Portland Health And Rehabilitation

Based on interviews and record review it was determined the facility failed to report allegations of abuse within the mandated timeframe for 3 of 4 sampled residents (#s 6, 65 and 66) for 1 of 5 FRI reports reviewed for abuse. This placed residents at risk for further abuse. Findings include:The facility's revised 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation revealed it was expected for the facility to immediately report all suspected and/or allegations of abuse in accordance with state and federal law. The policy defined immediately to mean as soon as possible but no later than two-hours after an allegation of abuse was made.On 9/26/25 at 11:09 AM, the state agency (SA) received a FRI for a 9/25/25 at 9:00 AM alleged abuse with Resident 6, Resident 65 and Resident 66.On 2/26/26 at12:28 PM Staff 2 (DNS) stated on 9/26/25 he completed the FRI and sent it to the SA and he was not aware of any other attempts to contact the SA within the required two-hour timeframe.On 2/26/26 at 12:41…

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

Based on interview and record review it was determined the facility failed to provide a bed hold policy for 1 of 1 sampled resident (#62) reviewed for hospitalization. This placed residents at risk for not being informed of their right to return to the facility. Findings include: Resident 62 was admitted to the facility in 1/2026 with a diagnosis of seizures. Resident 62's 1/26/26 Progress Note revealed she/he sat at the nurse's station, was observed to have tremors, and was unresponsive. Resident 62 was transported to the hospital for evaluation and treatment. Resident 62's clinical record did not have documentation to indicate a bed hold policy was provided to Resident 62 or her/his representative. On 2/27/26 at 11:11 AM Staff 3 (RNCM) stated Resident 62 was not stable when she/he was transported to the hospital. Staff 3 stated she did not notify Resident 62's representative of the bed hold policy. On 2/27/2026 at 11:53 AM Staff 1 (Administrator) stated the facility residents were not required to pay to hold their bed. All residents were allowed to return from a hospitalization,…

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 complete a comprehensive assessment for 2 of 7 sampled residents (#s 2 and 48) reviewed for pressure ulcer and unnecessary medications. This placed residents at risk for adverse side effects and worsening wounds. Findings include: 1. Resident 2 was admitted to the facility in 11/2025 with a diagnosis of dementia with behavioral disturbances. Resident 2's 11/2025 MAR revealed she/he was administered olanzapine (antipsychotic medication) for delusions, risperidone (antipsychotic medication) for delusions, and sertraline (antidepressant) for mood disorder. Resident 2's 11/18/25 admission MDS and associated CAA indicated she/he used psychotropic medications but there was no analysis of findings including her/his medical condition, history, and rationale for the continued use of psychotropic medications. On 2/27/26 at 8:59 AM Staff 16 (MDS Coordinator) reviewed the 11/18/26 admission MDS and verified she did not address Resident 2's mental health diagnosis, history or psychotropic medications, 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.

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 dependent residents received required assistance with ADL care for 2 of 2 sampled residents (#s 12 and 32) reviewed for ADL care. This placed residents at risk for lack of personal hygiene. Findings include:1. Resident 12 was admitted to the facility in 1/2021 with diagnoses of stroke and dementia.Resident 12's Annual MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.A review of Resident 12's care plan dated 1/19/26 revealed no interventions addressing facial hair removal or grooming preferences. Resident 12 was observed on 2/24/26 at 9:14 AM and on 2/25/26 at 8:55 AM with a significant amount of visible chin hair. On 2/24/26 at 9:16 AM, Resident 12 stated she/he did not want to have facial hair and would like staff to take care of her/his unwanted hair. On 2/25/26 at 10:13 AM, Staff 14 (CNA) observed Resident 12 's facial hair and stated her/his facial hair is really…

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 resident centered activities for 1 of 1 sampled resident (#7) reviewed for activities. This placed residents at risk for diminished psychosocial well-being and quality of life. Findings include: Resident 7 was admitted to the facility in 2019 with diagnoses including anxiety and dysphagia following cerebral infarction (difficulty swallowing following a stroke). The 9/25/25 Annual MDS revealed Resident 7 was cognitively impaired, speech was unclear and rarely understood and she/he was dependent on staff for all ADL and mobility needs. Resident 7 enjoyed watching television, to sit in the lobby, listen to music and individualized visits.Resident 7's 10/25/25 Activity Quarterly Progress Note Review revealed she/he enjoyed listening to music, to go outside for fresh air when the weather was good, to watch birds and staff fill the bird feeder outside her/his room window, make phone calls to family, sensory visits and one to one individualized visits. On 2/23/26 at 1:31 PM Resident 7 was observed to lie…

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 pressure ulcer care was provided to promote healing and physician orders were followed for 2 of 2 sampled residents (#s 11 and 48) reviewed for pressure ulcers. This placed residents at risk for delayed healing. Findings include: 1. Resident 11 was admitted to the facility in 10/2025 with a diagnosis of osteomyelitis (bone infection) and pressure ulcer. Resident 11's 2/3/26 Order Details revealed her/his ulcer was to be cleaned with wound cleanser, a full package, one gram of collagen powder was to be applied to the wound bed, a calcium alginate sheet was to be lighted packed, and then covered with a border dressing. On 2/25/26 at 10:56 AM Staff 4 (RNCM) was observed to perform pressure ulcer care to Resident 11's sacral pressure ulcer. The care included:-Wound cleanser was applied to clean gauze.-The ulcer periphery and wound bed was cleaned.-The ulcer was dried with clean gauze.-After gloves were removed, hand hygiene was performed, and new gloves were applied. -A collagen sheet 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 perform pre and post dialysis assessments on 1 of 1 resident (#3) reviewed for dialysis. This placed residents at risk for inadequate monitoring. Findings include:The facility's Dialysis Policy from 3/2025 states the facility provides ongoing monitoring of the dialysis access site and utilizes a Dialysis Flow Sheet to document resident specific dialysis care including monitoring of the catheter and fistula.Resident 3 was admitted to the facility in 1/2026 with diagnoses including chronic kidney disease.Physician orders from 1/29/26 included Resident 3 had a fistula (a connection port used to access blood vessels during dialysis) in her/his chest and she/he was to receive dialysis services three times a week.A 2/9/26 admission MDS cognitive assessment determined Resident to have no cognitive limitations.Review of records from 1/2026 and 2/2026 revealed Resident 3 received dialysis treatment on 1/28/26, 2/9/26, and 2/18/26. No record was found of pre or post dialysis assessments being completed for Resident…

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

Based on interview and record review it was determined the facility failed to ensure a resident or representative understood an arbitration agreement before signing for 2 of 3 sampled residents (#s 3 and 21). This placed residents at risk for inability to resolve concerns in court. Findings include: 1. Resident 3 was admitted to the facility in 1/2026 with a diagnosis of kidney disease. Resident 3's 1/29/26 State Arbitration Agreement form revealed on 1/29/26 she/he signed to accept the agreement. Resident 3's 2/3/26 admission MDS revealed she/he was cognitively intact. On 2/25/226 at 10:33 AM Resident 3 stated she/he was really sick when she/he admitted to the facility and did not recall all events. Resident 3 stated she/he did not know what an arbitration agreement entailed. Resident 3 stated if she/he knew the agreement meant she/he waived her/his right to file a lawsuit, she/he would not have signed the agreement. On 2/25/26 at 10:00 AM Staff 5 (Business Office Manager) stated she reviewed an arbitration agreement with a resident if she/he was cognitively intact and as soon…

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 that the facility failed to provide care in accordance with professional standards and failed to ensure care needs were met for 3 of 3 sampled residents (#s 1, 3 and 5) reviewed for call lights. This placed residents at risk for unmet care needs. Findings include: 1. Resident 5 was admitted to the facility in 2/2024 for diagnoses including congestive heart failure and surgical aftercare.Resident 5's care plan dated 2/26/24 indicated she/he needed moderate assistance with ADLs such as dressing, bathing, toileting hygiene and transfers.On 3/6/24 the State Survey Agency (SSA) received a complaint which stated Resident 5 had waited over 45 minutes the morning of 3/6/24 for help with personal care.On 7/9/25 at 11:21 AM Witness 1 (Complainant) stated when Resident 5 was at the facility, she/he would activate the call light and CNA staff would come in, turn off the call light and ask what she/he needed. Resident 5 made her/his specific request and…

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

Based on interview and record review, it was determined that the facility failed to implement care plan interventions for aspiration precautions for 1 of 3 sampled residents (#6) reviewed for respiratory services and aspiration precautions. This placed residents at risk for a lack of nutritional assistance and aspiration. Findings include: Resident 6 was admitted to the facility in 7/2025, with diagnoses including chronic respiratory failure and congestive heart failure.Resident 6's care plan dated 7/4/25 revealed she/he was on aspiration precautions and required one-to-one supervision for all meals.On 7/10/25 at 1:10 PM, Resident 6 was overheard calling out for staff in her/his room. Upon entering the resident's room, a meal tray with partially eaten food was observed on the resident's bedside table. No staff were observed present in the room with Resident 6. After the state surveyor exited the resident's room, Staff 6 (Speech Therapist) was observed to enter the resident's room and assist the resident to her/his care conference.On 7/10/25 at 1:40 PM, Staff 6 stated she was…

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

Based on interview and record review it was determined the facility failed to ensure residents were provided with the opportunity to organize and participate in Resident Council for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include: The facility's Resident Council policy dated 5/2002 indicated the following: -Resident Council was intended to promote resident interest and involvement in the Center as well as, a forum for residents to voice concerns and to suggest changes. -Resident Council was to meet monthly or at the frequency determined by the Council members. -Resident Council was open to residents of the Center. On 10/23/24 the facility had a census of 55 residents. A review of the facility's Resident Council Minutes revealed the last Resident Council meeting was on 3/20/24. On 10/25/24 at 10:53 AM Staff 14 (Activities Director) stated she was hired in 5/2024. She stated Resident Council meetings did not occur because residents…

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

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: The facility's Key Personnel list provided on 10/23/24, indicated Staff 14 was the facility's Activities Director. On 10/28/24 at 9:31 AM Staff 14 stated she was hired in 5/2024 and had minimal experience and no training in developing or implementing an activities program with the adult population residing in a nursing facility. Staff 14 stated she did not receive training when she was hired regarding developing an activities program or how to structure a daily program. Staff 14 stated she pretty much developed the activities program by using resources on the Internet. Staff 14 reported she was given no training or direction on how to work with residents with dementia or those who were unable to speak, and the previous administrator was supposed to enroll her in an activity training course but that…

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

Based on interview and record review it was determined the facility failed to complete nurse aide performance reviews every twelve months for 5 of 5 sampled CNAs (#s 5, 6, 7, 8 and 9) reviewed for staffing. This placed residents at risk for a lack of care by competent staff. Findings include: Review of personnel records found the following employees had not received their annual performance evaluations: -Staff 5 (CNA), hire date 8/31/23: no annual performance review was completed. -Staff 6 (CNA), hire date 5/1/23: no annual performance review was completed. -Staff 7 (CNA), hire date 8/9/22: no annual performance review was completed. -Staff 8 (CNA), hire date 6/14/19: no annual performance review was completed. -Staff 9 (CNA), hire date 6/20/17: no annual performance review was completed. On 10/25/24 at 3:52 PM Staff 11 (Business Office Manager) confirmed annual performance reviews for Staff 5, Staff 6, Staff 7, Staff 8 and Staff 9 were not completed. On 10/28/24 at 12:08 PM Staff 1 (Administrator) stated his expectation was annual CNA performance reviews would be completed every 12…

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 properly store laundry to prevent cross contamination for 1 of 1 facility reviewed for infection control. This placed residents at risk for cross contamination and the potential spread of infection. Findings include: On 10/24/24 at 2:22 PM during a tour of the facility's laundry room, a metal rack containing towels, fabric room divider curtains and sheets was observed against the wall opposite from the washing machines. The rack was draped with a cloth sheet that was held in place by metal binder clips. The top of the rack was completely uncovered. Staff 26 (Housekeeping / Laundry) stated the items on the rack were extra, new and clean items. When asked if this section of the laundry room was considered soiled or clean, Staff 26 reported the racks were on the soiled side of the room. She stated the rack had been in the soiled section for as long as she could remember. On 10/25/24 at 8:09 AM the rack with the same items was observed to still be stored on the soiled side of the laundry room. Staff 26 stated…

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

Based on interview, and record review it was determined the facility failed to ensure a resident was treated in a dignified manner and free from a derogatory slur for 1 of 4 sampled residents (#110) reviewed for dignity. This placed residents at risk for being treated in a disrespectful manner. Findings include: Resident 110 was admitted to the facility in 6/2023 with diagnoses including after care for surgical amputation and was assessed as cognitively intact. Review of the 6/15/23 FRI and facility investigation revealed on 6/14/23 Staff 20 (LPN) called Staff 18 (Former DNS) at 6:00 PM to report during the dinner service, Resident 110 overheard Staff 19 (Former Hospitality Aide) use the homophobic slur of faggot in conversation and Staff 21 (Former CNA) observed the comments. Staff 20 reported he interviewed Resident 110 who reported feeling afraid to be at the facility. Resident 110 did not want to be a whistle blower as she/he had experienced similar incidents in the past and she/he was later retaliated against. Staff 18 also interviewed Resident 110 who stated she/he overheard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents' bed mattresses were in good repair for 1 of 1 sampled resident (#5) reviewed for restraints and a comfortable environment free from offensive odors for 1 of 1 facility observed for environment. This placed residents at risk for an uncomfortable environment. Findings include: 1. Resident 5 was admitted to the facility in 8/2010 with diagnoses including abnormal posture, cognitive deficits and depression. Observations from 10/23/24 through 10/25/24 between the hours of 7:39 AM and 3:30 PM revealed Resident 5's bed mattress had a large divot in the center, covering approximately 3/4's of the entire mattress and was several inches deep. On 10/25/24 at 9:49 AM Staff 5 (CNA) reported Resident 5's bed mattress had a large divot in the center for at least the last year. On 10/25/24 at 10:23 AM Staff 23 (CNA) stated Resident 5's bed mattress was played out, old and needed to be replaced. Staff 23 stated Resident 5…

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

Based on observation, interview and record review it was determined the facility failed to ensure accurate assessments for 3 of 7 sampled residents (#s 14, 22 and 45) reviewed for communication, dental and ADLs. This placed residents at risk for unmet care needs. Findings include: 1. Resident 14 was admitted to the facility in 6/2023 with a diagnosis of chronic respiratory failure with hypoxia (a respiratory disorder that results in less oxygen entering the blood stream and less carbon dioxide getting out). A review of Resident 14's 7/22/24 Significant Change MDS revealed she/he was cognitively intact and had adequate hearing. On 10/23/24 at 10:30 AM Resident 14 was observed interacting with her/his roommate and Staff 27 (LPN) about sharing her/his extra oatmeal. Resident 14 was not able to hear her/his roommate or Staff 27 when they were speaking with normal to elevated vocal intensity. Resident 14 reported, I have to tell them to talk real loud to me. A review of Resident 14's Care Plan revealed no there were no interventions in place to address Resident 14's impaired hearing…

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 complete a PASARR (Preadmission Screening and Resident Review) Level II evaluation for residents with a positive Level I PASARR for 1 of 1 resident (#22) reviewed for PASARR. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: Resident 22 was admitted to the facility in 11/2022 with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), depression and panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness or abdominal distress). Resident 22's 11/9/22 PASARR Level I identified the resident to have indicators of a serious mental illness. Resident 22's 2/13/23 Quarterly Social Services Evaluation indicated the…

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

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 2 of 3 sampled dependent residents (#s 40 and 48 ) 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 5/2002 Specialized Activities Policy indicated the activity staff offered specialized activities to meet the specific resident needs. 1. Resident 40 was readmitted to the facility in 5/2024 with diagnoses of diabetes, pneumonia and metabolic encephalopathy (brain dysfunction caused by an underlying illness or organs not working well). Resident 40's 5/2024 (revised on 9/17/24 and 10/22/24) Care Plan revealed the following: -Resident 40 preferred to communicate in Korean. The facility was to provide a translator as necessary to communicate with the resident. -Invite the resident to scheduled activities. -Encourage the resident to go to activities as tolerated. -Encourage the resident to participate in activities that promote…

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

Based on observation, interview and record review it was determined the facility failed to provide appropriate and timely pain management for 1 of 3 sampled residents (#22) reviewed for pain. This placed residents at risk for pain. Findings include: Resident 22 was admitted to the facility in 11/2022 with diagnoses including right upper quadrant pain, low back pain and arthritis. Resident 22's 10/10/24 Annual MDS Assessment and CAAs revealed the resident was able to make her/himself understood and understand others without difficulty, had left hand contractures and received scheduled and PRN pain medication. Resident 22's 10/2024 Physician Orders directed the resident to receive daily wound care to her/his left hand and to administer PRN oxycodone (a narcotic drug used to treat moderate to severe pain) 30 minutes to an hour prior to treatment was provided. The orders also indicated the resident's fingers on her/his left hand were very contracted and painful to move. On 10/23/24 at 11:16 AM Resident 22 was observed in her/his room in bed. The resident's fingers on her/his left hand…

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 necessary services for the behavioral health care needs of residents and review and revise behavioral health care plan interventions to ensure interventions were appropriate and effective for 1 of 1 resident (#22) reviewed for PASARR (Preadmission Screening and Resident Review). This placed residents at risk for unmet behavioral health care needs and for not attaining their highest practicable well-being. Findings include: Resident 22 was admitted to the facility in 11/2022 with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), depression and panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness or abdominal distress). Resident 22's 2/13/23 Quarterly Social Services Evaluation indicated the resident experienced difficulty coping with…

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

Based on interview and record review it was determined the facility failed to ensure the correct POLST was readily available and accessible to enable staff to provide the appropriate interventions for 1 of 5 residents (#42) reviewed for choices. This placed residents at risk for not receiving care per their current wishes. Findings include: Resident 42 admitted to facility in 10/2023 with a diagnosis of chronic obstructive pulmonary disease. Resident 42's 10/5/23 admission MDS indicated she/he was cognitively intact. A public complaint received on 6/4/24 alleged Resident 42 wanted to be full code (all life saaving measures provided). The 6/4/24 public complaint alleged the resident's POLST was filled out incorrectly. Resident 42's clinical record revealed two signed POLST documents. The 10/4/23 POLST for Resident 42 indicated she/he wished to be full code. The 10/27/23 POLST for Resident 42 indicated she/he wished to be Do not resuscitate (DNR). On 10/28/24 Staff 4 (LPN care manager) interviewed resident 42, at which time Resident 42 indicated she/he was to be full code. Staff 4…

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

Based on observation, interview and record review it was determined the facility failed to establish an effective communication process between the facility and hospice provider in order to ensure the needs of the resident were addressed and met 24 hours per day for 1 of 1 resident (#48) reviewed for hospice. This placed residents at risk for unmet needs. The facility's 9/2017 Hospice Policy revealed the following: -The hospice and facility communicate, establish and agree upon a coordinated Plan of Care (POC) reflecting the hospice philosophy and based on an evaluation of the individual needs of the resident. -Hospice establishes the POC related to the terminal illness, related conditions, directives for management of pain and other uncomfortable symptoms. -The facility maintains a POC that is consistent with the hospice POC. The plan is reviewed and updated as needed but no less often then quarterly. -The hospice provider is responsible for notifying the facility of changes in provision of care. Resident 48 was admitted to the facility in 5/2024 with diagnoses including traumatic…

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

Based on interview and record review it was determined the facility failed to ensure a safe and orderly discharge for 1 of 3 sampled residents (#103) reviewed for discharge. This placed residents at risk for an unsafe discharge related to medication needs. Findings include: Resident 103 was admitted to the facility on 1/2024 with diagnoses including diabetes and cellulitis (a bacterial skin infection) of the lower leg. Resident 103's medication orders included the following medications: -Insulin Glargine-inject 19 units subcutaneously two times a day related to Type 2 diabetes mellitus. -Metformin oral tablet 1000 mg-Give one tablet two times a day for diabetes. -Oxycodone tablet 5 mg-Give 5 mg by mouth every 6 hours as needed for pain. On 1/31/24, a concern was received which alleged Resident 103 was discharged from the facility with no medications and the resident was an insulin-dependent diabetic. A review of the resident's Discharge Transition Plan dated 1/26/24 revealed none of Resident 103's medications were listed on the discharge form. Resident 103 discharged from 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 an RN was available for at least eight consecutive hours per day seven days per week for 4 of 68 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 12/1/23 through 2/6/24 revealed on 12/10/23, 1/2/24, 1/5/24 and 1/11/24, RN coverage was not provided for at least eight consecutive hours per day. On 2/9/24 at 9:55 AM Staff 19 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days. On 2/9/24 at 12:01 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of this investigation. Staff 2 stated the facility might have RN coverage on the dates identified and the facility would provide additional information by 2/12/24 at 5:00 PM if additional information was found. No additional information was received.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include: On 2/7/24 the facility had a census of 56 residents. On 2/8/24 Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 14 -Required two-person assistance with transferring: 11 -Had behavioral healthcare needs: 20 -Were determined to be at a high fall risk: 15 Observations from 2/7/24 through 2/8/24 from the hours of 8:00 AM to 3:30 PM revealed the following concerns: -2/7/24 at 9:41 AM the call light in room [ROOM NUMBER] was activated for 22 minutes and the call light in room [ROOM NUMBER] was activated for 17 minutes; -2/7/24 at 9:44 AM the resident in room [ROOM NUMBER] was yelling loudly and the roommate was yelling back, shut-up; -2/7/24 at 10:04 AM the call light…

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

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were complete and accurately reflected actual staff working for 25 of 68 days reviewed for sufficient staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 12/1/23 through 2/6/24 DCSDRs indicated the following days when the daily postings were inaccurate or incomplete: December 2023: -12/3/23; -12/4/23; -12/5/23; -12/7/23; -12/22/23; -12/23/23. January 2024: -1/1/24; -1/3/24; -1/4/24; -1/5/24; -1/6/24; -1/7/24; -1/11/24; -1/15/24; -1/16/24; -1/17/24; -1/18/24; -1/19/24; -1/20/24; -1/21/24; -1/25/24; -1/28/24. February 2024: -2/1/24; -2/2/24; -2/3/24. On 2/9/24 at 9:55 AM Staff 19 (Staffing Coordinator) confirmed the facility's failure to accurately complete required information on the DCSDRs.

Based on observation, interview and record review it was determined the facility failed to ensure a well maintained and homelike resident rooms for 2 of 3 halls reviewed for environment. This placed residents at risk for a non-homelike environment. Findings include: 1. Resident 11 was admitted to the facility in 9/2020 with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs to lows). On 7/11/23 at 12:53 PM a large patch of grey scratches measuring approximately one foot by one foot was observed on the wall next to the left side of Resident 11's bed. On 7/17/23 at 9:45 AM Staff 8 (Maintenance Director) stated he completed a walkthrough and necessary maintenance to each resident room on a quarterly basis as part of the facility's preventative maintenance program; however, he stated he was not painting resident rooms at this point on a quarterly basis and it had been a few years since they painted all of the rooms. Staff 8 also stated staff were responsible for adding items and issues in need of maintenance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to ensure resident shared equipment was appropriately disinfected for 3 of 3 halls reviewed for infection control. This placed residents at risk for spread of infection. Findings include: The Centers for Disease Control and Prevention website, section titled Transmission-Based Precautions, specified Contact Precautions were used for patients with known or suspected infections that represent an increased risk for contact transmission. Use disposable or dedicated patient care equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. The facility's 5/2015 Cleaning and Disinfecting Resident Care Items and Equipment Policy & Procedure specified reusable resident care equipment was cleaned and disinfected between residents. On 7/12/23 at 11:34 AM room [ROOM NUMBER] was observed with Enhanced Barrier Precautions (EBP: an infection control…

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 residents (#29) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 29 was admitted to the facility in 6/2020 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 29's 6/8/23 Quarterly MDS revealed the resident experienced short and long term memory loss and was severely impaired for decision-making. Resident 29's 7/2023 Physician Orders revealed the resident took her/his medications crushed with applesauce. Resident 29's clinical record revealed no physician order and no medication self-administration assessment which indicated the resident was able to safely store and self-administer medications. On 7/11/23 at 11:04 AM a small plastic medication cup was observed on Resident 29's bedside table. The cup contained a plastic spoon and what appeared to be applesauce and chunks of white…

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

Based on observation, interview and record review the facility failed to accurately code the MDS for 3 of 4 sampled residents (#s 17, 18 and 29) reviewed for positioning and dental. This placed residents at risk for unmet needs. Findings include: 1. Resident 18 was admitted to the facility in 2/2016 with diagnoses including hemiplegia (paralysis to one side of the body) which followed a cerebral infraction (stroke) which affected her/his left side. Resident 18's current physician orders directed staff it was okay for her/him to wear a sling every two hours a day on her/his left hand. The resident was to wear a hand splint daily. Resident 18's 5/13/23 Quarterly MDS, completed by Staff 2 (MDS Coordinator) assessed her/him without the use of a splint or brace. On 7/12/23 at 11:29 AM Resident 18 was observed to wear a brace/splint on her/his left hand. On 7/13/23 at 10:59 AM Staff 17 (CNA) stated Resident 18 usually wore her/his brace/splint several hours a day. On 7/17/23 at 10:18 AM Staff 2 (DNS) acknowledged Resident 18's 5/13/23 Quarterly MDS was miscoded for the use of a splint or…

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

Based on observation, interview and record review it was determined the facility failed to develop and implement care plans for 1 of 1 sampled resident (#35) reviewed for communication. This placed residents at risk for unmet needs. Findings include: Resident 35 was admitted to the facility in 5/2023 with diagnoses including diabetes. The 7/2023 care plan indicated Resident 35 experienced an altered communication need she/he only as spoke Korean. The care plan interventions were the following: -Resident preferred to communicate in Korean. -Monitor and document frustration level. -Wait 30 seconds before providing the resident with a word. -Provide a translator as necessary to communicate. Translator is: (blank). -Refer to speech therapy for evaluation and treatment as ordered. The 7/2023 care plan indicated Resident 35 experienced impaired cognitive functioning and directed staff to provide the following interventions: -Ask yes/no questions to determine the resident's needs. -Communicate with the resident/family/caregivers about the resident's capabilities and needs. -Use interpreter…

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

Based on interview and record review the facility failed to revise the care plan for 1 of 4 sampled residents (#9) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 9 was admitted to the facility in 9/2022 with diagnoses including depression. Record review revealed Resident 9 weighed 223.8 pounds on 2/14/23. On 7/11/23 she/he weighed 199.8 pounds which was a 10.72% weight loss. The 3/8/23 Nutrition Note revealed a Registered Dietitian referral was completed. The report indicated Resident 9 was referred due to weight loss and a significant change. The weight loss was related to a decreased food intake. Resident 9's 6/7/23 Quarterly MDS indicated a BIMS score of 2 (severe impairment) and no weight loss or weight gain over the past quarter. A 7/13/23 Nutrition Hydration Skin Committee Review Form indicated Resident 9 was reviewed for weight loss. During an interview on 7/12/23 at 2:55 PM Resident 9 was oriented to self, person, place and time. Resident 9 recalled she/he lost and gained weight recently and was unable to describe the reason…

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 Staff 12 (LPN) adhered to professional nursing standards related to provision of medications for 1 of 1 sampled resident (#150) during a medication administration observations. This placed residents at risk for not receiving ordered medications. Findings include: OAR [PHONE NUMBER] Scope of Practice Standards for Licensed Practical Nurses specified the board recognizes that the scope of practice for the licensed practical nurse encompasses a variety of roles, including but not limited to: Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall implement the plan of care by: - Implementing treatments and therapy, appropriate to the context 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.

2. Resident 29 was admitted to the facility in 6/2020 with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following a stroke. Resident 29's 9/22/22 ADL Self-Care Performance Deficit Care Plan revealed the following: - Nail care per licensed nurse. The resident was diabetic. - Report to licensed nurse if the resident was in need of nail care. Resident 29's 6/8/23 Quarterly MDS revealed the resident experienced short and long term memory loss, was severely impaired for decision-making and required extensive assistance from one person with dressing, personal hygiene and bed mobility. Resident 29's 7/2023 Physician Orders indicated diabetic nail care was to be performed by a licensed nurse weekly. The licensed nurse was instructed to document if the nail care was completed, not needed or refused. A review of Resident 29's 6/2023 and 7/2023 TARs related to nail care revealed the following: - 6/8/23: Resident refused. - 6/15/23: 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 develop and implement an activity care plan and failed to include residents in group and individual activities for 2 of 4 sampled residents (#s 26 and 35) reviewed for activities. This placed residents at risk for isolation and lack of social interaction and engagement. Findings include: 1. Resident 26 was admitted to the facility in 7/2019 with diagnoses including a stroke, dementia, and anxiety. Resident 26's 4/26/23 Quarterly MDS indicated her/his cognition was moderately impaired and was dependent on staff for care needs. The 4/27/23 Activity Quarterly Review revealed Resident 26 enjoyed music on her/his phone, TV (television)/movies and to watch the birds out of her/his window. Resident 26's 7/2023 care plan directed staff to provide assistance and escort her/him to activity functions. Resident 26's preferred activities were the following: individual visits, art, music, outdoors, animals, TV, movies and the outdoors. On 07/11/23 at 11:21 AM a gardening group activity was scheduled on the…

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

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (#11) reviewed for skin issues and positioning. This placed residents at risk for lack of necessary treatment. Findings include: 1. Resident 11 was admitted to the facility in 9/2020 with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs to lows). Resident 11's 4/20/23 Quarterly MDS revealed the resident experienced short and long term memory loss and was moderately impaired in decision-making. Resident 11's 7/2023 Physician Orders revealed the following order dated 6/28/23: - Soak right great toe twice daily and as needed in warm, soapy water or warm wash cloth and paint with betadine for ingrown toenail until resolved. - Okay to use cotton or dental floss underneath nail. - Contact podiatry to evaluate in house. - Notify for worsening drainage. On 7/11/23 at 12:48 AM Resident 11 was observed wincing in pain. Resident 11 stated she/he had an ingrown toenail on her/his right…

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

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decrease in range in motion for 1 of 3 sampled residents (#29) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include: Resident 29 was admitted to the facility in 6/2020 with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following a stroke. Resident 29's 6/13/20 Nursing Evaluation indicated the resident had contractures in her/his left arm. Resident 29's 6/20/20 admission MDS ADL Functional/Rehabilitation Potential CAA indicated the resident had left hemiparesis, right upper extremity weakness and contracture of the left hand. Resident 29's 9/20/20 Nursing Evaluation indicated the resident did not have contractures.…

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 monitor physician-ordered fluid restrictions for 1 of 1 sampled resident (#250) reviewed for dialysis care. This placed residents at risk for complications related to dialysis. Findings include: The facility's Fluid Restriction Worksheet Policy outlined the following procedure for residents on a fluid restriction: - List total fluid restriction ordered per physician in cc (cubic centimeters) per 24 hours. - Ask Nursing how much fluid is needed for medication passes in cc per 24 hours. - Subtract number two from number one to determine amount of fluid left for Dietary distribution. - Visit resident to determine preferences for fluid distribution by Dietary. Indicate cc of fluids to be provided at each meal and any other times. - The completed form is placed in the Dietary section of the Medical Record. A copy is placed in the Medication Administration Record (MAR) for the resident. The Dietary Manager also keeps a copy for his/her records. - Care plan is updated to reflect fluid restriction.…

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

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5%. There were seven errors out of 26 opportunities resulting in a 26.92% error rate. This placed residents at risk for adverse medication effects. Findings include: The facility 6/2017 Medication Administration Policy & Procedure specified the following: - The nurse signs for the medication after administration; - If the medication is unable to be administered, the nurse signs their initials, circles them and documents on the MAR/TAR the reason for non-administration. 1. Resident 150 was admitted to the facility in 7/2023 with diagnoses including cellulitis (skin infection). Resident 150's 7/2023 Physician Orders included the following medications: - Allopurinol 300 mg by mouth one time a day for gout (inflammation of the joints); - amlodipine besylate 10 mg one time a day for atrial fibrillation (irregular heartbeat); - aspirin delayed release 81 mg by mouth one time a day for blood clot prevention; - Centrum Performance vitamin one tablet by mouth…

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

Based on observation, interview and record review it was determined the facility failed to provide routine dental services for 1 of 1 sampled resident (#17) reviewed for dental care. This placed residents at risk of unmet dental needs. Findings include: Resident 17 was admitted to the facility in 11/2022 with diagnoses including cutaneous abscess (a pus-filled bump on or below the skin) of the buttock. Resident 17's 5/18/23 Quarterly MDS indicated she/he was cognitively intact. On 7/11/23 at 2:38 PM Resident 17 was observed to be edentulous (without natural teeth) and stated she/he discussed her need for dentures with Staff 5 (Social Services Director) four or five months ago and continued to wait for an update. On 7/13/23 at 12:42 PM Staff 5 stated she submitted a request to the resident's case manager to update her/his dental coverage to include dentures. Staff 5 stated the resident's case manager advised her to have the resident call the case manager to confirm she/he wanted the coverage changed. A review of the Resident 17's medical record revealed Staff 5 submitted a request to…

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

Based on interview and record review it was determined the facility failed to ensure resident records were accurate related to medication administration for 1 of 7 sampled residents (#150) reviewed for medication administration. This placed residents at risk for inaccurate health records. Findings include: 1. Resident 150 was admitted to the facility in 7/2023 with diagnoses including cellulitis (skin infection). Resident 150's 7/2023 Physician Orders included the following medications: - Allopurinol 300 mg by mouth one time a day for gout (inflammation of the joints); - Centrum Performance vitamin one tablet by mouth one time a day for supplement; - Finasteride 5 mg by mouth one time a day for overactive bladder; - cholecalciferol (vitamin D) 2000 units by mouth two times a day for supplement; - Preservision AREDS by mouth two times a day for supplement. Resident 150's 7/2023 MAR directed the following times each medication was to be administered: - Allopurinol 300 mg at 8:00 AM; - Centrum Performance vitamin at 8:00 AM; - Finasteride 5 mg at 8:00 AM; - cholecalciferol (vitamin D)…

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 residents were offered and received the pneumococcal vaccination according to Center for Disease Control and Prevention (CDC) guidelines for 2 of 5 sampled residents (#s 8 and 11) reviewed for immunizations. This placed residents at risk for acquiring pneumonia. Findings include: The 2/2023 CDC Pneumococcal Vaccination website, section titled, Pneumococcal Vaccination, indicated the following: - Vaccines help prevent pneumococcal disease which is any type of illness caused by Streptococcus pneumoniae bacteria. There are two kinds of pneumococcal vaccines available in the United States: * Pneumococcal conjugate vaccines (PCV13, PCV15 and PCV20) * Pneumococcal polysaccharide vaccine (PPSV23) - CDC recommends pneumococcal vaccination for adults [AGE] years old and older; - Adults 65 years or older who have previously received PCV13 should receive PCV20. a. Resident 8 was admitted to the facility in 11/2011 with diagnoses including…

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