Auburn Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 120> According to the 12/24/2024 admission MDS, Resident 120 had a moderate memory impairment, and medically complex diagnoses, including a multiple infections. According to a 01/05/2025 nursing progress note Resident 120 was observed to be congested with thick mucus and unable to expectorate. The note showed the doctor was called and the resident was transferred to the hospital. Record review showed no proof Resident 120 was offered a bed hold to ensure they were informed of the opportunity to return to their current room and understood how much that would cost.Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 5 sample residents (Resident 36, 120, & 25) and 1 closed record (Resident 19) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received and/or participated in care conferences for 6 (Residents 50, 57, 23, 25, 49, & 38) of 20 residents reviewed and failed to ensure Care Plans (CP) were updated and/or revised to reflect person-centered care for 1 (Residents 36) of 22 sample residents whose CPs were reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's undated Resident Participation - Assessments/Care Plans Policy, the resident/and or their representative had a right to participate in the resident assessment and development of the person-centered CP. This policy showed residents/representatives would receive seven-day advance notice of care conference meetings. The social services director or designee was responsible for maintaining care conference records. <Care Conferences> <Resident 50> According to 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.

Based on observation, interview, and record review the facility failed to ensure resident meals were prepared following the menu as directed for 1 of 1 meal preparations observed. The failure to prepare meals according to the dietician approved spreadsheet placed residents at risk of unmet nutritional needs, and other potential negative health/nutritional outcomes. Findings included . The menu for lunch service on 01/30/2025 showed the facility was serving a main entree of mandarin chicken that day. The menu showed residents requiring a regular menu would be served a scoop of the regular preparation of the mandarin chicken and residents requiring controlled carbohydrate (lower sugar) and renal (kidney) diets would be served a scoop of the diet preparation of the menu. Observation of lunch service on 01/30/2025 from 11:24 AM through 12:52 PM showed Staff Y (Kitchen Cook) serving meals for residents. Staff Y served a scoop of orange chicken from the same pan for residents requiring regular, controlled carbohydrate, and renal diets. There was no second pan of the diet specific main…

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

Based on interview and record review, the facility failed to ensure resident records were maintained comprehensively and readily accessible for 8 of 20 sample residents whose records were reviewed (Residents 1, 4, 120, 44, 33, 25, 49, & 23). The failure to ensure health records were added to the chart timely placed residents at risk for incomplete medical records, delays in treatment, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's undated Dialysis (a process for filtering the blood policy, the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice, including ongoing assessment of the resident's condition, and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The policy included the monitoring of the resident's condition during treatments, monitoring for complications, and for implementation of appropriate interventions. <Resident 1> According to the 01/22/2025 Annual MDS,…

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 performed Hand Hygiene (HH) in accordance with standard precautions and/or remove Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 1 supplemental resident (Residents 269), maintain clean resident equipment, cleanable surfaces throughout the facility, and establish a water management program that assessed and monitored measures to prevent the growth of Legionella (bacteria that could cause a serious lung infection), and other opportunistic waterborne pathogens in the facility's water systems. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment. Findings included . <Facility Policies> The facility's undated Resident Rights Policy showed that resident had a right to a safe, clean, comfortable and homelike environment. 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.

<Standing While Feeding> <Resident 4> According to an 11/26/2024 Significant Change MDS, Resident 4 had a functional limitation in range of motion to one side of their upper arms and required substantial assistance from staff for eating. Review of Resident 4's Self-Care care plan showed the resident required one person assistance with eating their meals. Observations on 01/28/2025 at 12:40 PM showed Staff C (Resident Care Manager) standing next to Resident 4 in the dining area. Staff C was assisting Resident 4 with their fluids during lunch by holding the cup while the resident would drink in between taking bites of food. Staff C continued to stand at Resident 4's side assisting with fluids until 1:05 PM, 25 minutes later, at which time Staff C grabbed a nearby chair. In an interview on 01/31/2025 at 1:06 PM, Staff F stated it was their expectation staff sit down next to a resident when assisting them with their meal. Staff F stated it would feel intimidating if staff stood while assisting a resident with eating or drinking.Based on observation, interview, and record review the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a device for 1 (Resident 48) of 4 residents reviewed for positioning and failed to provide informed consent regarding high-risk medications for 3 (Residents 64, 44, & 33) of 5 sample residents and 1 (Resident 419) supplemental resident. These failures placed residents at risk for loss of autonomy and the opportunity for alternative treatment options. Findings included . <Facility Policy> The facility's undated Restraint Free Environment Policy showed residents had the right to be treated with respect and dignity, including the right to be free from chemical restraints. <Device Consent> <Resident 48> According to the 11/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 48 was assessed to have modified independence for daily decision making and required substantial to maximal assistance 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 interview and record review, the facility failed to implement an effective program to ensure resident Advanced Directives (ADs - legal documents describing treatment wishes for when a resident is incapacitated) were included in the record and residents without ADs were offered assistance to formulate one for 2 (Residents 120 & 49) of 6 residents reviewed for ADs. This failure placed residents at risk for not having their treatment goals met and other negative health impacts. Findings included . <Facility Policy> According to the facility's 2024 Residents' Rights Regarding Treatment and Advance Directives policy, the facility would determine on admission if a resident had an AD in place, and if not, determine of the resident wanted to formulate one, and provide information on how to formulate an AD. The policy showed the facility would identify, clarify, and review with the resident any changes related to ADs during the care planning process. The policy showed the facility would review AD with the…

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

Based on observation, interview, and record review the facility failed to thoroughly investigate an injury accident for 1 (Resident 6) of 8 residents reviewed for accidents, rule out abuse for 1 (Resident 38) of 3 sampled residents reviewed for abuse and investigate a fall for 1 (Resident 419) of 2 reviewed for falls. Facility failure to complete thorough investigations placed residents at risk for further injuries, potential abuse, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2023 Incidents and Accidents policy, an accident was any unexpected or unintentional incident . which resulted or could result in injury or illness to a resident. The policy showed accidents must be entered into the incident report log and thoroughly investigated within five days of the incident. According to the facility's undated Abuse, Neglect, and Exploitation policy, the facility would identify, provide an ongoing assessment, and care plan for appropriate interventions. The facility would provide feedback regarding the concerns that were expressed…

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 <Resident 25> According to a 08/29/2024 Annual MDS Resident 25 admitted [DATE]. The MDS showed Resident 25 had their natural teeth without any issues. Review of a 06/27/2024 Activities of Daily Living CP, Resident 25 had no natural teeth and had an upper denture but no lower denture. The CP showed Resident 25 required staff assistance with cleaning the denture and the residents' mouth/gums twice daily. In an interview on 01/31/2025 at 9:27 AM Staff P stated Resident 25's MDS showed they had their natural teeth without issues. Staff P stated the MDS should show that the resident has the upper denture and no natural teeth. Staff P stated it was important for the MDS to be accurate to plan residents care appropriately. REFERENCE: WAC 388-97-1000 (1)(b). .Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment tool) accurately reflected the status for 5 (Resident 44, 36, 4, 6, & 25) of 20 residents reviewed for accuracy of assessments. This failure placed 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 <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 admitted to the facility on [DATE], had multiple medically complex diagnoses including anxiety, depression, and schizophrenia (a serious mental health condition that affects how people think, feel, and behave), and required the use of an antidepressant and antipsychotic medication during the assessment period. Review of the January 2025 medication administration records showed Resident 44 was receiving an antidepressant and antipsychotic medications daily. Review of a 07/03/2024 Level 1 PASRR showed Resident 44 had no serious mental illness indicators identified, and a Level II evaluation was not indicated. In an interview on 01/30/2025 at 1:54 PM, Staff E stated upon admission the Level 1 PASRR should be assessed by staff for accuracy. Staff E reviewed Resident 44's records and stated the Level I PASRR was inaccurate and should be, but was not updated as required.Based on interview and record review, the facility failed to ensure Pre-admission…

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 physician orders were clarified for 4(Residents 38, 64, 44 & 33) of 20 sample residents reviewed and physician parameters were followed for 2 of 5 residents (Resident 44, & 49) reviewed for unnecessary medications with 1 supplemental resident (Resident 50) reviewed. These failures placed residents at risk for ineffective treatments, medications errors, and delayed treatment. Findings included . <Facility Policy> The facility's undated Medication Orders Policy showed the elements of the medication order should be clarified for accuracy. The facility's undated Medication Administration Policy showed staff were to compare medication source (bubble pack, vial, etc.) with the Medication Administration Records (MAR) to verify resident name, medication name, form, dose, route, and time. The policy showed staff were to correct any discrepancies and report to nurse manager. <Clarifying Orders> <Resident 38> Observations on 01/29/2025 at 1:41…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nailcare and assistance with shaving facial hair for residents dependent on staff for Activities of Daily Living (ADLs - grooming, oral hygiene, nail care etc.) for 3 of 6 (Residents 120, 36, & 21) residents and 1 supplemental resident (Resident 169) reviewed for ADLs. This failure placed residents at risk for poor hygiene, skin impairment, and a diminished sense of self-worth. Findings included . <Facility Policy> According to the facility's 2024 ADLs policy, the facility would provide cares and services to residents who depended on staff for ADL assistance including bathing, dressing, grooming, and oral care. <Resident 120> According to the 12/24/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 120 had a moderate memory impairment and medically complex diagnoses including multiple infections. The MDS showed Resident 120 required substantial to maximum assistance with personal hygiene. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 36> According to a 11/28/2024 Quarterly MDS, Resident 36 had clear speech, was able to understand and be understood by others, and had no memory impairment. This MDS showed staff assessed Resident 36 to be at risk of developing pressure ulcers and had no ulcers, wounds, or skin problems. In an interview on 01/28/2025 at 8:36 AM, Resident 36 stated they had a rash on their abdomen and thighs which developed after they received a recent vaccination. Resident 36 stated the doctor ordered some medications that were helping to decrease the itching. Review of Resident 36's records showed the resident received a vaccination on 01/16/2025. Review of a 01/23/2025 communication form to the provider showed staff documented Resident 36 complained of increased itching which started on 01/16/2025 and had, some kind of dermatitis [swelling, redness, and itching]. According to a 01/23/2025 provider progress note, Resident 36 had some superficial scratches to both thighs and indicated the plan was to add a 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.

Based on observation, interview, and record review the facility failed to ensure residents were assessed for the need, ability, and safety of devices, and movement in bed for 2 of 5 residents (Residents 25 & 49) reviewed for accident hazards, and 1 supplemental resident (Resident 6). The failure to reassess use of a power wheelchair when required placed residents at risk for power wheelchair accidents. The failure to complete safety assessments for beds against the wall placed Residents 25 & 49 at risk of entrapment and injury. Findings included <Facility Policy> The facility's undated Motorized Chair Policy showed use of a power wheelchair was a right, rather than a privilege, and a resident must have the mental and physical capacity to safely operate a motorized chair as assessed by the Rehabilitation Department. The policy showed the resident must be trained by the Rehabilitation Department prior to authorization of motorized chair use. The policy showed a resident must sign a written agreement showing they would abide by safety rules related to use of a power wheelchair. The…

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

Based on interview and record review the facility failed to ensure 2 (Residents 120 & 38) of 5 sampled residents reviewed for nutrition received adequate weight monitoring. The failure to ensure a reweigh occurred after a significant weight change placed residents at risk for weight changes, and inaccurate assessment of nutritional status. <Facility Policies> According to the facility's 2023 Nutritional Management policy, the facility provided care and services to ensure resident maintained acceptable parameters of nutritional status . The facility's 2022 Weight Monitoring policy showed weight was a useful indicator of nutritional status and significant weight loss could indicate a nutritional problem. The policy showed a weight loss of greater than five percent (%) in one month represented a significant weight loss. <Resident 120> According to the 12/24/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 120 had a moderate memory impairment and medically complex diagnoses including multiple infections. According to a 01/05/2025 progress note, Resident 120 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 observation, record review, and interview, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards of practice for 1 of 1 sampled resident (Resident 23) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive and deliver per physician orders. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes. Findings included . <Facility Policy> According to an undated facility policy titled, Appropriate Use of Feeding Tubes, showed the facility would accurately document food and fluid intake. According to an undated facility policy titled, Flushing a Feeding Tube, showed the nurse would verify and accurately infuse water per physician orders. An undated facility…

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 a medication error rate of less than 5 Percent (%). Failure to properly administer 2 of 25 medications for 2 of 6 residents (Resident 10 & 419) observed during medication pass resulted in a medication error rate of 8 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> The facility's undated Medication Orders Policy showed the elements of the medication order should be clarified for accuracy. The facility's undated Medication Administration Policy showed staff were to compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time. <Medication Error> <Resident 10> Observations of medication pass on 01/29/2025 at 1:08 PM showed Staff S (Licensed Practical Nurse) prepared medications for Resident 10. Staff S identified the eye lubricant plus drops ordered…

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 Activities of Daily Living (ADLs) to include teeth brushing, transfers out of bed, and assistance with eating for 1 of 3 dependent residents (Residents 1) reviewed for ADL's. The failure to provide assistance with teeth brushing, transfers out of bed and eating to dependent residents, placed residents at risk for decreased intake, weight loss, poor hygiene, skin breakdown, embarrassment, and a diminished quality of life. Findings included . Review of the facility policy titled, ADL Care for Dependent residents, undated, showed the facility would provide appropriate treatment and services for dependent residents to ensure all ADL needs were met on a daily basis while attaining or maintaining the resident's highest practicable physical, mental and psychosocial well-being. Each resident's physical functioning would be assessed, included in the Care Plan (CP), and the CP interventions would be monitored on an on-going…

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 3 residents (Resident 1) reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure Physician Orders (PO) were reviewed, clarified and implemented upon admission and after a physician visit, and failed to document on new pressure ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure on the skin). These failures caused Resident 1 to experience skin breakdown, and placed all residents at risk for skin breakdown, pain, and diminished quality of life. Findings included . <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 05/01/2024, showed Resident 1 admitted to the facility on [DATE] after transferring from another nursing facility. The MDS showed Resident 1 was able to make needs known, able to make themselves understood, and able to understand others. The MDS showed Resident 1 had no behaviors, was…

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

Based on interview and record review, the facility failed to ensure direct care staff were provided the mandatory effective communication training. Failure to ensure the required effective communication training was provide placed all residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, training Requirements, undated, showed the facility would develop, implement, and maintain an effective training program for all new and existing employee's consistent with their role. Training would include at a minimum, effective communication for all direct care staff. Review of a facility Licensed Nurse (LN) 2024 training/inservice proposal showed no documentation of a communication training required or provided for LN's. Review of a facility Nursing Assistant Certified (NAC) 2024 training/inservice proposal showed no documentation of a communication training required or provided for NAC's. During an electronic mail (e-mail) communication on 05/10/2024, Staff A documented staff received Communication tracing as part of…

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

Based on observation, interview, and record review the facility failed to ensure residents were provided a comfortable homelike environment for 3 of 5 residents (Resident 1,12, 6) reviewed. The failure to ensure the facility boiler was repaired timely and water temperatures were maintained at comfortable levels, placed all residents at risk for decreased cleanliness, quality of life, dignity, and a homelike environment. Findings included . Review of the facility policy titled, Safe and Homelike Environment, dated 04/2023, showed the facility would provide a safe, clean, comfortable, and homelike environment. This included ensuring the residents received care and services safely. In an interview on 04/17/2024 at 2:07 PM, Staff A (Administrator) stated the facility had two boilers upstairs that supplied hot water to the shower and resident rooms, one of the boilers was leaking. Staff A stated one side of the facility's upper level was affected. Only warm water was available to wash hands, faces, provide showers, and baths. Staff A stated on Friday 04/12/2024 there was no hot water…

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 who were dependent on staff for assistance with Activities of Daily Living (ADLs-bathing, grooming, eating) received the assistance they required for 6 of 6 residents (Residents 12, 14, 9, 1, 3, & 10 ) reviewed for bathing and showers. The failure to provide bathing or showers placed all residents at risk for poor hygiene, embarrassment, and diminished quality of life. Findings included . Review of a facility Shower policy, date 05/2024, showed the facility would offer residents the preference of shower days and times and the resident's preference would be documented on the Care Plan (CP). When a resident refused a shower staff would re-approach the resident and notify the nursing leadership. <Resident 12> Review of an Annual Minimum Data Set (MDS, an assessment tool) dated 02/14/2024, showed Resident 12 was able to make their own decisions and had diagnoses including a neurological disease, cancer, diabetes, anxiety,…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent placing residents at risk for facility acquired infections. The failure to have an effective system of surveillance to identify possible contagious infections, prevent the spread of infection to there residents and staff, reporting a suspected outbreak, and controlling the spread of a Gastrointestinal (GI) infection to other residents for 3 of 3 residents (Residents 15, 18, & 19 ) reviewed for infections. The failure to ensure staff used appropriate Personal Protective Equipment (PPE), to ensure proper Hand Hygiene (HH) was performed, and failed to have an effective Water Management Policy (WMP), plan, and implementation of that plan placed all residents at risk for facility-acquired or healthcare-associated infections and related complications. Findings included . Review of the facility policy titled,…

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 implement their abuse and neglect policies and procedures regarding prevention, identification, investigation, and reporting of abuse. The facility failed to thoroughly investigate incidents and allegations of abuse, neglect, and misappropriation of residents property for 8 of 12 residents (Resident 1, 3, 5, 7, 8, 9, 12, 15) reviewed for incidents, failed to timely report incidents of abuse to the required entities for 1 of 2 residents (Resident 15) reviewed for allegations of sexually inappropiate touching, failed to identify incident as abuse for 2 of 2 residents (Resident 9, 10), and failed to ensure facility staff were trained on and implemented abuse policies and procedures for 2 of 4 staff (Staff C, D) involved in incidents, and the facility allowed Staff D to continue to render care to facility residents despite an allegation of verbal abuse. These failures placed the residents at risk for abuse by caregivers, and placed all…

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: (1) follow measurement tools and conversion tables when preparing modified consistency diets, (2) routinely monitor food temperature on the steam table during meal service, (3) ensure dietary staff were knowledgeable of food safety practices including the appropriate temperatures of Potentially Hazardous Foods (PHF). These failures placed residents at risk for aspiration (inhaling food contents into lungs), development of lung infections, acquiring food-borne illnesses, and a decreased quality of life. Findings included . <Preparation of Modified Consistency Diet> On 09/22/2023 at 9:47 AM during lunch service preparation, Staff BB (Kitchen Cook) was observed preparing puree (a smooth and creamy liquidized substance) texture food for residents with altered swallowing ability. Staff BB gathered the ingredients and mixed cut-up vegetables, chicken broth, and two slices of bread in a blender and stated the mixture was the pureed vegetable component of the meal. Staff BB checked the consistency and noted it was…

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

Based on interview and record review, the facility failed to ensure that, unless the facility employed a full-time Registered Dietitian (RD), the Director of Food and Nutrition services (Staff J) met Washington State requirements including the completion of an academic program in nutrition or dietetics (the practical application of the science of diet and nutrition in relation to health and/or diseases) approved by the American Dietetic Association/Dietary Manager Association. This failure compromised residents nutritional status and placed residents at risk for receiving unsafe dietary services from a staff without the required competencies and skills to carry out food and nutrition services management. Findings included . <Staff J> On 09/21/2023 at 9:08 AM, Staff E (Business Office Manager/Human Resources - HR) provided Staff J's (Dietary Supervisor) personnel file for review. The Application for Employment form showed Staff J applied for the position on 05/25/2023. The facility provided a staff list with the hire dates showed that Staff J was hired for the position of Dietary…

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: Cycle/planned and breakout menus were followed during meal service to residents; residents with specialized diets (Resident 429) were provided with meal options that met their needs; risks and benefits were discussed for residents (Resident 579) who elected to consume meals purchased outside of the facility. These failures placed residents at risk for less than adequate nutritional intake, consuming meal portion sizes and calories other than as planned by a Registered Dietician (RD), dissatisfaction with meals, and unmet nutritional needs. Findings include . <Unplanned Menus> Review of the Week 3- The Week At A Glance cycle menu provided by the facility showed the 09/21/2023- Thursday lunch menu was planned as: Meatballs with gravy, boiled red potatoes with parsley, dinner roll, and pound cake. Observation on 09/21/2023 at 11:21 AM showed the posted lunch menu outside of the main kitchen listed: Pot roast, buttermilk mashed…

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 food was procured, stored, prepared and served in accordance with professional standards of safety. Facility failed to ensure: (1) food safety was maintained and temperatures monitored in the resident refrigerator, (2) open foods were dated, (3) kitchen equipment (oven) was in good, working condition, (4) menu ingredients were ordered timely, and (5) ready-to-eat foods were covered during transport as required placed residents at risk for unsafe cooking temperatures, ingesting expired and/or contaminated food, and the development of food-borne illness. Findings included <Facility Policy> The facility's 2021 Food Receiving and Storage showed all foods stored in the refrigerator or freezer would be covered, labeled, and dated with the use by date. The policy instructed staff to maintain individual resident food items and snacks kept on the nursing unit refrigerator as followed: - All Potentially Hazardous Food items were kept below 41…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 5 (Resident 9, 27, 5, 64, and 56) of 5 residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABOs. Findings included . <Facility Policy> According to the revised December 2016 Facility ABO Stewardship- Orders for ABOs policy ABOs will be prescribed and administered to residents under the guidance of the facility's ABO Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. This policy also says appropriate indications for use of ABO's include meeting criteria for clinical definition of active infection. This policy stated when a culture and sensitivity was ordered, the results will be…

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 consider and act promptly to address concerns raised by residents at the Resident Council (RC). Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken left residents at risk for unresolved concerns, frustration, and a less-than-homelike environment. Findings included . Review of the facility's RC meeting minutes from February through July 2023 showed the facility held meetings on 02/17/2023, 04/21/2023, 05/19/2023, 06/16/2023, and 07/17/2023. The facility did not provide minutes for the 06/16/2023 but did furnish an attendance record. The facility did not have a meeting in August 2023. Review of the RC meeting minutes showed: - During the 02/17/2023 meeting, residents requested information about when the facility's bus would be available for outings as it was not in use at that time. Staff informed residents the bus would be available in 60 days. The 04/21/2023 meeting minutes showed the facility informed residents the bus issue 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 observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain a safe, clean, and comfortable environment, free of unpleasant noises, left residents at risk for a less than a homelike environment. Findings included . <Floor Trim> Observation on 09/25/2023 at 6:18 AM showed the thresholds for rooms 227, 228, 229, 230, 232, 235, 240, 243, 244, 247, 246 & 249 were missing black rubber trim between the hallway tiling and the tiling in the rooms. In an observation and interview on 09/27/2023 at 2:02 PM Staff A (Administrator) stated the trim was missing and should be replaced for the rooms identified <Elevators> Observation of the facility's two elevators on 09/21/2023 at 9:15 AM showed the paint on the handrail in the right elevator was worn off and looked unattractive. Both elevator cars had considerable scuff marks along the interior walls. Both elevator cars had unidentified garbage/debris visible…

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 initiate and thoroughly investigate the occurrences of events for 5 of 20 (Residents 32, 30, 9, 65, & 58) sampled residents whose facility incident reports were reviewed. The facility failed to investigate and correct reported resident grievances and mental health status, identify the cause of an injury, the development of a new wound, and implement protocols and interventions to prevent reoccurrence of events. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect and a decreased quality of life. Findings included . <Resident 32> According to the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had no cognitive impairment or depression diagnosis. The MDS showed Resident 32 exhibited no behavior during the assessment period. The MDS showed Resident 32 had occasional pain and was provided as-needed pain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 6 (Residents 9, 55, 66, 27, 53 & 17) of 8 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Resident 9> Resident 9 admitted to the facility on [DATE]. Record review showed Resident 9 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/02/2023 Discharge Minimum Data Set (MDS - an assessment tool), the resident discharged again to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 02/15/2023 or 08/02/2023 transfers. The facility 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 complete the comprehensive assessments within the regulatory timeframes for 12 of 12 (Residents 68, 24, 65, 27, 37, 373, 4, 5, 579, 9, 66, & 69) sampled residents, 2 of 2 (Residents 54 & 379) supplemental residents, and 1 of 3 (Resident 372) closed records reviewed for resident assessments and timing. The failure to ensure comprehensive admission and Annual Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed an admission MDS was completed within 14 days of admission, counting the day of admission as day 1. <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2019 RAI Manual outlined…

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 complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframes for 7 of 10 (Residents 9, 32, 53, 58, 62, 25, & 17) sampled residents and 1 of 3 (Resident 4) closed records reviewed for resident assessments and timing. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed a Quarterly MDS used an Assessment Reference Date (ARD) which was no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2019 RAI Manual showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical…

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 accurately assess 7 of 20 (Residents 9, 66, 37, 65, 69, 27, & 372) residents reviewed for accurate Minimum Data Set (MDS - an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 readmitted to the facility on [DATE] and received no narcotic medication during the assessment period. Review of the August 2023 Medication Administration Record (MAR) showed that during the assessment period (08/12/2023 - 08/18/2023), Resident 9 received narcotic (pain relieving medicine) medications on 08/01/2023 and 08/17/2023. In an interview on 09/26/2023 at 2:12 PM, Staff B (Director Of Nursing) stated Resident 9's MDS was inaccurate and should reflect the administration of narcotic medications twice during the assessment period. <Resident 66> According to the 08/29/2023 Admission/5 Day MDS, Resident 66 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: (1) all individuals who completed a portion of the assessment signed and certified to the accuracy of the portion they completed, and (2) the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of Care Area Assessments (CAA's) was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 10 (Residents 65, 37, & 69) residents whose comprehensive MDS assessments were reviewed. These failures placed residents at risk for inappropriate care planning and unmet care needs. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed the CAA process was designed to assist the assessor in systematically interpreting the information recorded on the MDS that facilitated decision-making regarding residents' plan of care. The policy showed CAA's were completed no later than 14 days after a resident's admission. The policy outlined Interdisciplinary Team (IDT) members…

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 Pre-admission Screening and Resident Review (PASRR) assessments were completed for 6 (Residents 30, 68, 76, 9, 55 & 17) of 9 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's 2022 Resident Assessment - Coordination with PASARR Program policy, all residents must have a PASRR screening prior to admission, and the facility would keep a copy of the screening in the resident's record. The policy showed the facility's Social Services department was responsible for ongoing maintenance of accurate PASRR screenings and PASRR screening should be updated as needed to reflect changes both positive and negative to a resident's mental health status. This policy showed if a PASRR level I was positive, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were comprehensively developed and implemented for 4 (Residents 30, 9, 65, & 62) of 20 sample residents. Failure to develop and implement comprehensive CPs left residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including dementia, difficulty walking, and muscle wasting. The MDS showed Resident 30 used a wheelchair. The MDS showed Resident 30 required extensive assistance with most Activities of Daily Living (ADLs) including bed mobility, transfers, locomotion (moving around) on and off the unit, toilet use, and personal hygiene. Review of the comprehensive CP showed the facility developed no CP addressing Resident 30's need for assistance with ADLs. Nowhere in the comprehensive CP were Resident 30's ADL needs explained to staff. 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 ensure care plans (CPs) were maintained, revised and updated as required for 10 (Residents 30, 58, 9, 55, 37, 69, 27, 53, 5, & 17) of 20 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> Review of an undated 2023 facility Care Plan Revisions Upon Status Change policy, a resident's comprehensive CP would be reviewed and revised as necessary, when a resident experienced a status change. This policy showed that upon identifying a change in status, the nurse would notify the Minimum Data Set (MDS - an assessment tool) nurse and the MDS nurse and interdisciplinary team would discuss the resident's condition. The CP would be updated with new or modified interventions and these interventions would be communicated to all staff involved in the resident's care. <Resident 30> According to the 06/18/2023 Quarterly MDS, Resident 30 had diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were followed and clarified for 7 (Residents 32, 5, 42, 68, 9, 53, & 37) of 20 sample residents; ensure medications were given within ordered parameters for 3 (Resident 38, 581, &53) of 20 sample residents; and staff were signing for tasks not completed for 1 (Resident 62) of 20 sample residents. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes. Findings included . <Facility Policy> According to a 2023 facility, Medication Administration policy, nursing staff would administer medications as ordered by the physician and administer the medications within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. This policy showed staff would: Obtain and record vital signs per POs and when applicable, hold the medication for those vital signs outside of the physician's prescribed parameters; observe…

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 Activities of Daily Living (ADL), related to cleanliness and grooming for 6 (Residents 9, 27, 24, 58, 37, & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 9), bathing (Residents 27, 24, & 58) oral care (Resident 37), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> Review of the facility's undated 2022 Activities of Daily Living policy showed the facility would provide ADLs in accordance with residents comprehensive assessment, Care Plan CP, and resident preferences to ensure a resident's ADL abilities do not deteriorate unless deterioration was unavoidable. <Shaving> <Resident 9> According to the 08/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 9 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed, monitored, and treated as required for 3 (Residents 373, 68, & 579) of 6 residents reviewed for non-pressure skin and 2 supplemental residents (Residents 30 & 58); failed to ensure fluid monitoring was in place for a for 1 (Resident 372) of 3 discharged residents whose records were reviewed; failed to ensure Blood Glucose (BG) was monitored for 1 supplemental resident (Resident 380); failed to ensure residents with constipation/diarrhea were provided bowel care for 1 (Resident 17) of 4 residents reviewed for constipation/diarrhea. These failures placed residents at risk for new or worsening skin impairment, fluid overload, uncontrolled BG, skin irritation, discomfort, embarrassment, and other negative health outcomes Findings included . <Skin Impairment> <Resident 373> According to the 09/13/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 373 had the capacity to make their own…

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 6 (Residents 24, 27, 53, 38, 68, & 62) of 10 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure accurate intakes were documented, identify and act on significant weight changes placed residents at risk for delayed identification of interventions for continued weight loss. Findings included . <Facility Policy> According to the facility October 2022 Weights Monitoringpolicy, the facility would ensure all residents maintained acceptable parameters of nutritional status including usual or desirable body weight range. The facility would use a systemic approach to optimize resident nutritional status. The process would include monitoring the effectiveness of interventions and revising them as necessary. Information gathered from the nutritional assessment would be used to develop an individualized Care Plan (CP) which addressed resident specific nutritional concerns and preferences.…

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 5 (Residents 30, 55, 49, 53 & 5) of 5 residents whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary medications, adverse side effects and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including anxiety, depression, and insomnia (difficulty sleeping). The MDS showed Resident 30 took Antidepressant (AD) medications. The MDS showed Resident 30 had 2 non-injury falls in the facility since the prior assessment. Review of Resident 30's Physician's Orders (PO) showed a 03/14/2023 PO to monitor the resident's hours of sleep every shift, related to insomnia. Review of the September 2023 Medication Administration Record (MAR) showed Resident 30 had a 07/28/2023 PO for an AD medication 50 Milligrams (MG), give half a tablet at 8 PM for…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 4 of 26 medications for 3 of 8 residents (Resident 66, 42, & 581) observed during medication pass resulted in a medication error rate of 15.38%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> According to a 2023 facility Medication Administration policy, staff would review the Medication Administration Record (MAR) to identify medication to be administered and would also compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time. <Resident 66> Observation of medication pass on 09/20/2023 at 8:42 AM, showed Staff S (Registered Nurse) enter Resident 66's room and hand the resident an anti-inflammatory inhaler medication to administer. At this time, Resident 66 looked at the inhaler and stated, this is not mine. Staff S…

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

Based on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance, palatable, and served at the proper temperature. Observation of meal preparation and interviews with 5 (Residents 27, 53, 25, 68, & 38) sample residents and 1 supplemental (Resident 40) resident identified concerns about the taste, temperature, and overall palatability of food served by the facility. Failure by the facility to ensure meals were at the proper temperature and palatable when served, placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals. Findings included . <Resident 68> In an interview on 09/19/2023 at 12:28 PM, Resident 68 stated the food was edible and stated it was usually not warm enough. Resident 68 stated they were not sure where the food started from but indicated by the time it came to their hallway it was luke warm. <Resident 38> In an interview on 09/19/2023 at 9:27 AM, Resident 38 stated the food was cold almost all of the time. <Resident 27> Review of a 05/09/2023 Quarterly Minimum Data Set…

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 <Ice Cart Service> Observations on 09/20/2023 at 3:42 PM showed Staff FF (Licensed Practical Nurse) obtain a resident's water pitcher from room [ROOM NUMBER]. Staff FF set the water pitcher down on the ice cart, used a scoop to get ice out of the bin, and then touched the scoop on the inside of the resident's water pitcher while filling it with ice. Staff FF then delivered that water pitcher to room [ROOM NUMBER] and went into room [ROOM NUMBER] to pick up another resident's water pitcher. Staff FF placed the next water pitcher down on the ice cart, picked up the contaminated scoop, put it into the main bin to get more ice, and again touched the scoop inside of the resident's water pitcher. Observations on 09/25/2023 at 12:14 PM showed the ice cart in the hallway with no ice scoop in the clear container in the front. On 09/25/2023 at 12:33 PM, staff approached the ice cart with a water pitcher, opened the lid, took the ice scoop out of the bin, and filled the water pitcher. Observations with Staff M on…

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

Based on observation, interview, and record review the facility failed to provide care in a manner that promoted resident respect and dignity for 4 (Residents 25, 429, 580, & 14) of 4 Residents reviewed for dignity concerns. Facility staff failed to obtain consent prior to sorting through and organizing Resident 25's personal belongings, treat Resident 429 in a dignified manner, provide silverware that was consistent with a homelike environment for Resident 580, and provide adaptive utensils for Resident 14. These failures placed residents at risk for feelings of diminished and disrespected. Findings included . <Room Organizing> <Resident 25> According to a 05/29/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 25 admitted to the facility 02/09/2018 and had intact cognition. Resident 25 was able to understand others and be understood in conversation. Observation on 09/19/2023 at 9:51 AM showed Resident 25 lying in bed. Their over-the-bed table was in front of them and contained several tissue boxes, papers, and various personal items. Resident 25's nightstand was…

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

Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 Residents (Residents 30 & 5) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' ability to exercise their right to make an informed decision about proposed treatments and prevented the residents from exercising their right to decline the treatments/therapies. Findings included . <Facility Policy> The facility's 2023 Psychotropic Medication policy showed residents who used psychotropic drugs would be educated on the risks and benefits of psychotropic drug use. <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had moderately impaired cognition (impaired memory and problem solving),…

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 allow 2 (Residents 62 & 27) of 20 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . <Bathing> <Resident 62> According to a 06/01/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 62 had clear speech, no memory impairment, and was able to understand and be understood by others. This MDS showed Resident 62 was assessed to require extensive physical assistance from staff for bathing and had no rejection of care. In an interview on 09/19/2023 at 9:47 AM, Resident 62 indicated they only got one shower each week and stated they were begging staff for showers twice weekly. Resident 62 stated, it was unsanitary to be bathed only one time a week and indicated it was, disgusting. On 09/25/2023 at 12:25 PM, Resident 62 stated, I only get bathing…

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 had the appropriate Advance Directive (AD) in place for 4 of 20 (Residents 65, 5, 373, & 24) reviewed for ADs. The facility failed to help residents (Resident 65) formulate an AD and document in the medical records that assistance was offered. The facility failed to obtain a copy from residents (Resident 5, 373, & 24) with an existing AD and make the documentation readily available in the medical records and accessible to facility staff. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The 2023 Residents' Rights Regarding Treatment and ADs showed the facility would determine if the resident had executed an AD upon admission, and if not, determine whether the resident would like to formulate an AD. The policy outlined if the resident had and AD, copies would be made and placed on the…

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

Based on interview and record review the facility failed to log/report an allegation of neglect for 1 (Resident 32) of 20 sample residents reviewed. This failure placed residents at risk for unidentified neglect, avoidable pain, and other negative health outcomes. Findings included . <Resident 32> According to the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had no cognitive impairment, and no depression. The MDS showed Resident 32 exhibited no behavior and did not experience hallucinations or delusions. The MDS showed Resident 32 had occasional pain and required as-needed pain medications. Review of a 08/24/2023 grievance form initiated by Resident 32 showed the resident stated they pressed their call light to request care. Resident 32 stated Staff L (Certified Nursing Assistant) responded by asking them why they called for care before turning off Resident 32's call light and leaving without providing care. The grievance form indicated Resident 32 then waited over an hour before receiving their pain medication. The form was signed by Staff A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 4 (Residents 9, 55, 66, & 17) of 8 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Resident 9> Resident 9 admitted to the facility on [DATE]. Record review showed Resident 9 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/02/2023 Discharge MDS, Resident 9 again discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided Resident 9 or their representative written information regarding the facility's bed-hold policy as required. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed for 3 (Residents 68, 9, & 66) of 8 newly admitted and readmitted residents reviewed, to provide residents and/or their representative with a summary of their baseline Care Plan (CP). This failure resulted in residents and/or families not being informed of their initial plan for delivery of care and services, and placed residents at risk for unmet needs, and possible complications. Findings included . <Facility Policy> According to a 2022 facility Baseline Care Plan policy, the facility would develop and implement a baseline CP for each resident within 48 hours of a resident's admission. This policy showed a written summary of the baseline CP would be provided to the resident and representative by completion of the comprehensive CP. Staff would obtain a signature from the resident/representative to verify the summary was provided and make a copy of the summary for the resident's records. <Resident 68> According to a 07/19/2023 admission Minimum Data Set…

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 individualized activity plans and ensure activity programs met the needs of each resident for 2 of 3 residents (Residents 38 & 58) reviewed for activities, and 1 supplemental resident (Resident 62). Failure to consistently implement meaningful individual activity plans left residents at risk for boredom, frustration, isolation, and a diminished quality of life. Findings included . <Resident 38> According to a 07/14/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 38 had no memory impairment, clear speech, and was able to understand and be understood by others. This MDS showed Resident 38 had no rejection of care and it was very important to the resident to be involved in their favorite activities. Review of a 03/03/2023 Activities evaluation showed staff documented Resident 38 was very active and participated in most activities, wished to participate in activities while in the facility, 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 residents were assessed and received necessary treatment and assistive devices to maintain vision abilities for 2 of 4 (Residents 65 & 62) residents reviewed for vision. Failure to identify vision deficits and to ensure residents received assistance with the use of corrective lenses left residents at risk for unmet needs and a diminished quality of life. Findings included . <Facility Policy> According to a 2023 Hearing and Vision Services policy, the facility would utilize a comprehensive assessment process for identifying and assessing a resident's vision abilities to provide person-centered care. The policy showed the facility would ensure all residents had access to hearing and vision services and receive adaptive equipment as indicated. The policy showed staff would refer any identified need for vision services/appliances to the social worker/designee who would be responsible for assisting residents to make appointments 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 2 (Residents 30 & 9) residents with Suicidal Ideation (SI) were investigated for root cause, or provided an environment free from items they were not assessed to be safe with; ensure fall mats were used appropriately for 2 of 4 (Residents 58 & 5) reviewed for falls. These failures left residents at risk for falls, injury, self-harm, and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including brain dysfunction, anxiety, depression, and dementia. The MDS showed Resident 30 had hallucinations and delusions, verbal behaviors that interfered with daily activities, and behaviors that disrupted care and/or the living environment. According to a nursing progress note on 04/27/2023 Social Services notified nursing that Resident 30 was having active suicidal thoughts, and had a plan. There was no corresponding…

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 admitted with Foley Catheters (F/C - a flexible tube inserted into the bladder) were assessed for the continued need for a F/C, attempted to remove the F/C as soon as possible, F/C tubing was secured with a leg strap to prevent accidental tugging and pulling, and a privacy bag (to cover the F/C bag) in place for 1 (Resident 66) of 3 residents reviewed for the F/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues. Findings included . <Resident 66> Review of Resident 66's nursing progress notes showed Resident 66 admitted to the facility on [DATE] and was transferred to the hospital on [DATE] for a change in respiratory condition. According to the 09/20/2023 Medicare 5-day MDS, Resident 66 readmitted on [DATE] and was assessed as cognitively intact and had the F/C during the 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 observation, interview, and record review the facility failed to implement ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 1 of 2 (Resident 69) residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> The facility's undated Hemodialysis [a process of purifying the blood of a person whose kidneys were not working normally] policy showed the facility should ensure each resident had ongoing assessment of their condition and was monitored for complications before and after dialysis treatments received at a certified dialysis facility. The policy outlined the need for ongoing communication and collaboration with the dialysis facility to ensure the development and implementation of the dialysis Care Plan (CP) by the nursing home and dialysis center staff. The policy instructed the licensed nurse to communicate…

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, interview, and record review, the facility failed to ensure drugs and biologicals were secured for 5 (Resident 54, 62, 66, 27, & 25) of 24 residents observed with medication in their rooms. The facility failed to ensure proper storage of drugs and biologicals on 2 (Medicare 2 and 2 South Hall Cart) of 4 medication carts. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents. Findings included . <Facility Policy> Review of a facility undated 2023 Medication Storage policy showed all medications would be stored in locked compartments such as medication carts or medication rooms. This policy showed medications administered by mouth would be stored separately from medications administered through other routes. <Medications at Bedside> <Resident 54> Observations on 09/19/2023 at 10:00 AM and on 09/20/2023 at 9:53 AM showed three bottles of pills at Resident 54's bedside and visible from the hallway. In an interview and observation on 09/20/2023 at 9:57…

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 laboratory (lab-blood test) tests were completed as ordered for 2 of 5 (Residents 49 & 5) sample residents whose drug regimens were reviewed, and 3 (Residents 58, 62, & 68) supplemental residents. This failure placed residents at risk of medical complications from lack of monitoring of chronic medical conditions, and other negative health outcomes. Findings included . <Resident 58> According to the 09/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 58 had multiple medical conditions including diabetes (difficulty controlling blood sugar). Review of the 09/16/2023 Physicians orders (POs) showed Resident 58 had a lab test ordered to measure average blood sugar levels. The September 2023 Medication Administration Record (MAR) showed the lab was complete. No lab results could be found in the resident's record. Review of the 09/21/2023 PO showed Resident 58 had the same lab test ordered and included two additional tests to be collected. No results could be found in the resident's record. <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 interview and record review, the facility failed to ensure resident records were complete, accurate, and readily accessible for 4 (Resident 49, 38, 68, & 9) of 20 sample residents whose records were reviewed. The facility failed to ensure Medication Administration Records (MAR), Treatment Administration Records (TAR), weight records, and meal consumption documentation was complete and accurately reflected the care provided. These failures placed residents at risk for unidentified and/or unmet care needs. Findings included . <Facility Policy> Review of the October 2022 facility Documentation in Medical Record policy showed the facility would include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. <Resident 49> According to the 07/13/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 49 admitted to the facility on [DATE]. Resident 49 had the capacity to make their own decision. Resident 49 had multiple complex…

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 administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 2 (Residents 5 and 49) of 5 residents reviewed for vaccinations. This failure placed residents at risk for contracting pneumonia, with its associated complications. Findings included . <Policy> The facility's undated Pneumococcal Vaccine (Series) policy showed each resident would be assessed for pneumococcal immunization upon admission. This policy showed pneumococcal vaccines would be offered in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. The policy showed for adults 65 years or older who only received a PPSV23 (pneumococcal polysaccharide vaccine), the facility would give one dose of PCV15 (pneumococcal conjugate vaccine) or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. <Resident 5> Review of Resident 5's immunization record showed a dose of PPSV23 was…

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

Based on interview and record review the facility failed to ensure any of the 97 staff were offered Covid-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) education on the benefits and potential risk associated with the Covid-19 vaccine. This failure placed staff at risk for not being able to make an informed decision about immunizations. Findings included . Review of an undated facility Covid-19 Vaccination policy showed it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 by educating and offering their staff the Covid-19 vaccination. This policy showed the facility will educate and offer the Covid-19 vaccine to residents, resident representatives and staff and maintain documentation of such. Review of the facility's staff Covid-19 vaccination status record showed no staff education was provided on Covid-19 vaccine risks and benefits for any of the staff currently working at the facility. 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.

Based on observation, interview and record review, the facility failed to ensure resident Wheelchairs (WCs) were maintain in good, safe, working order for 3 (Residents 30, 579 & 38) of 20 sampled residents reviewed. Failure to ensure WCs were in maintained in safe working condition left residents at risk for accidents, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2023 Preventative Maintenance for Wheelchairs policy, the facility would develop and implement as part of their preventative maintenance program, a system for WC safety and maintenance. The policy showed all staff were responsible for ensuring WCs requiring maintenance are not used by residents and were reported to maintenance for repairs. The policy showed wheels, arm rests and brakes should be checked weekly or as indicated. The policy showed facility staff should ensure brakes are in good repair and able to hold the chair still during transfers. <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to allow 7 (Residents 2, 14, 23, 118, 16, 18 & 25) of 8 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/ or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 2 admitted to the facility on [DATE], was cognitively intact and reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 01/04/2022 at 9:23 AM, Resident 2 stated they did not receive bathing as frequently as they wanted and stated, I want at least two bed baths a week but that's not what I get. Review of the Individual Service Plan (ISP - directions to staff regarding resident care) staff were directed, Bathing…

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 address required documentation for advanced directives, including incorporation into the care planning process, for 13 (Residents 14, 23, 19, 43, 55, 54, 61, 66, 18, 60, 36, 59, & 40) of 17 residents reviewed for Advanced Directives (ADs). These failures placed the residents at risk of losing their right to have their stated preferences/decisions regarding end-of-life care followed. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 14 admitted to the facility on [DATE] and was assessed as cognitively intact and was understood and able to understand conversation. In an interview on 01/04/2022 at 8:19 AM, Resident 14 stated they had a daughter but was not asked if they wanted to formulate an AD at the time of admission. Record review showed no indication Resident 14 was offered the opportunity to formulate an AD. According to admission paperwork dated 10/21/2021 a person other than…

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 timely notice, in writing, of changes in payment status and potential charges for services not covered under Medicare/ Medicaid for 5 (Residents 19, 18, 23, 2 & 49) of 5 residents reviewed. Failure to have a system to provide Notices of Medicare Non-Coverage (NOMNC- a notification that Medicare benefits were ending), and Advanced Beneficiary Notices (ABN- a notification of costs when services provided may not be paid by Medicare) and assist residents or their representatives to understand these notices or assist with the appeal process placed residents at risk of insufficient information to make care and financial decisions. Findings included . Resident 18 Record review showed, Resident 18 signed a NOMNC form on 12/23/2021 which acknowledged Medicare Part A skilled services would have a last covered day (LCD) of 12/27/2021. The NOMNC form was incomplete and did not list the contact information for the Medicare Health Plan for Resident 18 to appeal the notice. Resident 18 signed the ABN on 12/23/2021 and checked 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 notify the residents' representatives and ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 7 (Residents 19, 55, 16, 43, 118, 54 & 13) of 7 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . According to the facility's undated Transfer or Discharge Notice policy, staff are to notify the resident and/or representative in writing of the reason for, date of, and destination of the transfer or discharge. This policy also directs staff that a copy of the notice will be sent to the Office of the State LTCO. Resident 19 Resident admitted to the facility on [DATE]. According to a 08/30/2021 Discharge Minimum Data Set (MDS, an assessment tool), the resident was discharged to an acute…

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 the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 7 (Residents 19, 55, 16, 43, 118, 54 & 13) of 8 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . Resident 19 Resident 19 admitted to the facility on [DATE]. According to a 08/30/2021 Discharge Minimum Data Set (MDS, an assessment tool), the resident was discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided the resident or resident representative written information regarding the facility's bed-hold policy as required. During an interview on 01/06/2022 at 01:55 PM, Staff B (Director of Nursing) acknowledged there was no…

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 comprehensive admission and annual assessments were completed within the required time frames for 14 (Residents 13, 2, 55, 32, 118, 19, 23, 14, 18, 268, 43, 35, 16, & 40) of 24 sample residents reviewed. These failures placed residents at risk for unidentified care needs, delayed services, and decreased quality of life. Findings included . According to the Resident Assessment Instrument (RAI - a manual that instructs staff on timing requirements for assessments), admission assessments are required to be completed by the 14th calendar day of the resident's admission, and annual assessments are required to be completed within 14 days of the Assessment Reference Date (ARD, +14 days). Resident 55 Record review showed Resident 55 had an Annual Minimum Data Set (MDS, an assessment tool) with an ARD of 08/11/2021, but it was not completed until 10/03/2021, 53 days late. Additionally, Resident 55 had a Significant Change MDS with an ARD of 11/28/2021.…

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 accurately assess 15 of 24 residents (Residents 2, 14, 23, 43, 19, 55, 54, 268, 36, 214, 55, 18, 32, 38, & 35), reviewed for accurate Minimum Data Set (MDS- an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 2 According to the 12/20/2021 admission MDS, staff assessed the resident was cognitively intact and had no broken dentures. Observations on 01/04/2022 at 9:16 AM showed Resident 2 had a broken tooth on the upper left portion of their denture. The resident stated the denture was broken for a while. In an interview on 01/06/2022 at 12:55 PM, Staff Y (Licensed Practical Nurse- LPN) confirmed the resident's upper denture had a broken tooth and stated the MDS was incorrect. Resident 14 According to the 10/18/2021 admission MDS, Resident 14 was cognitively intact and assessed with no vision problems, did not use corrective lenses and received…

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 Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained and/or treatment plans were incorporated into the resident's care plan (CP) and that resident's with newly evident or possible serious mental illness indicators, intellectual or a related conditions were referred for level II evaluations for 2 (Resident 19 & 23) of 3 residents reviewed who required level II PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services, unmet psychosocial needs and mental distress. Findings included . Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses of bipolar disorder and schizophrenia, demonstrated no verbal or physical behaviors towards others, and received antipsychotic and antidepressant medication on seven 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 Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions and/or a PASRR was completed for each resident prior to admission, for 2 (Resident 19 & 62) of 6 and 1 (Resident 55) supplemental resident reviewed for unnecessary medications and/or level II PASRR. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . Facility Policy According to the facility's undated Admissions Criteria Policy, all new admissions and readmissions are screened for mental disorders (MD) and intellectual disabilities (ID) or related disorders (RD) per the . PASRR process The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. Resident 19 Resident 19 admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were maintained, revised and updated as required for 7 (Residents 14, 23, 54, 62, 18, 32, & 40) of 24 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS, an assessment) Resident 14 admitted to the facility on [DATE] and was cognitively intact, able to be understood and understand conversation and had multiple medically complex diagnoses. Resident 14's 10/12/2021 baseline care plan (CP) included goals of resident will [discharge] to a location that meets their needs (top 5 discharge goals) and Resident will have toileting needs met. In an interview on 01/11/2022 at 8:39 AM Staff B indicated this was not measurable as there were no discharge goals listed and no objective measurable context for toileting goals. According to a 11/06/2021 behavior CP, staff indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented for 9 (Residents 61, 18, 40, 60, 35, 13, 268, 14, & 38) of 24 residents reviewed. Failure to follow physician orders, clarify physician orders, document injection sites, ensure follow up appointments were scheduled and signing for tasks that were not completed placed residents at risk for medication errors, delay in treatment, and adverse outcomes. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS- an assessment tool) Resident 14 admitted to the facility on [DATE] and was assessed with diagnoses including heart disease, diabetes mellitus (DM), and lung disease. According to the resident's Physician Orders (PO) dated 10/23/2021, staff were directed to administer Insulin daily at bedtime related to diabetes. Review of December 2021 and January 2022 Medication Administration Records (MARs) showed there were no directions to nursing staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs), related to cleanliness and grooming for 8 (Residents 2, 14, 23, 118, 268, 32, 55, & 16) of 11 sample and 3 (43, 38, 35) supplemental residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (268), nail care (2, 14, 23, 118, 268, 55 & 16), bathing (2, 14, 23, 118, 268, 32, 55 & 43), and eating (43) placed the residents at risk for poor hygiene, soiled long nails, embarrassment and diminished quality of life. Findings include . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 2 was cognitively intact, had multiple wounds, and required extensive 2-person assistance with bed mobility, transfers, mobility on and off unit, dressing, toilet use and personal hygiene. According to this MDS, bathing did not occur during the assessment period. Observations on 01/03/2022 at…

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 received necessary treatment and assistive devices to maintain vision abilities for 6 (Residents 18, 19, 55, 23, 25 & 14) of 8 residents reviewed for vision and hearing. Failure to ensure residents received assistance with the use of corrective lenses left residents at risk for unmet needs and diminished quality of life. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 14 was cognitively intact and assessed with no vision problems and did not use corrective lenses. Observations on 01/04/2022 at 8:54 AM showed Resident 14 had glasses at at the bedside. In an interview at this time, the resident indicated the glasses were not correct stating, I can't focus very well, I need new ones. I saw an eye doctor months before I had my fall and I haven't gotten a new pair of glasses .I talked to the staff here and they never done anything about it . 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 ensure 5 (Residents 14, 23, 40, 60, & 35) of 9 sample residents and 2 (Residents 59 & 18) supplemental residents reviewed for Restorative Nursing Services received the services as they were assessed to require. These failures placed residents at risk for decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff and decreased quality of life. Findings included . Resident 23 According to the 11/02/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, and experienced one sided functional limitations of ROM for both upper and lower extremities. According to self-care performance Care Plans (CP) dated 10/26/2021 indicated Resident 23 was identified with a stroke (brain bleed) with left sided paralysis. There was no indication facility staff identified the resident required care or services related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 8 (Residents 14, 23, 118, 36, 32, 59, 35 & 38) of 15 sampled residents, and 2 supplemental residents (Residents 61 and 66), reviewed for nutrition and/or hydration, maintained acceptable parameters of nutritional status or were adequately monitored for hydration status. Failure to ensure accurate intakes were documented, identify and act on significant weight changes, and notify physicians of changes, placed the residents at risk for delayed identification of interventions for continued weight loss. Findings included . According to the facility's Weight Assessment and Intervention- Foundation policy, nursing staff will obtain resident weights on admission, the next day, and weekly for four weeks thereafter. This policy directs staff that any weight change of five pounds (Lbs.) for residents that weight 100 Lbs. or greater and three Lbs. for residents who weigh less than 100 Lbs. since the last weight assessment will be reweighed the next day for…

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

Based on observation, interview, and record review, the facility failed to ensure a system of documentation that included the amount of formula and water administered to each resident to met nutrition and hydration requirements for 2 (Residents 40 & 35) of 2 residents reviewed for enteral tube feeding (nutrition delivered into stomach or intestine by tube). The failure to not have directions for and documentation of the amount of formula infused, water infused, amount of water for flushing the tube, and amount of water provided with medications, placed residents at risk for metabolic complications from inadequate calorie or protein intake and/or inadequate hydration. Findings included . Resident 40 According to the 11/22/2021 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 40 had severe cognitive impairment, was sometimes able to understand and be understood, and had an enteral feeding tube. Resident 40 received 51% or more of their nutritional intake through tube feeding. An 08/28/2021 Physician's order (PO) showed Diabetisource at 85 cc (cubic centimeter) per hour…

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 (Residents 16 & 54 ) of three residents reviewed for respiratory care, were provided respiratory care, in accordance with professional standards of practice. The facility failed to ensure: Oxygen (O2) therapy was provided in accordance with physician orders (PO); Providers were notified of resident refusals of oxygen therapy; O2 humidifier bottle fluid levels were monitored to ensure functionality; and that O2 concentrator filters were clean and functional. These failures resulted in residents receiving the incorrect amount of oxygen and placed residents at risk for dry mucosa (nose and mouth), discomfort and respiratory distress. Findings included . Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 12/12/2021 5-day Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of chronic respiratory failure, and required the use of supplemental O2. Record review showed…

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 Dialysis policies and procedures were developed and implemented to ensure timely communication and coordination of care with kidney centers and provide consistent monitoring after dialysis treatments according to professional standards of practice for 4 (Residents 36, 60, 13, & 50) of 4 residents reviewed for dialysis services (a mechanical process of filtering the blood when the kidneys are not functioning). Failure to coordinate communication between the facility and the dialysis center on days of treatment and failure to monitor and document the resident's condition after dialysis placed the residents at risk for delayed identification of serious complications. Findings included . According to the facility Dialysis Policy (undated), the facility communicates with the dialysis center by completing the Dialysis Transfer Form to send with the resident to the appointment. The form includes any medication changes, medical or mental status changes and labs since the last dialysis appointment. The facility requires the…

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

Based on interview and record review, the facility failed to maintain eight hours of Registered Nurse (RN) coverage to directly supervise resident care, for 3 of 30 days (10%) reviewed for RN coverage. This failure placed residents at risk for inadequate assessments, delay in identification and response to changes in medical conditions and unmet needs. Findings included . Review of document titled, Staffing Pattern provided on 01/04/2022 had the review dates of staffing pattern from 12/04/2021 thorugh 01/04/2022. The document further showed that the facility did not have a RN on duty to assist with assessment of resident conditions on 12/04/2021, 12/05/2021 and 12/26/2021. During an interview on 01/11/2022 at 7:46 AM, Staff B (Director of Nursing) stated she was aware that there were staffing issues and the facility was working on actively recruiting. Review of a document provided by Staff A (Administrator) on 01/ at 5:00 PM, showed that there was not RN coverage on 05/09/2021, 05/23/2021 and 05/31/2021. REFERENCE: WAC 388-97-1080(3)(a). .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 3 (Residents 62, 43, & 13) of 5 residents reviewed for unnecessary medications, plus 3 (Residents 18, 60 & 32) supplemental residents, were free from unnecessary psychotropic drugs related to the failure to: develop and monitor individualized Target Behaviors (TBs), monitor for adverse side effects, ensure adequate indications for use, or implement non-drug interventions prior to the use of as needed psychotropic medication use. These failures placed residents at risk for receiving unnecessary psychotropic medications, unnecessary psychotropic medication side effects and a diminished quality of life. Findings included . Resident 43 Resident 43 re-admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly Minimum Data Set (MDS- an assessment tool), the resident was cognitively intact, had diagnoses of depression and anxiety disorder, demonstrated no behaviors and received antipsychotic and antidepressant medication on seven 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 maintain complete and accurate medical records for 11 (Residents 14, 23, 19, 16, 43, 55, 62, 66, 25, 32, & 59) of 24 residents whose records were reviewed. The Facility failed to ensure: staff completed and maintained resident inventories; documents were accurate with identifiable initials; or entered into resident records timely. Failure to ensure clinical records were complete and accurate placed residents at risk for unmet care needs and lost property. Findings included . Resident 14 According to the 10/18/2021 admission MDS (Minimum Data Set - an assessment tool) Resident 14 was assessed with multiple medically complex diagnoses including an above the knee leg amputation and required extensive two-person assistance with bed mobility and toileting. Review of bathing records showed staff provided Resident 14 with two showers each day on 12/06/2021, 12/07/2021, 12/10/2021,12/13/2021 but no bathing support was provided. Staff documented the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. Thirteen facility staff members (Staff KK, OO, MM, Y, I, PP, LL, O, H, BB, V, RR & E) were observed to fail to do one or more of the following: consistently perform hand hygiene before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP) notice posted outside of resident rooms; appropriately apply and/or wear the model N95 respirator they were fit tested for; ensure contaminated resident bedding ( pillows, positioning wedges, blankets) found on the floor was washed or replaced before placing them back on the resident's bed; and maintain infection control during wound care and medication pass. Additionally, staff failed to ensure resident equipment was stored off the floor and…

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

Based on interview and record review, the facility failed to ensure 7 (Staff G, I, O, R, J, K, & M) of 7 staff reviewed, received training regarding recognizing, reporting, and preventing resident abuse. The failure placed residents at risk for unidentified abuse, a lack of intervention in response to allegations of abuse or neglect, as well detracting from staff's ability to prevent abuse and or neglect of residents. Findings included . During an interview on 01/10/2022 at 11:43 AM, Staff I (Certified Nursing Assistant) indicated Abuse was discussed during meetings, but no formal inservicing was done since the former owners (a Change of Ownership occurred in February 2021) provided it. In an interview on 01/12/2022 at 10:39 AM, Staff A (Administrator) stated new hires received abuse education provided by Staff X (Office Clerk) via videos on hire. Staff A stated Staff J (Staff Development) provide these inservices annually to existing staff. In an interview on 01/12/2022 at 10:55 AM, Staff J stated they did not do abuse inservices and had not since they were hired. On 01/12/2022 at…

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 grievances were initiated, logged, addressed, and timely resolved for 2 (59 & 60) of 13 resident's reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform residents of the their findings and the actions taken, precluded the facility from identifying grievance trends and placed residents at risk of feelings of frustration, unimportance, decreased self worth and quality of life. Findings included . According to the April 2017 facility Grievance Policy, upon receipt of a grievance and/or complaint, the Grievance Officer/Designee will review and investigate the allegations and submit a written report of such findings to the Administrator within 5 working days of receiving the grievance and/or complaint. The resident would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct the identified problems. Resident 59 According to the 12/14/2021 Quarterly Minimum Data Set (MDS 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 initiate and thoroughly investigate, and timely resolve allegations of misappropriation and resident to resident verbal abuse for 1 of 1 (Resident 16) and 1 supplemental resident (Resident 61) reviewed for abuse. The facility's failure to investigate allegations of verbal abuse and misappropriation detracted from staffs' ability to determine if abuse had occurred and precluded them from identifying and implementing interventions to prevent reoccurrence. These failures placed residents at risk for unidentified and/or continued abuse and misappropriation, as well as feelings of helplessness and diminished self worth, related to the facility's lack of response to their reported concerns. Findings included . Facility Policy According to the facility's undated Abuse Investigation and Reporting [AIR] Policy, all reports of resident abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown source will be thoroughly…

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 complete and/or transmit the required Minimum Data Set (MDS - an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for 4 (Residents 118, 43, 19, & 13) of 7 sample residents with discharges reviewed for resident assessments. Findings included . Resident 118 Review of census documents showed Resident 118 admitted to the facility on [DATE]. According to progress notes dated 12/16/2021, the resident had a change in condition which required transfer to the hospital. Record review showed no MDS which reflected the resident was discharged with return either anticipated or not anticipated. According to an Entry Tracking MDS document, the resident readmitted to the facility on [DATE]. In an interview on 01/05/2022 at 2:11 PM, Staff B (Director of Nursing) reviewed the resident's record and confirmed there should be a Discharge MDS which correlated with the 12/16/2021 hospital discharge. Resident 13 A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed for 2 (Residents 2 & 118) of 4 newly admitted residents reviewed, to provide residents and/or their representative with a summary of their baseline care plan (CP). This failure resulted in residents and/or families not being informed of their initial plan for delivery of care and services and placed residents at risk for unmet needs and possible complications. Findings included . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 2 admitted to the facility on [DATE] and was assessed as cognitively intact. In an interview on 01/04/2022 at 9:14 AM, Resident 2 stated they were not given a copy of any CP since admission. Record review showed CPs were initiated on 12/14/2021 but no indication facility staff provided Resident 2 with a copy. Resident 118 Review of progress notes showed Resident 118 admitted to the facility on [DATE] and transferred to the hospital due to a change of condition on 12/16/2021.…

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 (Residents 13, 2, 14, 66 & 59) of 24 sample residents were provided treatment, care, and services in accordance with professional standards, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure residents received care for non-pressure related skin conditions, edema management, bowel management, alert monitoring and documentation for care and condition changes. These failures placed residents at a potential risk for decline in medical status and quality of life related to unmet care needs. Findings included . Resident 13 According to the 10/14/2021 Quarterly Medicare/5-day Minimum Data Set (MDS - an assessment tool) Resident 13 re-admitted to the facility on [DATE], and had a new primary diagnoses of acute pulmonary edema (fluid in the lungs) with acute respiratory (breathing) failure, and a long-standing diagnosis of end-stage kidney disease which required dialysis. The MDS…

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 on-going assessments, documentation, and prevention of pressure ulcers consistent with professional standards of practice for 2 (Resident 40 & 2) of 7 residents reviewed for pressure ulcers. Failure to assess and monitor pressure ulcers and implement preventative measures, such as positioning, placed residents at risk for deterioration in skin condition. Findings included . According to 2016 National Pressure Injury Advisory Panel (NPIAP) definitions of pressure injury staging, a Stage IV pressure injury was defined as full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon , ligament, cartilage or bone in the ulcer. Resident 40 According to the 11/22/2021 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 40 was assessed with severe cognitive impairment, had diagnoses including multiple sclerosis with hemiplegia (paralyzed on one side of the body), and 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.

Based on observation, interview, and record review, the facility failed to: ensure appropriate safety measures to prevent a fall were implemented for 1 (Resident 14) of 11 Residents reviewed for accidents, ensure hallways were free of accident hazards, and ensure hazardous materials stored in supply closets were secured. These failures left residents at risk for avoidable injury, and exposure to unsafe materials. Findings included . Resident 14 According to the 10/18/2021 admission MDS (Minimum Data Set, an assessment), Resident 14 was assessed with a history of falls and experienced a fall since admission to the facility. According to the falls risk Care Plan (CP) dated 10/12/2021, interventions for safety, related to falls included bilateral floor mats to decrease risk of potential injuries. Observations on 01/03/2022 at 2:35 PM showed Resident 14 lying in bed with one gray fall mat noted on the floor, on the right side of the bed. Observations on 01/04/2022 at 10:14 AM showed the resident lying in bed with a gray fall mat noted leaning up against the wall. A similar observation,…

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 medically related social services for 3 (Residents 23, 61 & 25) of 7 residents reviewed with behaviors. Failure to follow up after instances of refusals of care left residents at risk for unmet care needs and negative health outcomes. Findings included . Refer to CFR 483.25(k), F-697 Pain Management Resident 23 According to the 11/02/2021 admission Minimum Data Set (MDS- an assessment tool), Resident 23 had multiple complex diagnoses including depression, anxiety disorder, paralysis of the left upper and lower extremities, moderate cognitive impairment, and had no rejection of care but did demonstrate verbal behavioral symptoms towards others. In an interview on 01/04/2022 at 10:23 AM Resident 23 indicated they previously worked with therapies, but stopped participation related to issues with knee pain. The resident also indicated a fear of transfers because they were dependent on staff and, I am afraid I will fall. According to a…

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

Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and incorporated for 1 (Residents 13) of 5 sample residents and 1 (Resident 36) supplemental resident whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects and at risk of receiving medications without required pharmacist oversight. Findings included . The facility policy Medication Regimen Reviews (MRR) (undated) showed the consultant pharmacist performs a MRR for every resident in the facility reviewing mediation and are done upon admission and at least monthly thereafter. The pharmacist provides a report to the attending physician within 24 hours and a copy to the Director of Nursing and the Medical Director. Copies of the MRR, including the physician responses, are maintained as part of the permanent medical record. Resident 36 According to the 11/22/2021 Quarterly Minimum Data…

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 (Residents 14 & 13) of 5 sample residents and 1 (Resident 38) supplemental resident were free from unnecessary medications. Failure to ensure adequate monitoring and indications for use placed residents at risk for inadequate treatment of conditions and adverse side effects. Findings included . Resident 14 Resident 14 admitted to the facility on [DATE] and according to the 10/18/2021 admission Minimum Data Set (MDS- an assessment tool) was assessed with multiple medically complex diagnoses including diabetes. Review of the 11/2021 Medication Administration Records (MAR) showed physician orders (PO) to administer insulin each evening for treatment of diabetes. A second PO directed staff to check blood sugars three times a day and administer insulin as needed based on the results of the blood sugar checks (sliding scale). According to provider notes dated 11/23/2021, nursing staff were directed to discontinue the sliding scale…

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 a medication error rate of less than 5 percent (%). One (Staff II) of 3 Licensed Nurses made 2 errors during 30 opportunities, for 1 (Residents 33) of 6 residents observed for medication pass. This resulted in an error rate of 6.6%. This failure placed residents at risk for not receiving the intended therapeutic effects of physician ordered medication. Findings included . According to the undated facility Installation of Eye Drops policy, when administering two or more different eye drops allow three to five minutes between each application. On 01/11/2021 at 9:29 AM Staff II (Registered Nurse) was observed administering Resident 33's eye drops. Staff II administered Brimonidine 2% (used to treat Glaucoma) one drop to the right eye, waited 90 seconds and administered Cosopt Solution (used to treat Glaucoma) one drop to both eyes. Failing to wait 3-5 minutes constituted as one medication error. After waiting 90 seconds, Staff II administered Rhopressa 0.02% (used to treat Glaucoma) to both eyes. Failing to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Medications at the Bedside Resident 60 On 01/03/2022 at 12:30 PM, three medicine cups containing a powdered substance were observed on the bedside table. Resident 60 stated the medicine was their dialysis medication, Tums (an antacid) and they were not sure of the other medication. On 01/06/2022 at 8:13 AM, two medicine cups containing a powered substance were observed sitting on the bedside table. Resident 60 was out of the facility at dialysis. In an interview on 01/06/2022 at 8:26 AM, Staff SS (LPN) stated the resident left for dialysis at 5:00 AM, and medications were not administered until Resident 60 returned from dialysis. Staff SS stated the two medicine cups look like crushed medication, they could not identify the medication and stated the medication should not be left at the bedside. Resident 36 On 01/05/2022 at 8:28 AM, a medicine cup containing pills was observed on the bedside table in front of Resident 36. During an interview on 01/05/2022 at 8:36 AM, Staff Y (LPN) stated Resident 36 was alert 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 prompt dental services were provided for 4 (55, 2, 14 & 18) of 13 state pay residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs, and a diminished quality of life. Findings included . Resident 55 Resident 55 admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change Minimum Data Set (MDS- an assessment tool), the resident had severe cognitive impairment, required extensive assistance with oral care, had obvious or likely cavities or broken natural teeth, and had a mechanically altered diet, Record review showed Resident 55 was seen by the dentist on 03/02/2021 and 04/09/2021. Review of the 03/02/2021 dental consult showed the resident was assessed with red irritated gums, heavy wall to wall plaque and calculus, and broken teeth or root tips to the following lower teeth, numbers 20, 21, 24, 25, 26 &27. The dentist hand wrote on the form [Resident 55] would…

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 have a system to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for 1 (Resident 38) of 1 resident reviewed for hospice services. The facility did not develop or maintain a comprehensive hospice plan of care in collaboration with hospice, did not identify what services were to be provided by hospice, and did not obtain the hospice nurse visit notes and recommendations to implement into the resident's care. This failure placed Resident 38 at risk for not receiving necessary care and services. Findings included . Resident 38 The 06/02/2021 admission Minimum Data Set (MDS-an assessment tool) showed Resident 38 was admitted to the facility on [DATE] and had hospice services on admission. Resident 38's primary diagnosis was Alzheimer's disease with late onset. Review of the 06/28/2021 facility Care Plan (CP) showed Resident 38 had a terminal prognosis of dementia and failure to thrive. 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 2 (Residents 14 & 13) of 5 residents reviewed for vaccinations, were offered the recommended vaccinations. This failure placed residents at risk for contracting pneumonia and/or influenza, with the associated complications of infection. Findings included . Review of the Centers for Disease Control (CDC) 2021 Recommended Adult Immunization Schedule showed a person age [AGE] or older should receive 1 dose of the Pneumococcal polysaccharide 23 (PPSV23). If the PPSV23 was administered prior to age [AGE] years, administer 1 dose PPSV23 at least five years after previous dose. A person age [AGE] or older should receive 1 dose of the Pneumococcal conjugate 13 (PCV13) based on shared clinical decision making and if previously not administered. If a resident requires both pneumo vaccines, PCV 13 should be administered first and the PPSV23 should be administered at least 1 year apart. The CDC 2021 Recommended Adult Immunization Schedule (Table 1) 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.