Bremerton Trails Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate an allegation of misappropriation of a phone for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of loss of property, lack of communication with the community and a decreased quality of life.Findings included.Resident 1 was admitted on [DATE] with diagnoses including depression, and anxiety. The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 1 had moderate cognitive impairment, required substantial/maximal assistance from staff for bed mobility and moderate assistance to transfer to a chair. Resident 1's progress notes, dated 02/13/2026, showed Resident 1 reported their family member had removed their personal phone and would not return it. The notes showed the SSA [Social Service Assistant] staff completed a report to the state agency for concern for possible exploitation/control of resident communication device by family members.On 03/04/2026 at 9:17 AM, Staff A, Social Service Assistant,…

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 physician ordered medications for 1 of 3 residents (Resident 3) reviewed for medication administration. This failure placed residents at risk of increased pain, frustration and a decreased quality of life.Findings included.Review of the facility's policy titled, Pharmacy Services Overview, revised April 2019, showed pharmaceutical services consisted of: pharmacy services were available to residents 24 hours a day, seven days a week, and residents had sufficient supply of their prescribed medications and received medications in a timely manner. Resident 3 was admitted on [DATE], with diagnoses including chronic pain and spinal stenosis (narrowing of the spinal canal, causing pressure on the spinal cord, typically resulting in pain and numbness). The Minimum Data Set Assessment, dated 11/26/2025, showed Resident 3 was cognitively intact.On 03/02/2026 at 2:10 PM, Resident 3 said the facility continually ran out of their oxycodone (pain…

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

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 3 of 5 sampled residents (Resident 65, 8 & 12) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, unmet care needs, decreased self-worth and a diminished quality of life. Findings included 1) Resident 65 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS, an assessment tool), dated 06/06/2025, documented Resident 65 was severely cognitively impaired and required maximal assistance with cares. On 09/24/2025 at 12:04 PM, Resident 65 was yelling from their room Hello, I need to be cleaned up. Staff L, Licensed Practical Nurse (LPN), was standing at the medication cart parked outside Resident 65's door. Staff L walked away from the cart, down the hallway away from Resident 65's room and returned to the medication cart two minutes later. At 12:07 PM, Staff L, entered…

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

Based on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 38 of 38 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life. Findings included On 09/24/2025 at 11:53 AM, Staff T, Revenue Cycle Manager, said the residents did not have access to their personal fund accounts after hours. Residents only have access when the front desk was staffed from 8:30 AM until 6:00PM.On 09/24/2025 at 4:25 PM, Staff A, Administrator, said the residents did not have access to their funds on the weekends and after hours. Staff A said he was going to change that today by having a nurse cart with funds available if a resident requests money after hours.Reference WAC 388-97-0340 .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 38 of 38 residents reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.Findings included Resident 60 was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 08/01/2025, documented the resident was moderately cognitively impaired.On 09/23/2025 at 9:44 AM, Resident 60 said I don't get statements. On 09/24/2025 at 11:53 AM, Staff T, Revenue Cycle Manager, said I am trying to give the residents statements every 6 months. The last time I gave out statements was April 2025 and before that was October 2024. On 09/24/2025 at 4:25 PM, Staff A, Administrator, said the residents have not received quarterly statements and are not receiving them every month like he would prefer. Staff A said that was going…

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

Based on interview and record review, the facility failed to ensure the transfer of funds, from a resident personal fund account, was completed within 30 days following their discharge for 1 of 5 residents (Resident 111) reviewed for personal funds. This failure placed the residents and/or their representatives at risk for loss of funds and the interest accumulated.Findings included .A review of the list of personal fund accounts, listed Resident 111 with a balance of $2072.98On 09/24/2025 at 11:53 AM, Staff T, Revenue Cycle Manager, said Resident 111 had not been at the facility for over a year and Resident 111 still had money in their personal fund account. Staff T said he did not have access to Resident 111's account anymore and the previous company had not withdrawn the money.On 09/24/2025 at 4:25 PM, Staff A, Administrator, said Resident 111's account was not closed within 30 days of transfer and Staff A said he would call the previous company and have them take care of this now.Reference WAC 388-97-0340.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation and interview the facility failed to ensure painted ceiling surfaces was maintained in a homelike environment for 1 of 22 sampled residents (Resident 1) reviewed for homelike environment and sound levels were homelike in 1 of 1 hallway (room [ROOM NUMBER]- 77 Hallway) reviewed for exit door. These failures placed residents at risk for an environment that was not homelike and a decreased quality of life. Findings included.CEILING SURFACE:Resident 1 admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 09/12/2025, indicated Resident 1 was cognitively intact. On 09/22/2025 at 1:51 PM, Resident 1 pointed to an area on their ceiling that was missing paint. Observation of the area showed approximately 4 inches by 1.5 inches that was missing paint, and another adjacent area also missing paint. Resident 1 also pointed to two other areas that had plaster protruding from the ceiling, each the size of a 50-cent piece. Resident 1 said this was not the kind…

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 grievances were initiated, logged, addressed, and resolved in a timely manner to residents' complaints verbalized during Resident Council meeting for 3 of 3 months (July 2025, August 205 and September 2025) and for 3 of 3 sampled residents (Resident 33, 8 & 12) reviewed for grievances. The failure to initiate, log, investigate verbalized concerns, inform residents of their findings and actions taken, if any, prevented the facility from identifying care trends and determining if actions taken were effective in resolving the reported issues. These failures resulted in residents verbalizing the same complaints for multiple months without resolution, and placed residents at risk of feeling frustrated, unimportant, unheard, and a decreased quality of life.Findings included Review of the facility policy titled Grievances: Resident/Resident Representative no date, documented Responsibilities of Grievance Officer include:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored for side effects and target behaviors for 5 of 7 residents (Resident 105, 48, 1, 7, & 9) reviewed for unnecessary medication or behavioral/emotional. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life.Findings included Review of the facility's policy entitled, Psychotropic Medication Use, revised July 2022, documented: Residents receiving psychotropic medications are monitored for adverse consequences, including:1. anticholinergics effects - flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation;2. cardiovascular effects - irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interviews and record review, the facility failed to accurately code the Minimum Data Sets (MDS, an assessment tool) for 3 of 3 sampled residents (Resident 4, 3 & 2) reviewed for the communication restorative program. The failure to ensure all required components of a communication restorative program were met and were accurately coded placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 User's Manual (a guide used by facilities for accurately recording resident's health status and information), dated 10/2024, documented one restorative program that could be recorded on the MDS, was a communication program. Instructions from the RAI showed facilities could code, under the MDS communication program, activities provided to residents that were aimed at improving or maintaining their self-performance with functional communication skills (ability to convey…

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 baseline care plans were developed, implemented and given to the resident within 48 hours of admission for 3 of 3 sampled residents (Resident 107, 105 & 78) reviewed for new admission. This failure placed residents at risk for unidentified and/or unmet care needs, and other negative health outcomesFindings included .1) Resident 107 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) documented still in progress. The electronic health record (EHR) showed no baseline care plan had been created or was given to the resident. On 09/24/2025 at 2:48 PM, Resident 107 said they never received a baseline care plan 48 hours after admission. 2) Resident 105 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident was moderately cognitively impaired. The EHR showed the baseline care plan was initiated 09/22/2025, 8 days after Resident 105 was admitted . On 09/24/2025 at 3:28…

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 conferences (meetings with the interdisciplinary team and the resident and/or their representative to review and/or revise the care plan after each Minimum Data Set (MDS) assessments) occurred for 3 of 3 residents (Residents 4, 6, & 58) reviewed for care conferences, or to update resident care plans for 3 of 22 sampled residents (Residents 8, 12, & 1). This failure placed residents at risk of unidentified and unmet care needs, and a diminished quality of life. Findings included.Care Conferences: 1) Resident 4 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 06/23/2025, showed Resident 4 was cognitively intact. During an interview on 09/23/2025 at 7:47 AM, Resident 4, when asked if they have been included in quarterly care conferences where the facility reviewed their medication, therapy services, and general care, said they did not think the facility was doing them 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 initiate bowel protocol interventions for 4 of 8 residents (Resident 10, 78, 100 & 8) reviewed for constipation, to ensure blood glucose levels were appropriately monitored and intervened upon for 1 of 2 resident (Resident 67) reviewed for insulin, to provide documentation of events leading to hospitalization for 1 of 3 residents (Resident 12) reviewed for hospitalization, and to provide overall quality care for 1 of 22 sampled residents (Resident 2). These failures placed residents at risk of unmet care needs, constipation, hospitalizations and a diminished quality of life. Findings included .Bowel Protocol: Record review of the facility policy titled, Constipation, no date, defined constipation as three or more days of no bowel movement (BM). The policy documented the following interventions were to be implemented: Standard bowel care to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following:-…

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 maintain acceptable parameters for weight loss by ensuring proper implementation of interventions for 1 of 4 sampled residents (Resident 55) reviewed for nutrition. Additionally, the facility failed to maintain and ensure adequate fluid hydration and fluid restrictions were implemented for 4 of 4 sampled residents (Residents 107, 17, 12 and 4) reviewed for hydration. These failures placed residents at risk for continued weight loss, dehydration, fluid overload and a diminished quality of life.Findings included. MEALS MISSING DIETARY INTERVENTIONS1) Resident 55 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia and nutritional deficiency. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/29/2025, documented Resident 55 was severely cognitively impaired.On 09/24/2025 at 1:16 PM, Review of Resident 55's lunch ticket showed they were to have an enhanced diet (whole milk, extra butter,…

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 with mental health diagnoses were given appropriate treatment and/or services, for 2 of 2 sampled residents (Residents 12 & 1) reviewed for behavior and emotion, or for Resident Council (a group of residents in the facility that meets regularly to discuss care, activities, or concerns). This failure placed residents at risk of increased symptoms, emotional distress, and a diminished quality of life. Findings included.1) Resident 12 was admitted to the facility on [DATE] with diagnoses of depression, anxiety, and muscle weakness. Review of Resident 12's Quarterly Minimum Data Set (MDS) assessment, dated 06/29/2025, showed they were dependent on staff for cares. During an interview and observation on 09/23/2025 at 10:12 AM, Resident 12 alleged physical abuse by Staff AA, Certified Nursing Assistant (CNA). Resident 12 scrunched up their face, had tears in their eyes, and cried while talking about Staff AA. During this…

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 medications were necessary by providing residents with non-pharmacological interventions (NPIs, non-medication interventions) for pain management, documenting side effect monitors, and/or to reassess the necessity of medication on admission for 5 of 7 residents (Resident 2, 105, 1, 7, & 8) reviewed for unnecessary medication and pain. This failure placed residents at risk of unmet care needs, unnecessary medication, increased pain, and a diminished quality of life. Findings included .1) Resident 2 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 07/13/2025, documented Resident was severely cognitively impaired and required maximum assistance with cares. Review of a physician's order for Resident 2, dated 08/19/2025, showed an order for oxycodone (an opioid), at 5 milligrams (mg) once every 6 hours as needed for moderate to severe pain, with pain scale of 6-10 out of 10. Review of…

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

Based on observation, interview and record review, the facility failed to provide appetizing and palatable food when reviewed for kitchen services. This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served, a potential for less than adequate nutritional intake and weight loss.Findings included .Observation of the test/sample lunch tray on 09/24/2025 at 12:46 PM, showed a chicken patty, potato wedges, carrots, and coleslaw. The chicken patty was sampled and found to be difficult to chew and lacked palatability. In an interview on 09/24/2025 at 1:12 PM, Staff FF, Certified Nursing Assistant, said the chicken patty served for lunch was dry and difficult for residents to chew. On 09/24/2025 at 2:58 PM, Resident 107 was sitting in their wheelchair with the bedside table in front of them. When asked how lunch was, Resident 107 stated, the salmon was dry (lunch meal was chicken patty). Resident 107 said there was some sort of sauce (did not know what kind of sauce it was) but they had to pour it on the salmon to get the salmon burger 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, record review, and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 1 walk-in kitchen refrigerators. This failure placed residents at risk for food borne illness, and a diminished quality of life.Findings included .Record review of the facility policy, titled, Food Receiving and storage, revision date November 2022, documented, Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded.During an observation on 09/22/2025 at 10:14 AM, the walk-in kitchen refrigerator, was observed with the following expired, opened items: 1. Plastic Tupperware container of Coleslaw- labeled with a use by date of 07/10/20252. Plastic Tupperware container of Chicken Salad- labeled with a use by date of 09/18/20253. Plastic container of Thousand Islands Dressing - labeled with an open date of 06/17/20254. Plastic Ziplock bag containing several hot dogs- labeled with a use by date of 09/06/2025In an interview on 09/22/2025 at 10:26 AM, Staff GG, Dietary Manager, said the items placed…

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 Occupational Therapy (treatment that evaluates and treats people who have injuries, illnesses, or disabilities to help them live as self-sufficiently as possible by developing, recovering, or maintaining skills needed for everyday activities of life) for 2 of 3 (Resident 112 and 69) residents reviewed for therapy services. This failure placed residents at risk of decreased physical function, delay in returning home, and decreased quality of life.Findings included .RESIDENT 112Resident 112 was admitted on [DATE] with fractures from a motor vehicle accident. Resident 112's physician order, dated 08/26/2025, showed an order for OT [occupational therapy] evaluation and treat. Resident 112's medical provider admit visit, dated 08/27/2025, showed the assessment/plan was for OT eval and treat.On 11/05/2025 at 2:20 PM, Staff QQ, Occupational Therapist, said they had completed Resident 112's evaluation on 09/18/2025. When asked why Resident 112's…

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

Based on interview and record review, the facility failed to provide accurate and complete access to all resident records for 1 of 1 annual recertification survey. These failures had the potential risk of causing a delay in the survey process, not addressing resident concerns and a diminished quality of life. Findings included .On 09/22/2025 at 9:50 AM, the survey team entered Bremerton Trails Post Acute. The survey teams' business cards were provided to Staff B, Director of Nursing Services, for access to Point Click Care (PCC, the electronic health care (EHR) system used for record maintenance). On 09/22/2025 at 10:09 AM, during the Entrance Conference with Staff A, Administrator, and Staff B, Director of Nursing Services (DNS), they were reminded that surveyors needed access to all medical records within required timeframe. The Grievance log was also requested at this time. On 09/22/2025 at 11:33 AM, the Grievance log was provided with the last date of entry documented as 09/08/2025. On 09/22/2025 at 2:17 PM, PCC access was provided to surveyors.On 09/23/2025 at 8:37 AM, Staff A…

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

Based on observation, interview and record review, the facility failed to ensure infection control practices met professional standards regarding their Water Management Program, the laundry room, obtaining consent for vaccination for 4 of 5 residents (Residents 9, 1, 7, & 10) reviewed for vaccinations, and ensuring enhanced barrier precautions were followed for 1 of 3 observations (Resident 3) for transmission based precautions. These failures placed residents at risk of transmittable diseases, lack of informed consent, and a diminished quality of life. Findings included. Water Management Program: Review of the Centers for Disease Control and Prevention (CDC) toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 06/24/2021, documented its purpose was to help buildings develop and implement a water management program to reduce the spread of Legionella (a bacteria that lives in water and can make people sick when contaminated water is inhaled). The toolkit provided a list of where Legionella can grow in the building water…

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 antibiotic stewardship practices met professional standards for 3 of 3 months (Months June 2025, July 2025, and August 2025) reviewed for antibiotic line list (an infection control surveillance list that tracks and reviews antibiotics). This failure placed residents at unnecessary antibiotic usage, risk of developing Multi-Drug Resistant Organisms, and a diminished quality of life.Findings included.Review of a document titled Surveillance Criteria, dated 07/07/2022, showed the facility was using Loeb criteria to initiate antibiotic usage, as the minimum set of signs or symptoms that a resident likely had an infection and antibiotics were likely indicated, without confirmation of diagnostic testing. The facility was also using McGeer criteria, for definitive infection criteria, using diagnostic information. During an interview on 09/25/2025 at 12:30 PM, Staff F, Infection Preventionist/ Assistant Director of Nursing/Licensed Practical Nurse, said the point of antibiotic stewardship was to prevent unnecessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation and interview, the facility failed to ensure the kitchen's walk-in freezer was in good working condition in 1 of 1 facility kitchen. This failure placed residents at risk of food-borne illness, and a diminished quality of life.Findings included On 09/22/2025 at 10:05 AM, the kitchen's walk-in freezer door was observed to have ice and frost build up at the bottom right corner, preventing the door from closing completely. The opening measured approximately one inch. On 09/23/2025 at 10:05 AM, the kitchen walk-in freezer was observed to have the same ice buildup, and door was not shut completely. In an interview on 09/22/2025 at 10:32 AM, Staff GG, Dietary Manager, said the freezer door had been has been like this forever. Staff GG stated, the door has been broken ever since I started working here- about three months ago. Staff GG said as a result of the freezer door not shutting, the kitchen was responsible for maintaining proper temperatures in the freezer and refrigerator, completing 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 report an allegation of abuse within the required timeframe(s) for 2 of 5 residents (Residents 3 & 12) reviewed for abuse/neglect investigations. This failure placed residents at risk of abuse, fear and a decreased quality of life. Findings included .Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, documented the facility was to report all alleged violations immediately but no later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in seriously bodily injury. If the events that caused the allegation were not involving abuse, or if the reported events did not result in serious bodily injury, this could be reported in twenty-four hours to the Executive Director and to others. Resident 3 Resident 3 was admitted on [DATE] 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 interview and record review, the facility failed to ensure abuse or neglect investigations were thorough and complete for 2 of 2 residents (Residents 12 & 3) reviewed for abuse or neglect. This failure placed residents at risk of potential continuation of abuse or neglect, unidentified care needs, and a diminished quality of life. Findings included.1) Resident 12 was admitted to the facility on [DATE] with diagnoses of depression, anxiety, and muscle weakness. Review of Resident 12's Quarterly Minimum Data Set (MDS) assessment, dated 06/29/2025, showed they were dependent on staff for cares. During an interview on 09/23/2025 at 10:12 AM, Resident 12 alleged physical abuse by Staff AA, Certified Nursing Assistant (CNA). Resident 12 said Staff EE, CNA, was a witness to the incident with Staff AA, which happened in the bathroom last Saturday and involved Staff AA allegedly twisting their right nipple and laughing afterwards. Resident 12 said they screamed, Get away! During this interview, Resident 12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to ensure services provided met professional standards of practice by ensuring residents were provided scheduled medication, were updated promptly of medication unavailability, and/or were observed during medication administration, for 2 of 22 sampled residents (Residents 3 & 8) reviewed for professional standards, and to appropriately label multiuse medications for 1 of 3 medication carts (Olympic 2 cart) reviewed for medication storage observation. This failure placed residents at risk for medication complications, for receiving expired medication, and a diminished quality of life. Findings included.1) Resident 3 was admitted to the facility on [DATE], with diagnoses of hypertension (a condition where the force of blood against the artery walls is consistently too high) and heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's demands). The Quarterly Minimum Data Set (MDS, an assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) including bathing and meal preparation assistance for 3 of 6 sampled residents (Resident 107, 12 & 55) reviewed for ADLs and choices. The failure to provide assistance with bathing and meal set up for residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, diminished self-image, weight loss and a decreased quality of life.Findings included .1) Resident 107 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), documented still in progress. On 09/23/2025 at 9:57 AM, Resident 107 said they had not received a shower since being admitted to the facility and they wanted their fingernails clipped. The electronic health record (EHR) documented Resident 107 was given a shower on 09/20/2025 at 7:52 AM and 09/22/2025 at 12:32 AM and 6:29 PM. On 09/24/2025 at 2:58 PM,…

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 resident centered activities that incorporated the resident's preferences for 1 of 1 sample residents (Resident 78) reviewed for activities. This failure placed residents at risk for a diminished quality of life.Findings included .Resident 78 was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease (Progressive neurodegenerative disorder that affects movement, balance, and coordination). The Admission/ 5-Day Minimum Data Set, an assessment tool, dated 09/08/2025, documented Resident 78 was severely cognitively impaired. Review of Resident 78's Activities Preferences, dated 09/09/2025, showed Resident 78 enjoyed social visits, conversations, news, gardening, outdoor activities, and other activities of interest.Review of Resident 78's care plan, revised date 09/10/2025, documented the following interventions: Invite resident to social activities to do things with groups of people in a social setting.Offer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively assess the use of bedrails/side rails for 1 of 1 residents (Resident 67) reviewed for side rails. This failure placed residents at risk of accident hazards, unmet care needs, and a diminished quality of life. Findings included .The facility's policy entitled, Bed Safety and Bed Rails, Revised 2022, documented: The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Resident 67 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 06/30/2025, documented the resident was alert and oriented.Review of the Physician's order, dated 12/06/2024, documented Resident 67 was to have Bilateral bed mobility bars to assist with bed mobility.Review of 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.

Based on interview and record review, the facility failed to show evidence the Quality Assurance and Performance Improvement program plan (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice) was reviewed and updated with the current leadership. The facility failed to provide evidence that the committee staff and medical director participated in the QAPI program meetings. This failure placed residents at risk for adverse events and/or decreased quality of care and quality of life.Findings included .Record review of the document titled, QAPI Plan, listed annual review on 12/01/2022 and 12/01/2023. The document also listed QAPI committee members, and the name of the administrator listed was not the name of the current administrator.On 11/18/2025 at 1:39 PM, Staff A, Administrator, said, I do not have a new QAPI plan. Staff A stated, I was not here in 2023, that is old stuff.Review of the QAPI Meeting Minutes on 11/18/2025 at 2:13 PM, did not record the staff who were present 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 reviews, the facility failed to provide competent and sufficient staff to complete resident showers and personal care according to their plan of care for 5 of 11 residents (Resident 1, 2, 3, 4 and 5) reviewed for sufficient staffing. This failure placed residents at risk of poor hygiene, loss of dignity, frustration and a decreased quality of life Findings included.RESIDENT 1Resident 1 was admitted on [DATE]. The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 1 was cognitively intact.Resident 1's Activity of Daily Living Care Plan (ADL), dated 03/24/2025, showed Resident 1 required assistance with dressing, personal hygiene, transfers and required extensive assistance with bed mobility. The care plan showed Resident 1 was incontinent of bowel and bladder and staff were to check the resident every two hours and assist with toileting as needed.On 08/24/2025 at 10:46 AM, Resident 1's call light was observed on.On 08/24/2025 at 10:47 AM, Staff A, Certified…

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 administer medications per physician orders and guidelines for 4 of 5 residents (Resident 1, 2, 3 and 4) reviewed for medications. This failure placed residents at risk of clinical complications, unintended medication side effects, and infection. Findings included . Review of the facility's undated policy titled, Flexible Medication Pass Policy, showed AM medications to be administered between 6 AM and 10 AM, Midday medications to be administered between 10 AM and 2 PM and PM medications to be administered between 4 PM and 8 PM. The policy said that medications ordered TID [three times a day] shall be given every AM, Midday, and PM unless otherwise indicated by the nature of the medications. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnosis of medically complex conditions. The Minimum Data Set Assessment (MDS), an assessment tool, dated 01/23/2025, showed the resident was cognitively intact and required…

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

Based on interview, observation and record review, the facility failed to ensure staff maintained infection control practices by cleaning blood glucose monitors (a device that measures the amount of glucose in your blood) between residents, performing hand hygiene before and after resident care, and maintaining separation between clean and dirty tasks for 1 of 3 (Staff A) staff observed. This failure placed residents at risk of contagious disease, infection and clinical complications. Findings included . Review of the Center for Disease Control and Prevention (CDC) web page titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 08/07/2024, showed if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. Review of the CDC web page titled, Clinical Safety Hand Hygiene for Healthcare Workers, dated 02/27/2024, showed health care workers should clean their hands immediately before touching a patient, after touching a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure discharge planning included notification of necessary outside services for 1 of 3 sampled residents (Resident 8) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, re-hospitalization, and a decreased quality of life. Findings included . Resident 8 was admitted to the facility on [DATE] with diagnoses to include dementia, diabetes, and end stage kidney failure requiring dialysis (treatment that filters excess fluids and toxins from the blood). The admission Minimum Data Set, an assessment tool, dated 02/03/2025, showed Resident 8 was moderately cognitively impaired and needed one person assistance with most activities of daily living. Review of the Notice of Medicare Non-Coverage, dated 02/13/2025 and a progress note, dated 02/17/2025, showed Resident 8 was discharged from the facility to home on [DATE]. The progress note said several attempts were made to contact the son, whom Resident 8 lived 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 residents' mobility needs were addressed to access the community for 1 of 1 sampled resident (Resident 1) reviewed for accommodation of needs. This failure placed residents at risk of diminished independent functioning, socialization and mood disturbance. Findings included . Resident 1 was admitted on [DATE] with diagnoses including medically complex conditions and mood disorders. The Minimum Data Set, an assessment tool, dated 01/23/2025, showed Resident 1 was cognitively intact, had functional limitations with range of motion in their upper and lower extremities and utilized a power wheelchair for mobility. On 02/20/2025 at 10:18 AM, Resident 1 said they had made a mistake when they were threatened with physical harm by another resident, they became defensive and used their power wheelchair to run into the other resident. Resident 1 expressed remorse and said they knew it was wrong, but the facility had removed their power…

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 services provided met professional standard of practice when medications were discontinued without authorization from a medical provider, and physician's orders were not followed for 3 of 4 residents (Resident 1, 2, and 3). This failure placed residents at risk for medical complications, infection and discomfort. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE] with diagnoses including medically complex conditions and heart disease. Resident 1's provider orders for Nursing Home Transfer, dated 11/1/2024, showed the resident was transferred from the hospital to the facility with medication orders on the 'After Visit Summary Medication List.' Resident 1's 'After Visit Summary,' dated 11/01/2024, showed the resident had multiple medications to be administered every morning. Resident 1's progress notes, dated 11/01/2024 at 7:27 PM, showed the resident was re-admitted to the facility and the orders were noted 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, observation and record review, the facility failed to ensure infection control standards were followed related to the use of required personal protective equipment with residents on enhanced barrier precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions with residents in nursing homes) and hand hygiene during wound care for 1 of 3 residents (Resident 4) reviewed for wound care. This failure placed residents at risk of contracting and spreading infections. Findings included . Review of the facility's policy titled, Enhanced Barrier Precautions, revised 04/2024, showed EBP were to be used for residents with wounds. The policy showed that gowns and gloves were required when staff completed wound care. Review of the facility's policy titled, Dressings, Dry/Clean, revised 09/2013, showed that gloves were to be discarded after removal of a wound dressing and hand hygiene performed prior to donning clean gloves and applying a new…

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 3 of 6 staff members (Staff A, B, and C) used personal protective equipment in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading the illness. Findings included . A 03/18/2024 CDC update titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, showed when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. When leaving the room, all Personal Protective Equipment (PPE) including the N95 respirator should be removed. Review of Resident 1's progress note, dated 09/25/2024, showed Resident 1 tested…

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 an effective pest control program was maintained to keep the facility free of flies on 4 of 4 resident care units (Cove, Bayshore, Mt. View and Olympic) and prevent flies from laying eggs on 1 of 3 residents (Resident 1) reviewed for pest control. This failure placed the residents at risk of infection, maggot infestation, distress and decreased quality of life. Findings included . Review of the facility's undated policy titled, Insects/Pests: Resident Safety, showed that the center strives to protect the residents from insects and other pests and it is the responsibility of all staff members to detect and report immediately the presence of pests to the Executive Director and Director of Nursing and in the event that insects and/or pests are noted in a resident room immediate steps will be taken to prevent or decrease the risk for actual or potential harm. Review of the Journal of the American College of Clinical Wound Specialists,…

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 sufficient licensed nurses were available to administer medications timely for 3 of 4 residents (Resident 1, 2 and 3) reviewed for sufficient staffing. This failure placed residents at risk for clinical complications, frustration and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 08/02/2024, showed the resident was cognitively intact. On 08/06/2024 at 12:58 PM, Resident 1 said they had not received their medications on time. Resident 1 said for a long time they had been receiving them at 6:00 PM but lately it kept changing to different times, was inconsistent, and they had to wait a long time to receive medication needed for pain. Resident 1's Medication Administration Audit Report, dated 07/20/2024 through 08/20/2024, showed the following documentation: 07/20/2024 medications scheduled for the morning at 8:00 AM were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure resident rooms were clean and maintained for 5 of 5 sampled rooms (room [ROOM NUMBER], 13, 64, 16, and 21) reviewed for environment. This failure placed residents at risk for unsanitary living conditions, compromised dignity, and dissatisfaction with their living environment. Findings included . On 07/11/2024 at 2:45 PM, a Collateral Contact (CC 1) said when they arrived at the facility for a visit with their family member who had been recently admitted to room [ROOM NUMBER], they found the room unsanitary. CC 1 said a red liquid was splattered on the walls, the fan blowing on the resident was filled with dust, the baseboard heater appeared to have never been cleaned, the guest chair was horrifically stained and there was dirt and grime in the corners of the room. CC 1 said they ended up cleaning the room and the fan themselves. <room [ROOM NUMBER]> An observation of room [ROOM NUMBER], on 07/17/2024 at 10:55 AM, showed the room door with a…

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

Based on observation, interview and record review, the facility failed to ensure the survey results book included the results for 9 of 10 abbreviated (complaint) surveys that resulted in citations since the facility's previous recertification (annual) survey. These failures prevented residents, family members and visitors from exercising their right to review past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility. Findings included . On 07/09/2024 at 11:01 AM, the facility's survey results binder was observed in a wall mounted receptacle, across from the reception desk in the front lobby. Review of the survey binder showed it did not contain 9 of 10 complaint surveys that resulted in citations, since the facility's previous annual survey, conducted on 09/08/2023. The missing surveys results, and associated plans of corrections were for the following survey dates: 09/27/2023; 11/17/2023; 12/06/2023; 12/14/2023; 01/04/2024; 01/25/2024; 04/05/2024; 04/09/2024; and 05/07/2024. On 07/09/2024 at 11:39 AM, Staff B, 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.

Based on interview and record review, the facility failed to report to State Agency (SA) and investigate allegations of abuse for 2 of 4 sampled residents (Residents 20 & 60) reviewed for abuse. This failure placed residents at risk for further abuse violations and lack of protection. Findings included . Record review of the facility's policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property; undated, showed the facility was to ensure all alleged violations were reported immediately, but no later than two hours after the allegation was made, if the events that cause the allegation involve abuse or results in serious bodily injury, or no later that 24 hours if the events that cause the allegation do not involve abuse or did not result in serious bodily injury, to the Administrator and others. The policy showed the facility needed to ensure the immediate safety of the resident upon, suspend the identified employee immediately and pending outcome of investigation. <Resident 60> Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop and implement a discharge planning process that ensured required medical equipment was ordered, available at the time discharge, and documented in residents' discharge plans for 3 of 4 residents (Residents 144, 145 and 146) reviewed for discharge planning. These failures placed residents at risk for accidents, injuries, rehospitalization, and diminished quality of life. Findings included . Review of the facility's Resident's Discharge policy, revised 05/18/2023, showed the facility would complete a discharge summary for each resident before discharge which would include: A recapitulation of the resident's stay; a final summary of the resident's status, including the most recent nursing assessment; and a post-discharge plan of care which would assist the resident to adjust to his/her new living environment. Social services would assist with the development and coordination of services required to affect the resident's discharge. In the case 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 <Edema Monitoring/Management> <Resident 87> Resident 87 admitted to the facility on [DATE]. Review of the 06/12/2024 admission MDS, showed the resident had diagnoses including heart failure and required diuretic (medication that draws fluid from the body through urine) therapy. An edema care plan (CP), initiated 07/10/2024, directed staff to monitor, document and report to the provider any signs and symptoms of skin problems related to edema: redness, edema, blistering, itching, burning, bruises, cuts, other skin lesions. Resident 87 had 06/05/2024 orders for: a) Furosemide (a diuretic) daily, with direction to hold medication for a systolic blood pressure of less than 100. b) A 07/03/2034 order to monitor edema to bilateral lower extremities (BLE) every morning using edema scale: 1+ / slight indent disappears rapidly. 2+ / indent disappears in 10-15 seconds. 3+ / deep indent, disappears in 1-2 min. 4+ / deep indent, visible after 5 min. Notify provider if change in edema is noted. Review of the July 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 3 residents (Residents 37 and 48) reviewed for respiratory care. The facility failure to ensure residents receiving oxygen (O2) services had active orders for O2, an indication for use, O2 concentrator filters (used to protect the resident from inhaling dust and particulate matter) were routinely cleaned and maintained, and/or was administered by the ordered delivery method and documented on residents' administration records. Additionally, the facility failed to ensure bilevel positive airway pressure orders (BiPAP, a form of non-invasive ventilation therapy used to facilitate breathing) included instruction on when to check, and what solution should be used to fill the BiPAP humidifier chambers. These failures placed residents at risk for unidentified and/or unnecessary oxygen use, respiratory compromise,…

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 drugs and biologicals were labeled and dated when opened in accordance with accepted professional standards of practice, and expired medications were discarded for 3 of 3 medication carts (Olympic, Cove 1 and Cove 2) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes. Findings included . <Cove 2 Medication Cart> Observation of the Cove 2 medication cart on 07/12/2024 at 5:55 AM with Staff O, Registered Nurse (RN), revealed the following expired and/or undated medications: 1) A Lantus insulin pen for Resident 61, opened 05/28/2024. 2) A lispro insulin pen for Resident 61, was opened and undated. 3) A lispro insulin pen for Resident 27, was opened and undated. 4) A vial of lispro insulin for Resident 85, opened 05/30/2024. 5) A humolog insulin pen for Resident 6, opened 06/08/2024. 6) A lispro insulin pen for Resident 151, opened 06/04/2024. 7) A basaglar insulin pen for Resident 151, opened 06/04/2024. 8) A bottle of Vitamin E 180 mg with a best 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.

Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened, in 1 of 2 Nourishment Refrigerators/Freezers (Bayshore Dining Room). This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life. Findings included . <Nourishment Refrigerator> On 07/09/2024 at 10:38 AM, the Bayshore Dining Room Nourishment Refrigerator/Freezer was observed with the following undated, unlabeled, and opened items: 1. Tyson chicken tender bag 2. Foster Farm popcorn chicken bag 3. 4 ounce glass bottle of horseradish 4. 24 ounce glass bottle of salsa 5. 64 ounce plastic bottle of salsa 6. 24 ounce plastic bottle of Peppermint Califa creamer-with manufacturer expiration date of 04/02/2024 7. Plastic Tupperware container with beef and rice, labeled 05/27/2024 8. Slices of American cheese in the bottom drawer On 07/09/2024 at 10:54 AM, Staff Z, Dietary Manager, said kitchen aids were to temp the nourishment fridges, check dates, and without a date or expired should be thrown out. Staff Z stated, they 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.

Based on interviews, the facility failed to employ a qualified social worker (defined as an individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience in a health care setting working directly with individuals) on a full-time basis. This failure placed residents at risk for unmet psychosocial needs and a diminished quality of life. Findings included . On 07/09/2024 at 11:57 AM, when asked if they had a bachelor's degree, both Staff Q, Social Services Director, and Staff X, Social Services Assistant, stated, No. Refer to: F644 Coordination of PASRR and Assessments F758 Free from Unnecessary Psychotropic Medications Reference WAC 388-97-0960 (2)(a)(b) .

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QA&A activities. This failure detracted from the effectiveness of the QA&A committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life. Findings included . On 07/13/2024 at 1:09 PM, Staff A, Administrator, said the facility QA&A committee met monthly and the included the Director of Nursing, Administrator, Social Work, Resident Care Managers, Registered Dietician, all department heads and the Medical Director. When asked for a copy of the sign in sheets/attendance sheets to show the Medical Director had attended the meeting at least once in the past two quarters, Staff A, who had just recently started at the facility, indicated they did not know where they were located and would have to find them and then email them after exit. An email was received 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 inform the resident and/or their legal representative, in advance, of the risks and benefits associated with the use of antipsychotic medications (medications capable of affecting the mind, emotions, and behavior) and obtain informed consent prior to administering the medication(s) for 1 of 5 residents (Resident 87) reviewed for unnecessary medications. These failures precluded residents and/or legal representatives from making informed decisions regarding proposed psychotropic medication and prevented them from exercising their right to refuse/decline the proposed medication. Findings included . Resident 87 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 06/12/2024, showed the resident had severe cognitive impairment, no mental health diagnoses and received no psychotropic medications. Review of the electronic health record showed Resident 87 had a 06/18/2024 order to start risperidone…

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 grievances were initiated, logged, investigated, and or promptly resolved/responded to for 6 of 12 residents (Residents 10, 29, 33, 37, 46, and 54) reviewed for Resident Council and grievances. This failure placed residents at risk for feelings of frustration, powerlessness, and decreased quality of life. Findings included . <Resident 33> Resident Council meeting minutes, dated 02/29/2024, showed Resident 33 had stated there were not enough linens. The February grievance log showed no entry for Resident 33. On 07/13/2024 at 10:48 AM, when asked if anyone had responded to the grievance regarding the lack of linens, Resident 33 said, no, I didn't hear back about it. <Resident 10> Grievance log, dated 06/06/2024, showed an entry regarding Resident 10 losing two items. On 07/08/2024 at 3:03 PM, when asked if the facility responded to resident concerns, or if the Grievance Official provided a rationale for the response, Resident 10 said, I filed a grievance because staff called me a liar and I never heard back. 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 Pre-admission Screening and Resident Review (PASRR) Level II evaluations were referred and or completed timely for 2 of 6 residents (37, 9) reviewed for PASRRs. This failure placed residents at risk for inappropriate placement, and not receiving timely and necessary mental health services. Review of 42 CFR 483.106(b)(2)(ii) showed an individual who entered a nursing facility (NF) as an exception (an exempted hospital discharge), but later was found to require more than 30 days of NF care, the facility must refer the resident for a Level II PASRR evaluation, and the State mental health or intellectual disability authority must conduct the evaluation within 40 calendar days of admission. Findings included . <Resident 37> Resident 37 admitted to the facility on [DATE]. Review of the 06/03/2024 admission Minimum Data Set (MDS, an assessment tool) showed the resident was cognitively intact, had a diagnosis of depressive disorder and required 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 resident care plans were reviewed, revised, and accurately reflected resident care needs for 4 of 31 sampled residents (Residents 37, 87, 27 and 48) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life. Findings included . <Resident 37> Resident 37 re-admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 06/08/2024, showed the resident was cognitively intact, had obvious or likely cavities and/or broken natural teeth, received supplemental oxygen and required the use of a bilevel positive airway pressure (BiPAP a device that helps with breathing by providing non-invasive mechanical ventilation.) Review of the 06/10/2024 dental care area assessment (CAA) showed, Resident 37's obvious/likely cavities and broken natural teeth would be addressed in their comprehensive care plan (CP). Review of Resident 37's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 31 sampled residents (Residents 87, 37, 13, and 27) reviewed for medication management. The failure to follow, obtain, and/or clarify incomplete physicians' orders when indicated, to sign for medication(s) that were administered, to document the reason and notify the provider when medications were held, placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs. Findings included . <Resident 87> Resident 87 admitted to the facility on [DATE] with an order for oxycodone (pain medication) every six hours as needed for moderate to severe pain of 4-10 on a scale of 1 to 10. The July 2024 Medication Administration Record (MAR) showed facility staff administered the oxycodone outside of the physician ordered parameters on the following occasions: 07/07/2024 at 9:14 PM for a pain level of 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.

Based on observation and interview facility failed to provide assistance with Activities of Daily Living (ADL), related to grooming for 1 of 4 sampled residents (Resident 20). This failure placed residents at risk for, matted hair, feeling unclean, and diminished quality of life. Findings included . Resident 20 was admitted to facility 03/12/2021. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 05/10/2024, indicated Resident 20 was moderately cognitively impaired, impaired on one side of both upper and lower extremities, and required partial/moderate assistance with personal hygiene, which included combing hair. On 07/08/2024 at 10:54 AM, Resident 20 said their hair was in a solid matt in the back. Observation showed hair behind their head to be tangled and stuck together in clumps. Resident 20 said, it really bothers me to have clumps in the back of my head. It makes me feel less than. On 07/11/2024 at 2:44 PM, Resident 20 said they had told the Certified Nursing Assistant's (CNA) about 200 times about the matting issue every time they had their hair washed.…

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 Podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 1 resident (Resident 27) reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life. Findings included . The Personal Needs Policy, dated 12/20/2024, showed, facility must provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Resident 27 admitted to the facility on [DATE] with diagnosis including hemiplegia (paralysis) and hemiparesis (weakness) to the right side of the body due to stroke (damage to the brain due to loss of blood flow), diabetes, and ulcer to the left heel. The admission Minimum Data Set,…

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 timely identify, assess, develop and implement nutritional interventions, and evaluate the effectiveness of the interventions for 1 of 4 residents with weightloss (Resident 87) reviewed for nutrition. 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 for 1 of 1 resident (Resident 37) reviewed with a fluid restriction. These failures placed residents at risk for continued weight loss, inadequate nutrition, fluid volume overload, fluid and electrolyte imbalances and other medical complications. Findings included . <Weight Loss> Resident 87 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an Assessment tool), dated 06/12/2024, showed the resident had no swallowing issues or significant weight loss. A potential nutritional risk care plan, revised 06/21/2024, with a goal of no significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to comprehensively assess the use of bedrails/side rails and obtain accurate and complete informed consent from the resident for the use of side rails for 1 of 5 residents (Resident 27) reviewed for accidents. This failure placed the resident at risk for lack of informed care and decreased quality of life. Findings included . The Safety Device policy, dated 09/2022, showed, the center requires the use of the Safety Device Data Collection, Assessment, and Information evaluation when mobility bars or bed rails were in place. Resident 27 admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) to the right side of the body due to stroke (damage to the brain due to loss of blood flow), and open wound of right back wall. The admission Minimum Data Set, an assessment tool, dated 05/19/2024, indicated the resident was bed bound, needed extensive assistance for Activities of Daily Living and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to develop a dementia care plan that addressed the physical, mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 2 residents (Resident 87) reviewed for dementia care. These failures placed residents at risk for unmet physical and psychosocial needs, increased behaviors and decreased quality of life. Findings included . Resident 87 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 06/12/2024, showed the resident had severe cognitive impairment, a diagnosis of non-Alzheimer's dementia, displayed signs of delirium to include continuous inattention, but demonstrated no behaviors or rejection of care, and received no psychotropic medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) showed the resident had a diagnosis of non-Alzheimer's dementia, which affected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure 1 of 5 residents (Residents 87) reviewed for unnecessary medications, was free from unnecessary psychotropic drug use. The failure to have an adequate indication for use, approved diagnosis, and to identify individualized Target Behaviors (TBs) the medication was implemented to treat, placed residents at risk to receive unnecessary medications and/or experience adverse side effects Findings included . Resident 87 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 06/12/2024, showed the resident had severe cognitive impairment, a diagnosis of non-Alzheimer's dementia, displayed signs of delirium to include continuous inattention, but demonstrated no behaviors or rejection of care, and received no psychotropic medications. On 07/07/2024 at 2:21 PM, Resident 87's daughter and son in law were present at bedside. They reported Resident 87 was in a locked memory care unit prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with their Activities of Daily Living (ADLs) received assistance to eat their meals in the dining room for 2 of 3 sampled residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for lack of stimulation, decreased meal intake and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE] with diagnoses including dementia, depression, and a nutritional deficiency. The Minimum Data Set (MDS), an assessment tool, dated 05/29/2024, showed Resident 1 had severe cognitive impairment and was dependent on staff for transfers and mobility in a wheelchair. Resident 1's activity care plan, dated 12/22/2020, showed Resident 1 was dependent on staff for activities, cognitive stimulation, and social interaction. The care plan showed the resident spent much of their time sitting in the dining room, where…

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 prevent the development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) when they failed to consistently complete pressure ulcer care for 1 of 3 sampled residents (Resident 2) reviewed for pressure ulcers. Resident 2 experienced harm when they developed an unstageable pressure ulcer (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) to their right buttock that required debridement (a medical procedure that removes dead, damaged, or infected tissue from a wound). These failures placed residents at risk for infection, medical complications and a diminished quality of life. Findings included . According to the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Manual, dated October 2023, pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In addition, external factors, such as excess moisture and tissue…

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, facility staff failed to follow accepted infection control practices during the provision of wound care for 1 of 3 residents (Residents 2) reviewed for wound care. This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/2022, showed staff should wear gloves when they come in contact with non-intact (open) skin and perform hand hygiene immediately after glove removal and before moving from work on a soiled body site to a clean body site on the same person. Resident 2 was admitted on [DATE] with diagnoses of dementia and muscle weakness. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/14/2024, showed the resident had an unstageable pressure injury (a pressure injury that is a full thickness skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on the observation, interview and record review, the staff failed to perform hand hygiene and change gloves when providing pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) care for 3 of 3 sampled residents (Resident 2, 3 and 4) reviewed for pressure ulcers. This failure placed residents at risk of infection and medical complications. Findings included . Review of the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/2022, showed staff should wear gloves when they come in contact with non-intact (open) skin and perform hand hygiene immediately after glove removal and before moving from work on a soiled body site to a clean body site on the same patient. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE]. The Minimum Data Set (MDS)assessment, dated 03/10/2024, showed Resident 2 was cognitively intact and had a stage 4 pressure ulcer (pressure ulcer that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to recognize a clinical change of condition from the resident's baseline for 1 of 1 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for unmet care needs, poor decision making and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses of medically complex conditions and mental health disorders. Resident 1's Minimum Data Set assessment, dated 01/12/2024, showed the resident was cognitively intact and had no signs of delirium (a mental disturbance characterized by new or acutely worsening confusion) present. Resident 1's MDS, dated [DATE], showed the resident was assessed for signs and symptoms of delirium and had no acute mental status changes and/or signs and symptoms of delirium present. Resident 1's provider note, dated 04/04/2024, showed Resident 1 was sent to the emergency room for a reported seizure and suspected stroke. Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to immediately notify the resident's emergency contact when 1 of 4 sampled residents (Resident 1) experienced a significant change of condition. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, providing support, delayed medical treatment, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Physician Notification of Resident Change in Condition, showed their procedure was for facility staff to notify the resident representative immediately, if there was a significant change in condition, regardless of the time. Resident 1 was admitted on [DATE] with diagnoses including cancer and respiratory disease. Resident 1's progress note, dated 01/28/2024, showed the resident was observed to be very sweaty, with rapid eye movements, shaking, had labored breathing, was not responding to verbal commands, and was transported to the emergency…

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 implement speech therapy's recommendations for safe oral intake for 1 of 1 sampled residents (Resident 2) reviewed for accidents. This failure placed residents at risk of medical complications, choking and diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia. The annual Minimum Data Set, an assessment tool, dated 12/29/2023, showed the resident was severely cognitively impaired, had no natural teeth and required setup assistance for eating. Resident 2's Speech Therapy discharge recommendations, dated 07/26/2023, showed to facilitate safe and efficient swallowing, it was recommended Resident 2 used the following strategies during oral intake: alternation of liquid/solids, bolus size modifications (alternating food consistency) and rate modification. On 03/07/2024 at 2:23 PM, Staff D, Unit Manager, said when therapy staff made recommendations for a resident, a communication…

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 provided care by outside healthcare providers in a timely manner for 1 of 3 (Resident 1) residents reviewed for outside resources. This failure placed residents at risk of unmet care needs and services. Findings included . Resident 1 was admitted on [DATE] with diagnoses including cancer and mental illness. On 03/06/2024 at 11:00 AM, Collateral Contact 1 (CC1), said the facility had failed to make follow up appointments and/or assisted with transportation for Resident 1 to the cancer center. CC1 said the facility had told them they did not have transportation to out of town appointments. Resident 1's medical provider notes, dated 07/03/2023, showed Resident 1 was followed by the cancer center for a cancer diagnosis and had decided in June of 2022 to not resume treatment but to continue interval surveillance of the cancer. The note further showed the resident had an appointment on 07/11/23 to discuss the cancer. Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation and record review, the facility failed to implement their infection control program during an influenza outbreak. The facility failed to ensure personal protective equipment (PPE) was utilized correctly by 2 of 7 staff (Staff C and D) for 3 of 24 residents (Resident 1, 23 & 25) and failed to ensure the clinical status of residents with signs of influenza were monitored for 6 of 8 residents (Residents 5, 6, 8, 13, 15 and 23) reviewed for infection control system and tracking implementation during an outbreak. This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . The facility's Influenza Outbreak Checklist, undated, showed the facility's response to an influenza outbreak was to implement daily, active surveillance for acute respiratory illness among all residents, test for influenza for ill persons and to implement droplet precautions for all residents with suspected or confirmed influenza;…

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 influenza vaccines were provided for 13 of 15 residents (Residents 1, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for immunizations. These failures placed residents at risk for acquiring, transmitting, and/or experiencing potentially avoidable complications from the influenza virus. Findings included . Review of the facility's policy, titled Vaccination of Residents' Policy and Procedure, revised 12/2022, showed .all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated <Resident 1> Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's electronic health record (EHR) on 11/30/2023, showed no documentation or indication to support the facility provided information about the influenza vaccine and the vaccine was not offered. <Resident 3> Resident 3 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to follow physician's orders for 1 of 3 residents (Resident 1) with skin conditions. This failure placed residents at risk for development and/or worsening of skin conditions, infection, and medical complications. Findings included . Review of the facility's policy titled, Pressure Ulcer Prevention and Treatment, revised 02/03/2023, showed to manage moisture associated skin issues by using the appropriate moisture barrier. Resident 1 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (poor circulation) and diabetes. Resident 1's Minimum Data Set, an assessment tool, dated 10/06/2023, showed the resident was occasionally incontinent of urine and always incontinent of bowel. Review of a wound consultant note, dated 11/21/2023, showed the resident had new gluteal (to bottom) skin breakdown and nursing had been applying zinc cream which was causing rough and dry skin. Review of a physician's order, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide necessary care and services for 5 of 9 sampled residents (Residents 1, 2, 6, 7 and 4) reviewed for nursing services related to sufficient staffing. This failure placed residents at risk for unmet care needs, discomfort, medical complications, and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 08/12/2023, showed Resident 1 had severe cognitive impairment, incontinent of urine and bowel, required extensive assistance of two persons for transfers from bed to wheelchair and one person for eating. On 11/06/2023 at 7:57 AM, 8:37 AM, 9:48 AM, 10:00 AM, 11:10 AM and 12:22 AM, Resident 1 was observed sitting in their wheelchair in the dining room facing the TV. On 11/06/2023 at 12:40 PM Staff E, Certified Nursing Assistant (CNA), said they started their shift at 9:00 AM and 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 interview, observations and record review, the facility failed to ensure residents were free of physical restraints when 1 of 1 resident (Resident 3) had the wheelchair brakes locked to prevent them from self-propelling. This failure placed the residents at risk for injury, frustration, and a decreased quality of life. Findings included . Resident 3 was admitted on [DATE] with a diagnosis of dementia. The quarterly Minimum Data Set, an assessment tool, dated 08/15/2023, showed the resident was severely cognitively impaired, had no physical restraints and used a manual wheelchair. Resident 3's safety device evaluation, dated 09/07/2023, showed an evaluation for a reclining wheelchair. The evaluation showed the reclining wheelchair was used for positioning and the medical symptom the wheelchair treated was dementia with poor trunk support. A question on the evaluation form which addressed if the wheelchair restricted freedom of movement was not filled in. Resident 3's safety device care plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to implement wound treatment orders and care interventions for 2 of 3 residents (Resident 4 and 5) with pressure ulcers (a skin wound caused by pressure which limits blood flow to the skin). This failure placed residents at risk for development and/or worsening of wounds, infection, and medical complications. Findings included . Review of the facility's policy titled, Wound Prevention and Treatment, dated 02/03/2023, showed a resident with pressure ulcers would receive continued preventive interventions and necessary treatment and services to promote healing and prevent infection. 1. Resident 4 was admitted on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/16/2023, showed the resident had a stage 4 (a pressure ulcer that extends to muscle, tendon or bone) pressure ulcer and required extensive assistance by two staff for bed mobility. Resident 4's progress note, dated 11/07/2023, documented an assessment by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide physician ordered wound treatment for 1 of 3 sampled residents (Resident 1) reviewed for quality of care related to wound care. This failure placed residents at risk for worsening skin conditions, medical complications, and unnecessary pain. Findings included . Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set assessment, dated 07/10/2023, showed the resident was cognitively intact and had ulcers (open sore or wound that develops on the skin) that required the application of dressings (bandages). Review of Resident 1's physician's order, dated 08/16/2023, showed an order for a dressing and ointment to be applied daily to the resident's leg. Review of Resident 1's Outpatient Wound Clinic records, dated 08/23/2023, showed the resident's dressing appeared to have not been changed, no product was in the dressing and the resident could not remember the last time the dressing was changed. The Outpatient Wound Clinic record,…

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

Based on interview and record review, the facility failed to ensure their surety bond (a written agreement wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for) covered an amount greater than or equal to the value of resident funds deposited in the facility's resident trust account. This failure placed 39 of 98 residents, who had trust accounts with the facility, at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . Review of the facility's surety bond, dated 08/31/2023, showed it covered an amount not to exceed: $44,000. This amount was the maximum insured amount for resident monies placed in the facility's trust account. During an interview on 09/07/2023 at 1:23 PM, Staff D, Business Office Manager, stated that the facility's surety bond should be at or above a value that covered all personal funds deposited by residents in the facility trust. Review of the facility's Trial Balance report, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure residents either had an advanced directive in place, or failed to provide the residents and/or their representatives written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 10 residents (Resident (R) 30, R23, R27, R50, R45, R49, R70, R4, R56, R41) of 12 reviewed for Advanced Directives. Findings included . Review of the facility policy Advance Directives, dated 05/2023 (sic), revealed, Policy: A resident has the right to refuse treatment, to refuse to participate in experimental research, to participate in health care decision-making and to formulate an Advance Directive in accordance with State law. The center strives to comply with all valid Advance Directives (per State law), including provisions for refusal or withdrawal of artificially provided nutrition and hydration . Procedure: 1. Provide information about the center's resident rights policies to each…

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 a safe, sanitary, homelike environment was maintained on 2 of 5 halls (Olympic 1 & 2). Failure to provide necessary maintenance and repairs in resident rooms for damaged walls, furniture, blinds, and baseboard heating units, resulted in avoidable hazards, uncleanable surfaces, and an inability to ensure resident privacy. These failures placed residents at risk for accidents, injuries, and decreased quality of life. Findings included . During initial rounds on the Olympic unit on 09/05/2023 from 9:27 AM - 10:21 AM, multiple resident rooms were observed with heavily gauged walls, large unpainted and un-sanded wall patches, cracked and torn chair cushions, damaged blinds with missing slats, and damaged baseboard heaters with bent and protruding element covers (sheet metal). A walkthrough of rooms on the Olympic 1 and 2 halls was conducted on 09/07/2023 at 10:16 AM, with Staff H, Maintenance Director, and Staff R, Regional Director of Maintenance, and showed the following: Resident Rooms 39-1 Multiple deep gauges…

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 grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of care concerns during resident council meetings for 3 of 5 months (June, July, and August 2023) of resident council minutes that were reviewed. Additionally, there was no documentation or indication facility staff informed residents of the corrective actions taken, if any, to address the reported concerns. These failures prevented the facility from ensuring resident concerns were timely and effectively addressed, that care trends were identified, and placed residents at risk of feelings of powerlessness, frustration, diminished self-worth and decreased quality of life. Findings included . Review of the facility's Grievances policy, revised 01/27/2023, showed staff would encourage residents or their representatives to report and/or discuss all grievances so issues may be resolved. Staff were directed 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 provide assistance with nail care for 5 of 30 residents (Residents 50, 6, 2, 26 & 97) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care to residents who were dependent on staff for the provision of such care, placed residents at risk for unmet care needs, poor hygiene, diminished self image and decreased quality of life. Findings included . Review of the facility's policy entitled Personal Needs, revised 12/20/22, showed, The center strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents . Personal care and support include but is not limited to the following . Nail care . Resident 50 Review of R50's undated admission Record located in R50's electronic medical record (EMR) under the Profile tab revealed R50 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included, chronic combined heart failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respiratory services consistent with professional standards of practice for 4 of 5 residents (Residents 26, 41, 50 and 27) reviewed for respiratory care. The fcility's failure to monitor, assess and address resident responses to oxygen (O2) therapy, follow physician's orders for the provision of humidified oxygen, ensure only residents with orders for O2 were administered it, and ensure oxygen concentrator filters (used to protect the resident from inhaling dust and particulate matter) were present and routinely cleaned and maintained, placed residents at risk for respiratory compromise, bloody noses and other potential negative healthcare outcomes. Findings included . Resident 26 Resident 26 was admitted to the facility on [DATE]. According to the 08/10/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of chronic lung disease, and required the use of supplemental…

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

Based on observations, interviews and review of policies and procedures, the facility failed to ensure that it stored, prepared, and served food in accordance with professional standards. This can affect 25 of 98 residents who ate food from the kitchen. Findings included . Observation on 09/05/23 at 9:15 AM, during the initial kitchen tour revealed four, four-ounce cartons of protein shakes that were in the walk-in refrigerator in a stainless-steel container without date labels. Further observation of the Cove unit resident refrigerator located in the dining room of that unit revealed another unlabeled four-ounce protein shake carton. The carton labeled Sysco Imperial Strawberry Shake had a warning label on the back indicating store frozen, thaw under refrigeration, shake well before using. After thawing, keep refrigerated, use within 14 days of thawing. The contents label on the carton included non-fat milk. Interview with Staff P, Food Service Director (FSD), at 9:15 AM on 09/05/23 indicated the shakes, known as mighty shakes, in the walk-in refrigerator were to be used today…

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, staff interview, and policy review, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a notice including the reason the services were ending or what the options were prior to the discontinuation of therapy services. This had the potential to affect one of three residents (Resident (R)82) who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review. Findings included . Review of the electronic medical record (EMR) for R82 revealed he was admitted to the facility on [DATE] and was readmitted on [DATE]. R82 had Medicare benefits and when he was discontinued from skilled therapy services on 08/23/23, he had not exhausted his Medicare benefit days. However, the facility failed to notify his representative regarding the expiration of benefits prior to the expiration date. Further review of the EMR failed to reveal any documentation of R82 and/or R82's representative being given written notification 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 residents comprehensive plans of care were developed, implemented, and accurately reflected residents' care needs for 2 of 30 residents (Residents 26 & 42) reviewed. The failure to incorporate the specialized equipment residents were assessed to require into their plans of care, such as weighted silverware, tilt-in-space wheelchair and fall mats, placed the resident at risk for decreased independence, unmet care needs and a diminished quality of life. Findings Included . Resident 26 Resident 26 admitted to the facility on [DATE]. According to the 08/10/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact and required setup and supervision with eating. Review of Resident 26's Physician's orders showed a 03/08/2023 order for weighted utensils secondary to tremors (involuntary shaking or movement.) Review of Resident 26's breakfast and lunch tray cards on 09/05/2023 at 12:08 PM, at bedside,…

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 services provided met professional standards of practice for 2 of 30 sample residents (Residents 56 & 97) reviewed. Facility nurses' failure to obtain, accurately transcribe, follow, and clarify Physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes. Findings included . Resident 56 Resident 56 admitted to the facility on [DATE]. According to the 08/09/2023 quarterly Minimum Data Set (MDS, an assessment tool) the resident had difficulty swallowing and received 26-50% of their total calories via enteral feeding. Review of Resident 56's Physician's orders showed the resident had the following enteral feeding orders: 1) A 05/23/2023 order to administer Jevity 1.5 at 40 ml/hr. for 12 hours a day, on at 6:30 PM and off at 6:30 AM, for a total of 480 ml of formula per day; and a 05/23/2023 order…

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 an environment free of accident hazards for 1 of 6 residents (Resident 33) reviewed for accidents. The facility's failure to provide adequate supervision and to follow facility policy and procedures for a missing resident, resulted in the facility taking no action for 15 hours after Resident 33 was identified as missing. This failure placed Resident 33 at risk for serious harm and injury. Additionally, the facility failed to maintain a resident's environment free of hazards, by failing to identify and repair baseboard heaters in resident rooms that were bent and protruding from the wall, exposing residents to the sharp edges of sheet metal, and presenting a tripping hazard. These failures placed residents at risk for avoidable falls, injuries and/or lacerations. Findings included . Review of the facility's undated Missing Resident Action Plan showed when a missing resident was identified, staff were directed to: search all areas 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 1 of 2 residents (Resident 6) reviewed for indwelling urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag) had a valid medical justification for urinary catheterization, was assessed for removal of the catheter timely, and received catheter care in accordance with professional standards of practice, and infection control and prevention guidelines. This failure placed the resident at risk for loss of bladder tone and normal bladder function, catheter associated urinary tract infections and other negative health outcomes. Findings included . According to the facility's Indwelling Catheters policy, revised 07/2023, all residents with an indwelling catheter required a medical justification for the initiation and continued use of a catheter. A comprehensive assessment would be conducted to identify underlying factors to support a medical justification for catheter use, staff would determine…

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 enteral nutrition (delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with Physician's orders and professional standards of practice for 1 of 2 residents (Residents 56) reviewed for enteral nutrition. The failure to administer enteral formula in accordance with physician's orders; to identify incomplete, duplicative and/or conflicting orders and clarify and/or correct those orders, placed residents at risk for inadequate nutrition, hydration, and other adverse health outcomes. Findings included . Resident 56 Resident 56 admitted to the facility on [DATE]. According to the 08/09/2023 quarterly Minimum Data Set (MDS, an assessment tool) the resident had difficulty swallowing and received 26-50% of their total calories via enteral feeding. Review of Resident 56's 08/08/2023 Nutrition Evaluation showed the resident was on a regular diet with their oral nutritional…

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 adaptive equipment with meals, for 1 of 1 (Resident 26) of two residents reviewed who required it. Failure to provide adaptive equipment that the resident was assessed to require, placed the resident at risk for decreased independence, meal intake, unmet needs, and diminished quality of life. Findings included . Resident 26 Resident 26 was admitted to the facility on [DATE]. According to the 08/10/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact and required setup and supervision with eating. During an interview on 09/05/2023 at 12:08 PM, Resident 26's lunch tray was delivered. Resident 26 expressed frustration with kitchen staff, and stated that they often failed to follow the instructions written on the tray card. Review of the Resident 26's lunch tray card showed the resident was on a consistent carbohydrate diet, and required weighted utensils (used to provide additional weight 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 provide urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care and maintenance, in accordance with accepted infection control practices for 1 of 4 residents (Resident 6) reviewed for urinary catheters. This failure placed the resident at risk for catheter associated urinary tract infections and/or transmission of infection to others. Additionally, the facility's failure to maintain and repair resident furniture and walls, resulted in multiple uncleanable surfaces, detracted from staffs' ability to maintain a clean sanitary environment and placed residents at risk for contracting communicable diseases. Findings included . Resident 6 Resident 6 admitted to the facility on [DATE]. According to the 07/10/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact and had an indwelling urinary catheter. On 09/05/2023 at 3:45 PM a strong smell of urine was present…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to ensure the resident call system was functioning properly for 2 of 30 sampled residents (Residents 56 and 9) reviewed for call lights. This failure placed residents at risk for delayed staff response to potential emergencies and resident needs, falls, injury, frustration, and decreased quality of life. Findings included . During initial rounds on 09/05/2023 at 9:19 AM, observation of the call light panel at the Olympic nurse's station showed room [ROOM NUMBER] was activated (lit up), which indicated a resident in the room activated their call light for assistance. However, no audible alarm was heard, and observation of the Olympic unit hallways showed no call lights were on outside of the resident rooms. Observation of the call light panel on 09/05/2023 at 10:03 AM, showed room [ROOM NUMBER] remained activated, with no audible alarm, and no resident call lights on in the hallway. Upon entering room [ROOM NUMBER], Residents 9 and 56 were lying in bed.…

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.