Bothell Health Care

Based on observation, interview, and record review, the facility failed to maintain glucometer (a device for measuring the concentration of sugar in the blood) disinfection per manufacturers' recommendations for 4 of 4 glucometers in Wing 300, reviewed for safe operating condition. This failure placed residents at risk of inaccurate blood sugar readings and potential negative outcomes. Findings included . Review of the facility's policy titled, Glucometer Disinfection, revised in May 2024, showed that glucometers were disinfected to prevent transmission of blood borne (can be spread through contamination by blood and other body fluids) diseases to residents and employees. The policy further showed that the facility would ensure that glucometers were cleaned and disinfected after each use and according to the manufacturer's instructions. The glucometers should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA - a federal agency that protects human and environmental health by regulating pollutants and enforcing laws) - registered healthcare…

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 provided care and services in a manner that maintained and promoted dignity while providing meal assistance for 1 of 2 residents (Resident 70), reviewed for meal observations. This failure placed the resident at risk for a diminished self-worth and overall well-being. Findings included . Review of the facility's undated document titled, Resident Handbook included the resident bill of rights which showed that residents had the right to be treated with respect and dignity. Resident 70 admitted to the facility on [DATE]. Observation and interview on 03/28/2025 at 1:00 PM, showed Staff Z, Certified Nursing Assistant (CNA) was standing while assisting Resident 70 with their lunch who was sitting in their wheelchair. Staff Z stated that they usually do not sit while they assisted residents with their meals. Staff Z stated that sitting when feeding a resident would be better because then the residents would not feel they are rushed.…

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 inform the resident and/or their representative before administering psychotropic (mind altering) medications for 1 of 5 residents (Resident 34), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Review of the facility's undated document titled, admission Agreement, showed, Consent for Medical Treatment: The resident has the right to make health care decisions, including consenting to or refusing treatment. Review of the facility's undated document titled, Resident Handbook, showed, Residents have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Review of the psychiatric progress note dated 04/17/2024 showed Resident 34 had diagnoses of Parkinson's…

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 an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 1 of 3 residents (Resident 70), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility's undated document titled, admission Agreement, showed that Residents/Legal Representatives have been given written materials about resident's right to accept to or refuse medical treatments as provided by state law and has been informed of resident's right to formulate Advance Directives. Review of Resident 70's Social Service History &…

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 issue Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notification of Medicare (federal health insurance program for people age [AGE] or older) Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 2 of 3 residents (Resident 25 & 73), reviewed for beneficiary notification. These failures placed the residents and/or their representatives at risk of not being fully informed and losing their right to an appeals process. Findings included . Review of the facility's undated document titled, Resident Handbook, showed that the residents have the right to receive notices in writing. Further review of the document showed that the resident has the right to be informed about Medicare eligibility and coverage. Review of the undated NOMNC Form…

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 transmit the resident Minimum Data Set (MDS - an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 22 residents (Resident 69), reviewed for transmitting MDS assessments. This failure placed the residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11, revised in October 2024, showed all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 2 of 5 residents (Residents 55 & 34), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 5 residents (Resident 2). These failures placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities. Findings included . Review of the facility's policy titled, Resident Assessment - 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 interview and record review, the facility failed to ensure a resident centered discharge plan was in place for 1 of 1 resident (Resident 96), reviewed for discharge planning. The failure to begin the discharge planning process at admission placed the resident at risk for delayed discharge, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Planning Process, revised in May 2024, showed, If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented in the electronic medical record. An active individualized discharge care plan will address .discharge destination .identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. Resident 96 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 12/26/2024 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge summary was completed and included a recapitulation (overview) of the resident's stay for 1 of 1 resident (Resident 96), reviewed for discharge summary. This failure placed the resident at risk for unsafe discharge, complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Planning Process, revised in May 2024, showed, The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer . Resident 96 admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (an assessment tool) dated 02/07/2025 showed Resident 96 was discharged 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 implement and/or provide activity plan for 1 of 1 resident (Resident 45), reviewed for activities. This failure placed the resident at risk of boredom, decreased mood, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities, revised in February 2025, showed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Resident 45 was admitted to the facility on [DATE] with a diagnosis that included Dementia (a medical condition affecting memory, thinking and social abilities). Review of the quarterly Minimum Data Set (an assessment tool) dated 02/20/2025, showed Resident 45's preferred language was Mandarin (Chinese language) and activity preferences that included reading and keeping up with the news. Review of the activity care plan initiated on 12/28/2024, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 15), reviewed for hospice services. This failure placed the resident at risk of not receiving the necessary hospice care services, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Coordination of Hospice Services, revised in September 2024, showed the facility will maintain communication with hospice and identify, communicate, follow, and document all interventions put into place by hospice and the facility. Review of the face sheet printed on 04/01/2025 showed Resident 15 admitted to the facility on [DATE]. Review of the hospice order dated 01/30/2025, showed that Resident 15's hospice referral was made. Review of Resident 15's medical records (electronic and paper charting) did not show documentation of hospice care visit notes. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received trauma informed care, trigger assessment, and trauma-informed care assessment in accordance with professional standards of practice for 3 of 4 residents (Residents 8, 34 & 76), reviewed for mood/behavior. These failures placed residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . Review of the facility's policy titled, Trauma Informed Care, revised in May 2024, showed that it was the policy of the facility to ensure residents who are trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice. The policy showed, Each resident will be screened for a history of trauma upon admission. The policy further stated that if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of anticoagulants (medication that prevent blood clot) for 2 of 5 residents (Residents 55 & 45), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Medication Monitoring, revised in January 2025, showed, the facility takes a collaborative, systemic approach to medication management, including the monitoring of medications for efficacy and adverse side consequences. The policy further showed licensed nurses with periodic oversight by nurse managers shall adhere to facility policies and current standards of practice for administration and monitoring of medications. RESIDENT 55 Review of the face sheet printed on 03/28/2025 showed Resident 55 initially admitted to the facility on [DATE]. Review of the January 2025 to March 2025…

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

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 refrigerators (Medication Storage A), reviewed for medication storage. This failure placed the residents at risk of receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage, revised in May 2024, showed that the facility would ensure all medications housed on the premises would be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the undated package insert document for Tubersol (tuberculin - purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [a serious illness caused by a type of bacteria that mainly affects the lungs]) showed an open multi-dose vial of Tubersol which has been opened and in use for 30 days…

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 Certified Nursing Assistants (CNAs) had the required dementia (memory loss) management training upon hire for 2 of 5 staff (Staff U & Staff V), reviewed for sufficient and competent Nurse staffing. This failure placed the residents at risk for potential negative outcomes and unmet care needs. Findings included . Review of the facility's policy titled, Required Training, Certification and Continuing Education of Nurse Aides, revised in September 2024, showed, It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. STAFF U Review of the undated facility's employee record showed Staff U, CNA, was hired on 07/09/2024. It further showed no documentation that Staff U received the required dementia management training. STAFF V Review of the undated facility's employee record showed Staff V, CNA, was hired on 04/23/2024. It further showed no documentation that Staff V received the required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely information about medical appointment for 1 of 1 resident (Resident 1), reviewed for planning and implementation of care. The failure to notify the resident's representative of Resident 1's medical appointment led to the cancellation of the medical procedure and prevented the resident's representative the ability to exercise their right to make an informed decision. Findings included . Review of the face sheet showed Resident 1 was admitted to the facility on [DATE] with a diagnosis that included dementia (a group of symptoms affecting memory, thinking and social abilities). Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 09/05/2024 showed that Resident 1 had moderate cognitive impairment. Review of the nursing progress notes dated 09/15/2024 showed that Resident 1 was on alert for increased confusion. Review of the communication care plan initiated on 09/09/2024 showed Resident 1 required supervision in all…

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 a summary/copy of the baseline care plan to the residents and/or their representatives for 4 of 4 residents (Residents 334, 32, 57 & 183), reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Baseline Care Plan, revised in May 2023, showed that a written summary of the baseline care plan shall be provided to the resident and their representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: the initial goals of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. RESIDENT 334 Resident 334 admitted to the facility on [DATE]. On…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff and the hours worked for each shift for 4 of 5 days reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's form titled, Report of Nursing Staff Directly Responsible for Resident Care, showed that the forms had no actual number of staff and the hours worked on the nurse staffing form on 01/17/2024, 01/18/2024, 01/19/2024 and 01/20/2024. Further review of the forms showed the census was not written on the form on 01/18/2024, 01/19/2024 and 01/20/2024. Observations on 01/17/2024 at 8:44 AM, on 01/18/2024 at 8:49 AM, on 01/19/2024 at 12:28 PM and on 01/20/2024 at 11:05 AM, showed the facility's daily nursing staffing form posted on the wall by Director of Nursing Service's (DNS) office did not display the actual number of nursing staff and hours…

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 appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) and failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 2 of 4 medication carts (300 & 400 Hall Medication Carts), reviewed for medication storage. In addition, the facility failed to maintain proper temperature for 2 of 2 refrigerators in the medication storage room (Medication Storage Room Refrigerator A & B). These failures placed the residents at risk for receiving compromised, ineffective, and expired medications. Findings included . Review of the facility's policy titled, Labeling of Medications and Biologicals, revised in May 2023, showed, All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. Review of the facility's policy titled, Medication Storage, revised in May 2023, showed the temperatures are…

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 infection control practices for hand hygiene and/or proper use of gloves were followed during peri-care (cleaning of private areas), wound care, and medication administration for 3 of 3 residents (Residents 42, 23 & 48), and failed to do hand hygiene during meal observations for 2 of 2 staff (Staff M & T), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings Included . Review of the facility's policy titled, Hand Hygiene, revised in May 2023, showed that the use of towelettes (antimicrobial-impregnated wipes) are not a substitute for using an Alcohol-Based Hand Rub (ABHR) or antimicrobial soap. It also showed that the use of gloves does not replace hand washing and if the task required gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. HAND HYGIENE AND GLOVE USE RESIDENT 42 Observation and interview on 01/18/2024 at 1:49 PM, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure bed rails/side rails were safe to use for 4 of 4 residents (Residents 42, 47, 5 & 1), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Proper Use of Side Rails, revised in May 2023, showed the facility was to check the rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. RESIDENT 42 Resident 42 admitted to the facility on [DATE] with a diagnosis that included aftercare following joint replacement surgery and muscle weakness. Review of the admission Minimum Data Set (MDS- an assessment tool) dated 12/28/2023, showed Resident 42 was cognitively intact. Review of the Activities of Daily Living (ADL) care plan intervention, revised on 01/02/2024, showed Resident 42 required two-person extensive assist for bed mobility (moving in bed), 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 resident's personal clothing were kept safe from loss/theft and failed to follow their process for missing/lost items for 1 of 1 resident (Resident 18), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Personal Belongings, revised in May 2023, showed that the facility will exercise reasonable care for the protection of the resident's property from loss or theft. If an item is on the inventory sheet (the list that has resident's belongings) and is lost the facility will reimburse the resident. Review of the facility's policy titled, Resident and Family Grievances, revised on 10/31/2023, showed that all staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. Prompt efforts include…

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 allegation of abuse was reported to the State Agency within the required time frame for 1 of 1 resident (Resident 44), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), required the nursing home employee (or other mandated reporter) to make a report if they had reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations. Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse,…

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 allegation of abuse was thoroughly investigated for 1 of 1 resident (Resident 44), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised in May 2023, showed that when a suspicion of abuse, neglect or exploitation, or reports of neglect or exploitation occur, an immediate investigation was warranted. Investigations includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, exploitation, and/or mistreatment had occurred, the extent, and cause and providing complete and thorough documentation of the investigation. Resident 44 admitted to the facility 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 provide a written transfer/discharge notice to the residents/representatives describing the reason for transfers for 2 of 5 residents (Residents 63 & 21), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharge. Findings included . Review of the facility's policy titled, Transfer and Discharge [including discharge Against Medical Advice], revised in May 2023, showed that for emergency transfers/discharges, the facility should provide transfer notice as soon as practicable to resident and representative. The policy further showed that the facility should document assessment findings and other relevant information regarding the transfer in the medical record. RESIDENT 63 Resident 63 admitted to the facility on [DATE]. Review of the progress note dated 02/04/2023, showed Resident 63's representative had requested that Resident 63 be transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 2 of 5 residents (Residents 63 & 21), reviewed for hospitalization. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed Hold, revised in May 2023, showed that prior to and at the time of transfer for hospitalization or therapeutic leave the facility will provide to the resident and/or the representative written notice, which specifies the duration of the bed hold policy. RESIDENT 63 Resident 63 admitted to the facility on [DATE]. Review of the progress note dated 02/04/2023, showed Resident 63 was sent to the hospital for altered mental status. Review of Resident 63's clinical record did not show that a bed-hold notice was provided to Resident 63 and/or their representative. During a joint record review and interview on 01/19/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 2 of 17 residents (Residents 23 & 53), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for dental care, dentures, and incontinence care placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised in May 2023, showed that the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan policy also showed, Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. RESIDENT 23 DENTAL Resident 23 readmitted to the facility on [DATE]. Review of the significant change in status Minimum Data Set (MDS-an assessment tool) dated 11/13/2023,…

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 consistently provide nail care and denture care for 2 of 3 residents (Residents 44 & 53), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised in May 2023, showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy titled, Providing Nail Care, revised in May 2023, showed that routine cleaning and inspection of nails will be provided during scheduled showers and as needed. RESIDENT 44 Resident 44 admitted to the facility on [DATE] with a diagnosis that included left hemiplegia (left sided weakness). Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 01/04/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and provide risks and benefits for bed rail/side rail use to meet the needs of 1 of 4 residents (Resident 5), reviewed for accident hazards. This failure placed the resident at risk for injury and a diminished quality of life. Findings included . Review of the facility's policy titled, Proper Use of Side Rails, revised in May 2023, showed that the facility shall assess the resident for .risks associated with the use of side/bed rails. The side rail policy also showed that the facility shall obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use. Resident 5 readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/02/2024 showed Resident 5 required partial/moderate assistance for rolling left and right in bed, and for lying to sitting in bed. Observations on 01/16/2024 AM at 10:16 AM and on 01/18/2024 AM at 8:46…

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 coordinate services for 1 of 2 residents (Resident 23) who had identified dental needs. The failure to follow through and coordinate dental services placed the resident at risk for dental pain, dental complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Dental Services, revised in May 2023, showed, It is the policy of this facility . to assist residents in obtaining routine . and emergency dental care. The dental policy also showed that the emergency dental services includes services needed to treat any problem of the oral cavity that required immediate attention by a dentist. Resident 23 readmitted to the facility on [DATE]. Review of the significant change in status Minimum Data Set (an assessment tool) dated 11/13/2023, showed Resident 23 had obvious or likely cavity or broken natural teeth. Review of Resident 23's January 2024 Medication Administration Record, showed an order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate use of antibiotic medication (used to treat infection) was followed for 1 of 4 residents (Resident 280), and failed to ensure standardized tools and criteria were utilized for antibiotic stewardship program (such as Loeb Minimum Criteria [minimum set of signs/symptoms used to determine whether to treat an infection with antibiotics] and/or SBAR [Situation, Background, Assessment, and Recommendation - a toolkit that helps staff/prescribing clinicians communicate about suspected UTIs [Urinary Tract Infections-bladder infection] and facilitates appropriate antibiotic prescribing) to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance. These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility's…

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 reported concerns were addressed and investigated timely for 3 of 8 residents (Residents 5, 7 & 9), reviewed for grievances. This failure placed the resident at risk for unmet care needs, and a diminished quality of life. Findings included . Record review of the grievance policy dated 05/2023, showed the following policy explanation and guidelines: 4. A resident may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC [Long Term Care] facility stay. 8. Grievances may be voiced in the following forum: (a). Verbal complaint to a staff member. 10. Procedure: (b). The staff member receiving the grievance will take any immediate actions needed to prevent further potential violations of any resident right. RESIDENT 5 Review of a resident interview form dated 09/18/2023, showed Resident 5 informed Staff C, Social Service Director, that they would prefer not to have agency…

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 possible allegations of abuse and/or neglect were investigated for 1 of 8 residents (Resident 10), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse and/or neglect, and a diminished quality of life. Findings included . Resident 10 admitted to the facility on [DATE]. Review of the significant change in status Minimum Data Set assessment (an assessment tool) dated 07/24/2023 showed the resident had moderately impaired thinking, was able to make needs known, and required assist for care needs. Review of an investigation summary dated 09/21/2023, showed on 09/19/2023, the resident was interviewed for any care concerns when an allegation of abuse was made by another resident in the facility. Review of the interview form dated 09/19/2023, revealed Resident 10 was questioned by Staff C, Social Service Director, on how they were treated by staff. The resident expressed concerns with staff that…

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

Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage, were labeled, dated when opened, and closed shut. The facility also failed to separate clean work areas from soiled work areas and keep the kitchen clean from debris and garbage. These failures had the potential to affect all 81 residents in the facility who consumed food from the kitchen. Findings included . Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 11/2022, documented Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded. On 10/10/2022 at 8:23 AM, the following observations in the kitchen were made with, and verified by the Dietary Manager, Staff C: 1. The dry storage room contained one bag of pasta that was not labeled and dated. It also contained one bag of cake mix that was not labeled, dated, or closed shut. 2. The walk-in refrigerator contained one bag of salmon, teriyaki chicken, beef, ham, a container of soup and a block of…

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

Based on observation and interview, the facility failed to ensure expired medications and laboratory supplies were properly discarded to prevent the potential use of the medications and supplies in 1 of 2 medication storage rooms observed. This failure placed the residents at risk to receive ineffective medications, use compromised laboratory supplies, and possibly experience adverse side effects. Findings included . Observation of Station B Medication Room on 10/11/2022 at 2:48 PM, revealed the following expired medications: - One bottle of Gabapentin (for nerve pain) Sol [solution] 250/5 ml [milliliter] 300 cc [cubic centimeters] bottle, 250 cc left in bottle, with an expiration date of 05/2022. - Two bottles of Loperamide Hydrochloride (for diarrhea) Oral solution 1 mg [milligrams] per 7.5 ml (4 fl. oz. - 120 ml) with an expiration date of 05/2022. - One Combivent Respimat inhalation spray 20 mcg [micrograms]/100 mcg per actuation 120 metered doses with an expiration date of 08/2022. - Four bottles of Docusate Sodium (for constipation) 200 mg capsules one with 30 tablets with an…

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

Based on observation, interview, and record review, the facility failed to ensure the oxygen (O2) nasal canula (a thin tube inserted into the nose to deliver O2) was dated and in a plastic bag when not in use for 1 of 1 resident (Resident 66) reviewed for respiratory care. This failure placed the resident at risk for infection and related complications. Findings included . Review of the facility's policy titled, Oxygen Concentrator, dated 05/2022, revealed, Care of the resident-Cannulas should be changed weekly and dated .Document in the resident's clinical record to change tubing/bag weekly and date the tubing. Observation on 10/10/2022 at 10:44 AM, revealed Resident 66's O2 tubing that was connected to the concentrator by his bedside was not dated. The tubing was also not dated or bagged that was on his wheelchair. Observation on 10/10/2022 at 4:21 PM revealed that Resident 66's O2 tubing that was connected to the concentrator by his bedside was not dated. The oxygen tank located on the resident's wheelchair, had tubing that was also not dated, and the tubing was lying across 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.