Soundview Rehabilitation And Health Care INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and and Control Guidelines and standards of practice for 2 of 2 hallways (Portage Hall and Ship Harbor Hall) reviewed for Contact Precautions (infection control measures used to prevent the spread of germs through direct or indirect contact by wearing a gown and gloves before entering the resident room) for residents (Resident 20, 33, and 49) and ensure appropriate disinfection of blood glucose meters (device used to measure blood glucose levels) between each resident use. The facility failed to ensure staff were compliant with appropriate hand hygiene practices during wound care for 1 of 1 residents (Resident 28). These failures placed all residents and staff at risk of potential infection. Findings included .According to the Centers for Disease Control (CDC) titled, Transmission-Based Precautions, dated 04/03/2024, Contact Precautions are used for patients with known or suspected…

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 the facility failed to maintain a resident call light system that was functionable and audible, as required in 2 of 2 halls (Portage Hall and Ships Harbor Hall). This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included .<SHIPS HARBOR HALL> In an observation on 03/23/2026 at 12:49 PM room [ROOM NUMBER] call light was on, visible, not audible. In an observation on 03/24/2026 at 12:48 PM room [ROOM NUMBER]'s call light was on, visible, not audible. In an observation on 03/25/2026 at 9:27 AM room [ROOM NUMBER]'s call light was on, visible, not audible. In an observation on 03/23/2026 at 10:28 AM, the call light was on for room [ROOM NUMBER]-1 but it was not audible. In an observation on 03/23/2026 at 11:50 AM, the call light was on for room [ROOM NUMBER] but it was not audible. In an observation on 03/23/2026 at 2:59 PM, the call lights were on for room's 1 and 3 but they were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for three of three residents (27, 31, and 28) reviewed for dignity. This failure had the potential to result in embarrassment and psychological harm to Resident's when staff members failed to provide privacy during care.Findings included . Review of the undated facility policy Resident Rights showed employees shall treat resident's with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility and include the right to a dignified existence, be free from abuse, participate in care planning and treatment, and be supported by the facility to exercise their rights. Review of the admission packet included an undated copy of Your Rights as a Resident showed residents have the right to choose their activities, schedules and health care they want. Residents have the right to plan…

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 observations and interviews, the facility failed to ensure a clean, safe, comfortable and homelike environment for 2 of 2 halls (Portage Hall and Ship Harbor Hall), 1 of 1 shower rooms and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for restraints and securement of a cable box device, and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for floorboards. Failure to maintain carpets, floorboards, shower rooms and bed rails and floorboards in good repair and safely functioning, and carpets and shower room in sanitary condition placed residents at risk for diminished quality of life and compromised dignity. Findings included .<SHOWER ROOM> On 03/25/2026 at 8:56 AM observed the shower room to have a bathroom to the left upon enter with a sign noting for staff use, a room which was tiled and had missing shower head and handle with various items stored and another room which contained the shower room. The storage room contained various items in the corner, piled high, hair washing blow up sink,…

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 the identification of verbal and mental abuse, and the protection of residents from their Alleged Perpetrator/Alleged Perpetrators (AP/APs), after allegations of abuse were reported to the facility for 1 of 1 residents (Resident 14) reviewed for abuse/neglect. This failure placed all residents at risk for further abuse, fear, and unmet care and services. Findings included .Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated as version 09/21/2022 documented the facility residents have the right to be free from abuse, neglect, and misappropriation of resident property, and exploitation to include verbal and mental abuse. The facility would not condone any form of resident abuse or neglect, protect residents from harm during investigations and screening and training employees.Resident 14 admitted to the facility on [DATE] with diagnoses to include fracture and urinary…

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 the facility failed to ensure a resident was not administered an antipsychotic (medication that affected the brain, emotions, or behaviors) unless the medication was necessary to treat a specific condition documented in the clinical record for 1 of 5 sampled residents (Resident 35), reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life.Findings included .As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls 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, the facility failed to ensure reporting of alleged verbal and mental abuse, resident to resident altercations, to the State Agency for 2 of 2 residents (Resident 14 and unidentified resident), reviewed for abuse/neglect reporting. This failure placed residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.Findings included .Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated as version 09/21/2022 documented the facility would report per the Nursing Home Guidelines, The Purple Book, facility staff were mandated reporters and thy would report to state agency if they had a reasonable cause to believe or suspect abuse occurred to a vulnerable adult.Review of the Nursing Home Guidelines, also known as the Purple Book, dated October 2015 showed the facility was to report to the state agency and one method of reporting was by the state reporting log. The incident was to be reported via the reporting log within 5 days of discovery.Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five (Resident 31) residents reviewed for care planning. The failure to ensure the comprehensive care plan was implemented to maintain or attain the residents highest practicable well-being placed the residents at risk of not receiving services that would meet their needs, and a decreased quality of life.Findings included .Resident 31 was admitted to the facility on [DATE] with diagnoses to include chronic venous insufficiency (condition that damages leg veins and causes blood to pool in the legs), weakness, chronic pain and depression.Review of Resident 31's Activities of Daily Living (ADL) care plan documented they required extensive assist of 2 staff to turn and reposition in bed and also for personal care to be completed to help prevent them from rolling too close to the edge of the bed.Review of Resident 31's Kardex (resident care directive for Nursing…

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 provide assistance with grooming, including nail care for 3 of 4 residents (9, 31 and 37) reviewed who were unable to carry out their ADL's (activities of daily living) independently. Facility failure to provide the resident, who was dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life.Findings included .Review of the facility's policy, titled, ADL's revised July 2015, documented Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex (tool that shows how to care for the resident), which is accessed in Point of Care (POC). Any changes noted in the resident's performance or abilities will be reported to the licensed nurse. <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses to include hemiplegia left hip fracture 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, the facility failed to ensure 2 of 3 residents (Resident 14 and 27) reviewed received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The failure to secure a wound vacuum (wound vac-medical device that uses controlled suction to speed healing of chronic or deep wounds) when ordered, provide pressure relieving devices and supplements as ordered for Resident 27 placed them at risk for delay in healing and poor quality of life. The failure to coordinate timely a timely orthopedic appointment per resident's orders and preferences placed them at risk for delay in healing for Resident 14. These failures placed all residents at risk for delay in care and treatment, confusion, and potentially poor quality of life. Findings included .<RESIDENT 14>Resident 14 admitted to the facility on [DATE] with diagnoses to include fracture and urinary tract infection.In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively assess, and revise interventions as needed to prevent or address significant weight loss for two of five residents (3 and 11) reviewed for nutritional status and weight loss. These failures placed residents at risk for significant decline in nutritional status and related complications.Findings included .<RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include orthopedic aftercare (surgery of left femur), and a urinary tract infection (infection of any part in the urinary system). Review of Resident 3's MDS (resident assessment tool) admission assessment dated [DATE] documented they had a potential nutritional risk due to their leg fracture and urinary tract infection. Review of Resident 3's nutrition care plan documented they were to have weekly weights, Registered Dietitian (RD) to evaluate and make diet change recommendations as needed, and to monitor labs, all interventions were initiated…

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 respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 2 residents (Resident 11 and 44) reviewed for respiratory care. The facility failed to ensure a Trilogy device (portable ventilator-a medical device that mechanically moves breathable air into and out of the lungs to assist or replace spontaneous breathing) orders were complete and in place, to include the prescribed pressure settings, checking, refilling and cleaning of the device. The facility failed to ensure oxygen (O2) was administered with appropriate physician orders to titrate O2 and change O2 tubing. These failures placed residents at risk for ineffective assisted ventilation, shortness of breath, decreased oxygen saturation and other respiratory complications.Findings included . Review of the facility's undated policy titled, Oxygen Safety and Storage, documented that nasal cannulas…

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, the facility failed to ensure 1 of 1 residents (Resident 6), reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing), had consistent, completed and accurate assessments on the facility's dialysis communication form (a form containing vital information about the resident which is sent to the dialysis center for coordination of care and services). This failure placed the resident at risk for medical complications and unmet care needs.Review of the undated facility policy titled, Dialysis, documented that the licensed nurse will complete the post dialysis assessment upon the resident's return to the facility from dialysis.<RESIDENT 6>Resident 6 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (the final stage of long-term kidney failure requiring dialysis to survive).Resident 6 has dialysis every Tuesday, Thursday, and Saturday.In a record review of post dialysis…

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 a medication error rate of less than 5 percent (%, unit of measure). During observation of 26 opportunities for error, 3 of the 26 medications were administered late, resulting in an error rate of 11.54 %. Further, Resident 2 received medications when they should have been held. These failures placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration.Findings included .Review of the facility policy titled, Medication Administration undated showed medication administration will be provided to residents in a manner that is safe and by the route directed through the Primary Care Provider's (PCP) orders. All persons administering medicine will understand and utilize the 6 Rights of medication administration including right time by checking the frequency of the ordered medication or treatment, double checking that they are giving the ordered dose at 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, the facility failed to ensure residents were free from significant medication errors when medications were not administered per physician orders for 1 of 5 residents (Resident 35) and medications not documented when administered for 1 of 1 residents (Resident 7) reviewed for medication management. These failures placed residents at risk for medical complications, unintended health consequences, and a diminished quality of life.Findings included .Review of the facility's undated policy titled, Medication Administration, documented that that medications will be documented after giving the ordered medication. Staff are to enter all required data including the time, route, and any other specific information.<RESIDENT 7> Resident 7 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mental health condition characterized by intense, alternating mood episodes), major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper labeling of insulin (injectable medication that regulates blood sugar) in 1 of 2 medication carts (Portage Hall Medication Cart), failed to correctly monitor temperatures of vaccines in medication fridge, and secure medication carts according to current standards of practice in 2 of 2 medication carts (Portage Hall and Ship Harbor Hall Medication Carts), and 1 of 1 medication rooms reviewed for medication storage and handling. These failures placed residents at risk of receiving compromised or ineffective medications, unauthorized access to medications and biologicals, and potential drug misuse.Findings included . Review of the undated facility policy titled, Medication Administration, documented that general administration practices include checking the medications for expiration dates, keep medication cart locked when not in physical control, and to document medications as given on the medication administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure resident choices/preferences regarding their bathing schedule were obtained and honored for 4 of 6 sampled residents (Residents 1, 2, 3, 4, and 7) reviewed for preferences. This failure placed residents at risk of being unable to exercise their rights, not having their choices/preferences honored, and a diminished quality of life. Findings included.<RESIDENT 1>Resident 1 was admitted to the facility with a diagnosis of a stroke with right arm and leg weakness. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 01/22/2026, documented that the resident had no cognitive impairment, and did not receive a shower during the MDS assessment period. Review of Resident 1's Baseline Care Plan, dated 01/15/2026, showed no documentation the resident was asked their daily preferences regarding bathing/showering. Review of Resident 1's Self-Performance Deficit care plan, dated 01/20/2026, documented the resident required…

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 develop a policy, comprehensively assessed residents, documented risk and benefits, ensured ongoing monitoring and maintenance for 3 of 3 sampled residents (Residents 4, 5, and 6) reviewed for bed rails/side rails. These failures placed residents at risk for injury, entrapment, and a diminished quality of life. Findings included.<RESIDENT 4>Resident 4 was to the facility with diagnoses to include heart failure and fall with weakness. Review of the resident's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 02/02/2026, documented the resident had moderate cognitive impairment.Review of Resident 4's Enabler Device Assessment, dated 01/27/2026, documented they used a half side rail (did not specify how many or where the side rail was) to maximize their independence and was unable to remove the side rail. Risk and benefits for the use of the side rail was explained to the resident. There was no documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, what information was conveyed to the receiving provider, or a bed hold offered upon transfer, of discharges and/or transfers, as required for 2 of 4 sampled residents (Residents 2, and 3), reviewed for hospitalization and bed hold. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. This failure placed residents and/or their representatives to participate in the resident's right to hold their bed while in the hospital or why they were transferred to the hospital, and diminished quality of life. Findings included.Review of the facility's policy titled, Admission, Transfer &…

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 interviews and record reviews, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . Review of the key personnel list, provided by the facility during the entrance conference meeting on 05/08/2025, showed no staff names were listed under the dietary manager. During an interview on 05/08/2025 at 8:53 AM, Staff E, Dietary Services, stated that the kitchen did not currently have a dietary manager. Staff E stated there had been a dietary manager with certification, but they no longer work for the company. During an interview on 05/12/2025 at 11:15 AM, Staff A, Administrator, stated the facility did not have a dietary manager and the person filling in did not have dietary credentials. Reference WAC 388-97-1160 (1)

Based on observation and interviews, the facility failed to properly store, distribute and serve food in accordance with professional standard for food service safety. The facility failed to store perishable foods properly and failed to dispose of outdated foods timely in 2 of 2 storage areas. These failures placed residents at risk of food borne illness. Findings included . During an observation and interview of the dry food storage room on 05/08/2025 at 9:18 AM, individual 1.5-ounce containers of honey mustard dressing were noted in a cardboard box on a shelf. The cardboard box documented must be refrigerated. The individual containers showed keep refrigerated on the label. Staff E, Dietary services, stated they would need to dispose of the dressing as it was not kept in the refrigerator. On 05/08/2025 at 12:27 PM, the pantry area in the resident dining room was reviewed. A plastic container of shredded cheese was noted in the refrigerator with a sticker that showed exp date May 3rd, a bin of individual 1.5 ounce containers of honey mustard dressing was sitting on the counter, 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, the facility failed to dispose of garbage properly for 2 of 2 dumpsters. Failure to ensure garage was disposed of properly and the area was clean and free of litter, placed residents at risk for contamination of their environment by attracting bugs, rodents, birds and other germ carrying vectors. Findings included . During an observation on 05/08/25 at 3:04 PM, there were two dumpsters outside the facility. Neither dumpster had the lids closed. An unnamed staff person was observed placing garbage inside the dumpster, and did not close the lid. Surrounding the dumpsters, there were plastic bags of garbage, one of which had a tin can inside, protein drink carton with straw sticking out the top, scattered debris behind the dumpsters and two 5-gallon buckets filled with a thick sludge material with water sitting on top of the sludge. Beside the dumpster area was a knee-high pile of yard waste (branches and pinecones,) three mattresses, a cloth recliner chair and four mini refrigerators. There were flies noted flying around the area. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards were met for 1of 1 sampled residents (Resident 134) reviewed for intravenous (IV - into the vein) medication administration, 3 of 5 residents (Residents 18, 19, and 29) reviewed for unnecessary medication review, and for 1 of 2 residents (Resident 19) reviewed for pressure ulcers. These failures placed the residents at risk of complications, worsening infections, delay in healing, and adverse outcomes. Findings include . Review of the facility policy titled, Introduction and Intravenous Policies, undated states the nursing staff should review physician orders, evaluate the appropriateness of the orders, verify medication compatibility prior to administration, maintain the IV site and system .all IV administration tubing should be labeled with date, time, and nurse initials .tubing should be changed every twenty-four hours for intermittent infusions . all dressing should be assessed and documented every eight…

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 staff were com-pliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 2 units (Ship Harbor and Portage) reviewed for transmission-based precautions (TBP) for residents (Residents 4, 12, and 28) who had tested positive for Coronavirus Disease 2019 (COVID-19 -an infectious disease-causing respiratory illness with symptoms) The facility failed to ensure licensed staff implemented the use of Enhanced Barrier Precautions (EBP) for 2 of 2 residents (Residents 19, and 134) while they provided direct care to residents on EBP, failed to ensure staff were compliant with appropriate hand hygiene practices during perineal care (process of cleaning genitals and anal area) for 1 of 1 resident (Resident 12), and failed to ensure they had a system in place for the transport of clean linens for 1 of 1 laundry rooms. These failures placed all residents and staff at risk of potential infection. Findings included .…

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 residents were evaluated and assessed for safe administration of medications for 2 of 3 residents (Residents 26, and 134), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment placed the residents at risk for medication errors, adverse medication interactions, and complications. Findings included . Review of the facility policy titled, Self-Administration of Medications, undated stated as part of the evaluation comprehensive assessment the resident will be assessed for cognition and physical ability to determine self-administration would be safe or clinically appropriate .once resident was assessed and deemed safe and appropriate, the medical record will be documented and the care plan updated . self-administered medications will be stored in a safe and secure place, not accessible to other residents. <RESIDENT 26> Resident 26 admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 2 of 3 residents (Residents 4, and 6), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, anxiety, and a diminished quality of life. <Resident 4> Resident 4 was a long-term resident at the facility. According to the quarterly MDS (an assessment tool), dated 02/18/2025, Resident 4 was severely cognitively impaired. During an observation on 05/09/2025 at 10:44 AM, Resident 4 was in bed with no call light within reach. During an observation on 05/09/2025 11:21 AM, Resident 4 was in bed with no call light within reach. During an observation on 05/09/2025 at 11:43 AM, Resident 4 was in bed with no call light within reach. During multiple observations on 05/12/2025 at 8:45 AM, 9:08 AM, 10:17 AM, 10:41 AM, 12:11 PM, 1:31 PM, and 1:53 PM, Resident 4 was in bed, with no call light within reach. The call…

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

Based on interviews and record reviews, the facility failed to complete annual staff performance reviews as required for 3 of 5 sampled staff (Staff N, S, and T). The facility also did not ensure that the required 12 hours of education based on these evaluations were completed for 2 of 5 staff members (Staff S and T). This failure placed residents at risk of receiving care from inadequately trained and/or underqualified staff, which diminished the quality of life. Findings Included . Review of the document titled 'CNA_hours_HCA_12mos', documented that from April 2024 to May 2025, Staff M was missing 5 of 12 hours of annual education, and Staff T was missing 2 of 12 hours of yearly education. A review of employee files on 05/12/2025, provided by the Facility Administrator, revealed that there were no annual evaluations for staff members N, S, and T. During an interview on 05/14/2025 at 10:52 AM, Staff A, Administrator, stated that Staff T was missing 2 of the 12 required hours of education and annual evaluations, Staff S was missing 5 of the required 12 hours of education and annual…

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 a medication error rate of less than 5 percent (%, unit of measure). During observation of 25 opportunities for error, 2 of the 25 medications were administered late, resulting in an error rate of 8 %. These failures placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration. Findings included . <Resident 24> Resident 24 was a short-term resident at the facility. According to the admission MDS assessment dated [DATE], the resident was not cognitively impaired. According to the National Institute of Health (NIH), Levothyroxine, which was a medication administered for thyroid issues, is absorbed better in the body when it is taken on an empty stomach and should be administered 30 to 60 minutes before breakfast. During an observation on 05/12/2025 at 8:32 AM, Staff G, Agency Licensed Practical Nurse (LPN), administered Resident 24's 7:00 AM dose of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly label and/or discard undated, opened vials of aplisol (solution used to test for persons with possible Tuberculosis- an infectious respiratory disease) and ensure refrigerated drugs were stored at proper temperatures in 1 of 1 medication rooms. This failure placed the residents at risk of receiving compromised or ineffective medications. Findings included . Review of a facility policy titled, Storage of Medications, dated [DATE], Documented that the facility should maintain a temperature log and record temperatures at least once a day. <REFRIGERATOR TEMPERATURE LOGS> Review of the temperature log for the medication refrigerator in the medication room for [DATE] showed no temperature was recorded for [DATE], [DATE], [DATE] or [DATE]. Review of the temperature log for the medication refrigerator in the medication room for [DATE]-13th, 2025, showed no temperature was recorded for [DATE], [DATE], [DATE], [DATE] or [DATE]. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible for 1 of 5 residents (Resident 11) reviewed for unnecessary medications and 1 of 3 residents (Resident 383) reviewed for pain. The facility failed to ensure the residents' medical records had active orders and complete and accurate Medical Administration Records (MAR) which placed the residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled Medication and Flexible Pass Time, revised 10/27/2023, stated to double check the MAR prior to giving medication and to follow the ten rights of medication administration. Review of a facility's undated policy titled, Ten Rights of Medication Administration, documented right response and right documentation were part of the ten rights. <Resident 383> During a review of the narcotic book (record of medication administration of medications…

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

Based on interviews and record review, the facility failed to designate one individual as the Infection Preventionist (IP) who worked at least part-time at the facility. This failure placed the residents at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices. Findings included . Review of the facility provided policy titled, 'Infection Preventionist', undated, showed the IP was to be employed on-site and at least part-time. In an interview on 02/07/2025 at 10:35 AM, Staff A, Administrator, stated they had not had an IP on-site for over 2 months and no individual had been designated as the on-site facility IP at the time of the recent Influenza outbreak. In an interview on 02/07/2025 at 1:35 PM, Staff B, Registered Nurse, stated they believed Staff C was the IP of the facility but was unsure. In an interview on 02/07/2025 at 3:00 PM, Staff C, Director of Nursing, stated they had an IP certificate but had not worked as the IP in the facility at any time and no staff had been working on-site as the IP in the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 2 of 6 residents (Residents 1, and 2) who had physician orders to obtain daily and weekly weights were obtained accordingly. This failed practice placed residents at risk of poor health outcomes and a diminished quality of life. Findings included . On 01/30/2025 a weight policy & procedure was requested from the facility and the facility was unable to provide the requested policy or procedure. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure, hypertension (HTN), and cardiorespiratory conditions. Review Resident 1's Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], showed the resident had passed away in the facility. Review of Resident 1's Care Plan printed on 01/27/2025, showed the following focus problems: -Hypertension initiated on 01/06/2025 (2 days after the resident passed away) and -At risk for altered respiratory status/difficulty breathing related to including chronic…

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 the facility failed to conduct thorough investigations for 3 of 3 residents (Resident 1, 2 and 3) reviewed for abuse/neglect. Failure to conduct thorough investigations to identify root cause(s) and all contributing factors placed residents at risk for unidentified abuse or neglect, inappropriate corrective actions, and ineffective care planning. Findings included . <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include right femur fracture, closed fracture without routine healing, and repeated falls. Review of the admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed that Resident 1 was cognitively intact. Review of Resident 3's Kardex (resident information for nursing assistant's [NACs] derived from the care plan) dated 08/05/2024, showed the resident required one staff to assist with transfers and had posterior hip precautions (do not bend the hip past 90 degrees, do not cross legs, do not bend over) in place.…

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, the facility failed to protect the residents' right to be free from abuse and neglect by staff for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failed practice placed residents at risk for further abuse and/or neglect and potential injuries. Findings included . Review of the facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 09/21/2022, showed the facility did not condone any form of resident abuse or neglect and to aid in abuse prevention, all staff were expected to report any signs and/or symptoms of abuse/neglect to the Administrator or Director of Nursing Services (DNS) immediately. During abuse investigations, residents will be protected from harm by the following measures, employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the Administrator. Resident 1 admitted to the facility on [DATE] with diagnoses…

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, the facility failed to immediately report to the state agency potential abuse and/or neglect for 1 of 3 residents (Resident 1) reviewed for allegations of abuse and/or neglect. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 09/21/2022, showed the facility reporting requirements, guidelines, and timelines are found in the Nursing Home Guidelines, The Purple Book. An alleged violation of abuse, neglect, abandonment, or financial exploitation, or a suspected physical or sexual assault will be reported immediately, as soon as the victim is protected from further harm, or within 24 hours, if the alleged violation does not involve a potential crime or if an injury of unknown source did not result in serious bodily injury. Review of the Nursing…

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

Based on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) license completed a Nursing Assistant Certified (NAC) class and passed the state license exam within four months of hire for 1 of 1 NAR's (Staff E) reviewed for staff licenses. This failure placed residents at risk to receive care from unlicensed staff. Findings included . Record review of the facility staff list showed Staff E was hired on 04/24/2024 as a NAR. Review of the daily staff assignment sheets from 08/25-8/29/2024, showed that Staff E worked the night shift on 08/27/2024 and 08/28/2024. During an interview on 08/29/2024 at 4:31 PM, Staff A, Administrartor, stated Staff E had a current NAR license, and were involved in a program to become an NAC, but did not know their status of completion. In an email correspondence dated 09/03/2024 Staff A stated Staff E's hire date was 04/24/2024 and that they had been working as an NAR until 8/29/2024 and was only eligible to work until 08/24/2024. Staff A stated Staff E was no longer eligible to work as an NAR and they…

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

Based on interview, and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff J) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . In a review of the staff list showed Staff J had been employed at the facility since 12/07/2021. On 05/23/2024 11:12 AM, Staff J, Dietary Manager (DM), stated they were not a certified DM. Staff J stated they been in the position for a short time and was not enrolled in a program to obtain their certification. On 05/23/2024 at 12:14 PM Staff A, Chief Operating Officer, stated Staff J had been in the position a short time and they were working getting Staff J enrolled in a program to obtain their certification. Refer to WAC 388-97-1160 (2)(3)(a)(b)(i) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and national standards of practice for 2 of 2 hallways (Portage and Ship Harbor) throughout the facility. The facility failed to ensure the implementation of Enhanced Barrier Precautions (EBP) for 14 of 14 residents (Resident 30, 6, 9, 19, 17, 12, 2, 13, 16, 4, 235, 188, 189, and 190) reviewed for transmission-based precautions. The facility failed to establish an infection surveillance plan for a Coronavirus Disease 2019 Outbreak (COVID-19 -an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) for 29 of 35 residents. they failed to implement a respiratory protection plan (RPP) for 28 of 59 employed…

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

Based on interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices. Findings included . Review of the facility policy titled, Infection Prevention and Control Program (IPCP), dated June/2023, showed that the facility was to designate an infection prevention specialist (Infection Preventionist [IP]) who would be responsible for coordinating and overseeing the IPCP. The IP would incorporate the antibiotic stewardship program, and would be qualified through special training certification, education, and experience . Duties included but not limited to surveillance, antibiotic stewardship, data analysis, outbreak management, prevention on infections, immunizations, safe injectable medication…

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, the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for 4 of 4 sampled residents (Residents 12, 19, 27 and 23) reviewed for dignity. This failure had the potential to result in psychological harm to residents when staff members failed to treat residents in a dignified manner and honor their rights. Findings included . Review of the undated facility policy, Resident Rights, showed employees shall treat residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility and include the right to a dignified existence, be free from abuse, participate in care planning and treatment, and be supported by the facility to exercise their rights. Review of the admission packet included an undated copy of Your Rights as a Resident, showed residents have the right to choose their activities, schedules, and health care they want.…

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 observations, interviews, record review, the facility failed to develop and/or implement policies and procedures for ensuring a communicable disease outbreak for Coronavirus Disease 2019 COVID-19) was reported to the state reporting agency (Complaint Resolution Unit - CRU) 1 of 1 disease outbreaks reviewed and failed to report 1 or 1 residents (Resident 32) reviewed for death. The facility failed to report a communicable disease outbreak in the facility, failed to report an unexpected death in the facility, and failed to log either on the state reporting log. This failure to report to the required state agency and log the outbreaks and unexpected deaths on the state reporting log placed all residents at risk for unidentified and uninvestigated concerns. Findings included . Review of the facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 09/21/2022, showed the facility reporting requirements, guidelines, and timelines are found in the Nursing Home…

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 the facility failed to provide written notice to 4 of 4 residents (Resident 18, 240, 241 and 242) and their family member in a manner, which they understood, of the facility's intention and justification for discharging the resident. The facility also failed to provide the resident and their family member information on their right to appeal the discharge decision, including contact data for advocacy groups. Findings included . Review of an undated facility policy titled, Your Rights as A Resident, showed that notice of transfer or discharge must be given at least 30 days ahead of time, except that it may be given on shorter notice (but still as soon as practicable before transfer or discharge). You have the right to expect that the facility will provide you with sufficient preparation and orientation to ensure a safe and orderly transfer or discharge. Review of the facility policy, Discharge Against Medical Advice (AMA), dated 10/27/2023, showed the facility will advise…

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 professional standards were met for 2 of 2 (18 and 235) residents reviewed for bowel management, 2 of 2 (9 and 30) residents reviewed for percutaneous endoscopic gastrostomy (PEG) tube (tube inserted into the stomach to aid in supplemental nutrition), 1 of 1 (Resident 8) residents reviewed for a toileting plan, and 1 of 1 (Resident 6) residents reviewed for positioning and comfort. The facility failed to ensure licensed nurses administered necessary bowel medication to prevent constipation, failed to ensure nursing staff offered toileting to a resident when necessary, failed to ensure a hospice (end of life) resident was positioned for comfort, and failed to ensure licensed nurses stored unused supplemental formula according to manufacturer guidelines, used clean supplies, and that the supplies were labeled and dated. These failures placed the residents at risk for complications, potential infections, and adverse outcomes. Findings…

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, the facility failed to ensure adequate supervision to prevent accidents for 1 of 1 resident (Resident 7) reviewed for falls. The facility failed to adequately supervise Resident 7 who had 9 falls in 90 days, and placed residents who were assessed to be fall risk and placed residents at risk for injury and negative outcomes. Findings included . Review of the facility policy titled, Fall Assessment and Management, revised 09/21/2022, showed the facility will establish ad resident-centered fall prevention plan based on relevant assessment information .nursing staff, physician and pharmacist will review the residents medications that could relate to falls .staff will look for possible links between falls . the staff will identify resident specific risk and causes to try an prevent the resident from falling. Resident 7 admitted to the facility on [DATE] with diagnoses including dementia, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (an assessment…

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

Based on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 5 of 23 sampled residents (Residents 9, 185, 85, 27 and 18), 1 of 2 family complaints and 2 of 2 anonymous complaints that had concerns related to staffing on 2 of 2 halls (Portage and Ship Harbor). The facility had insufficient staff to ensure residents received prompt call light response, assistance with activities of daily living including toileting, oral care, repositioning, and meal assistance and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk to experience feelings of frustration, vulnerability, diminished quality of life, and unmet care needs. Findings included . <FACILITY ASSESSMENT> Review of the facility's assessment, dated 11/22/2023, showed the average daily census was 31 and the facility averaged one to four admits and one to four discharges daily. The assessment showed the Director of Nursing Services…

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

Based on interview, and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 6 of 6 sampled staff (Staff C, D, H, P, S, and BB ) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Facility Assessment, updated on 11/22/2023, showed nurse aides would participate in an annual skill fair and are assessed annually for care competencies by qualified nurses. Licensed nurses were also assessed each year for skills/competencies by qualified nurses and consultant educators, in various areas such as IV (intravenous) care, medicine administration/pass, and wound care. The facility would address areas of weakness as determined in nurse aides' performance reviews.…

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 observations, and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws 1 of 1 medication storage rooms. The facility failed ensure vaccines were dated when opened and failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in a separate locked permanently affixed compartment, and access to the locked box was not accessible to others. These failures placed residents at risk for having unintended access to drugs that should have been securely stored. Findings include . Review of the facility policy titled, Controlled Substances, dated 2024, showed only authorized staff should have access to controlled drugs . controlled medication was locked at all times and access was recorded .the Director of Nursing Services (DNS) maintains a list of who has access to controlled substances containers. In an observation and interview on 05/24/2024 at 1:32 PM, with Staff C, Registered Nurse (RN)/Resident Care Managers…

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, the facility failed to ensure the provided liability notice was completed accurately for 3 of 3 sampled residents (Residents 135, 136, and 137) reviewed for liability notices. This failure placed residents at risk of not being fully informed of the potential cost of continued services. Findings included . <RESIDENT 135> Resident 135 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection (bladder infection), and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 135's required form, the Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN - a form that provides information to the beneficiary so that they can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility), showed the facility used an expired ABN form, there was no resident name documented, and there were blank spaces where information should have…

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, the facility failed to provide a written bed-hold notice, at the time of transfer or within 24 hours of transfer to the hospital, for 1 of 1 resident (Resident 18) reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 18 admitted to the facility 06/07/2023 and was a long-term care resident. According to the admission Minimum Data Set (an assessment tool) assessment, dated 05/03/2024, the resident had no cognitive impairment. Review of Resident 18's progress note, dated 11/02/2023 at 1:25 PM, showed the resident was transported to the hospital. The note showed no information regarding offering the resident a bed hold. Review of Resident 18's social service note, dated 11/03/2023, showed there was no mention of offering a bed hold to the resident. Review of Resident 18's progress note, on 03/02/2024 at 5:52 PM, showed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) screening for residents for a serious mental illness (SMI), intellectual disability (ID) or a related condition was completed if the scheduled discharge did not occur for 1 of 5 sampled residents (Resident 19) reviewed. Additionally, the facility failed to ensure a resident with a Level 1 PASRR screening form was complete prior to admission to the nursing facility for 1 of 8 sample residents (Resident 240) reviewed. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or intellectual disability care needs. Findings included . <RESIDENT 19> Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Level I (pre-screen to determine if a resident may have a SMI, ID, or related condition and is typically completed by the referring entity) PASRR form showed no Level II (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to review and revise care plans for 2 of 4 sampled residents (Resident 18 and 19) reviewed for care planning. These failures placed residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life. Findings included . <RESIDENT 18> Resident 18 admitted on [DATE] with diagnoses which included respiratory failure, kidney failure, and polyneuropathy (nerve disease that impairs sensation and movement). The resident had six hospitalizations since admission and most recently readmitted on [DATE]. Review of the bowel monitors, dated 02/15/2024 to 05/06/2024, showed Resident 18 had no bowel movement from 02/23/2024 to 03/03/2024 (10 days), 03/07/2024 to 03/12/2024 (six days), 04/30/2024 to 05/06/2024 (seven days). Review Resident 18's admission Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem 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 interview, and record review, the facility failed to develop, implement, and document a person-centered discharge planning process for 3 of 3 discharged residents (Resident 240, 241 and 242) when reviewed for discharge planning. Failure to initiate and update a discharge plan consistent with the resident's or their representatives' expressed desires and goals led to the residents leaving the facility against medical advice (AMA) and placed the residents at risk for medical complications, a decreased sense of self-worth and poor quality of life. Findings included . Review of the facility policy, Discharge Against Medical Advice (AMA), dated 10/27/2023, showed the facility will advise residents of the risks of early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. The policy directs the nurse or social worker to: -Advise resident of the risks to their health and well-being if they choose to leave with an unstable medical condition. -Obtain and witness…

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 1 of 2 residents (Resident 4) was provided physician ordered pressure relief interventions. Failure to implement use of off-loading boots, in accordance with the wound care team's recommendation, placed residents at risk for pressure ulcer (PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear [a combination of downward pressure and friction]) development, worsening of their PU, and a diminished quality of life. Findings included . Resident 4 was admitted to the facility 04/14/2024 with diagnoses that included congestive heart failure, atrial fibrillation (irregular heartbeat), and an unstageable (full thickness tissue loss where the depth of the sore is completely obscured by eschar in the wound bed) PU on their left and right buttock. Review of Resident 4's wound care progress note, dated 04/18/2024, showed the treatment…

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 2 of 2 sampled residents (Resident 13 and 235) reviewed for use and care of a catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. This failure placed residents at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications. Findings included . Review of the facility policy, Catheter Care, Urinary, dated 2024, showed the facility's purpose was to prevent urinary catheter-associated complications, including urinary tract infections. This included infection control practices directed staff to use aseptic (a set of guidelines to eliminate pathogens [organisms] and reduce infection risk during medical procedures) technique when handling or manipulating the catheter drainage system. <RESIDENT 13> Resident 13 admitted to the facility on [DATE] with diagnoses that included injury…

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 1 of 2 sampled residents (Resident 237) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure there was an order with parameters in place and failed to ensure oxygen (O2) tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life. Findings included . Resident 237 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety disorder, and cachexia (great weight loss and muscle loss). Review of Resident 237's 05/01/2024 to 05/28/2024, Medication Administration Record (MAR), showed a physician order to check resident's O2 saturations (percentage 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, the facility failed to ensure 1 of 1 sampled residents (Resident 19) reviewed for dialysis services received consistent, ongoing communication and collaboration with the dialysis facility regarding care and services for dialysis residents, including the failure to consistently and accurately complete Resident 19's pre and post dialysis assessments and to obtain and review the dialysis run sheets, prevented staff from identifying how many liters of fluid were removed, what complications, if any, occurred (low blood pressure etc.) and what medications were administered, what labs were drawn, the lab results, and whether there were order changes and/or any follow up required. The nursing home failed to communicate, and to coordinate medication administration arrangements on dialysis days. Additional failed practice included that the facility did not have a policy to delineate each of the facility and the dialysis center responsibilities. The lack of consistent communication…

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, the facility failed to consistently provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 sampled residents (Resident 19). Failure to ensure timely processing and administration of ordered medications placed residents at risk for discomfort and pain, anxiety, and unmet needs. Findings included . Resident 19 admitted to the facility on [DATE] with diagnoses to include end stage renal (kidney) disease (is an advanced stage of chronic kidney disease, when the kidneys can no longer filter wastes and fluids from the body), depression, and gout. Review of the admission Minimum Data Set (an assessment tool) assessment, dated 04/15/2024, showed Resident 19 was alert, oriented and able to make their needs known. Resident 19 had moderate pain and was on a scheduled pain medication regimen with as needed pain medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 5 sampled residents (Resident 7 and 27) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that residents received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . As referenced in the Food and Drug Administration (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there 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 record review, and interview the facility failed to develop, implement and maintain an in-service training program ensure 2 of 2 Nursing Assistant's (Staff H and BB) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs. Findings included . Review of the Facility Assessment, updated on 11/22/2023, showed the facility utilizes the following training topics during all staff in-services or department meetings at multiple times throughout the year: - Communication - effective communications for direct care staff with residents/family. Resident's rights and facility responsibilities - educate staff members on the rights of the resident and the responsibilities of a facility to properly care for its residents. - Abuse, neglect, and exploitation - educate staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, 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, the facility failed to provide care in a manner that promoted resident respect and dignity for 3 of 8 sampled residents (Resident 3, 4, and 5) reviewed for dignity. Additionally, the facility failed to follow up with the residents for additional information, monitor residents for psychosocial harm, and document or make care plan revisions. This failed practice placed residents at risk for diminished self-worth, humiliation, embarrassment, and a decreased quality of life. Findings included . Review of the undated facility policy, Your Rights as a Resident, showed Your right to be treated with dignity and respect is the foundation on which all other resident rights are based. Review of the facility's Nursing Assistant Standards of Care, undated, showed Residents were to be spoken to and treated with respect. Review of a facility's abuse investigation alleged by a named resident, dated 04/02/2024, revealed three additional residents (Residents 3, 4, and 5) who reported…

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, the facility failed to implement their policy regarding identifying and investigating potential allegations of abuse and neglect for 3 of4 residents (Resident 3, 4, and 5) reviewed for abuse and neglect. The failure to identify potential abuse, timely report allegations of potential abuse, complete timely and thorough investigations of the potential abuse, assess and monitor the residents for physical and psychosocial harm, notify responsible parties and providers, and to document the allegations and revise resident care plans placed residents at risk for injury, fearfulness, frustration, humiliation, and further potential abuse. Findings included . Review of a facility investigation, dated 04/02/2024, showed a sample of residents were interviewed to determine if there were additional residents who had concerns with Staff B, Certified Nursing Assistant (CNA). The results of the interviews revealed three residents (Resident 3, 4, and 5) who had voiced allegations of abuse…

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

Based on interview, and record review, the facility failed to thoroughly investigate for an allegation of possible abuse and/or neglect for 1 of 3 sampled residents (Resident 2) reviewed for allegations of abuse and/or neglect. The failure to obtain witness statements from the alleged staff member Staff B, Certified Nursing Assistant (CNA), other key staff who regularly worked with Staff B, and/or received reports from residents about Staff B's treatment of them, and to investigate allegations made by additional residents, compromised the facility from making an informed decision if abuse was substantiated, identifying the extent and impact of the potential abuse, and placed residents at risk for unidentified abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 09/21/2022, showed all reports of resident abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source would be thoroughly investigated by facility management. Review of the Nursing Home…

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, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. Failure to monitor and document Resident 1's condition when they were diagnosed with a urinary tract infection and pneumonia and failure to accurately and timely document when clots/bleeding were observed in the resident's brief, resulted in inaccurate and missing information in Resident 1's clinical record and placed the resident at risk for unidentified complications. This failure placed residents at risk for medical complications, unidentified change in condition, and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include inoperable right ankle fracture and heart attack. Review of Significant Change Minimum Data Set (MDS- and assessment tool), assessment, dated 01/05/2024, showed Resident 1 was cognitively intact.…

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, the facility failed to thoroughly assess and stage a newly identified pressure injury (PI - a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device), inform the resident's physician, obtain treatment orders, and develop an individualized care plan for a new PI for 1 of 3 sampled residents (Resident 1) reviewed for PI's. This failure placed residents at risk for deterioration of their wounds and for diminished quality of life. Findings included . Review of the facility's policy titled, Skin Integrity, dated 06/2023, showed the following: If a PI was present the facility would provide treatment to heal and to prevent additional PI's, preventative measures would be re-evaluated when a resident developed a new PI, PI documentation would include the stage and description of the wound, identification of potential complications, any signs of infection, presence of pain, and description of the dressing 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.