Secora Rehabilitation Of Cascadia

Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health care and services and develop a comprehensive, person-centered behavioral health care plan for 1 of 1 sampled resident (#16) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's Behavioral Health Services policy, last revised 10/15/22, indicated the facility: -provided trauma informed care which referred to approaches to care that treat the whole person, taking into account past trauma and the resulting coping mechanisms when attempting to understand behaviors and treat the resident; -ensured necessary care and services were person-centered and reflected the resident's goals for care; -monitored residents for signs and symptoms of depression, anxiety disorders, verbal behavioral symptoms directed towards others such as screaming at others. Resident 16 was admitted to the facility in 2/2025 with diagnoses including…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#35) reviewed for unnecessary medications. This placed residents at risk for adverse side effect of medications. Findings include: The facility's 8/1/23 Medication Errors policy outlined the following: -A significant medication error is one which causes the resident discomfort or jeopardizes their health and safety. -In the event of a significant medication error, immediate action is taken as necessary to protect the resident's safety and welfare. -The prescriber is notified promptly of the error. -A medication error/adverse reaction report is completed. Resident 35 was admitted to the facility in 3/2024 with diagnoses including vascular dementia (cognitive decline caused by damage to the blood vessels in the brain) and a stroke. A review of Resident 35's 4/4/24 admission MDS revealed she/he was cognitively intact and received anticoagulant therapy. A review of Resident 35's health record revealed a 4/12/24 signed…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#7) reviewed for restraints. This placed residents at risk for mistreatment. Findings include: On 6/8/23, the Past Noncompliance was corrected when the facility implemented a plan of correction, which included: -Residents on the same unit were interviewed and no other restraints were found to be improperly utilized; -Educated the staff responsible and placed on corrective discipline; -Provided in-service training to all nursing staff for abuse and neglect which included the use of restraints; and -Provided signature sheet verifying nursing staff had completed the training. Resident 7 was admitted to the facility in 5/2023, with diagnoses including stroke and repeated falls. Resident 7's care plan dated 5/4/23 revealed she/he was a high fall risk and had a history of falls. Staff were to encourage Resident 7 to transfer to her/his bed, wheelchair or ambulate when she/he was on the unit to prevent further falls. On 6/7/23 the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide pain management to 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at increased risk of unmanaged pain. Findings include: The facility's pain management policy, revised 10/2022 recognized a resident's right to be free of pain and promoted pain relief utilizing a pain management plan during the resident's stay at the facility. Facility procedures included an initial pain assessment upon admission for all residents. Resident 3 admitted to the facility in 10/2023, with diagnoses including spinal fractures and chronic pain syndrome. Resident 3's physician orders dated 10/23/23 included a prescription for morphine tablets (15 mg), to be administered every 12 hours for pain. Resident 3's care plan dated 10/24/23 revealed she/he was at risk for acute pain related to her/his diagnoses following a spinal cord injury. Interventions were to administer medications as ordered, anticipate need for pain relief and…

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

Based on observation and interview it was determined the facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed. This placed the residents at risk for unaddressed concerns and needs related to resident care and quality of life. Findings include: On 11/15/23 at 11:30 AM the resident council group meeting was held in the facility dining room with state surveyors. The facility dining room did not provide privacy as the dining room was open to the lobby and living room. There were no doors or barriers to provide privacy. During the meeting, staff walked into the dining room to administer medications to one of the residents, one staff sat in the corner on her computer, the hallways were loud with staff and residents walking past the dining room and staff were vacuuming nearby while residents were speaking making it difficult to hear them. On 11/15/23 at 2:14 PM Resident 2 stated there were privacy concerns with resident council meetings. She/he confirmed the resident council meetings were held in the facility dining room. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure a clean and homelike environment for 1 of 1 facility and for 1 of 1 sampled resident (#26) reviewed for homelike environment and clean wheelchairs. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: 1. On 11/15/23 at 9:29 AM to 10:06 AM the floor vents in the north hallway were observed with a thick layer of dust on the vent covers. On 11/15/23 at 1:40 PM the floor vents in the north hallway were observed with a thick layer of dust on the vent covers. On 11/15/23 at 10:07 AM Staff 22 (Housekeeping) acknowledged the floor vents were dirty and housekeeping was not responsible to clean them. Staff 22 stated the facility did not have a housekeeping manager. On 11/15/23 at 10:11 AM Staff 1 (Administrator) acknowledged the facility did not have a housekeeping manager. Staff 1 confirmed the floor vents were dirty with a thick layer of dust and needed to be cleaned. 2. Resident 26 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 implement its abuse policy and procedure to screen new hires for 5 of 5 staff (#s 4, 5, 6, 7, and 8) reviewed for background checks. This placed residents at risk for abuse. Findings include: The facility's Abuse Policy revised 7/23/19 indicated seven key components which included the screening of potential employees for history of abuse. On 11/14/23 a random sample of five newly hired staff members was reviewed for background and reference checks with Staff 3 (Human Resources). There was no evidence criminal history checks were completed for Staff 4 (CNA), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Maintenance Manager) and Staff 8 (Maintenance Assistant) had reference checks conducted prior to their employment at the facility. On 11/14/23 at 1:42 PM Staff 3 (Human resources) acknowledged the criminal history checks for Staff 5 and Staff 6 were not completed.

Based on observation and interview it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 3 of 3 sampled residents (#s 4, 10, and 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 4 was admitted to the facility in 2023 with diagnosis including severe protein-calorie malnutrition. Resident 10 was admitted to the facility in 2018 with diagnosis including cerebrovascular (condition which affects the blood vessels in the brain) disease. Resident 13 was admitted to the facility in 2023 with diagnosis including severe protein-calorie malnutrition. On 11/13/23 multiple plastic bags were observed tied together in a chain which extended and hung from the cords of Residents 4, 10 and 13's overbed lights. On 11/13/23 at 10:55 AM Resident 4 stated her/his overbed light cord was too short and she/he could not independently use the light without the extension the plastic bags provided. On 11/14/23 at 1:00 PM Staff 7…

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

Based on observation, interview and record review it was determined the facility failed to provide a menu as requested for 1 of 3 sampled residents (#153) reviewed for choices. This placed residents at risk for decreased food intake, weight loss and lack of choices being honored. Findings include: Resident 153 was admitted to the facility in 2023 with diagnoses including fracture of the spine. Resident 153's 11/9/23 Mini Nutritional Evaluation indicated the resident was at risk for nutritional decline related to impaired mobility and chronic pain. Resident 153's 11/9/23 ADL Self Care Performance Deficit and At Risk for Nutritional Decline Care Plans revealed the following interventions: -Ambulation: Distant supervision with ambulation with the assistance of one person. Devices used: front wheel walker, back brace and verbal cueing. -Locomotion: substantial/maximum assistance for wheelchair mobility with the assistance of one staff. Device used: wheelchair with footrests. -Provide feeding/dining assistance as needed. -The resident received a regular diet with a regular texture and…

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

Based on interview and record review it was determined the facility failed to assist residents with formulating an advance directive for 3 of 3 sampled residents (#s 12, 27 and 304) reviewed for advance directive. This placed residents at risk of not having their healthcare wishes followed. Findings include: 1. Resident 12 was admitted to the facility in 2023 with diagnoses including diabetes. Resident 12's Advance Directive Review dated 4/21/23 indicated the resident wanted assistance formulating an advance directive plan. A review of Resident 12's clinical record revealed no advance directive on file. On 11/14/23 at 1:47 PM Staff 10 (Social Services Director) stated she had not followed up with the resident to assist her/him with formulating an advance directive and the resident had not completed an advance directive. 2. Resident 27 was admitted to the facility in 2020 with diagnoses including depression. Resident 27's Advance Directive Review dated 12/20/22 indicated the resident wanted assistance formulating an advance directive plan. A review of Resident 27's clinical record…

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 weight gain and vision for 2 of 3 sampled residents (#s 8 and 18) reviewed for nutrition and sensory communication. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 8 admitted to the facility in 2023 with diagnoses of Multiple Sclerosis (disease of the nerve cells). Resident 8's 5/12/23 Quarterly MDS indicated she/he weighed 119 lb (pounds). Resident 8's 11/1/23 Quarterly MDS indicated she/he experienced no weight gain over the past six months. The MDS indicated she/he weighed 142 lb. Resident 8's weight documentation revealed the following: -5/17/23 at 122 lb. -10/12/23 at 144.5 lb. -11/9/23 at 142 lb. On 11/16/23 at 2:13 PM Staff 20 (MDS Coordinator) confirmed the 5/12/23 MDS and 11/1/23 MDS weights and stated Resident 8 should have been assessed for a weight gain. On 11/16/23 at 2:28 PM Staff 2 (DNS) acknowledged Resident 8's weight were not assessed correctly on the 11/1/23 MDS. 2. Resident 18 was admitted to the facility in…

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

Based on observation, interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 1 sampled resident (#40) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 40 admitted to the facility in 2023 with diagnoses including intercranial (head) injury. Resident 40's 11/13/23 Physician Order directed staff to use a bedside impact absorbing floor mat next to the resident's bed while she/he was in bed. The 11/13/23 Care Plan for Resident 40 directed staff to provide a bedside impact absorbing floor mat next to Resident 40's bed while she/he was in bed. On 11/13/23 at 11:21 AM Resident 40 was observed in bed with the fall mat folded and placed next to her/his bedside table away from the bedside. On 11/15/23 at 2:20 PM and 11/16/23 at 10:40 AM Resident 40 was observed in bed without a fall mat on the floor at the bedside. On 11/17/23 Staff 14 (CNA) stated she obtained information to care for residents in the resident's care plan. She stated the care plan was expected to be followed 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 observation, interview and record review it was determined the facility failed to ensure comprehensive, person-centered care plans were revised for 2 of 3 sampled residents (#s 13 and 18) reviewed for nutrition, position and mobility. This placed residents at risk for unmet care needs. Findings include: The facility's 10/2022 Care Plan Policy indicated the resident care plan was reviewed after each assessment except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 1. Resident 13 was admitted to the facility in 2023 with diagnoses including severe protein-calorie malnutrition and epilepsy (seizure disorder). A 6/13/23 admission MDS and associated CAAs revealed Resident 13 was cognitively impaired and for staff to provide one-to-one feeding and dining assistance as needed. A Care Plan initiated on 6/19/23 revealed the resident was at risk for nutritional decline and required one-to-one supervision with meals. On 11/14/23 at 12:57 PM Resident 13 was observed in bed with her/his lunch…

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 discharge planning was developed and implemented for 2 of 5 sampled residents (#s 203 and 303) reviewed for discharge planning. This placed residents at risk for unmet care needs. Findings include: 1. Resident 303 was admitted to the facility in 2023 with diagnoses including stroke. Resident 303's Progress Notes dated 4/14/23 revealed the resident was discharged from the facility. A review of Resident 303's clinical record revealed no indication the facility developed and documented a discharge plan or discussed the discharge plan with the resident and the resident's representative. On 11/15/23 at 12:35 PM and 11/16/23 at 9:50 AM Staff 1 (Administrator) and Staff 10 (Social Services Director) confirmed there was no discharge plan in the resident's clinical record. Staff 1 stated his expectation was for discharge planning to begin within 72 hours of a resident's admission to the facility. Staff 1 stated he would have liked better documentation of Resident 303's discharge plan. 2. Resident 203 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 complete a discharge summary for 1 of 5 sampled residents (#206) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 206 was admitted to the facility in 2023 with diagnoses including metabolic encephalopathy (chemical imbalance affecting the brain). The resident was discharged from the facility on 8/2/23 on a resident initiated discharge. A review of Resident 206's medical record indicated there was no discharge summary documentation. On 11/16/23 at 2:12 PM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 206. Staff 2 stated it was her expectation for discharge summaries to be completed upon discharge.

Based on observation, interview and record review it was determined the facility failed to provide adequate grooming and toenail care for 2 of 5 sampled residents (#s 18 and 47) reviewed for ADLs. This placed residents at risk for unmet ADL needs. Findings include: 1. Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 10/6/23 Annual MDS revealed the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and was dependent upon staff for personal hygiene. Resident 18's 10/26/23 ADL Self Care Performance Deficit Care Plan indicated the resident required extensive assistance with personal hygiene. Observations conducted on 11/13/23 at 11:29 AM and on 11/14/23 at 11:24 AM revealed Resident 18 was in bed with white hairs approximately one inch in length on her/his chin. Resident 18 was unable to answer questions or converse about her/his personal hygiene preferences on either of these occasions. On 11/13/23 at 12:41 PM Witness 2 (Family Member) stated Resident 18 was no longer able 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 provide an ongoing person-centered activities program for 1 of 3 sampled residents (#18) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Programs Policy and Procedure dated 11/28/17 outlined the following: -The resident who was confined or choose to remain in his/her room was provided with in-room recreation programs in keeping with life-long interests. Staff assisted the resident with recreation programs that could be pursued independently. -For the resident who had withdrawn from previous activity interests/customary routines and isolated self in room/bed most of the day: a. Provide activities just before or after meal time and where the meal was served (out of the room). b. Provide in-room volunteer visits, music or videos of choice. c. Encourage volunteer-type work. d. Invite to special events with a trusted peer or family/friend. e. Engage in activities that give the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure safety hazards were not accessible for 1 of 2 halls reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 37 was admitted to the facility in 2023 with diagnoses including stroke. Resident 46 was admitted to the facility in 2023 with diagnoses including stroke. On 11/13/23 at 1:42 PM the resident bathroom and shower room to the right of room [ROOM NUMBER] was observed with an unlocked cabinet which contained four blue disposable razors, an unlabeled personal electric shaver and five bottles of cleaning chemicals. On 11/14/23 at 5:41 AM the resident bathroom and shower room to the right of room [ROOM NUMBER] was observed with an unlocked cabinet which contained two blue disposable razors, an unlabeled personal electric shaver, shampoo, hair conditioner, a purple deodorant stick and four bottles of cleaning chemicals. On 11/15/23 at 9:31 AM and 10:08 AM the resident bathroom and shower room to the…

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

Based on interview and record review it was determined the facility failed to prevent complications of tube feeding for 1 of 1 sampled resident (#303) reviewed for tube feeding. This placed residents at risk for complications related to tube feeding. Findings include: Resident 303 was admitted to the facility in 2023 with diagnoses including stroke. Resident 303's Progress Notes dated 4/13/23 indicated the resident was bleeding profusely from her/his feeding tube site. Pressure was applied but the resident continued to bleed through the towels [used to apply pressure]. The resident's feeding tube was not completely out [dislodged from the resident's abdomen]. The resident was sent to the hospital. A review of Resident 303's clinical record revealed no indication the resident ever attempted to pull on the feeding tube. There was no explanation for the cause of the partially dislodged feeding tube and no indication a facility investigation was completed. No new interventions were developed to prevent a reoccurrence after the resident returned from from the hospital on 4/14/23. On…

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

Based on observation, interview and record review it was determined the facility failed to obtain a physician order and develop a care plan for the use of an oral suction machine for 1 of 1 sampled resident (#18) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: Resident 18 was admitted to the facility in 2019 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 18's 10/6/23 Annual MDS revealed the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and had a feeding tube in place. On 11/13/23 at 10:00 AM and 2:34 PM Resident 18 was observed in bed and an oral suction machine at the resident's bedside. The canister of the oral suction machine contained a yellow liquid and was about a third of the way full. Resident 18 was unable to answer questions or converse about the oral suction machine on either of these occasions. No evidence was found in Resident 18's health record to indicate an order or a care plan for the oral suction machine…

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

Based on interview and record review it was determined the facility failed to follow up timely on pharmacist recommendations for 1 of 5 sampled residents (#47) reviewed for unnecessary medications. Findings include: Resident 47 was admitted to the facility in 2023 with diagnoses including COPD (a disease which causes airflow blockage). Resident 47's 9/2023 MAR revealed the resident was administered the following medications: - Multivitamin (supplement) once daily in the AM. - Doxycycline (antibiotic) twice daily for 14 days with a start date of 9/23/23. - Magnesium Chloride (supplement) twice daily. A pharmacist's Note To Attending Physician/Prescriber dated 9/26/23 was sent to Resident 47's physician with a recommendation to consider holding the resident's mineral supplements while the resident was administered doxycycline due to a significant interaction. Resident 47's 9/2023 and 10/2023 TARs revealed no changes were made to Resident 47's multivitamin, doxycycline and magnesium chloride administration. A copy of the 9/26/23 Note To Attending Physician/Prescriber with a handwritten…

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 prevent potential contamination of the ice machine in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: The Federal Food Sanitation Rules code 5-402.11 Backflow Prevention directed facilities to ensure a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 10/3/22 at 9:30 AM the ice machine was observed to drain directly into the plumbing without an air gap. This allowed for backflow into the ice machine from the sewer. Staff 7 (Kitchen Manager) reported, It's been like that since I started working here in September 2022. On 10/6/22 at 2:47 PM Staff 1 (Administrator) confirmed the ice machine did not have an air gap. He stated, I didn't know that was an issue.

Based on interview and record review it was determined the facility failed to use the services of an RN for eight consecutive hours per day for 16 of 30 days reviewed for staffing. This placed residents for unmet medical-based care needs. Findings include: A review of the Direct Care Staff Daily Reports dated 9/1/22 through 9/30/22 revealed there were 16 days (9/1, 9/2, 9/3, 9/7, 9/8, 9/9, 9/10, 9/15, 9/16, 9/17, 9/21, 9/22, 9/23, 9/24, 9/29, 9/30) with no RN coverage. On 10/7/22 at 11:15 AM Staff 2 (DNS) stated she was under the impression if she was present in the facility she was counted as an RN on the daily staffing report and was not aware she had to dedicate time for direct patient care. Staff 2 confirmed there was no RN coverage on the identified dates.

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 were assessed for safe self-administration of medications for 3 of 3 sampled residents (#s 35, 39 and 141) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 39 was admitted to the facility in 9/2022 with diagnoses including type 2 diabetes mellitus. On 10/3/22 at 10:10 AM Resident 39 was lying in her/his bed with an overbed table within reach. A medication cup which contained two white, round pills was on Resident 39's overbed table and no nursing staff were present in the room. Resident 39's health record did not include evidence the resident was assessed for safe self-administration of medications. No documentation was found to indicate Resident 39 was able to correctly identify her/his medications and the reason for their use. On 10/5/22 at 7:03 AM and 7:30 AM Staff 4 (LPN) and Staff 5 (LPN) stated during…

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

Based on interview and record review it was determined the facility failed to obtain, request and review copies of advance directives if available or periodically review resident wishes to execute an advance directive for 2 of 4 sampled residents (#s 39 and 141) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 141 was admitted to the facility in 8/2022 with diagnoses including juvenile diabetes and end-stage kidney disease. No evidence was found in Resident 141's health record to indicate the facility discussed advance directives with the resident or resident representative. On 10/4/22 at 4:18 PM Staff 8 (Social Services) confirmed the facility did not discuss the benefit of advance directives with Resident 141 upon admission. 2. Resident 39 was admitted to the facility in 9/2022 with diagnoses including osteomyelitis (bone infection) of the spine and depression. No information was found in Resident 39's health record to indicate the facility discussed advance directives with the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure the building was kept in good repair for 3 of 29 resident rooms and 1 of 1 main resident lobby area reviewed for environment. This placed residents at risk for living in an unkempt and unhomelike environment. Findings include: During resident screening throughout the day on 10/3/22, it was found that rooms [ROOM NUMBERS] had broken window blinds. Additionally, room [ROOM NUMBER] had large scrapes and gouges on the wall next to the bed and the floor had an approximate six inch in diameter spot that appeared to be dirty flooring on the left side of the room. In the residents' lobby area, there were three leather-like arm chairs which had ripped armrests with large areas of leather missing and uncleanable fabric exposed. On 10/7/22 at 12:00 PM Staff 1 (Administrator) and the surveyor completed a facility walk-through. Staff 1 verified the broken window blinds, ripped chairs and dirty flooring. Staff 1 stated it was important 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 document evidence of sufficient preparation and orientation to residents to ensure a safe and orderly transfer from the facility for 1 of 1 sampled resident (#43) reviewed for hospitalization. This placed residents at risk for misinformation. Findings include: Resident 43 was admitted to the facility in 7/2022 with diagnoses including second degree burn of right foot and open wound of left foot. Resident 43's 8/22/22 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 43's health record revealed no documentation to indicate the resident was prepared and notified regarding the discharge to the hospital. No evidence was found to indicate Resident 43 was informed about where she/he was going and if the resident understood the reason for the discharge. On 10/10/22 at 9:09 AM Staff 2 (DNS) was notified of the findings of this investigation and acknowledged there was no documentation in Resident 43's health record which indicated the resident was informed 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 invite and include residents to activities events for 1 of 2 sampled residents (#38) reviewed for activities. This placed residents at risk for social isolation. Findings include: Resident 38 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke) with right-sided hemiplegia (paralysis). Resident 38's 3/24/22 admission MDS indicated the resident was sometimes understood, was able to understand others and was totally dependent on staff assistance for locomotion on and off the unit. The MDS indicated Resident 38 was unable to complete the activity preferences interview, there was potential for resident isolation and the Activity Director would investigate areas of interest through trial and error. Resident 38's care plan included an activities focus, last revised 3/28/22, which included the following interventions: - Activity Director will continue to attempt to learn resident needs on a…

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

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#141) reviewed for unnecessary medications. This placed residents at risk for adverse health consequences. Findings include: Resident 141 was admitted to the facility in 8/2022 with diagnoses including juvenile diabetes and end stage renal disease. An 8/26/22 physician order indicated Resident 141 was prescribed insulin Lispro-aabc Solution 100 unit/ML; subcutaneously before meals per sliding scale. The order specified to notify the medical provider if the resident's blood sugar was 400 or greater. A 9/23/22 physician order indicated Resident 141 was prescribed insulin Lispro Solution 100 unit/ML; subcutaneously before meals and at bedtime per sliding scale. The order specified to notify the medical provider if the resident's blood sugars were 350 or greater. A review of Resident 141's health record indicated the following times when the resident's medical provider was not notified of blood sugars as per physician orders: -9/1/22 at 11:30…

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 physician orders for splint devices were implemented for 1 of 2 sampled residents (#15) reviewed for mobility. This placed residents at risk for worsening contractures. Findings include: Resident 15 was admitted to the facility in 11/2017 with diagnoses including cerebral infarction (stroke). Resident 15's 8/15/22 Quarterly MDS indicated the resident had upper extremity impairment to one side and used a splint. Resident 15's 10/2022 physician orders included the following: - Apply hand splint to left hand [every day], wear for four hours during the day. Monitor BID for alteration in skin. Resident 15's 10/2022 TAR revealed the following documentation for the splint physician order: - 10/3/22 days: checkmark with staff initials; - 10/3/22 evenings: NN with staff initials; - 10/4/22 days: NN with staff initials; - 10/4/22 evenings: NA with a checkmark and staff initials; - 10/5/22 days: + with a checkmark and staff…

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

Based on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#91) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include: Resident 91 was admitted to the facility in 9/2022 with diagnoses including cancer. Resident 91's 9/30/22 admission MDS indicated the resident used supplemental oxygen. On 10/3/22 at 9:56 AM Resident 91 was lying in bed in her/his room and receiving oxygen which was produced and delivered from an oxygen concentrator. The concentrator was powered on and set at two LPM (liters per minute) of oxygen. A humidifier bottle was attached to the concentrator, dated 9/21/22 and contained no fluid. A nasal cannula and tubing was attached to the oxygen concentrator and placed in Resident 91's nose. Observations from 10/3/22 at 12:12 PM through 10/6/22 at 12:03 PM revealed no humidifier bottle attached to the oxygen concentrator. On 10/05/22 at 11:16 AM Resident 91 was not in her/his room and the nasal cannula was 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 implement appropriate adaptive dining equipment for 1 of 3 sampled residents (#38) reviewed for nutrition. This placed residents at risk for decreased food intake and an undignified dining experience: Findings include: Resident 38 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke) with right-sided hemiplegia (paralysis). Resident 38's care plan for ADL self care performance deficit with eating, last revised 3/18/22, included the intervention to use a scoop plate (an adaptive meal plate with a high, curved rim which enables food to be rolled back onto the spoon to minimize spillage) for all meals for maximum independence. Resident 38's health record included an 8/23/22 physician order for the following: - Scoop plate for resident meals to promote self-feeding abilities. Observations of Resident 38 were conducted from 10/3/22 through 10/7/22 between the hours of 7:56 AM and 4:15 PM. During these observations, Resident 38 was in her/his wheelchair in the…

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

Based on observation 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 facility garbage area reviewed for sanitary disposal of garbage. This placed residents at risk for exposure to pathogens related to the harborage and feeding of pests. Findings include: On 10/6/22 at 2:01 PM old furniture, a broken door, broken service carts, empty food boxes, large empty vegetable cans (with remnants of vegetables inside), and empty half-gallon milk jugs (with remnants of milk inside) were observed to be discarded outside of the kitchen door on the pavement and grassy area adjacent to the kitchen door on the north side of the building. Staff 7 (Kitchen Manager) stated the kitchen staff placed larger food garbage items such as cans and boxes outside of the door prior to taking them to the dumpster around the corner from the kitchen door. He stated the boxes and other recyclables were also placed outside the kitchen door before they were broken down and added 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.