Rock Hill Health & Rehabilitation

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 1, 6, 9, and 15) reviewed for unnecessary medications were 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, and to ensure appropriate indications were present for psychotropic medications and that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. consents were obtained prior to administration of psychotropic medications. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . As referenced in the Food and Drug Administration (FDA) Safety Information, anti-psychotic medications have serious side effects and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system in which residents' records were complete, accurate, accessible, and systematically organized for 3 of 5 residents (Residents 6, 7, and 10) reviewed for accurate PASRR (Preadmission Screening and Resident Review), Medication Administration Records (MAR) and Treatment Administration Records (TAR). Failure to ensure clinical records were complete and accurate made it impossible to determine what care and services were provided, or should have been provided, and placed residents at risk for medical complications, unmet care need and for diminished quality of life. Findings included: Review of the facility policy titled Documentation Standards-Resident Health Record, undated documented the policy of the community is to maintain a Resident Health Record that reflects the accurate and progressive condition of the resident, including care provided, interventions and outcomes, in a manner that is consistent with current health care and legal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately report to the state agency potential abuse/neglect of 1 of 4 residents (Resident 10) reviewed for accidents. Failure to report potential allegations of abuse and/or neglect placed residents at risk for unidentified abuse, and therefore, continued mistreatment and a poor quality of life. Findings included . According to the Nursing Home Guidelines - The Purple Book, sixth edition, dated October 2015, showed Individual mandated reporters must immediately report to the Department's hotline when there is a reasonable cause to believe an incident is abuse, neglect, abandonment, mistreatment, substantial injuries of unknown source, should be reported to the Department of Social Health Services (DSHS) Hotline number, logged within five days and Police or 911 called. Examples of substantial injuries may include, but are not limited to, the following: Abrasions, burns, deep lacerations, bruises of deep color and depth, or those occurring in areas not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notification of facility-initiated transfer and/or discharge was completed for 3 of 4 residents (Residents 31, 37, and 144) reviewed for hospitalizations. The facility failed to ensure the transfer/discharge notice with all the required information was provided in a timely, practical manner upon an emergency transfer to the hospital. This failure placed residents and their representatives at risk of not receiving accurate information related to resident's discharge. Findings included . Review of Resident 31's medical record showed they were transferred to the emergency department on 03/28/2025 and there was no documentation that the notice of transfer/discharge had been provided to the resident and/or their representative, only a progress note from Staff G, Social Services stating that a notice had been sent to the ombudsman. Review of Resident 37's medical record showed they were transferred to the emergency department on 03/11/2025 and there was no documentation that the notice of transfer/discharge 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 interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 3 of 4 residents (Residents 31, 37, and 144) 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 . Review of Resident 31's medical record showed they were transferred to the emergency department on 03/28/2025 and there was no documentation of a bed hold notice being provided to the resident or their representative. Review of Resident 37's medical record showed they were transferred to the emergency department on 03/11/2025 and there was no documentation that the bed hold notice had been provided to the resident or their representative. Review of Resident 114's medical record showed they were transferred to the emergency department on 04/28/2025 and there was no documentation that the bed hold notice had been provided to the resident or their representative. In an interview on 04/29/2025 at 1:41 PM, Staff I, Registered Nurse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans were revised as required for 2 of 5 residents (Resident 10 and 15) reviewed for psychotropic medication review. This failure had the potential to impact staff knowledge of resident needs, placing resident's at risk for decreased quality of care and negative outcomes. Findings included . According to the Resident Assessment Instrument (RAI) manual, dated October 2024 showed the RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining his or her highest practical level of well-being. The focus of the psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure 1 of 7 sampled staff (Staff EE) had an active professional Nursing Assistant Certification (NAC). Findings included . Review of Staff EE's employment record showed they were hired on [DATE] as an NAC. Review of the NAC certification in Staff EE's employee record dated [DATE] showed it had expired on [DATE]. Review of the staff roster provided on [DATE] showed Staff EE was an NAC. Review of the website Washington State Provider Credential Search on [DATE] showed Staff EE's, NAC certification expired as of [DATE]. Review of Staff EE's timecard showed they had worked at the facility on the following dates, without a certification: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], [DATE], and [DATE]. In an interview on [DATE] at 10:12 AM Staff L, Business Office manager, stated Staff EE was hired on their birthday and their certification was active when they were hired. Staff L stated they failed to follow up to ensure Staff EE had gotten their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly provide professional standards of care and services for 3 of 5 residents (Residents 10, 15, and 27) reviewed for medication management. The facility failed to hold cardiac medications per physician orders, and to reassess abnormal blood pressure (BP) or heart rate (HR) values and notify the provider of abnormal findings. This failed practice placed residents at risk for adverse health effects, medication complications, hospitalization, and a diminished quality of life. Findings included . <RESIDENT 15> Resident 15 admitted on [DATE] with cardiac diagnoses of atherosclerosis of aorta (hardening of heart valve), prosthetic heart valve, hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident 15's physician's orders directed the nurses to give Amlodipine 5 MG daily and hold the dose for systolic blood pressure SBP- the first number, called systolic blood pressure, measures the pressure in your blood vessels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 resident (Resident 6) reviewed for hydration were consistently monitored and received adequate fluids. This failure placed residents at risk for dehydration, constipation, urinary tract infections (UTI), and other health complications including worsening cognitive impairment and behavioral changes. Findings included . Resident 6 admitted to the facility on [DATE] with diagnosis including severe vascular dementia and a history of UTI's. The resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 04/09/2025, documented the resident had significant cognitive impairment and required extensive assistance with activities of daily living including eating. The resident had no rejection of care. Review of the Registered Dietician (RD) assessment dated [DATE] showed Resident 6's estimated daily fluid needs were 1900 cc. Review of the Med Nutrition Therapy progress note dated 01/02/2025 at 7:03 PM, showed no documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an interview, observation, and record review, the facility did not adequately reassess, report, or provide effective pain management for 1 of 1 (Resident 1). This oversight resulted in the resident experiencing discomfort during routine tasks such as repositioning and peri-care. Furthermore, the situation may have affected the resident's quality of life and increased the risk of developing bed sores. Findings Included . <Resident 1> Resident 1 was a long-term resident of the facility. According to the admission MDS dated [DATE], Resident 1 was mildly cognitively impaired. Review of policy titled 'Pain Assessment and Management' dated 03/25/2024, documented: Staff will identify situations or interventions that increase resident pain, staff will know why pain medication is being administered, and staff will conduct and document pain levels when residents' pain increases . During an observation on 04/25/2025 at 8:37 AM, Resident 1 was in the hall next to the nursing cart where Staff H, Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 5 sampled staff (Staff M), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings Included . Staff M was hired on 12/02/2022 as a nursing assistant certified (NAC). In a review of Staff M's performance evaluation showed it was an annual evaluation but was not dated or signed by the evaluator or the staff. The performance evaluation was one page and at the bottom of the page indicated there was two pages to the evaluation. No other documents were provided for Staff M's performance evaluation. In an interview on 05/01/2025 at 11:30 AM Staff A, Administrator stated they had just recently gotten evaluations caught up to August of 2025 and they were now doing the evaluations on the staff's anniversary date. No other information was provided. Reference WAC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services including all procedures that assured accurate order entry, dispensing and administration of medications in the facility, occurred for 1of 1 resident (Resident 7) reviewed for pharmaceutical services. The failure to ensure accurate orders and administration for Resident 7 resulted in a duplication error and placed residents at risk for adverse outcomes. Findings included . Resident 7 admitted on [DATE] with diagnoses which included osteoporosis. Review of Resident 7's physician's orders dated 12/08/2024 documented an order for Alendronate 70mg once per week on Monday at 5:00 AM to treat osteoporosis. Review of Resident 7's physician's orders dated 04/08/2025 showed a duplicate order was entered for Alendronate 70mg per week on Sunday at 7:00 AM to treat osteoporosis. Review of the Medication Administration Record for the month of April 2025 showed signatures for both doses of Alendronate signed as given:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services including all procedures that assured accurate order entry, dispensing and administration of medications in the facility, occurred for 1of 1 resident (Resident 7) reviewed for pharmaceutical services. The failure to ensure accurate orders and administration for Resident 7 resulted in a duplication error and placed residents at risk for adverse outcomes. Findings included . Resident 7 admitted on [DATE] with diagnoses which included osteoporosis. Review of Resident 7's physician's orders dated 12/08/2024 documented an order for Alendronate 70mg once per week on Monday at 5:00 AM to treat osteoporosis. Review of Resident 7's physician's orders dated 04/08/2025 showed a duplicate order was entered for Alendronate 70mg per week on Sunday at 7:00 AM to treat osteoporosis. Review of the Medication Administration Record for the month of April 2025 showed signatures for both doses of Alendronate signed as given:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 nursing assistant certified (NAC) (Staff M) failed to receive the required dementia care, abuse and neglect, communication and quality assurance performance improvement (QAPI) training's and 12-hour training. These failures to ensure NACs received required training placed residents at risk of less than competent care and services from staff. Findings included . Staff M was hired 12/02/2022. In a review of Staff M's training record showed: -A signed statement of understanding for Abuse /Neglect Policy and Procedures on 03/22/2024 -A signed document dated 02/22/2024 titled Mandated Reporter -A completed abuse and neglect quiz dated 02/22/2024. -A signed and completed test titled, Care of the Cognitively Impaired No other training documents were provided for Staff M. In an interview on 04/29/2025 at 10:34 AM Staff L, Business Office Manager stated the facility is not gathering information on 12 hours of education for agency NAC's. Staff L stated for in-house staff there is an online training system for 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 provide the necessary supervision and services for 1 of 3 residents (Resident 1), reviewed for elopement. The failure to provide the necessary supervision and services for Resident 1 resulted in an elopement and placed the resident at risk for injury. Findings included . Review of the facility policy titled Resident Wandering Policy undated, showed residents would be assessed for wandering risk at admission. A resident would be determined an increased risk for wandering for an assessment score of 9 or higher and the following interventions would be put into place: - Consent for wander guard placement - Notification to the provider of the wander risk - Care plan would reflect risk of wandering - Resident specific information placed in the wander risk book located at the nurse's station - Residents at risk of wandering would be reassessed quarterly and as needed, nursing would ensure wander guard bracelets for placement daily and document in 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 observations and interviews, the facility failed to provide a safe, sanitary, and homelike environment on 2 of 2 resident units and 1 of 1 outdoor space reviewed for the environment. The failure to ensure walls, ceilings, floors, and outdoor spaces were homelike and in good repair, and water temperatures were comfortable, placed residents at risk for diminished quality of life in their home. Findings included . <RESIDENT ROOMS AND HALLS> based on is 2 of 2 units . An observation of resident rooms and halls on 05/14/2024 at 1:43 PM showed: -room [ROOM NUMBER] wallboard coming loose from the wall near the window. - Two broken ceiling tiles on 100 hall near the exit sign and in the back hall. - A two by four-inch spot of tan paint over a cream-colored wall next to room [ROOM NUMBER]. - room [ROOM NUMBER] had large dark circular staining in the floor wax. - room [ROOM NUMBER] had gouges in the drywall behind where the headboard of the bed would be. - room [ROOM NUMBER] had a large, gouged area in 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 provide adequate supervision, implement interventions, and update the care plan to prevent accidents/falls for 1 of 1 sampled resident (Resident 31) reviewed for accidents/incidents. This failure caused Resident 31 to have recurrent falls resulting in injury for 5 of 11 falls reviewed, and placed residents at risk for falls, injury, and a decreased quality of life. Findings included . Resident 31 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses to include chronic respiratory failure with hypoxia (low blood oxygen levels), severe protein calorie malnutrition(inadequate intake of food, protein, calories, and other essential nutrients), muscle wasting and atrophy of left thigh(decrease in strength of muscles), metabolic encephalopathy (brain disfunction), cognitive communication deficit (difficulty communicating from injury to the brain), and dementia (memory loss). A review of the resident's Quarterly…

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

Based on interview and record review, the facility failed to complete required annual performance evaluations for 3 of 3 Certified Nursing Assistants (CNAs) (Staff E, F, G ), who had been employed at the facility greater than one year. Failure to complete annual performance evaluations, and ensure staff members had met yearly performance and competency requirements, placed residents at risk for dimished quality of care. Findings included . Staff E, CNA, was hired 01/04/2013. Review of Staff E's requested employee file information showed no Annual performance review was provided for the prior year. Staff F, CNA, was hired 06/09/2020. Review of Staff F's requested employee file information showed no Annual performance review was provided for the prior year. Staff G, CNA, was hired 12/06/2021. Review of Staff G's requested employee file information showed no Annual performance review was provided for the prior year. In an interview on 05/14/2024 at 9:20 AM, Staff A, Administrator, stated the annual performance evaluations were not done. Refer to WAC 388-97-1680 (2)(a-c) .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens. The failure to ensure they had hot water in the kitchen handwashing sink, to use safe procedures for cooling foods to be re-used at a later meal, to use safe dishwashing procedures, and to do hand hygiene after cleaning counters and before dishing up foods placed residents at risk for foodborne illnesses. Findings included . In an observation and interview on 05/13/2024 at 9:20 AM, the kitchen handwashing sink water was lukewarm to touch. Staff Q, Dietary Manager, stated the hot water repairmen were onsite and they would have the hot water fixed soon. In an interview on 05/13/2024 at 10:07 AM, Staff Q stated they did not have a process for cooling foods to be re-used at a later meal. Staff Q stated when they cooled foods for re-use, they cooled them in a 2-inch-deep pan at room temperature, then later they would put the foods in the refrigerator to finish cooling, but they had no process for checking the food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistants (CNAs) (Staff E, F, G), reviewed for training, had the required 12 hours per year of in-service education and the required annual dementia training. This failure placed residents at risk of less than competent care and services from staff. Findings included . Staff E, CNA, was hired on 01/04/2013. Review of their employee file showed they did not have the required 12 hours of in-service education for the prior year. Staff F, CNA, was hired on 06/09/2020. Review of their employee file showed they did not have the required 12 hours of in-service education or the required dementia training for the prior year. Staff G, CNA, was hired on 12/06/2021. Review of their employee file showed they did not have the required 12 hours of in-service education or the required dementia training for the prior year. In an interview on 05/14/2024 at 9:20 AM, Staff A, Administrator, stated the facility training program had changed and there were challenges retrieving some of the older training…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor 1 of 2 residents (Resident 21) choices regarding bathing. The facility failed to accommodate resident's preferences for bathing frequency. This failed practice placed residents at risk for unmet bathing needs and diminished quality of life. Findings included . Record review of the facility's policy titled, Bath/Shower, dated 12/2023, showed staff were to ensure residents received bathing per their preferences and the policy also showed if the resident refused shower, to report to the Licensed Nurse and/or Resident Care Manager (RCM) and to offer different type of bathing service, to offer different day or time and have another team member attempt to ask and re-approach the resident. Family may also be called in to assist with resident's refusal. <RESIDENT 21> Resident 21 was admitted to the facility on [DATE]. According to the annual Minimum Data Set (an assessment tool) assessment, dated 04/17/2024, the resident was cognitively intact. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process (a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings), was followed for 2 of 5 sampled residents (Resident 37 and 8) for medication review. Failure to refer Resident 8 for Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) services as indicated, and implement the Level II recommendations received for Resident 37, placed the residents at risk for not receiving care and services in the most integrated setting appropriate to their needs. Findings included . <RESIDENT 37> Resident 37 admitted [DATE] with diagnoses which included bipolar disorder (a serious mental illness characterized by extreme…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fully develop a baseline care plan and/or to provide a written summary of the baseline care plan information that included all of the required elements to 3 of 5 sampled residents (Residents 15, 191, and 37) reviewed for baseline care plans. This failure placed residents at risk of not being informed of their medications, dietary instructions, services, and treatments to be administered, or goals of care, and could lead to unmet care needs. Findings included . <RESIDENT 15> Resident 15 admitted to the facility on [DATE] with diagnoses to include left femur fracture, falls, Alzheimer's (a brain disease that causes impaired memory, thinking, behavior, and language skills), diabetes (DM), and hypertension (HTN [high blood pressure]). Review of Resident 15's current medical record, showed the baseline care plan was incomplete. There was no information regarding: pain, skin conditions or risk factors, fall risk, bladder incontinence, nutrition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive care plan for 1 of 3 residents (Resident 18) reviewed for nutrition. The facility failure to weigh the new resident and to implement orders for daily weights placed residents at risk for unrecognized weight loss or weight gain. Findings included . Resident 18 admitted to the facility on [DATE]. Review of Resident 18's hospital Discharge summary, dated [DATE], showed an order for daily weights. Review of Resident 18's weight history from the date of admission to 05/15/2024, showed staff had documented only one weight, on the day of admission, 04/03/2024. In an interview on 05/14/2024 at 11:29 AM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated they don't always get the discharge summaries when residents admit to the facility, so they can't go by that. Staff C stated they didn't review the discharge summaries; they thought another nurse would do that. Staff C stated Resident 18 had been refusing 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 cleanliness of respiratory care tubing equipment for three of five sampled residents (Residents 31, 33, and 141) reviewed. Failure to replace oxygen administration equipment or nebulized medication equipment placed residents at risk for using soiled equipment and for acquiring infections. Findings included . <RESIDENT 31> Resident 31 was admitted to the facility on [DATE], re-admission on [DATE], with diagnoses to include chronic respiratory failure with hypoxia (low blood O2 levels), and chronic obstructive pulmonary disease (COPD) [a disease that blocks air flow and makes it difficult to breathe]. Review of the Resident 31's physician orders showed O2 therapy continuously through a nasal cannula (NC, tubing that delivers oxygen into the nose through prongs) and aerosol breathing treatments daily via nebulizer (aerosolizes medications) machine. There were no orders to change O2 tubing, change nebulizer tubing, or cleaning/replacing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 8) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure consents were obtained and the resident received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Findings included . <RESIDENT 8> Resident 8 readmitted to the facility on [DATE] with diagnoses that included major depressive disorder, unspecified dementia (was dementia without a type of specific diagnosis) with psychotic disturbance (hallucinations [usually visual], delusions, and delusional misidentifications), anxiety disorder, and hypertension. Review of the March 2024 Medication Administration Records (MAR), showed Resident 8 received an antidepressant medication (bupropion) for a diagnosis of major depression, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to store medications in a safe place for 1 of 1 resident (Resident 18) reviewed who had medications stored in their room. This failure placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored. Findings included . Resident 18 admitted to the facility on [DATE]. In an observation/interview on 05/09/2024 at 1:46 PM, observed Lantus (a type of insulin) and Humalog (a type of insulin) pens being stored in a basin on Resident 18's windowsill in their room. Resident 18 stated those insulins had been there since the previous Friday. In an observation/interview on 05/09/2024 at 4:22 PM, Staff B, Registered Nurse/Director of Nursing Services, was observed removing the insulins from Resident 18's room, they were unable to provide any information why the medications were being stored in the resident's room. Refer to WAC 388-97-1300 (2) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for 1 of 4 residents (Resident 21) reviewed for skin conditions. The failure to ensure clinical records were complete and accurate placed residents at risk for unmet needs. Findings included . Resident 21 admitted to the facility on [DATE]. According to the Annual Minimum Data Set (an assessment tool) assessment, dated 04/17/2024, the resident was cognitively intact. Resident 21 had a diagnosis of atrial fibrillation (an irregular heart rhythm) that required a blood thinner medication. In an observation on 05/09/2024 at 11:59 AM, Resident 21's feet and lower legs were observed have scattered bruising in various stages of healing. Review of Resident 21's weekly skin assessments, dated 05/04/2024 and 05/11/2024, showed no documentation of any bruising. Review of the Treatment Administration Record from 05/01/2024 through 05/14/2024, showed staff were to monitor Resident 21 for any adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use adequate infection control practices for 1 of 1 residents (Resident 18) observed for wound incontinent care and wound cares. Staff failed to change gloves and perform necessary hand hygiene during the cares which resulted in contamination of the resident's bedding, clothing, and the light pull cord. Staff also failed to use good principles of infection control when they wiped the resident's groin during incontinent cares, then while still wearing the same contaminated gloves wiped the rash in the resident's abdominal folds. These failures placed residents at risk of communicable diseases and/or healthcare associated diseases, and diminished quality of life. Findings included . Resident 18 admitted to the facility on [DATE]. In an observation of incontinent care on 05/13/2024 at 11:39 AM, Staff N, Nursing Assistant Certified (NAC), and Staff O, NAC, provided Resident 18 incontinent care. Staff N was observed to wipe Resident 18's groin, then while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the resident/resident representative written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to, or a statement of the resident's appeal rights for 1 of 3 sampled residents (Resident 1) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses that included a brain bleed, muscle weakness and paralysis on their left side, cognitive communication deficit, and dysphagia (difficulty or discomfort in swallowing). Review of Resident 1's progress notes, dated 02/04/2024 through 3/05/2024, showed Resident 1 experienced an emergency and was transferred to the emergency room on [DATE]. In an interview on 03/05/2024 at 4:00 PM Staff C, Registered Nurse (RN), stated they were not involved in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident/resident representative at the time of transfer or within 24 hours of transfer, a written notice that specified the bed hold policy for 1 of 3 residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk of being unaware of the right to hold their bed while in the hospital. Findings included . In a review of an undated facility policy titled, Bed Hold and Return to Facility Policy, showed the facility would provide the resident or representative with the information about bed hold policy, in an emergency, as soon as possible but no later than 24 hours after the transfer and a copy of the bed hold or release record would be filed in the resident's medical record. Resident 1 admitted to the facility on [DATE] with diagnoses that included brain bleed, muscle weakness and paralysis on their left side, cognitive communication deficit, and dysphagia (difficulty or discomfort in swallowing). 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 the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 Halls (Forest Hall). 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. These failures placed all residents, visitors, and staff at risk of developing and/or transmitting disease. The facility was currently in a Covid-19 outbreak. Findings included . Review of the CDC (Centers for…

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

Based on observations, interviews, record review, the facility failed to develop and/or implement policies and procedures for ensuring a communicable disease outbreak for Coronavirus Disease 2019 COVID-19) was reported to the state reporting agency (Complaint Resolution Unit - CRU) 1 of 1 disease outbreaks reviewed. The facility failed to report a communicable disease outbreak in the facility for five days after the outbreak was identified and failed to log the outbreak on the state reporting log. This failure to report to the required state agency and log the outbreak on the state reporting log placed all residents at risk for unidentified and uninvestigated exposure to a communicable disease. Findings included . Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, revised 09/21/2022, stated the facility followed the Washington State reporting guidelines found in the Nursing Home Guidelines, The Purple Book, for reporting requirements, methods of reporting, reporting guidelines, and reporting timelines. The facility will…

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

Based on observation and interview, the facility failed to provide a homelike environment for three of five resident care areas (Artist Hall, Forest Hall, and dining room) reviewed for environment. The facility failed to ensure the dining area was free of dust and dirt build up on the blinds, walls were painted and repaired, and floor tile was clean and free of cracks and peels. The facility failure to provide maintenance services placed residents at risk for diminished quality of life. Findings included . In observations on 02/14/2023: > Forest Hall the flooring had numerous cracks throughout the hallway, with the edges of the tile along the walls were peeling away from the wall. The color of the tile was discolored brown and discolored. The walls had discolored stains that dried dripping down to the floorboard. There was a ceiling tile missing, showing exposed pipes and electrical wires in the middle of the hallway. > Dining room blinds were observed to be covered in dust and dirt during the meal service, and the floor into the dining room was brown and discolored. In observations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the resident or their designated representatives of the resident's medication regimen for 2 of 3 residents (5 and 10) reviewed for psychotropic medication treatment. The facility failed to inform the resident and/or their designated representatives prior to treatment of their mental health diagnosis with the use of psychotropic (drug that effects the mental state) medications. This failure to provide the residents and their representatives the opportunity to make an informed health care decision related to their treatment placed the residents at risk for potential unwanted medications and treatments. Findings include . Review of the facility policy titled, Behavior Management and Psychotropic Medication Policy and Procedure, undated stated that each resident at the facility will be free from unnecessary drugs, including psychotropic medication .upon admission resident that receive psychotropic medications will be assessed for use .consent will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of two (25) residents reviewed for advance directives had been given information verbally and in writing to formulate an advance directive. This failure placed the resident at risk of not having their personal preferences followed regarding their care, unwanted medical services, and a diminished quality of life. Findings included . ADVANCE DIRECTIVES An advance directive was written ahead of time, a health care advance directive was a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care per the Centers for Medicare & Medicaid Services (CMS) glossary. Resident 25 admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease affecting right dominant side (stroke), hemiplegia and hemiparesis of right side (muscle weakness or partial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered care plans for two of three (2 and 10) residents reviewed for positioning and mobility and one of three (19) residents reviewed for fall prevention. This failure to ensure the comprehensive care plan was implemented placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Comprehensive Person-Centered Care Plan, dated October 2017 showed that the comprehensive care plan is developed to incorporate the residents, goals, preferences, and services required to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. <POSITIONING/MOBILITY> RESIDENT 10 Resident 10 admitted to the facility on [DATE] with diagnoses to include Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were provided with interventions to maintain or prevent declines in range of motion for two of two residents (10 and 27) reviewed for positioning and mobility. This failure had the potential to result in decreased mobility, contracture and/or increased pain and diminished quality of life. Findings included . RESIDENT 27 Resident 27 admitted [DATE] following a stroke. The resident had residual deficits involving cognition and physical mobility and required extensive assistance for activities of daily living. Review of the resident's treatment orders on 02/15/2023 showed following discontinuation of skilled therapies, the resident was set up for the following restorative nursing programs to maintain cognitive function and prevent contractures (permanent shortening of muscle due to lack of use): Nursing restorative Range of Motion (ROM) program: Restorative Nursing Assistant (RNAC) will spend at least 15 minutes or as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents (8) 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 and provide documented evidence of clinical rationale for the administration of psychotropic medications. This failure placed the resident at risk for potential medication related side effects. Findings Include . In review of the facility policy titled, Behavior Management and Psychotropic Medication Policy and Procedure, undated, stated that residents drug regime will be free from unnecessary drugs, to include psychotropic drugs. An unnecessary drug was defined as any drug used in excessive dose to include duplicate drug therapy, without adequate monitoring, without adequate indications for its use and in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident 8 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 a medication error rate of less than five percent (%). Failure of 1 of 3 nurses (Staff C) to properly administer 3 of 26 medications for 1 resident (Resident 27) observed during medication pass resulted in a medication error rate of 11%. This failure placed the residents at risk for adverse side effects due to improper medication administration. Findings included . Review of the facility policy titled, Enteral (stomach) tube medication administration, (revised [DATE]) showed medications for enteral (administration of nutrition or medication via the digestive tract) tubes were administered separately and to flush the tube between each medication by placing 15 milliliters (mL) (or prescribed amount) of water through the tube using gravity flow, pour dissolved/diluted medication in syringe and allow the medication to flow by gravity, and flush tube with 15mL of water between each medication. In an observation of medication…

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

Based on observation, interview and record review the facility failed to maintain 1 of 2 nourishment refrigerators. Failure to ensure foods were properly dated and labeled resulted in the potential for food borne illness related to expired and outdated foods. Findings included . Review of the undated facility policy titled: Use and storage of food brought into facility by family showed all foods and beverages: • Will be labeled with resident name and initial date of opening. • Should be thrown away that are past the manufacturer's expiration date or use by dates. • If there are no manufacurer expiration or use by dates, they are to be thrown out 3 days after opening. In an observation of the main dining room kitchenette refrigerator on 02/13/2023 at 12:18 PM, the following items were found: • A yogurt dated 11/03/22- with an expiration date of December 2022; • An unlabeled jug of opened apple juice; • A half of a frozen pie with no date or label; • Ice cream container, opened, unlabeled; • Two plastic condiment containers with red sauce in them, unlabeled and undated; • An unlabeled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff used appropriate hand hygiene practices during wound dressing, toileting care, and proper placement of a urinary catheter bags in accordance with infection control standards of practice for two of two (10 and 27) residents observed during care. This failed place all residents and staff at risk for potential infection. Findings included . <HAND HYGIENE> Review of the facility policy titled, Hand Hygiene Policy, revised October/2017, stated the facility followed hand hygiene protocol to break the cycle of infection and control the spread of infection/outbreaks. Hand hygiene was either with an alcohol-based gel or soap and water .all staff and volunteers who had contact with residents would follow these guidelines when there was potential contact with body fluids .before and after resident contact .and after removing gloves. RESIDENT 27 Resident 27 admitted on [DATE] and required a gastrostomy (opening to the stomach) tube 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.