Avamere Rehabilitation Of Coos Bay

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 9 sampled residents (#52) reviewed for staffing. This placed residents at risk for accidents. Findings include:Resident 52 was admitted to the facility in 7/2025 with diagnoses including fracture of left leg, anxiety, and difficulty in walking. The care plan dated 7/12/25 identified Resident 52 as high risk for falls. Staff were instructed to keep her/his call light within reach at all times and DO NOT leave the resident unsupervised in the bathroom or on the bedside commode. A 7/16/25 admission MDS BIMS assessment indicated a score of 13 (cognitively intact). On 8/20/25 at 8:05 AM, the call light time log showed Resident 52 activated her/his call light at 7:45 AM. Staff 17 (LPN Charge Nurse) entered the room the room at 8:06 AM-21 minutes later. On 8/20/25 at 8:30 AM Staff 17 stated he entered Resident 52's room because the call light had been on for a while. At 8:36 AM Resident 52 stated she had been waiting on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents received timely incontinence care for 2 of 10 residents (#6 and 15) reviewed for staffing. This placed residents at increased risk for skin breakdown and loss of dignity. Findings include:1. Resident 6 was admitted in 7/2025 with diagnoses including kidney failure and muscle weakness. The admission MDS dated [DATE] identified the resident as frequently incontinent of urine and she/he required assistance with toileting. Resident 6 was cognitively intact and did not have any behaviors of rejection of care. The 7/15/25 Urinary Incontinence CAA identified frequent incontinence and dependance on staff for safe completion of toileting hygiene and needs. Resident 6's care plan dated 7/23/25 directed staff to encourage the use of the call light for assistance, offer frequent toileting opportunities, provide frequent check and change throughout each shift, and perform peri care after each incontinent episode.A Documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services for 1 of 1 sampled resident (#6) reviewed for medications and respiratory services. This placed residents at risk for unmet respiratory needs. Findings include:Resident 6 was admitted in 7/2025 with diagnoses including sleep apnea and edema (swelling caused by fluid retention).Per the facility's Oxygen Administration policy and procedure, documentation must include:-Date and time of oxygen setup or adjustment-Oxygen flow rate, route, and rationale-Frequency and duration of treatment-Reason for PRN administration-Assessment data before, during, and after the procedure-Resident's tolerance of the procedure The admission MDS dated [DATE] identified Resident 6 was cognitively intact and exhibited no behaviors. Resident 6 was not on oxygen therapy.A physician order dated 8/7/25 instructed staff to administer oxygen at two liters per minute via nasal cannula PRN for shortness of breath. No…

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 determined the facility failed to ensure a resident's pain medication was available for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for uncontrolled pain. Findings include: Resident 3 was admitted to the facility in 9/2023 with a diagnosis of chronic pain. Resident 3's 6/18/25 Annual MDS revealed she/he was cognitively intact. Resident 3's 6/2025 MAR revealed on 6/12/25 she/he was administered one dose of oxycodone (narcotic pain medication). Resident 3's 4/2025 Order Summary Report revealed she/he was to be administered oxycodone every eight hours PRN for pain. Progress Notes revealed the following:6/12/25 follow up with Resident 3's clinic for an oxycodone refill. Staff were notified they were no longer able to use the emergency supply of oxycodone. 6/13/25 The pharmacy reported Resident 3's oxycodone was on hold pending clarification of which physician was allowed to prescribe refills. Resident 3's 8/2025 Orders Summary Report revealed she/he was to be administered oxycodone every eight hours…

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 determined the facility failed to ensure a resident's denture was replaced timely for 1 of 1 sampled resident (#3) reviewed for dental. This placed residents at risk for weight loss. Findings include: Resident 3 was admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 3's ADL report revealed at times she/he required assistance with oral care. Resident 3's 1/14/15 Care Conference Information form revealed Resident 3 reported the facility lost her/his lower denture. Resident 3 stated she/he set the lower denture on the bedside table and did not place the denture in her/his denture cup. Resident 3 also stated at bedtime she/he requested a snack and at that time she/he could not find her/his lower denture. Resident 3 stated a CNA looked for the denture in the linens, laundry, and dietary department but the denture was not located. Resident 3's 7/9/25 Progress Note revealed Staff 1 (Administrator) notified Staff 12 the facility was to replace Resident 3's lost denture. On 8/20/25 at 8:01 AM Resident 3 stated in 1/2025…

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

Based on observation and interview it was determined the facility failed to provide clean and sanitary smoking equipment for 1 of 4 sampled residents (#21) reviewed for smoking. This placed residents at risk for respiratory issues and cross-contamination. Findings include: Resident 21 admitted to the facility in 6/2025 with diagnoses including nicotine dependency and visual loss. The 6/9/25 Smoking Safety Evaluation revealed Resident 21 was alert and oriented, had visual impairment, and required staff supervision while smoking, including the use of a smoking apron.The 8/6/25 Quarterly MDS revealed Resident 21 had a BIMS of 14, which indicated the resident was cognitively intact.On 8/18/2025 at 1:17 PM, Staff 20 (CMA) assisted Resident 21 to the supervised smoking area. Staff 20 and Staff 33 (CNA) stated no clean smoking aprons were available, as the only remaining apron was moldy. Staff 20 stated he would not want to put a moldy apron on himself, nor would he want to put it on any resident.On 8/18/2025 at 1:19 PM, Staff 33 was told by Staff 2 (DNS) they did not have any more smoking…

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 it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food borne illness. Findings include: On 5/2/24 at 11:48 AM Staff 26 (Cook/Dietary Aide) was observed to cut a hamburger patty with gloved hands on the cutting board attached to the steam table. Staff 26 placed the hamburger patty on a plate. Staff 26 then grabbed a rag from the red bleach bucket and wiped the cutting board and knife. The cutting board was observed to still be wet when Staff 26 used the same gloved hands to grab a skinned baked potato and cut it on the wet cutting board with the same knife. On 5/2/24 at 11:50 AM when asked about the drying time after wiping a surface, Staff 26 stated she, had no idea. When asked when it was appropriate to change gloves, Staff 26 stated she changed gloves often and had a box of gloves next to her work surface. When asked why she did not change her gloves after using the rag from the bleach bucket and before…

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 determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 5/1/24 at 1:17 PM Staff 22 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 22 stated when wet laundry was not completed in the washing machine at the end of her shift, she left the wet laundry in the washing machine overnight. Staff 22 stated the next morning she transferred the wet laundry to the dryer and did not rewash the laundry. On 5/2/24 at 8:52 AM Staff 23 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 23 stated multiple times a week she left wet laundry in the washing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals, and failed to ensure proper storage temperatures were logged and maintained for 2 of 2 treatment carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and adverse medication side effects. Findings include: 1. On [DATE] at 3:20 PM two vials of tuberculin (used for the testing in the diagnosis of Tuberculosis) were observed to be opened; one was dated October of an illegible year and another was dated [DATE]. The manufacturer's instructions indicated to discard the medication 30 days after opening. On [DATE] at 3:20 PM Staff 12 (LPN) acknowledged the two vials of tuberculin were opened and expired. 2. On [DATE] at 3:20 PM the medication refrigerator temperature logs were observed to be blank on [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 3:20 PM Staff 12 (LPN) acknowledged the temperature logs 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.

Based on observation, interview, and record review it was determined the facility failed to ensure resident rooms were cleaned for 1 of 3 sampled residents (#9) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: Resident 9 admitted to the facility in 2024 with diagnoses including respiratory failure and heart failure. Review of Resident Council notes for 2/2024 indicated residents reported a lot of dirt on the floors and the floors needed to be swept more. Observations made from 4/29/24 through 5/1/24 revealed a visible layer of white and gray dust and hairs underneath Resident 9's bed. Review of the Daily Cleaning Check-Off form indicated Resident 9's room was cleaned on 4/27/24. On 5/1/24 at 12:24 PM Staff 19 (Housekeeping Manager) stated housekeeping staff cleaned one of three resident halls per day. Staff 9 stated the daily cleaning of resident rooms consisted of cleaning the bathroom, taking out the trash, wiping down high touch areas, sweeping and mopping. Staff 19 stated it was brought to her attention that 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 it was determined the facility failed to protect residents' right to be free from verbal abuse from Staff 24 (RN) for 1 of 1 sampled resident (#20) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Abuse policy, revised 4/2021, stated the facility and staff would protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including facility staff. Resident 20 was admitted to the facility in 2023 with diagnoses including major depressive disorder and anxiety disorder. Resident 20's 2/7/24 Comprehensive MDS indicated the resident was cognitively intact. Resident 20's 2/26/24 Care Plan indicated the resident was independent with bathing and required set up help only. Resident 20 showered one time per week per the resident's request. Resident 20's 4/2024 shower logs revealed the resident frequently refused showers. A 3/31/24 Progress Note indicated Staff 24 (RN) approached Resident 20 in the morning about taking a shower. Resident 20 refused and stated she/he would take 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 interview and record review it was determined the facility failed to ensure residents were free from misappropriation by Staff 34 (CNA) for 1 of 1 sampled resident (#302) reviewed for misappropriation of personal funds. This placed residents at risk for financial abuse. Findings include: The facility's revised 4/2021 Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Resident 302 admitted to the facility in 3/2022 with diagnoses including multiple sclerosis. The 4/2023 Comprehensive MDS identified Resident 302 to be alert and oriented. On 5/23/23 a Facility Reported Incident was reported indicating Resident 302 bought Staff 34 (CNA) a scrub top (nurse apparel shirt) purchased on-line for $34.00. Resident 302 stated she/he expected Staff 34 to pay her/him back. Staff 34 paid Resident 302 $20.00. On 5/2/24 at 9:13 AM and at 2:10 PM Staff 34 was unable to be reached via phone. On 5/2/24 at 9:53 AM Staff 5 (Social Services Director) observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents with contractures received ROM services and equipment to prevent further decrease in ROM and skin breakdown for 1 of 1 sampled resident (#4) reviewed for mobility. This placed residents at risk worsening contractures. Findings include: Resident 4 admitted to the facility on [DATE] with diagnoses including quadriplegia and rheumatoid arthritis. The 2/4/24 admission ADL CAA indicated Resident 4 had impaired ROM and the Care Plan would refer to restorative and/or skilled therapy as appropriate. Resident 4's clinical record included a copy of a 11/29/21 Care Plan from Resident 4's previous facility. The Care Plan indicated Resident 4 had contractures to her/his bilateral hands and legs related to rheumatoid arthritis. Interventions included the use of palm protectors to be worn during the day. The 1/31/24 Care Plan revealed no indication of Resident 4's contractures or use of a palm device. Review of a 3/15/24…

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 determined the facility failed to assess falls and provide treatment to prevent falls for 1 of 1 sampled resident (#25) reviewed for accidents. This placed residents at risk for falls and injuries. Findings include: Resident 25 admitted to the facility in 2022 with diagnoses including weakness and heart failure. The 1/26/24 Annual MDS indicated Resident 25 was cognitively intact. On 4/29/24 at 1:31 PM Resident 25 stated she/he fell out of the sit-to-stand (a device used to transfer residents between seated to standing positions) several months ago. On 4/30/24 Resident 25's clinical record was reviewed. No fall assessments or incident reports were found. On 4/30/24 a fall assessment was requested from Staff 2 (DNS). On 4/30/24 at 10:31 AM Staff 2 (DNS) stated Resident 25 did not have a fall from the sit-to-stand device, but was assisted to the floor by staff and stated, So it wasn't a fall. Staff 2 stated no assessment was completed. On 5/1/24 at 2:12 PM Staff 2 provided a written statement dated 5/1/24 from Staff 20 (CNA) that indicated,…

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 it was determined the facility failed ensure oxygen was administered as ordered and maintain oxygen concentrators for 2 of 3 sampled residents (#s 36 and 251) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include: 1. Resident 36 was admitted to the facility in 8/2023 with diagnoses including chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream). The 1/15/24 Significant Change MDS indicated Resident 36 was moderately cognitively impaired. Multiple observations from 4/29/24 through 5/1/24 revealed Resident 36 used an oxygen concentrator. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger. Resident 36's physicians order dated 4/2/24 indicated: - clean external filter on the oxygen concentrator every Tuesday on night shift. The 4/2024 TAR indicated on 4/23/24 the external filter on the oxygen concentrator was cleaned by Staff 21 (LPN) who worked the night shift. On 4/29/24 at…

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

Based on interview and record review it was determined the facility failed to follow pharmacist recommendations in a timely manner for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: Resident 30 admitted to the facility in 2023 with diagnoses including major depressive disorder and psychosis. The 1/16/24 pharmacist recommendation indicated Resident 30 did not display psychotic behavior but had issues with depression, and to consider an order to increase nortriptyline (antidepressant) to 50 mg daily at bedtime for depression and to decrease aripiprazole (antipsychotic) to 2 mg daily for psychosis. The pharmacist recommendation was not signed by the physician until 2/4/24 (19 days after the recommendation was made). The physician recommendation included to discontinue nortriptyline and start Lexapro (antidepressant) 5 mg daily. On 5/1/24 at 2:12 PM Staff 2 (DNS) stated the expectation was for pharmacist recommendations to be reviewed and signed by the physician within 7…

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 determined the facility failed to have a dialysis agreement in place for 1 of 1 sampled resident (#45) reviewed for dialysis. This placed residents at risk for not receiving dialysis services. Findings include: Resident 45 admitted to the facility in 4/2024 with diagnoses including dependence on renal dialysis. On 4/30/24 a copy of the dialysis agreement was requested from Staff 4 (Corporate RN). On 4/30/24 at 1:52 PM Staff 4 stated the facility did not have a dialysis agreement in place for Resident 45.

Based on interview and record review it was determined the facility failed to accurately document medication administration for 1 of 4 sampled residents (#33) reviewed for physician orders. This placed residents at risk for inaccurate medical records. Findings include: Resident 33 admitted to the facility in 3/2024 with diagnoses including hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) and septic arthritis (an infection in the joint fluid and tissues). a. A physician order dated 4/1/24 instructed staff to administer one tablet of levothyroxine 50mcg (a thyroid medication) one time a day at 5:00 AM. A review of Resident 33's April 2024 MAR revealed the resident did not receive the scheduled dose on 4/26/24 at 5:00 AM. There were no progress notes in the resident's clinical record to indicate the reason for the missed dose. On 5/2/24 at 1:50 PM Staff 3 (RNCM) stated the documentation for 4/26/24 on the MAR was inaccurate. Staff 3 stated she contacted Staff 32 (LPN) on 5/2/24 and Staff 32 indicated Staff 32 administered…

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 determined the facility failed to ensure residents were offered a pneumonia vaccine for 1 of 5 sampled residents (#30) reviewed for immunizations. This placed residents at risk for infections. Findings include: The facility's Pneumococcal Vaccine Policy dated 3/2022 indicated, assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. Resident 30 admitted to the facility in 8/2023 with diagnoses including depression. A review of Resident 30's clinical record revealed she/he did not receive a pneumonia vaccine and there was no indication the resident was offered a pneumonia vaccine upon admission to the facility. On 5/2/24 at 1:30 PM Staff 18 (IP) stated upon admission a resident was to be offered vaccinations if eligible, including the pneumonia vaccine. Staff 18 confirmed Resident 30 was not offered the pneumonia vaccine upon admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure comfortable temperatures were maintained in all areas of the facility for 1 of 1 facility. This placed residents at risk for an uncomfortable environment. Findings include: 1. On 3/8/23 at 2:32 PM Witness 6 (Family Member) stated he complained for days about the dining room being too cold. Witness 6 stated one of the two heating vents in the dining room did not work and Resident 10 was not comfortable eating in the dining room. On 3/8/23 at 2:44 PM Staff 35 (Maintenance Director) was asked to measure environmental temperatures in the facility. Staff 35 stated he was aware the living room was cold due to the facility replacing the baseboard heater with two new wall heaters but the room needed more heaters. Staff 35 also stated he learned of the cold temperature in the dining room that day and was working on a repair. The following environmental temperatures were obtained: - Outside of room [ROOM NUMBER]: 66 degrees -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it as determined the facility failed to follow physician orders and ensure bowel care interventions were followed for 3 of 5 sampled residents (#s 6, 16 and 24) reviewed for medications. This placed residents at risk for unmet needs and bowel complications. Findings include: 1. Resident 6 was admitted to the facility in 2013 with diagnoses including dementia. A 2/6/23 Note to Attending Physician/Provider signed by Resident 6's physician on 2/8/23 revealed the facility was to complete labs to check the valporic acid level (blood test to check medication levels), CBC (complete blood count) and hepatic panel (liver functioning) in one week on 2/15/23. A review of the clinical records revealed the ordered labs were not completed. On 3/8/23 at 1:43 PM Staff 5 (RNCM) reviewed the Note to Attending Physician/Prescriber for labs and stated the ordered labs were not completed. 2. Resident 16 was admitted to the facility in 2019 with diagnoses including dementia 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 and interview it was determined the facility failed to ensure equipment was properly sanitized for 1 of 1 kitchen reviewed. This placed resident at risk for food borne illnesses. During random observations on 3/6/23 and 3/10/23 in the common dining room, plastic pitchers were observed in use by CNAs who assisted residents by pouring their beverages of choice during meal service. On 3/6/23 from 10:15 AM to 11:30 AM the three compartment sink was observed not in use. On 3/9/23 at 10:30 AM Staff 23 (Dietary Aide) stated the three compartment sink was only used when the dishwasher was not working. Staff 23 was observed to touch a plastic pitcher held in an unused three compartment sanitation sink and stated the plastic pitchers could not be placed in the dish machine because the dish washer damaged the pitchers. Staff 23 stated the pitchers were cleaned just like at home with soapy water. On 3/9/23 at 12:13 PM Staff 6 (Dietary Manager) observed three plastic pitchers on the clean dish shelf and confirmed the three compartment sink was not used to sanitize 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 it was determined the facility failed to ensure call lights were within reach for 2 of 2 sampled residents (#s 19 and 30) reviewed for call lights. This placed residents at risk for unmet needs. Findings include: 1. Resident 19 admitted to the facility in 2021 with diagnoses including Parkinson's disease (a brain disorder that affects movement). On 3/7/23 at 9:54 AM Resident 19 stated her/his call light was not always placed where she/he could reach it. On 3/8/23 at 11:18 AM Resident 19 was lying in bed. The call light was on the recliner behind the head of the bed. Resident 19 stated she/he could not reach the call light. On 3/8/23 at 11:24 AM Staff 3 (LPN-RCM) confirmed Resident 19's call light was on the recliner and Resident 19 would not be able to reach the call light. Staff 3 stated staff were expected to keep call lights in resident's reach. On 3/9/23 at 10:47 AM Staff 2 (DNS) confirmed call lights were expected to always be within residents' reach. 2. Resident 30 admitted to the facility in 2021 with diagnoses including…

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 determined the facility failed to investigate an injury of unknown origin for 1 of 2 sampled residents (#47) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 47 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease which caused obstructed airflow). In a public complaint on 1/6/23 Witness 7 (Complainant) stated Resident 47 was admitted to the hospital and observed to have multiple bruises on her/his lower abdomen and groin area. A 12/13/22 admission Nursing Database revealed no documentation of bruising on Resident 47's lower abdomen and groin area. A 12/15/22 Progress Note revealed Resident 47 was found on the floor and obtained a small injury to her/his left forearm but no other injury. A 12/20/22 Progress Note revealed Resident 47 fell with no injuries. A 12/22/22 Weekly Skin Audit revealed Resident 47 had no new skin areas and did not identify bruising to the lower abdomen or groin area. A 1/2/23 Weekly Skin Audit revealed Resident 47…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to assess and complete a significant change assessment for 1 of 1 sampled resident (#13) reviewed for dialysis. This placed residents at risk for unmet needs. Findings include: Resident 13 was admitted to the facility in 2022 with diagnoses including end stage renal disease. An admission assessment dated [DATE] documented a BIMS score of 15 (indicating cognitively intact), a depression score of one (no depression), she/he had no behaviors and occasional pain of one (scale of zero-10 with zero meaning no pain and 10 indicating the worst pain imaginable). A Quarterly assessment dated [DATE] documented a BIMS score of nine (moderately impaired), a depression score of six (mild depression), rejection of care one to three days in a seven day period and almost constant pain of nine. On 3/8/23 at 4:07 PM Staff 5 (RNCM) stated Resident 13 had a decline in mood when her/his significant other was hospitalized . Staff 5 stated 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 it was determined the facility failed to revise care plans and conduct quarterly care planning conferences for 3 of 5 sampled residents (#s 19, 23 and 24) reviewed for ADLs, constipation and care planning. This placed residents at risk for unmet needs. Findings include: 1. Resident 19 was admitted to the facility in 2021 with diagnoses including Parkinson's disease (a brain disorder affecting movement). A 9/20/22 progress note revealed Resident 19 had a care conference. At the time of the survey no documentation was found in clinical records indicating a care conference was held after 9/20/22. On 3/7/23 at 2:28 PM Staff 4 (Social Service Director) stated care conferences were completed quarterly based on the MDS schedule. Staff 4 confirmed Resident 9 was scheduled for a care conference in 12/2022 but was unable to find documentation to indicate the care conference was conducted. 2. Resident 23 was admitted to the facility in 2021 with diagnoses including stroke. An Annual MDS was completed in 8/2022. A review of Resident 23's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure dialysis services were provided to 1 of 1 sampled resident (#16) reviewed for dialysis. This placed residents at risk for lack of dialysis services. Findings include: Resident 13 was admitted to the facility in 2022 with diagnoses including end stage renal disease. a. An alert note dated 10/28/22 indicated Resident 13 had a central venous catheter (a tube inserted into a vein) in the chest and a new left arm fistula (a connection between an artery and a vein) for dialysis treatments. An admission Database dated 10/28/22 did not identify the presence of the central venous line or the fistula. The current care plan for dialysis services identified a dialysis access site in the left arm, restricted blood pressures and lab draws on the left arm, provided information related to monitoring for the fistula for bleeding and to obtain dry weights (weights obtained after the resident received dialysis). The 3/2023 MAR instructed staff 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 it was determined the facility failed to reassess, implement and revise behavioral healthcare needs for 1 of 1 sampled resident (#12) reviewed for mood/behavior health. This placed residents at risk for unmet psychosocial wellbeing. Findings include: Resident 12 was admitted to the facility in 2021 with diagnoses including depression. A review of 3/1/22 through 7/24/22 progress notes revealed Resident 12 had no documented behaviors. A 5/3/22 Quarterly MDS revealed a BIMS score of 15 (cognitively intact), no acute mental status change, a depression scale of 0 (no depression symptoms) and no behaviors. A 7/25/22 progress note revealed Resident 12 accused Staff 30 (RA) of hitting her/him. A 7/26/22 progress note stated Resident 12 was crying and stated Staff 30 did not hit her/him. A 7/28/22 progress noted revealed an investigation regarding an allegation of abuse was completed and abuse was ruled out. An 8/1/22 Comprehensive MDS revealed a BIMS score of 15, no acute mental status change, a depression score of 7 (mild depression) and one day…

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 determined the facility failed to monitor psychotropic medication for 1 of 5 sampled residents (#24) reviewed for medications. This place residents at risk for unnecessary medications. Findings include: Resident 24 was admitted to the facility with diagnoses including chronic pain and anxiety disorder. The facility's 8/25/20 Psychoactive Medication Management Guideline indicated residents who received psychotropic medications would have a supporting diagnosis, targeted behavior for use and be monitored for effectiveness of the medication therapy. A 1/17/23 Psychoactive Medication Review progress note revealed Resident 24 was stable on current medications and the care plan was updated. A 2/9/23 signed physician order indicated as of 10/28/22 Resident 24 received trazodone (antidepressant medication) by mouth at bedtime for insomnia. Resident 24's clinical record revealed no sleep monitor or care plan related to the resident's sleep. On 3/8/23 at 11:35 AM Staff 10 (CNA) stated Resident 24 was not monitored for sleep and there was no…

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 it was determined the facility failed to promptly provide emergency dental services and interventions to meet residents' needs for 1 of 2 sampled residents (#9) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include: Resident 9 admitted to the facility in 2021 with diagnoses including diabetes. A 6/2/22 Annual MDS Dental CAA revealed Resident 9 wore full lower dentures. A 7/5/22 Grievance Form revealed Resident 9's dentures were missing. A dental appointment was made for 10/20/22, the soonest date available. An 8/17/22 Physician Order revealed Resident 9's diet texture was changed to soft and bite size due to dental repair. A 9/2/23 Grievance Form revealed Resident 9's spouse wanted information regarding missing dentures and was notified the dental appointment was on 10/13/22. A 9/8/22 progress note revealed Resident 9 had a dental appointment on 10/19/22 that was changed to 10/13/22. An undated Referral Form indicated Resident 9 had insurance approved for upper and lower dentures on 11/2/22. 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 observation, interview and record review it was determined the facility failed to ensure meals were provided to meet the needs of residents for 3 of 4 sampled residents (#s 13, 20 and 22) reviewed for food and kitchen. This place residents at risk for lack of adequate nutrition and allergic reactions. Finding include: 1. Resident 13 was admitted to the facility in 10/2022 with diagnoses including heart failure and kidney disease. The 3/2023 TAR indicated Resident 13 was allergic to grapes and raisins. Immunization records revealed Resident 13 obtained a skin rash if she/he consumed grapes or raisins. On 3/9/23 at 9:39 AM Witness 8 (Family Member) stated Resident 13 was provided oatmeal raisin cookies on her/his meal tray earlier in the week and the cookies appeared to be made with chocolate chips until they opened the wrapped cookies together and realized the cookies contained raisins. Wrapped cookies with raisins were observed in Resident 13's room. On 3/9/23 at 10:46 AM Staff 6 (Dietary Manager) was shown the cookies with raisins from Resident 13's room and acknowledged…

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 determined the facility failed to accurately track and document the COVID-19 status of 1 of 8 sampled facility staff (#37) reviewed for vaccinations. This placed residents at risk for infection. Findings include: A COVID-19 Staff Vaccination Status for Providers spreadsheet provided 3/6/23 revealed Staff 37 (RN) had a non-medical exemption for the COVID-19 vaccination. On 3/8/23 at 10:08 AM Staff 37 stated she thought COVID-19 vaccines were optional for staff at the facility, but she was vaccinated. Staff 37 stated she signed a vaccination declination form because she had two COVID-19 vaccinations and the facility had not asked her for proof of her COVID-19 vaccination. On 3/8/23 at 2:16 PM Staff 22 (Human Resources) stated he tracked the staff COVID-19 vaccinations. Staff 22 stated when new staff were not interested in the COVID-19 vaccination he let the DNS or infection preventionist know. Staff 22 also stated the facility was pretty lenient about non-medical exemptions and new staff did not need to explain why they needed a non-medical…

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