Laurelhurst Post Acute & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 1 of 1 residents (#357) reviewed for misappropriation. This placed residents at risk for lack of medication efficacy and loss of property. Findings include: Resident 357 admitted to the facility in 9/2024 with diagnoses including hip fracture and lung disease. A 9/20/24 physician order instructed staff to administer Oxycodone (a pain reliever) one to two tablets every four hours as needed for pain. A 9/24/24 admission MDS revealed Resident 357 had a BIMS score of 14, which indicated the resident was cognitively intact, and Resident 357 had frequent pain and received PRN pain medications. A review of Resident 357's clinical record revealed the following: -Discharge paperwork dated 10/9/24 indicated Resident 357 took home 56 Oxycodone tablets. -Discharge summary dated [DATE] indicated Resident 357 took home all medications. -Narcotic logbook records dated 10/9/24 and 10/11/24 revealed…

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 report timely to the State Agency an incident of alleged misappropriation of medications for 1 of 1 sampled residents (#357) reviewed for misappropriation. This placed residents at risk for diversion of medications and misappropriation of property. Findings include: The facility's 9/2022 Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy indicated the following: -It is the policy of this facility that all suspected alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to Federal and/or State regulations. -All covered individuals of the facility are mandatory reporters. It is the responsibility of the Administrator and Director of Nursing Services to ensure that these policies and procedures are followed. Resident 357 admitted to the facility in 9/2024 with diagnoses including hip fracture and lung disease. The…

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

Based on interview and record review it was determined the facility failed to provide dignified and respectful care for 1 of 3 residents (# 101) reviewed for respect and dignity. This placed residents at risk of loss of dignity. Findings include: The facility's policy regarding dignity states the following: - Residents shall be cared for in a manner that promotes and enhances her or his sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - Residents were to be treated with dignity and respect at all times. Resident 101 was admitted to the facility in 6/2023 with diagnoses including depression and dementia. A 6/4/23 Care Plan included instructions to provide Resident 101 with brief changes due to incontinence. A 6/30/23 Alleged Abuse report included statements from Resident 101 regarding care and comments from Staff 3 (CNA) which included: -One morning I saw [Staff 3] standing there, yelling at me . why did you say those things about me? You want me to get fired? I didn't say anything to [Staff 3] because I was scared. I didn't know why…

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 had access to petty cash on an ongoing basis for 3 of 3 sampled residents (#s 17, 42 and 242). This placed residents at risk for lack of access to personal funds. Findings include: 1. Resident 17 was admitted to the facility in 2020 with diagnoses including stroke. Resident 17's 9/3/23 Annual MDS indicated she/he had no cognitive impairment. On 11/1/23 at 10:25 AM a sign was observed on the counter of the Business Office which indicated resident trust withdrawal hours were as follows: -Business Office, Monday thru Friday from 9:00 AM - 4:30 PM -Front Desk, Saturday 8:30 AM - 4:00 PM and Sunday 8:30 AM - 2:00 PM On 10/30/23 at 1:47 PM Resident 17 stated her/his daughter helped to manage her/his personal funds and the facility also held money for her/him. Resident 17 stated she/he tried to withdraw money from her/his facility-held funds last night but the teller wasn't there so I couldn't get my money. Resident 17 stated she/he can only access her/his money during business hours. On 11/1/23…

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 maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 10/31/23 through 11/6/23 identified the following issues: -Rooms 117, 375 and 378 had closet doors with veneer coverings that were torn, lifting and peeling. -room [ROOM NUMBER] had a brown water-stained ceiling tile outside the bathroom area and a large hole in the wall behind the resident's bed with exposed drywall and missing paint. -room [ROOM NUMBER] had a large chunk of window ledge that was missing with exposed wood and jagged edges. The countertop laminate was missing on the sink with sharp edges and exposed wood. -Hall 200 had two missing handrail endcaps, one near the elevator and the other near the dining room. -Hall 200 had an approximate 12 inch deep gouge on the lower wall near room…

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 transfer notices with appeal rights were provided in writing to residents and their representatives and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 3 of 3 residents (#s 19, 46 and 193) reviewed for hospitalizations. This placed residents at risk of inappropriate transfers, lack of access to an advocate to inform them of their options and rights and a decreased quality of life. Findings include: 1. Resident 19 was admitted to the facility in 2022 with diagnoses including left leg fracture. A 10/12/23 Progress Note indicated Resident 19 was sent to the hospital. A 10/15/23 Progress Note indicated Resident 19 readmitted to the facility. No evidence was found in Resident 19's health record to indicate transfer notices with appeal rights were provided in writing to her/his and their representatives or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfers to the hospital. On 11/2/23 at 4:28 PM Staff 33 (Social…

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 residents with a written notice of the facility's bed-hold policy at the time of transfer to the hospital for 3 of 3 sampled residents (#s 19, 46 and 193) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: The facility's undated Bed-Hold Agreement for Oregon indicated the following: -When a resident was discharged to the hospital, the resident or their legal representative would be offered the option of holding the bed the resident currently occupied. At the time of the transfer from the facility to the hospital, the discharging nurse would give the resident or their legal representative a copy of this agreement. If possible, the agreement should be reviewed and completed at that time. -If the agreement was not completed by the time the resident was discharged from the hospital, Admissions Coordinator at the facility would contact the resident or their legal representative within 24…

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

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 7, 43, 53 and 54) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of care by competent staff. Findings include: On 10/31/23 a review of the facility staff training records for CNAs employed over one year revealed the following: -Staff 7 (CNA), hire date 9/24/2012; had no annual performance review documentation on file. -Staff 43 (CNA), hire date 4/18/2002; had no annual performance review documentation on file. -Staff 53 (CNA), hire date 7/9/2012; had no annual performance review documentation on file. -Staff 54 (CNA), hire date 9/30/2014; had no annual performance review documentation on file. On 11/2/23 at 11:23 AM Staff 19 (Human Resource Director) confirmed she was unable to provide annual performance review documentation for Staff 7, Staff 43, Staff 53 and Staff 54.

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were posted in a prominent place readily accessible to residents and visitors for 1 of 1 facility. This placed residents at risk for incorrect staffing information. Findings include: Multiple observations from 10/30/23 through 11/3/23 between the hours of 7:30 AM and 9:30 PM revealed the facility had a skilled building with two floors and a separate building with three floors for long-term care residents. The DCSCRs were only observed in the skilled building, on the first floor unit. The postings were accessible to residents and visitors of the first floor unit only. No DCSCRs were observed in the long-term care building. On 10/30/23 at 3:01 PM Staff 1 (Administrator) confirmed the DCSDRs were located in the skilled building on the first floor unit. On 11/3/23/ at 10:11 AM Staff 13 (Staffing Coordinator) confirmed there were no DCSCR postings in the long-term care building and the current posting location in the skilled building would not be…

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

Based on observation and interview it was determined the facility failed to ensure medications and biologicals where secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility's Storage of Medications Policy and Procedure dated 11/2020 stated: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals were locked when not in use. Unlocked medication carts were not left unattended. 1. On 10/30/23 at 10:12 AM the treatment cart on the second floor of the skilled care building was unlocked and unattended by staff. On 10/30/23 at 10:12 AM Staff 50 (LPN) confirmed the cart was left unlocked. 2. On 11/1/23 at 12:38 PM the treatment cart on the second floor of the skilled care building was unlocked and unattended by staff. On 11/1/23 at 12:38 PM Staff 50 (LPN) confirmed the cart was left unlocked. 3. On 10/31/23 at…

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

Based on observation, interview and record review it was determined the facility failed to ensure food was labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen and 3 of 3 dining room/snack refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness and unappetizing meals. Findings include: The facility's 6/2020 Food Preparation and Handling policy states: -Food was to be covered and dated for storage. 1. On 10/30/23 at 9:17 AM the following items were observed in the facility's main kitchen: Walk-in refrigerator: -Three small uncovered bowls of applesauce were undated. -A covered dish of a smooth beige substance was undated. -A sandwich wrapped with cling film labeled, PBJ was undated. It was hard to the touch. -A small covered bowl of cottage cheese was undated. -Five small covered bowls of watermelon cubes labeled, 27. There was nothing on the label to indicate the date the bowls were placed in the refrigerator. -One small covered bowl of sliced strawberries with no label or date. -A chef salad…

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 nurse aides completed 12 hours of annual training for 3 of 5 sampled CNAs (#s 7, 52 and 53) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 11/2/23 at 2:11 PM Staff 19 (Human Resource Director) provided a list of the following CNA training hours: -Staff 7 (CNA): received 6 hours of annual training; -Staff 52 (CNA): received 4.25 hours of annual training and -Staff 53 (CNA): received 0 hours of annual training. On 11/2/23 at 2:11 PM Staff 19 (Human Resource Director) acknowledged the identified CNAs lacked 12 hours of required annual training.

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 (#60) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: The facility's 8/2020 Psychoactive Medication Management Guideline Policy specified to obtain informed consent for psychotropic medication use. Resident 60 was admitted to the facility in 2021 with diagnoses including acute kidney failure and major depressive disorder. Resident 60's 2/23/23 Physician Order indicated the resident was prescribed Abilify (antipsychotic) for major depressive disorder. Resident 60's 2/2023 and 3/2023 MARs revealed the resident received Abilify daily. Review of Resident 60's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of Abilify. On 11/2/23 at 4:44 PM Staff 2 (DNS) reviewed Resident 60's health record, acknowledged there was no documentation to indicate…

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

Based on observation and interview it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 1 of 1 sampled resident (#60) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 60 was admitted to the facility in 2021 with diagnoses including heart failure. On 10/30/23 at 2:40 PM multiple plastic bags were observed tied together in a chain which extended from the cord of Resident 60's overbed light and wrapped around the resident's right assist bar of her/his bed. Resident 60 stated the cord of her/his overbed light was too short and she/he could not independently use the light without the extension the plastic bags provided. On 11/3/23 at 10:10 AM Staff 25 (Maintenance Director) stated he expected staff to report to him when a resident's overbed light cord was too short so he could replace it with a longer one. Staff 25 observed the plastic bags tied to the cord of Resident 60's overbed light and stated he was not aware…

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 narcotic medications were properly secured for 1 of 1 resident (# 342) reviewed for pain medications. This placed residents at risk for loss of property and drug diversion. Findings include: Resident 342 was admitted to the facility in 2023 with diagnoses including heart failure and chronic pain syndrome. Resident 342's 2/2/23 Care Plan indicated the resident used Oxycodone (narcotic pain medication) for chronic pain due to arthritis in both knees. A Nursing Facility Reported Incident dated 3/28/23 indicated 10 pills of Oxycodone used to treat Resident 342 for pain were missing on 3/28/23. A medication reconciliation for Resident 342 was conducted on 3/28/23. Care staff and management were unable to locate the missing medication. On 11/1/23 at 3:07 PM Staff 4 (RN) stated Staff 5 (CMA) reported she left a bubble pack of Oxycodone pills at Resident 342's bedside and 10 pills were missing. Staff 4 stated Resident 342 was assessed and an incident report was started immediately. Staff 4 stated when…

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

Based on interview and record review it was determined the facility failed to accurately assess residents for dialysis and cognition for 2 of 5 sampled residents (#s 6 and 39) reviewed for dialysis and nutrition. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 39 was admitted to the facility in 2020 with diagnoses including end-stage renal disease. Resident 39's 5/3/20 Care Plan revealed the resident required dialysis three times a week. Resident 39's 7/31/23 Annual MDS indicated the resident did not receive dialysis. There was no urinary status/dialysis CAA completed. On 11/3/23 at 12:16 PM Staff 3 (RNCM) reported she was responsible for completing Resident 39's Annual MDS related to dialysis. She confirmed Resident 39 continued to receive dialysis and the 7/31/23 MDS was inaccurate. 2. Resident 6 was admitted to the facility in 2023 with diagnoses including depression. A review of Resident 6's 6/4/23 admission MDS indicated the resident was not assessed for cognition. An 8/4/23 Nursing Progress Note revealed Staff 3…

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 program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#57) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: The facility's 2/2005 Activities Policy revealed the facility was to encourage each resident to maintain normal leisure activity. The facility would provide an activities program that addressed the intellectual, social, spiritual, creative and physical needs, capabilities and interest of each resident. The activity program would promote each resident's self-respect by providing activities that supported self-expression and choice. Resident 57 was admitted to the facility in 2020 with diagnoses including anxiety, major depressive disorder and insomnia. Resident 57's 12/31/22 Annual MDS revealed the resident had no cognitive impairment. Her/his activity preferences indicated it…

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 1. Based on interview and record review it was determined the facility failed to provide treatment for non-pressure skin impairment for 1 of 3 sampled residents (#192) reviewed for pressure ulcers. This placed residents at risk for infection and delayed healing. Findings include: Resident 192 was admitted to the facility in 2023 with diagnoses including neck fracture. Resident 192's 2/2023 TAR revealed no treatment or orders for skin breakdown on the resident's buttocks and thighs. A Progress Note dated [DATE] revealed the resident was sent to the hospital for altered mental status. A Hospital Wound, Ostomy Service Department Progress Note dated [DATE] revealed Resident 192's buttocks were red with excoriation (raw irritated skin) in the gluteal cleft (the groove between the buttocks) and a rash. The resident's right upper rear thigh had moisture associated skin deterioration, a fungal rash and excoriated skin. The resident's buttocks and perineal (area between the genitals and anus) skin were red and a rash 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 ensure residents received restorative services for 1 of 2 sampled residents (#17) reviewed for therapy services. This placed residents at risk for decreased ROM and mobility. Findings include: Resident 17 was admitted to the facility in 2020 with diagnoses including stroke. An 8/9/22 Therapy Referral Form indicated Resident 17's Restorative Nursing Plan included active ROM exercises three times per week. Resident 17's 9/3/23 Annual MDS indicated she/he had no cognitive impairment and required extensive physical assistance from one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. A review of Resident 17's Care Plan revealed her/his Restorative Nursing Plan was revised on 9/14/23 to include the following goals: -gait distance and safety -independence and safety with transfers On 10/30/23 at 2:12 PM Resident 17 was observed to sit in a wheelchair and hold her/his right arm on the arm rest using her/his left hand. Resident 17 stated she/he last had…

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 oxygen was administered as ordered for 1 of 1 sampled resident (#42) reviewed for respiratory care. This placed residents at risk for adverse respiratory outcomes and discomfort. Findings include: The facility's 10/2010 Oxygen Administration Policy indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. -Unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute. Resident 42 was readmitted to the facility in 8/2019 with diagnoses including acute respiratory failure with hypercapnia (too much carbon dioxide in the blood) and hypoxia (low levels of oxygen in body tissues). Resident 42's 8/19/23 Annual MDS revealed the resident had no cognitive impairment, experienced shortness of breath or trouble breathing with exertion and shortness of breath or trouble breathing when lying flat. Resident 42's 10/2023 Physician Orders directed the resident 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 observation, interview and record review it was determined the facility failed to ensure appropriate provisions for dialysis care were implemented and to ensure post-dialysis communication with the dialysis center was received for 1 of 1 sampled residents (#39) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include: The facility's 11/2020 Care of the Dialysis Resident Policy and Procedure revealed the following: -Emergency procedures and other pertinent information was documented on the resident's care plan. -Nursing staff were to send a dialysis communication form to the dialysis center and the dialysis center completed a designated portion of the form each time a resident was scheduled for dialysis. Resident 39 was admitted to the facility in 2020 with diagnoses including end-stage renal disease. a. Resident 39's 8/26/22 Care Plan indicated the resident received dialysis three times per week, the resident had a left upper extremity AV fistula (a connection for dialysis access), the dialysis Emergency Procedure Instructions and an…

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

Based on interview and record review it was determined the facility failed to provide trauma-informed care for 1 of 1 resident (#40) reviewed for abuse. This placed residents at risk for re-traumatization, unidentified triggers and unmet care needs. Findings include: Resident 40 was admitted to the facility in 2019 with diagnoses including depression. Resident 40's 9/27/22 cognitive assessment indicated no cognitive impairment. On 12/6/22 Resident 40 experienced physical abuse from a staff member which resulted in increased stress and triggered Post Traumatic Stress Disorder (PTSD) for the resident. Review of Resident 40's records revealed an assessment for trauma-informed care was not performed consistent with Resident 40's mental health needs. On 11/6/23 at 11:10 AM Staff 33 (Social Service Director) confirmed a trauma assessment was not completed for Resident 40 to identify potential triggers of PTSD.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for increased depression. Findings include: Resident 6 was admitted to the facility in 2023 with diagnoses including depression. An 8/4/23 Consultant Pharmacist's Medication Regimen Review (MRR) revealed Resident 6 received Cymbalta 30 mg daily (antidepressant) and lansoprazole 30 mg twice daily (proton pump inhibitor). It was recommended to increase Cymbalta to 60 mg and consider discontinuation of lansoprazole 30 mg if needed. On 9/5/23 the pharmacist made a repeat recommendation to increase Cymbalta to 60 mg and consider discontinuation of lansoprazole 30 mg if needed. A review of Resident 6's health record revealed no documentation to indicate the 8/4/23 or 9/5/23 pharmacy recommendations were acted upon. On 11/6/23 at 1:28 PM Staff 2 (DNS) confirmed she was unable to provide documentation in response to pharmacy recommendations dated 8/4/23 or 9/5/23.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from medication error rates of five percent or greater for 2 of 7 sampled residents (#s 494 and 495) reviewed for medication administration. The facility's medication administration error rate was 6.7 percent. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 494 was admitted to the facility in 2023 with diagnoses including arthritis. On 11/1/23 at 12:31 PM Staff 38 (CMA) administered Tylenol 650 mg oral tablets to Resident 494. Resident 494's 11/2023 MAR revealed the resident had a physician order for Tylenol 650 mg rectal suppository PRN. The resident did not have an order for Tylenol 650 mg oral tablets PRN. On 11/1/23 at 12:31 PM Staff 38 verified Resident 494's PRN Tylenol order was for rectal suppository not oral tablets. 2. Resident 495 was admitted to the facility in 2023 with diagnoses including chronic pain. On 11/3/23 at 9:27 AM Staff 39 (CMA) applied two lidocaine 5% patches to Resident 8's back. 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 and interview it was determined the facility failed to ensure waste was properly contained in dumpsters and garbage storage areas were maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for potential exposure to pathogens related to the harborage and feeding of pests. Findings include: On 11/2/23 at 9:06 AM the following was observed in and around the garbage area used by kitchen and care staff: -The garbage area contained three large metal dumpsters. -One dumpster was uncovered and contained bagged and unbagged food debris and food packaging, bagged and unbagged care items including used briefs, resident care gloves, procedure masks, N-95 masks and face shields. -Food debris was scattered on the ground around and under the dumpsters. -Food packaging was scattered on the ground around the dumpsters. -Used resident care gloves and procedure masks were on the ground near the dumpsters. -A squirrel was observed eating a piece of food near the dumpsters. Outside of the garbage area, a large…

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 disinfection practices to prevent COVID-19 or other infections for 2 of 4 halls and 1 of 1 laundry room. This placed residents at risk for infections. Findings include: The EPA (Environmental Protection Agency) approved list of COVID-19 disinfectants revealed Lonza Disinfectant Wipes Plus 2 was effective against COVID-19 with a wet contact time of four minutes and Ecolab Peroxide Multi Surface Cleaner and Disinfectant was effective against COVID-19 with a wet contact time of 30 seconds. On 10/20/22 at 9:58 AM Staff 21 (Housekeeper) was asked to demonstrated the use of Ecolab Peroxide Multi Surface Cleaner and Disinfectant on surfaces. Staff 21 sprayed the peroxide cleaning product on the front of the washing machine and immediately dried the surface with a towel. Staff 21 also verbally described the process she used to clean and sanitize dirty linen bins and surfaces with the peroxide cleaning product with Staff 23 (Housekeeping Manager) present and the cleaning process did not include…

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

Based on observation, interview and record review it was determined the facility failed to thoroughly assess residents after a fall for 1 of 2 sampled residents (#27) reviewed for accidents. This placed resident at risk for falls. Findings include: Resident 27 admitted to the facility in 8/10/2022 with diagnoses including lung and brain cancer. A review of the 8/22 admission MDS revealed Resident 27 had a BIM score of 14 which indicated she/he was cognitively intact. The MDS also indicated Resident 27 reported no pain. An Incident Report from the 10/9/22 fall was provided to the surveyor. A 10/13/22 Incident Report revealed the investigation did not address Resident 27's condition after the fall. Resident 27 refused scheduled Morphine from 10/1/22 - 10/3/22. Scheduled Morphine was discontinued on 10/3/22. No pain medications were administered from 10/1/22 - 10/8/22. From 10/9/22 through 10/11/22 and 10/13/22 through 10/16/22 Resident 27 received PRN pain medication daily for pain rated 3 to 10 out of 10 on the pain scale. On 10/17/22 at 12:07 PM and on 10/19/22 at 9:47 AM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review in was determined the facility failed to provide ordered treatment to prevent pressure ulcers from developing and to promote healing of pressure ulcers for 2 of 3 sampled residents (#s 11, 38) reviewed for pressure ulcers. This placed residents at increased risk for worsening skin condition. Findings include: 1. Resident 11 admitted to the facility in 2020 with diagnoses including dementia and diabetes. A 10/8/22 physician order revealed Resident 11's heels were to be floated. On 10/17/22 at 12:22 PM Resident 11 was observed lying in bed without her/his heels floated. A sign above resident's head indicated to float heels and the heels. On 10/18/22 at 9:29 AM Resident 11 was observed lying in bed without her/his heels floated. On 10/19/22 at 11:38 AM Resident 11 was lying in bed without her/his heels floated. At 11:39 AM Staff 26 (LPN) confirmed Resident 11's heels were not floated. Staff 26 stated Resident 11's heels needed to be floated because they were boggy…

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

Based on observation, interview and record review it was determined the facility failed to ensure resident wheelchairs were in safe working order for 1 of 2 sampled residents (#60) reviewed for accidents. This placed residents at risk for injuries. Findings include: Resident 60 was admitted to the facility in 12/2021 with diagnoses including diabetes and surgical amputation. The 9/20/22 Annual MDS indicated Resident 60 had a BIMS score of 15 which indicated she/he was cognitively intact. A Care Plan dated 10/6/22 indicated Resident 60 used an electric wheelchair for mobility. Observations from 10/18/22 through 10/20/22 on day and evening shifts revealed Resident 60's wheelchair did not have an arm rest on the left side of her/his wheelchair and the arm rest on the right side had no cushion; just a metal frame. The frame was wrapped in plastic tape and had zip ties to keep the metal pieces together and the metal pieces had sharp edges. The control stick was a metal lever with nothing covering it for protection from injuries. Resident 60 slept in her/his wheelchair but could not lay…

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 obtain physician orders for oxygen usage for 1 of 1 sampled resident (#60) reviewed for respiratory care. Findings include: Resident 60 was admitted to the facility in 12/2021 with diagnoses including diabetes and surgical amputation. The Annual MDS dated [DATE] indicated the resident utilized oxygen. On 10/18/22 at 10:24 AM Resident 60 was observed wearing oxygen via nasal cannula (device used to deliver oxygen) connected to an oxygen concentrator (filters and generates medical grade oxygen). Resident 60 stated she/he always wore oxygen to help with shortness of breath. On 10/20/22 at 3:58 PM Staff 5 (LPN) acknowledged Resident 60 did not have an order for oxygen and should not have it on without an order.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review in was determined the facility failed to treat pain for 1 of 2 sampled residents (#70) reviewed for pain. This placed residents at increased risk for unmanaged pain. Findings include: Resident 70 was admitted to the facility in 6/2021 with diagnoses including dementia, stroke, and hemiparesis (inability to move) of left side of body. The 10/19/22 Skin and Wound Evaluations revealed Resident 70 had three deep pressure injuries (skin is non-blanchable deep red, maroon or purple), three unstageable pressure ulcers due to eschar/slough (cannot be confirmed because it is covered by dead tissue), one Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone) and two unstageable [NAME] Terminal ulcers. A 10/5/22 physician order indicated to premedicate Resident 70 every day shift with Morphine prior to all wound care due to pain from wound care. A review of the 10/2022 MAR and Narcotic Sign Out Log…

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 medication error rate was less than 5%. There were 26 medication administration opportunities with eight errors resulting in an error rate of 30.77%. This placed residents at risk for adverse medication side effects. Findings include: Resident 52 was admitted to the facility in 9/2022 with diagnoses including stroke, dysphagia (difficulty swallowing) and feeding tube placement. The facility's Administering Medication through an Enteral Tube Policy and Procedure dated 11/2018 indicated staff were to crush medications, administer each separately, dilute medications and flush the feeding tube between medications with room temperature or warm purified water. Physician orders dated 9/9/22 indicated: -If administering multiple medications per scheduled dose provide five to 10 mls of warm water between medications. An observation of Staff 7 (LPN) on 10/20/22 at 8:50 AM revealed the following medications administered incorrectly: -Clopidogrel Bisulfate (blood thinner) Oral Tablet 75 mg…

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.