Green Valley Rehabilitation Health Center

Based on interview and record review it was determined the facility failed to provide a Restorative program for 1 of 1 sampled resident (#55) reviewed for restorative. This placed residents at risk for increased weakness. Findings include: Resident 55 was admitted to the facility in 9/2024 post joint replacement. Resident 55's Care Plan revised on 9/26/25 revealed she/he had limited mobility, and interventions include a nursing restorative program. The program included walking. Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact. On 1/26/26 at 11:22 AM Resident 55 stated she/he received exercises and then it suddenly stopped. Resident 55's clinical record did not have documentation to indicate she/he currently received a restorative program or a rationale for discontinuation. On 1/29/26 at 10:29 AM Staff 5 (Director of Rehabilitation) stated Resident 55 was not on the current list of residents who received restorative services. On 1/29/26 at 11:05 AM Staff 33 (Restorative Aide) stated Resident 55 had a respiratory illness and restorative was discontinued.…

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 personal hygiene was provided for 1 of 4 sampled residents (#55) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 55 was admitted to the facility in 9/2024 with a diagnosis of joint replacement. Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact. Resident 55's Care Plan last revised on 9/26/25 revealed she/he had an ADL self-care performance deficit and interventions included she/he was dependent on staff for personal hygiene. On 1/26/26 at 11:17 AM Resident 55 stated she/he needed assistance to shave and preferred to be clean shaven. Resident 55 also stated she/he did not receive many showers. Resident 55 was observed in bed and was not shaved. Resident 55's facial hair was approximately 0.25 inches long. An undated facility shower schedule revealed Resident 55's shower days were scheduled for Tuesday and Thursday mornings. Resident 55's 12/31/25 through 1/21/26 shower documentation and Progress Notes revealed 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 it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 3 sampled residents (#61) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: Resident 61 was admitted to the facility in 11/2025 with diagnoses including dementia, post-traumatic seizures, and anxiety. The 11/11/25 admission MDS indicated a BIMS assessment score of 15 (cognitively intact) and Resident 61 was unable to complete her/his interview for her/his Preferences for Routine and Activities. The MDS indicated staff knew it was important for Resident 61 to participate in religious activities, spend time outdoors and do things with groups of people.A 11/14/25 Care Plan indicated staff were to invite the resident to leisure programs. No information about Resident 61's preferences for activities were identified. The 12/28/25 through 1/27/26 Task: Activity Involvement document revealed Resident 61 was not offered activities during the last 30 days.On 1/27/26 at 9:40 AM,…

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

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 a resident's smoking paraphernalia was stored securely and failed to ensure a resident was evaluated for safety after a fall for 1 of 3 sampled residents (#71) reviewed for smoking and falls. This placed residents at risk for injury. Findings include.Resident 71 was admitted to the facility in 8/2023 with a diagnosis of paraplegia. Resident 71's 1/2/26 BIMS revealed she/he was cognitively intact.1. A Smoking -Supervised Smokers policy last revised 12/2025 revealed residents who wish to smoke were to be evaluated. Smoking paraphernalia would be managed by nursing staff and made available during smoking times. Resident 71's Care Plan last revised on 12/31/25 revealed she/he was an independent smoker. Interventions included cigarettes and lighters were required to be stored at the nurse's station. On 1/27/26 at 9:32 AM Resident 71 was observed in the smoking area. Resident 71 had a black bag in her/his lap. When…

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

Based on observation, interview and record review the facility failed to effectively manage the resident's pain for 1 of 3 (#66) sampled residents reviewed for pain management. This placed residents at risk for unmanaged pain. Findings include: Resident 66 was admitted to the facility in 2022 with diagnoses including severe osteoarthritis (a disease which destroys the cartilage protecting bones and cause pain, stiffness and reduced mobility) and chronic pain. The resident's 11/2025 BIMS revealed a score of 14 (cognitively intact).A review of the resident's pain monitoring (1-10 scale of pain level with 10 indicating the worst pain possible) in the TAR for the previous 12 months revealed the following:2/2025: Pain levels of 6-10 reported on 26 of 28 days.3/2025: Pain levels of 6-9 reported on 27 of 31 days.4/2025: Pain levels of 6-10 reported on 28 of 30 days.5/2025: Pain levels of 6-10 reported on 30 of 31 days. 6/2025: Pain levels of 6-8 reported on 25 of 30 days. 7/2025: Pain levels of 6-8 reported on 25 of 31 days.8/2025: Pain levels of 6-8 reported on 30 of 31 days.9/2025: Pain…

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 thoroughly assess a resident with trauma for 1 of 2 sampled residents (#61) reviewed for behaviors. This placed residents at risk for re-traumatization. Findings include:Resident 61 was admitted to the facility in 11/2025 with diagnoses including insomnia, post-traumatic seizures, and anxiety. The 11/11/25 admission MDS indicated a BIMS score of 15 (cognitively intact) for Resident 61. The 11/11/25 ACTs My Way assessment indicated Resident 61 was sensitive to loud noises due to military service and Staff 23 (Activity Assistant) conducted the interview.A 11/14/25 Care Plan revealed no information about Resident 61's PTSD (Post Traumatic Stress Disorder) triggers. The 1/2026 Monitors revealed Resident 61 slept from two to 11 hours per day during the month. On 1/27/26 at 10:05 AM, Resident 61 stated she/he had PTSD and no one was aware he/she required a particular environment to sleep well. Resident 61 sat at the side of her/his bed with the television on and stated she/he needed sound in 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 provide dental services for 1 of 3 sampled residents (#5) reviewed for dental. This placed residents at risk for weight loss and unmet dental needs. Findings include: Resident 5 was admitted to the facility in 3/2024 with a diagnosis of diabetes. Resident 5's 3/19/25 health care provider summary revealed Resident 5 was seen for chronic conditions and her/his dental status. The summary indicated Resident 5 requested to see a dentist for possible implants. Resident 5's 1/20/26 NP Wound Note reveals she/he had mild cognitive impairment. Resident 5's 1/27/26 Care Plan revealed she/he did not have teeth, and staff were to refer to a dentist for evaluations. On 1/26/26 at 3:58 PM Resident 5 stated she/he did not have teeth and wanted implants. Resident 5 stated no one spoke to her/him forever regarding dental services. On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated Resident 5 was able to be transported to dental appointments, but she did not see any dental referrals in her/his clinical record.

Based on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering an influenza vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights. Findings include:1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact.A review of Resident 9's medical record indicated she/he received an influenza vaccine on 10/2/25. No consent for the influenza vaccine was found in Resident 9's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered influenza vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 9 did not have a signed consent for the influenza vaccine she/he received on 10/2/25.On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any…

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

Based on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering a COVID-19 vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights. Findings include:The facility Infection Prevention & Control COVID-19 Immunization policy with revision date 1/7/25 indicated all residents would be offered the COVID-19 vaccine when available and the resident's medical record would contain documentation of an acceptance or refusal of the vaccine. 1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact.A review of Resident 9's medical record indicated she/he received a COVID-19 vaccine on 10/2/25. No consent for the COVID-19 vaccine was found in Resident 9's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered COVID-19 vaccines when they were available, and a consent 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 staff a registered nurse (RN) for eight consecutive hours per day seven days per week for 21 out of 78 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:A review of the facility's Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 indicated there were 21 days without RN coverage for eight consecutive hours. The dates were as follows: -8/3/25-8/8/25-8/10/25-8/11/25-8/16/25-8/17/25-8/18/25-8/19/25-8/24/25-8/25/25-8/29/25-8/31/25-9/1/25-9/7/25-9/15/25-9/29/25-10/20/25-10/25/25-10/27/25-10/28/25-11/3/25 On 1/15/26 at 9:23 AM, Staff 27 (Staffer) and Staff 23 (LPN) stated they were told to start reporting the RN manager on the Direct Care Staff Daily Report on 1/13/25. On 1/15/26 at 11:52 AM, Staff 1 (Administrator) stated it was the expectation for staff to call off work two hours before their shift to give time for additional staff to be found to cover. Payroll documentation of RN working on the above listed days were requested. 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 make prompt efforts in resolving a resident's grievance for 1 of 7 sampled residents (#23) reviewed for misappropriation. This placed residents at risk for unresolved grievances. Findings include:A revised Resident Rights Grievances Policy and Procedure (revised in 3/2023) indicated the grievance officer with assistance of Social Services, responsibility to oversee the grievance process, receive and track grievance through conclusion, lead any necessary investigations, maintain confidentiality, and issue written grievance decisions. Staff will immediately report to the Grievance Officer any grievance alleging violations related to misappropriation of resident property. The Grievance Officer will make reports available within seven business days of filing. A summary report of the investigation will be available to the resident, and a confidential file will be maintained on grievance decisions and investigations for three years. Resident 23 was admitted to the facility in 2/2025, with a diagnosis 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 report an incident of potential neglect for 1 of 9 sampled residents (#28) reviewed for elopement. This placed residents at risk for accidents. Findings included:Resident 28 was admitted to the facility in 2/2025, with diagnoses including anxiety and cognitive communication deficit (difficulty in expressing or understanding language). A 3/7/25 Elopement Investigation Report revealed on 3/6/25 around 4:30 PM, Resident 28 was found approximately a block away from the facility next to a busy street. The investigation stated root cause was Resident 28 was confused and her/his wander guard (electronic monitoring device) was not functioning. There was no documented evidence Resident 28's elopement was reported to the State Survey Agency for the elopement incident on 3/6/25. On 1/14/26 at 9:48 AM, Staff 40 (Former Administrator) stated she could not remember if Resident 28's elopement was reported to the state but stated she would not report an elopement because it was no longer listed on the FRI form. On…

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

Based on interview and record review, it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 9 sampled residents (#28) reviewed for accidents. This placed residents at risk for accidents. Findings include:Resident 28 was admitted to the facility in 2/2025, with diagnoses including anxiety, and cognitive communication deficit (difficulty expressing or understanding language). A 2/7/25 admission MDS revealed Resident 28's BIMs score was three (severe cognitive impairment). A 3/4/25 Care Plan indicated Resident 28 had episodes of wandering and had a Wander Guard (electronic monitoring device) placed on her/his wheelchair. Interventions included checking placement of Wander Guard on the wheelchair every shift and distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. A 3/2025 TAR instructed staff to check Resident 28's Wander Guard placement on the left area of her/his wheelchair every shift with a start date of 3/4/25. There was no documented…

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 was treated with dignity for 1 of 3 (#1) residents reviewed for dignity. This put residents at risk for a decreased quality of life. Records reveal: Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 admission MDS revealed she/he was cognitively intact and required moderate assistance from staff for transfers. On 10/24/25 at 11:54 AM, Resident 1 stated while speaking with Staff 5 (Speech Therapist) about self-transferring for toileting needs she/he was told to only get up with staff assistance and to urinate in the bed when staff were not available. She/He stated the comment was mortifying and caused her/him to feel degraded. On 10/27/25 at 11:45 AM, Staff 5 stated she did not remember Resident 1. She stated she often instructs residents to follow all safety and assistance recommendations to prevent possible injuries. She stated if she was aware a resident was transferring in an unsafe manner to use…

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

Based on record review and interview it was determined the facility failed to ensure a resident's medications were given according to provider orders and a wound was properly monitored for 1 of 5 residents (#1) reviewed for medications and wound care. This put residents at risk for adverse medication reactions, infections, and death. Records reveal: The facility Wound Treatment Management policy revised 4/1/25 stated the effectiveness of wound care treatments would be monitored with ongoing assessments of the wound until healed.Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 admission MDS revealed she/he was cognitively intact, had pain daily, and had a surgical wound. On 10/24/25 at 11:54 AM, Resident 1 stated the facility ran out of her/his pain medications multiple times and the facility staff did not implement wound observations or treatment after her/his wound care needs changed. She/He stated they were constantly in pain while at the facility and was admitted to the hospital with an…

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 assure there was sufficient nursing staff available to provide nursing and related services to meet the residents' needs safely and timely for 2 of 2 units reviewed for staffing. This placed residents at risk for missed or delayed care, missed or late meals, an increase safety risk for falls and aspiration, and a decline in health status. Findings include: Intermittent call light and staffing observations conducted on 1/29/25 from 8:15 AM to 5:00 PM revealed call light wait times up to 27 minutes. Intermittent call light and staffing observations conducted on 1/30/25 from 5:00 AM to 2:00 PM revealed call light wait times up to 40 minutes. Review of the facility's grievances found the following: - On 11/6/24, staff entered Resident 24's room and found Resident 24 soaked so bad that it was dripping off of [her/his] bed onto the ground and there was a huge puddle of pee underneath. Additionally, the resident was found laying flat in bed with no oxygen, her/his oxygen saturation was 79% (normal is…

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

Based on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 1 of 3 sampled residents (#8) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 8 was admitted to the facility in 1/2024, with diagnoses including respiratory failure with hypoxia (lack of oxygen) and asthma. Resident 8's 2/2024 Physician's Orders indicated staff was to administer oxygen continuously at 2 liter per minute via nasal cannula. This order was discontinued when Resident 8 was sent out to the hospital. Resident 8 re-admitted on 12/2024 without an order for oxygen. On 1/31/25 at 12:20 PM, Staff 3 (SSD) confirmed Resident 8 had an appointment on 12/9/24 at summit surgical. Staff 3 remembered her/him coming back upset about the appointment. On 1/31/25 at 10:38 AM, Staff 44 (CNA) stated Resident 8 should have had oxygen when she/he went out to the appointment on 12/9/24. Resident 8 came back and her/his pulse oxygen reading was at 64%. Staff were supposed…

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.

3. A 9/8/24 at 9:37 AM interview with Staff 7 (CNA) revealed she reported the ICF unit refrigerator was in unsanitary condition, and the sandwiches had no label for expiration date. Staff 7 reported she did not use the food in the unit refrigerator as she was concerned it was expired and unsafe for consumption. On 9/8/24 at 9:46 AM observation of the unit refrigerator revealed eight sandwiches without date labels and one food-soiled and broken refrigerator shelf (previously taped together). An unsanitary sticky wooden corner shelf was food-soiled and holding peanut butter, syrup, bananas and crackers. The floor surrounding the refrigerator was soiled and sticky. An expired orange and a soiled washcloth sat on top of the refrigerator. On 9/13/24 at 9:18 AM observation of the unit refrigerator revealed no change from initial observation five days earlier except for addition of date labels on sandwiches. A 9/13/24 at 9:34 AM interview with Staff 60 (Infection Prevention Nurse) confirmed the wooden shelf was uncleanable and soiled with sticky food. He stated the shelf was uncleanable…

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 the risk and benefits for the use of an antipsychotic medication to a resident/responsible party prior to administration for 4 of 5 sampled residents (#s 55, 87, 164, and 165) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including pulmonary embolism (blockage of a lung artery). A review of the 9/2024 MAR instructed staff to administer sertraline (to treat depression) one time a day for depressive episodes with a start date of 7/27/24. The MAR instructed staff to administer lorazepam (to treat anxiety) every four hours as needed for nausea and agitation with a start date of 8/29/24. No information was found in the record to indicate the resident or responsible party were provided risk and benefits information for the use of sertraline or lorazepam. On 9/13/24 at 8:36 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they knew there…

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 a response to Resident Council grievances for 1 of 1 resident group reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being. Findings include: A grievance policy revised 3/2023 indicated the grievance officer (administrator) would take immediate action to prevent further potential violations of any resident right while a grievance was investigated. Review of Council Minutes notes dated 7/16/24 revealed : -CNAs: No improvement-getting worse. - Council members also wanted reimbursement for lost or stolen items and voiced concern about menus not being followed. -Call light response time was awful. -Head phones being used 8/2024 Council Agenda notes revealed: -CNAs not knocking on bathroom doors -CNAs have attitudes -Meals were up to 1.5 hours late -Resident laundry being delivered to wrong rooms. During a resident council meeting on 9/10/24 at 2:51 PM, residents stated the facility staff did not respond to concerns or grievances voiced by resident council.…

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' rooms were clean, in good repair and free of clutter for 5 of 5 sampled residents (#s 2, 62, 71, 98, and 162) reviewed for ADLs and environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. On 9/10/24 at 11:44 AM Resident 2's room was observed with the following: -Multiple tissue boxes, paperwork, cups, utensils, books, and a miniature arctic air conditioner on the bedside table. The air conditioner had approximately one half inch of brown dust on the vents and on the internal filters. -Food boxes, pop cans, and paperwork on the floor and the bedside table. Resident 2 stated she/he had the arctic air conditioner for three years and nobody cleaned it for her/him. Resident 2 stated she/he did not like her/his room so cluttered and asked staff to help clean her/his room, but nobody…

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 a written grievance, resolution, or communication with a resident or representative for 3 of 17 sampled residents (#s 63, 98 and 162) and 1 of 2 units reviewed for dignity, food, staffing and accidents. This placed residents at risk for unresolved concerns. Findings include: 1. Resident 63 admitted to the facility in 5/2024 with diagnoses including heart failure and chronic kidney disease. Review of a 7/18/24 Discharge MDS indicated Resident 63 was cognitively intact. On 9/11/24 at 3:59 PM Staff 51 (Scheduler) stated Resident 63 reported a missing ring to staff on 8/13/24. She stated a sign was made to alert staff, and a written grievance was given to management. Observation of the sign mentioned by Staff 51 revealed the wording missing on 8/13/24 silver ring with this symbol (large image of a masonic symbol). Please give to nurse if found! Review of the 8/2024 grievance log revealed no grievances related 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 provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: The 7/2024 Council Minutes indicated Staff 7 (Activities Director) recorded the minutes as the person responsible. On 9/10/24 at 8:48 AM Staff 7 (Activity Director) stated she worked for the facility in the activities department since 5/2023 and was promoted to the Director position in 7/2024 which included responsibility to organize the Resident Council. Staff 6 acknowledged she did not have an activities certification. On 9/13/24 at 1:07 PM Staff 1 (Administrator) confirmed the certification for Staff 7 was not completed as required.

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 1 of 14 sampled residents (#24) and 2 of 2 units (Skilled unit and long-term unit) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. A review of an 4/15/24 Intake Information revealed a public complaint received by the State Agency indicated the facility was short-staffed for CNAs. Due to inadequate staffing CNAs could not provide showers for all the residents scheduled for the evening shift. A review of Council Minutes dated 4/19/24 revealed call light wait times were up to 30 to 45 minutes, especially on the night shift. A review of Council Minutes dated 7/16/24 revealed call light wait times were awful. A review of a 7/31/24 Intake Information revealed a public complaint received by the State Agency indicated the facility was short-staffed for both CNAs and nurses. There was difficulty for night nurses to provide care…

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 staff a registered nurse for 8 consecutive hours per day 7 days per week for 7 out of 93 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 4/1/24 through 4/30/24, 7/1/24 through 7/31/24, 8/8/24 through 8/31/24 and 9/1/24 through 9/8/24 revealed there were seven days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 9/13/24 at 8:37 AM and 11:25 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they would look at the RN coverage. No additional information was provided related to the required RN coverage.

Based on interview and record review it was determined the facility failed to post accurate and complete staffing information for 6 of 6 days reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: On the following days and times the Direct Care Staff Daily Report revealed the following : -9/8/24 at 3:00 PM, all three shifts no census was documented for day and evening shift. -9/9/24 at 3:36 AM, 9/8/24 posting for the night shift did not have census documented. -9/10/24 at 9:58 AM, no census documented on day shift. -9/11/24 at 6:57 AM no census documented for day shift; 10:12 AM, no census documented on day shift. -9/12/24 at 10:01 AM, no census documented for day shift. 9/13/24 at 8:20 AM, no census documented for day shift. On 9/13/24 at 8:37 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated staff should document census each shift on the report.

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 19, 163 and 262) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1. Resident 19 admitted to the facility in 8/2024 with diagnoses including a fracture of the left femur and chronic kidney disease. Review of an 8/7/24 Medicare 5-Day MDS indicated Resident 19 was cognitively intact. Review of a Patient and Facility Arbitration Agreement revealed Resident 19 signed the document on 8/29/24. On 9/11/24 at 10:16 AM Resident 19 stated she/he knew what arbitration meant but did not remember signing an agreement at this facility. On 9/12/24 at 4:37 PM Staff 59 (Admissions Coordinator) stated she told all new admissions they had the right to decline or agree and had 30 days to change their mind. She stated she explained the definition and process of arbitration and offered a copy to all…

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 appropriate use of PPE and failed to follow infection control standards for 2 of 2 units and 1 of 1 laundry room reviewed for infection control. The facility additionally failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident uses for 1 of 1 sampled resident (#20) reviewed during CBG checks. This placed residents at risk for the spread of infection and placed all residents who required CBG checks at risk for bloodborne illness. Findings include: 1. On 9/9/24 at 3:28 AM Staff 38 (LPN) was observed sitting on a stool across the hall from the nurses' station on the long-term side of the facility with no mask on. Staff 30 (LPN) was observed sitting at the nurses' station with no mask on. At 3:56 AM Staff 38 was observed coming out of an empty resident room with no mask on. Staff 38 stated COVID-19 caused some staffing issues, but CNA staff could still complete their work.…

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 safe system for a resident's self-administration of medication for 1 of 6 sampled residents (#44) reviewed for accidents. This placed residents at risk for adverse medication reactions. Findings include: Resident 44 admitted to the facility in 2021 with a diagnosis of heart disease. An 4/22/24 annual MDS revealed Resident 44 was cognitively intact. A 5/12/23 Self-Administration of Medication form revealed Resident 44 was assessed to be capable of self-administration of medications. The form did not indicate which medications Resident 44 was able to self-administer. A care plan initiated 9/2023 revealed Resident 44 was not able to walk and propelled in a wheelchair with staff assistance. The care plan also indicated Resident 44 self-administered over-the-counter supplements which were kept at her/his bedside. The care plan did not identify which medications she/he could self-administer. A 9/2024 MAR revealed Resident 44 had orders to self-administer supplements which were kept at the resident's…

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 was assisted with formulating an advance directive for 1 of 3 sampled residents (#164) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored. Findings include: Resident 164 admitted to the facility in 2022 with a diagnosis of chronic kidney disease. A 7/30/24 IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form revealed Resident 164 was able to voice her/his needs but was cognitively impaired. The form also indicated she/he wanted to formulate an advance directive with the assistance of her/his friend. Progress Notes from 7/30/24 to 9/9/24 did not include a follow up note to indicate staff communicated with Resident 164 or her/his friend to assist with formulating an advance directive. On 9/10/24 at 4:01 PM Staff 3 (Social Services) stated she recalled Resident 164 verbalizing she/he wanted to formulate an advance directive. Staff 3 indicated if assistance was provided it would be documented in the progress notes.…

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 notify the physician or resident representative regarding refusals and changes in condition for 3 of 7 sampled residents (#s 55, 86 and 165) reviewed for medications, change of condition and catheter care. This placed residents at risk for delay in treatment. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including chest pain. A review of the 9/2024 TAR instructed staff to administer a lidocaine patch to the affected area one time a day for pain. From 9/1/24 through 9/9/24 Resident 55 refused the patch nine times out of nine opportunities. No documentation was found in Resident 55's clinical record the physician was notified of the refusals from 9/1/24 through 9/9/24. On 9/10/24 at 4:51 PM Staff 1 (Administrator) confirmed the physician was not notified at any time from 9/1/24 through 9/9/24 regarding the lidocaine patch refusals. 2. Resident 86 admitted to the facility in 3/2024 with diagnosis including UTI and paraplegia (impairment in lower extremities). A 6/18/24…

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 report timely to the State Survey Agency for an allegation of elopement for 1 of 7 sampled residents (#93) reviewed for accidents. This placed residents at risk for elopement. Findings include: Resident 93 was admitted to the facility in 6/2024 with diagnoses including dementia, stroke, alcohol abuse and seizures. A FRI dated 9/9/24 indicated on 9/6/24 Resident 93 left the facility, and it was reported to the State Agency on 9/9/24. On 9/13/24 at 8:37 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated staff did not report the elopement to the facility administration staff until 9/9/24. Refer to F689

Based on interview and record review it was determined the facility failed to thoroughly investigate an injury for 1 of 9 sampled residents (#82) reviewed for abuse and accidents. This placed residents at risk for neglect of care. Findings include: Resident 82 admitted to the facility in 1/2024 with diagnoses including stroke. A 7/24/24 FRI indicated Staff 74 (CNA) showered Resident 82 and bumped the resident's foot on the wall while exiting the shower room. Staff 74 left the facility prior to the end of her shift and left Resident 82 sitting in the shower chair. Staff 75 (CNA) reported the resident's toe was bleeding and there was no report or communication given to staff about the resident being left alone. A 7/25/24 facility Investigation completed by Staff 5 (Unit Manager-LPN) specified the following summary of Resident 82's injury on 7/24/24: after Resident 82 was assisted with a shower Staff 74 bumped the resident's foot on the wall while exiting the shower room, but did not realize the resident had an injury to her/his toe. Staff 74 left the resident in her/his room with…

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

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalizations. This placed residents at risk for lack of access to an advocate to inform them of their options and rights. Findings include: 1. Resident 95 admitted to the facility in 7/2024 with a diagnosis of cancer. A Progress Note dated 7/6/24 revealed Resident 24 requested to be sent to the hospital for shortness of breath. Emergency services were called and the resident was transferred to the hospital. Resident 95's clinical record revealed no documentation to indicate the State Long-Term Care Ombudsman was notified. On 9/12/24 at 11:36 AM Staff 63 (Medical Records) stated she worked in her current position for eight years and never sent a message to the State Long-Term Care Ombudsman. On 9/12/24 at 11:54 AM Staff 56 (Regional RN) stated medical records staff were to send resident discharge information to the ombudsman office. 2. Resident 262…

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 a bed hold policy for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to their right to return to the facility. Findings include: 1. Resident 95 admitted to the facility 7/2024 with a diagnosis of cancer. A Progress Note dated 7/6/24 revealed Resident 24 requested to be sent to the hospital for shortness of breath. Emergency services were called and the resident was transferred to the hospital. Resident 95's clinical record revealed no documentation to indicate Resident 95 or her/his representative were provided a bed hold policy at the time of discharge. On 9/12/24 at 11:19 AM Staff 22 (Social Services) stated she was not sure who provided residents with a bed hold policy when they were transferred to the hospital. On 9/12/24 at 11:25 AM Staff 58 (LPN) stated when a resident was sent to the hospital she was not sure who provided the resident or representative the bed hold policy. Staff 58 stated at other facilities…

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 related to interventions for personal equipment for 3 of 12 sampled residents (#s 2, 86 and 164) reviewed for ADLs, medications and respiratory care. This placed residents at risk for unmet needs. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. An observation on 9/10/24 at 11:44 AM revealed a mini arctic air conditioner on Resident 2's bedside table and a suction machine on the resident's night stand. A 7/4/24 care plan revealed no information regarding the air conditioner or the suction machine. On 9/10/24 at 11:58 AM Staff 4 (Unit Manager-LPN) acknowledged there was no information regarding the air conditioner or the suction machine on the resident's care plan. 2. Resident 86 admitted to the facility in 3/2024 with diagnosis including depression and paraplegia (impairment in lower extremities). A 6/18/24 revised care plan indicated the following: -All staff were to involve Resident 86 in decisions about her/his care.…

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 staff did not falsify documentation for 1 of 1 staff (#20). This placed residents at risk for adverse medication reactions. Findings include: On 6/25/24 the Past Noncompliance was corrected when the facility identified the cause of the incident and determined vital signs were not obtained by a CMA prior to medication administration resulting in a drop in blood pressure. The plan of correction included: -6/28/24 nurse and CMA education was provided related to the 10 rights of medication administration. -7/3/24 an audit was initiated for residents with blood pressure parameters -7/3/24 the facility reported Staff 20 (CMA) to the Oregon State board of Nursing. -7/3/24 education was initiated to all nurses and CMAs regarding standards and scope of practice related to their licensure and obtaining vital signs prior to medication administration. Resident 41 was admitted to the facility in 8/2023 with a diagnosis of paraplegia (inability to move legs). A 7/10/24 annual MDS revealed Resident 41 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 observation, interview and record it was determined the facility failed to provide care and services to maintain good grooming for 3 of 4 sampled residents (# 62, 86 and 98) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 62 admitted to the facility in 6/2022 with diagnoses including chronic pain. A public complaint was received on 5/2/24 which alleged Resident 62 received only four showers in the month of 5/2024. The In Room Care Plan instructed staff to shower Resident 62 on Mondays and Fridays. The Documentation Survey Report dated 5/1/24 through 5/31/24 revealed Resident 62 received three showers in the month of 5/2024. On 9/8/24 11:50 PM Resident 62 was observed lying in bed. The resident's hair appeared greasy, and body odor was present. On 9/8/24 at 12:50 PM Resident 62 stated she/he received four showers a month which was not enough. Resident 62 stated she/he was supposed to receive two showers a week but was not getting them. On 9/9/24 at 1:09 PM Staff 36 (CNA) and Staff 68 (CNA) stated there was not enough time 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 observation, interview and record review it was determined the facility failed to provide meaningful activities for dependent residents for 2 of 2 sampled residents (#s 14 and 54) reviewed for activities. This place residents at risk for lack of social interaction and isolation. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnoses including dementia and depression. A 7/8/24 Annual MDS indicated it was very important for Resident 14 to do her/his favorite activity and go outside when the weather was good. Resident 14's mobility device included her/his wheelchair. A 7/8/24 IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting Form indicated Resident 14 had outbursts due to her/his frustrations and no activities staff were in attendance at the care conference. The meeting activity note indicated Resident 87 has been spending [her/his] time resting/napping in bed, watching tv, using personal cell phone, reading, doing puzzle books, enjoys going outside when the weather is nice in [her/his] power chair, eating meals in [her/his] room and…

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

Based on interview and record review it was determined the facility failed to follow through on services to maintain hearing for 1 of 2 sampled residents (#86) reviewed for communication and sensory. This placed residents at risk for lack of adequate hearing. Findings include: Resident 86 admitted to the facility in 3/2024 with diagnoses including depression and paraplegia (impairment in lower extremities). A 5/7/24 IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting Form indicated Resident 87 required hearing services which required orders for her/his ears to be cleaned. A 5/31/24 Quarterly MDS indicated Resident 86 had no hearing aids and her/his hearing was adequate. On 9/11/24 at 9:21 AM Staff 80 (CNA) stated Resident 86 had issues with her/his hearing. On 9/12/24 at 11:53 AM Staff 3 (Social Services) stated she was aware Resident 87 had ongoing wax build-up in her/his ears which was to be addressed through physician orders and acknowledged there was no follow-through by nursing to ensure the orders were in placeand services provided after the 5/7/24 care…

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 a pressure ulcer was assessed and provided treatment timely for 1 of 3 sampled residents (#98) reviewed for pressure ulcers. Findings include: Resident 98 admitted to the facility in 7/2024 with a diagnosis of a stroke. A 7/12/24 NSG (Nursing) Admission/readmission Evaluation form revealed Resident 98 was admitted to the facility with no pressure ulcers. A 7/19/24 admission CAA revealed Resident 98 was at risk to develop pressure ulcers due to incontinence and assistance was required for repositioning. Staff were to reposition the resident every two hours. A 9/2/24 Direct Care Staff Daily Report revealed a RN worked on the the evening and night shifts. A 9/2/24 Progress Note revealed a CNA reported Resident 98 had an open area to her/his coccyx which was the size of the tip of a cotton swab. A request for orders was sent to the physician. Resident 98's clinical record revealed no comprehensive assessment of the pressure ulcer until 9/5/24. A 9/5/24 Wound Evaluation revealed Resident 98…

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 adequate catheter and incontinent care for 3 of 15 sampled residents (#s 24, 86 and 164) reviewed for ADLs, accidents and catheter care. This placed residents at risk for unmet incontinent care needs. Findings include: 1. Resident 24 admitted to the facility in 6/2024 with a diagnosis of heart disease. Resident 24's 6/13/24 annual MDS indicated she/he was cognitively intact. On 9/8/24 at 11:35 AM Resident 24 reported she/he regularly waited 30 minutes for the call light to be answered by staff when she/he needed bowel and bladder care. She/he stated the delayed call light responses by staff caused significant frustration and emotional stress from waiting this length of time with a soiled brief. On 9/9/24 at 8:44 AM call light response observations revealed the following: -Resident 24's call light was activated at 8:44 AM. Staff went to her/his door at 9:06 AM and left the call light activated. -At 9:09 AM staff…

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 respiratory care and services in accordance with physician orders and standards of practice for 3 of 5 sampled residents (#s 2, 55 and 87) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. An observation on 9/10/24 at 11:58 AM revealed a suction machine on the resident's nightstand covered in dust. There was a yankauer (oral suctioning tool) lying on the nightstand covered with dust, and the canister (collects body fluids such as mucus) was half full of a yellowish liquid with white debris. A physician order dated 2/18/20 indicated to check the suction machine canister weekly on Saturday night, if used that week replace the canister every night shift every Saturday. On 9/10/24 at 11:44 AM Resident 2 stated she/he did not use the suction machine for three or four years. On 9/10/24 at 11:58 AM Staff 4 (Unit Manger-LPN) acknowledged the dirty suction…

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

Based on interview and record review the facility failed to provide pain medications as ordered for 1 of 4 sampled residents (#262) reviewed for pain management. This placed residents at risk for uncontrolled pain. Findings include: Resident 262 admitted to the facility in 8/2024 with diagnoses including a leg fracture and pain due to internal orthopedic prosthetic devices. The admission MDS with an ARD of 8/26/24 revealed Resident 262's BIMS score was 15 which indicated she/he was cognitively intact. Resident 262 had frequent pain presence which effected her/his sleep quality and day-to-day activities occasionally, with a level of eight on a scale of zero to 10. A 9/2024 MAR instructed staff to administer oxycodone (to treat moderate to severe pain) 5 mg tablet every four hours PRN for moderate pain. If the pain level was below two, administer zero mg, pain level from two to five administer five mg, pain level five to 10 administer 10 mg. On 9/7/24 Resident 262 was administered 10 mg for a pain level of eight at 1:07 AM, at 5:14 AM she/he was administered 10 mg for a level of eight…

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 residents received proper dialysis care and services after dialysis for 1 of 3 sampled residents (#58) reviewed for personal property. This placed residents at risk for dialysis complications. Findings include: Resident 58 admitted to the facility in 2/2023 with diagnoses including end stage renal disease (kidney disease) and dependence on renal dialysis (a process of removing waste products and excess fluid from the body). A review of a 6/19/24 Significant Change MDS indicated Resident 58 was cognitively intact. On 9/8/24 at 10:48 AM Resident 58 stated she/he had a fistula (surgically created passage in the arm connecting an artery to a vein) in her/his left arm and she/he had no issues with her/his dialysis treatment on every Tuesday, Thursday, and Saturday. She/he stated staff did not check her/his fistula or vitals upon return from dialysis. Resident 58's 11/8/23 care plan indicated the resident was receiving hemodialysis three times a week. The interventions included monitoring for…

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

Based on interview and record review it was determined the facility failed to obtain specialized physician appointments for 1 of 1 sampled resident (#62) reviewed for ADLs. This placed resident at risk for lack of specialized care. Findings include: A public complaint was received on 5/2/24 which alleged the facility failed to arrange the resident's nerve block procedure per physician orders. Resident 62 admitted to the facility in 6/2022 with diagnoses including chronic pain. A 1/13/23 physician order indicated the resident was to have a referral to neurology and cardiology for evaluation and a bilateral ultrasound guided glenohumeral injection (needle into the shoulder joint to deliver an injection). On 9/13/24 at 8:45 AM Staff 3 (Social Services) acknowledged the direction to schedule appointments was not addressed.

Based on observation, interview and record review it was determined the facility failed to obtain a resident's medication for 1 of 6 sampled residents (#164) reviewed for medications. This placed residents at risk for increased pain. Findings include: Resident 164 readmitted to the facility in 8/2024 with a diagnosis of post-surgical repair of leg fractures. A 9/2024 MAR revealed staff were to apply a fentanyl patch (narcotic pain medication) with a start date of 9/9/24. The MAR indicated the patch was not applied. On 9/11/24 at 8:39 AM Witness 11 (Pharmacy Technician) stated the pharmacy did not receive a valid prescription from the provider. On 9/9/24 the pharmacy requested a new prescription but did not yet receive it. On 9/11/24 at 8:44 AM Staff 31 (LPN) stated if a medication was not available from the pharmacy the CMA was to notify the nurse and the nurse would follow up with the pharmacy. On 9/11/24 at 8:49 AM with Staff 21 (LPN Staffing Coordinator) a fentanyl patch was observed in the automated medication dispensing system. Staff 21 stated if a resident did not have 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 monitor residents on psychotropic medications for 2 of 5 sampled residents (#s 87 and 164) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 87 admitted to the facility in 3/2024 with diagnosis which included bipolar (mood swings) disorder. The 6/28/24 revised care plan indicated Resident 87 used psychotropic medications and to monitor effectiveness and side effects of the medications. The 8/2024 MAR indicated Resident 87 received duloxetine (antidepressant medication) daily as of 7/30/24 related to her/his bipolar depression. An 8/20/24 Psychotropic Medication Review indicated Resident 87's aripiprazole (antipsychotic medication) and quetiapine (antipsychotic medication) were reviewed and were ordered to address hallucinations, delusion and rejection of care. Duloxetine was also reviewed with no indication for the specific use of the medication. The 8/2024 Monitors indicated no monitor was in place for…

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

Based on interview and record review it was determined the facility failed to prevent a significant medication error for 1 of 6 sampled resident's (#41) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include: On 6/25/24 the Past Noncompliance was corrected when the facility identified the cause of the incident and determined vital signs were not obtained by a CMA prior to medication administration resulting in a drop in blood pressure. The plan of correction included: -6/28/24 nurse and CMA education was provided related to the 10 rights of medication administration. -7/3/24 an audit was initiated for residents with blood pressure parameters. -7/3/24 the facility reported Staff 20 to the Oregon State board of Nursing. 7/3/24 education was initiated to all nurses and CMAsregarding standards and scope of practice related to their licensure and obtaining vital signs prior to medication administration. Resident 41 admitted to the facility in 8/2023 with a diagnosis of paraplegia (inability to move legs). A 6/2024 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 use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 39 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: A review of the Direct Care Staff Daily Reports from 1/14/24 through 2/25/24 revealed the following days with no RN coverage for eight consecutive hours: -2/10/24 -2/11/24 -2/18/24 On 2/28/24 at 9:51 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility lacked RN coverage on the identified dates. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily reports were accurate for 20 of 39 days reviewed for staffing. This placed residents at risk for inaccurate staffing information. Findings include: A review of Direct Care Staff Daily Reports and nursing staff time sheets from 1/14/24 through 2/25/24 revealed the Direct Care Staff Daily Reports were inaccurate for the number of staff on duty and the hours staff worked for the following dates: - 1/18/24 through 1/19/24 - 1/23/24 through 1/25/24 - 1/27/24 - 2/2/24 through 2/7/24 - 2/9/24 - 2/10/24 - 2/12/24 through 2/17/25 - 2/19/24 On 2/29/24 at 12:24 PM Staff 1 (Adminstrator) indicated via email the Direct Care Staff Daily Reports were inaccurate.

Based on interview and record review it was determined the facility failed to ensure residents were provided bathing for 3 of 6 sampled residents (#s 1, 4 and 9) reviewed for ADLs. This placed residents at risk for a decline in hygiene. Findings include: 1. Resident 1 was admitted to the facility in 2023 with diagnoses including cancer. An 10/2013 bathing record revealed Resident 1 was to receive bathing on Mondays and Fridays. Resident 1 received three of six showers. On 11/14/23 at 2:54 PM a request was made to Staff 2 (DNS) to provide documentation to indicate Resident 1 received two showers a week. No additional information was provided. 2. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes. A 6/21/23 Annual MDS and CAAs revealed the resident was weak and and was dependent or required extensive assistance with most ADLs. An 10/2023 and 11/2023 bathing report revealed the resident received four of ten showers and the resident refused two showers. The resident was not documented to have a shower for 27 days. An 10/26/23 BIMS Evaluation (cognitive…

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 medication was administered as prescribed for 1 of 3 sampled residents (#4) reviewed for incontinent care and failed to ensure call lights were answered timely to address bowel care needs for 1 of 10 sampled (#2) residents reviewed for call lights. This placed residents at risk for ineffective medication regimen and unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes. A 9/2023 and 10/2023 TAR revealed the resident was to be administered clotrimazole cream (antifungal) for five days from 9/27/23 through 10/1/23. The cream was not available on 9/27/23 and 9/28/23. The cream was subsequently only administered for three days. On 11/14/23 at 11:15 AM Staff 3 (LPN Resident Care Manager) acknowledged the cream was not administered as prescribed. 2. Resident 2 was admitted to the facility in 2023 with diagnoses including paralysis. A 9/21/23 Grievance Form revealed Resident 2 reported concerns including long call light response…

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 oxygen flow rates were documented for 2 of 4 sampled residents (#s 1 and 10) reviewed for respiratory therapy. This placed residents at risk for lack of documented oxygen needs. Findings include: 1. Resident 1 was admitted to the facility in 2023 with diagnoses including cancer. An 10/16/23 physician order revealed the resident was to be administered one to four liters of oxygen to keep her/his saturation levels greater than 90% and staff were to document the oxygen levels and the liters provided. The order also indicated the oxygen was to be used to maintain an oxygen saturation of 92% or greater. Progress Notes from 10/16/23 through 11/1/23 revealed the following: -10/16/23 oxygen saturation was 92%, the resident wore oxygen but staff did not document how much oxygen was required. -10/20/23 oxygen saturation was 94%, the resident wore oxygen but staff did not document how much oxygen was required. -10/21/23 oxygen saturation was 97%, the resident wore oxygen but staff did not document how…

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 physician orders regarding a narcotic pain medication resulting in an excessive dose for 1 of 3 sampled residents (#12) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 12 was admitted to the facility in 7/2023 with diagnoses including heart disease. Review of a physician's order dated 7/18/23 revealed the resident was to receive liquid hydromorphone (narcotic pain medication) 1.5ml (20mg/ml) by mouth every hour for pain. In a written statement on 9/20/23 at 10 AM Staff 13 (LPN) indicated Staff 14 (CMA) realized she had administered too much hydromorphone to Resident 12 and did not confirm the dose prior to administration. Review of a progress note dated 9/20/23 at 3:21 PM revealed Resident 12 was administered 15 ml of hydromorphone instead of 1.5 ml. The note indicated Hospice was notified and told the facility to monitor the resident every 30 minutes for two hours and then once every hour. The note indicated the resident 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 lab results were reviewed by a physician in a timely manner for 1 of 3 sampled residents (#8) reviewed for UTI. This placed residents at risk for delayed treatment. Findings include: Resident 8 was admitted to the facility in 2023 with diagnoses including heart disease. Progress Notes revealed on 10/4/23 Resident 8's Physician Assistant assessed the resident for reports of tea colored urine. Orders were provided to obtain and urine sample and culture if indicated. An 10/2023 TAR revealed staff were to obtain a urine sample to rule out a UTI and the lab was to be notified when the sample was obtained. An 10/9/23 Lab Results Report revealed Resident 8 had a UTI, the urine was cultured and the reported date of the results was 10/9/23. The results included the antibiotics which would be effective against the organism found in the resident's urine. The report indicated the results were faxed on 10/9/23. A Progress Note dated 10/11/23 revealed the resident's Physician Assistant reviewed the urine culture…

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 call light was accessible for 1 of 3 sampled residents (#3) reviewed for call lights. This placed residents at risk for incontinence. Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses including a stroke. A 5/5/23 Quarterly MDS indicated Resident 3 was cognitively intact. A 5/15/23 Bowel and Bladder Screener assessment indicated Resident 3 was at times incontinent of bowel and bladder. A 6/2023 bowel record indicated the resident was incontinent on 6/26/23 night shift. On 6/28/23 Witness 3 (Complainant) stated Resident 3 reported on 6/26/23 at 3:00 AM she/he did not have a call light accessible, had to call out for help, staff did not come timely and was subsequently incontinent. On 11/15/2023 12:18 PM Staff 10 (CNA) stated Resident 3 was able to use the call light and if the resident did not have a call light was able to call out verbally for assistance. Staff 10 indicated on 6/26/23 she was not assigned to care for Resident 3. At some point during the night shift…

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 proper flavor and food palatability was maintained for 1 of 1 facility kitchen reviewed for food service and 5 of 8 sampled residents (#s 19, 40, 43, 46 and 399) reviewed for food. This placed residents at risk for food that was not palatable or appetizing. Findings include: 1. Resident 399 was admitted to the facility in 2021 with diagnoses including paralysis on the right dominant side and cognitive communication deficit. A 1/18/23 Meal/Temperature Audit revealed resident food comments included that the meat was a little difficult to chew. The 2/22/23 and 4/20/23 Meal/Temperature Audits revealed resident food comments included that the food was bland. A 3/27/23 Dining Committee Meeting Minutes revealed resident food comments included that the meat was tough. On 5/17/23 at 12:55 PM Staff 9 (Dietary Manager) was observed during lunch meal service to scrape the sides of a pan of grits to serve the few remaining meals. On 5/17/23 at 1:22 PM a food test tray was sampled. The cheesy grits…

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 ensure processes were followed to provide a clean and sanitary kitchen for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. 1. On 5/17/23 at 9:12 AM the Dish Machine Log for 5/2023 was reviewed and no temperatures or chemicals were yet recorded for 5/17/23. Staff 11 (Dietary Manager) was observed using the dish machine to wash dishes and was asked to test the chemical level of the low temperature dish machine. Results revealed the sanitizer level was at ten instead of 100 parts per million as required. Staff 4 (Dietary Manager) was called. On 5/17/23 at approximately 9:15 AM Staff 4 stated the kitchen typically used the dish machine to clean dishes left from the previous meal before breakfast was served and chemical levels and temperatures were not usually checked until after breakfast. Staff 4 stated all dishes would be rewashed because standards were not met. On 5/17/23 at 3:16 PM Staff 4 stated a new chemical system for the dish machine was installed in 3/2023 and 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 a homelike dining experience for 1 of 3 dining rooms (main) reviewed for dining, and failed to speak to residents respectfully for 1 of 1 sampled resident (#15) reviewed for dignity. This placed residents at risk for an unhomelike environment and mental anguish. Findings include: 1. On 5/15/23 at 12:33 PM the main dining room center table had five residents at the table for lunch. One resident was served their meal, but then other tables in the dining room were served before the rest of the residents at the center table were served. The last resident at the center table was not served their meal until 12:53 PM, 20 minutes after the first resident was served. On 5/17/23 at 12:41 PM the main dining room center table had eight residents at the table for lunch, three residents were served their meals and were eating. The meal cart was moved to a hallway and the meal service in the dining room stopped until the next meal cart came out. The last resident at the center table was not served…

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 update and involve the resisidents in the care plan for 4 of 16 sampled residents (#s 9, 43, 73, and 102) reviewed for accidents, positioning and care planning. This placed residents at risk for unmet needs. Findings include: 1. Resident 43 was admitted to the facility in 10/2018 with diagnoses including Rheumatoid arthritis (RA). Review of an incident report dated 1/10/23 revealed Resident 43 was found on the floor in the resident's room after an unwitnessed fall. The incident report indicated the resident self transferred from bed to use the bathroom, fell and was bleeding from the forehead. The report also indicated the resident was at risk for falls due to decreased mobility related to RA, muscle wasting, abnormal gait and repeated falls. The resident was determined to have poor safety awareness. Review of a care plan for falls revised 1/17/23 revealed Resident 43 was at risk for falls due to reconditioning, gait and balance problems and a history of falls at home. Interventions included bed canes,…

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 3 of 16 sampled residents (#s 15, 19 and 46) and 2 of 4 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident Council Minutes reviewed for 8/30/22, 10/18/22, 11/22/22 and 4/19/23 indicated a concern with long call light wait times on all shifts. In observations on 5/17/23 the following was revealed on (ICF) Intermediate Care Facility Halls A and B: -7:28 AM the call light monitoring system at the nurses' station room [ROOM NUMBER]-1 indicated 75 minutes. -7:46 AM Staff 29 (CMA) entered room [ROOM NUMBER]-1 with medications and when she exited the call light was still on. Staff 29 stated she thought 10-1 would like a cup of coffee. -7:53 AM a staff member entered room [ROOM NUMBER]-1 with coffee and the light was turned off (one hour and 40 minutes). -8:28 AM through 8:37 AM the call light monitoring system at…

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

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were accurate and posted in a prominent location for 5 of 5 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: 1. The DCSDRs were compared against the nursing schedule for the first five days of the survey. The review indicated discrepancies. On 5/15/23 at 3:48 PM the nurse on the Intermediate Care hall was observed talking with another staff member who asked about additional staffing due to call ins. The nurse stated no additional staff were coming into work and they were down two staff for the shift. A review of the 5/15/23 DCSDR revealed only an adjustment to the census number and no adjustment to the number of staff as a result of the call ins for that day. Additionally, the DCSDR forms for 5/16/23 to 5/19/23 revealed adjustments to the census numbers only. On 5/19/23 at 10:24 AM Staff 2 (DNS) was asked about the process related to staffing. Staff 2 stated the staffing…

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 use PPE appropriately for 1 of 4 halls (subacute B) and 1 of 3 dining rooms (main dining room) reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: On 5/15/23 at 12:33 PM Staff 44 (CNA) served meals in the main dining room. Staff 44 wore gloves, delivered and set up a meal for a resident, returned to the meal cart with the same gloves without completing hand hygiene and began to get another meal tray out for another resident. Staff 44 stated she wore the gloves because at times the residents required their meals to be cut up. Staff 44 stated she did not sanitize her hands in between serving residents because she wore gloves and did not change her gloves between residents. On 5/17/23 at 8:23 AM Staff 45 (NA) exited room [ROOM NUMBER] with gloves on, removed them as she went through the hall, balled the dirty gloves into her hand and went into room [ROOM NUMBER]. Staff…

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 notify a resident of a medication change for 1 of 4 sampled residents (#17) reviewed for care planning. This placed residents at risk for lack of notification and participating in treatment decisions. Findings include: Resident 17 was admitted to the facility in 2021 with diagnoses including drowsiness. A 1/2023 MAR instructed staff to administer Modafinil (reduces extreme sleepiness) 200 mg daily which was discontinued on 1/4/23. On 1/4/23 staff were instructed to administer Modafinil 100 mg daily. No documentation was found in the clinical records Resident 17 was notified of the change of dosage of Modafinil. On 5/15/23 at 1:05 PM Resident 17 stated she/he was prescribed Modafinil, the dosage was reduced and she/he was not notified of the reason for the reduction. On 5/22/23 at 9:45 AM documentation was requested regarding if Resident 17 was notified of a dosage change for Modafinil from Staff 2 (DNS) and Staff 28 (Regional Nurse Consultant). At 10:53 AM Staff 28 stated there was no additional…

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 call lights residents could activate and ensure residents had comfortable mattresses for 2 of 9 sampled residents (#s 5 and 451) reviewed for accommodation of needs and environment. This placed residents at risk for unmet needs. Findings Include: 1. Resident 451 was admitted to the facility in 5/2023 with diagnoses including central cord syndrome (an incomplete spinal cord injury) and heart failure. A Care Plan revised 5/15/23 revealed Resident 451 required extensive assistence to fully dependent for all care and staff were to ensure Resident 451's call light was within reach. On 5/16/23 at 1:58 PM Resident 451 was observed in bed, her/his call light was placed on her/his stomach approximately two inches from her/his hand. Resident 451 stated she/he could not move her/his hand to the call light, and when it was within reach it was hard to push. The call light was tapped three times and it did not activate. On 5/16/23 at 2:02 PM Staff 41 (LPN Unit Manager) stated Resident 451's call…

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 offer and periodically review advance directives for 2 of 4 sampled residents (#s 5 and 251) reviewed for advance directives. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 2022 with diagnoses including hypertension. A 1/31/23 Quarterly MDS revealed Resident 5 had a BIMS score of 15 which indicated she/he was cognitively intact. A 7/28/22 Acknowledgement Form revealed Resident 5 received a blank copy of an advance directive. An 10/26/22 IDT Care Plan Conference/Welcome Meeting Form revealed Resident 5 did not have an advance directive on file but did not indicate if the resident wished to complete one. On 5/17/23 at 5:05 PM Staff 5 (Social Servics Director) stated advance directives were handled by admissions staff on admit to the facility and they were not reviewed periodically. On 5/17/23 at 12:00 PM Staff 1 (Administrator) stated advance directives were to be offered and reviewed on admission and quarterly. 2. Resident 251 was admitted to…

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

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of advanced beneficiary information for 1 of 3 sampled residents (#454) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities. Findings include: Resident 454 was admitted to the facility with Medicare Part A services in 2022. On 11/15/22 a Notice of Medicare Non-coverage was provided related to a pending discontinuation of Medicare Part A services on 11/17/22. According to the Skilled Nursing Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 11/17/22 paying privately. No evidence of written notification of financial responsibility was provided upon surveyor request. On 5/17/23 at 2:56 PM Staff 43 (Social Services Director) stated Resident 454 should have received an Advanced Beneficiary Notification form to inform her/him of her/his financial liability, but she/he did not.

Based on interview and record review it was determined the facility failed to comprehensively assess 2 of 5 sampled residents (#s 19 and 46) reviewed for unnecessary medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 46 was admitted to the facility in 2021 with diagnoses including anxiety and contracture. An 8/2/22 Annual MDS revealed Resident 46's BIMS score was 15 which indicated she/he was cognitively intact. The section for Preferences for Routine and Activities was not assessed for Resident 46. On 5/22/23 at 8:28 AM Staff 2 (DNS) stated she would expect the MDS to be completed timely. 2. Resident 19 was admitted to the facility in 2021 with diagnoses including low back pain, depression and Bipolar disorder (mental illness characterized by extreme mood swings). An 7/21/22 admission MDS revealed Resident 19's BIMS score was 15 which indicated she/he was cognitively intact. Resident 19 received scheduled pain medications and received PRN pain medications or was offered and declined PRN pain medications. Resident 19 should have a pain…

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 develop a baseline care plan to meet the immediate care needs for 1 of 5 sampled residents (#251) reviewed for medications. This placed residents at risk for unmet care needs. Findings include: Resident 251 was admitted to the facility in 2023 with diagnoses including infection and diabetes. A review of Resident 251's baseline care plan revealed interventions for diabetes, hypertension, ADL and mobility deficits, falls and depression. The baseline care plan did not address Resident 251's infection and antibiotic use, anticoagulant use, heart failure, anxiety disorder, chronic and acute pain related to gout, discitis (infection of the disc space) and bladder cancer for which she/he was being treated. On 5/18/23 at 10:17 AM Staff 46 (Assistant DNS) was asked about care plan development and stated the floor nurse started the care plan based on the initial assessment and then the Unit Manager reviewed and added other pertinent care needs. Staff 46 agreed there were additional problems that should have been…

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 develop a resident centered activity care plan for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for lack meaningful activities. Findings include: Resident 12 was re-admitted to the facility in 2020 with diagnoses including cognitive deficit and legal blindness. A 5/6/22 Annual MDS indicated it was very important for the resident to listen to music, be around pets, keep up with the news and it was very important for the resident to do her/his favorite activities. A care plan last revised in 1/2023 indicated the resident liked to watch television, eat meals in her/his room and spend time with her/his family. The interventions did not indicate the type of television the resident preferred. The care plan also did not indicate the resident liked pets, music, and that the resident liked to keep current on the latest news. On 5/18/23 at 2:46 PM Staff 35 (Activity Director) stated she just started to work at the facility and was starting to familiarize herself with the…

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

Based on interview and record review it was determined the facility failed to provide ADL care for 2 of 9 sampled residents (#s 102 and 400) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: 1. Resident 102 was admitted to the facility in 12/2022 with diagnoses including dementia. Review of shower records dated 12/23/22 through 2/15/23 revealed: Resident 102 received one shower from 12/25/22 through 1/1/23. Resident 102 received one shower from 1/2/23 through 1/10/23. In an interview on 5/17/23 at 7:15 AM Witness 10 (Complainant) said Resident 102 did not receive showers or baths while at the facility. Witness 10 said the resident's family gave the resident at least one shower because the facility did not offer showers. Witness 10 said the resident's preference was to receive at least two showers a week. In an interview on 5/17/23 at 9:18 AM Staff 2 (DNS) acknowledged Resident 102 did not receive at least two showers a week per the resident's preference. 2. Resident 400 was admitted to the facility in 2023 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 observation, interview and record review it was determined the facility failed to develop a meaningful activity program for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: Resident 12 was re-admitted to the facility in 2020 with diagnoses including cognitive deficit and legal blindness. A 5/6/22 Annual MDS indicated it was very important for the resident to listen to music, be around pets, keep current with the latest news and to do her/his favorite activities. A Care Plan revised in 1/2023 indicated the resident liked to watch television, eat meals in her/his room and spend time with her/his family. The interventions did not indicate the type of television the resident preferred. The care plan also did not indicate the resident liked pets, music, and she/he liked to keep current with the latest news. An Activity Provided task form revealed from 4/15/23 to 5/15/23 activities were not offered. On 5/16/23 at 2:18 PM Staff 33 (CNA) stated Resident 12's health declined, she/he did 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 interview and record review it was determined the facility failed to follow physician orders and care plans for 1 of 4 sampled residents (# 73) reviewed for care planning. This placed residents at risk for unmet needs. Findings include: Resident 73 was admitted in 2022 with diagnoses including chronic pain and adjustment disorder with mixed anxiety and depressed mood. An 8/16/22 revised care plan indicated to involve Resident 73 in her/his care and decision making daily and Resident 73's ventral hernia (a protrusion of intestine or abdominal tissue through a weak spot in the stomach muscle) added to her/his chronic pain. An 10/13/22 physician note revealed Resident 73 needed to lose weight in order to be a surgical candidate. A 12/20/22 physician note indicated Resident 73's ventral hernia was worsening and to refer to general surgery for evaluation. A 1/13/23 Provider Order Sheet identified a referral for bariatric surgery that needed to occur before hernia surgery. On 5/15/23 at 2:17 PM Resident 73 stated she/he had an appointment with a surgeon on 1/13/23 who made 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 provided routine eye appointments for 1 of 2 sampled residents (#42) reviewed for communication and sensory needs. This placed residents at risk for worsening vision. Findings include: Resident 42 was admitted to the facility in 2023 with diagnoses including cataracts (clouding of the eye lens impairing clear sight). A 7/9/22 admission MDS indicated Resident 42 had visual impairment and was not able to see distance due to cataracts. The resident was at risk for continued vision loss. Review of resident 42's record revealed there was no scheduled vision appointments to ensure the resident's cataracts were monitored. An 4/11/23 Quarterly MDS indicated Resident 42 was cognitively intact. On 5/15/23 at 11:01 AM Resident 42 stated she/he was diagnosed with cataracts before admission to the facility. The facility was aware of the cataracts and did not yet set up an appointment. On 5/7/23 at 3:35 PM Staff 5 (Social Services Director) stated she was not aware Resident 42 had cataracts. If she…

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

Based on interview and record review it was determined the facility failed to provide ROM for 1 of 5 sampled residents (#60) reviewed for mobility. This placed residents at risk for decreased ROM. Findings include: Resident 60 was admitted to the facility in 2023 with diagnoses including a stroke. A 1/12/23 admission MDS indicated Resident 60 required the assistance of two staff for most ADLs. The resident participated in therapy and was at risk for continued decline, contractures and muscle weakness. The goal was to minimize risks. A Care Plan initiated 1/29/23 indicated the resident had limited mobility and staff were to provide daily gentle ROM as tolerated. The resident's record from 4/15/23 to 5/16/23 did not have documentation to indicate ROM was provided. An 4/18/23 Quarterly MDS indicated the resident did not have functional limitation in ROM to the arms or legs. On 5/17/23 at 2:24 PM Staff 18 (Therapy Director) stated he did not work with Resident 60. Staff 18 stated the therapy notes indicated the resident was able to move her/his arms and legs but refused to feed…

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 investigate falls and supervise meals per care plan for 2 of 11 sampled residents (#s 84 and 99) reviewed for accidents and nutrition. This placed residents at risk for injury and choking. Findings include: 1. Resident 84 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty swallowing) and dementia. The 3/28/23 care plan indicated the resident had an ADL self-care performance deficit and was to be supervised while eating. The care plan further indicated resident 84 had a swallowing problem related to not having upper dentures with a goal the resident would have no choking episodes. Staff were to monitor, document and report as needed signs or symptoms of dysphagia including: -pocketing -choking -coughing -drooling -holding food in her/his mouth -several attempts at swallowing -refusing to eat -appearing concerned during meals Meal observations on 5/16/23 through 5/22/23 during breakfast and lunch revealed Resident 84 in her/his bed with the door and curtain…

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 risk and benefits for the use of bed canes were discussed with residents' responsible parties for 1 of 7 sampled residents (#12) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 12 was admitted to the facility in 2016 with diagnoses including dementia and legal blindness. A 9/27/22 cognitive assessment form indicated the resident had a score indicating severe memory issues. A Fall investigation dated 4/29/23 indicated the resident was found on the floor with her/his left hand hanging onto the bed cane. The resident did not sustain an injury. A 5/8/23 Restraint versus Enable Screen form indicated the resident requested the bilateral bed canes for mobility. The resident was assessed to be oriented to person, had impaired cognition, and had poor safety awareness and attempted to get out of bed on her/his own. The resident had recent falls. The assessment indicated the bed canes did not limit the resident's movement and helped assist her/him with…

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

Based on observation, interview and record review it was determined the facility failed to ensure food preferences were honored for 2 of 8 sampled residents (#s 46 and 400) reviewed for food. This placed residents at risk for lack of food choices. Findings include: 1. Resident 400 was admitted to the facility in 2023 with diagnoses including palliative care and chronic obstructive pulmonary disease. A 5/10/23 Dietary Profile indicated Resident 400 received a puree diet texture and liked bananas, muffins, beef, chicken and turkey but did not like sausage. A 5/11/23 BIMS evaluation revealed Resident 400 was cognitively intact. On 5/15/23 at 1:18 PM Resident 400 stated food came to her/him automatically and she/he received no choices for meals. Resident 400 stated preferences were asked during a recent interview but her/his preferences were not included in the food provided. On 5/17/23 at 9:31 AM Staff 9 (Dietary Manager) stated based on current food production sheets there were no alternative choices available for residents on a puree texture diet. On 5/18/23 at 12:01 PM with Staff 11…

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.