Alderwood Park Health And Rehab Of Cascadia

Based on interview and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 7 resident interviews (Residents 3, 9, 22, 50, 57, 59 and 63) and one family interview (Resident 5) in three of three hallways and Resident Council minutes. The facility had insufficient staff to ensure residents received prompt call light response and assistance to meet the needs of the residents in accordance with resident preferences. These failures placed residents at risk for unmet care needs and negative outcomes. Findings included . <PAYROLL STAFFING DATA REPORT (PBJ)> Review of the facility past four quarter reports, dated 01/01/2024 through 12/31/2024, showed the facility had excessively low weekend staffing; there had been no change over the past year. <FACILITY ASSESSMENT> Facility Assessment last updated 07/31/2023 through 07/31/2024, showed the facility had an average of 316 residents annually who required 2-person assistance for daily care, noting a high amount relative to the benchmark. Additionally, the facility 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 interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 4 of 4 residents (Residents 1, 5, 34, and 276) reviewed for accurate and complete medical records. The facility failed to ensure the residents medical records contained hospice provider notes and orders, lab monitoring results, and complete blood sugar monitoring for residents. Failure tomaintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Finding included . Review of the facility policy titled, Resident Medical Record, revised 10/15/2022 stated medical records are maintained on each resident in accordance with accepted professional standards and practice .are complete, accurately documented, clear, concise, complete reflecting resident's responses and outcomes relate to their care, readily accessible, and systematically organized. <RESIDENT 5> Resident 5 readmitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff were com-pliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 5 nurses (Staff C) during medication administration, 1 of 1 resident (Resident 50) during catheter care, and for 1 of 1 resident (Resident 14) reviewed for transmission-based precautions (TBP) of a resident who had tested positive for Respiratory syncytial virus (RSV). The facility failed to ensure staff followed appropriate infection control practices during medication administration and performed appropriate hand hygiene during urinary catheter care. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards. This failure placed all residents and staff at risk for potential infection. Findings include . Review of the facility policy titled, Infection Prevention and Control Program, revised 10/15/2022 stated that the facility will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary assistance for oral care, and bathing for 3 of 5 residents (Residents 20, 69 and 276) dependent on staff to ensure their needs were met. This failed practice placed residents at increased risk for increased risk for embarrassment, diminished dignity, negative outcomes including poor quality of life and psychosocial harm. Findings included . According to the facility policy, Activities of Daily Living (ADL)'s- AM (morning) cares revised 11/14/2017 showed AM care is provided to refresh the resident, provide cleanliness, comfort, and neatness, to prepare the resident for breakfast, to assess the resident's condition and needs and to promote psychosocial wellbeing. Staff were to assist the resident as needed to brush teeth or dentures. The ADL's-PM/HS (bedtime) care showed care at bedtime prepared the resident for sleep and assist the resident as needed with oral hygiene. <BATHING> <RESIDENT 69> Resident 69 admitted 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 ensure the daily nurse staffing information was being posted in a place readily accessible to residents/visitors and included the required information on 2 of 6 days (02/22/2025 and 02/23/2025) of the recertification survey. This failure placed residents, family members and visitors at risk of not being fully informed of current staffing levels and resident census information. Findings included . In observations on 02/23/2025 at 7:45 AM the facility's daily nursing staffing was found posted on a wall near the entrance of the building. The nurse staffing information was dated for 02/21/2025. There was no other staffing forms found. In review of the posted staffing on 02/23/2025 at 7:45 AM, dated 02/21/2025, showed total actual hours worked for day shift was completed and evening and night shift were blank. In an interview on 02/27/2025 at 8:25 AM, Staff H, Staffing Coordinator stated they were responsible for posting the daily staffing daily and if they were not working on the weekend would rely on another…

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

Based on observation and interview, the facility failed to ensure a system was in place to accurately reconcile controlled medications in 1 of 5 medication carts reviewed for narcotic storage/reconciliation. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medication. Findings included . Facility policy titled Management and Destruction of Controlled Substances dated 11/28/2017 showed: The two licensed nurses visually inspect and counts each scheduled medication . and verifies the quantity on hand matches the declining inventory record. If any discrepancy is identified both nurses remain on duty and the Chief Nursing Officer is notified. In an observation and interview on 02/24/2025 at 1:45 PM, Staff V, Registered Nurse was counting the narcotic medications for [NAME] Cart. Page 24 of the narcotic book showed 1 tablet left but there was no narcotic medication in the cart. Page 30 of the same narcotic book also showed 1 tablet left but there was no narcotic medication in the cart. Staff V stated that the count was off on the book 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 ensure 2 of 5 sampled residents (5 and 34) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure a medical provider assessed and documented a rationale for extended use of an as necessary (PRN) psychotropic medication for use over 14 days and failed to monitor for appropriate symptoms. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . Review of the facility policy titled, Psychoactive Drug Use, revised 10/15/2022, stated that the clinical rational should be documented in the medical record .justification should include description of symptoms, why the resident symptoms need to be managed by a psychoactive drug, description of the treatment, and why the present dose was necessary to manage the symptoms. <RESIDENT 5> Resident 5…

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

Based on observation and interview, the facility failed to ensure that drugs and biologicals were removed when expired in 2 of 5 medication carts, and 1 of 2 medication refrigerators. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe physical or psychological dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. Additionally, 2 medication carts were found unlocked without a nurse close by. These failures placed residents at risk for receiving expired medication and vaccines, and risk of having unintended access to drugs that should have been securely stored. Findings included . Facility policy titled Medication Management, revised date 10/15/2022 showed: Unlocked medication/treatment carts are under nurse control at all times. Medications and treatment supplies are not used beyond their expiration dates. Medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. <UNLOCKED…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely laboratory results to meet the needs of two of five residents (1, 5 and 279) reviewed for medication usage. These failed practices had the potential for negative complications related to delay of obtaining and follow up of laboratory results along with a risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions. Findings included . Review of the facility's policy titled Laboratory, Radiology, Transfusion, and other Diagnostic Services revised [DATE], showed lab services are provided to detect risk for disease, stratify a person into disease or non-disease state, in which the population is ., monitor a condition. Services are to be accurate and timely. Services are considered timely if laboratory tests are completed and results provided to the facility or the resident physician within time frames normal for appropriate intervention.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order was obtained and routine cleaning was provided for a CPAP machine (non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) for 1 of 4 residents (Resident 1) reviewed for respiratory care. This failed practice placed the resident at risk of respiratory infection, respiratory distress, lack of restful sleep and diminished quality of life Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with exacerbation (COPD - group of diseases that cause airflow blockage and breathing problems), obstructive sleep apnea (OSA - residents repeatedly stop and star breathing while they sleep) and chronic respiratory failure. Review of Resident 1's progress note dated 11/11/2024, showed Resident 1 had their CPAP machine brought into the facility from their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the assistance with activities of daily living (ADL's) for 1of 5 sampled residents (Residents 1) reviewed for activities of daily living. The facility failed to provide residents, who were dependent on staff for assistance with hygiene including oral care, meal assistance, and consistent monitoring for incontinence placed residents at risk for diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, urine retention, and overactive bladder and muscle weakness. Review of Resident 1's Quarterly Minimum Data Set (MDS-An Assessment Tool) dated 07/24/2024 showed a Brief Interview for Mental Status (BIMS-an assessment used to monitor cognition) was not able to be conducted as they were rarely/never understood. In an interview on 10/25/2024 at 9: 15 AM, Resident 1 was not able to engage in meaningful conversation about their care needs. Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance with activities of daily living to include personal hygiene and bathing for 2 of 3 sampled dependent (Residents 1 and 3) residents reviewed for activities of daily living (ADL's). The facility's failure to provide the residents, who were dependent on staff for assistance with grooming and bathing placed residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Activities of Daily Living, revised 11/28/2021, showed assistance was provided to residents who need extensive or total assistance with maintenance of nutrition, grooming, oral hygiene, toileting, and other personal cares. Review of the facility's policy, Quality of Life, revised 10/15/2022, showed the facility provided the necessary service to maintain good grooming and personal hygiene for residents unable to carry out their activities of daily living. <RESIDENT 1> Resident 1 was a long-term resident of the facility with diagnoses to…

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

Based on interview, and record review, the facility failed to ensure the facility identified and provided the needed care and services for 1 of 3 sampled residents (Resident 2) reviewed for the medication management of constipation. This failed practice placed residents at risk for bowel constipation, fecal impactions, and a decreased quality of life. Findings included . Resident 2 was a long-term resident with diagnoses to include constipation, muscle weakness, and pain. Review of Resident 2's physician orders showed the following bowel medications for constipation. • Polyethylene Glycol (MiraLAX) one time a day routinely, • Milk of Magnesia (MOM) as needed for constipation if no bowel movement (BM) for three days and • Bisacodyl suppository as needed for constipation if the MOM had no results. Review of Resident 2's Documentation Survey Report v2 (direct care givers documentation), dated 04/15/2024 through 04/30/2024, showed Resident 2 had no BM from 04/15/2024 through 04/19/2024 (five days), and from 04/27/2024 through 04/30/2024 (four days). Review of Resident 2's April 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary Manager (Staff Q) had proper qualifications. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . In an interview on 03/19/2024 at 09:19 AM, Staff Q, Dietary Manager (DM), stated they had been in the position for two to three months as the facility DM. Staff Q stated they did not currently have a certificate of completion for a DM course. Staff Q stated they had not finished their class to be a certified DM. Staff Q stated they were enrolled in the class for a month and were still working toward their certificate. In an interview on 03/25/2024 at 2:00 PM, Staff A, Administrator, stated they thought Staff Q had a year to finish the course. Refer to WAC 388-97-1160 (1)(2)(3) (a)(b)(i) .

Based on observation, interview, and record review, the facility failed to provide for a resident council group to meet privately, to voice concerns with the group's invited guests without facility disruption and interference on 1 of 1 resident council meetings, as the resident group had expressed concern about for years. This failure placed the residents at risk for unmet care needs and prevented the residents' rights to have privacy to meet to express concerns and enhance the residents' quality of life at the facility. Findings included . Review of the facility policy titled, Resident Rights, dated 10/15/2022, showed the facility will take measures to ensure that each resident has the right to personal privacy including accommodations for meetings of family and resident groups. <RESIDENT COUNCIL MEETING MINUTES> Review of the resident council minutes of 06/23/2023 at 10:15 AM, showed the group was interviewed about if there was enough space for everyone who wanted to attend. The response recorded was no. Review of the resident council minutes of 08/29/2023 at 10:14 AM, showed 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 written notification of facility-initiated transfer and/or discharge was completed for 3 of 5 sampled residents (Residents 16, 18, and 77) reviewed for hospitalizations. The facility failed to ensure the transfer/discharge notice with all the required information was provided in a timely, practical manner upon an emergent transfer to the hospital. This failure placed residents and their representatives at risk of not receiving accurate information related to resident's discharge, and potential for diminished quality of life. Findings included . <RESIDENT 16> Resident 16 admitted [DATE] with a history of falls. The resident was alert and oriented and had a designated representative to receive information about their care. Review of Resident 16's current medical record, showed they were transferred to the hospital on [DATE] and were admitted to the hospital. The record showed the facility failed to provide a notice of transfer to the resident 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 ensure the required notice of a bed hold was provided for 3 of 5 sampled residents (Residents 16, 18, and 77) reviewed for hospitalizations. This failure placed residents at risk of being uninformed of their rights regarding bed holds. Findings included . <RESIDENT 16> Resident 16 admitted [DATE] with a history of falls. The resident was alert and oriented and had a designated representative to receive information about their care. Review of Resident 16's medical record, showed they had a fall and was transferred to the hospital on [DATE] and was admitted . The record showed the facility failed to provide a bed hold notice to the resident and their representative as required. <RESIDENT 18> Resident 18 admitted to the facility on [DATE], with diagnoses to include pneumonia (lung inflammation caused by bacterial or viral infection), chronic obstructive pulmonary disease (COPD) (condition involving constriction of the airways and difficulty or discomfort…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to include personal hygiene and bathing for 4 of 4 sampled dependent residents (Residents 1, 8, 2, and 278), reviewed for activities of daily living (ADL's). Facility failure to provide the resident's, who were dependent on staff for assistance with grooming and showers placed residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Activities of Daily Living, revised 11/28/201, showed assistance is provided to residents who need extensive or total assistance with maintenance of nutrition, grooming, oral hygiene, toileting, and other personal cares. <RESIDENT 1> Resident 1 admitted on [DATE] with diagnoses to include stroke with left side hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body), spinal cord…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and communication for Advance Directives (AD) to reflect resident desires for 2 of 2 resident's (Resident 46 and 55) reviewed for AD. This failed practice placed residents at risk of losing their right to have their desired wishes and intervention followed in the event of a healthcare emergency. Findings included . Review of the facility's policy titled, Advanced Directives/Health Care Decisions, dated [DATE], revealed as part of resident rights, an individual may make their own healthcare decision to accept or refuse medical or surgical treatment and formulate AD to determine on admission whether the resident had executed an AD or had given other instructions that care he or she desires in case of subsequent incapacity .If the resident's had not executed an AD, the facility advises the resident and family of the right to establish an AD, and plan now for the chance of a future serious injury or illness. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the resident's Power of Attorney (POA) was notified timely for 1 of 2 residents (Resident 38) reviewed for notification of change of condition. The facility failed to notify the POA there was a change in condition that resulted in a speech therapy (ST) evaluation, a down grade in texture to the resident's diet, and there was a medication error in which the resident was administered unprescribed medications. This failure placed residents POA at risk of not being informed of resident status and potential for receiving less than optimal care. Findings included . Review of the facility policy titled, Resident Change of Condition, dated 11/28/2017, stated the facility was to inform the residents representative when there may be an incident/accident involving the resident where a physician must be involved, a need to alter treatment . the facility should notify the resident representative of the residents' condition. Resident 38 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 interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of allegations of potential abuse or neglect for 2 of 3 sampled residents (Resident 25 and 40) reviewed for allegations of abuse and/or neglect. The failure of staff to identify, report, and initiate an investigation for allegations placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Abuse, revised 08/2023, showed the facility staff reports any alleged violations involving verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, and misappropriation immediately in accordance with State regulations through established procedures (including to the State survey and certification agency). <RESIDENT 25> Resident 25 admitted [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 interview, and record review, the facility failed to ensure 1 of 5 sampled resident (Resident 21) reviewed for the Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability or Related Condition and a serious mental illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) process when Resident 21 had a positive Level I PASRR (a screening to determine if a resident may have a SMI/ID related condition and if positive a Level II PASRR is required) and a Level II PASRR (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) was not completed or followed up on after referral. This failure placed the resident at risk for unmet care needs, unmet mental health needs, and a decreased quality of life. Findings included . Resident 21 admitted to the facility on [DATE] with diagnoses to include major depressive disorder, generalized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to review and revise care plans for 2 of 3 sampled residents (Resident 2 and 8) reviewed for nutrition, and 1 of 5 sampled residents (Resident 58) reviewed for unnecessary medications. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life. Findings included . Review of the facility policy titled, Care Plans, revised 10/15/2022, showed the care plan should be consistent with the residents' specific conditions, risks, needs, preferences and with standards of practice including measurable objectives. The care plan should reflect interventions and timetables to meet the resident's needs, as identified in relation to the resident's response to the interventions or changes in the resident's condition .The care plan should be updated as needed to reflect any change in condition .The interventions should be personal, reflect current professional standards of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility identified and provided needed care and services for 2 of 2 sampled residents (Residents 10 and 58) reviewed for medication management parameters and 1 of 1 sampled resident (Resident 1) reviewed for skin management. The facility failed to ensure appropriate lab test and weight monitoring were completed for medication management and failed to identify and treat a skin rash. These failures placed residents at risk for receiving medications outside of suggested parameters for their heart rate, weight gain, and for untreated skin conditions or infection and a decreased quality of life. Findings included . <MEDICATION MANAGEMENT> RESIDENT 10 Resident 10 was admitted to the facility on [DATE] with diagnoses to include hypothyroidism (abnormally low thyroid gland), hypertension (high blood pressure), and congestive heart failure (the heart can't pump blood well enough to give your body a normal supply). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 1 sampled resident (Resident 1) reviewed for trauma informed care. The facility failed to educate 4 of 5 staff (Staff N, P, W and Y), assess, monitor, and care plan residents' experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience). This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of the facility policy, Trauma Informed Care, revised 10/15/2022, showed trauma survivors receive culturally competent, trauma-informed care in accordance with professional standard of practice and accounting for resident experiences and preferences in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of 1 of 3 Licensed Nurses (Staff H) to properly administer 2 of 29 medications for 1 of 3 residents (Resident 25) observed during medication pass resulted in a medication error rate of 6.9%. These failures placed the residents at risk for not receiving medications as prescribed. Findings included . Review of the facility's policy titled, Oral Medication Administration, released 01/01/2018, directed the nurse to validate the order against the medication packaging, confirm correct dose, correct route, and time/frequency. Review of Resident 25's physician's orders directed nurses to administer pantoprazole sodium (a medication to treat acid reflux) delayed release every morning at 7:00 AM and Claritin by mouth in the morning at 7:30 AM for allergies. In an observation on 03/25/2024 at 8:42 AM, Staff H, Licensed Practical Nurse (LPN), prepared medications to administer to Resident 25. Staff H said they were administering pantoprazole late as it 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 medications were secured and not accessible to residents and consumption of medications during observations of 2 of 3 nurses (Staff H and X). These failures placed the residents at risk of adverse side effects from receiving pain medications too close to the next dose that potentially could cause undesirable side effects and potential drug misuse. Findings included . Review of the facility's policy titled, Medication Management, revised 10/14/2022, directed staff not to keep multi dose medications in the immediate treatment area and store the medications per manufacturer's recommendations. The policy showed bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the interdisciplinary resident assessment team. <UNATTENDED MEDICATIONS> Resident 25 admitted on [DATE] with diagnoses to include gastro-esophageal…

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

<MEDICATION ADMINISTRATION> In an observation on 03/25/2024 at 8:53 AM, Staff C was observed to administered medications to Resident 26 at the bedside. Staff C placed two medication cups with medication pills in each on the over the bed table in front of the resident. Staff C then asked the resident if they could reposition the resident to safely take their medications, Staff C then placed their bare hands on the resident's pillow behind their head and placed it on the side of the mattress. Staff C then placed their bare hands on the shoulders of the resident and pulled the resident over to the side to sit up straight. The resident was observed to pick up the medication cup and place it to their mouth, they then tapped cup with their finger so the pills would fall out of cup and into their mouth. While the resident was tapping cup, one pill fell out of the cup and landed on the resident's chest. Staff C, with their bare contaminated hand picked up the pill and placed it back into the medication cup, and the resident continued to take their pills. In an interview on 03/25/2024 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 interview and record review, the facility failed to prevent verbal and physical abuse for 1 of 4 sample residents (Resident 1), reviewed for abuse. Resident 2, who had known verbal and physical aggressive behaviors toward residents related to their dementia was verbally and physically abusive to Resident 1. This failed practice placed Resident 1 and all other residents at potential risk for verbal and physical abuse and diminished quality of life. Findings included . Review of the facility's undated and untitled procedure and process to assist in preventing abuse, showed the facility would identify, correct, and intervene in situations in which abuse was more likely to occur through the analysis of the features of environment, deployment of staff on each shift in sufficient number to meet the needs of the resident. The staff assigned would have knowledge of the individual residents' care needs, the assessment, care planning and monitoring of residents with needs and behaviors which might lead 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 notify 1 of 1 resident's (Resident 1) wound care provider of the resident's refusal of the ordered wound care treatment. This failed practiced placed residents at risk for health complications and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease (reduced circulation of blood caused by a narrowed or blocked blood vessel), non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of the skin, pain in the right leg and depression. Review of the focus care plan problem dated 12/11/2023 showed Resident 1 had an actual wound to their right lower extremity. The following interventions were included: -Report abnormalities to the medical doctor, dated 12/11/2023; -The resident continued to refuse to allow staff to complete dressing changes, dated 01/04/2024; -The Provider and Vascular were aware of refusals, dated…

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

Based on interview and record review the facility failed to notify the resident representative when there was a significant incident involving a resident for 1 of 4 residents (Resident 1) reviewed for incidents. Failure to notify the guardian for Resident 1 following an incident resulted in the guardian being uninformed of a significant incident where the authorities were called and lacking the ability to advocate or be involved in decisions at the time of the incident. Findings included . Review of Resident 1's medical record showed there was a court appointed guardianship papers in place appointing the named guardian to advocate for and make all financial and medical decisions on behalf of the resident. Review of a progress noted, dated 07/08/2023 at 2:49 PM, showed Resident 1 was displaying physical behaviors directed toward staff. The note stated the resident was throwing items into the hallway and yelling. A supervisor was called (Staff F, Housekeeping Supervisor), Resident 1 shoved Staff F, then threw items at Staff F which included human waste, liquids and a glass. 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 resident medical records contained complete and accurate documentation of resident incidents for 1 of 4 residents (Resident 1) reviewed for incidents. Lack of accurate and complete documentation for Resident 1 placed the resident at risk for lack of thorough review of their person-centered goals, plan of care and ensuring accurate information is available to all disciplines and providers involved in the resident's care. Findings included . Review of Resident 1's medical record showed a progress noted, dated 07/08/2023 at 2:49 PM, the resident displayed physical behaviors directed toward staff. The progress note documented the resident was throwing items into the hallway and yelling. A supervisor was called (Staff F, Housekeeping Supervisor), Resident 1 shoved Staff F, and then threw items (human waste, liquids, and a glass) at Staff F. In an interview on 08/21/2023 at 11:00 AM, Staff F stated they were involved in an incident with Resident 1 on 07/08/2023. Staff F stated one of their housekeepers was attempting 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.