Arlington Health And Rehabilitation

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, accessible and systematically organized for 1 of 1 resident (Resident 17) for dialysis and 1 of 2 residents (Resident 5) reviewed for unnecessary medications. These failures placed residents at risk for not having their medical records accurate and incorrect/incomplete information being considered when making medical decisions. Findings included . <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 had diagnoses to include chronic pain syndrome and generalized anxiety syndrome. In a record review of Resident 5's physician orders included Methadone 5 milligrams (mg) 1 tablet by mouth every eight hours as needed for severe pain and Acetaminophen (pain medication to relieve mild to moderate pain) 325 mg two tablets every four hours as needed for pain. Resident 5 had as needed pain management non-pharmacological interventions to include…

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

Based on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2-nourishment refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . On 01/29/2025 at 9:23 AM observed the following in the facility kitchen refrigerator: - applesauce in a container with a green lid-undated and not labeled - opened cottage cheese container with no open date -opened freezer jam with no open date. Observed a note on the front of the refrigerator which read, all items in the refrigerators/freezers need to have labels with item and date on them no exceptions. On 01/29/2025 at 9:23 AM observed a cabinet which contained a refrigerator labeled Fruit Bar. The lower portion of the cabinet was a refrigerator containing trays…

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 Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 5 of 16 residents (Residents 1, 12, 16, 22, and 32) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed the Care Area Assessment process reflects conditions, symptoms, and other areas of concern that are common in nursing home residents. The CAA process provides for further…

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 and record review, the facility failed to review, revise and implement a comprehensive plan of care to included resident specific information for 6 of 18 sampled residents (Residents 12, 22, 34, 40, 16, & 33) reviewed for care plans. The failure to establish and implement care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs and preferences. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses that included dementia. <WANDERING> Review of Resident 22's care plan dated 05/11/2022 showed they were at risk for wandering. Interventions for Resident 22's wandering included assessing for fall risk, ensuring needs were met, identifying a pattern of wandering, use of a wander guard and the use of the fenced patio if they were looking for sun. Review of Resident 22's Document Survey Report for 1/01/2025…

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 5 of 7 resident's (Resident 13, 19, 20, 40, and 260) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This failure placed all residents at increased risk of unmet care needs, medical complications and decreased quality of life. Findings included . Review of the facility Policy titled Notification of Change in Condition dated 08/30/2024 showed the facility shall promptly notify the resident, their provider, and primary contact of changes in the resident's condition and/or status. The care provider would be notified by the nurse when necessary or appropriate in the best interests of the resident. <RESIDENT 13> <WEIGHTS> Resident 13 admitted to the facility on [DATE]. Admitting diagnoses to include Congestive Heart Failure (CHF - a chronic condition in which the heart does not pump blood as…

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 (1 and 22) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and updating care plans. The facility failed to ensure Resident 22's use of an as needed psychotropic medications was limited to 14 days. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . Review of the facility policy titled Psychotropic Medications updated 01/01/2023 showed, residents on psychotropic medications will be reviewed by the psychotropic team quarterly and more frequently, if indicated. During the quarterly…

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 that staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 4 hallways with Enhanced Barrier Precautions (EBP), 1 of 1 observations for wound care (Resident 33), 1 of 3 residents observed during personal care (Resident 13) and 1 of 1 housekeeping staff observed for hand hygiene. The facility failed to ensure that staff used the Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during high contact resident care activities and failed to perform proper hand hygiene. These failures placed all residents and staff at risk for the potential transmission of infections. The facility was currently in a gastrointestinal virus outbreak. Findings included . Review of a facility policy titled, Enhance Barrier Precautions, dated 10/03/2022 showed - EBP to be implemented for residents with wounds, indwelling medical devices, or residents infected…

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 residents (Resident 5 and 263) were properly assessed for the safety of self-medication administration. This failed practice placed residents at risk for medical complications and medication errors. Findings included . Review of a facility policy titled, Self-Medication Administration dated 09/16/2022 showed: Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. <RESIDENT 263> Resident 263 was admitted on [DATE] with diagnoses to include left hip fracture with surgical repair. Resident was alert, oriented and can verbalize needs. In an observation and interview on 01/30/2025 at 9:30 AM, an eye drop container labeled Pataday Ophthalmic Solution (eye drop to treat itching and redness in the eyes due to allergies)…

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 the required beneficiary notice for 2 of 3 residents (Residents 47 and 265) reviewed for liability notices. Failure to provide the appropriate form for the beneficiary notice and failure to give the Notice of Medicare Non-Coverage (NOMNC) 48 hours before the Medicare Part A's last covered day placed the residents at risk for not being fully informed of their rights to appeal the decision to end skilled services and/or the potential costs of continued services if the residents wished to stay longer at the facility. Findings included . <RESIDENT 47> Resident 47 was discharged on 01/22/2025. Last covered day of Medicare Part A service was 01/01/2025. Review of the Advance Beneficiary Notice of Non-coverage (ABN) form signed by Resident 47's spouse showed the facility used Centers for Medicare and Medicaid Services (CMS) form R-131. Per CMS guidelines, Skilled Nursing Facilities (SNF) should be using CMS-10055 forms for SNF ABN. In an interview on 01/31/2025 at 2:33 PM, Staff F, Social Service Director, stated that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly initiate, resolve and document resident grievances for 2 of 4 sampled residents (Resident's 45 and 25) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing clothing, broken furnishing and placed residents at risk for frustration and diminished quality of life. Findings included . Review of the facility policy, titled, Grievance Policy and Procedure for Residents, revised date 04/15/2024, showed grievances were resolved immediately when possible, by the individual receiving the grievance. The policy showed grievances would be completed within 5 days and the resident would be notified and updated if the grievance took longer than 5 days. <RESIDENT 45> Resident 45 admitted to the facility on [DATE]. According to the Minimum Data Set (MDS-an assessment tool) assessment, dated 12/15/2024, 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 policies and procedures for timely reporting of alleged financial exploitation of 1 of 2 residents (Resident 16) reviewed for abuse/neglect. The facility failed to report to the state agency and law enforcement when a resident voiced concerns related to their financial affairs. This failure by the facility to identify, report, and investigate an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Abuse and Neglect, dated 08/2024 stated the facility will report allegation(s) of abuse and neglect to the appropriate authorities. Allegations of abuse and neglect will be reported to the Department of Social and Health Services (DSHS) following the nursing home reporting guidelines the Purple Book. Review of the Nursing Home Guidelines, The Purple Book, October…

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 and record reviews the facility failed to review and revise care plans for 2 of 12 residents (Residents 40 and 1) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team placed residents at risk for unmet care needs, adverse health effects and diminished quality of life. Findings included . Review of the facility policy titled, Care Plan Policy, revised on 08/16/2024, showed care plans are updated with any status change and revised based on changing goals, preferences, and needs of the resident. <RESIDENT 40> Resident 40 admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses that included diabetes type two (a chronic condition that affects how the body uses sugar for energy), chronic obstructive pulmonary disease (group of lung diseases that restrict breathing), and high blood pressure. <ACCIDENTS/FALLS> In a review of Resident 40's Significant Change Minimum Data Set (MDS- an assessment tool) dated…

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 the necessary activities of daily living care (ADL) and services for 1 of 4 residents (Resident 263) reviewed for bathing. This failure placed the resident at risk for hygiene issues and for diminished quality of life. Findings included . Review of the facility policy titled Bathing revised on 07/01/2017 showed: Bathing schedule will be based on resident's personal requests and physical health needs. Refusal of shower/bath will be documented and reported to Licensed Nurse (LN). Resident 263 was admitted to the facility on [DATE] with diagnoses to include Left hip fracture with surgical repair. The resident was alert and can verbalize needs. According to the resident's care plan, they required 2-person maximum assist with transfers. In an interview on 01/30/2025 at 9:24 AM, Resident 263 verbalized that they had not had a shower since they were admitted at the facility and had asked staff if they can have a shower. 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 provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration dated 10/15/2023 showed oxygen would be provided to residents to improve oxygenation and comfort to residents experiencing respiratory difficulties. The procedure included storing cannula's (tubing inserted into the nose to supply oxygen) and add oxygen to be administered by licensed staff and requires a physician order. Resident 40 admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses that included diabetes type two (a chronic condition that affects how the body uses sugar for energy), chronic obstructive pulmonary…

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, and record review the facility failed to develop a dementia care plan that addressed the physical, mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 4 residents (Resident 22) reviewed for dementia care. These failures placed residents at risk for unmet physical and psychosocial needs, increased behaviors and decreased quality of life. Findings included . Resident 22 admitted to the facility on [DATE] with diagnoses that included dementia. In a review of Resident 22's Care Area Assessment (CAA-an assessment which directs the care plan development) for cognitive loss/dementia dated 11/13/2024 showed they were severely impaired, had a memory problem with confusion, disorientation and forgetfulness. The description of the impact of cognitive loss/dementia on the resident was noted to be, Resident's care plan addresses cognition impairment. Staff will continue…

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 ensure drugs and biologicals (diverse group of medicines made from natural sources) were refrigerated after opening from 2 of 2 medication carts (Medicare and North Hall) and expired medications and biologicals were disposed of timely in accordance with professional standards from 1 of 2 medication rooms (Medicare Hall). These failures placed residents at risk to receive expired medications, ineffective medication from lack of refrigeration, to experience adverse side effects and other potential negative health outcomes. Findings Included . On 02/03/2025 at 9:49 AM observed the refrigerator of the medication room to contain 3 vials of lorazepam (an antianxiety medication) in a small, clear bag with the expiration date of 10/2024. In addition, observed a small bag with a label that read, Promethegan, the expiration date printed on the label (2023) was crossed out and replaced by a handwritten date of 04/2025. On 02/03/2025 at 10:45 AM observed an open bottle of Acidophilus, a probiotic, with directions to refrigerate after…

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 foods were served in a timely manner and were palatable for 1 of 1 Halls (South Hall) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings Included . In a review of facility policy titled Long Term Care Policy & Procedure Manual labeled food temperatures, undated, showed the facility recommended ranges of temperatures for the safe holding, storage and serving of foods such as hot cereal and hot beverages (coffee and tea) was at 165 degrees Fahrenheit or above. These are the standards suggested for food acceptance and palatability as well as safety. On 01/31/2025 at 8:47 AM observed a full cart of meals on trays in the hallway of South Hall. None of the trays had been served. In an interview on 01/31/2025 at 8:47 AM Staff I, Licensed Practical Nurse (LPN), stated the carts had just arrived a few minutes…

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 have a system in place that ensured effective consistent communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 3 residents (Resident 22) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care and integrate it into the facility care plan. This failure placed the resident at risk for not receiving necessary care and services and/or unmet care needs. Findings included . Review of the facility contract with hospice, titled Nursing Facility Services Agreement dated 02/04/2020 showed in section 2.1.2 coordination with hospice regarding plan of care included design of plan, modification and monitoring of residential hospice patient. The nursing facility shall coordinate with hospice in development of a plan of care. Nursing facility agreed to abide by the plan of care. In a review of Resident 22's progress notes dated 11/13/2024 showed resident was admitted to hospice care. Review…

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 a thorough investigation for three of three residents (1, 2, and 3) reviewed for complete and thorough investigations. The facility failed to thoroughly investigate an unexpected hospitalization that led to the death of Resident 1 and failed to thoroughly investigate two allegations of abuse towards residents (2 and 3) that involved the same staff member [Staff I, Nursing Assistant Certified (NAC)]. This failure to investigate timely and thoroughly placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . Review of the facility policy titled, Abuse and Neglect, undated stated the facility will utilize the nursing home reporting guidelines the Purple Book, October 2015 edition to investigate all allegations of abuse, and/or neglect . the facility social services, Director of Nursing services (DNS), or administrator will investigate and act to protect residents and will closely monitor…

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 policies and procedures for timely reporting of an unexpected death were in place for 1 of 3 residents (Resident 1) reviewed for abuse/neglect. The facility failed to report to the state agency when a resident was sent to the hospital and unexpectedly died hours later. This failure by the facility to identify, report, and investigate an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Abuse and Neglect, undated stated the facility will report allegation of abuse and neglect to the appropriate authorities . Allegations of abuse and neglect will be reported to the Department of Social and Health Services (DSHS) following the nursing home reporting guidelines the Purple Book. Review of the Nursing Home Guidelines, The Purple Book, [DATE] (sixth edition)…

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 accurately assess 1 of 3 sampled residents (Resident 8) reviewed for accuracy of assessments. The failure to ensure a resident had an accurate assessment placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 8 admitted to the facility on [DATE]. Review of Resident 8's Quarterly Minimum Data Set (MDS -an assessment tool) assessment, dated 10/16/2023, showed the resident was coded they were receiving hospice care while a resident in the facility. In an interview 01/11/2024 at 12:12 PM, Staff C, Registered Nurse/MDS Nurse, stated Resident 8's MDS coding they were on hospice was a mistake. Refer to WAC 388-97-1000 (1)(b) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability or Related Condition and a serious mental illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) assessments were completed for all residents with newly evident or possible serious mental disorders for 2 of 5 sampled residents reviewed (Residents 2 and 22). This failure resulted in potential unidentified residents mental health needs, delay in access to Level II PASRR (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) services and decreased quality of life. Findings included . <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include transient ischemic attack (blockage of blood supply to the brain). Review of Resident 2's admission Level I PASRR (a screening to determine if…

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 nutritional care and services for 1 of 3 residents (Resident 8) reviewed for nutrition and/or hydration. The failure to offer meal replacements and supplements when the resident consumed less than 50% of their meals placed residents at risk for nutrition-related complications and for diminished quality of life. Findings included . The resident admitted to the facility on [DATE]. On 01/11/2024, a review of the amount of meals eaten task, for the past 30 days, showed Resident 8 ate less than 50% of the 30 meals offered. On 01/11/2024, a review of the meal replacement for less than 50% of the meal eaten task, for the past 30 days, showed Resident 8 was not offered meal replacements when they ate less than 50% of their meals. 0n 01/11/2024, a review of the supplement for less than 50% of meal eaten task, for 30 days, showed Resident 8 was not offered any supplements when they ate less than 50% of their meals. In an interview on 01/11/2024 at 11:19…

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 15 and 21) reviewed for unnecessary medications, were free of unnecessary psychotropic medications. The facility failed to ensure there were valid diagnoses for use of psychotropic medications, to consistently monitor and care plan target behaviors, to monitor for adverse side effects, and to attempt gradual dose reductions. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . Review of a policy titled: Psychotropic Medications, (dated 2019), showed the facility would ensure residents taking psychotropic medications were reviewed quarterly and as needed for proper diagnosis, target behaviors, behavior monitoring, care planning and gradual dose reductions. The facility would conduct AIMS (Abnormal Involuntary Movement Scale) assessments for residents with orders for antipsychotic…

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.