situation. During an interview on 1/13/25 at 4:12 p.m., NF1 stated, I don't think the facility staff took the resident's concerns seriously. Review of resident #11's progress notes written by staff member M, dated 12/30/24, are as follows: - 12/30/24 at 12:24 p.m., Resident requested to go to Hospital this AM 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, interview and record review, the facility failed to ensure physician orders were present in the EHR for 2 (#s 2 and 5) residents; and failed to ensure oxygen supplies/equipment were labeled consistently to show the date the supplies were cleaned or changed, for 5 (#s 1, 4, 5, 6, and 7) sampled residents. Findings include: During an observation and interview on 12/16/24 at 12:15 p.m., resident #4 stated his oxygen tubing was not labeled until this morning. The tubing had a date of 12/16. Resident #4 stated he never saw the tubing labeled before this date. Resident #4's oxygen humidifier was not dated. During an interview on 12/16/24 at 2:30 p.m., resident #1 stated she did not see her oxygen tubing labeled prior to that day. During an observation and interview on 12/16/24 at 2:37 p.m., resident #7 stated her oxygen tubing and nebulizer were placed in a plastic bag and labeled, this morning, but prior to day, the respiratory supplies were not labeled with a date. During an interview with resident #6 and NF1, on 12/16/24 at 2:48 p.m., NF1 stated, That's brand new,…

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 encourage and properly implement resident dietary preferences for 1 (#10); and failed to have a consistent process in place to address therapeutic diets over the weekend, when a new diet was ordered/modified, to ensure the change was addressed timely for safety, for 1 (#10) of 10 sampled residents. Findings include: During an interview on 12/16/24 at 3:57 p.m., resident #10 stated she only had problems swallowing food when it was a dry or tough meat like chicken or pork. Resident #10 stated she had no problems swallowing any other foods. Resident #10 stated dry meats were easier to swallow if they had a sauce or gravy added to it. She stated she had expressed her concerns with eating the dry meat during a care conference earlier in the month. Resident #10 stated, just this morning (12/16/24), her diet order had been changed, and there was no assessment for her swallowing ability completed by a staff member or the physician. Resident #10 stated she was able to cut up her food herself, if needed, and stated she…

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 obtain water temperatures that were within the CDC's recommended temperatures to prevent the growth of legionella; and obtain water temperatures in resident areas for 4 (#s 1, 4, 5, and 8) of 10 sampled residents; failed to ensure temperatures were completed frequently enough to follow the facility policy; failed to provide staff with adequate Legionella education; and failed to properly clean areas where legionella could be found (such as the eyewash stations, an ice machine, and sinks/toilets specifically, for 1 (#9) of 10 sampled residents; and failed to ensure oversight or intervention was completed from the infection preventionist when a resident was recently diagnosed with legionella. Findings include: 1. Review of a facility document, titled Risk Management Plan for Water Borne Illnesses, no date, showed, Table 6: Hot Water to Resident Areas: Testing of water temps: frequency: Weekly . Review of a facility document, titled…

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 interviews and record reviews, the facility failed to conduct quarterly and annual care conferences and include residents and their representatives to facilitate ongoing participation in the plan of care and goals, for 7 (#s 1, 9, 10, 11, 12, 13, and 14) of 7 sampled residents investigated regarding care conferences. Findings include: 1. During an interview on 10/15/24 at 9:25 a.m., resident #1 stated he had not attended a care conference and was never invited to attend. Resident #1 stated he, . just take(s) their word for it that care plan is what I want. Sure, I'd attend if I could. Review of resident #1's EHR social worker progress notes, dated 11/22/23 through 10/16/24, reflected resident #1 had not had a care conference since 3/1/24. Resident #1 did not have a care conference documented in the progress notes for the Quarterly MDS on either 7/16/24 or 10/16/24. 2. During an interview on 10/16/24 at 12:09 p.m., NF2 stated she had not been invited to attend care conferences for resident #14, and 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 observations, interviews, and record review, the facility failed to ensure residents knew how to file a grievance, resolve resident grievances promptly, and maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision, for 8 (#s 1, 4, 5, 6, 7, 8, 9, and 15) of 15 sampled residents investigated regarding grievances. Failure to thoroughly investigate grievances had the potential to result in failure to recognize and address potential resident abuse, neglect, or other care and service concerns that needed to be addressed. Findings include: 1. During an interview on 10/15/24 at 9:25 a.m., resident #1 stated he did not know how to file a grievance and usually called the ombudsman or the State Survey Agency. 2. During an interview on 10/15/24 at 1:45 p.m., resident #4 stated she was not aware of a grievance form or how to fill one out. 3. During an interview on 10/15/24 at 1:47 p.m., resident #5 stated she was not aware of 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.

Based on interviews and record review, the facility failed to report to the State Survey Agency and Adult Protective Services, allegations of abuse by staff for 1 (#15); and report findings for one investigation to the State Survey Agency, for 1 (#16) of 16 sampled residents. Findings include: 1. During an interview on 10/15/24 at 4:15 p.m., resident #15 stated, A CNA wound me up in the bathroom and called me white trash, and a woman across the hall was threatening to fight me over my soda one day. It's traumatic for me, and at that care conference they said it was old news, and we need to deal with current issues. Resident #15 stated she was never offered counseling and would like counseling. Resident #15 stated she was, . fearful staying here (at the facility) being called white trash and threats from the room across the way because I wouldn't give her my pop. During an interview on 10/15/24 at 5:10 p.m., staff member A stated, She (resident #15) changes her story. At the care conference we were not talking to her about the [racial slur] word incident anymore, and we needed 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 interviews and record review, the facility failed to thoroughly investigate and prevent further potential abuse while the investigation was in progress for allegations of abuse by staff for 1 (#15) of 16 sampled residents. Findings include: During an interview on 10/15/24 at 4:15 p.m., resident #15 stated, A CNA wound me up in the bathroom and called me white trash, and a woman across the hall was threatening to fight me over my soda one day. It's traumatic for me, and at that care conference they said it was old news, and we need to deal with current issues. Resident #15 stated she was never offered counseling and would like counseling. Resident #15 stated she was, . fearful staying here (at facility) being called white trash and threats from the room across way because I wouldn't give her my pop. During an interview on 10/15/24 at 5:10 p.m., staff member A stated, She (resident #15) changes her story. At the care conference we were not talking to her about the [racial slur] word incident anymore, and we needed to move forward. I didn't really do an investigation into her…

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, licensed nursing and certified staff failed to follow standards of practice for wound care, for 1 (#6) of 5 sampled residents; Resident #6 developed a pressure ulcer which deteriorated to a Stage IV. It was identified physician orders for treatments were not followed multiple times, over multiple shifts, and on multiple days. Findings include: During an interview on 5/20/24 at 1:30 p.m., staff member D, a certified staff member, stated pressure relieving interventions included turning and repositioning, putting a cushion in their (for a resident with wound) wheel chair, and a different mattress on their bed for pressure relief. Staff member D stated if there was a change in a resident wound appearance, or if there was a new wound, it would be reported to the nurse right away. During an interview on 5/20/24 at 1:40 p.m., staff member E, a certified staff member, stated resident's with wounds were to be turned and repositioned every two hours. Staff member E stated changes in resident's skin would be reported to the nurse right away so it can be…

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, it was identified the facility staff were aware of a resident's wound status, and use of a mechanical lift, but failed to develop a care plan problem, goals, or interventions for the prevention of the pressure ulcer to her right heel and back, for 1 (#15); and failed to develop a care plan for pain management for a resident who had pain during wound care, for 1 (#6) out of 5 sampled residents. Findings include: 1. During an interview on 5/20/24 at 8:54 a.m., NF2 stated it appeared like resident #15 was developing more wounds after admission to the facility, and the wounds were not showing improvement. During an interview on 5/20/24 at 9:53 a.m., resident #15 stated she had gotten a skin tear on her back, from the hoyer (mechanical) lift sling, as staff pulled the sling out from under her, rather than use the proper process for removal. The tear was caused by pulling the sling out from under her, rather than rolling her from side to side, to remove the sling. Resident #15 stated the skin tear progressed to a Stage III pressure ulcer. Resident #15…

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 1 (#6) of 3 sampled residents was medicated for pain 30 minutes prior to pressure ulcer dressing changes. Findings include: During an interview on 5/20/24 at 1:30 p.m., staff member D stated complaints of pain were to be reported to the nurse. During an interview on 5/20/24 at 1:40 p.m., staff member E stated if a resident is in pain, the nurse can give them pain medication. During an interview on 5/20/24 at 1:45 p.m., staff member F stated pain medication was to be administered prior to dressing changes if the resident complained about pain during dressing changes. Resident #6 was admitted to the facility on [DATE] and readmitted after surgical repair of a hip fracture related to a fall on 4/29/24. Upon admission, on 2/6/24, the resident had a pink pannus and sacrum, but had no open areas. On 2/13/24 assessment showed the resident's skin worsened, and the provider was notified with orders to apply a dressing and get the resident into the wound…

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 baseline care plan, and provide the resident or their representative with a written summary of the resident's baseline care plan, for 1 (#114) of 16 sampled residents. Findings include: During an observation and interview on [DATE] at 8:16 a.m., resident #114 was lying on her bed with her lights off. Resident #114 stated her husband had passed away recently, and she was unable to care for herself at home alone. Resident #114 stated she had been at the facility for three or four days and had not received any documentation related to her care or care plan. Review of resident #114's EHR, accessed on [DATE], showed the resident was admitted on Friday, [DATE], accompanied by her daughter. Review of resident #114's care plan, dated [DATE], showed the initiation of a number of care areas. However, the resident-specific information in each care area was not completed. The goals for each of the care areas were also…

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 follow the established care plan, evaluate the effectiveness of interventions, or revise the comprehensive care plan for 1 (#1) of 16 sampled residents. Findings include: During an observation on 12/20/23 at 2:05 p.m., resident #1 was sitting in a high-backed wheelchair, participating in an activity. Resident #1 had contractures to both upper extremities, with the right side being worse than the left. Resident #1 was not able to reach the game pieces because of the contractures. Activity staff were moving the game pieces for the resident. Review of resident #1's care plan, initiated on 12/19/14, and revised on 3/9/21, showed the resident was at risk for contractures and had interventions including encouraging participation in ADLs and active ROM to both of his legs, which included hamstring and calf stretches. There were no interventions for the resident's upper extremity contractures to prevent further deterioration. During an interview on 12/20/23 at 4:17 p.m., staff member I stated he did not have any…

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 provide the care and services necessary for contractures and the ROM for residents admitted with limited range of motion, for 2 (#s 1 and 39) of 2 sampled residents with contractures. Findings include: 1. During an observation on 12/20/23 at 2:05 p.m., resident #1 was sitting in a high-backed wheelchair, in the dining room. Resident #1 had contractures to both arms, with the right arm being worse than the left. Review of resident #1's Annual MDS, with an ARD of 11/1/23, showed the resident had a diagnosis of Cerebral Palsy with limited range of motion in both upper and lower extremities and required assistance with most activities of daily living. During an interview on 12/20/23 at 4:17 p.m., staff member I stated there were no exercises, including active or passive range of motion, as part of resident #1's care. During an interview on 12/20/23 4:20 p.m., staff member L stated if a resident needed ROM or other exercises, they needed to be done by the therapy department. Staff member L stated the facility 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.

Based on interview and record review the facility failed to ensure a nurse aide completed a NATCEP program within four months of full-time employment at the facility, for 1 (staff member K) of 3 sampled staff members. Findings include: During an interview on 12/21/23 at 7:50 a.m., staff member K stated she had worked for the facility for one year and was an NA (nurse aide - not certified) Staff member K stated she had restrictions on what tasks she was able to perform independently and which tasks required supervision from a CNA or a licensed nurse. Review of staff member K's employment record, provided on 12/21/23 at 8:30 a.m., showed the staff member was hired as a regular full-time employee on 11/1/22. Review of an interfacility email, sent on 10/13/23 and provided on 12/21/23 at 9:07 a.m., showed the facility had identified an issue with three NAs who were missing their certifications and needed to be enrolled in an approved nurse aide training program so they could complete their training. During an interview on 12/21/23 at 10:38 a.m., staff member A stated the missing…

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 ensure the medication error rate was less than five percent affecting 2 (#s 3 and 17) of 4 sampled residents. The calculated error rate was 8.11 percent. Findings include: 1. During a medication administration observation on 12/20/23 at 8:02 a.m., staff member M administered senna 8.6 mg to resident #3. Review of resident #3's MAR, dated 12/20/23, showed the resident was to received senna 8.6 mg and docusate sodium 50 mg. During an interview on 12/20/23 at 9:48 a.m., staff member M identified the stock bottle of senna which was the medication provided to resident #3 at 8:02 a.m. Staff member M stated the bottle only had senna, and the resident should have received the brand containing both senna and docusate sodium. 2. During a medication observation on 12/20/23 at 8:25 a.m., staff member L administered acetaminophen 500 mg, two tablets, and ferrous sulfate 325 mg, to resident #17. Review of resident #17's MAR, dated 12/20/23, showed the resident was supposed to receive acetaminophen at 7:00 a.m., and should…

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

Based on interview and record review, the facility failed to ensure they maintained an effective training program for all newly hired and existing staff and staff providing services under contractual agreement, ensuring staff received training during orientation regarding prohibiting and prevention of abuse, neglect, misappropriation of resident property and exploitation for 4 (staff members C, D, G, and H) of 10 staff members. This deficient practice had the potential to affect residents provided services by the staff who had not recieved the abuse prevention training. Findings include: A review of facility's policy and procedure titled, Preventing Abuse, with a revision date of 8/1/23, showed: Training: 1. During orientation and ongoing, provide new and existing staff in-service training in the following topics: a. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; b. Identifying how person-centered thinking, planning, and practice skills contribute to a facility culture of prevention and identification of abuse,…

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 hired personnel had a completed criminal background check prior to working at the facility for 1 (Staff member I) of 10 staff members. This deficient practice had the potential to affect all residents of the facility. Findings include: A review of facility's policy and procedure titled, Preventing Abuse, with a revision date of 8/1/23, showed: Policy: The facility has processes In place to assist in preventing abuse, neglect, misappropriation of resident property, End exploitation . Screening . 2.Complete background checks of new employees and returning employees prior to hire/rehire . Review of staff member I's Personnel file showed a hire date of 4/4/23. A criminal background check was completed on 9/11/23. During an interview on 11/8/23 at 11:00 a.m., staff member A stated it was the expectation that all newly hired and rehired staff have a criminal background check completed prior to their employment. Staff member A stated shortly after he was hired it had come to his attention that the background checks were…

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.