Avamere Crestview Of Portland

Based on interview and record review it was determined the facility failed to provide staff with appropriate competencies and skills to attain and maintain the highest practicable well-being for 1 of 1 sampled resident (#20) reviewed for communications and activities. This placed residents at risk for unmet needs. Findings include: The facility's 2/2022 Trauma-Informed and Culturally Competent Care policy indicated all staff received orientation and in-service training regarding cultural competency as an aspect of resident-centered care. Resident 20 was admitted to the facility in 7/2016 with diagnoses including dementia. On 9/11/2024 at 11:59 AM Staff 14 (CNA) stated he had been an employee at the facility for over a year and had not received any cultural competency training. On 9/12/2024 at 10:56 AM Staff 15 (CNA) stated she had been an employee at the facility for over 12 years and had never participated or completed any cultural competency training. On 9/13/2024 at 12:42 PM Staff 4 (Staffing Coordinator) stated she was unaware of any cultural competency training program at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being for 5 of 14 sampled residents (#s 7, 20, 34, 46 and 51) reviewed for behaviors, communication and sensory care, dental and PASARR. This placed residents at risk for unmet needs and decreased dignity. Findings include: The facility's 9/2004 Social Services Program Policy and Procedure revealed the following: -The social services program shall assist facility staff, family and friends of the resident to help meet the resident's personal and emotional needs. -Duties of the social services department include assessing the psychosocial and emotional needs of each resident, developing interventions to address residents' needs and preferences to ensure or enhance quality of life and dignity, making referrals as needed and documenting the outcomes and assisting each resident in obtaining appropriate clothing.…

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 maintain a clean and sanitary environment in the facility's ice machine, dry storage, and dish drying area for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of potential infections related to foodborne pathogens and cross contamination. Findings include: 1. On 9/6/24 at 9:43 AM, the facility's ice machine was observed to drain onto the floor approximately six inches from the in-floor drain underneath the ice machine. The linoleum flooring under the ice machine was disintegrated and pulled away from the concrete floor. A puddle of brown, moldy water formed on the concrete floor and flowed underneath the linoleum and onto the floor around the ice machine and in the direct path to the walk-in freezer. A chunk of an unknown brown porous substance the approximate size of a baked potato was observed under the ice machine. Staff 10 (Dietary Manager) observed this, donned exam gloves and removed the item. She stated it looked like wadded up paper towels to collect 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 and interview it was determined the facility failed to follow proper infection control precautions for 1 of 1 sampled resident (#40) reviewed for catheter care and while handling clean laundry for 1 of 1 laundry areas. This placed residents at risk for cross contamination and risk of infection. Finds include: According to the Center for Disease Control and Prevention: Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. B.2: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 1. Resident 40 admitted to the facility in 9/2022 with diagnoses including a urinary tract infection. On 9/11/2024 at 12:14 PM Resident 40 was observed to ambulate independently in his/her wheelchair as his/her catheter bag dragged on the ground. On 9/11/2024 at 12:17 PM Staff 2 (DNS) confirmed catheter bags should not drag on the ground. 2. On 9/12/2024 at 2:06 PM Staff 19 (Housekeeping) was observed to push an uncovered rolling rack of clean resident clothing down the hall. The rack was left unattended in…

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 dignity for 1 of 4 sampled residents (#23). This placed residents at risk for lack of dignity. Findings include: Resident 23 was admitted to the facility in 3/2022 with a diagnosis of dementia. Resident 23's Annual MDS completed on 3/14/2024 indicated Resident 23 was significantly cognitively impaired. Resident 23's revised 8/16/2024 Care Plan indicated Resident 23 had meals served on Styrofoam dishware. On 9/9/2024 through 9/11/2024 between the hours of 11:49 AM and 1:15 PM Resident 23 was obseved to eat meals off of Styrofoam dishware. On 9/12/2024 at 10:20 AM Staff 18 (LPN) stated the facility had not attempted to implement alternatives such as plasticware. Staff 18 confirmed the loss of dignity related to residents eating from Styrofoam dishware. On 9/12/2024 at 11:00 AM Staff 10 (Dietary Manager) acknowledged the use of Styrofoam dishware was a dignity concern. On 9/13/2024 at 2:06 PM Staff 1(Administrator) acknowledged the use of Styrofoam dishware was a dignity concern.

Based on interview and record review it was determined the facility failed to ensure a consent was obtained prior to administering antipsychotic medications to residents for 1 of 5 sampled residents(#24) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 24 was admitted to the facility in 7/2024 with diagnoses including fracture and dementia. Resident 24's 7/30/24 Physician Order indicated the resident was prescribed valproic (antipsychotic) for schizoaffective disorder. Resident 24's 8/2024 and 9/2024 MARs revealed the resident received valproic daily. Review of Resident 24's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of valproic. On 9/11/24 at 9:57 AM Staff 13 (RNCM) reviewed Resident 24's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of valproic and confirmed a consent was not obtained from Resident 24 or her/his representative prior to the resident…

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

Based on observation, interview and record review it was determined the facility failed to honor a resident's preference to get dressed for 1 of 4 sampled residents (#34) reviewed for ADLs. This placed residents at risk for lack of choices and self-determination. Findings include: Resident 34 was admitted to the facility in 10/2023 with diagnoses including blindness. Resident 34's 10/9/23 admission MDS indicated she/he was severely visually impaired, usually able to make her/himself understood to others, required substantial-to-maximal assistance for upper body dressing and was dependent on staff for lower body dressing. The MDS also indicated it was somewhat important to the resident to be able to choose what clothes she/he wanted to wear. Resident 34's 7/15/24 ADL Self Performance Deficit Care Plan revealed the resident was totally dependent on staff to get dressed. On 9/9/24 at 12:24 PM and 9/10/24 at 1:21 PM Resident 34 was observed in bed and wore a hospital gown. Resident 34 stated it was not her/his preference to wear a hospital gown and staff did not offer to assist her/him…

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

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of abuse for 1 of 4 sampled residents (#267) reviewed for dignity. This placed residents at risk for abuse and neglect. Findings include: Resident 267 was admitted to the facility in 9/2024 with diagnoses including malignant brain cancer. A 9/9/24 Grievance communication Form stated Resident 267 had concerns related to her/his night shift CNA not being responsive to the call light and not friendly during care. The DNS and LPN Resident Care Manager spoke with Resident 267 and her/his family about the concerns and determined Resident 267 can be overstimulated by noise and her/his care plan was updated. The conclusion of the grievance stated the CNA would not be working with Resident 267 anymore. On 9/10/24 at 10:00 AM Resident 267 stated on her/his first night in the facility there was a night shift CNA who did not take care of her/him and took her/his call light away. Resident 267 stated she/he called her/his brother to get assistance. Resident 267 was tearful…

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

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 4 sampled residents (#267) reviewed for dignity. This placed residents at risk for abuse and neglect. Findings include: Resident 267 was admitted to the facility in 9/2024 with diagnoses including malignant brain cancer. A 9/9/24 Grievance communication Form stated Resident 267 had concerns related to her/his night shift CNA not being responsive to the call light and not friendly during care. The DNS and LPN Resident Care Manager spoke with Resident 267 and her/his family about the concerns and determined Resident 267 can be overstimulated by noise, her/his care plan was updated. The conclusion of the grievance stated the CNA would not be working with Resident 267 anymore. On 9/10/24 at 10:00 AM Resident 267 stated on her/his first night in the facility there was a night shift CNA who did not take care of her/him and took her/his call light away. Resident 267 stated she/he called her/his brother to get assistance. Resident 267 was tearful when she/he described…

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 accurate assessments for 2 of 12 sampled residents (#s 11 and 20) reviewed for communication, dental, and activities. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 11 was admitted to the facility in 6/2023 with diagnoses including chronic diastolic (congestive) heart failure (a condition where the left heart ventricle becomes stiff and does not pump blood efficiently) and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen or there is too much carbon dioxide in the blood). A review of resident 11's 6/25/24 annual MDS revealed she/he was cognitively intact and had no oral or dental issues. On 9/9/24 at 11:03 AM Resident 11 was observed to have teeth that were gray and jagged. Resident 11 stated she/he needed dental care and she/he had tooth decay, missing and broken teeth. Resident 11 stated she/he used a medicated mouthwash prescribed by her/his doctor to treat the infections in her/his teeth. She/he also said…

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 incorporate PASARR (Preadmission Screening and Resident Review) Level II recommendations into residents' assessments and care plans for 1 of 1 sampled resident (# 51) reviewed for PASARR coordination of care. This placed residents who have a mental health disorder at risk for delayed care and services to attain their highest practicable level of well-being. Findings include: Resident 51 was admitted to the facility in 6/2024 with diagnoses including stroke, dysphasia, post traumatic stress disorder, depression and anxiety. On 7/3/24 a PASARR Level II Mental Health Evaluation was conducted for Resident 51. The reason for the referral was noted as .concern about mood-related symptoms and history of depression and anxiety symptoms . The evaluation included the following recommendations: -Participation in support groups for individuals who have suffered a stroke. -A daily plan for that would be helpful for the resident to deal with difficult situations. Resident 51's 9/2024 MAR included the following…

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

Based on interview and record review it was determined the facility failed to comprehensively complete a baseline care plan within 48 hours of a resident's admission for 1 of 4 sampled residents (#267) reviewed for dignity. This placed residents at risk for unmet needs. Findings include: Resident 267 was admitted to the facility in 9/2024 with diagnoses including anxiety, depression and a history of mental and behavioral disorders. On 9/10/24 at 10:00 AM Resident 267 stated on her/his first night in the facility there was a night shift CNA who did not take care of her/him and took her/his call light away. Resident 267 stated she/he called her/his brother to get assistance. Resident 267 was tearful when she/he described the night. A 9/10/24 admission MDS indicated Resident 267 had mild cognitive impairment. On 9/12/24 at 12:37 PM Resident 267 tearfully stated the incident that happened on her/his first night in the facility reminded her/him of the pain she/he had from childhood trauma related to her/his mother putting her/him in a dark room and being told to be quiet. A 9/12/24…

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 observation, interview, and record review it was determined the facility failed to revise care plans for 2 of 6 sampled residents (#s 19 and 28) reviewed for pressure ulcers and nutrition. This placed residents at risk for unmet needs. Findings include: 1. Resident 28 was readmitted to the facility in 7/2024 with diagnoses including dysphagia (difficulty swallowing foods or liquids). Resident 28's 7/7/24 admission MDS revealed the resident was moderately cognitively impaired, had a feeding tube and required supervision or touching assistance with eating. Resident 28's 7/12/24 Dining Safety Care Plan revealed the following: -The resident was not to use straws. -The resident was to be in the atrium for meals. On 9/9/24 at 1:02 PM Resident 28 was observed in her/his room, in bed. Resident 28 ate from her/his lunch tray that was placed on an overbed table in front of the resident. A water pitcher with a straw was observed next to the lunch tray. On 9/10/24 at 9:59 AM and 9/11/24 at 9:14 AM a partially empty water pitcher with a straw was observed on Resident 28's overbed table…

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 recapitulation of the resident's stay was completed accurately for 1 of 2 sampled residents (#261) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 261 was admitted to the facility in 12/2023 with diagnoses including hemiplegia (inability to move) of the right dominant side. A 1/1/24 Progress Note indicated Resident 261 had two pressure ulcers noted on her/his right and left buttock. A 2/8/24 Progress Note indicated Resident 261 had multiple superficial open areas and excoriation noted to buttocks. A review of Physician Orders indicated Resident 261 had a 2/28/24 order to apply calmoseptin barrier cream daily and as needed to Resident 261's buttocks. A 3/14/24 Discharge Skin Summary stated Resident 261 had no skin impairments at time of discharge. A 3/14/24 Discharge Summary stated Resident 261 had treatment orders for A&D cream to bilateral lower extremities with no evidence of any other treatment orders. A 3/19/24 Discharge MDS stated…

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 appropriate treatment and services in communication for 1 of 1 sampled resident (#20) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 20 was admitted to the facility in 7/2016 with diagnoses including dementia. Resident 20's 6/28/24 Care Plan indicated a language barrier due to the Resident's primary language being Laotian or Thai. Interventions indicated in the resident's Care Plan instructed staff to contact Optimal Interpreter Services for assistance in communication. Resident 20's 6/29/2024 Annual MDS revealed the primary language for Resident 20 was English and he/she needed or preferred to use an interpreter to communicate with a doctor and health care staff. The Communication CAA completed 6/19/2024 indicated language was a concern as the primary language for Resident 20 was Laotian or Thai. On 9/9/2024 at 2:17 PM Staff 14 (CNA)…

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 dependent residents received ADL care for 1 of 4 residents (#33) reviewed for ADLs. This placed residents at risk for unmet care needs. Findings include: Resident 33 was readmitted to the facility in 6/2022 with diagnoses including dementia. Resident 33's 3/20/24 Annual MDS revealed the resident was severely cognitively impaired, required substantial/maximal assistance with upper body dressing and was dependent upon staff for lower body dressing. Resident 33's 4/12/24 ADL Self Care Performance Deficit Care Plan indicated the resident required assistance from one staff to get dressed. On 9/9/24 at 2:34 PM Resident 33 was observed in her/his room in bed and wore a hospital gown. Resident 33 was unable to answer any questions about her/his care or routine. On 9/11/24 at 11:50 AM and on 9/12/24 at 11:58 AM Resident 33 was observed in her/his room and sat in her/his wheelchair. The resident was dressed in a pink dress with yellow flowers. On 9/12/24 at 10:40 AM Staff 23 (CNA) and at 10:52 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.

Based on observation, interview, and record review it was determined the facility failed to provide a person-centered activity program for 3 of 3 sampled residents (#s 7, 20, and 33) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include: The facility's 2/2023 Activity Evaluation Policy indicated the following: -An activity evaluation was conducted as part of the comprehensive assessment to help develop an activities plan that reflected the choices and interests of the resident. -The resident's activity evaluation was conducted by activity department personnel, in conjunction with other staff who evaluate related factors such as functional level, cognition and medical conditions that may affect activities participation. -The resident's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences were included in the evaluation. -The activity evaluation was used to develop an individual activities care plan that allowed the resident to participate in activities of his/her choice…

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

Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were received for 1 of 6 sampled residents (#34) reviewed for communication and sensory care. This placed residents at risk for unmet hearing needs. Findings include: The facility's 2/2018 Care of Hearing Impaired Resident Policy revealed staff will assist the resident (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services. Resident 34 was admitted to the facility in 10/2023 with diagnoses including blindness. Resident 34's 10/17/23 Communication Care Plan revealed the following: -The resident had a hearing deficit. -The resident's family visited daily and could help answer specific questions for the resident. Resident 34's 7/11/24 Quarterly MDS revealed the resident was moderately cognitively impaired, experienced moderate difficulty hearing and was able to make her/himself understood. Resident 34's 9/2024 Physician Orders directed auditory consults as…

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 assess pressure ulcers and update care plans for 1 of 2 sampled residents (#19) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: 1. Resident 19 was admitted to the facility in 2016 with diagnoses including a stroke. A 9/10/24 review of Resident 19's physician orders revealed an 8/23/24 order for her/his right ear to clean with normal saline, pat dry, leave open to air and monitor for signs of infection every day for a pressure sore. A 9/10/24 review of Resident 19's care plan revealed no evidence of a care plan for Resident 19's pressure ulcer on her/his right ear. A 9/10/24 review of Resident 19's medical record revealed no evidence of a wound assessment of her/his right ear pressure ulcer. On 9/11/24 at 10:04 AM Resident 19 was observed to have a wound on the front, external part of her/his right ear. The wound was red, raised and had a scab on it. The wound had the appearance of a stage 2 pressure ulcer (a wound with partial…

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 appropriate care and services related to enteral (tube) feeding for 1 of 4 sampled residents (#28) reviewed for nutrition. This placed residents at risk for nutritional complications and weight loss. Findings include: The facility's 11/2018 Enteral Tube Feeding via Continuous Pump Policy and Procedure revealed the following: -Check the label on the enteral formula against the physician order (prior to starting the feed). -Hang the feeding bag on the IV (intravenous) pole and label initials, date and time the formula was hung/administered and initial that the label was checked against the order directly on the formula bag. Resident 28 was readmitted to the facility in 7/2024 with diagnoses including dysphagia (difficulty swallowing foods or liquids). Resident 28's 7/7/24 admission MDS revealed the resident was moderately cognitively impaired, had a feeding tube and received more than 51 percent of her/his calories by way of tube feeding. Resident 28's 8/26/24 Physician Orders directed…

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 who were trauma survivors received trauma-informed care for 3 of 3 sampled residents (#s 7, 34, and 51) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: The facility's 8/2022 Trauma-Informed and Culturally Competent Care Policy and Procedure revealed the following: -Traumatic events included abuse, neglect, serious injury or illness, racism, war and historical trauma. -Universal screening of residents was to be performed, which included a brief, non-specialized identification of possible exposure to traumatic events. -Screening included information such as trauma history, trauma-related symptoms, concerns with sleep or intrusive behaviors, behavioral or interpersonal concerns, historical mental health diagnosis, substance abuse, protective factors and resources available and physical health concerns. -The initial screening identified the need for further assessment and care. -Individualized care plans were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure proper storage of biologicals on 1 of 1 medication rooms during random observations for medication storage. This placed residents at risk of unsafe access to stored biologicals. Findings include: On [DATE] at 2:32 PM two Pfizer COVID 19 vaccines were observed in the medication refrigerator with an expiration date of [DATE]. On [DATE] at 2:33 PM Staff 24 (CMA) verified the two Pfizer COVID 19 vaccines were expired. On [DATE] at 2:45 PM Staff 2 (DNS) confirmed the two Pfizer COVID 19 vaccines expired on [DATE].

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure routine dental services were provided for 1 of 3 sampled residents (#46) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 46 was admitted to the facility on [DATE] with a diagnosis that includes severe protein calorie malnutrition. Resident 46's 5/10/2024 admission Nursing Database assessment indicated the resident had no natural teeth, tooth fragments or missing teeth. An 8/13/2024 Physician Order instructed the facility to schedule dental, visionary, auditory, and podiatry consultations as indicated. No evidence was found in Resident 46's clinical record to indicate additional dental needs were offered to the resident. On 9/10/2024 at 2:30pm Resident 46 stated he had been interested in new dentures because it would make eating easier. On 9/11/2024 at 2:57pm Staff 5 (Social Services Director) stated that dental services were not offered to Resident 46. On 9/11/2024…

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 resident's environment remained free from accident hazards related to a mechanical lift for 1 of 2 sampled residents (# 7) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 7 was admitted to the facility in 3/2022 with diagnoses including Type 2 Diabetes. A 3/18/22 admission MDS identified Resident 7 had no cognitive impairment. A 3/18/22 care plan identified Resident 7 as a moderate risk for falls. A 7/8/23 Nursing Care Note stated Staff 11 (LPN) with the assitance of Staff 20 (CNA) misused a mechanical lift during the transfer of Resident 7 which caused the lift to tilt forward while moving Resident 7 backwards. Resident 7 was struck by the lift across the nose and left cheek. A 7/12/23 hospital record indicated Resident 7 was diagnosed with a closed head injury and concussion as a result of being struck by the mechanical lift on the left side of her/his face. On 1/25/24 at 12:32 PM Staff 11 (LPN Resident Care Manager) confirmed Resident…

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

Based on interview and record review it was determined the facility failed to provide adequate urinary incontinence care for 2 of 3 residents (#s 2 and 6) reviewed for incontinence care. This placed residents at risk for unmet bladder care needs. Findings include: 1. Resident 2 was admitted to the facility in 11/2022 with diagnoses including Idiopathic Normal Pressure Hydrocephalus (a condition caused by impaired mobility, urinary urgency and incontinence). Resident 2's admission MDS identified the resident had severe cognitive impairment. Resident 2's 12/2/22 Care Plan revised on 4/28/23 indicated she/he had functional bladder incontinence due to her/his primary diagnosis. Resident 2's care interventions included frequent urinary checks, including brief changes and peri care. A 6/19/23 Witness Report indicated Resident 2 waited for over four hours to receive bladder incontinence care and Resident 2 urinated on her/his self. Review of bowel and bladder records for June of 2018 revealed a 4.5-hour delay between bladder incontinence care services. On 1/25/24 at 3:10 PM Staff 1…

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 an adequate number of qualified staff to ensure residents received adequate care and services for 1 of 3 residents (#2) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in 11/2022 with a diagnosis of Idiopathic Normal Pressure Hydrocephalus (a condition caused by impaired mobility urinary urgency and incontinence). Resident 2's admission MDS identified the resident had severe cognitive impairment. Resident 2's 12/2/22 Care Plan indicated the resident had functional bladder incontinence due to her/his primary diagnosis. Resident 2's care interventions included frequent urinary checks including brief changes and peri care. A 6/19/23 Witness Report indicated Resident 2 waited for over four hours to receive bladder incontinence care which resulted in Resident 2 urinating on her/his self. A review of Resident 2's June 2018 bowel and bladder records revealed Resdient 2 was not provided bladder incontinence care from 5:08 PM 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 free from unnecessary medication for 1 of 3 sampled residents (#60) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 60 was admitted to the facility in 8/2023 with diagnoses including diabetes. An 8/28/23 admission MDS indicated the resident was cognitively intact. Resident 60's 10/2023 Physician's orders revealed the resident was to receive: Insulin Lispro before meals and Insulin Glargine at bedtime. On 10/16/23 at 10:27 AM Resident 60 stated on 10/6/23 around 7:00 AM Staff 5 (Agency LPN) entered her/his room and administered the morning insulin dose. Resident 60 stated Staff 5 re-entered her/his room and quickly administered another shot of insulin. Resident 60 stated she/he asked Staff 5 if the medication was ordered by the physician and Staff 5 stated, Yes. Resident 60 noted the medication was labeled Tresiba (a long-acting insulin), an insulin not ordered for Resident 60. Resident 60 did not say…

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 protect the resident's right to be free from verbal and mental abuse by Witness 2 (Visitor/spouse of Resident 2) for 1 of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for verbal and mental abuse. Findings include: Resident 1 was admitted to the facility 8/2023 with diagnoses including diabetes, PTSD (post-traumatic stress disorder) and major depression. Resident 1's 8/2023 admission MDS indicated a BIMS score of 15 which indicated she/he was cognitively intact. The resident's 8/25/23 care plan revealed she/he was a PTSD survivor, was at risk for trauma and indicated a trigger was invasion of privacy. The care plan included a goal to prevent re-traumatization. An 8/28/23 admission Social History evaluation revealed Resident 1 had a history of trauma related to sexual abuse by a family member of the opposite sex. An 8/30/23 physician's progress note revealed Resident 1 received Prazosin (high blood pressure medication) for anxiety and experiencing reported nightmares…

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 thorough investigation was completed for 1 out of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for lack of complete investigations to rule out abuse. Findings include: Resident 1 was admitted to the facility in 8/2023 with diagnoses including diabetes, PTSD (post-traumatic stress disorder) and major depression. Resident 1's 8/2023 admission MDS indicated a BIMS score of 15 which indicated she/he was cognitively intact. Resident 1's medical record revealed an Incident Report dated 9/18/23. The incident was described as a complaint of verbal abuse from a visitor of another resident, and uninvited entry into [her/his] room. The report lacked documentation of staff interviews regarding the incident between Resident 1 and Witness 2 (Visitor/spouse of Resident 2) on 9/17/23. The 9/18/23 Incident Report indicated abuse and neglect was unsubstantiated due to unable to anticipate visitors reaction and behavior. There was no documentation to describe how verbal and mental abuse…

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

Based on interview and record review it was determined the facility failed to ensure a resident with a history of trauma received trauma- informed care for 1 of 1 sampled resident reviewed for abuse and a safe environment. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: Resident 1 was admitted to the facility in 2023 with diagnoses including diabetes, PTSD (post-traumatic stress disorder) and major depression. Resident 1's 8/2023 admission MDS indicated a BIMS score of 15 which indicated she/he was cognitively intact. The resident's 8/25/23 Care Plan revealed she/he was at risk for trauma and included triggers of invasion of privacy. The care plan included a goal to prevent re-traumatization. An 8/28/23 admission Social History evaluation revealed Resident 1 had a history of trauma related to sexual abuse by a family member of the opposite sex. An 8/30/23 physician's progress note revealed Resident 1 received Prazosin (high blood pressure medication) for anxiety and experiencing reported nightmares of reliving prior abuse. 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 exercise reasonable care for the protection of the resident's property from loss or theft for 4 of 5 sampled residents (#s1, 9, 42 and 52) reviewed for personal property. This placed residents at risk for living in an unhomelike environment. Findings include: The facility's Personal Property Policy dated 8/2022 outlined the following: - The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. - The facility promptly investigates any complaints of misappropriation or mistreatment of resident property. 1. Resident 1 was admitted to the facility in 3/2022 with diagnoses including Cerebral Palsy (a condition that affects movement and coordination). Resident 1's 2/9/23 Quarterly MDS revealed the resident was cognitively intact. A 3/20/23 Lost or Damaged Items Form signed by Staff 9 (Social Services Director) revealed the following: - Resident 1 was missing 15 pairs of socks, a blue sweatshirt, a black skirt and a short sleeve red top with sparkles.…

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 sufficient nursing staff to meet resident care needs in a timely manner for 6 of 6 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: 1. On 6/7/23 at 1:07 PM Resident 13 stated it took a long time, at times up to an hour, for staff to answer her/his call light, especially at night and on the weekends. On 6/8/23 at 2:48 PM and 3:08 PM Staff 31 (LPN) and Staff 32 (CNA) stated there was not enough time in their shift to complete tasks and respond to the residents' needs timely. On 6/9/23 at 2:43 PM Staff 14 (LPN) stated it was difficult to get nursing tasks done timely. Staff 14 stated there was not enough staff to ensure timely care for residents who required the assistance from two staff. On 6/9/23 at 2:38 PM the following call light times were displayed on the nursing station two monitor and no staff were in each of the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 4 of 5 medication carts observed. This placed residents at risk for misappropriation of medications and drug diversion. Findings include: The facility's 11/2020 Storage of Medications Policy & Procedure specified medication carts containing drugs and biologicals were locked when not in use and unlocked medication carts were not left unattended. On 6/7/23 from 11:13 AM to 11:15 AM, an unlocked and unattended medication cart was observed at nursing station three. CNA and therapy staff were in the area and the contents of the cart were accessible. On 6/7/23 at 12:00 PM an unlocked and unattended medication cart was observed at nursing station two. Staff 14 (LPN) walked to the area and locked the cart. On 6/7/23 at 3:44 PM an unlocked and unattended medication cart was observed adjacent to room [ROOM NUMBER]. On 6/9/23 at 7:55 AM an unlocked and unattended medication cart 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 review it was determined the facility failed to treat residents in a dignified manner for 1 of 1 resident reviewed for dignity. This placed residents at risk for an undignified existence. Findings include: The facility's 2/2021 Dignity Policy & Procedure specified each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. Individual preferences of the resident are identified through the assessment process. Resident 14 was admitted to the facility in 8/2013 with diagnoses including quadriplegia and traumatic brain injury. Resident 14's 3/11/23 Annual MDS indicated the resident was non verbal, was able to respond with facial expressions and her/his hearing was adequate. Resident 14's Care Plan indicated the resident moved her/his left leg, smiled and enjoyed having staff chat with her/him.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide residents with a baseline care plan for 1 of 1 sampled resident (#115) reviewed for new admissions. This placed residents at risk for being uniformed of their plan of care. Findings include: The faility's Care Plans-Baseline Policy, revised 12/2016, revealed the staff were to assure the resident's immediate care needs were met and maintained, and a basleline care plan would be developed with in 48 hours of admission. The ressident and their representative will be provided a summary of the baseline care plan. Resident 115 was admitted to the facility on [DATE] with diagnoses including osteoporosis (brittle bones). Review of Resident 115's medical record indicated no evidence of a baseline care plan. On 6/7/23 at 3:20 PM Resident 115 stated she/he had not received a copy of her/his baseline care plan. On 6/12/23 at 10:29 Staff 30 (LPN/Resident Care Manager) stated Resident 115 was provided a copy of her/his care plan at 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 implement care plans for 1 of 4 sampled residents (#114) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 114 was admitted to the facility in 3/2023 with diagnoses including wrist fracture. Record review of Resident 114's 3/2023 care plan revealed she/he required assistance from one person to complete colostomy bag (small pouch used to collect waste from the body) care. In an interview on 6/12/23 at 11:45 AM Resident 114 confirmed on 4/2/23 she/he did not receive assistance when she called for help to empty her/his full colostomy bag and the bag of waste exploded all over her/himself and the floor. Resident 114 stated she/he was very embarrassed when this occurred. In the same interview Witness 4 (Spouse) stated he came to the facility and helped to clean Resident 114 after the colostomy bag explosion and staff placed a towel over the bowel contents on the bathroom floor. A facility incident report dated 4/2/23 revealed Resident 114 experienced a full…

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 comprehensive, person-centered care plans for ADLs and nutrition were revised for 2 of 6 sampled residents (#s1 and 24) reviewed for dental and nutrition. This placed residents at risk for unmet care needs. Findings include: 1. Resident 1 was admitted to the facility in 3/2022 with diagnoses including Type 2 diabetes. Resident 1's 2/9/23 Quarterly MDS revealed the resident was cognitively intact. Resident 1's 5/12/23 Annual MDS revealed the resident ate independently and required set-up assistance. Resident 1's 5/17/23 ADL Self-Care Care Plan indicated the resident required assistance to eat. On 6/13/23 at 10:24 AM Staff 12 (CNA) and at 2:06 PM Staff 11 (CNA) stated Resident 1 ate independently. On 6/14/23 at 10:45 AM Staff 13 (RNCM) stated Resident 1 required set-up assistance at mealtimes and otherwise ate independently. Staff 13 reviewed Resident 1's Care Plan and confirmed it was inaccurate and needed to be updated. On 6/14/23 at 1:38 PM Staff 2 (DNS) acknowledged the findings and…

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

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 2 sampled residents (#24) reviewed for position and mobility. This placed residents at risk for increased swelling and discomfort. Findings include: Resident 24 was admitted to the facility in 3/2022 with diagnoses including hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following stroke. Resident 24's 3/22/23 Annual MDS revealed the resident was cognitively intact. Resident 24's 5/31/23 Physician Orders indicated the following: - Apply size F tubigrip (provides continuous support for the management of strains, sprains, and swelling) to left forearm due to swelling in right hand, on in AM and off at HS. On 6/7/23 at 1:10 PM Resident 24 was observed sitting in her/his wheelchair with her/his left arm hanging down to the side of her/his wheelchair. Resident 24 was not a wearing tubigrip on her/his left arm and all five fingers on her/his left hand were swollen. Resident 24 stated…

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

Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled residents (#1) reviewed for communication and sensory care. This placed residents at risk for unmet vision needs. Findings include: Resident 1 was admitted to the facility in 3/2022 with diagnoses including Type 2 diabetes. Resident 1's 2/9/23 Quarterly MDS revealed she/he was cognitively intact. A review of Resident 1's clinical record revealed a prescription for eyeglasses dated 5/23/23. On 6/7/23 at 2:00 PM Resident 1 was observed without eye glasses and stated she/he had trouble seeing out of both of her/his eyes. Resident 1 stated she informed Staff 13 (RNCM) and her/his eye doctor she/he was interested in obtaining eye glasses. Resident 1 stated she/he did not understand why she/he could not get eye glasses. On 6/13/23 at 2:34 PM Staff 9 (Social Services Director) stated she asked residents on a quarterly basis about their interest in scheduling a vision appointment and/or having glasses. If the…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents with limited mobility received appropriate services and equipment for 1 of 2 sampled residents (#24) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: The facility's Resident Mobility and Range of Motion Policy revised 7/2017 indicated the following: - Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. - The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. - Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. - The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident…

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

Based on observation, interview and record review it was determined the facility failed to determine if a resident's clinical condition necessitated urinary catheterization and failed to obtained a physician order for urinary catheterization for 1 of 1 sampled resident (#11) reviewed for urinary catheters. This placed residents at risk of unnecessary urinary catheterization and infections. Findings include: Resident 11 was admitted to the facility in 4/2021 with diagnoses including diabetes. On 6/7/23 at 12:18 PM Resident 11 was observed with a urinary catheter bag and tubing in place. The 4/26/23 Annual MDS, revealed Resident 11 had an indwelling urinary catheter, and was not on a toileting program. Review of Resident 11's medical records did not provide a clinical diagnosis for the use or a physician order for the use of a urinary catheter. On 6/13/23 at 12:08 PM Staff 2 (DNS) and Staff 35 (LPN/Resident Care Manager), confirmed Resident 11 had no clinical diagnosis or physician order for the placement of an indwelling catheter.

Based on observation, interview and record review it was determined the facility failed to follow physician orders and failed to ensure respiratory equipment was properly maintained for 1 of 3 sampled residents (#6) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and discomfort. Findings include: The facility's 10/2010 Oxygen Administration Policy & Procedure specified the following: - Ensure the proper flow of oxygen was being administered; - Check the humidifying bottle to be sure it was in good working order, there was water in the humidifying bottle, the water level was high enough that the water bubbled and re-check to ensure adequate water level. Resident 6 was admitted to the facility in 9/2022 with diagnoses including respiratory failure. Resident 6's 5/4/23 Quarterly MDS indicated the resident used oxygen. Resident 6's 6/2023 Physician Orders included the following: - Oxygen at two liters per minute via nasal cannula; - Ensure foam covers were in place around nasal cannula tubing; - Oxygen tubing changed every week, labeled 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 limit orders for PRN antipsychotic medication to 14 days and not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropritateness of medications for 1 of 5 sampled residents (# 42) reviewed for medications. This placed residents at risk for adverse side effects for the use of antipsychotic medication. Findings include: Resident 42 was admitted to the facility in 1/2022 with diagnoses including dementia, Post Traumatic Stress Disorder, anxiety and depression. Record review on 6/12/23 revealed Resident 42 was ordered PRN Olanzapine (antipsychotic to treat mental disorders) 5mg every six hours to start 1/23/23 with no end date for the order. Resident 42 was given the medication on the following dates; -1/31/23 -2/3/23 - refused the mediation on 3/14/23, 3/15/23 and 3/16/23. Record review on 6/12/23 revealed Resident 42 was ordered PRN Quetiapine (antipsychotic to treat mental disorder) 25mg every six hours to start 1/23/23 with no end date for the order.…

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.