North Cascades Health and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals were labeled and dated, expired medications were removed in the medication cart and medications were not left at bedside unattended. Failure to label and date 2 of 2 intravenous (IV) medications, not dating insulin vials after opened, keeping expired medications in 2 of 4 medication carts and 3 random observations of medications at bedside unattended, placed residents at risk for adverse effects for receiving expired medications, taking the wrong medications and a diminished quality of life. Findings included .According to the facility policy titled Medication Storage, review date 01/2025 documented, note the date on the label for insulin vials and pens when first used. Outdated .are immediately removed from stock, disposed of according to procedures for medication disposals. <MEDICATION CARTS> In an observation on 04/08/2026 at 11:22 AM, inside Medication Cart B on the second floor, was an insulin pen with an expired date of 04/03/2026. According to Staff P, Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a nourishing, palatable, well-balanced diet that met residents' daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 4 of 14 residents (Resident 19, 35, 119, and 121) reviewed for the facility meeting the dietary needs of each resident. This failure placed all residents at risk of unintended weight loss, malnutrition, depression, feelings of helplessness, and a diminished quality of life.Findings included . In an interview and observation on 04/07/2026 at 2:39 PM, Resident 121 stated the facility food does not look or taste good. The lunch tray was uncovered, on Resident 121's overbed table, pushed to the side of them, with three pieces of uneaten fish and a scoop of brown rice and carrots. In an interview on 04/07/2026 at 12:29 PM, Resident 119 stated their fish was cold and dried out. Resident 119 stated their coffee was warm for the first time ever. In an interview on 04/07/2026 at 1:01 PM, Resident 35 stated the food was terrible and they would not feed it 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 observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions in 2 of 4 snack/nourishment refrigerators. The failure to monitor and document refrigerator temperatures, label opened food/beverage items, discard expired food items in the unit refrigerators placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.Findings included .In an observation on 04/10/2026 at 3:25 PM, the second-floor nourishment refrigerator contained 12 small bottles of drinkable yogurt, with an expiration date of 03/31/2026, dairy creamer with an expiration date of 2/2026, a plastic bag contained an undated to go box, and opened, undated, salad dressing in the door. During the observation, no temperature logs were observed. In an observation and interview on 04/10/2026 at 09:37 AM, the nutrition fridge on the first floor, showed there was a temperature log to be documented and signed daily. The temperature and signature boxes were blank for 04/08/2026 and 04/09/2026 and there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document and address issues raised by the Resident Council group for seven of seven months (September, October, November, December of 2025 and January, February and March 2026) meeting minutes reviewed. Failure of activity staff to document concerns and grievances filed by the resident council in the meeting minutes and failure to report back to the council group in writing with a response, rationale and action taken placed the residents at risk for having unresolved, ongoing care concerns. Findings included . Review of the facility policy, titled Resident Council updated January 2017, documented resident council members have the right to gather and discuss thoughts, ideas, or issues related to their care and treatment. The meeting begins by reading minutes from the previous meeting, then reviewing new and old business with an opportunity for members to express concerns. Concerns brought forth by the Council are resolved via the Center grievance policy. The center communicates a response and/or decisions to the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to comprehensively assess and monitor the need for physical restraints for 2 of 2 residents (Residents 41 and 55) reviewed for physical restraints. The facility failed to assess, obtain consent and physician order, care plan and document ongoing evaluation of the need for the restraint. These failures placed residents at risk for harm and diminished quality of life. Findings included . The Centers for Medicare and Medicaid Services (CMS) defined Physical Restraints as Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual Appendix PP). A review of the facility policy titled, Physical Restraints and Enablers/Devices, updated in January showed the residents have the right to be free from any physical restraints imposed for purposes of discipline or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with grooming, including shaving and nail care for 3 of 4 residents (Residents 89, 104 and 121) reviewed who were unable to carry out their ADL's (activities of daily living) independently. The failure to provide residents, who were dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life. Findings included . <RESIDENT 89> Resident 89 was admitted to the facility on [DATE] with diagnoses to include traumatic brain bleed, multiple sclerosis (chronic disease where the body's immune system mistakenly attacks the protective covering of the nerves in the brain and spinal cord), and chronic obstructive pulmonary disease (COPD - progressive, long-term lung disease that makes it hard to breathe). Review of Resident 89's admission minimum data set (MDS - an assessment tool), dated 01/05/2026, documented they were dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 5 residents (Residents 28, 72, 104, and 106) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and document Resident's 72 and 106's for possible injury after abuse allegations. The facility failed to order mental health services as ordered for Resident 104. Additionally, the facility failed to ensure Resident 28 received care and treatment for their catheter. This placed the residents at increased risk for decline in conditions, unmet care needs, increased discomfort, psychosocial distress and less than optimal quality of care and life. Findings included . <RESIDENT 72> In an interview on 04/10/2026 at 11:51 AM, Resident 72 stated this week Staff GG, Licensed Practical Nurse (LPN) left pills for them to take when they wanted to. Staff GG then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 1 of 4 sampled residents (Resident 3) reviewed for ROM and restorative nursing services. This placed residents at risk for developing new contractures (permanent, abnormal shortening of muscles, tendons, or skin) and/or worsening of existing contractures.Findings Included .Resident 3 was admitted to the facility on [DATE] with diagnoses to include history of stroke, which affected their dominant right side. On 04/08/2026 at 10:16 AM Resident 3 was observed in their bed. Resident 3 right hand was observed balled into a fist the with the exception of their ring finger and middle finger. No splints, hand rolls, or other devices were observed on or near them. Review of Resident 3' care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents (Resident's 18 and 56) sampled for accidents and for 4 of 6 sampled residents (Resident 30, 50, 79, and 105) reviewed for smoking. Failure to ensure smoking materials (cigarettes and lighters) were secured for a safe environment to protect other residents from potential fire hazard and failed to ensure residents did not experience falls placed residents at risk for avoidable injuries and diminished quality of life. Findings included . Review of the facility policy titled: Fall Management and Neurological Check, updated January 2025 stated a fall assessment was completed on admission and interventions were implemented based on the assessment. The care plan was reviewed quarterly and after a fall to determine effectiveness of current interventions and Licensed Nurses updated care plans to reduce or prevent falls. A systemic review of current interventions was completed post fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate fluids to maintain hydration for 2 of 6 sampled residents (Resident 56 and 89) reviewed for hydration and 1 of 6 sampled residents (Residents 121) reviewed for nutrition. Failure to implement, monitor and accurately document fluids consumed to ensure fluid restrictions were implemented per provider's orders placed residents at risk for dehydration, fluid overload, and a diminished quality of life. Findings included . Review of the facility's policy titled, Hydration Program, dated May 2019, documented staff are to offer fluids to residents unless contraindicated by a physician order for fluid restrictions. The policy documented that water pitchers are available at bedside for residents not on fluid restrictions. <RESIDENT 89> Resident 89 was admitted to the facility on [DATE] with diagnoses to include a brain bleed, multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents (Resident 89) reviewed for respiratory care. The facility failed to follow physician orders, ensure that appropriate orders for oxygen administration were to include flow rate and to develop a comprehensive respiratory care plan. These failures placed residents at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility's policy titled, Respiratory Care, Oxygen Administration, dated December 2017, documented that oxygen is administered per physician's order. Physician orders should specify method of administration, liter flow, and parameters for duration and/or frequency of administration. Resident 89 admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure with hypoxia (tissues and organs in the body do not receive enough oxygen to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system in which residents' records were complete and accurate for 2 of 5 residents (Resident 28 and 121). This failure placed residents at risk of not having their medical records accurate and incomplete information being considered when making medical decisions.Findings included . <RESIDENT 28> Resident 28 admitted to the facility on [DATE] with diagnoses to include hereditary spastic paraplegia (rare genetic disorder characterized by stiffness and weakness in the legs) and neuromuscular dysfunction of the bladder (loss of bladder control). Review of Resident 28's discharge orders from the hospital, dated 03/14/2026, timestamped 03/16/2026, documented they had suprapubic catheter change. Review of Resident 28's care plan dated 04/08/2026 documented that they had an indwelling catheter (a tube inserted into the bladder) and did not specify which type of catheter or any specific care instruction related to this specific catheter. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control practices were followed for 1 of 2 residents (Resident 28) observed for would care and 1 of 6 staff (Staff R) observed for medication administration. These failures placed residents at risk of potential infection.Findings included .<WOUND CARE OBSERVATION> Resident 28 was admitted to the facility on [DATE] with multiple decubitus ulcers (injuries to the skin and underlying tissue caused by prolonged pressure on the skin) on their buttocks and bilateral legs, osteomyelitis, hereditary spastic paraplegia (inherited progressive weakness and stiffness in the legs, affecting mobility over time) and suprapubic catheter. Review of Resident 28's Treatment Administration Record (TAR) dated April 2026 documented they had Enhanced Barrier Precautions (EBP) related to implanted medical device and wounds. In an observation on 04/09/2026 at 11:02 AM, outside of Resident 28's room, there was EBP signage, which directed staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure timely reporting of a sexual abuse allegation to the State Agency for 1 of 1 resident (Resident 1), reviewed for abuse/neglect reporting. This failure placed all residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse. Findings included .Review of the facility policy titled, Abuse Reporting and Response updated October 2022 the facility will immediately report all suspected and/or allegations of abuse in accordance with state and federal law.events that involve allegations of abuse or result in serious bodily injury will be reported immediately but not later than 2 hours after.Resident 1 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (chronic mental health condition characterized by intense mood swings), agoraphobia (fear of not being able to escape or get help), and anxiety disorder.Resident 1's admission Minimum Data Set (MDS - an assessment tool) dated 11/10/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to conduct thorough investigations for 2 of 4 residents (Residents 1 and 2) reviewed for abuse, neglect and/or misappropriations. The failure to conduct thorough investigations placed all residents at risk for repeat incidents, potential injury, and unmet care needs. Findings included .Review of the facility policy titled, Abuse Investigations, updated October 2022 documented the facility will conduct a thorough investigation of potential suspected and/or allegations of abuse, neglect and misappropriations in accordance with state and federal regulations.the administrator is the abuse coordinator and will be responsible for overseeing the investigations.the facility will identify and interview involved persons including alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. <RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (chronic mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for medications were followed for 1 of 3 (Resident 3) sampled residents. This failure placed residents at risk for unmet needs, injury, and ineffective and/or delayed treatments. Findings included .Resident 3 admitted to the facility on [DATE] with diagnoses to include seizures and fracture of the first lumbar vertebrae.Review of Resident 3's care plan dated 01/14/2026 documented Resident 3 had a seizure disorder with a goal for them to remain injury free from seizure activity.In an interview on 03/02/2026 at 9:30 AM Resident 3 stated their antiseizure medications were late several times and there were some nurses that understood the importance of their medications and some that did not. Resident 3 stated they had spoken with Staff M, Licensed Practical Nurse, about their concerns.In an interview on 03/02/2026 at 10:31 AM Staff M stated they had met with Resident 3 and discussed concerns about their antiseizure medication being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 potential abuse/neglect allegations were thoroughly investigated for 1 of 2 residents (Resident 2), reviewed for unexpected death. This failure placed residents at risk for unidentified abuse and/or neglect and a diminished quality of life.Findings included .Review of the facility policy titled, Abuse Investigation, updated [DATE] documented the center conducted thorough investigations of potential, suspected and/or allegations of abuse, neglect.in accordance with state and federal regulations. The center identified and interviewed others who might have knowledge of the allegations, maintained complete and thorough documentations of the investigation, and patterns, tends or events that would suggest abuse/neglect. Resident 2 was admitted to the facility on [DATE] with diagnoses to include bladder tumor, kidney disease and vasovagal response (fainting spell caused by a sudden, temporary drop in blood pressure). Resident 2 was 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 ensure 1 of 2 residents sampled for legal representative, (Resident 3) had an accurate designation of legal representative on file in the facility, in case of decreased capacity. This failure placed the resident at risk of violation of resident rights to appoint a legal representative for decisions.Findings included.According to the facility's policy titled, Advanced Directives, dated January 2025, showed that during the admissions process, the facility identifies the resident's primary decision maker or appropriate legal representative and invokes this person at any time the resident is assessed as unable to make relevant health care decisions.Resident 3 re-admitted to the facility on [DATE] with diagnosis of developmental delay.Review of facility medical record revealed, Resident 3 was their own responsible party and emergency contact to contact Collateral Contact (CC) 2 who was listed as family. There was no Durable Power of Attorney (DPOA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a system to ensure Physician's Orders for Life Saving Treatments (POLSTs-a document the resident completes to declare their wishes for Cardiopulmonary Resuscitation [CPR] or No CPR) were in place for immediate access to nurses and failed to ensure each resident's electronic medical record (EMR) accurately and consistently reflected the resident's code status for 1 of 1 resident (Resident 2) related to lifesaving treatment orders. The failure to access and follow the POLST instructions for CPR or ensure the POLST was readily available for Resident 2 placed residents at risk for receiving unwanted CPR against their known wishes, avoidable trauma, and other negative health outcomes.Findings included . <Facility Policy>According to the facility's policy titled CPR policy, updated [DATE] showed the POLST or Advanced Directive (AD) is placed in a binder and located in a central and accessible location of the facility, or on each unit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 2 of 3 residents (2 and 3) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected an adverse event for Resident 2 and hospital visit report for Resident 3. These failures to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included .<RESIDENT 2>Review of an incident report investigation dated [DATE] at 5:30 AM, documented that Resident 2 had an episode of syncope (temporary loss of consciousness and posture due to insufficient blood flow to the brain) on the toilet around 2:00 AM. The nurse checked their vitals, and the resident was up in their chair for 30 minutes and then went to bed.Review of the clinical record including progress notes did not include 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 employ a qualified social worker when reviewed for qualifications of a social worker for a facility licensed for more than 120 beds. This failure placed residents at risk of not having access to medically related social services, inability to coordinate care, and a diminished quality of life. Findings included .Review of the facility's daily census report provided on 12/16/2025 at 10:58 AM, showed that the facility had 122 available beds. During an interview on 12/16/2025 at 1:47 PM, Staff F, Divisional Social Services, stated the acting social services director, Staff, E, Social Services Director, did not hold a bachelor's degree or qualifications. Staff F stated two new social service staff were hired on 12/15/2025. Staff F stated they had actively sought to fill the social service position with a person who had the required qualifications and had been at the facility at least weekly to support Staff E. During an interview on 12/16/2025 at 3:51 PM, Staff E, stated the prior social service director left employment with…

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

Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed and resolved timely in response to residents' verbal conveyance of concerns for 1 of 1 resident (Resident 1), who verbalized complaints. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to the resident repeatedly reporting the same issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings included.In an interview on 12/16/2025 at 9:38 AM, Resident 1 stated they had multiple concerns and grievances about their care. Resident 1 stated they had a meeting with the social worker and resident care manager on 12/15/2025 at which time they expressed multiple grievances. Resident 1 stated they had asked several times for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to conduct thorough investigations for 5 of 6 residents (Resident 3, 4, 5, 6, and 7) reviewed for abuse and neglect. The failure to conduct thorough investigations placed all residents at risk for repeat incidents, potential injury, and unmet care needs. Findings included .Review of the facility policy titled, Abuse Investigation, dated 10/2022 stated it's the facility process to conduct a thorough investigation of potential, suspected, and/or allegations of abuse and neglect.the facility will identify and interviews involved persons, included the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. <RESIDENTS 3 and 4> Review of an allegation dated 12/05/2025 revealed Resident 4 alleged that they were inappropriately touched by their roommate (Resident 3). Resident 3 admitted [DATE] with diagnoses which included cognitive impairment. According to Resident 3's care plan updated 12/03/2025, the care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their person-centered plan of care for 1 of 1 resident (Resident 2) reviewed for pressure ulcers and 1 of 1 resident (Resident 1) reviewed for weights and respiratory care. The failure to obtain physician ordered laboratory testing, weekly weights and provide respiratory care in accordance with physicians' orders placed residents at risk for continued infection, delays in treatment, unmet care needs and a decreased quality of life.Findings included . <RESIDENT 2> Resident 2 re-admitted to the facility on [DATE] with diagnoses which included sacral pressure wound infection, history of pressure ulcers of the sacrum, hips and heel, and urinary tract infection. Review of Resident 2's hospital discharge orders dated 11/26/2025 showed the resident had orders for weekly laboratory tests which included: Weekly labs while on intravenous antibiotics which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's received care and services in accordance with professional standards for one of one resident (Resident 2) reviewed for pressure ulcers. Failure to follow physician's orders for wound treatment and follow established standards of infection control procedures for wound care, placed residents at risk for adverse outcomes, wound deterioration, infection and decreased quality of life. Findings included . Review of the facility policy titled Skin Integrity, with a revised date of July 2025, documented that in the event a resident was admitted with or develops a skin ulcer/pressure ulcer, wound care was provided to treat, heal and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. Resident 2 re-admitted to the facility on [DATE] with diagnoses which included sacral pressure wound infection, history of pressure ulcers of the sacrum, hips and heel, and urinary tract infection. The resident 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 interview and record review, the facility failed to conduct thorough investigations for 3 of 3 residents (Residents 1, 2, and 3) whose investigations were reviewed for thorough investigations, and failed to log 1 of 1 (COVID - Coronavirus Disease 2019) communicable disease outbreak. The failure to log, and conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred. These failures placed residents at risk for repeat incidents and injury. Findings included . Review of the facility policy titled, Abuse Investigation, updated October 2022, states the Administrator is the designated abuse coordinator and is responsible for overseeing staff that assist with investigations . the facility will identify, and interview involved persons that may have knowledge of incident . the facility will ensure complete and thorough documentation, investigate trends and patterns. Review of the facility 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 Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 3 residents (Residents 4, 5, and 6) reviewed for PASRR. This failure placed residents at risk for not receiving timely and necessary mental health services, and decreased quality of life. Findings included . Review of the facility policy titled, PASRR Process Policy and Procedure, revised 01/01/2025, states the facility will validate the Level I, if there were none, medical records or designee will obtain .if a Level II was indicated the social worker will validate, within a timely period . follow up as needed federal PASRR rules. <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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure residents were free from avoidable accidents when fall prevention care plans were not implemented for 1 of 3 residents (Resident 2) reviewed for accidents/incidents. These failures placed all residents at risk for lack of consistent interventions, unmet care needs, and a diminished quality of life. Finding included . Resident 2 admitted to the facility on [DATE] with diagnoses that included vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), chronic pulmonary obstructive disorder (COPD - lung disease), and heart failure. The Quarterly MDS assessment dated [DATE] documented the resident had severe cognition impairment and had a history of falls. Review of Resident 2's care plan focus dated 10/04/2024, documented the resident was at risk for falls related to deconditioning, and balance problems. The care plan documented an intervention that was to provide assist with transfers and ambulation…

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

Based on interviews and record review the facility failed to ensure annual Certified Nursing Assistant (CNA) performance reviews were completed for 6 of 11 CNAs (Staff F,G,H,I,J and K) who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of those CNAs and the quality of care provided to residents. Findings included . Review of facility employee records on 01/22/2025 showed the following CNAs hired greater than one year did not have annual performance evaluations completed for the prior year: - Staff F, CNA, date of hire was 05/18/2023, - Staff G, CNA, date of hire was 04/04/2023, - Staff H, CNA, date of hire 07/12/2023, - Staff I, CNA, date of hire 06/03/2009, - Staff J, CNA, date of hire 11/22/2023, - Staff K, CNA, date of hire 12/16/2006. In an interview on 01/22/2025 at 1:00 PM, Staff B, Director of Nursing Services, stated the facility was behind on completing annual evaluations for nursing assistants. Refer to WAC 388-97-1680(2)(b)(i)

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5 percent (%, unit of measure). During observation of 34 opportunities for error, 1 of 2 Licensed Nurses (LN, Staff P), made thirty-one errors, an error rate of 91 %. This placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration. Findings included . <RESIDENT 46> A review of the January 2025 Physician's orders and Medication Administration Record (MAR) for Resident 46 showed one pill for blood sugar regulation was ordered to be administered at 7:00 AM, one injection for blood sugar regulation, one pill for iron deficiency, and one pain patch were due to be administered at 8:00 AM, and one aspirin tablet for blood clotting was due to be administered at 9:00 AM. During an observation of medication administration on 1/21/2025 at 12:07 PM, Staff P, licensed practical nurse (LPN) was observed administering medications to Resident 46. Staff P administered one injection for blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 required notice of transfer/discharge at the time of discharge or transfer to the hospital for 1 of 2 sampled residents (Resident 50) reviewed for hospitalization. This failure placed residents at risk for lack of knowledge of their rights related to transfers and discharges. Findings included . <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses which included congestive heart failure impacting fluid balance. Review of Resident 50's clinical record on 01/17/2025 showed the resident had a change of condition and was transferred to the emergency department on 12/15/2024. Review of Resident 50's clinical record on 01/17/2025 showed no documentation the required transfer/discharge notice had been provided to Resident 50. In an interview on 01/22/2025 at 11:50 AM, Staff B, Director of Nursing Services, stated a transfer form was being completed which was sent to the hospital with residents, but not provided 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 provide written bed hold notices at the time of transfer to the hospital for 2 of 2 sampled residents (Residents 50 and 72) reviewed for hospitalizations. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses which included congestive heart failure impacting fluid balance. Review of Resident 50's clinical record on 01/17/2025 showed the resident had a change of condition and was transferred to the emergency department on 12/15/2024. Review of Resident 50's clinical record on 01/17/2025 showed no documentation of bed hold notice was provided to Resident 50 when they were transferred to the hospital on [DATE]. In an interview on 01/22/2025 at 11:50 AM, Staff B, Director of Nursing Services (DNS), stated the process was that if the patient was able, the nurse would review the bed hold…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bathing, nail care, grooming, and assist the residents out of bed for 3 of 4 dependent residents (Residents 20, 58 and 68) reviewed for activities of daily living (ADL's). Facility failure to provide the residents, who were dependent on staff for assistance with ADL's, placed the resident and others at risk for unmet care needs, poor hygiene, injury due to nail breakage, diminished dignity, and decreased quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, (ADL's) revised July 2015, showed the nursing assistants (NAC) will assist with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex (NAC guide to proving care), which was accessed in Point of Care (POC). <RESIDENT 58> Resident 58 admitted to the facility from the hospital on [DATE]. Review of Resident 58's care plan showed the resident preferred showers during the day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 of 5 resident's (Resident's 58 and 68) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This placed the residents at increased risk of discomfort, unmet care needs, and medical complications. Findings included . <RESIDENT 58> Resident 58 admitted to the facility on [DATE] with diagnoses to include high blood pressure, dementia and constipation. Review of Resident 58's physician orders dated 10/19/2023, showed staff were directed to give Milk of Magnesia (MOM-medication used to treat constipation) as needed if the resident did not have a bowel movement for three days, if no results from MOM, administer a Bisacodyl suppository as needed, if no results from suppository administer a Fleet enema and notify the MD if no results. Review of the bowel monitoring documentation beginning 11/01/2024…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (a mechanical way of removing waste from the body when the kidneys no longer function) center for 1 of 1 resident (Resident 335) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre- and post-dialysis assessments and consistently ensure communication between the facility and dialysis center about what occurred during HD was completed, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes. Findings included In a review of the facility's policy titled Dialysis, dated March 2015 stated the facility would communicate with the dialysis center by completing the Dialysis Transfer Form .the facility would require the dialysis center to provide the following information upon the resident's return from dialysis: - pre-dialysis and post-dialysis weight, the post-dialysis weight was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 5 residents (Resident 26, 68 and 72) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications and to obtain consent including a discussion of risks and benefits of the psychotropic medication, monitor and document behaviors and or symptom. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Findings included . As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure 1 of 7 residents (Resident 46) observed during medication pass were free from significant medication errors. This placed the resident at risk for complications and decline in condition. Findings included . Review of the package insert for Lispro insulin showed the medication started to act 15 minutes after administration, with a peak time of one hour, and continued to work for two to four hours. The package inserts further stated taking too much Lispro insulin could cause low blood sugar, and the medication should be taken exactly as the doctor ordered. In an observation on 12/21/2025 at 12:07 PM, Staff P, Licensed Practical Nurse (LPN) was observed administering Resident 46's 8:00 AM Lispro insulin, four hours late. During an interview on 12/21/2025 at 12:07 PM, Staff P, was asked when Resident 46's blood sugar was taken. Staff P stated that they took Resident 46's blood sugar sometime around 6:00 AM. Review of Resident 46's Medication Administration Record (MAR) showed that Resident 46 had orders 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 observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws appropriately for 2 of 2 (1st Floor and 2nd Floor) Medication Storage Rooms. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. These failures left controlled substances to be unintended with access to drugs that should have been securely stored. Findings included . In an observation and interview on 01/17/2025 at 10:08 AM, in the 2nd floor medication storage room there was a refrigerator. In the refrigerator there was a black box that was not permanently affixed to the refrigerator. Staff U, Licensed Practical Nurse/Resident Care Manager confirmed the controlled substances were placed in the black box. Staff U stated they did not have a permanently affixed lock box for their Scheduled II-V's controlled substances that were required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff were complaint with Infection Prevention and Control Guidelines and standards of practice for 1 of 1 resident room (room [ROOM NUMBER]) that's on Transmission-Based Precaution (TBP), 1 of 4 residents' rooms (room [ROOM NUMBER]) that's on Enhanced-Barrier Precaution (EBP) and 1 of 1 resident during catheter care (Resident 45). The facility failed to ensure staff used appropriate hand hygiene practices in caring for a Clostridium Difficile [(C. diff) a highly contagious bacteria that can infect the gut and cause watery diarrhea] positive resident and when performing catheter care and wearing appropriate Personal Protective Equipment [(PPE) - specialized clothing clothing or gear worn to pretect for infection or illness] during high contact resident care activities. These failures placed all residents and staff at risk for potential infections. Findings include . Review of the facility policy titled, Transmission Based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly refer, reimburse or document on 1 of 1 resident (Resident 1) who had their dentures dropped, broken and subsequently lost at the facility. This failed practice placed the resident at risk of diminished quality of life and financial impact. Findings included . Review of the facility's policy titled, Dental Services - Dentures, dated October 2017, showed The Center assists residents as necessary or requested upon notification and confirmation of lost or damaged dentures, within 3 days of notification and confirmation, referred resident with lost or damaged dentures for dental services and documented the referral in the medical record. The Center reimbursed for confirmed damage or loss of dentures in the following circumstances: 1) Confirmed loss of dentures within the Center, 2) Damage of dentures that occurs as a result of Center actions, which may include, but is not limited to dentures which were dropped. Resident 1 admitted 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 ensure the residents' rooms, shower room and hallways for 1 of 2 floors were clean and free of damaged walls. These failed practices placed the residents on the first floor at risk of diminished quality of life. Findings included . In a phone interview on 08/27/2024 at 5:10 PM, Collateral Contact (CC) 1, Resident 2's family member, stated the facility did not appear to be clean. CC 1 stated they had to request the floor to be cleaned of food items from under the resident's bed. CC 1 stated the second floor was like a completely different business from the first floor. CC 1 stated there were stains on the walls on the first floor, it was unkept and not clean. In an interview on 08/28/2024 at 1:18 PM, Resident 4, stated sometimes the floor in their room did not get mopped and their room was not dusted. In an observation and co-interview on 08/28/2024 at 1:35 PM, Resident 3 and CC 2, Resident 3's family member, stated they did not find the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 6), reviewed for falls received the implementation of an intervention to reduce the risk of further falls. This placed Resident 6 and other residents at further risk of falls, potential injury and diminished quality of life. Finding included . Resident 6 was readmitted to the facility on [DATE] following an acute care hospitalization for encephalopathy (damage or disease that affects the brain). Resident 6 diagnoses included seizure disorder, Parkinsonism (collection of movement symptoms associated with several conditions including Parkinson's disease), and pain. Review of Resident 6's care plan showed, the resident was at risk for falls related to deconditioning and gait and balance problems which was initiated on 07/11/2024. The interventions identified and dated for 07/11/2024, included ensure the call light was within the resident's reach, educate the resident about safety reminders, follow 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 the direct care data of both contract and agency staff was accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Quarter 4) for the Fiscal Year (FY) 2023 reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility. Findings included . Review of the PBJ information submitted by the facility showed for the 2023 4th Quarter the facility was 106 hours short of the required hours. In an interview on 08/06/2024 at 11:30 AM, Staff A, Administrator, stated the contracted agency staff were not using the time clock was why their hours were not captured on the PBJ report. In an email communication received on 08/06/2024, the Nursing Home Policy & Program Manager noted they had previously provided the facility with written and verbal information and guidance…

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

Based on interview and record review, the facility failed to provide the required refund for 3 of 4 sampled residents and/or their resident representative (Resident 3, 4, and 6) within the required 30 days after the resident's discharge. This failed practice placed the resident and/or resident representative at risk of financial hardship. Findings included . Review of the facility's policy titled, Resident Refunds, updated May 2007, showed the Nursing Center processes refunds to resident or their estates within the earlier of 30 days from the date of the resident's death or discharge from the center. Where a third-party payor (such as Medicare or an HMO [Health Maintenance Organization]) has not paid the Center on behalf of the resident, amount billed to such third-party payor decreased the amount of any resident refund until the third-party's payment is made. The facility's policy had a handwritten notation, Waiting for Med [Medicare] B to payout prior to issue refund. Once Med B claim submitted will issue refund. In an interview on 06/03/2024 at 2:08 PM, Staff P, Business Office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure 1 of 1 sampled resident (Resident 2) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications for use, and diagnoses were present for psychotropic medications. Resident 2 had a decline in their function, increase in falls, and a decline in their cognition after the start of psychotropic medications. These failures placed residents at risk of receiving unnecessary psychotropic medications and for medication-related complications. Findings included . As referenced in the State Operations Manual Appendix PP, date 02/03/2023, referenced the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (Resident 1) reviewed for notification of change of condition. The facility failed to notify the POA timely of the start of an antibiotic for a respiratory tract infection and of a ground level fall. This failure placed all the residents' POA at risk of not being informed of residents' status. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia, fractured hip, and depression. Review of a Late Entry, nursing progress note dated 03/28/2024, showed a new order was received for Levaquin (an antibiotic) for five days, Mucinex (nasal decongestant) for 10 days and Albuterol (medication used to treat bronchospasms) the family was notified, and Resident 1 was placed on alert by Staff B, Registered Nurse (RN). Review of nursing progress note dated 03/29/2024, showed Resident 1 was heard calling out for help and was…

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

Based on interview and record review the facility failed to ensure 1 of 2 new hired Licensed Practical Nurses (LPN) nursing staff (Staff A) received their credentials (username and password) to document in the facility's electronic medical record prior to working independently. This facility failed practice recorded Staff A, LPN falsely documented nursing notes, medication administration record (MAR) and treatment administration record (TAR) as completed by Staff B, Registered Nurse (RN). Findings included . Review of the facility's policy titled, Electronic Signature, updated June 2016 showed authorized employees and contractors are assigned a credential, commonly a username with a password or pin, which is used as an electronic signature. An attestation statement is signed to certify that they have sole access to and are the sole user of the password/pin. Employees and contractors are instructed that they will not share their password/pin and that doing so will be grounds for disciplinary action up to and including immediate termination. Review of Staff B, Electronic Signature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 direct care data of both contract and agency staff was accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarters (Quarter 3) for the Q3's Fiscal Year (FY) 2023 (which included July 2023 through September 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility. Findings included . Review of the CASPER (Certification and Survey Provider Enhanced Reports) PBJ Staffing Data Report dated FY Quarter 3 2023 (July 1 - September showed the result of Excessively low weekend Staffing Triggered=Submitted Weekend Staffing is excessively low. In an interview on 03/03/2024 at 11:32 AM, Staff A, Administrator, stated all hours were submitted through the corporation based on the payroll system. In an interview on 03/04/2024 at 9:13 AM, Staff T, [NAME]…

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

Based on interview and record review, the facility failed to ensure that they had an individual who had Based on interview, and record review, the facility failed to ensure they had an individual who had completed specialized training in infection prevention and control as their designated Infection Preventionist. This failure placed all residents and staff at risk for unmet infection control issues and/or care needs. Findings included . In an interview on 03/03/2024 at 10:41AM, Staff E, Licensed Practical Nurse (LPN)/Staff Development/Infection Preventionist (IP), stated they were the acting IP in the facility. Review of the Centers for Disease Control and Prevention (CDC) certificate provided by the facility on 03/07/2024, showed that Staff E had completed their Nursing Home Infection Preventionist Training Course on 03/06/2024. In an interview on 03/08/2024 at 10:52AM, Staff E confirmed they had taken over the IP role at the facility in December of 2023 and they had not completed their IP training course test until 03/06/2024. In an interview on 03/08/2024 at 12:03PM, Staff A,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services for 4 of 10 sampled residents (Resident 50, 71, 191, and 39) reviewed. The failure: 1) to provide wound care treatment recommendations made by the contracted wound care providers, 2) to offer ice for pain as ordered, 3) to obtain a food texture consult as ordered, 4) to obtain a physical therapy consult as ordered after a fall, 5) to administer oxygen as ordered, and 6) to monitor and assess a resident with an infection, placed the residents at risk for unmet care needs, pain, wounds that didn't heal, difficulty eating, more falls, and diminished quality of life. Findings included . <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses to include morbid obesity, chronic pain in the left leg, and other abnormalities of gait and mobility. According to the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 01/12/2024, the resident had no cognitive impairment, no…

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

Based on interview, and record review, the facility failed to complete required annual performance reviews for 3 of 3 sampled Certified Nursing Assistants (Staff H, J, and M) reviewed for annual review after one year of employment. Failure to complete annual performance evaluations and provide in-service education as needed based on performance evaluations placed all residents at risk for diminished quality of care. Findings included . On 03/04/2024 at 1:00 PM, a list of sample staff documentation was requested to the facility for Staff H Certified Nursing Assistant (NAC), Staff J, NAC, and Staff M, NAC, which included their annual performance evaluations. None were provided. In an interview on 03/05/2024 at 2:13 PM, Staff E, Licensed Practical Nurse/Staff Development Coordinator (SDC), stated they were now responsible for performance evaluations for NAC's, and had only conducted one performance evaluation since accepting the position in December 2023. Staff E stated they were not aware whether the prior SDC had completed performance evaluations timely. In an interview on 03/07/2024…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure two of two medication rooms had unexpired medications. In addition, the facility failed to ensure medications were secured and not accessible to residents. These failures placed the residents at risk of receiving expired medications and potential drug misuse. Findings included . <FIRST FLOOR MEDICATION STORAGE ROOM> On 03/03/2024 at 11:55 AM, an observation and interview was conducted with Staff S, Registered Nurse (RN), in the first-floor medication room. Inside of the freezer particles of debris along the side and front of the freezer was observed. The freezer contained several ice packs. The refrigerator had debris scatter throughout the inside. Staff S stated they were not aware who maintained the cleanliness of the medication refrigerator/freezer, and the surveyor should ask the kitchen staff. The floor of the medication room was obviously dirty with scuff marks and dirt. When Staff S was asked who maintained the floors in the medication…

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

Based on record review, and interview, the facility failed to ensure 3 of 5 employees, (Staff H, J, and M) reviewed for training, had the required 12 hours per year of in-services, abuse, and dementia training. This failure placed residents at risk of less than competent care and services from staff. Findings included . Review of Staff H, Certified Nursing Assistant (CNA), employee record showed Staff H was hired June of 2009. For the year of June 2022 through June 2023, the facility was unable to provide documentation Staff H had completed the required 12 hours of annual in-services or required abuse training. Review of Staff J, CNA, employee record showed Staff J was hired in August of 2016. For the year of August 2022 through August 2023, the facility was unable to provide documentation Staff J had completed the required 12 hours of annual in-services or required abuse training. Review of Staff M, CNA, employee record showed Staff M was hired in November of 2022. For the year of November 2022 through November 2023, the facility was unable to provide documentation Staff M 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.

Based on observation, interview, and record review, the facility failed to honor residents' rights to have an opening and functioning dining room (1st floor dining room) for breakfast where residents could eat and socialize while they ate. The failure to open the dining room for breakfast resulted in residents having to eat in the hallways or in their rooms and placed them at risk for isolation and diminished quality of life. Findings included . Review of the Resident Handbook, revised date December 2023, showed We encourage all residents to eat in the dining room, which is designed for a pleasant dining experience. Review of the undated facility dining room schedule showed there was no scheduled breakfast service in a facility dining room. In observations on 03/04/2024 between 8:22 AM and 8:27 AM, Residents 48 and 66 were observed eating in the hallway by the 1st floor nursing station. In an interview on 03/06/2024 at 11:39 AM, Resident 25 stated they would like to eat breakfast in the dining room but had not been offered to eat in the dining room for about a year, and they 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, interview and record review, the facility failed to accommodate the needs and preferences of 1 of 1 resident (Resident 50) reviewed for accommodation of needs. The facility failed to provide a chair for the resident to sit in so they could spend time out of bed, and to provide a wheelchair (w/c) that met the resident's needs. This failure placed residents at risk being confined to their bed with no option of anywhere to go outside of their bed. Findings included . Resident 50 admitted to the facility on [DATE] with diagnoses to include morbid obesity, chronic pain in the left leg, and other abnormalities of gait and mobility. According to the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 01/12/2024, the resident had no cognitive impairment and no unhealed pressure injuries, but they did have Moisture Associated Skin Damage (MASD - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration) and were at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 6 residents (Residents 72 and 50) who were reviewed for abuse and neglect were free of abuse and neglect. Resident 72 was abused when staff forced them to receive care when they had refused. Resident 50 was neglected when they were confined to their bed for months, did not provide the resident an option of a chair or other furniture they could sit in so they could get out of bed, and to provide a wheelchair that met the resident's needs. These failures placed the residents at risk for abuse and neglect, unmet needs, and diminished quality of life. Findings included . <RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnoses to include alcoholic liver cirrhosis (chronic disease of the liver) with ascites (accumulation of fluid in the abdominal cavity), alcohol dependence, depression, and pain. Review of Resident 72's Significant Change in Status Minimum Data Set (MDS- an assessment tool) assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to conduct thorough investigations for 1 of 6 residents (Resident 72) reviewed for thorough investigations and had corrective action taken following an investigation where a staff to resident abuse allegation was verified. This failure placed all residents at risk for abuse, and diminished quality of life. Findings included . Resident 72 was admitted to the facility on [DATE] with diagnoses to include alcoholic liver cirrhosis (chronic disease of the liver) with ascites (accumulation of fluid in the abdominal cavity), alcohol dependence, depression, and pain. Review of Resident 72's Significant Change in Status Minimum Data Set (MDS - an assessment tool) assessment, dated 01/19/2024, showed the resident had no cognitive impairment and they did not reject care. Review of Resident 72's statement documented by Staff A, Administrator, dated 02/20/2024, showed the resident told Staff M, Certified Nursing Assistant (NAC), they did not want their brief changed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Level II 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) and identify and refer for Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) PASRR recommendations when the resident experienced a change in their psychiatric conditions for 1 of 5 resident's (Resident 65) reviewed for PASARR. The failed to obtain a Level II assessment timely residents experienced hallucinations and delusions, delayed the implementation of recommendations, and left resident at risk for unmet mental health needs and a diminished quality of life. Findings included . Resident 65 was admitted to the facility from the community on 01/09/2023 with diagnoses to include mental disorder, depression, dementia with behavioral disturbance and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 2 residents (Resident 87) reviewed for wandering. The facility failed to ensure a licensed nurse completed the assessment of a wander guard device (worn device that alerts related to location) before they documented the task was completed. This failure placed the resident at risk for an inaccurate assessment, negative outcomes, and potential elopement risk. Findings included . Review of the facility policy titled, Elopement/Wandering, updated March 2018, showed the licensed nurse was to complete an evaluation for placement and function of the device every shift. The licensed nurse then will document in the resident's medical record. Resident 87 admitted to the facility on [DATE] with diagnoses including Alzheimer's and anxiety. The admission Minimum Data Set (MDS - an assessment tool) assessment, dated 02/18/2024, showed the resident had severe cognition impairment, and wore a wander guard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to consistently conduct and document pre and post dialysis assessments, ensure consistent ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (Resident 61) reviewed for dialysis. This failure had the potential to place residents who receive dialysis at risk for unmet care needs and medical complications. Findings included . Review of the facility policy titled, Dialysis, dated March 2015, showed the center communicates with the dialysis center by completing the Dialysis Transfer Form and sending new labs obtained .the Dialysis Transfer Form showed the following: medication changes since last dialysis appointment, labs since last dialysis appointment, changes in medical or mental status since last dialysis appointment .The policy further stated the facility would initiate fluid restrictions upon recommendations of the dialysis unit. Resident 61 admitted [DATE] and received dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Resident 65 and 3) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications and to monitor and document behaviors and or symptom. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Findings included . As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 1 of 1 resident (Resident 87) reviewed for accurate and complete medical records. The facility failed to ensure the medical record for Resident 87 reflected the lack of guardianship, and the authority limitations of the court appointed visitor. This failure by the facility to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Finding included . Resident 87 admitted to the facility on [DATE] with diagnoses including Alzheimer's, and anxiety. The admission Minimum Data Set (MDS - an assessment tool) assessment, dated 02/18/2024, showed the resident had severe cognition impairment. Review of Resident 87's medical record on 03/03/2024, showed no advanced directive, no information for a power of attorney (POA), or a physician's order for life-sustaining treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control and transmission-based precautions (TBP) were being followed for 1 of 1 resident rooms (room [ROOM NUMBER]) on contact TBP. This failure placed residents and staff at risk for transmission of communicable diseases. Findings included . In an observation on 03/03/2024 at 10:39 AM, room [ROOM NUMBER] had a contact TBP signage outside of the room. The contact TBP signage showed everyone who entered the room must clean/wash their hands, put on gloves and a gown. In an observation and interview on 03/03/2024 at 11:23AM, Staff P, Licensed Practical Nurse (LPN), read the contact TBP signage outside of room [ROOM NUMBER] and entered with a surgical mask on. Upon leaving room [ROOM NUMBER], Staff P stated the contact precautions were for the resident in bed 2, they were going to see the resident in bed 1 and did not need to wear any personal protective equipment (PPE - equipment worn to minimize exposure to hazards 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws, and expired medications were discarded appropriately for two of two (1st Floor and 2nd Floor) Medication Storage Rooms. These failures placed residents at risk to receive expired medications and to experience adverse side effects and other potential negative health outcomes. Findings include . <FIRST FLOOR> In an observation on 12/15/2023 at 11:01 AM, the 1st Floor medication room refrigerator was medications for all three carts on the unit. On one of the shelves in the refrigerator was a metal black box with a hole, the box was partially open, no lock visible. Inside the box was six bottles of liquid concentrated Lorazepam (anti-anxiety) medication. Lorazepam was a scheduled Class four controlled substance (effects brain function). In the refrigerator there was two bottles of barium swallow (medication to take before a procedure) 2% weight/volume with expiration date of…

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

Based on observation, interview and record review, the facility failed to store food in accordance with food safety standards in the facility kitchen and in 2 of 2 resident nourishment refrigerators. The failure to maintain a sanitary nourishment refrigerator placed residents at risk for foodborne illnesses. Findings included . <FIRST FLOOR NOURISHMENT REFRIGERATOR/FREEZER> In an observation on 12/15/023 at 11:20 AM, the 1st Floor nourishment refrigerator and freezer were both soiled with various types of food matter, there was stains on the inside of the doors of the refrigerator and freezer. The outside door handles to the refrigerator and freezer were visible soiled with thick layer of dust on the top of the refrigerator. The temperature log for 12/15/2023 was blank. In an interview on 12/15/2023 at 11:23 AM, Staff W, Dietary Cook, stated they were not responsible for cleaning the nourishment refrigerator and freezer, they stated they thought housekeeping was the one that would do that. Staff W stated they would update the temperature log for today. <SECOND FLOOR NOURISHMENT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personal food policy for foods brought in from the outside and stored in 2 of 2 resident (1st and 2nd floor) nourishment refrigerators/freezers. The failure to properly store residents' personal foods placed the residents at risk for foodborne illness. Findings included . Review of the facility's policy titled Resident Personal Refrigerators and Foods Brought into Center by Family/Visitors, dated August 2020, showed food was to be covered, labeled, dated, and discarded according to guidelines. Review of the facility policy titled, Nursing Unit Refrigerator Storage Guide, dated May 2018, showed that all resident food must have name, room number, and use by date. All unlabeled items will be discarded. Packaged foods when opened are labeled with use by date as follows: - Pudding within two days. - Homemade/leftovers that was brought in from outside the facility in three days or less. - Cut fruit or vegetables three days or less. - Lunch meat/sandwiches in three days. - Jello, milk, cottage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abuse policies and procedures were implemented by failing to thoroughly investigate allegations of abuse and neglect, ensure investigations identified the root cause of the incident, completed timely, interview staff involved and protect the resident for 14 of 16 sampled resident incidents investigations (Residents 1, 2, 3, 4, 5, 6, 14, 15, 17, and 18) reviewed for allegations of abuse and neglect. These failures placed residents at risk for unidentified abuse and/or neglect and diminished quality of life. Findings included . Review of the facility policy titled, Abuse Investigation, updated October 2022, stated the facility will conduct a thorough investigation of potential, suspected and/or allegations of abuse and neglect. The facility will identify and interview all potential persons involved in the allegation investigation. The facility will investigate patterns, trends, and events that suggest possible abuse and neglect. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have sufficient nursing staff to provide nursing services to 6 of 14 sampled residents ( Residents 4, 7, 8, 9, 14 and 15), and failed to respond to call lights in a timely manner for 1 of 2 floors (1st Floor) reviewed for staffing. The facility failed to ensure there was sufficient nursing staff to provide services such as bathing, and toileting to the residents. Failure to timely respond to resident call lights, and have sufficient, competent Nursing Assistants Certified (NAC), resulted in missed bathing, and delayed toileting needs for the residents. This failure placed residents at risk for unmet care needs, discomfort, and a diminished quality of life. Findings included . Review of the facility assessment dated [DATE] with a look back of September 2021 through September 2022, showed that the average census was 87. The assessment stated the facility had a known ability to care for difficult, and high acuity (more severe) residents. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 floors (2nd Floor). The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. The facility failed to ensure staff used personal protective equipment (PPE) in accordance with national standards and failed to disinfect reusable medical equipment according to manufactures instructions. These failures placed all residents, visitors, and staff at risk of developing and/or transmitting disease. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to obtain the Level II Preadmission Screening and Resident Review (PASARR a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) and follow recommendations for 1 of 1 resident (Resident 18) reviewed for PASARR. Facility failure obtain the Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) timely delayed the implementation of recommendations and left the resident at risk for unmet mental health needs and a diminished quality of life. Findings included . Resident 18 was admitted to the facility on [DATE] with diagnoses to include lymphedema (a condition of localized swelling), severe obesity, and atrial fibrillation (abnormal heart rhythm). Review of a facility investigation, dated 11/12/2023 at 7:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive, person-centered care plan to meet the needs of 1 of 3 residents (Resident 3) reviewed for care planning. This failure placed residents at risk for injuries to their skin and a diminished quality of life. Findings Included . Resident 3 was admitted to the facility on [DATE] diagnoses included dementia and chronic lower extremity edema. Resident 3 was on hospice services in place. In a review of the facility's injury of unknown source incident report, dated 10/17/2023, showed Resident 3 was found to have a bruise to their left lower leg. The incident report concluded the resident was unable to provide how they obtained the injury. The facility linked the injury to Resident 3 bumping into their wheelchair (w/c) when it was parked next to their bed. Resident 3 was described as alert to themselves only. In a review of Resident 3's care plan, dated 07/27/2023, showed the resident had potential for impaired skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure 1 of 1 sampled resident (1) who was admitted with osteoarthritis and pain in both of their needs and legs were transferred in manner to prevent potential injury. This placed resident at risk for potential injury during transfers and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include cellulitis (a deep infection of the skin caused by bacteria) of the right toe, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and pain. In a review of Resident 1's care plan, dated 09/19/2023, showed the resident had a self care performance deficit related to activity intolerance, impaired balance, and morbid obesity. The goal showed that the resident would improve their current level of function in transfers to limited assistance. There were no detailed interventions regarding Resident 1's pain during transfers related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct thorough investigations for 2 of 4 residents (Resident 1 and 2) reviewed for potential abuse or neglect. The failure to conduct complete and thorough investigations placed residents at risk for repeat incidents, injury, and lack of appropriate corrective action on the part of the facility. Findings included . Review of Chapter two of the Nursing Home Guidelines, sixth edition, showed that A thorough investigation was a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences .The investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. It should also allow the nursing home 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 observation, interview and record review, the facility failed to ensure resident care plans were reviewed and revised to accurately reflect resident needs and preferences for 1 of 4 residents (Resident 2) reviewed for allegations of abuse and neglect. This failure placed Resident 2 at risk for psychosocial harm when the care plan was not updated to reflect a preference for staff of a specific gender for toileting and personal care and the facility continued to schedule staff of the non-preferred gender to care for the resident. Findings included . Review of an allegation of neglect investigation, dated 10/10/2023, showed Resident 2 was alleged not to have received care by a named staff member. The incident investigation showed the facility identified the resident had refused the care from the named staff member and stated it was due to the resident's preference for staff of the opposite gender only to provide personal care. The investigation summary, dated 10/16/2023, stated the facility had updated the resident's care plan to reflect the resident preference of staff of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 sampled residents (Resident 1) reviewed for quality of care. Failure to assess residents skin risk factors, identify a change in the residents skin, and implement care planned interventions for residents with non-pressure skin conditions accurately and thoroughly. This failure placed residents at risk for delayed wound healing, medical complication, increased pain, and a diminished quality of life. Findings included . Resident 1 admitted [DATE] and was alert and oriented. Review of the admission nursing assessment and progress note, dated 09/19/2023, showed the resident was admitted with a yeast rash to ABD [abdominal] folds, groin, both buttocks, sacrum and coccyx [tailbone]. Review of the admission Mininum Data Set (MDS - a required assessment of the resident's status) assessment, dated 09/26/2023, showed Resident 1 was always incontinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report allegations of neglect to the State Agency within 24 hours and to log the allegations in the facility's reporting log as required for 4 of 4 identified residents (Resident 3, 4, 5, and 6) reviewed for abuse/neglect. The failure to report, log and timely investigate allegations of neglect placed residents at risk for ongoing unaddressed neglect, and decreased quality of life and other negative healthcare outcomes. Findings included . Review of the facility policy titled, Washington Mandatory Reporter, dated August 2012, showed the facility would ensure policies were developed and implemented which required staff to report abuse and neglect, and all allegations involving abandonment, abuse, neglect, financial exploitation, or misappropriation are reported immediately to the department and confirms that reports are made through established processes in accordance with state law. Review of an allegation of potential neglect involving Resident 5 showed a facility staff member (Staff E, Certified Occupational Therapy…

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