Stafholt Health And Rehabilitation Of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) received medically related social services assistance to understand their financial matters. This failed practice placed Resident 1 and other residents at risk of financial exploitation. Findings included .Resident 1 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a serious mental illness characterized by extreme mood swings) and cataracts with visual loss to both eyes. The Quarterly Minimum Data Set assessment dated [DATE] showed the resident was cognitively intact and had severely impaired vision, with no vision or sees only light, colors or shapes.Review of an online report sent to the Washington State Hotline dated 08/11/2025, documented a concern Resident 1 had not made a payment to the facility in over a year. The report noted Resident 1 had an individual, Collateral Contact (CC) 1, who assisted them with their finances. When the facility reached out to CC 1, they asked 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 interview and record review, the facility failed to ensure that 1 of 5 residents (Resident 155) reviewed for informed consent had received the information of risks and benefits of their proposed care related to psychoactive medications (substances that affect a person's mental processes, behavior and mood). This failure placed the resident at risk for potentially unknown or unwanted side effects, and decreased quality of life. Findings included . Facility policy titled, 'Psychoactive Drug Use', revision date of 10/15/2022, showed psychoactive drug documentation guidelines were to document in the resident's medical record, by the appropriate discipline on designated forms assessment as indicated: Resident/resident advocate notification, education, and consent of psychoactive medication. Resident 155 admitted to the facility on [DATE] with diagnoses to include right femur fracture, major depressive disorder, anxiety disorder and chronic pain syndrome. Review of Resident 155's admission orders 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 observation, interview and record review the facility failed to ensure resident care plans were reviewed and revised for 1 of 2 residents (Resident 51) reviewed for activities of daily living. This failure placed residents at risk for lack of appropriate care and services by the staff. Findings included . Resident 51 admitted to the facility on [DATE] with diagnoses which included history of strokes and was dependent on staff for activities of daily living such as grooming and hygiene. Review of Resident 51's care plan on 03/20/2025 documented the resident had their own teeth and was able to perform oral hygiene with supervision and cueing and preferred to use their electric toothbrush, initiated on 01/31/2025. In an interview on 03/18/2025 at 1:48 PM, CC1 stated Resident 51 had an electric toothbrush but they could tell it had not been used. CC1 stated they did not think the staff were brushing the resident's teeth. CC1 stated they had asked about it before, and they had checked recently and did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 2 sampled residents (Resident 206) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . Resident 206 admitted to the facility on [DATE] with diagnoses to include chronic ulcer of the foot, high blood pressure and altered mental status. Review of Resident 206's Brief Interview for Mental Status (BIMS-an assessment tool used to screen for cognitive impairment) dated 03/12/2025 showed a score of 12 out of 15, indicating the resident had moderate impairment. <ORAL CARE> Review of the admission Minimum Data set (MDS-an assessment tool) assessment dated [DATE] showed Resident 206 required set up assistance for oral hygiene. Review of Resident 206's care plan dated 03/06/2025 documented the resident had their own teeth, was missing their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and implement resident centered pain intervention for one of four sampled residents (Resident 51) reviewed for pain. This failure placed residents at risk for unrelieved pain, lack of participation in therapy and a decreased quality of life. Findings included . Resident 51 admitted [DATE] with diagnoses which included strokes and history of falls, and a hospital acquired pressure ulcer of the sacrum. Review of Resident 51's admission Minimum Data Set (MDS, a required assessment tool) showed the resident had cognitive impairment. The MDS showed the resident's pain was rated by resident interview and the resident response was that their pain was occasional, and the numeric rating was 9 on a scale of 0 through 10, with 10 being the highest. The MDS stated the resident had a non- stageable pressure ulcer. Review of Resident 51's most recent pain assessment dated [DATE] utilized the non-verbal pain scale and rated the resident's pain at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide notification to the resident's representative of a change in treatment for 1 of 1 resident (Resident 4) reviewed for medication changes. This failed practice prevented the resident's representative from being informed and participating in care decisions. Findings included . Resident 4 was admitted to the facility on [DATE] with diagnoses to include chronic heart disease along with congestive heart failure, low blood pressure, and kidney failure. Review of a progress note dated 09/19/2024 at 11:53 PM, showed a new order for Lasix (medication used to treat fluid retention) 20 milligrams (mg) twice daily and a laboratory test ordered for to be completed 09/23/2024. Review of the September 2024, Medication Administration Record showed Resident 4 received a dose of Lasix 20 mg on the morning of 09/20/2024. In a phone interview on 10/02/2024 at 9:10 AM, Collateral Contact (CC)1, Resident 4's Representative stated they were not informed 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 interview and record review the facility failed to ensure 3 of 3 residents (Residents 1, 2 and 3) who had orders for daily weights were weighed daily. This failed practice placed residents at risk of diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with a diagnosis to include congestive heart failure. Review of Resident 1's care plan showed a focus problem of chronic congestive heart failure with an initiated date of 06/10/2024. The care plan included interventions to monitor the resident's weight as ordered and to monitor for signs and symptoms of congestive heart failure which included weight gain unrelated to intake and swelling of the legs and feet dated 06/10/2024. Review of the August 2024 Medication Administration Record (MAR) showed an order for daily weights in the morning for weight monitoring with a start date of 08/02/2024. Resident 1 had no documented weights fored 16 of 29 days in August 2024. Review of the September 2024 MAR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 3 of 6 facility nursing staff responsible for providing cardiopulmonary resuscitation (CPR) were current in their CPR training. This failure had the potential risk of the facility having a lack of staff who were properly trained in CPR readily available to respond in an emergency. Findings included . Review of the facility's policy titled, Cardiopulmonary Resuscitation, revised on [DATE], did not show the process the facility used to ensure the nursing staff maintained their current Healthcare Provider CPR certifications. Resident 1 was admitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia (low oxygen) and dependence on supplemental oxygen. Review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST) form showed Resident 1 had elected full treatment to attempt resuscitation/CPR. Review of facility's investigation report 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 ensure 1 of 3 residents (Resident 2), reviewed for non-pressure related skin ulcer/wound, received treatment and care in accordance with professional standards of practice. This failed practice placed Resident 2 at risk when they developed myiasis (a parasitic infection of fly larva in human tissue) to their non-pressure wounds and placed all residents at risk of further decline in their conditions, discomfort, and a diminished quality of life/quality of care. Findings included . Review of the Center for Disease Control and Prevention (CDC) site on Myiasis dated 07/16/2024, showed untreated or open wounds were risk factors that made people more likely to get infected in areas where myiasis occurs. The flies are attracted to and lay their eggs on and in open wounds and mucous membranes. Resident 2 was admitted on [DATE] with diagnoses to include embolism (blood clot of an artery) and thrombosis (clotting of the blood) of arteries of the lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services was coordinated for 1 of 3 sampled residents (Resident 1) reviewed for dental services. Failure to follow up on dental referrals and ensure the coordination of dental services for residents who were edentulous (having no teeth) placed the residents at increased risk for difficulty chewing, associated health complications, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include mild cognitive impairment, cognitive communication deficit, depression, and need for assistance with personal care. Review of Resident 1's Clinical Census showed Resident 1 had Medicaid actively effective as of 02/02/2024. Review of Resident 1's Dental Care Area Assessment (CAA- an investigation of a triggered assessment area) dated 01/16/2024, showed Resident 1 was edentulous and interventions included to minimize the risks related to being edentulous. Review of a progress note dated…

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

Based on interview and record review the facility failed to ensure residents had the right to voice grievances related to call light response time, missing personal items, and excessive wait times without fear of retaliation. The failure to allow the Resident Council Committee (RCC) to file grievances on complaints/concerns without the fear of retaliation placed residents at risk for ongoing unmet care needs, unresolved missing property and diminished quality of life. Findings included . Review of the facility's policy titled, Complaints and Grievances, dated 11/28/2017, showed an individual had the right to voice grievances to the facility or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which had been furnished as well as which had not been furnished and other concerns regarding their Long-Term Care facility stay. The facility should make prompt efforts by the facility to resolve grievances the resident may have. The Executive Director/Designee was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 3 resident's (Resident 3 and 4) choice of bathing frequency was honored. The facility failed to provide and honor the resident's care planned bathing preference. This failed practice placed residents at risk for a diminish quality of life. Findings included . <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include compression fracture of the fourth thoracic vertebra, anxiety, and weakness. Review of the care planned Activity of Daily Living (ADL) focus problem, dated 03/18/2024, showed Resident 3 preferred to take a bath three times weekly. Review of the March and April 03/18/2024 through 04/04/2024, Documentation Survey Reports, showed Resident 3 did not have a bath the first week they were in the facility and had two baths the following week until discharge on [DATE]. (Two baths within 18 days). In an interview on 04/04/2024 at 12:58 PM, Collateral Contact (CC) 1, Resident 3's family member stated 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 interview and record review the facility failed to provide the required refund for 1 of 4 sampled residents and/or their resident representative (Resident 1) 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 . Record review showed Resident 1 was admitted to the facility on [DATE] and was discharged from the facility on 11/21/2023. Review of a Complaint Resolution Unit report, dated 03/26/2024, showed the facility did not provide the resident/resident representative a refund for 10 days as the facility claimed they were owed money for supplies. In an interview on 04/04/2024 at 12:29 PM, Staff A, Business Office Manager, stated the facility had issued a refund of $3,147.42 for Resident 1 back in January 2024 and the refund check was mailed out on 02/05/2024, 75 days after Resident 1 was discharged . In an interview on 04/04/2024 at 5:00 PM, Staff I, Interim Administrator,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of potential abuse and neglect for 1 of 1 incident sampled resident (Resident 3) reviewed for abuse and neglect. This failed practice prevented the facility from identifying the potential extent and nature of the allegation of abuse and neglect and placed residents at risk of diminished quality of life. Findings included . Review of the facility's policy titled, Abuse Prevention, Identification, & Reporting, revised on 10/31/2017, showed the facility would conduct an investigation of alleged abuse and neglect, use observation, interviews, and record review to gather and corroborate information. Staff are mandatory reporters and required to fulfill the responsibility of reporting and they must notify the State Survey Agency. RESIDENT 3 Resident 3 admitted to the facility on [DATE] with diagnoses to include compression fracture of the fourth thoracic vertebra, anxiety, and weakness. Review of an email Collateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange hospice services for 1 of 1 resident (Resident 2) reviewed for hospice care. Failure to ensure hospice services were arranged or Resident 2 was transferred to a facility that offered Resident 2's preferred hospice agency denied the resident of their hospice benefit. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses of fractured hip, Alzheimer's disease, heart arrhythmia, kidney disease, diabetes, hypothyroidism, high blood pressure, and weakness. Review of a Health Status Note dated 10/12/2023, showed Collateral Contact (CC) 2, Resident 2's family member informed the staff they would like a referral for hospice sent to a specific hospice agency. The Certified Physician Assistant was notified, and a telephone order was placed. Review of a Nutritional Review Note, dated 11/05/2023, showed Resident 2 was on hospice prior to hospitalization and a hospice referral was ordered. Review of Resident 2's medical record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) was provided pain management consistent with the resident's choices and goals for comfort and dignity. This failed practice placed the resident at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility's policy titled, Pain Management, revised 10/15/2022, showed the facility recognized the resident's right to be free of pain and promoted pain relief through the use of the Pain Management Plan during the resident's duration of stay to help the resident attain or maintain their highest practicable level of well-being and to prevent or manage pain to the extent possible. Resident 1 was admitted to the facility on [DATE] with diagnoses to include severe oral candidiasis (mouth infection caused by a yeast fungus), chronic pain syndrome with opiate (class of drug used to reduce moderate to severe pain) dependency, fibromyalgia (chronic disorder that causes pain and…

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

Based on observations, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws for 2 of 2 medication refrigerators (East Hall and [NAME] Hall) in the Medication Storage Rooms. These failures placed residents at risk to receive inactivated medications and/or vaccines and may experience adverse side effects and other potential negative health outcomes. Findings included . Review of the facility policy titled, Medication Management, revised on 10/15/2022, stated medications and biologicals are stored appropriately according to manufacturer's guidelines .medications should be stored under proper conditions such as temperature and light in compliance with applicable federal and state laws and regulations. In an observation on 02/06/2024 at 10:20 AM, the East Hall medication storage room had a small refrigerator with temperature logs on the outside. The document showed a section titled AM Temperatures, and PM Temperatures. The logs showed the following: - September 2023, AM section had no temperatures logged 20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a homelike environment for 1 of 2 dining rooms (East Dining Room), and 1 of 2 halls (East Hall), and 8 out of 20 resident rooms (Rooms 7, 12, 16, 17, 20, 21, 27, and 29) reviewed for environment. The facility failed to ensure that residents were served their meals in a home like environment, failed to ensure lightening fixtures were cleaned and repaired, and failed to ensure resident's rooms flooring and doors were clean and in good repair. The facility failure to provide maintenance services and homelike dining experience placed residents at risk for diminished quality of life. Findings included . <EAST DINING ROOM> RESIDENT 3 Resident 3 admitted to the facility on [DATE] with diagnoses included Alzheimer's disease. Review of Resident 3's care plan on 02/07/2024, there was no focus, goal, or intervention the resident required or requested to have their meal served on a cafeteria tray. RESIDENT 7 Resident 7 admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), to holistically analyze the plan of care for 6 of 9 sampled residents (Residents 15, 28, 8, 18, 31, and 40) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide residents assistance with Activities of Daily Living (ADL) to include personal hygiene and bathing for 5 of 5 sampled dependent residents (Residents 5, 15, 28, 41 and 46), reviewed for ADL. The failure to provide the resident's, who were dependent on staff for assistance with grooming and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Activities of Daily Living, revised 02/28/2019, showed assistance is provided to residents who need extensive or total assistance with maintenance of nutrition, grooming, oral hygiene, toileting, and other personal cares. <RESIDENT 5> Resident 5 admitted on [DATE] with diagnoses to include Alzheimer's disease (memory loss), physical debility, muscle weakness, and the need for assistance with ADL care. Review of the clinical record, showed Resident 5 was dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 4 of 5 sampled residents (Residents 16, 35, 8, and 28) reviewed for unnecessary medications, were free of unnecessary psychotropic medications. The facility failed to ensure there were valid diagnoses for use of psychotropic medications, monitoring, valid consents for use, and attempted gradual dose reductions (GDR - is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . <RESIDENT 16> Resident 16 admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, anxiety, depression, and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] showed the resident had severe cognitive impairment. Review of Resident 16's physician orders showed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to serve meals that were at a safe temperature and appetizing for 2 of 2 sampled residents (Residents 8 and 31) and 2 of 2 halls reviewed for food quality. This failed practice placed residents at risk for decreased nutritional intake and food borne illness. Findings included . Review of an untitled and undated facility document, showed daily mealtimes for the facility were breakfast at 8:45 AM, lunch at 12:15 PM, dinner at 5:30 PM, and evening snack at 8:00 PM. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] with diagnoses that include stroke affecting their left side, major depressive disorder, and chronic pain. In an interview on 02/06/2024 at 9:10 AM, Resident 8 stated facility meals were cold, there were not many options, and the menu contains the same repeated food items. <RESIDENT 31> Resident 31 admitted to the facility on [DATE] with diagnoses to include acute respiratory failure (the air sacs of the lungs cannot release…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standard of practice for 1 of 2 hallways (East Hall), for 1 of 1 resident during catheter care (Resident 8) and failed to implement their respiratory protection plan (RPP) for 32 of 79 employed staff. The facility failed to ensure the staff used appropriate hand hygiene practices, staff were wearing personal protective equipment (PPE) in accordance with national standards, clean and disinfect universal resident medical equipment, and staff following appropriate infection control practices on and around medication administration carts. This failed place all residents and staff at risk for potential infection. Findings included . Review of the facility policy titled, Infection Prevention and Control Program, revised 10/15/2022, stated the program was designed and implemented to identify and reduce the risk of infections among residents, and staff . It should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) were screened, educated on risk and benefits, and/or offered the vaccine for 4 of 5 sampled residents (Residents 15, 16, 28, and 35) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease and a diminished quality of life. Findings included . Review of the facility policy titled, Pneumococcal Program, revised 05/31/2023, showed all residents and family members receive education regarding the benefits, potential side effects and general safety of receiving the of pneumococcal immunization. Residents are then offered and given the pneumococcal vaccine in accordance with physicians' orders unless contraindicated, resident had already received, or refused. The facility will provide a copy of the vaccine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 criminal background checks were completed for 2 of 5 sampled facility staff (Staff U and V) and failed to ensure the Omnibus Reconciliation Act (OBRA) Nurse Aide Registry (a database to ensure nurse aides meet federal requirements and are eligible to work in a skilled nursing facility) checks were completed for 3 of 3 sampled Nursing Assistants (Staff O, T, and V) reviewed for staff qualifications and background review. These failures placed all residents at risk for abuse/neglect. Findings included . Review of the facility policy titled, 'Preventing Abuse, last revised on 08/01/2023, showed the facility was to: - Complete background checks of new employees and returning employees prior to hire/rehire. - Check the OBRA Nurse Aide Registry to ensure OBRA certification, prior to the employment of a Nursing Assistant (NA). <STAFF U> Staff U, Licensed Practical Nurse (LPN), had a hire date of 07/01/2023. Review of Staff U's employee file showed the background check was dated 02/07/2024. <Staff V> Staff V, Nurse Aide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 28) reviewed for respiratory care and services was provided care consistent with professional standards of practice. The facility failed to ensure the concentrator (a medical device that provides pure oxygen) was set to the ordered flow rate. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs, diminished quality of life and negative outcomes. Findings included . Review of the facility's oxygen therapy policy undated, directed the staff to verify the physician order prior to initiating oxygen therapy and to monitor oxygen parameters as needed. Resident 28 admitted to the facility on [DATE] diagnoses included COPD (a group of diseases that cause airflow blockage and breathing problems), obstructive sleep apnea (residents repeatedly stop and star breathing while they sleep) and dementia (memory loss) and required supplemental oxygen (O2) use.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 routine dental services were coordinated for 1 of 1 sampled resident (Resident 40) reviewed for dental services. Failure to ensure dental services were coordinated placed residents at increased risk for health complications associated with caries and poor dentition. Findings included . Resident 40 admitted to the facility on [DATE] with diagnoses to include fracture of the right leg, history of falling, and other specified disorders of teeth and supporting structures. Review of the care plan, dated 08/24/2023, showed that Resident 40 had oral/deal health problems exhibited by several decayed teeth. On 02/05/2024 at 10:20 AM, Resident 40's mouth was observed which had missing teeth and signs of decay (discolored teeth, receding gums). In an interview on 02/08/2024 at 10:54 AM, Resident 40 stated they had a bridge for their teeth that they did not use anymore and kept it in their drawer. Resident 40 stated they had oral pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 1 resident (Resident 1) had their rights respected and honored when their choice to have a personal phone to communicate with whom they chose was taken away. This failed practice placed the resident and all other residents at risk of diminished quality of life and at risk of losing their resident rights to have access to their personal phone. Findings included . In an interview and observation on 12/21/2023 at 1:51 PM, Resident 1 was lying in bed and stated that they had not slept well because of all this mess with not having their phone. No phone was observed in the resident's room. The resident stated they paid quite a bit of money to stay at the facility and their phone was gone. The resident stated it had made them feel very bad, when their phone disappeared, and they could not call anyone. The resident stated they were so upset and wanted their phone back. The resident stated they wanted to know who had come into their room and took their phone as it had been working. Review of the State Hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 3 residents (Resident 1) reviewed. Failure to properly position and secure Resident 1 in their wheelchair (w/c) caused the resident to experience a fall out of their w/c during transportation in the facility van, placing them at risk for injury. Findings included . Resident 1 admitted [DATE] with diagnoses which included a history of stroke with left sided weakness and other physical limitations. The resident was alert and oriented with some short-term memory loss. Review of the Resident 1's care plan, dated 10/28/2019, showed they required extensive assistance with activities of daily living, extensive 2-person assistance for transfers using a lift device and used a tilt-in-space w/c (a w/c designed to recline to provide comfort and positioning support). The resident's record showed they had impaired trunk control strength for sitting positioning due to a prior stroke. In an interview on…

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