Tigard Rehabilitation And Care

Based on interview and record review it was determined the facility failed to ensure residents were offered the COVID-19 vaccine for 2 of 5 sampled residents (#s 11 and 62) reviewed for immunizations. This placed residents at risk for COVID-19 illness. Findings include:Review of the CDC's Staying Up To Date with COVID-19 Vaccines, dated 11/19/25, https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, documented CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making.Getting the 2025-2026 COVID-19 vaccine is especially important if you. are living in a long-term care facility.1. Resident 11 was admitted to the facility in 2022 with a diagnosis of Parkinsonism.A review of Resident 11's immunization record revealed Resident 11 was not offered the COVID-19 vaccine.On 5/7/26 at 2:01 PM Staff 14 (Corporate IP) stated Resident 11 was eligible for the COVID-19 vaccine, but it was not offered to the resident. 2. Resident 62 was admitted to the facility in 2024 with a diagnosis of osteomyelitis of the vertebrae.A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure non-pressure skin wounds were monitored for 1 of 3 sampled residents (#6) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds and delays in treatment. Findings include:Resident 6 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes.A 4/17/25 Clinical admission Progress Note, completed by Staff 4 (LPN), indicated Resident 6 had some redness with a small healing blister to her/his front left knee that was present upon admission.The 4/18/25 care plan revealed Resident 6 had impaired skin integrity due to a current blister on the left thigh/shin and immobility.A review of Resident 6's medical record, including a review of the 4/2025 TAR, revealed no assessment of the wound and no monitoring of the wound. Resident 6 discharged to the hospital on 4/22/25 for an unrelated diagnosis.On 11/13/25 at 2:45 PM Staff 4 confirmed he completed Resident 6's clinical…

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 newly identified pressure ulcer wounds were comprehensively assessed and wound care orders were obtained and implemented for 1 of 3 sampled residents (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:The facility's 4/2018 Pressure Ulcer/Skin Breakdown - Clinical Protocol - Assessment and Recognition specified the nurse shall describe and document/report the following:Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (leaking fluid) or necrotic (dying/dead) tissue and pain assessment.The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing; - Document the results of all wound assessments; - Assess and document physical…

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

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 1 of 3 narcotic books reviewed for medication administration. This placed residents at risk for drug diversion. Findings include:The facility's policy for reconciling controlled substances, revised 11/2022, stated the system for reconciling the receipt, dispensing and disposition of controlled substances included the following:-Records of personnel access and usage;-Medication administration records;-Declining inventory records; and-Destruction, waste and return to pharmacy records.-Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile and inventory the count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DNS.A 3/27/25 FRI indicated narcotic medication for two residents was missing and unaccounted for.A 3/31/25 investigation report revealed the facility was unable to…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 5 admitted to the facility in 2011 with diagnoses including anxiety, mood and personality disorder. The 7/20/23 Care Plan indicated Resident 5 had behaviors of refusing cares, refusing all wound cares and other cares including bathing and hygiene tasks. Resident 5 was not easily directed and interventions by staff escalated the resident's agitation. Resident 5 had history of being verbally and physically aggressive toward staff. Interventions included: to not argue with the resident and to discontinue attempts to treat if she/he became agitated and reapproach later. A 1/6/25 Facility Reported Incident indicated the following:- - On 1/4/25 Resident 5 told Staff 21 (RN) to go to Hell when attempting to complete wound care. Staff 21 was heard by CNA Staff reply to Resident 5, I'm already in Hell. You're Satan's bitch, aren't you? Staff 21 also…

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 ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses. A review of the facility policy Refrigerator and Freezer policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee. On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25. On 1/14/25 at 1:09 PM Staff 16 (Dietary Manager) stated he was not aware of the process for monitoring the resident foods refrigerator utilized by the care team. He stated he had taken the temperature of the refrigerator on 1/10/25 when he placed the log on the front of the refrigerator. On 1/15/25 at 9:59 AM foods were observed 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 residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care. Findings include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. A 10/12/24 admission MDS revealed Resident 52's preferred language was Spanish and she/he needed an interpreter to communicate with health care staff. A 10/28/24 care plan revealed Resident 52 spoke Spanish. A review of the medical record revealed the following English language documents were issued to and signed by Resident 52: - 10/14/24 Portable Orders for Life-Sustaining Treatment (POLST), - 10/22/24 Notice of Medicare Non-Coverage, - 10/29/24 Notice of Medicare Non-Coverage, - 1/9/25 SNF Discharge Instructions/Recapitulation of Stay. On 1/14/25 at 11:52 AM Witness 2 (Complainant) stated she visited with Resident 52 and she/he complained the facility provided documents to her/him in English only and requested she…

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 mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: A facility Mail and Electronic Communication policy, revised in 2017, stated, Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). During the resident council meeting on 1/14/25 at 2:00 PM residents stated their mail was not delivered to them on Saturdays. On 1/15/25 at 10:04 AM Staff 20 (Activities Director) stated mail was delivered Monday through Friday only. Staff 20 stated mail delivered to the facility on Saturdays was not given to resdients until the next Monday morning. On 1/15/25 at 11:31 AM Staff 1 (Administrator) stated resident mail was to be delivered to the residents on the same day it was delivered to the facility.

Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed residents at risk for unmet needs. Findings include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. An 10/16/24 Utilization Review assessment revealed Resident 52 had chronic suicidal ideation comments. An 10/26/24 Progress Note revealed Resident 52 yelled and swung at staff, was combatiative, and refused to have her/his vitals done. A 11/5/24 Progress Note with a licensed clinical social worker revealed Resident 52 was referred to her by the facility for a depressed mood. Resident 52 expressed feeling depressed following recent medical complications and loss of independence, had depressed mood, sadness, feelings of helplessness, difficulties concentrating, and some irritability. Resident 52 expressed recent suicidal ideation with no intent or plan. A review of Resident 52's medical record revealed no monitoring for mood or behaviors. A review of…

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

Based on interview and record review it was determined the facility failed to provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings Include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. An 10/5/24 hospital progress note revealed Resident 52 had a a right foot ulcer. An 10/8/24 Clinical admission revealed a right lateral (outer edge) foot diabetic foot ulcer was identified. Daily Skilled Evaluations completed 10/9/24 through 10/18/24, 10/20/24 through 11/1/24, 11/4/24, and 11/5/24, identified Resident 52's right lateral foot diabetic ulcer was not evaluated. 10/14/24, 10/17/24, 10/25/24, 11/1/24, and 11/19/24 Physician Progress Notes revealed no information related to Resident 52's right lateral foot diabetic ulcer. A 11/21/24 Skin Check assessment revealed Resident 52 was identified to also have a venous ulcer (a chronic wound that occurs when blood pools in the veins of the legs, damaging the skin and causing an open sore) on the left front…

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 assessed after weight loss was identified for 1 of 3 sampled residents (# 34) reviewed for nutrition. This placed residents at risk continued weight loss. Findings include: Resident 34 admitted to the facility on [DATE] with diagnoses including malnutrition and type 1 diabetes. The 8/13/24 Care Plan indicated Resident 34 had a nutritional problem related to ongoing malnutrition and weight loss since admit. The goal was for Resident 34's weight to be within acceptable parameters set by the RD and Interdisciplinary team. Interventions included distant supervision, high protein foods and supplements. Review of Resident 34's Weight Summary report indicated the following: - 6/25/24 weight of 200.6 pounds. - 7/10/24 through 9/4/24 weight averaging 205.5 pounds. - 9/16/24 no weight taken. - On 9/23/24 Resident 34's weight was 174.6 pounds (32.5-pound weight loss). On 9/26/24 a progress note indicated the identified…

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

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 1/14/25 at 1:30 PM Staff 2 (DNS) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA). No performance reviews were provided. On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged no performance reviews were completed for the identified CNA staff.

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect. This placed residents at risk for a decrease in their quality of life. Resident 2 admitted to the facility in 11/2023, with diagnoses including hyperlipidemia (a condition caused by high levels of fat in the blood). Resident 1 admitted to the facility in 2/2024, with diagnoses including chronic systolic heart failure. A 7/17/24 Facility Reported Incident indicated Resident 1 was observed having a verbal altercation with Resident 2 in the facility parking lot. It was reported the altercation began after Resident 2 requested Resident 1 to return a spare wheelchair that Resident 1 had borrowed. Resident 1 during the verbal altercation was observed spitting in Resident 2's face before staff intervened and separated both residents. A 7/17/24 witness statement by Staff 3 (Medical Records Director) and Staff 4 (ADNS) indicated Resident 1 spat in the face of Resident 2 during the resident's…

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 free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential repeat sexual abuse incidents. Findings include: Resident 1 was admitted to the facility in 11/2023, with diagnoses including severe sepsis and post-traumatic stress disorder. A 11/8/23 admission MDS Assessment, Section C: Cognitive Patterns, identified Resident 1 with severe cognitive impairment. Resident 1's 11/17/23 Care Plan identified the resident with a history of trauma related to domestic violence with interventions, including maintaining personal space boundaries and announcing self before approaching. Resident 2 was admitted to the facility in 8/2023, with diagnoses including encephalopathy and dementia with behavioral disturbance. An 11/24/23 Quarterly MDS Assessment, Section C: Cognitive Patterns, identified Resident 2 with severe cognitive impairment. Resident 2's 8/18/23 Care Plan identified the resident with inappropriate sexual behavior…

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 treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include: Resident 8 admitted to the facility in 5/2023, with diagnosis including diabetes. Resident 8's 10/10/23 physican orders instructed staff to clean the right toe diabetic wound with wound cleanser, apply a thin layer of AD (ointment) to the wound and periwound, and to secure the wound with bordered foam. The dressing was to be changed three times per week and as needed. Resident 8's October 2023 TAR revealed no wound care was done between 10/11/23 through 10/27/23. On 4/10/24 at 11:15 AM, Staff 2 (DNS) verified wound treatments were not completed from 10/11/23 through 10/27/23.

Based on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for safety and coordination of care. Findings include: Resident 2 was admitted to the facility in 2023 with diagnoses including schizoaffective disorder and stimulant abuse. An 11/1/23 admission MDS identified Resident 2 had no cognitive impairment. Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself. An 11/27/23 Nursing Care Note identified Resident 2 was unarousable while care staff attempted to provide catheter care. Resident 2's head was positioned in a downward angle. Care staff contacted emergency care services and resident 2 was noted to have refused to be transferred to the hospital. An 11/28/23 Provider Note indicated after the emergency…

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

Based on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substances for 1 of 1 sampled resident (#2) reviewed for behavioral emotional health. This placed residents at risk for a decline in mood and potential risk for reduced quality of life. Findings include: Resident 2 was admitted to the facility in 10/2023 with diagnoses including schizoaffective disorder and stimulant abuse. Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself. Resident 2's 11/1/23 Care Plan identified the facility was to provide Resident 2 with continued resources related to drug addiction counseling. On 12/4/23 at 12:19 PM Staff 4 (SSD) stated Resident 2 declined the offer of drug support services and counseling. Staff 4 indicated…

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 training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 1 of 1 CNA (#12) reviewed for annual nurse aide training performance. This placed residents at risk for lack of care by competent staff. Findings include: On 8/8/23 a review of the facility's staff training records for CNAs employed over one year revealed the following: -Staff 12 (CNA), hired 6/15/22, had no performance review and no documentation of regular in-service training. On 8/10/23 at 1:02 PM Staff 16 (Clinical Operations Education Director) confirmed the facility did not have a system in place to conduct annual nurse aide training performance reviews for Staff 12.

Based on observation and interview it was determined that the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness. Findings include: 1. Observations from 8/9/23 at 9:53 AM through 8/10/23 at 9:40 AM revealed the ceiling of the kitchen had three round uncovered air vents (approximately 12 inches in diameter) which all had surrounding areas which were blackened colored, jagged, had hanging loose debris and were blowing air over the food prep area and serving areas. On 8/9/23 air was observed blowing over the food service area during the lunch meal service. On 8/9/23 at 2:09 PM Staff 6 (Dietary Manager) stated the missing vent covers were being cleaned and painted. 2. On 8/9/23 between 11:49 AM and 12:30 PM during lunch meal service observations Staff 7 (Cook) did not change her gloves or conduct hand hygiene after touching multiple surfaces in the kitchen, including the food prep areas and utensils. Staff 7 used the same gloved hand to handle rolls and sandwiches…

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 have the Medical Director or designee attend the QAA (quality assessment and assurance) committee for 2 of 3 quarters reviewed for QAA. This placed residents at risk of not receiving care and services for optimal resident outcomes. Findings include: Documentation of QAA meeting minutes were requested from 1/2023 through 8/2023 and the only documentation provided was the sign in sheets from 4/2023 and 8/2023 which revealed the Medical Director attended on 4/21/23 but did not attend on 8/8/23. No other documentation was provided. On 8/11/23 at 12:01 PM Staff 1 (Administrator) and Staff 21 (DNS) stated they held monthly QAA meetings and all major department supervisors attended. Staff 1 and Staff 21 stated the Medical Director did not attend the Quarterly QAA meetings on a regular basis but was highly encouraged to attend. Staff 1 stated she could not find any documentation from 1/2023 through 3/2023 the Medical Director attended the quarterly QAA meetings.

1. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include: Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. A review of the current Facility Assessment revealed no evidence a risk assessment had been completed and there was no information referring to a facility policy or procedure to prevent the growth and spread of water-borne pathogens in the facility's main…

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

Based on observation and interview it was determined the facility failed to maintain a safe environment for 1 of 1 courtyard areas reviewed for environment. This placed residents at risk for accidents. Findings include Observations from 8/8/23 through 8/10/23 revealed no safety warnings or other cautionary measures in place for a broken and raised section (two to three inches) of a pathway in the courtyard. On 8/8/23 at 12:23 PM Resident 15 was observed in her/his wheelchair in the courtyard. The resident had difficulty navigating the broken section of the pathway. The resident was unable to crossover the broken pathway and appeared to be stuck. On 8/9/23 at 10:03 AM Resident 15 stated that she/he went outside daily and regularly got stuck on the broken section of the pathway. She/he then stated staff would usually notice or Resident 15 would use her/his cell phone to call for help. On 8/9/23 at 10:48 AM Staff 5 (Maintenance Director) stated he was aware of the broken section of the pathway in the courtyard. He further stated he had only been at the facility approximately one month…

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

Based on observation, interview and record review it was determined the facility failed to ensure the medication error rate was less than 5%. There were 28 medication administration opportunities with 8 errors resulting in an error rate of 28%. This placed residents at risk for adverse medication side effects. Findings include: The undated facility policy for care of tube feeding (gastrostomy) indicated the following: 5.e. Medications will be administered by gravity. If problems with gravity and administration occur, a very small amount of pressure with the syringe to attempt flow and then remaining administration will be by gravity, unless otherwise noted by the physician. Resident 9 admitted to the facility in 2023 with diagnoses including stroke. The 7/27/23 Physician Order indicated Resident 9 was to receive the following medications: -acetaminophen 500 mg 2 tabs via gastric tube TID; -docusate sodium (laxative) 100 mg via gastric tube BID; -ezetimibe (cholesterol medication) 10 mg via gastric tube once daily; -ferrous sulfate (supplement) 325/65 mg via gastric tube once daily;…

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 hot food was served at preferable temperatures for 1 of 1 lunch meal reviewed for food concerns. This placed residents at risk for inadequate food temperatures. Findings include: On 8/7/23 interviews with Residents 39 and 297 revealed meals were often served cold. When meals were received, the hot foods were usually cold and had to be warmed up. A review of Resident Council minutes from 4/2023 through 7/2023 revealed cold food was an ongoing concern. The Resident Council minutes did not document actions taken to address the cold food. On 8/9/23 a lunch meal test tray was requested by the survey team. During the lunch meal service a total of 49 minutes passed between the first meal tray being placed in the first meal cart to when the survey team received the lunch meal test tray. The lunch meal consisted of roasted pork loin and broccoli. Both items were determined to be lukewarm in temperature. On 8/9/23 at 1:33 PM Staff 8 (Activities Director) stated cold food was an ongoing concern…

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 the garbage area dumpsters were covered for 1 of 1 facility garbage areas reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include: Observations of the facility garbage dumpster were made on 8/7/23 and 8/9/23 through 8/11/23. The garbage dumpster was located outside of the facility kitchen. The garbage dumpster was left open despite having covers. A strong odor was noticeable from the open trash dumpster. From 8/9/23 to 8/11/23 there were multiple bags of trash inside the dumpster. On 8/9/23 at 2:09 PM the observations of the uncovered garbage dumpster were shared with Staff 6 (Dietary Manager). Staff 6 stated he was unaware the garbage dumpster was uncovered. On 8/10/23 at 10:05 AM Staff 1(Administrator) was informed of and shown the uncovered garbage dumpster. She stated she was not aware the garbage dumpster was to be covered at all times.

Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 8/8/23 a review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 3/27/23 had no documentation they completed 12 hours of in-service training. -Staff 12 (CNA), hired 6/15/22 had no documentation they completed 12 hours of in-service training. -Staff 13 (CNA), hired 10/14/22 had no documentation they completed 12 hours of in-service training. -Staff 14 (CNA), hired 1/5/23 had no documentation they completed 12 hours of in-service training. -Staff 15 (CNA), hired 2/1/23 had no documentation they completed 12 hours of in-service training. On 8/8/23 at 9:06 AM Staff 16 (Clinical Operations Education Director) confirmed the facility was unable to provide documentation to verify any…

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 offer the resident the opportunity to participate in the care planning process for 1 of 4 sampled residents (#19) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 19 admitted to the facility on [DATE] with diagnoses including anxiety disorder. On 8/7/23 at 10:11 AM Resident 19 stated she/he would like to attend her/his care conference and did not recall attending one in the past. On 8/8/23 Resident 19's medical record was reviewed and revealed no care conferences were completed since she/he admitted to the facility. On 8/8/23 at 11:03 AM Staff 3 (Social Services Director) acknowledged Resident 19 did not have a care conference completed since she/he admitted to the facility on [DATE].

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an Advance Directives for 1 of 3 sampled residents (#14) reviewed for Advanced Directives. This placed residents at risk for not having their health care preferences honored. Findings include: A record review on 8/7/23 revealed no advance directive or documentation to indicate Resident 14 was informed of or provided written information concerning their right to formulate an advance directive. On 8/9/23 at 2:33 PM Resident 14 stated she/he completed an Advance Directive during her/his hospital stay prior to admission. On 8/10/23 at 11:34 AM Staff 3 (Social Services) stated the facility provided an Advanced Directive form to Resident 14 upon admission. Staff 3 (Social Services) confirmed the facility did not follow up to ensure a copy of the Advance Directive was obtained and placed in the medical record.

Based on interview and record review it was determined the facility failed to provide NOMNC (Notice of Medicare Non Coverage) and SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 2 of 3 sampled residents (#s 247 and 248) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 247 admitted to the facility with Medicare Part A services on 1/19/23. The last day of coverage for skilled services was 2/13/23. Resident 247 remained in facility. A review of the medical record revealed no evidence a NOMNC was provided to Resident 247 when skilled services ended. Resident 248 admitted to the facility with Medicare Part A services on 1/20/23. The last day of coverage for skilled services was 3/3/23. The resident remained in the facility until 5/5/23. A review of the medical record revealed no evidence SNF ABN was provided to Resident 248 when skilled services ended. On 8/8/23 at 11:57 AM Staff 3 (Social Services Director) was unable to find the required beneficiary forms for…

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 and implement physician orders and provide bowel medication in a timely manner for 2 of 6 sampled residents (#s 26 and 43) reviewed for medications and tube feeding. This placed residents at risk for medical complications from constipation and adverse side effects of medications. Findings include: The facility's undated Bowel Care Protocol indicated if a resident did not have a BM (bowel movement) in 72 hours a licensed nurse was to perform an abdominal assessment and offer Miralax (a laxative) in eight ounces of liquid. It was okay to use the Miralax on top of existing Miralax order, if it existed. If there were no results in 24 hours they were to notify the physician. For any resident on narcotics, request an order for scheduled or PRN stool softeners or Miralax. 1. Resident 26 admitted to the facility on 8/2022 with diagnoses including dementia and depression. a. Resident 26's Physician Order Report signed by the physician on 7/28/23 revealed an order for Miralax powder. Staff were to administer…

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 elopement interventions were in place for 1 of 3 sampled residents (#26) reviewed for accidents. This placed residents at risk for lack of supervision and increased elopement risk. Findings include: Resident 26 admitted to the facility in 8/2022 with diagnoses including dementia and depression. A review of Resident 26's clinical record from 4/11/23 through 7/13/23 revealed the resident wandered throughout the halls and facility with the use of her/his walker, entered other residents rooms and at times, was difficult to redirect. Resident 26's Physician Order Report signed by the physician on 7/13/23 revealed the resident was an elopement risk with a start date of 6/5/23 and her/his elopement precautions was to make sure the resident had her/his name band on at all times and staff were to document her/his whereabouts and if the resident was exhibiting exit seeking behavior. A review of Resident 26's 7/2023 and 8/2023…

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 records were complete and accurate for 3 of 6 sampled residents (#s 7, 14 and 44) reviewed for medications and death. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 44 admitted to the facility on [DATE] with diagnoses including heart failure, chronic pulmonary disease and diabetes. A review of Resident 44's [DATE] admission orders revealed she/he was coded a DNR (Do Not Resuscitate) and no CPR (Cardiopulmonary Resuscitation) was to be initiated. A signed copy of Resident 44's [DATE] POLST (Physician Orders for Life-Sustaining Treatment) revealed she/he was a [Full Code] and to initiate CPR. A [DATE], [DATE] and [DATE] Late Nursing Note entry indicated Resident 44's code status: DNAR - No CPR. Do Not Attempt Resuscitation (allow natural death). A [DATE] Nursing Noted indicated Staff 25 (LPN) around 2200 hours found Resident 44 unresponsive with no pulse or respirations. After finding…

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.