Cascade Terrace Post Acute

Based on observation, interview and record review it was determined the facility failed ensure food was labeled and stored in a manner to avoid spoilage in 1 of 1 kitchen and 2 of 3 nurses stations reviewed for sanitary food storage. The facility also failed to ensure the ice machine was plumbed correctly to prevent backflow of contaminated matter into the ice machine for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: The facility's undated Key Food Safety Practices policy indicated: -All food must be labeled and dated when opened; and -Raw ingredients will be free from contamination. 1. On 4/21/25 at 9:22 AM the following items were observed in the unit refrigerator located behind Nurses Station One: -Two unlabeled, undated covered plastic ramekins of peanut butter; -One unlabeled, undated covered plastic coffee mug containing a clear liquid and ice; -One previously opened, unlabeled and undated 32 fluid ounce container of Med Pass 2.0+ Vanilla Fortified Nutritional Shake. On 4/21/25 at 9:22 AM Staff 27 (LPN)…

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 were assessed for safe self-administration of medications for 1 of 1 sampled resident (#28) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include: Resident 28 was admitted to the facility in 2/2025 with diagnoses including dementia. Resident 28's 3/1/25 admission MDS indicated the resident had no cognitive impairment. On 4/23/25 at 1:28 PM, Resident 28 had Aspercreme lidocaine gel (a topical pain reliever primarily used for muscle or joint pain) on her/his bedside table, within reach. Resident 28 stated the Aspercreme was used on her/his heels. Review of Resident 28's health record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer the Aspercreme lidocaine gel. On 4/23/25 at 1:28 PM, Staff 13 (CNA) stated residents should not have any medications at their bedside and if medications…

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 to maintain the privacy and confidentiality of resident records for 3 of 3 sampled residents (#s 14, 28 and 48) reviewed for privacy. This placed residents at risk for loss of dignity and privacy. Findings include: The facility's 4/2014 Management and Protection of Protected Health Information (PHI) Policy indicated it was the responsibility of all personnel with access to resident and facility information to ensure that such information was managed and protected to prevent unauthorized release or disclosure. 1a. Resident 48 was admitted to the facility in 3/2025 with diagnoses including cellulitis (a common bacterial infection of the skin). Observations on 4/24/25 from 12:08 PM to 12:13 PM revealed an unlocked computer screen on one of the facility's treatment carts in the south hallway. The computer screen displayed a picture of Resident 48 as well as the resident's name, gender, date of birth , age, allergies, code status, attending physician, vital signs and her/his scheduled treatments. On 4/24/25…

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 2. Resident 320 was admitted to the facility in 4/2025 with diagnoses including stroke and Type 2 Diabetes (a chronic condition characterized by high blood sugar levels). A review of resident 320's health record revealed her/his admission MDS assessment was in progress and overdue by five days on 4/28/25. On 4/28/25 at 1:31 PM Staff 33 (Assistant Regional Director of Clinical Services) acknowledged Resident 320's admission MDS was not completed within her/his first 14 days in the facility. Staff 33 stated an accurate MDS assessment was necessary to initiate a person-centered care plan for Resident 320. Based on interview and record review it was determined the facility failed to complete comprehensive assessments within 14 days of admission for 3 of 3 sampled residents (#s 318, 320, 468) reviewed for comprehensive admission assessments. This placed residents at risk for unmet care needs. Findings include: 1. Resident 318 admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus 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 ensure the MDS was coded accurately related to dental and hearing for 2 of 2 sampled residents (#s 3 and 16) reviewed for dental and communication. This placed residents at risk for inaccurate assessments. Findings include: The facility's 11/2019 Certifying Accuracy of the Resident Assessment Policy revealed any information captured on the MDS reflected the status of the resident during the observation period for that assessment. 1. Resident 3 was admitted to the facility in 2/2012 with diagnoses including traumatic brain injury. A 6/3/24 Dental Treatment Record indicated Resident 3 was fully edentulous (lacking teeth). Resident 3's 12/24/24 Annual MDS revealed the resident was not edentulous. On 4/21/25 at 12:59 PM Resident 3 was observed in her/his room without any natural teeth. On 4/25/25 at 12:10 PM Staff 33 (Assistant Regional Director of Clinical Services) acknowledged Resident 3's Annual MDS was inaccurate and the resident should have been coded as edentulous. 2. Resident 16 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 6 sampled residents (#28) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include: Resident 28 was admitted to the facility on [DATE] with diagnoses including dementia. Resident 28's 2/23/25 Bowel and Bladder Care Plan indicated the resident had a catheter due to urine retention and was incontinent of bowel. Resident 28's 2/23/25 [NAME] (a quick reference for CNAs to access a resident's care information)indicated the resident received bathing/showering on Monday and Thursday, day shift or per preference. Resident 28's 3/1/25 admission MDS indicated the resident had intact cognition and was dependent with bathing/showering. Resident 28's 3/2025 and 4/1/25 through 4/23/25 bathing task logs indicated the resident received bathing/showering on the following days: - 3/6, 3/20, 3/27, 3/31, 4/3, 4/10 and 4/23. A review of…

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

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 an ongoing person-centered activity program for 2 of 3 sampled residents (#s 28 and 118) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Programs policy, revised 6/2018, indicated the following: -The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. -Activities were based on the comprehensive resident-centered assessment and the preferences of each resident. -All activities were documented in the resident's medical record. -Individualized and group activities were provided that reflected the schedules, choices and rights of the residents. 1. Resident 28 was admitted to the facility in 2/2025 with diagnoses including dementia. Resident 28's 3/1/25 admission MDS indicated the resident was cognitively intact. 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 obtain an ordered Ankle Foot Orthosis (AFO, a brace worn on the lower leg to provide support and control to the ankle and foot), identify and assess a skin condition or follow physician orders for parameters for a cardiac medication for 3 of 9 sampled residents (#s 3, 13 and 18) reviewed for position and mobility, skin conditions and unnecessary medications. This placed residents at risk for injury, worsening skin conditions and adverse side effects related to uncontrolled hypertension. Findings include: 1. Resident 3 was admitted to the facility in 2/2012 with diagnoses including hemiplegia (a condition characterized by paralysis on one side of the body). A 12/12/24 Progress Note revealed Resident 3 was not appropriate for a prefabricated AFO due to her/his left hemiplegia and required a custom orthosis instead. Resident 3's 12/24/24 Annual MDS revealed the resident was severely cognitively impaired and experienced lower extremity impairment on one side. Resident 3's 1/24/25 PT Evaluation…

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 dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: The facility's Hemodialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly) Care Policy and Procedure, dated 9/1/24 indicated the following: -The licensed nurse completed the dialysis center communication information prior to the resident leaving for dialysis. -Upon the resident's return, the post-dialysis assessment portion of the form was to be completed and attached to the resident's medical record. -Residents who required hemodialysis were provided ongoing assessment and monitoring before and after dialysis treatments including monitoring for complications, issues were documented by the licensed nurse and the medical providers were notified. Resident 6 was admitted to 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 monitor for adverse side effects (ASE) of medications for 1 of 1 sampled resident (#468) reviewed for Anticoagulant medication. This placed residents at risk for medication complications. Findings include: Resident 468 was admitted to the facility on 4/2025 with the diagnosis including Peripheral vascular disease. The April 2025 MAR identified Clopidogrel Bisulfate (anticoagulant medication) 75mg one tablet PO QD at bedtime for clot prevention. There was no evidence that adverse side effects were monitored. Side effects for the medication included according to the Mayo clinic website, Collection of blood under the skin, deep, dark purple bruise. On 4/21/25 at 1:34 PM the resident showed her/his arms which had multiple bruises covering both arms. On 4/21/25 at 1:34 PM Resident 468 stated she/he did not know where she/he got the bruises. In a 04/24/25 interview at 12:23 PM with Staff 36 (CNA) stated that skin checks were completed once a week, and no bruising had been noted. Staff 3 had noted a new skin tear…

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 1 of 3 sampled residents (#4) reviewed for ADL care. This placed residents at risk for unmet needs. Findings include: Resident 4 was admitted to the facility in 8/2024, with diagnoses including stroke and cerebral edema (excess fluid in the brain, which causes swelling). Resident 4 was discharged in 9/2024. Resident 4's admission Nursing Database form dated 8/9/24 revealed she/he was alert but not oriented to person, time, or place; she/he was nonverbal and unable to express understanding. Resident 4 was considered an extensive assist for all ADL's and was a one person total assist for bathing. Resident 4's care plan dated 8/10/24 revealed she/he was to be bathed or showered twice a week. On 1/16/25 at 9:40 AM, Witness 4 (Complainant) stated she visited the resident almost daily when she/he was at the facility and bathing just wasn't done. She noted Resident 4 was non verbal and could not refuse showers or baths and recalled family members washed the resident's hair because it would…

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 tube feeding was administered according to physician orders for 1 of 3 sampled residents (#4) reviewed for physician orders. This placed residents at risk for insufficient nutrition. Findings include: Resident 4 was admitted to the facility in 8/2024, with diagnoses including stroke and cerebral edema (excess fluid in the brain, which causes swelling). Resident 4 was discharged in 9/2024. Resident 4's admission Nursing Database form dated 8/9/24 revealed she/he was alert but not oriented to person, time, or place; was nonverbal and unable to express understanding. Resident 4 was found to have a nutritional problem or potential nutritional problem due to her/his NPO (nothing by mouth) and impaired swallowing status. Resident 4's care plan dated 8/10/24 revealed she/he was NPO and received her/his nutrition via a PEG tube. Resident 4's initial physician orders for tube feeding were as followed: -PEG Tube feeding: Standard formula with fiber - Jevity 1/2 (or equivalent) 290 ml 5x/day (0700, 1100, 1500,…

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 adequate hand hygiene and appropriate use, reuse, disinfection and storage of PPE for 2 of 3 halls reviewed for infection control and failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of waterborne pathogens for 1 of 1 facility reviewed for infection control. This placed residents at risk for the spread of infectious diseases and exposure to waterborne pathogens. Findings include: 1. The facility's 3/2023 Transmission Based Precautions Policy and Procedure specified the following related to droplet precautions: -Masks are donned upon entry into a resident's room with droplet precautions. -Masks are removed prior to leaving the resident's room and hand hygiene is performed. -Residents remain on droplet precautions for the duration of illness or per CDC guidelines. The facility's 12/2021 Hand Hygiene Policy specified hand hygiene…

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 maintain comfortable sound levels for 2 of 3 hallways observed for environment. This placed residents at risk for an uncomfortable environment. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including anxiety and major depression. Multiple observations from 1/22/24 through 1/24/24 between the hours of 7:30 AM and 9:45 PM revealed Resident 52 frequently yelled and her/his yelling was audible on two of the three facility hallways. Other residents were heard yelling shut up to Resident 52 and Resident 52 yelling back, make me. Resident 52's yelling was noted during daytime and evening observations. On 1/22/24 at 9:52 AM Resident 38 reported Resident 52 yelled for hours every night and day since she/he was admitted to the facility. Resident 38 stated the yelling was mind numbing. Resident 38 stated she/he spoke to multiple staff about Resident 52's yelling and everyone was aware Resident 52 yelled but the yelling continued daily. On 1/23/24 at 11:19 AM Witness 1 (Family)…

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 timely call light responses for 5 of 5 sampled residents (#s 8, 18, 38, 57 and 59) reviewed for sufficient staffing. This placed residents at risk for delayed and unmet needs. Findings include: 1. Resident 59 was admitted to the facility in 1/2024 with diagnoses including arm fracture. On 1/22/24 at 12:18 PM Resident 59 stated after she/he turned on her/his call light, she/he waited 30 to 40 minutes for staff to respond. Resident 59 stated she/he used her call light when she/he needed her/his soiled incontinence brief changed and it was uncomfortable to sit in a pissy brief for 30 to 40 minutes. On 1/24/24 at 8:39 AM the call light monitor was observed and indicated Resident 59's call light was triggered at 7:58 AM and was unanswered by staff for 41 minutes. On 1/24/24 at 12:13 PM the call light monitor was observed and indicated Resident 59's call light was triggered at 12:01 PM. Resident 59 stated her/his 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 ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 27, 36 and 39) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed of their legal rights. Findings include: The facility's undated Alternative Dispute Resolution Agreement Between Resident and Facility stated: Revocation of the Agreement. This Agreement may be canceled by the Resident by delivering written notice of revocation to the Facility not later than 5:00 PM local time on the fifth (5th) day after the date the Resident or their representative signs this Agreement. 1. Resident 36 was admitted to the facility in 5/2022 with a diagnosis of stroke. On 1/30/24 at 11:06 AM Resident 36 stated she/he did not recall signing an arbitration agreement. Record review revealed Resident 36 signed the facility's arbitration agreement on 1/19/21. On 1/30/24 at 10:11 AM Staff 44 (Director of Admissions) stated she was responsible for going over 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 ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 4, 24, 25, 26 and 27) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 1/30/24 at 12:28 PM Staff 35 (Staffing Manager) provided a list of training hours for the sampled staff and confirmed the following: -Staff 4 (CNA): 9.5 annual training hours; -Staff 24 (CNA): 11.5 annual training hours; -Staff 25 (CNA): 11.5 annual training hours; -Staff 26 (CNA): 11.5 annual training hours and -Staff 27 (CNA): 11.5 annual training hours. On 1/30/24 at 2:38 PM Staff 1 (Administrator) stated she expected all CNA staff to receive 12 hours of annual in-service training.

Based on interview and record review it was determined the facility failed to ensure consent was obtained prior to administration of a vaccine for 1 of 5 sampled residents (#51) reviewed for immunizations. This placed residents at risk for lack of information related to immunization risks, benefits and potential side effects. Findings include: Resident 51 was admitted to the facility in 8/2023 with diagnoses including heart failure. Resident 51's health record revealed a 1/23/24 Physician Order for the RSV (respiratory syncytial virus) vaccination. Resident 51's 1/2024 MAR indicated Staff 21 (LPN) administered the RSV vaccine to Resident 51. Review of Resident 51's health record revealed no evidence to indicate Resident 51 provided consent for the vaccination. There was no documentation to indicate the risks, benefits and potential side effects of the RSV vaccine were discussed or reviewed with Resident 51 prior to administration. On 1/25/24 at 1:21 PM Resident 51 stated she/he received the RSV vaccine last night after dinner. Resident 51 stated she/he did not sign a consent form…

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 accommodation of resident needs related to light pull cords for 2 of 2 sampled residents (#s 19 and 51) reviewed for accommodation of needs. This placed residents at risk for loss of independence. Findings include: Resident 19 was admitted to the facility in 4/2023 with diagnoses including heart failure. Resident 51 was admitted to the facility in 8/2023 with diagnoses including heart failure. On 1/23/24 at 2:16 PM Resident 51's overbed light was observed on the wall, above and behind the resident's bed. The overbed light's pull chain was observed to be approximately four inches long and out of Resident 51's reach. Resident 51 stated she/he could not reach the pull chain and she/he had to rely on staff to turn it off and on for her/him. Resident 51 stated the light often shined in her/his eyes while she/he tried to fall asleep because staff did not turn off the light before they left the room. On 1/26/24 at 11:39 AM Staff 22 (Maintenance Director) stated he conducted room audits weekly…

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's representative and physician of a resident's suicide attempt for 1 of 5 sampled residents (#52) reviewed for unnecessary medications. This placed resident representatives and physicians at risk for being uninformed of current resident status and residents at risk of unmet treatment needs. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including depression with psychotic features. Resident 52's 11/8/23 admission MDS indicated the resident was cognitively intact and she/he experienced moderately severe depression and delusional thinking. The MDS assessment also indicated the resident exhibited physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others which significantly interfered with the resident's care and participation in activities/social interactions. Resident 52's 1/2024 Face Sheet (a document that gives a resident's information at a quick glance) listed Witness 2 (Family) as the first…

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

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by Resident 40 for 1 of 3 sampled residents (#22) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 1/2023 Abuse Policy & Procedure specified the following: - Abuse is defined as willful infliction of injury or intimidation resulting in physical harm, pain or mental anguish. Injury is defined as extreme physical pain. Resident 22 was admitted to the facility in 8/2023 with diagnoses including cirrhosis of the liver (impaired liver function). Resident 22's 11/18/23 Quarterly MDS indicated the resident was cognitively intact. Resident 40 was admitted to the facility in 8/2023 with diagnoses including weakness on one side following a stroke. Resident 40's 11/17/23 Quarterly MDS indicated the resident was cognitively intact. On 1/22/24 at 9:31 AM Resident 22 stated on 11/19/23 at nighttime, Resident 40 beat [her/him] up outside in the smoking area. Resident 22 stated Resident 40 kicked her/his legs, punched…

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 alleged violation timely to the state agency for 2 of 3 sampled residents (#s 5 and 22) reviewed for abuse. This placed residents at risk for delayed and incomplete investigations. Findings include: The facility's 1/2023 Abuse Policy and Procedure specified the following: - All staff members were considered mandatory reporters, and as such, were obligated to report using the state reporting mechanism. - If there was abuse or a serious injury the staff member must report the incident within two hours of forming the suspicion to the state survey agency. 1. Resident 5 was admitted to the facility in 12/2020 with diagnoses including traumatic brain injury. Resident 5's 9/25/23 Quarterly MDS indicated the resident had a memory problem and was moderately cognitively impaired. Resident 5's 12/19/23 at 1:57 PM Progress Note written by Staff 19 (LPN) identified yellowish bruising and swelling to the resident's upper left arm, the resident's left arm was painful during an assessment and an x-ray 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 investigate injuries of unknown origin and rule out potential abuse or neglect for 1 of 4 sampled residents (#8) reviewed for falls. This placed residents at risk for abuse and neglect. Findings include: Resident 8 was admitted to the facility in 7/2019 with diagnoses including vascular Parkinsonism (a brain condition that causes slow movements, stiffness and tremors.) Resident 8's health record revealed an incident report dated 7/17/23 was completed after Resident 8 reported she/he fell on 7/14/23. Interviews with staff working on 7/14/23 revealed no staff witnessed Resident 8 falling or on the floor. The report indicated Resident 8 would not have been able to get up from the floor by herself/himself if a fall occurred. During the fall investigation, a bruise was noted above Resident 8's left eyebrow and the resident had abrasions on her/his left hip and left lower leg. The abrasion on Resident 8's left hip was cleaned and a foam dressing was applied. The incident report concluded Resident 8 had 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 implement care plan interventions in the area of fall prevention for 2 of 4 sampled residents (#s 14 and 35) reviewed for falls. This placed residents at risk for potential injury. Findings include: 1. Resident 14 was admitted to the facility in 8/2020 with diagnoses including Parkinson's disease (a progressive disease of the nervous system). Resident 14's 9/5/23 Fall Scale revealed the resident overestimated or forgot her/his limits, had a history of falls, had impaired gait (manner of walking) and was at high risk for falling. Resident 14's 9/6/23 Fall Care Plan indicated the following: -Bilateral fall mats when the resident was in bed. -Resident 14 was at high risk to fall. Resident 14's 12/1/23 Quarterly MDS Assessment revealed the resident experienced moderate cognitive impairment. Observations of Resident 14 conducted from 1/23/24 through 1/25/24 between 9:37 AM to 7:39 PM revealed the resident to be in bed. No fall mats were observed on the resident's floor. On 1/25/24 at 3:04 PM 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.

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 care plans were revised to accurately reflect the needs of residents for 1 of 1 sampled resident (#52) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including dysphagia (difficulty swallowing). Resident 52's 11/8/23 admission MDS indicated the resident experienced loss of liquids/solids from her/his mouth when eating or drinking, held food in her/his mouth/cheeks or residual food in her/his mouth after meals, coughed or choked during meals or when swallowing medications and had complaints of difficulty or pain when swallowing. The MDS assessment also indicated the resident received a mechanically altered and therapeutic diet and she/he required substantial/maximum assistance with eating. Resident 52's 12/7/23 SLP Discharge Summary completed by Staff 38 (SLP) recommended Resident 52 receive a regular…

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 medication orders for 1 of 5 residents (# 52) reviewed for unnecessary medications. This placed residents at risk for medication side effects. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including depression with psychotic features. On 1/7/24 Resident 52 was prescribed Seroquel to address behavior/mood changes related to depression with psychotic features. On 1/9/24 Resident 52 was prescribed Oxycodone every six hours as needed for pain. The orders instructed this medication was not to be given within two hours of Seroquel administration. Review of Resident 52's 1/2024 MAR revealed the following: -On 1/9/24 Resident 52 received Seroquel at 4:23 PM and received Oxycodone at 4:24 PM, 1 minute apart in administration. -On 1/10/24 Resident 52 received Oxycodone at 4:37 PM and received Seroquel at 6:14 PM, 1 hour and 37 minutes apart in administration. -On 1/11/24 Resident 52 received Seroquel at 8:00 AM and received Oxycodone at 9:21 AM, 1 hour and 21 minutes…

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 CNAs received annual performance reviews for 2 of 5 randomly selected CNA staff (#s 25 and 26) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 1/30/24 with Staff 35 (Staffing Manager) indicated the following employees had not received their annual performance evaluations: -Staff 25 (CNA), hire date 12/30/14: no annual performance review was completed. -Staff 26 (CNA), hire date 11/26/22: no annual performance review was completed. On 1/30/24 at 11:39 AM Staff 35 confirmed annual performance reviews for Staff 25 and Staff 26 were not completed. On 1/30/24 at 2:38 PM Staff 1 (Administrator) stated she expected that annual CNA performance reviews would be completed by the end of the month of each staff member's hire date.

Based on interview and record review it was determined the facility failed to administer a medication as ordered for 1 of 1 resident (# 164) reviewed for medication administration. This placed residents at risk for adverse medication side effects. Findings include: On 9/30/23, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and staff were trained on steps to take to ensure correct medication administration which included: -Nursing managers performing a review of new medication orders. -Follow-up on any needed clarification or corrections for new medication will be performed. -Random medication administration audits being performed weekly for four weeks and monthly for three months. -Audits results will be brought to the Quality Assurance and Performance Improvement committee for review. Resident 164 was admitted to the facility in 7/2023 with diagnoses including respiratory failure with a lack of oxygen intake. Hospital discharge orders from 7/14/23 included instructions to administer hydromorphone 8 mg tablets every 6 hours…

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

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Daily Staff Reports (DCSDR) were accurate for 7 of 42 days reviewed for staffing. This placed residents and the public at risk for lack of awareness of nurse staffing levels. Finding include: A review of the DCSDR from 11/1/22 through 12/15/22 revealed 49 instances where the actual number of staff (RNs, CNAs and NAs) working was not recorded accurately. On 12/15/22 at 9:25 AM Staff 14 (Staffing Coordinator) stated she was not aware the DCSDR was to reflect the actual count of staff working on the floor as the DCSDR was completed the previous night for the whole day. Staff 14 confirmed the DCSDR was not updated at the beginning or during the shift to reflect accurate staffing count. On 12/15/22 at 2:47 PM Staff 1 (Administrator) confirmed the DCSDR did not reflect the actual count of the staff working on the floor.

Based on interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 3 sampled residents (#207) reviewed for dignity. This placed residents at risk for loss of dignity. Findings include: Resident 207 was admitted to the facility in 6/2021 with diagnoses including throat and lung cancer. A 7/9/22 Cognitive Loss/Dementia CAA indicated Resident 207 was able to make her/his needs known, required extensive assistance with her/his ADLs and had no vision or hearing problems. Resident 207 received end-of-life care and a decline was expected. A Facility Reported Incident dated 6/3/22 revealed the following: -On the evening of 6/3/22 at approximately 7:00 PM Staff 4 (CNA) witnessed Staff 5 (CNA) mock Resident 207 who requested coffee. Resident 207 had cancer and required removal of tissue from her/his mouth, tongue and throat. As a result, her/his speech was severely affected and she/he slurred her/his words and had poor enunciation. -Staff 4 indicated she overheard Staff 5 laugh and mock Resident 207 because of how many…

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 received showers for 1 of 2 sampled residents (#107) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 107 was admitted to the facility 2/1/21 with diagnoses including stomach ulcers. A 2/1/21 admission Nursing Database revealed the resident was cognitively intact, had impaired mobility, required extensive assistance of one staff for bathing and preferred showers. A 2/2021 CNA documentation form revealed the resident did not receive a shower from 2/1/22 through 2/8/21. Resident 107 discharged on 2/8/21. On 12/15/22 at 10:48 AM, 11:06 AM and 11:46 AM Staff 2 (DNS) stated residents were offered two showers a week. Staff were to document the type of bathing provided or if bathing was refused. Staff 2 indicated there was no documentation to indicate Resident 107 was offered showers.

Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than five percent for 3 of 4 residents (#s 6, 16 and 25) reviewed for medication administration. The facility's medication error rate was 13%. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 25 was admitted to the facility in 2019 with diagnoses including hypothyroidism (low thyroid hormone). Resident 25's current physician's orders included: - levothyroxine sodium (thyroid hormone) 175 micrograms with instructions to take the medication on an empty stomach and do not take the medication within two hours of taking magnesium, calcium, iron, vitamins or omeprazole (treats acid reflux). Administer in addition to levothyroxine 13 micrograms. - levothyroxine sodium 13 micrograms. - multivitamin with minerals tablet, one tablet daily. - Glucerna (liquid dietary supplement) 237 ml daily in the morning. On 12/15/22 at 9:16 AM Staff 15 (LPN) was observed to administer levothyroxine 175 micrograms,…

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.