Life Care Center Of Coos Bay

Based on interview and record review it was determined the facility failed to ensure lab services were provided when ordered for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for unnecessary blood draws. Findings include:Resident 24 admitted to the facility in 9/2024 with diagnoses including diabetes and anxiety.A 12/4/25 pharmacy recommendation revealed Resident 24 received a thyroid replacement medication but a TSH (Thyroid-Stimulating Hormone) laboratory test within the last year was not located in the resident's medical record.A 12/10/25 physician order revealed an order for a fasting lipid panel, TSH and serum magnesium concentration laboratory test scheduled for 12/10/25.A review of the 12/2025 TAR revealed the task to draw labs for a fasting lipid panel, TSH and serum magnesium concentration was completed on 12/10/25 at 5:34 AM.A review of the 12/11/25 lab results revealed results to the lipid panel and magnesium tests, but no indication of results for the TSH lab test.A review of Resident 24's record revealed no indication of the TSH…

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 the staffing information was posted in a location easily accessible to residents and visitors. The facility also failed to post accurate and complete staffing information for 4 of 46 days reviewed for staffing. This placed residents and visitors at risk for incomplete, inaccessible, and inaccurate information. Findings include: On 9/23/24 at 11:00 AM the Direct Care Staff Daily Report was observed to be posted above standing eye level on a wall behind the nurse's station counter. On 9/24/24 at 3:12 PM the Direct Care Staff Daily Report was not filled out for the evening (2:00 PM to 10:00 PM) shift. On 9/26/2024 at 8:40 AM the Direct Care Staff Daily Report was posted without any data. Review of the Direct Care Staff Daily Reports for 8/12/24 through 9/26/24 revealed missing census data for 8/31/24 evening shift and missing nursing hours for the night shift on 9/16/24. On 9/26/24 at 12:25 PM Staff 34 (Staffing Coordinator/Admissions Coordinator) stated the staffing sheet was always…

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 implement enhanced barrier precautions (EBP; requires staff to wear gown and gloves with resident contact) and transmission based precautions for 2 of 3 sampled residents (#s 3 and 9) reviewed for pressure and non-pressure ulcers. This placed residents at risk for cross-contamination. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. On 9/23/24 at 12:02 PM Resident 3 was observed to have scabs and a wound dressing on her/his right shin. Resident 3's room was not identified to require EBP. On 9/24/24 at 7:50 AM Staff 25 (LPN) stated each day staff were provided a list of residents who required EBP. Staff stated Resident 3 was not on the list. On 9/24/24 at 8:15 AM Staff 2 (DNS) stated residents who had wound care should be on EBP. 2. Resident 9 admitted to the facility in 7/2024 with a diagnosis of a leg fracture. On 9/25/24 at 8:32 AM Resident 9 was observed to have a sign on the door indicating EBP and droplet precautions (mask required)…

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

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 6 staff members (#s 11, 18, 38, 39 and 40) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 5/25/18, had 10 hours and 46 minutes of documented training from 9/26/23 through 9/26/24 -Staff 18 (CNA), hired 5/18/22, had five hours and 36 minutes of documented training from 9/26/23 through 9/26/24 -Staff 38 (CNA), hired 8/2/23, had no documented training from 9/26/23 through 9/26/24 -Staff 39 (CNA), hired 3/29/18, had five hours and 52 minutes of documented training from 9/26/23 through 9/26/24 -Staff 40 (CNA), hired 4/13/22, had four hours and 41 minutes of documented training from 9/26/23 through 9/26/24 On 9/26/24 at 4:58 PM Staff 2 (DNS) stated all CNA staff were given competency evaluations upon hire and annually in March of each year. She stated in-service training 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 it was determined the facility failed to ensure residents were included in care planning for 1 of 2 sampled residents (#31) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 31 was admitted to the facility in 7/2022 with diagnosis including autism. A review of Resident 31's profile sheet revealed Witness 2 (Family Member) was Resident 31's responsible party and guardian. A review of Psychosocial Notes from 7/31/23 through 7/17/24 revealed the following: -10/26/23 Quarterly care conference held with Witness 2 via phone. -5/6/23 note did not indicate the meeting was a care conference and attendance did not include Witness 2. No documentation Witness 2 was invited to a care conference meeting. -7/17/24 late entry for 7/11/14 note did not indicate the meeting was a care conference meeting and did not include documentation Witness 2 was in attendance or was invited. No additional documentation was found in Resident 31's clinical record which indicated Witness 2 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 it was determined the facility failed to ensure residents' current advance directive information was reflected in clinical records for 3 of 5 sampled residents (#s 3, 45 and 51) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. A 7/9/24 admission MDS revealed Resident 3 was cognitively intact. A care plan initiated 7/16/24 indicated Resident 3 had an advance directive and staff were to honor her/his wishes. Resident 3's clinical record did not include a copy of her/his advance directive. On 9/25/24 at 10:00 AM Resident 3 stated she/he had an advance directive and her/his medical provider had a copy of the form. On 9/25/24 at 10:10 AM Staff 4 (Social Service Director) stated upon admission a resident was provided information related to advance directives. If a resident stated she/he had an advance directive staff were to follow-up and obtain a copy for the clinical record. Staff 4…

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 representative was notified of hospitalizations for 1 of 2 sampled residents (#33) reviewed for notification. This placed resident representatives at risk for lack of care decisions. Findings include: Resident 33 admitted to the facility in 4/2023 with a diagnosis of dementia. Resident 33's clinical record indicated Witness 6 (Family Member) was Resident 33's first emergency contact. On 9/23/24 at 3:52 PM Witness 6 stated in the recent past she/he was not notified when Resident 33 was admitted to the hospital. Progress Notes revealed on 8/17/24 Resident 33 had a change of condition and was transported to the hospital for evaluation and treatment. There was no indication Witness 6 was notified. On 9/25/24 at 1:58 PM a request was made to Staff 24 (LPN IP) to provide documentation Witness 6 was notified of Resident 33's hospitalization. No additional information was received.

Based on interview and record review it was determined the facility failed to provide written notification regarding a change in coverage for 1 of 3 sampled residents (#9) reviewed for Medicare notification of non-coverage. This placed residents and their representatives at risk for unknown financial liabilities. Findings include: Resident 25 was admitted to the facility in 7/2024 with diagnosis including fracture of the left leg. A review of the 7/16/24 admission MDS indicated Resident 9's BIMS was 9 which indicated moderate cognitive impact. A NOMNC (Notice of Medicare Non-Coverage) form was signed by Resident 9 on 7/22/24. It was not documented if her/his responsible party was contacted or made aware of the form and the effective date Medicare would no longer pay for skilled nursing services, which was 7/25/24, or how to appeal the decision if they disagreed. On 9/26/24 at 10:39 AM Witness 1 (Family Member) stated she was Resident 9's responsible party and she/he was able to understand the NOMNC form. Witness 1 stated the facility did not contact her regarding the NOMNC form, 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 provide a building in good repair 2 of 3 sampled residents (#s 11 and 20) reviewed for environment. This placed residents at risk for unsafe and unhomelike environment. Findings include: Resident 11 admitted to the facility in 12/2023 with diagnoses of vertigo (sense of spinning when someone is still) and unsteadiness on feet. Resident 20 was admitted to the facility in 3/2024 with diagnoses including muscle weakness and unsteadiness on feet. A review of the 8/30/24 MDS indicated revealed Resident 11's BIMs score was 13 which indicated Resident 11 was moderately cognitively impaired. A review of the 9/5/24 MDS indicated revealed Resident 20's BIMs score was 15 which indicated Resident 20 was cognitively intact. On 7/5/24 a public complaint was received which indicated the floor of Resident 11's room was so uneven that her/his bedside table would roll across the room. On 9/24/24 at 10:11 AM Resident 11 stated her/his room was going downhill, and staff had to engage the brakes on everything in her/his room or…

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 protect residents' rights to be free from verbal and physical abuse by Staff for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. A review of Resident 56's care plan dated 6/12/24 revealed Resident 56 had impaired cognitive ability with a score of 10 on her/his BIMS assessment. Interventions included allow extra time for the resident to respond to questions and instructions, ask yes and no questions to determine the resident's needs, identify yourself at each interaction, face Resident 56 when speaking and make eye contact, reduce any distractions. The care plan…

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 report to the State Survey Agency an allegation of abuse for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. On 7/5/24 the State Survey Agency received a public complaint which indicated on 6/15/24, during the night shift, Staff 15 (Agency LPN) came out into the hallway from Resident 56's room and bragged about his interaction with Resident 56. Staff 15 stated Resident 56 pushed her/his bedside table into Staff 15 , which upset Staff 15, and he grabbed Resident 56's bed covers into a ball, pushed down on Resident 56's chest and told her/him 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 investigate an allegation of abuse for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. On 7/5/24 the State Survey Agency received a public complaint which indicated on 6/15/24 during the night shift Staff 15 (Agency LPN) came out into the hallway from Resident 56's room and bragged about his interaction with Resident 56. Staff 15 stated Resident 56 pushed her/his bedside table into Staff 15, which made Staff 15 mad, and he grabbed Resident 56's bed covers into a ball and pushed down on Resident 56's chest and told her/him to never do that…

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 update the care plan for 3 of 7 sampled residents (#s 3, 9, and 43) reviewed for positioning and pressure ulcers. This placed residents at risk for unmet care needs. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of fractured ribs. Resident 3's admission MDS revealed she/he was cognitively intact. On 9/23/24 at 12:02 PM Resident 3 was observed with a wound dressing on her/his right shin. Resident 3 stated there was an open area on her/his shin for at least one month. Resident 3's care plan initiated on 7/16/24 was not revised to address her/his shin wound. On 9/25/24 at 11:12 AM Staff 2 (DNS) acknowledged Resident 3's care plan was not revised to address her/his skin issue. 2. Resident 43 admitted to the facility in 2/2024 with a diagnosis of kidney disease. A 2/9/24 admission MDS revealed Resident 43 was cognitively impaired and had a left hand contracture. An Occupational Therapy…

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 provide shaving for 1 of 3 sampled residents (#43) reviewed for ADLs. This placed residents at risk for lack of self esteem. Findings include: Resident 43 admitted to the facility in 2/2024 with a diagnosis of a stroke. On 9/23/24 at 12:45 PM and 9/24/24 at 2:51 PM Resident 43 was observed to have long facial hair . A 2/9/24 admission MDS revealed Resident 43 was cognitively impaired, was able to make needs known, and required assistance for most ADLs. On 9/23/24 at 3:30 PM Witness 7 (Family Member) stated Resident 43 preferred to have no facial hair. On 9/24/24 at 3:06 PM Staff 31 (CNA) stated residents were shaved on shower days. Resident 43 had a shower on the day shift, she was not sure the reason Resident 43 was not shaved, and acknowledged her/his facial hair was likely not shaved for several days. On 9/24/24 at 3:45 PM Resident 43 stated she/he usually liked to not have facial hair. Resident 43 also stated her/his facial hair was so long she/he required a weed whacker to shave.

Based on observation, interview and record review it was determined the facility failed to provide care to a non-pressure skin injury and failed to provide preparation for a medical procedure for 2 of 2 sampled residents (#s 3 and 21) reviewed for non-pressure skin conditions and medical procedures. This placed residents at risk for delayed care needs and treatment. Findings include: 1. Resident 3 was admitted to the facility with a diagnosis of heart disease. On 9/23/24 at 12:02 PM Resident 3 was observed to have a wound dressing on her/his right shin. Resident 3 stated there was an open area on her/his shin for at least one month. Weekly Skin Integrity Data Collection forms reveled on 8/14/24 and 9/16/24 Resident 3 was assessed to have scabs to the right shin. Resident 3's clinical record did not indicate the shin wound was measured, assessed to determine cause, or treatment orders were obtained, and her/his care plan initiated on 7/16/24 was not revised to address her/his shin wound. A 9/25/24 Skin Related Injury investigation revealed Resident 3 reported to the a State surveyor…

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 treatment was provided for a resident's decreased ROM for 1 of 4 sampled residents (#36) reviewed for positioning. This placed residents at risk for pain. Findings include: Resident 36 admitted to the facility in 4/2023 with a diagnosis of Parkinson's disease. An 4/19/24 annual MDS and associated CAAs indicated Resident 36 was confused at times, required staff assistance for ADLs, and was able to make needs known. The CAAs also indicated Witness 8 (Family Member) was very involved in Resident 36's care. On 9/23/24 at 4:19 PM Witness 8 stated Resident 36 had a contracture to her/his hands and was not aware if staff provided ROM. On 9/26/24 at 9:55 AM Resident 36 was observed to not be able to straighten her/his third and fourth fingers on both hands. Resident 36 stated her/his hands hurt to straighten. Review of Resident 36's clinical record revealed no treatments or care plan related to her/his decreased finger ROM. On 9/26/24 at 9:55 AM Staff 26 (PT) stated at that time therapy was not…

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

Based on observation, interview and record review it was determined the facility failed to provide adequate urinary catheter care and incontinent care for 1 of 5 sampled residents (#43) reviewed for pain and incontinence. This placed residents at risk for unmet urinary catheter needs and UTI. Findings include: Resident 43 admitted to the facility in 4/2024 with diagnoses including retention of urine and acute kidney failure. A 2/7/24 care plan revealed Resident 43 had an indwelling catheter with interventions including catheter care every shift, change catheter every month and change bag PRN. Every shift was to observe and report to the physician any signs and symptoms of a UTI, pain, burning, blood tinged urine, cloudy urine, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, and change in patterns. A 5/10/24 Quarterly MDS indicated Resident 43's BIMS was 12 which indicated moderately impaired cognition. Resident 43 had an indwelling catheter. A review of Resident 43's MAR…

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 the nutritional care plan for 1 of 5 sampled residents (#36) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 36 admitted to the facility admit in 4/2023 with a diagnosis of Parkinson's disease. An 4/16/24 Nutrition: Assessment/Nutritional Data Collection form indicated Resident 36 was at nutritional risk due to her/his Parkinson's disease and mental health disorders. Resident 36 was also assessed to have difficulty swallowing. The RD assessment indicated Resident 36 had a gradual weight loss but was stable. The current plan of care was to be continued which included snacks BID. A care plan revised on 6/23/24 revealed Resident 36 was to be provided snacks BID. There was no documentation in Resident 36's record to indicate she/he was provided snacks BID On 9/26/24 at 1:08 PM Staff 2 (DNS) stated staff did not enter the task for Resident 36's snacks correctly and the CNA task only included meal intake. On 9/27/24 9:12 AM Staff 33 (CNA) stated if 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 non-pharmacological interventions were provided prior medication administration and document a rational for no gradual dose reduction for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 43 admitted to the facility in 2/2024 with a diagnosis of dementia. a. A 7/10/24 Pharmacy Consultation Report revealed Resident 43 was administered venlafaxine (antidepressant) daily, amitriptylline (antidepressant) every evening, citalopram (antidepressant) daily and mirtazapine (antidepressant; can be used to stimulate appetite) every evening for malnutrition. A recommendation was to decrease the citalopram. A physician response revealed the recommendations were accepted. Citalopram was to be tapered and discontinued. The response also indicated in approximately two months a gradual dose reduction was to start for Resident 43's venlafaxine. A 9/4/24 Pharmacy Consultation Report revealed venlafaxine was to be assessed…

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 blood sample was obtained for 1 of 1 sampled resident (#21) reviewed for laboratory tests. This placed residents at risk for delayed treatment. Findings include: Resident 21 was admitted to the facility in 4/2023 with a diagnosis of a stroke. A 7/2024 TAR revealed on 7/10/24 staff were to obtain a blood sample for blood chemistry. Resident 33's record did not have blood chemistry results. On 9/25/24 at 1:58 PM a request was made to Staff 2 (DNS) and Staff 24 (LPN IP) to provide laboratory results. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a resident was offered a dental appointment for 1 of 2 sampled residents (#3) reviewed for dental services. This placed residents at risk for oral pain. Findings include: Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. A 7/13/24 Nutrition: Assessment/Nutritional Data Collection form revealed Resident 3 had Missing/broken/decaying teeth. A 7/9/24 admission MDS revealed Resident 3 was cognitively intact and had no dental issues including cavities. On 9/23/24 at 10:00 AM and 11:57 AM Resident 3 was observed with missing bottom front teeth and Resident 3 reported she/he had cavities. Resident 3 stated the facility did not inquire if she/he wanted assistance scheduling a dental appointment On 9/25/24 at 10:23 AM Staff 4 (Social Service Director) stated if a resident was assessed to have dental issues she/he was notified and followed up with a resident for dental care. Staff 4 stated he was not notified Resident 3 had dental concerns. On 9/25/24 at 11:17 AM Staff 2 (DNS)…

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 antibiotics were not used unless indicated and failed to monitor antibiotic usage for 1 of 5 sampled residents (#48) reviewed for urinary catheters or UTIs. This placed residents at risk for unnecessary antibiotic usage and drug resistant infections. Findings include: Resident 48 admitted to the facility in 2024 with diagnoses including chemical imbalance affecting the brain and repeated falls. An admission MDS dated [DATE] indicated Resident 48 was cognitively intact. The MDS also revealed Resident 48 had a history of falls. Review of progress notes revealed Resident 48 had two falls on 9/21/24, was sent to the hospital for evaluation and treatment, and returned with a diagnosis of UTI. Review of a 9/21/24 UA showed Resident 48's urine was cloudy and contained bacteria. No urine culture (test for type of antibiotic capable of killing the bacteria) was present. A 9/22/24 provider order revealed staff were to administer…

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 provide advance directive information, or follow up with or assist residents or resident representatives with formulation of an advanced directive for 4 of 7 sampled residents (#s 2, 3, 34 and 40) reviewed for advanced directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 7/8/22 unlabeled document indicated Resident 2 was given information on advance directives and offered assistance to complete the process. Resident 2's Care Plan Conference Records for 9/12/22, 12/12/22 and 3/30/23 indicated POLST (Physician Order for Life Sustaining Treatment) for her/his advance directive. A 3/3/23 Quarterly MDS revealed Resident 2 had moderate cognitive impairment. On 6/14/23 at 11:41…

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 sufficient staffing to meet the needs of residents for 2 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: On 6/12/23 at 11:41 AM Resident 23 stated she/he had to wait 30 minutes for staff to answer her/his call light and staff told her/him it was because they were short-staffed. Resident 23 stated the facility was short-staffed since she/he admitted to the facility two years ago. On 6/12/23 at 12:35 PM Resident 1 stated she/he turned on her/his call light, waited, and ended up falling asleep. An hour later the call light was still on. Resident 1 stated she/he did not activate the call light often as she/he did not want to bug the staff, and the staff would get in trouble if they stayed late. On 6/12/23 at 1:31 PM Resident 14 stated recently a CNA had three hallways to herself and residents waited an hour and a half to two hours on night shift for assistance.…

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 snacks were removed after discharge and/or labeled for 1 of 1 unit refrigerator (East Hall). This placed residents at risk for decreased quality of food. Findings include: On 6/13/23 at 1:54 PM Staff 14 (Dietary Manager) stated the food brought in by resident families had to be in single serving packages. The food was kept in the East Hall refrigerator. The kitchen staff monitored the refrigerator temperatures but the nursing staff were responsible for ensuring the food was dated, not expired and labeled with residents' names. On 6/14/23 at 12:44 PM with Staff 28 (MDS Coordinator) the East Hall resident snack refrigerator was observed to have one box of frozen pastries with a use-by date of 11/11/22. The pastries were not labeled with a resident's name. The refrigerator had five yogurts labeled with Resident 108's name with use-by dates which were dated before 6/14/23. Staff 28 indicated Resident 108 was discharged from the facility and the yogurt should have been removed.…

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 provide written grievance communications and resolutions regarding care and treatment concerns for 1 or 4 sampled residents (#256) reviewed for abuse. This placed residents at risk for unresolved concerns and grievances. Findings include: Resident 256 was admitted to the facility in 2022 with diagnoses including Parkinson's disease (progressive disease of the nervous system marked by tremors). An 10/18/22 admission MDS indicated Resident 256 was cognitively intact. An 10/13/22 care plan indicated to assist Resident 256 with mobility as needed. A 11/1/22 revised care plan indicated Resident 256 was able to ambulate with nursing assistance in the facility using a four wheel walker, self ambulate in her/his room and would call for setup assistance. The 11/21/22 Area of Focus: Concern and Comment Program indicated residents had the right to file grievances orally and the program was to be utilized anytime a concern, comment or grievance occurred that involved a resident. On 6/12/23 at 6:39 PM Resident 256…

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, and physical abuse for 1 of 4 sampled residents (#35) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 35 was admitted to the facility in 2022 with diagnosis including autism. Resident 37 was admitted to the facility in 2022 with diagnosis including cognitive communication deficit (difficulty thinking and how someone uses language). A 2/13/23 Communication with Physician note revealed Resident 37 scratched, hit and verbally attacked a CNA who was caring for her/him. A 3/3/23 Quarterly MDS revealed Resident 37's BIMS score was 11 indicating moderate cognitive impairment. An 4/28/23 Quarterly MDS revealed Resident 35 was hardly understood and was severely cognitively impaired. A 5/18/23 Alert Note indicated it was reported to Staff 2 (DNS) that Resident 14 witnessed Resident 37 hit Resident 35 in the shoulder twice and stated for her/him to stay the fuck out of [her/his] room and away from Resident 37. A 5/18/23 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 observation, interview and record review it was determined the facility failed to revise care plan interventions for 1 of 4 sampled residents (#2) reviewed for non-pressure skin conditions. This placed residents at risk for medical complications. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 3/3/23 Quarterly MDS revealed Resident 2 had impairment to both of her/his upper extremities. An 4/25/23 medical evaluation indicated Resident 2 had edema (swelling caused by excess fluid trapped in the body's tissue) in her/his left upper extremity which previously resolved when Resident 2's hand was elevated, but now the entire arm was edematous. A 5/30/23 revised care plan had no indication of staff interventions for Resident 2's edema. A 6/12/23 nutrition/dietary note indicated Resident 2 had pitting edema and the physician 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 it was determined the facility failed to complete discharge summaries including a recapitulation of stay and a final summary of residents' status upon discharge for 1 of 2 sampled residents (#53) reviewed for discharge. This placed residents at risk for unsafe discharges. Findings include: Resident 53 admitted to the facility in 2023 with diagnoses including kidney disease. A 5/5/23 Progress Note revealed Resident 53 discharged to home with her/his spouse, and was sent home with medication and discharge instructions. A 5/5/23 Discharge Summary Information assessment included no recapitulation of Resident 53's stay or final summary of her/his status at the time of discharge On 6/14/23 at 4:38 PM Staff 2 (DNS) reviewed Resident 53's Discharge Summary Information assessment and confirmed it did not include a recapitulation of stay. Staff 2 stated she expected staff to add information about the resident's progress with rehabilitation and nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure treatments were provided for 1 of 4 sampled residents (#257) reviewed for non-pressure skin conditions. This placed residents at risk for adverse medical conditions. Findings include: Resident 257 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) and spina bifida (birth defect of the spine and spinal cord which could cause symptoms including weakness and paralysis). A 7/18/23 admission Collection Tool indicated Resident 257 had a linear ulceration to the back of the right thigh which was 14 inches long. Review of the resident's TAR and Progress notes from 7/18/22 through 7/23/22 revealed there was no treatment or monitoring to the right thigh ulceration. A Progress Note dated 7/24/22 indicated, upon admission, the resident had an open area to the back of her/his thigh. The note indicated the resident reported, after admission to the facility, no one looked at the open area. 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 address RD recommendations for 2 of 7 sampled residents (#s 9 and 40) reviewed for unnecessary medications and nutrition. This placed residents at risk for weight loss. Findings include 1. Resident 9 was admitted to the facility in 2021 with diagnoses including dementia and protein-calorie malnutrition. A 12/23/22 Annual MDS indicated Resident 9 required set-up assistance for eating and she/he was rarely understood. The 6/2023 Task: ADL-Snacks indicated no snacks were offered to Resident 9 from 6/1/23 through 6/15/23. A 6/2/23 revised care plan indicated Resident 9 was at risk for weight fluctuation and to assist her/him with meals as needed. A 6/13/23 Resident at Risk Meeting Note and revised care plan indicated to provided fortified snacks to Resident 9 twice a day. On 6/12/23 at 12:28 PM Resident 9 was observed in her/his room with untouched food in front of her/him on a bedside table. Resident 9's hands were tucked under her/his blanket. On 6/12/23 at 3:08 PM Resident 9 was observed in bed…

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 resident food preferences were honored for 1 of 4 sampled residents (#23) reviewed for food preferences. This placed residents at risk for unmet needs. Findings include: Resident 23 was admitted to the facility in 2021 with diagnoses including diabetes and macular degeneration (blurred or no vision). A 2/3/23 Annual MDS indicated Resident 23's BIMS score indicating she/he 15 was cognitively intact. A 2/8/23 care plan indicated Resident 23 needed assistance with ordering her/his food. Review of the 11/3/22 and 5/4/23 Quarterly Nutritional Data Collection indicated Resident 23 liked cheerios and bananas, and Does not like this writer [writer of the report] or foods offered by facility. Very negative and has many food complaints. No documentation of Resident 23's food dislikes were documented. On 6/12/23 at 11:43 AM Resident 23 stated CNA staff went over the menu with her/him and took her/his order and every day she/he never received what she/he ordered. Resident 23 stated one day she/he ordered soup…

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 determine the facility failed to provide adaptive eating equipment for 1 of 2 sampled residents (#2) reviewed for position and mobility. This placed residents at risk for loss of dining independence. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 3/3/23 Quarterly MDS revealed Resident 2 had impairment to both of her/his upper extremities. A 1/18/23 revised care plan indicated Resident 2 was to wear her/his hand splint for all meals, utensils slid into the pocket on the palm side of the splint and Resident 2 should be able to eat with minimal assistance. Staff were to assist Resident 2 with meals as needed. A 5/23/23 MR (Magnetic Resonance) Cervical Spine without Contrast revealed Resident 2 had degenerative changes to the spine at all levels which explained her/his muscle…

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.