Canterbury House

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of 3 of 16 sample residents (Residents 67, 3, & 10) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included . <Facility Policy>According to the facility's March 2019 updated Resident Assessment Instrument (RAI) Policy, the facility would complete MDS assessments per the RAI Manual.<Resident 67> According to the 12/27/2025 Annual Minimum Data Set (MDS – an assessment tool), Resident 67 had multiple medical conditions including anxiety and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity, from intense highs characterized by mania to deep lows characterized by depression, that disrupts daily functioning, sleep, and concentration). The MDS showed Resident 67 was given antipsychotic, antianxiety, and antidepressant medications during the assessment period. The MDS showed Resident 67's 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 observation, interview, and record review the facility failed to ensure residents' Care Plans (CPs) were comprehensive and implemented for 1 of 18 (Resident 22) sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policy>The facility was unable to provide a policy describing their CP development and implementation standards and expectations. <Resident 22> According to the 12/18/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had multiple complex conditions including diabetes, depression, anxiety and a chronic heart condition. Review of the revised 10/16/2025 Impaired psychosocial well-being related to depression and anxiety CP showed Resident 22's target behaviors included refusing their medications. This CP included no directions to staff showing what to do when Resident 22 refused their medications. No other CP was developed to address Resident 22's needs related to refusing medications. Review of the January 2026…

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 facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 2 of 3 sampled residents (Residents 1 & 29) reviewed for ADLs. The failure to provide bathing and grooming assistance for (Residents 29) and nail care for (Resident 1) left residents at risk for body odors, unmet care needs, and a decreased self-worth and/or quality of life. Findings included <Facility Policy>The facility policy titled, Bath or Shower Assistance, updated 11/2016, showed the facility provided ADL assistance according to the resident's Care Plan (CP) and the resident's need for assistance.<Resident 1> According to the 12/26/2025 5-day Minimum Data Set (MDS - an assessment tool) Resident 1 had medically complex conditions including diabetes (a condition making it more difficult to control blood sugar), respiratory failure, and muscle weakness. The MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain safe water temperatures for 2 of 14 resident room sinks (Rooms 215 & 301) reviewed for water temperatures; and failed to secure potentially hazardous items in 1 of 2 clean utility rooms (West Nursing Station clean utility room) reviewed for accident hazards. These failures placed residents at risk for accidents, injury, and a diminished quality of life.Findings included.<Policy>According to the facility's July 2008 Washington State Water Temperature Regulations policy, the facility must ensure the hot water system maintained water temperatures at 110 degrees Fahrenheit (F), plus or minus 10 F, for fixtures used by residents and staff.<Water temperatures> <room [ROOM NUMBER]> Observation on 01/13/2026 at 10:33 AM showed the hot water temperature of the sink in room [ROOM NUMBER]'s bathroom was 123 F. No residents were present. Observation on 01/13/2026 at 11:32 AM showed Resident 46 independently using the sink in room [ROOM…

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 identification, investigation, protecting, and reporting of abuse and neglect incidents. The facility failed to thoroughly investigate incidents and allegations of abuse, sexual abuse, and neglect for 7 of 9 residents (Resident 2, 1, 4, 3, 5, 6, 7) reviewed for incidents, failed to identify and report incidents as potential for abuse or neglect related to falls and bruises for 2 of 2 residents (Resident 2, 8), and failed to ensure facility staff implemented abuse policies and procedures and protected residents from further abuse by staff for 1 (Staff D) of 6 staff involved in incidents, when Staff D went back to Resident 4 and Resident 5's room despite an allegation of verbal abuse, and failed to timely report allegations of sexual abuse to local authorities as required for 1 of 2 residents ( Resident 2) reviewed for sexual abuse allegations. These failures 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 Based on interview and record review, the facility failed to ensure 5 of 6 residents (Resident 1, 3, 12, 14, 15 ) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to document identified target behaviors, monitor all target behaviors, document when behaviors occurred, implement and document behavioral interventions before administering medications, assess the effectiveness of the interventions before increasing medications, and to have as needed psychotropic medication (affects behavior, mood, thoughts, or perception) orders with stop dates and physician reassessment for extended use. These failures left residents at risk for unnecessary medications, adverse side effects, unmet needs, and diminished quality of life Findings included . Review of the facility policy titled, Psychotropic Drugs, updated 10/2022, showed the facility would evaluate and implement interventions for residents on psychotropic…

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 3 (Resident 1, 12, 3) of 6 residents or resident representatives reviewed were fully informed orally and in writing of the potential risks associated with the use of psychotropic medications (medications that alter the thought process). In addition, based on interview and record review the facility failed to obtain informed consent for devices used for 1 (Resident 1) of 4 residents reviewed for devices. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications. Findings included . Review of the facility policy titled, Informed Consent for Psychotropic Drugs, updated 09/2017, showed the facility would obtain informed consent form the resident or resident representative before the drug prescribed is administered. The licensed nurse would review the drug, dosage 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 the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 1 of 7 (Resident 23) residents reviewed for PASRR Level II. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy> According to the facility's July 2015 Mental Health Rehabilitation Services policy, residents diagnosed with a mental illness or developmental disability would be prescreened through the PASRR process and receive the treatment they were assessed to require from the evaluation. The policy showed the social services department was responsible for reviewing all residents receiving a Level II PASRR screening. <Resident 23> According to the 09/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 had medically complex diagnoses including a history of stroke, alcohol dependence, and a psychotic disorder. The MDS showed Resident 23 took…

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 Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 7 (Residents 22, 57, & 13) residents and 2 supplemental residents (Resident 185 & 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 22> According to the 08/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had diagnoses including depression, bipolar disorder, and Post Traumatic Stress Disorder (PTSD). The MDS showed Resident 22 took antidepressant medications. This MDS showed Resident 22 admitted on [DATE]. According to the September 2024 Medication Administration…

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/or implement comprehensive Care Plan's (CP) for 6 of 20 sampled residents (Residents 53, 70, 32, 43, 45, & 16) whose CPs were reviewed. The failure to develop comprehensive, individualized, or implement CPs with resident-specific goals and/or interventions, placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Care Plan Development> <Resident 53> According to a 09/02/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 53 was admitted to the facility on [DATE] with multiple medically complex diagnoses. Review of Resident 53's comprehensive CP showed an Establish the baseline Plan of Care problem was initiated by staff on admission. This CP, over 30 days after Resident 53's admission, did not have any measurable or individualized goals established by staff. <Resident 70> According to an 08/09/2024 admission MDS, Resident 70 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 70, 53, 185, & 13) of 20 sample residents whose CPs were reviewed. The facility failed to ensure residents received and/or participated in care conferences that included the Interdisciplinary Team (IDT) for 2 (Residents 21 & 43) residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Care Plan Revision> <Resident 70> According to an 08/09/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 70 was admitted to the facility on [DATE] with multiple medically complex diagnoses. Review of Resident 70's comprehensive CP showed an Establish the baseline Plan of Care problem was initiated by staff on admission. This CP listed an intervention that Resident 70 was on isolation precautions for having a Peripherally Inserted…

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 assistance with Activities of Daily Living (ADL - personal hygiene and other daily routines) was provided for 8 of 11 residents reviewed for ADL (Residents 70, 21, 20, 13, 22, 43, 16, & 45). The failure to provide assistance with getting out of bed, nail care, and bathing placed residents at risk of poor hygiene, diminished sense of self-worth, skin impairment, and frustration. Findings included . <Assistance With Getting Out of Bed> <Resident 70> According to an 08/09/2024 admission MDS, Resident 70 had no memory impairment, was assessed with a functional limitation in range of motion to one side of the lower extremity and had no rejection of care. This MDS showed staff assessed Resident 70 required substantial assistance to roll side to side in bed, was dependent on staff for upper and lower dressing, and transfers from bed to chair were not attempted due to medical condition or safety concerns. Observations on 09/29/2024 at 9:45…

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 3 of 7 residents (Resident 70, 16, & 43) reviewed for Range of Motion (ROM) and 1 supplemental resident (Residents 46) received a Restorative Nursing Program (RNP) as ordered. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to the facility's March 2019 Restorative Program policy, residents would be evaluated for restorative needs on admission, quarterly, and with significant changes. The policy showed restorative nursing assistants and other staff would provide RNPs to residents and document on a restorative flow sheet. <Resident 70> According to an 08/09/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 70 had multiple medically complex diagnoses including muscle weakness and difficulty in walking. This MDS showed Resident 70 had a recent surgical procedure involving tendons, ligaments, or muscles, had 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.

<Resident 185> According to a 09/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 185 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 185 with no memory impairment. In an interview on 09/30/24 at 9:45 AM, Resident 185 stated they felt the facility did not have enough staff, especially at shift change, on the night shift. Resident 185 stated they would have to wait anywhere from 15 minutes to one hour to get assistance from staff with their toileting needs.Based on observation, interview, and record review the facility failed to have sufficient nursing staff to provide timely assistance to residents, supervise care of residents, meet Activities of Daily Living (ADL) needs including showering/bathing, assisting residents out of bed, and call light response time as evidenced by information provided by 13 (Resident 21, 234, 38, 45, 72, 185, 18, 54, 62, 21, 35, 71, & 61) residents interviewed. These failures placed residents at risk for unmet care needs, accidents, and a decreased quality of life. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and followed up timely for 3 of 5 residents (Residents 3, 13, & 23) whose medication regimens were reviewed and 2 supplementary residents (Residents 46 & 16). This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 3 had multiple medically complex diagnoses including dementia, depression, a bipolar disorder (a mental illness characterized by extreme mood swings) and a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and required the use of antidepressant and antipsychotic medications during the assessment period. Review of Resident 3's records showed no documentation that…

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 3 & 23) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 3 had multiple medically complex diagnoses including dementia, depression, a bipolar disorder (a mental illness characterized by extreme mood swings) and a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and required the use of antidepressant and antipsychotic medications during the assessment period. This MDS showed staff documented the last Gradual Dose Reduction (GDR) was 05/16/2023, over a year ago, and a GDR was not documented by a physician as clinically contraindicated. Review of Resident 3's September 2024 Medication Administration…

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 7 of 26 medications for 2 of 5 residents (Resident 72 & 4) observed during medication pass resulted in a medication error rate of 26.92 %. 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> Review of the 01/2024 facility, Medication Administration Guidelines policy showed medications should be administered in accordance with written orders of the prescriber. Medications should be verified three times before administering; when pulling a medication package from the medication cart, when the dose is prepared, and before the dose is administered. The policy showed long-acting, extended released, or enteric coated dosage forms should not be crushed. <Resident 72> Observations of medication pass on 10/01/2024 at 9:45 AM, showed Staff FF (Licensed Practical Nurse) prepare…

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 drugs and biologicals were secured, dated when opened, expired medications and biologicals were disposed of timely in accordance with professional standards, medications were stored at beside only for assessed residents, and ensure medication carts were locked and secured when staff were not present for 2 of 4 medications carts, 1 of 2 medication rooms, and 1 shower room. These failures placed residents at risk for receiving expired medications and access to unsecured, prescription medications. Findings included . <Facility Policy> Review of the facility's Medication Storage policy, dated 01/2024, showed medications and biologicals would be stored properly to support safe, effective drug administration. The medication supply would only be accessible to licensed nursing personnel. The policy showed medications would be stored so that various routes of administration would be separated. Internally administered medications would be stored separately from medications such as creams, lotions, and ointments.…

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

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 4 of 5 residents (Resident 37, 48, 35, & 59) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's updated September 2022 Arbitration Agreement policy in the admission Agreement packet showed the admissions coordinator would review the arbitration agreement with the resident upon admission to the facility. The policy showed the admissions coordinator was responsible for any questions the resident had about the contract. <Resident 37> According to the 04/09/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 37 was alert and oriented with 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 <Transmission Based Precautions> According to a 09/21/2024 progress note, Resident 34 tested positive for COVID-19 on that date. The note showed necessary precautions were put in place for Resident 34. According a 09/21/2024 progress note Resident 25 was placed on aerosol contact precautions on that date related to their roommate Resident 34 testing positive for COVID-19. A 09/28/2024 progress note showed Resident 25 tested positive for COVID-19 on that date. Observation on 09/30/24 02:23 PM showed an Aerosol Contact Precaution sign outside room [ROOM NUMBER], both residents in that room were isolated. The sign directed anyone entering the room to put on a gown, gloves, eye protection and an N-95 respirator prior to entering the room. The sign directed everyone to remove all their PPE before leaving the room and replace their eye protection and respirator. At that time Staff O (CNA) heard one of the residents in the room cry out. Staff O already wore eye protection and a respirator and put on a gown and gloves…

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 32> Review of Resident 32's records showed an electronically signed form dated 05/24/2021, titled Authorizations and Designations that indicated the resident did not provide an AD to the Facility. Review of Resident 32's notes from the following Care Conferences; 01/10/2024 (admission), 02/01/2024 (quarterly), 04/26/2024 (annual), and 07/29/2024 (quarterly), showed the box indicating a review of Annual and admission paperwork reviewed with resident for AD was not marked for any of the care conferences, indicating a review was not completed with the resident. Review of Resident 32's records showed no AD. According to the 09/07/2024 Quarterly MDS, Resident 32 was understood, had clear comprehension, had multiple medically complex conditions and was admitted to the facility on [DATE]. In an interview on 10/02/2024 at 1:21 PM, Staff D stated AD should be provided to residents on admission and social services should follow up every quarter with the resident for changes. Staff D stated it was very important…

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 their Grievance policy for 3 of 3 residents (Resident 54, 70, & 53) reviewed for Grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life. Findings included . <Facility Policy> Review of a facility policy titled, Grievance Procedure, updated November 2016, showed residents had the right to voice grievances orally regarding their care and treatment, interactions with other residents, and other concerns during their stay. Staff would be trained at orientation and periodically on the center's grievance procedure which included the need to take grievances seriously, what to do with grievances, when to put grievances in writing, and when to report to their supervisor. <Resident 54> According to the 07/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 54 was understood, had clear comprehension, and had no cognitive…

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 report significant injury of unknown origin for 1 of 1 resident (Resident 16) reviewed. The facility's failure to report a large hematoma of unknown origin on Resident 16's right calf, placed Resident 16 and all residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Reporting and Response, published September 2017, showed staff would immediately report all alleged or suspected violations to the supervisor and Executive Director (ED). The policy showed the ED or designee would report injuries of unknown source to the state agency immediately, but no later than two hours. This policy showed the facility would identify the staff responsible for implementation of corrective actions, expected date of implementation, and those responsible for monitoring. The policy showed failure to report potential abuse/neglect timely by staff 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 thoroughly investigate and rule out abuse/neglect for 2 of 12 sampled resident's (Resident 16 & 4) reviewed for investigations. Facility failure to complete thorough investigations placed residents at risk for potential abuse and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Investigation, revised October 2022, showed the facility maintained complete and thorough documentation of the investigation. The policy showed the facility would determine, through investigation, if the abuse/neglect had occurred, the extent, and the cause of the injury. <Resident 16> According to the 08/07/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of paraplegia, non-Alzheimer's dementia, and chronic pain syndrome. The assessment showed Resident 16 was taking blood thinner 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 implement a system to ensure residents received required written notices at the time of transfer/discharge for 3 (Residents 65, 16, & 53) of 4 residents and notify the Office of the State Long-Term Care Ombudsman (LTCO) for 2 of 4 residents (Resident 16 & 53) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the Resident's Representative (RR) of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure required LTCO notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Resident 65> According to the 09/25/2024 Discharge Return Anticipated Minimum Data Set (MDS - an assessment tool), Resident 65 admitted on [DATE] and had no memory…

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 (RR) a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 (Residents 67, 16, & 53) of 4 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 that was necessary for decision making. Findings included . <Facility Policy> According to page 6 of the facility's admission Agreement, updated 05/2017, the facility would provide a bed-hold notice in accordance with applicable regulations and discuss bed-hold rates with the resident and their representative at the time of transfer to an acute hospital. <Resident 67> Review of Resident 67's 09/19/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return…

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 physician's orders were clarified for 1 of 21 sample residents (Resident 29), or followed for 2 of 21 sample residents (Residents 4 &3). These failures placed residents at risk for unneeded care and unmet care needs. Findings included . <Clarifying Orders> <Resident 29> According to the 07/10/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 29 had medically complex diagnoses including cancer and high cholesterol. Review of the physician's orders showed a 08/15/2024 order for a fiber supplement, give one pill as needed. The order did not include a dosage. In an interview on 10/04/2024 at 2:13 PM Staff B (Director of Nursing) stated the order should include a dose and needed clarification <Following Orders> <Resident 4> According to the 09/04/2024 Quarterly MDS, Resident 4 had medically complex diagnoses including a chronic ulcer. The MDS showed Resident 4 received opioid medications. Record review showed a 12/06/2023 order for an opioid pain medication, give twice a day for chronic…

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

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 1 of 5 sample residents (Resident 32) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's updated July 2015 Activities Program policy the facility would provide an ongoing program of activities designed to meet the interests as well as physical, mental, and psychosocial well-being of each resident. For residents confined to their room, the Activity Department would provide and assist with in-room activities in keeping with needs, abilities, and interests of residents. <Resident 32> According to a 05/15/2024 Quarterly admission Minimum Data Set (MDS - an assessment tool) activities were very important for Resident 32. The MDS showed Resident 32 preferred to have books and newspapers, listen to music, and participate in their activities of choice. The assessment showed Resident 32 had moderate…

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 free of accident hazards for 4 (Residents 41, 57, 43, & 16) supplemental residents reviewed. The failure to ensure residents were free from potential restraints (Resident 41), ensure staff safely used and monitored air mattresses (Residents 57, 16, & 43), ensure sharps (syringe needles, razors etc.), and chemicals were stored safely, placed residents at risk for potential restraints, injury, exposure to soiled medical equipment, and unsafe chemicals. Findings included . <Resident Mattress> <Resident 41> According to the 06/27/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 41 had moderate memory impairment and needed substantial assistance from staff to roll from side to side in bed. Observation on 09/30/2024 at 2:21 PM showed a folded blanket placed under the right side of Resident 41's mattress between the mattress and the bed frame. The blanket raised the right side of the mattress one-to-two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 5 of 5 sample residents (Residents 32, 45, 53, 185, & 22) reviewed for oxygen administration were provided care consistent with professional standards of practice. Failure to provide oxygen treatments and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's December 2017, Oxygen Administration Policy, oxygen would be provided in accordance with physician's orders, state and federal regulations, and standards of practice. Safety precautions and care of oxygen delivery equipment were performed according to state and federal regulation and manufacturer guidance, equipment that was soiled would be replaced. Oxygen liter flow would be set by a licensed nurse in accordance with physician's orders including liter flow and parameters for duration and frequencies. <Providing Oxygen as 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 ensure pain management was provided to residents consistent with professional standards of practice including the failure to offer nonpharmacological interventions, identify parameters for administration of as needed (PRN) pain medications, and administer pain medications timely for 1 of 2 residents (Resident 16) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain and a decreased quality of life. Findings included . <Resident 16> According to a 09/03/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 16 admitted [DATE] and was severely cognitively impaired. The assessment showed Resident 16 received pain medications routinely and PRN. The MDS showed Resident 16 did not receive non-medication interventions for pain. The MDS showed a pain assessment interview should not be conducted with Resident 16/Resident Representative (RR) at the time of the assessment. 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.

Based on interview and record review, the facility failed to ensure 2 of 20 sample residents (Residents 23 & 72) were free from significant medication errors. These failures placed residents at risk for incorrect dosage, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> Review of the 01/2024 facility, Medication Administration Guidelines policy showed medications should be administered in accordance with written orders of the prescriber. Medications should be verified three times before administering; when pulling medication package from medication cart, when dose is prepared, and before dose is administered. <Resident 23> According to the 09/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 had diagnoses including stroke with communication deficits, dementia, a history of alcohol dependence, psychotic disorder, and a disorder related to personality and behaviors. The MDS showed Resident 23 was administered routine antipsychotic medication. Review of the September 2024 Medication Administration Record (MAR) 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 obtain timely laboratory services to meet the needs of 1 (Resident 3) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (an assessment tool), Resident 3 had multiple medically complex diagnoses including heart failure, high blood pressure, diabetes (a chronic disease in which the body has trouble controlling blood sugars), lung disease, and a thyroid disorder. Review of Resident 3's September 2024 Medication Administration Records showed a 09/05/2024, STAT [immediate] order for a Complete Blood Count (CBC - a comprehensive blood test), a Comprehensive Metabolic Panel (CMP - a blood test that measures chemical balance in your blood), and a Thyroid-Stimulating Hormone level (TSH - a blood test to measure how well the thyroid is functioning) related to the resident having…

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 food and drinks served to residents were stored and distributed under sanitary conditions for 1 of 1 facility kitchen. The failure to store canned and frozen food appropriately, ensure food was covered when distributed in the hall, and ensure the ice machine was clean, placed residents at risk for spoiled food and foodborne illness. Findings included . <Facility Policy> According to the facility's February 2011 Dented Cans policy, all canned food items should be inspected by dietary staff upon delivery. The policy showed cans with significant dents should not be used and instead returned to the vendor <Dry Storage> Observation of the facility's dry food storage area on 09/29/2024 at 9:27 AM showed one large can of apricots, one large can of sliced apples, and three cans of diced pears that were all significantly dented. In an interview at that time Staff CC (Food and Nutrition Service Aide) stated cans with dents should be discarded. Staff CC said the dented cans should not be in the dry…

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 residents records were complete and accurate and readily accessible for 3 of 20 residents (Resident 16, 43, & 45) whose records were reviewed. The facility failed to ensure Task Care Record documentation was complete and accurate. Failure to ensure residents records were complete and accurate placed residents at risk for unmet care needs and inaccurate assessments. Findings included . <Resident 16> Review of Resident 16's August 2024 Task Care Records (documentation of resident specific cares offered/provided) showed staff failed to document multiple cares on multiple days. Similar findings were noted on Resident 16's September 2024 and October 2024 Task Care Records. <Resident 43> Review of Resident 43's July 2024 Task Care Records showed staff failed to document multiple cares on multiple days. Similar findings were noted on Resident 43's August 2024, September 2024, and October 2024 Task Care Records. <Resident 45> Review of Resident 45's June 2024 Task Care Records showed staff failed to document multiple cares…

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 the necessary care and services in accordance with professional standards of practice. The facility failed to ensure physician orders were followed, implemented timely, or were clarified as needed; Care Plans (CP) developed for 3 (Resident 2, 4, 3) of 3 residents reviewed; medications were not provided as ordered, for 1 (Resident 5) of 3 residents reviewed; and to monitor weights and bowels, act on, or implement their policies for 4 (Residents 3, 2, 1, 4 ) of 4 residents reviewed. These failures placed all residents at risk for unmet care needs, and decreased quality of life. Findings included . <Following, Implementation & Clarification of Physicians Orders & CP> <Resident 2> Review of an admission Minimum Data Set (MDS, an assessment tool) showed Resident 2 admitted to the facility on [DATE], was able to make their needs known, make their own decisions, and had behaviors of rejecting care four to six days out…

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 3 of 3 (Residents 3, 4, 1) residents reviewed for Pressure Ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, implement wound provider recommendations, and preventative skin measures placed all resident's at risk for deterioration in skin condition(s), pain, and diminished quality of life. Findings included . Review of the facility policy titled, Skin Integrity, updated 10/2022, showed to maintain the resident's skin integrity and promote healing of skin ulcers/PU's/wounds the facility would use a systematic approach and monitoring process to evaluate and document skin integrity. When a resident admitted to the facility with or developed a skin ulcer/PU/wound the facility would provide care to treat, heal, and prevent,…

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 for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent, timely weights and re-weights, identify significant weight changes timely, notify interested parties timely, and implement Registered Dietician's (RD) recommendations placed the residents at risk for delayed identification of interventions to prevent continued weight loss and decreased quality of life. Findings included . Review of the facility policy titled, Weights, revised on 10/12/2023, showed weighing criteria included obtaining a weight on the day of admission then weekly for one month. The policy showed guidelines for residents who may need to be weighed weekly due to; food intake declined and persisted, slow trending weight loss or gain, significant weight loss or gain, multiple stage two Pressure Ulcers (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to obtain informed consent for residents who were assessed to require a decision maker due to cognitive impairments before performing Covid-19 testing for 5 (Residents 6, 7, 2, 8, 9) of 5 residents reviewed for resident's rights. These failures placed all residents with decision makers unable to exercise their right to be fully informed in a language they could understand and removed their ability to refuse Covid-19 testing. Findings included . Review of the facility, Notice of Resident Rights under Federal Law policy, updated 10/2016 showed the resident had the right to formulate an advanced directive (included a durable power of attorney (DPOA) and health care directives the resident chooses) and to have rights exercised by a representative, whether the resident was judged incompetent or not, to the extent allowed by law. <Resident 6> Review of a Significant Change Minimum Data Set (MDS, an assessment tool), dated 01/19/2024, showed Resident 6 had 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 record review and interview the facility failed to ensure residents and/or their Resident Representative (RR) was provided a transfer or discharge notice in writing in a language or manner they understood and send a copy to the State Long-Term Care Ombudsman (SLTCO). The notice must contain the reason for transfer or discharge, location, a statement of appeal rights, and information for contacting the Ombudsman. The failure to provide written transfer/discharge notice to 4 of 4 residents (Resident #28, #32, #33, #60) upon facility-initiated transfer to the hospital prevented residents from inappropriate discharge, provide residents with access to an advocate who can inform them of their options and rights and to ensure the SLTCO is aware of facility practices and activities related to transfers and discharges. Findings included . Review of the 10/2019 facility policy Transfer and Discharge showed the facility would provide a written notice of transfer to the resident using the Resident Notice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide residents or the Resident's Representative (RR) with a bed-hold notice upon transfer to the hospital for 3 of 4 residents (Resident 28, 33, and 60) reviewed for hospitalization. The failure to provide a copy of the written bed-hold notice and reserve bed payment policy upon transfer to the hospital, regardless of payment source, prevented residents from exercising their rights and choice to return to the facility upon hospital discharge. Findings included . The 10/2019 Bed-hold policy showed the nursing staff would provide the resident and/or their RR a copy of the Notice of Bed Hold Policy upon transfer or discharge to the hospital. The policy showed the resident or responsible party would complete the bed-hold notice and sign to hold or refuse the bed-hold. <Resident 28> Review of the 05/22/2023 Significant Change Minimum Data Set (MDS- an assessment tool) showed Resident 28 was cognitively intact and could make themselves…

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 medications and vaccinations were stored at the appropriate temperature and failed to dispose of expired medications in a timely manner in 2 of 2 medication rooms (East and [NAME] Medication Room) and 1 of 3 medication carts (East Medication Cart) reviewed for medication storage. The failure to dispose of expired medications placed residents at risk for narcotic drug diversion and at risk of administration of expired or discontinued medication. The failure to monitor and document refrigerator temperatures twice daily when storing vaccinations placed residents at risk for administered vaccinations that were no longer useful. Findings included . <Facility Policy> The undated facility policy Discontinued Medications directed staff to remove discontinued medication from the medication cart immediately upon receipt of an order to discontinue the medication to avoid continued administration. The undated facility policy Controlled Substances showed controlled substances had a potential for abuse and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure 3 of 4 nurses (Staff P- Licensed Practical Nurse/LPN, Staff K- LPN, Staff N- LPN) followed hand hygiene procedures when in direct contact with residents. The failure to complete hand hygiene during medication administration placed residents at risk for illness, infections, and diminished quality of life. Findings included . <Hand Hygiene> Observation of Medication Pass on 08/07/2023 at 9:09 AM showed Staff P (Licensed Practical Nurse - LPN) wearing gloves and prepared to administer a syringe of diabetic medication to a resident in room [ROOM NUMBER]. Staff P stated to the resident they would be right back, removed gloves and left the room. Staff P went to the medication cart, helped another nurse find something in the cart, grabbed a new pair of gloves and returned to room [ROOM NUMBER]. Staff P did not use hand gel (alcohol-based hand sanitizer) when entering room [ROOM NUMBER] and did not use hand gel before putting on the gloves. Staff P…

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered Care Plan (CP), and the resident's choices for 1 resident (Resident 36) of 7 residents reviewed for pain, non-pressure skin, and oxygen management. The failure to assess, care plan, monitor, and follow Physician Orders (PO) placed Resident 36 at risk for overdose of opioid medication, untreated skin issues, worsening medical conditions, and diminished quality of life. Findings included . The 05/25/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 36 participated in the assessment, was cognitively intact, able to make self-understood, understand others, had no behaviors, and no refusals of care. Resident 36 had multiple complex diagnoses including intervertebral disc degeneration (breakdown of the spaces between the bones of the back) and opioid dependence. Resident 36 was assessed…

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 free from accidents and hazards for 1 of 1 resident (Resident 54) reviewed for smoking. The failure to assess Resident 54's smoking safety and develop a Care Plan (CP) to monitor and prevent accidents placed Resident 54 at risk for falls, burns, other injuries, and diminished quality of life. Findings included . The 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 54 was cognitively intact, able to make themself understood and understand others. Resident 54 was assessed with unsteady walking and turning, and used a walker. Resident 54 was assessed to require supervision when walking inside their room and the hallway and extensive assistance with locomotion off the unit. An observation on 08/06/2023 at 7:05 AM showed Resident 54 exited the locked entrance door of the facility. Resident 54 exited the building unsupervised. In an interview on 08/06/2023 at 7:50 AM, Staff A (Administrator) stated the facility was non-smoking. Staff A stated one resident 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.