Belmont Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident assessments accurately reflected the health status and/or care needs for 4 of 20 residents (Residents 43, 80, 7 & 24) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to ensure active diagnoses, oral assessments, Level II Pre-admission Screening and Resident Review (PASRR) status, and restorative services accurately reflected residents' health status and care provided, placed residents at risk for unidentified and/or unmet care needs. Findings included .Resident 43Resident 43 was admitted to the facility on [DATE]. Review of the 03/23/2025 Annual and 12/02/2025 Significant Change MDS showed the resident was edentulous (no natural teeth or tooth fragments) and had no abnormal mouth tissue, ulcers, masses, or lesions. Oral Assessment Review of Resident 43's dental consultations showed the following: A dental consult, dated 09/09/2025, instructed staff to assist Resident 43 with cleaning their oral tissues 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 record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) was completed and/or reflected accurate mental health diagnosis for 2 of 5 sampled residents (Residents 2 and 7) reviewed for PASRR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life.Findings included. Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (recurring intrusive thoughts or concerns), vascular dementia (a type of cognitive impairment caused by reduced blood flow to areas of the brain), and depression (mood disorder that causes a persistent feeling of sadness or loss of interest). Resident 2's Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/04/2026, indicated severe cognitive impairment with inattention and disorganized thinking continuously present. Resident 2 was admitted to the facility with a Level 1 PASRR, dated 10/20/2025, received from the transferring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for 5 of 20 sampled residents (36, 2, 80, 7 & 43) reviewed for care plans. The failure to establish care plans that were individualized placed residents at risk for receiving inconsistent and/or inadequate care.Findings included. Resident 36 Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set, MDS-an assessment tool, dated 01/26/2026 documented Resident 36 was cognitively intact and on continuous oxygen therapy. On 02/23/2026 at 3:07 PM, Resident 36 was observed wearing a nasal cannula that was administering oxygen. A review of Resident 36's care plan, on 02/24/2026, did not show oxygen therapy listed as a focus, goal, or intervention/task. On 02/26/2026 at 11:32 AM, Staff X, Licensed Practical Nurse / Resident Care Manager said while looking at Resident 36's care plan that they did not have an oxygen care plan and they should. Staff X said her expectation was for oxygen to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services to ensure that residents received weekly showers for 1 of 2 residents (3) reviewed for activities of daily living (ADLs). This failure placed the residents at risk of poor hygiene and a diminished quality of life.Findings included .Resident 3 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 01/26/2026, documented Resident 3 was cognitively intact and was dependent to substantial/moderate assist with ADLs. On 02/23/2026 at 2:09 PM, Resident 3 said they had one shower since they had been in the facility. Resident 3 said things keep happening that delayed the shower, like physical therapy. Resident 3 said the nurse believed they were refusing showers. Resident 3 said they were not refusing and they would like a shower. A review of Resident 3's care plan on activities of daily living self-care performance deficit related to weakness, immobility, surgery on the nervous…

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 was consistently posted to include the actual nursing staff hours worked for 3 out of 6 days (02/22/2026, 02/23/2026 and 02/27/2026). This failure caused the facility's staffing information not to be readily available to residents and visitors who may wish to review it. Findings included .On 02/23/2026 at 9:53 AM, upon entrance to the facility, the daily nurse staffing was posted on the wall outside of the therapy room, it showed the dates for 02/19/2026, 02/20/2026 and 02/21/2026. No daily nurse staffing was posted for 02/22/2026 or 02/23/2026. On 02/27/2026 at 8:56 AM, the daily nurse staffing was from 02/26/2026. Staff B, Director of Nursing Services was walking past, was stopped and asked to confirm the daily nurse staffing posted on the wall. Staff B confirmed the daily nurse staff posting was dated 02/26/2026. Staff B said the daily nurse staffing should have been updated. When observation from 02/23/2026 were explained, Staff B said the daily nurse staffing should be…

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

Based on observation, interview and record review, the facility failed to ensure written menus were followed, planned menu items were served at the appropriate serving size, substitutions only occurred when necessary and were approved by the Registered Dietician and communicated to the facility residents, and appropriate serving sizes were provided. These failures detracted from residents' ability to determine if they wanted the main meal or the alternative meal when filling out their menus for the week, due to uncertainty if the listed meal would actually be served. This placed residents at risk of receiving food they did not request, therapeutic diet not being followed, and dissatisfaction with meals. Findings included Review of the posted menu showed on 02/26/2026 the lunch meal would be country fried steak, garlic mashed potatoes, garden blend vegetables with banana pudding. Residents on renal diets, two-gram sodium diets, or low fat/low cholesterol diets would be served a baked beef patty, garlic mashed potatoes, garden blend vegetables with banana pudding or oranges with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure recommendations of gradual dose reductions were followed for 3 of 4 sampled residents (1, 2, & 3) reviewed for gradual dose reductions. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of vascular dementia and anxiety disorder. The quarterly minimum data set (MDS), an assessment tool, dated 08/19/2025, documented Resident 1 has severe cognitive impairment and required substantial to maximal assistance with activities of daily living (ADL).The care plan, dated 11/22/2024, documented staff would monitor target behaviors and monitor for side effects. The care plan, dated 05/15/2025, documented Resident 1 would receive hospice services and staff will assess the resident's coping strategies and respect their wishes.On 09/15/2025 at 12:39 pm, Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 2 of 3 residents (6 & 8) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including a cognitive communication deficit. The quarterly Minimum Data Set (MDS/An assessment tool), dated 02/06/2025, documented Resident 6 had no cognitive impairment Care Plan, dated 07/31/2024, documented Resident 6 wished to return home with their son. Care Plan, dated 12/20/2024, document Resident 6 was waiting to discharge with their son until the Medicaid application was complete. Progress notes, dated 02/03/2025, showed Resident 6 was wanting to know discharge plans. The resident was told the Medicaid application 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 accurately assess and identify a change in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 2 of 3 residents (5 & 6) reviewed for urinary incontinence. Failure to identify and assess/determine causative factors of urinary incontinence placed residents at risk for unmet care needs and decreased quality of life. Findings included . <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including a fracture of the arm. The admission Minimum Data Set (MDS/an assessment tool), dated 01/28/2025, documented Resident 5 had no cognitive impairment and was frequently incontinent of urine. The Bowel and Bladder Evaluation, dated 01/31/2025, documented Resident 5 was continent of urine. No further assessment or interventions were implemented. Care Plan, dated 02/25/2025, documented Resident 5 was occasionally incontinent of bladder related to diuretic…

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 pain management to adequately control residents pain for 1 of 3 sampled residents (1) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease (a lung disease with limits air flow and breathing). On 02/27/2025 at 3:46 PM, Resident 1 said when they were discharged , the facility sent them with a large bag full of medication. It was very overwhelming for Resident 1 to be given a bag with many different medications. Because Resident 1 was so overwhelmed, they did not notice any concerns with their pain medication. Resident 1 discovered once home they were sent home with only three oxycodone (a narcotic pain medication). Resident 1 experienced pain until they could get to the appointment with their community provider. No prescription was sent…

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 repeatedly implement antibiotic protocols to ensure antibiotics were appropriately prescribed for 1 of 3 sampled residents (1), reviewed for antibiotic use. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. On 02/27/2025 at 3:46 PM, Resident 1 said when they were sent home they were sent with a large bag full of medications. They did not know what all of the medications were for, and it was very confusing. Resident 1 went to their doctor and went through everything. They found two antibiotics that had many pills left. Resident 1 said they were never told to discontinue the medication but thinks they should have since they were getting these medications in the hospital. Resident 1 said it was very confusing. The Hospital…

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 pneumococcal vaccine (used to prevent pneumonia and sepsis), was provided for 1 of 3 residents (1), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. The Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination, dated 01/15/2025, documented Resident 1 wished to receive the pneumococcal vaccine. The documents were signed by the nurse on the same day. Review of Resident 1's electronic health record showed no documentation that Resident 1 was provided a pneumococcal vaccination. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said there was a consent signed from the resident indicating they would like the vaccine. Staff B said…

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 COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was provided for 1 of 3 residents (1), reviewed for immunizations. The failure to provide the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. The Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 01/15/2025, documented Resident 1 wished to receive the COVID-19 vaccine. The documents was signed by the nurse on the same day. Review of Resident 1's electronic health record showed no documentation that Resident 1 was provided a COVID-19 vaccination. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said…

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 an Advanced Directive (AD, a written instruction of health care directions) for 4 of 5 sampled residents (Residents 59, 28, 43 & 60 ) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 59 was admitted to the facility on [DATE]. The Quarterly Minimal Data Set (MDS, an assessment tool), dated 10/10/2024, documented Resident 59 was cognitively intact. Resident 59's Electronic Health Record (EHR), documented an AD receipt was signed by Resident 59 on 10/15/2024, indicating Resident 59 had chosen not to formulate an AD at this time. Review of Resident 59's EHR documented, prior to 10/15/2024, no other attempts to offer or assist Resident 59 with formulating an AD. On 11/06/2024 at 2:43 PM, Staff I, Patient Advocacy Resource, said he was unable to locate any other AD's for Resident 59. At 2:54 PM, Staff B, Director of Nursing…

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 <Olympic Hallway> On 11/13/2024 at 11:02 AM, observation of the carpet in the activity room in the Olympic Hallway showed the carpet was worn and heavily soiled. There was a three by four-foot circular stain just inside and to the right of the entrance. Five additional one by one-foot dark brown circular stains with distinct edges were noted on the carpet throughout the room. The stains appeared to be the result of spilled liquids that had dried prior to being cleaned up. On 11/05/2024 at 1:12 PM, Staff C, Resident Care Manager, said the activity room had been previously used as the assist dining room. <Mountainview Hallway> On 11/13/2024 at 11:04 AM, observation of the carpet in front of the first kiosk in the Mountainview hallway showed the carpet had been cut in multiple places and replaced with non-matching carpet (different color and pattern). An approximately eight-foot by four-foot section of carpet had been replaced with darker brown carpet with a different pattern and an approximately 18 foot by…

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 grievances were initiated, logged, investigated, and/or promptly resolved/responded to for 1 of 1 residents (Resident 40) and the Resident Council reviewed for grievances. This failure placed residents at risk for feelings of frustration, powerlessness, and a decreased quality of life. Findings included . Review of the facility's policy titled Grievances, revised 02/01/2017, showed that general concerns could be voiced at Resident Council (a group of residents that meet regularly to discuss living at the facility) meetings, and that the concern would be evaluated and investigated. A response would occur within three working days to the individual with the concern, to acknowledge the steps taken for resolution. <Resident Greivance> Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessement tool), dated 10/17/2024, documented Resident 40 was cognitively intact. On 10/22/2024, Resident 40 filed 2…

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 resident and/or their representative for 4 of 4 sampled residents (Residents 18, 40, 16 & 60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy section, Admission/Discharge/Transfer, revised in 11/2016, said Information shall be provided to the resident and/or his/her representative in a language they can understand at the time of .transfer to the general acute hospital. 1) Resident 18 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 08/05/2024, documented the resident was cognitively intact. A review of Resident 18's progress notes in the electronic health record (EHR) showed Resident 18 transferred to the hospital on [DATE] and discharged from the hospital 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 provide a bed hold notice to the resident and/or their representative for 3 of 4 sampled residents (Residents 40, 16 &60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about bed hold and a diminished quality of life. Findings included . 1) Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 10/17/2024, documented Resident 40 was cognitively intact. Resident 40's Electronic Health Record (EHR) showed Resident 40 was transferred to the hospital on [DATE] and discharged from the hospital and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a bed hold notice. On 11/12/2024 at 10:05 AM, Staff E, Resident Care Manager/Registered Nurse, said Social Services completed bed hold notifications, but could 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 interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS, an assessment tool) accurately reflected the status for 6 of 25 sampled residents (Residents 53, 10, 21, 56, 176 & 23) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 53 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 53 was moderately cognitively impaired, had a weight loss of 5% or more and was on a prescribed weight loss program. On 11/12/2024 at 12:45 PM, Staff B, Diretor of Nursing Services (DNS), said when a Resident was on a prescribed weight loss program the facility should be monitoring weights weekly with the interdisciplinary team, the Registered Dietitian should be completing weekly reviews, and there must a Physician order for the diet plan. Staff B said the Resident must be involved in the weigh loss program too. When asked about…

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 care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 7of 35 residents (Residents 62, 176, 376, 67, 23, 28, and 21) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 62 admitted to the facility on [DATE]. An Activities of Daily Living (ADL) self-performance CP, revised 04/26/2024, directed staff to provide one person assistance with bathing per the resident's chosen schedule. The care plan did not identify what the resident's chosen bathing schedule was. 2) Resident 176 admitted to the facility on [DATE]. On 11/04/2024 at 3:38 PM, Resident 176 said they wanted a shower at least every three days but was scheduled for only one. An ADL CP, revised 10/30/2024, showed the resident required substantial assistance with bathing. The care plan did not identify the resident's desired type (shower,…

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 dependent residents were provided scheduled bathing/showering opportunities for 6 of 8 residents (Residents 43, 19, 64, 176, 67 and 62) reviewed for activities of daily living (ADL's). This failure placed residents at risk of not having their ADL care needs met and a diminished quality of life. Findings included . 1) Resident 43 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, an assessment tool) dated 10/22/2024, documented Resident 43 was moderately cognitively impaired and required substantial/maximal assistance with showering/bathing. The Shower Schedule dated 10/6/2024, documented Resident 43's shower day was to occur on Tuesdays during day shift. Resident 43's shower record, dated 10/15/2024 through 11/7/2024, documented no bathing activity was documented from 10/15/2024 until 10/29/2024, for 14 days. There were no refusals documented. On 11/08/24 at 9:59 AM, Staff Q, Certified Nursing Assistant, when informed…

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 restorative services at the frequency residents were assessed to require for 6 of 7 residents (Residents 48, 22, 55, 46, 25 and 61) reviewed with restorative nursing programs (RNPs). The failure to provide RNPs at the frequency residents were assessed to require, placed residents at risk for decrease in Range of Motion (ROM), development and/or progression of contractures, increased dependance on staff for care needs and a diminished quality of life. Findings included . 1) Resident 48 admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively intact, and did not receive restorative nursing services during the assessment period. A restorative nursing care plan, initiated 08/15/2024, showed the resident would be provided active ROM restorative program to bilateral (both) upper extremities (UE) and lower extremities (LE) five times a week (5x/wk.), to maintain ROM and prevent contracture…

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 receiving enteral feedings, were administered enteral formula at the physician ordered rate and volume for 1 of 1 resident (Resident 21) reviewed for enteral feeding. The facility also failed to ensure routine resident weights were obtained, reviewed, weight loss trends identified, and nutritional nutritional interventions were timely identified and implemented for 2 of 2 residents (Resident 64 and 21) reviewed for weight loss. Additionally, the facility failed to have a system in place that ensured fluid intake was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated, and labs were monitored for fluid and electrolyte imbalances for 2 of 2 residents (Resident 58 and 10) reviewed with a fluid restrictions. These failures placed residents at risk for continued weight loss, inadequate nutrition, fluid volume overload, fluid and electrolyte imbalances and other medical complications. Findings…

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

Based on observation, interviews and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 7 resident interviews (Resident 18, 19, 59, 64, 376, 40 & 58), Resident Council interviews (Residents 40 & 59) and Staff interviews (Staff E, BB, CC, DD, EE & H) and as evidenced by failed practices in many identified quality of life and quality of care areas. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including grooming and showers, assessments, care planning, care plan revision, restorative services, hospice services and infection control in accordance with established clinical standards, and resident needs and preferences. These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life. Findings included . <Resident Interviews> On 11/04/2024 at 11:03 AM, Resident 18, said staff would come in and tell them they were busy and would have to wait. At 11:18 AM, Resident 19 said staff took a long time to…

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

Based on observation and interview, the facility failed to ensure expired medications and supplies were removed/discarded in 1 of 2 medication storage rooms (Medicare A and Medicare B medication room) reviewed for medication storage and labeling. This failure placed residents at risk of receiving compromised and/or ineffective medications and medical supplies. Finding included . On 11/04/2024 at 2:50 PM, the following outdated medications and supplies were observed: - Package of blood glucose lancets, label read, facility should use or discard by 06/30/2024 - 3 bottles of blood glucose strips, expired 08/22/2024. - Ibuprofen 200 milligram (mg), opened, expired 09/2024. - Vitamin B-6 100 mg opened, expired 10/2024. - Daily Vitamin formula plus iron, opened, expired 08/2024. - Arexvy (a vaccine to protect against lower respiratory tract disease) 120 micrograms (mcg)/0.5mg vial in fridge, expired, label read, use or discard by 09/25/2024. - Tuberculin Purified Protein Derivative vial in fridge, date accessed 09/13/2024, expired 10/13/2024. - Bottle of Urine Reagent Strips (used to test…

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 prepare food in a manner that ensured meals were appetizing, palatable and served at appropriate temperatures for 9 of 15 sampled residents (56, 43, 58, 19, 18, 59, 64, 13 and 126) reviewed for dining. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals. Findings included . <Resident Interviews> On 11/04/2024 at 2:02 PM, Resident 56 said, the food here stinks, the food texture is pasty, it feels like you are eating glue, like they glued it all together. The soups seem to be leftover stuff from other meals. At 12:14 PM, Resident 43 said the food did not always taste good and was often that the hot was not hot and the cold was not cold. On 11/05/2024 at 9:27 AM, Resident 58 stated, The food is terrible. It is not good. On 11/04/2024 at 11:00 AM, Resident 19 said he wanted a hot meal, the meals were consistently cold, and the bacon always had the taste of oil. Resident 19 said they had sent meals back because it was cold. At 11:05 AM, Resident 18 said the food was cold…

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 residents' received therapeutic diets as prescribed by the physician, and/or assessed by the interdisciplinary team for 5 of 23 residents whose meals were observed (Residents 46, 24, 10, 50 and 42), and to provide the correct portion size for 6 of 6 residents (Residents 42, 71, 24, 43 64 and 127) observed with orders for small or large portions. Failure to ensure residents' received physician ordered therapeutic diets and/or portion sizes placed residents at risk for medical complications and/or unmet nutritional needs. Findings included . <Therapeutic Diets> On 11/12/2024 at 11:20 AM, dietary staff had already placed beverages and condiments on all resident trays and placed them into the tray carts. Observation of the trays at that time, showed each tray had been provided a container of tartar sauce. Review of the therapeutic menu for the lunch meal, which consisted of cakes, rice pilaf with mushrooms, seasoned green peas with chocolate cream pie, showed the following diet types were not to receive…

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 seek/ obtain approval from the Resident Council, and to ensure residents were provided a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased from 14 hours to 15 hours. These failures precluded residents from having input about extending the time between meals beyond 14 hours and placed them at risk for feelings of hunger and inadequate nutrition. Findings included . a) The Garden Room and Medicare A hall were served dinner at 5:00 PM and breakfast at 8:00 AM, for a total of 15 hours in between meals. b) Medicare B was served dinner at 5:10 PM and breakfast at 8:10 AM, for a total of 15 hours in between meals c) [NAME] Mountain and Mountain View Halls were served dinner at 5:15 - 5:20 PM and breakfast at 8:15 - 8:20 AM, for a total of 15 hours in between meals. On 11/14/2024 at 7:45 AM, Staff B, Director of Nursing Services, said they were unable to find documentation to show they sought approval from the Resident Council prior to extending the time between Dinner and Breakfast…

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 have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 64 & 28) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care, to have documentation in residents' Electronic Health Records (EHR) that showed what hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) had visited, when they visited, and what care was provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included . Review of the facility's Hospice Service Agreement, effective date [DATE], showed the facility and hospice would each designate…

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 perform hand hygiene, follow Personal Protective Equipment (PPE, equipment worn to minimize exposure to a variety of hazards requirements for a resident on Enhanced Barrier Precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions with residents in nursing homes) orders, failed to prevent cross-contamination for food and PPE carts, and failed to prevent medical equipment from touching the floor for 3 of 25 sampled residents (Resident 7, 21 & 56) and 1 of 3 halls (Med Cart B Hall) reviewed for infection control practices. These failures placed residents at risk of developing and transmitting infections and a decreased quality of life. Findings included . <EBP> 1) Resident 7 was admitted to the facility on [DATE] and had diagnoses including dysphagia (difficulty swallowing) and aphasia (a language disorder that affects a person's ability to understand and express written 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 provide pneumococcal vaccines for 3 of 6 residents (Residents 176, 10 and 21) reviewed for vaccinations. This failure placed the residents at a higher risk for contracting pneumococcal infections, related complications, and a decreased quality of life. Findings included . 1) Resident 176 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 10/24//2024, showed the resident's pneumococcal vaccinations were not up to date and documented the pneumococcal vaccination had not been offered. A Resident Consent For Influenza, Pneumococcal, and COVID-19 Vaccination form, dated 10/18/2024, showed Resident 176 consented to the vaccination and checked the box on the form that stated, Yes, I wish to receive the pneumococcal vaccine according to the CDC's recommended schedule. Review of the Electronic Health Record (EHR) showed the resident was not provided the pneumococcal vaccination despite giving written consent 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 and interview the facility failed to maintain the emergency fire doors in 1 of 3 main halls (outside room [ROOM NUMBER]) reviewed for maintenance were in working order. This failure placed residents and staff at risk for falls, avoidable injury, and a diminished quality of life. Findings included . During an observation on 11/04/2024 at 1:00PM, a square metal piece in the floor of Medicare A and Medicare B hallway was loose and sticking up. Facing north, the right fire door was closed to test whether or not the metal piece would hold the door and then allow the door to be opened. The exit bar had to be pushed upward and with a moderate amount of force in order to open the door. Staff P, Licensed Practical Nurse, walked by as the door was being tested and stated, oh good, that's back again, pointing to the metal piece. On 11/05/2024 at 9:31 AM, the fire door was observed to be closed. Staff O, Certified Nursing Assistant (CNA) attempted to open the door, pushing against the exit bar with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 3 of 4 sampled residents (Resident 19, 48 & 63) reviewed under resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . Facility policy titled Residents Rights, revised 11/23/2016, documented, The resident has a right to dignified existence, self-determination and communication with, and access to individuals and services inside and outside the Facility. On 11/04/2024 at 10:34 AM, Staff F, Certified Nursing Assistant (CNA), walked into room [ROOM NUMBER]B without knocking or announcing themself. At 10:46 AM, when asked about how staff show dignity to residents before entering a resident room, Staff F said knocking on the door and introducing myself. When asked if it was acceptable to walk in without knocking or announcing themselves, Staff F said no, I…

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 record review and interview, the facility failed to ensure that residents had signed consent prior to psychotropic (group of drugs to treat mental health conditions) medication administration and that residents had the correct risks and benefits provided, for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of receiving medication without knowledge of the medication or correct side effects, and a decreased quality of life. Findings included . Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of depression (overwhelming feeling of sadness and hopelessness) and dementia (condition affecting memory and thinking) with psychosis (detachment from reality). Review of the Annual Minimum Data Set, an assessment tool, dated 08/26/2024, showed Resident 21 was dependent on staff for care. <Consent Form> Resident 21 was prescribed risperidone, which is an antipsychotic…

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 choices regarding bathing frequency were honored for 2 of 4 residents (Residents 376 and 176) reviewed for choices. The facility's failure to accommodate resident preferences related to frequency and type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . 1) Resident 376 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/05/2024, showed the resident was cognitively intact, required physical assistance with bathing, and choices related to bathing were identified as Very Important. On 11/04/2024 at 2:59 PM, Resident 376 reported that they were not asked how many or what type of bathing they preferred. Rather, upon admission they were informed they would get one shower a week on Sundays. Since I have been here, I have had one shower (resident made air quotes with her…

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 the Pre-admission Screening and Resident Review (PASRR, a screening tool used to identify mental health needs) was accurate and a referral for Level II PASRR was sent in a timely manner for 2 of 5 sampled residents (Residents 60 and 56) reviewed for PASRR. This failure placed residents at risk for not receiving specialized mental health services, and a decreased quality of life. Findings included . 1) Resident 60 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) dated 09/25/2024 documented that Resident 60 was cognitively intact and had a diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) A Level I PASRR, dated 09/05/2024 documented that Resident 60 was diagnosed with anxiety disorders (mental health disorders characterized by intense, excessive, and persistent worry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 25 sampled residents (Resident 56 and 126). This failure placed residents at risk for unidentified/ unmet care and safety needs, and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 56 was admitted to the facility on [DATE]. Resident 56 had diagnoses that included surgical amputation (removal of a limb), muscle weakness, and hypertension (high blood pressure). The Medicare 5-day Minimum Data Set Assessment (MDS, an assessment tool), dated 11/04/2024, showed Resident 56 needed assistance from staff for activities such as transferring to and from bed to a wheelchair or going from a sitting to a standing position. <Activities> Review of Resident 56's Activity Assessment, dated 09/26/2024, showed that Resident 56 enjoyed various activities including exercise groups, puzzles, and men's group. During 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 1 of 3 residents (Resident 176) reviewed for communication, were provided appropriate treatment and services to maintain hearing. The failure to complete Resident 176's earwax removal treatment, resulted in Resident 176 indicating their ears remained clogged with wax and they still had difficulty hearing. This placed the resident at risk for feelings of frustration, diminished self-worth and decreased quality of life. Findings included . Resident 176 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 10/24/2024, showed the resident was cognitively intact, had moderate difficulty hearing in some environments and did not have hearing aids or other hearing devices. On 11/04/2024 at 4:05 PM, Resident 176 reported they were experiencing ear pain and could not hear very well due to earwax build-up. The resident said he asked staff to declog their ears. The resident said the nurses put Debrox…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review, the facility failed to consistently provide treatments as ordered, and implement timely and appropriate interventions to prevent the worsening of PU (PU/PI, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 3 sampled residents (Resident 64), reviewed for pressure ulcers. This failure may have contributed to worsening/deterioration of the PU to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis). This failure placed residents at risk for skin injuries, PUs/PIs, and a diminished quality of life. Findings included . <Policy> Facility policy titled, Skin Care Policy/Procedure, revised 06/2016, stated, It is the policy of the facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injuries…

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 administer parenteral (routes other than the digestive system to give fluids or medication) medication in a manner consistent with professional standards for 1 of 1 sampled residents (Resident 126) reviewed for antibiotics. This failure placed residents at risk for complications, infections, and a diminished quality of life. Findings included . Review of the Electronic Health Record (EHR) showed Resident 126 was admitted to the facility on [DATE]. Resident 126 had diagnoses including sepsis (bloodstream infection) and cellulitis (bacterial skin infection). Review of the Medicare-5 Day Minimum Data Set Assessment, dated 10/28/2024, showed Resident 126 received intravenous (IV, through a vein) antibiotics. Review of the EHR showed Resident 126 had a single lumen peripherally inserted central catheter (PICC, a thin long tube that goes through a vein in the arm and goes to the larger veins near the heart for giving medications). Review of the EHR 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 orders were followed for 2 of 2 residents (Residents 72 and 10) reviewed for dialysis. This failure put residents at risk for medical complications and a decreased quality of life. Findings included . Resident 72 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) documented Resident 72 was cognitively intact. Resident 72's diagnosis included End Stage Renal Disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids) and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). Resident 72 had a dialysis fistula (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for dialysis) to their left arm. Review of the Electronic Health Record (EHR) showed that Resident 72 was going to dialysis three times a week from…

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 the pharmacist's Medication Regimen Review (MRR) recommendations were acted upon for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of decreased effects of medication, medication complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Regimen Review, revised 08/2017, showed the MRR recommendations were to be provided to the responsible physician, facility's Medical Director, and the Director of Nursing within a week of the review. The provider would then document in the resident's medical record what was reviewed and if any actions needed to be taken. Nursing was responsible for providing a written response to the review, to be given to the pharmacist and to the facility to be filed. Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on on interview and record review, the facility failed to ensure quality of care for 2 of 5 residents (Resident 72 & 56) reviewed for unnecessary medications related to providing ordered medication. This failure placed residents at risk for medical complications and a decreased quality of life. 1) Review of the Electronic Health Record (EHR) showed Resident 10 was admitted to the facility on [DATE]. Resident 10 had a diagnosis of ESRD, required renal dialysis, and had a port (implanted venous access device). Review of the Quarterly Medicare MDS, dated [DATE], showed Resident 10 was cognitively intact. Resident 10 had an order for removing the dressing on Resident 10's port two hours after dialysis on Tuesday, Thursday, and Saturday. Review of the November 2024 administration record showed the dressing was not being removed. Review of the November 2024 progress notes showed staff were not removing the dressing to prevent infection. During an interview on 11/12/2024 at 9:14 AM, Staff C, RCM, said 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 residents were free from unnecessary psychotropic (affecting the mind) medications by ensuring Gradual Dose Reductions (GDR) were attempted for 1 of 5 residents (Resident 27) reviewed for unnecessary medications and that GDR recommendations that included laboratory tests were followed up on for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . 1) Resident 27 was readmitted to the facility on [DATE] with diagnoses of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The Annual Minimum Data Set, (MDS, an assessment tool) 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 record review and interview, the facility failed to ensure residents received COVID-19 vaccines that were consented for, for 2 of 7 residents (Residents 10, 21) reviewed for vaccinations. This failure placed residents at risk for a decreased immune response to COVID-19, related complications if infected, and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 10 was admitted to the facility on [DATE] and consented to receive the COVID-19 vaccination on 05/13/2024 and 10/29/2024. During an interview on 11/13/2024 at 8:51 AM, Staff C, Resident Care Manager (RCM), said the COVID-19 vaccinations were not previously ordered from the supplier, and now the infection control nurse was aware and would be ordering. During an interview on 11/14/2024 at 8:34 AM, Staff B, Director of Nursing (DNS), said it did not meet expectations that Resident 10 signed consent and the COVID-19 vaccine was not ordered from the supplier. 2) Review of the EHR 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 ensure care plan conferences were held with the resident for 1 of 3 sampled residents (Resident 2) reviewed for participation in care planning. This failure placed residents at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic kidney disease. The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/13/2024, documented Resident 2 was cognitively intact and required substantial assistance from staff with activities of daily living. The care plan, revised on 04/10/2024, documented Resident 1 wished to return to their apartment. Interventions included that the facility would evaluate/record abilities and strengths and determine gaps which effected discharge with an interdisciplinary team. Review of Resident 2's electronic health record from…

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 a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic kidney disease. The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/13/2024, documented Resident 2 was cognitively intact and required substantial assistance from staff with activities of daily living. The care plan, revised on 04/10/2024, documented Resident 1 wished to return to their apartment. The facility would evaluate/record abilities and strengths and determine gaps which effected discharge with an interdisciplinary team. On 10/14/2024 at 3:25 PM, Resident 2 said he wanted 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 accurately assess and determine appropriate treatments for a chronic skin condition for 1 of 3 sampled residents (Resident 1) reviewed for skin conditions, non-pressure. This failure placed all residents at risk for unmet needs, pain and discomfort, declining health, and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease (the vessels of the heart become narrowed or blocks affecting the legs and feet), and peripheral angiopathy (a buildup of fat in the arteries of the legs and arms). The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/27/2024, documented Resident 2 has moderate cognitive impairment and was dependent on staff for assistance with activities of daily living. The care plan, revised 09/01/2024, documented Resident 1 had diabetes mellitus and was at risk for skin breakdown. The resident would have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide necessary diabetic nail care and treatment in accordance with professional standards for 1 of 3 sampled residents (Residents 1) reviewed for foot care. This failure placed residents at risk for developing further medical complications, discomfort and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease (the vessels of the heart become narrowed or blocks affecting the legs and feet), and peripheral angiopathy (a buildup of fat in the arteries of the legs and arms). The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/27/2024, documented Resident 2 had moderate cognitive impairment and was dependent on staff for assistance with activities of daily living. The care plan, revised 09/01/2024, documented Resident 1 has diabetes mellitus. The resident required daily inspection of feet for sores, blisters,…

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 (IPC) guidelines and standards of practice for 4 of 4 units (Mountain View, [NAME] Mountain, Medicare A and Medicare B) reviewed for IPC procedures when the facility failed to ensure staff followed standards of practice related to donning (placing on) recommended Personal Protective Equipment (PPE) prior to entering a room with resident(s) who were positive for COVID-19 (a highly transmissible respiratory virus) and following recommendations to keep doors closed to rooms with residents on aerosol precautions due to COVID-19, and source control masking. This failure placed all residents, staff and visitors at risk for contracting and potentially spreading COVID-19. On 01/02/2024 at 9:25 AM, the facility lobby was observed with a sign indicating there were COVID-19 positive residents in the facility and all staff were to wear N95s for source control. Staff A, Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including toileting for one of three residents (Resident 3) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Date Set, (MDS) an assessment tool, dated 12/09/2023, documented Resident 3 was cognitively intact and required maximum assistance from staff for toileting. The care plan intervention, initiated on 07/31/2023, documented the resident was to be toileted in the morning when waking, after meals, and at night. Review of the ADL task record for toileting showed Resident 3 was toileted 27 times in the previous 30 days, less than once per day. Review of a facility investigation report, dated 12/08/2023, documented Resident 3 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 offer the influenza and pneumococcal vaccine to 2 of 8 sampled residents (Resident 1 and 2). This failure placed residents at risk for developing influenza and pneumonia and medical complications. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 11/14/2023, documented the resident was moderately cognitively impaired. Resident 1's medical record did not show documentation of the resident's influenza or pneumococcal vaccine status. The medical record did not document if the resident was offered or received an influenza or pneumococcal vaccine. Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired, and the influenza and pneumococcal vaccine was not offered. Resident 2's medical record did not show documentation of the resident's influenza or pneumococcal vaccine status. 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 residents and/or resident representatives were provided education on the risks and benefits including potential side effects of the COVID-19 (a highly infectious respiratory illness caused by a virus) vaccine and ensure documentation of the acceptance or refusal to receive the vaccine was in the medical record for 3 of 8 sampled residents (Residents 1, 2 & 8) reviewed for COVID-19 immunizations. This failure placed residents and resident representatives at risk of not having the opportunity to make an informed decision about the COVID-19 vaccine and the adverse health effects of this communicable disease. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's immunization record on 01/04/2024, showed no documentation of an updated COVID-19 vaccination or documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the…

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

Based on interview and record review, the facility failed to consider and act promptly to address concerns raised by residents for 4 of 4 sampled months (June 2023, July 2023, August 2023 & September 2023) reviewed for Resident Council. This failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken, left residents at risk for unresolved concerns, frustration, a less than homelike environment, and a diminished quality of life. Findings included . A facility policy titled, Resident and Family Grievances including Missing Items Policy, dated 08/19/2022, documented grievances may be voiced verbally during resident or family council meetings and the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Review of the facility's resident council meeting minutes showed residents voiced concerns about the following: <June 2023 > 1) The Garden Room doors needed to be fixed so residents could get in and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents' care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 22 sample residents (Residents 58, 33, 64, 49, 57, and 36) whose CPs were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 58's electronic health record (EHR) showed the resident had a provider order, dated 06/21/2023, to titrate oxygen to maintain oxygen saturation greater than 90 %. The order did not include what diagnosis or condition the oxygen was intended to treat. Review of Resident 58's comprehensive CP showed no oxygen or respiratory CP had been developed or implemented. On 10/12/2023 at 1:47 PM, Staff B, Director of Nursing (DON), stated that Resident 58's comprehensive CP needed to be revised to include the resident's use of supplemental oxygen. Resident 58's urinary catheter (a flexible tube used to empty the bladder and collect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 4 of 8 sampled residents (Residents 64, 33, 83 and 58) reviewed for ADLs and choices. Failure to provide assistance with nail care and/or bathing to residents depend on staff for care, placed the residents at risk for unmet needs, poor hygiene, diminished self-image, and decreased quality of life. Findings included . 1) Resident 64 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 09/04/2023, showed the resident required extensive assistance with bed mobility, dressing and bathing. On 10/10/2023 at 11:17 AM, Resident 64 said that their toenails had not been cut since they admitted to the facility and stated, They need it. Resident 64's toenails were observed and were long, thick, untrimmed, and starting to curve around the end of the toes. Resident 64's ADL care plan (CP), revised 09/11/2023, showed there was no direction to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation and record review, the facility failed to provide an ongoing program of activities to meet the individual residents' interests and needs for 3 of 5 sampled residents (Residents 9, 69 and 49) reviewed for activities. This failure placed the residents at risk for boredom, isolation, and a diminished quality of life. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment (MDS), dated [DATE], showed the resident was cognitively impaired and it was very important for the resident to do things with groups of people. Resident 9's Activity Quarterly Evaluation, dated 10/10/2023, showed the resident liked group activities that included bingo, music events and birthday/holiday socials. Resident 9's care plan, dated 08/05/2023, showed the following interventions: engage in simple, structured activities that avoid overly demanding tasks, provide a program of activities that accommodates abilities, introduce residents with similar…

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 respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 3 of 4 sampled residents (Residents 57, 49 and 58) reviewed for respiratory care when the facility failed to identify and implement maintenance and monitoring orders for resident continuous positive airway pressure/bilevel positive airway pressure machines (CPAP/BIPAP, a form of non-invasive ventilation therapy used to facilitate breathing) and to document the administration of oxygen on resident(s) Medication Administration Records(MAR). This placed residents at risk for unidentified and/or unnecessary oxygen use, respiratory compromise, and other negative health care outcomes. Findings included . 1) Resident 57's Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/15/2023, showed the resident required the use of a BIPAP and supplemental oxygen during the assessment period. Resident 57's physician'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 observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges and/or failed to document refrigerator temperatures for 2 of 3 refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life. Findings included . <Out of Range Temperatures> Review of the July 2023, August 2023, September 2023, and October 2023 temperature logs for the Reach-In refrigerator in kitchen, showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: July 2023: 4th 44F, 7th 42F, 8th 43F, 9th 44F, 10th 42F, 16th 43F, 17th 46F, 19th 42F, 21st 43F, 22nd 44F, 23rd 46F, 26th 46F, 30th 42F, 31st 50F. August 2023: 5th 42F, 6th 45F, 7th 45F, 8th 44F, 10th 44F, 12th 42F, 13th 43, 14th 47F, 15th 49F, 17th 43F, 20th 43F, 21st 45F, 22nd 47F, 24th 42F, 27th 44F, 28th 45F, 29th 47F. September 2023: 3rd 42F, 4th 43F, 5th 44F, 7th 43F, 9th 42F, 10th 47F, 11th 48F, 12th 46F, 15th 46F, 16th 42F, 17th 43F, 18th 46F, 18th 43F,…

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 care and services were provided in a dignified manner which maintained and enhanced quality of life for 2 of 2 sampled residents (Resident 51 & 55) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, disrespect, decreased self-worth and a diminished quality of life. Findings included . 1) Resident 51 admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS, an assessment tool), dated 09/16/2023, documented Resident 51 was cognitively intact. On 10/09/2023 at 2:18 PM, Resident 51 said she requested assistance from staff to use the bathroom prior to breakfast. Resident 51 said they were told staff could not assist residents until after staff had finished delivering breakfast trays to all residents. Resident 51 said this resulted in them urinating in their night gown and on their recliner chair. Resident 51 stated, I'm tired of this. Resident 51 said staff did not come in to change…

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

Based on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 1 of 20 (Resident 58) sample residents reviewed for timely assessments. Failure to timely complete resident quarterly assessments, placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's), showed quarterly assessments must be completed no later than the ARD +14 calendar days. Resident 58's electronic health record showed a quarterly MDS had an ARD of 09/26/2023. Review of the quarterly MDS completion date showed it was not completed until 10/13/2023, 17 days after the ARD. On 10/13/2023 at 9:21 AM, Staff D, MDS Assistant, said Resident 58's 09/26/2023 quarterly MDS assessment was completed late. Reference WAC 388-97-1000(5)(d) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to ensure assessments were accurate and reflected the residents' health status for 1 of 20 sampled residents (Resident 33) reviewed for assessments. This failure placed residents at risk for receiving unnecessary medications and/or unmet care needs. Findings included . Resident 33 admitted to the facility on [DATE]. Resident 33's Level I Pre-admission Screening and Resident Review (screening tool for intellectual disabilities or mental illness), dated 03/31/2023, showed the resident had indicators of serious mental illness related to diagnoses of depression and anxiety disorders. Resident 33's admission orders, dated 04/02/2023, showed the resident had orders for an antianxiety medication for a diagnosis of anxiety, and an antidepressant medication for a diagnosis of depression. The admission Minimum Data Set (MDS, an assessment tool), dated 04/06/2023, documented Resident 33 received antidepressant medication on five of five days during the assessment…

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 services provided met professional standards of practice for 3 of 20 sampled residents (Residents 49, 57 and 58) of 20 reviewed. The failure to follow and/or clarify incomplete physician's orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) A physician order for Resident 58, dated 06/21/2023, documented to provide Foley catheter care (a flexible tube used to empty the bladder and collect urine in a drainage bag) and check function every shift. Resident 58's electronic health record (EHR) showed a 08/30/2023 nurses note which documented Resident 58's urinary catheter was discontinued. Resident 58's August and September 2023 Treatment Administration Record (TAR) showed facility nurses signed they provided catheter care and validated the catheter was functional on 08/31/2023 day, evening, and night shift; and 09/01/2023 day and night shift, after the catheter had been discontinued. On 10/12/2023 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.

Based on observation, interview and record review, the facility failed to consistently assist with the application of a hearing aid for 1 of 2 residents sampled residents (Resident 36) reviewed for communication. This failure placed residents at risk for communication difficulties, frustration, and diminished quality of life. Findings included . Resident 36's physician orders, dated 08/22/2022, showed the facility staff were to assist the resident in application of the left hearing aid every morning and the hearing aid was kept in the medication room at night. On 10/09/2023 at 3:33 PM, Resident 36 said they had trouble obtaining their hearing aid from staff in the morning. The resident said they wanted to wear the hearing aid. At 3:33 PM, Resident 36 was observed with no hearing aid in the left ear. On 10/10/2023 at 11:42 AM, Resident 36 was observed with no hearing aid in the left ear. On 10/11/2023 at 11:13 AM, Resident 36 was observed with no hearing aid in the left ear. At 2:37 PM, Resident 36 was observed with no hearing aide in the left ear. Resident 36 said they wanted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide services to prevent decline in range of motion for 1 of 3 sampled residents (Resident 9) reviewed for mobility. This failure placed residents at risk for loss of functional mobility, further decline in range of motion and discomfort. Findings included . Resident 9 admitted to the facility on [DATE]. The Minimum Data Set (an assessment), dated 07/11/2023, showed the resident had functional limitation in range of motion in their upper and lower extremities. Resident 9's medical provider progress note, dated 09/13/2023, showed Resident 9 had contractures (fixed tightening of joints) of both knees. Resident 9's electronic health record on 10/12/2023 at 2:57 PM, showed no documentation of a nursing restorative program. On 10/12/2023 at 3:00 PM, Staff V, Therapy Program Manager, said Resident 9 was seen in July of 2023 for therapy. Staff V said the therapist established a nursing restorative program for the resident when the resident was discharged…

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 nutrition and hydration between meals for 1 of 4 sampled residents (Resident 69) reviewed for nutrition. This failure placed the resident at risk for thirst, hunger, and discomfort. Findings included . Resident 69 was admitted to the facility on [DATE] with a diagnosis of dementia and malnutrition. The Minimum Data Set, an assessment tool, dated 07/21/2023, showed the resident had impaired cognition and required extensive assistance for eating and transfers. Resident 69's Registered Dietician nutrition note, dated 10/08/2023, showed the resident was underweight and staff were to provide support and encouragement for the resident to consume as many foods and beverages as possible. Resident 69's care plan, dated 07/31/2023, showed staff were to offer and encourage snacks/fluids between meals, encourage to drink fluids of choice at least 1000 cubic centimeter [milliliters]/day, and offer drinks during one-to-one visits. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide individualized non-pharmacological care approaches and/or meaningful activities for 1 of 2 sampled residents (Resident 69) reviewed for dementia. This failure placed residents at risk for unnecessary medications, unrelieved distress, and a diminished quality of life. Findings included . Resident 69 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident 69's Medical Provider Progress Note, dated 09/26/2023, showed the resident had a diagnosis of dementia and was seen for persistent anxiety, agitation, and constant yelling, screaming. Review of Resident 69's care plan, dated 07/31/2023, showed no documentation related to Resident 69's constant yelling and screaming. Resident 69's Behavior/Psychoactive Medication interdisciplinary team (IDT) review, dated 09/28/2023, showed the resident had a target behavior of agitation and calling out repeatedly. The review showed the behaviors had worsened since 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 that nursing assistants demonstrated competency caring for residents after a fall for 1 of 3 residents (Resident 1) reviewed for falls. This failure placed the resident at risk for delayed medical attention, unnecessary pain, and potential clinical complications. Record review of the facility's undated policy titled, Incidents and Accidents, showed that in the event of an incident or accident, immediate assistance will be provided, and any injuries will be assessed by the licensed nurse and the affected individual will not be moved until safe to do so. Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 04/28/2023, showed the resident was cognitively intact and had a prior fall with injury. On 08/23/2023 at 10:13 AM, Resident 1 stated that they had taken themselves to the bathroom on 07/18/2023 in the evening and had fallen. The resident stated that two nursing assistants put them back 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.