Avamere Rehabilitation of Burien

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to reassess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved for 1 of 2 residents (Resident 47) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and embarrassment. Findings included . <Facility Policy> According to the facility's April 2018 Urinary Incontinence policy, nursing staff would assess residents and document the circumstances related to incontinence. The physician would identify potentially treatable medical conditions and address causes related to urinary incontinence. The policy showed facility staff would identify environmental interventions and assistive devices such as grab bars, urinals (bottles male residents can urinate in), bedside commodes, and walkers to facilitate toileting. Based on the assessment and causes of the incontinence, staff would provide scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored, returned, and/or discarded when expired for 1 of 3 medication carts (Middle Medication Cart) and 1 of 1 medication rooms observed. The failure to ensure unneeded medications were returned to the pharmacy upon resident discharge and to ensure medications carts were secured when not in use by a nurse placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications. Findings included . <Facility Policy> According to the facilty's revised November 2020 Storage of Medications policy, discontinued, outdated, and deteriorated drugs and biologicals must be retumed to the dispensing pharmacy or destroyed. The policy showed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) that contained drugs and biologicals must be locked when not in use and unlocked medication carts must not be left unattended. <Medication Room> Observations of the medication room on 05/12/2025 at 9:41 AM with Staff P (Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: ensure staff followed contact precautions (a type of isolation precaution used to prevent the spread of infections transmitted by direct or indirect contact) for 1 resident (Resident 183) of 1 reviewed for contact precautions; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear and gowns used to prevent exposure to infectious materials) for one supplemental Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in long-term care settings) room (room [ROOM NUMBER]); ensure staff used appropriate Hand Hygiene (Staff R); ensure the facility was free of uncleanable surfaces; ensure urinals (plastic bottles used to pass urine for resident with mobility issues) were sanitary. These failures placed residents at risk for exposure to and development of infectious diseases. Findings included . <Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely laboratory (lab) services to 2 of 3 residents (Resident 1 & Resident 6) reviewed for lab services. The failure to ensure adequate lab supplies to allow nursing staff to obtain timely urine samples for diagnosis and treatment of infections placed residents at risk of illness, hospitalization, and diminished quality of life. Findings included . <Resident 1> The 02/09/2024 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted to the facility with a urinary tract infection and amputations of both lower extremities. The MDS showed Resident 1 had a history of stroke with communication impairment and was unable to complete a cognitive evaluation. Resident 1 required physical assistance from staff for all care, including incontinence of urine and bowels. Review of the 02/19/2024 physician visit note showed Resident 1 was seen for follow up on mental status changes and pain on urination. The physician assessment showed Resident 1 had left lower abdominal pain 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 have sufficient nurse staff to provide and supervise care of residents as evidenced by information provided in a Resident/Surveyor interview, for 9 residents (Residents 10, 44, 29, 60, 32, 67, 63, 17, 240 & 7) interviewed, and 3 (Staff R, BB, & M) staff interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADLs) including showers, nail care and call light responses. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNP's not being done for 3 of 9 residents (Residents 63, 17 & 44) reviewed for RNP. Findings included . <ADLS, Showers, & Nailcare> <Resident 10> Observations on 02/21/2024 at 8:53 AM, 10:48 AM, & 12:22 PM, on 02/22/2024 at 9:02 AM and 11:51 AM, on 02/23/2024 at 9:13 AM, and on 02/27/2024 at 8:45 AM and 1:54 PM showed Resident 10 lying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was prepared, stored, and served under sanitary conditions. Facility staff failed to: Label and date food after preparation, discard expired and spoiled foods; keep kitchen vents and fans free from dirt/dust build-up; maintain availability of running hot water in the handwashing sink; consistently perform hand hygiene when working in between areas in the kitchen; and prevent bare hand contact with ready to eat foods during food preparation. These failures contributed to an unsanitary kitchen environment and placed residents at risk for food-borne illness. Findings included . <Facility Policy> According to the facility policy titled, General Food Preparation and Handling, revised January 2018, food items would be kept free from injurious organisms and substances. The policy showed foods were checked and stored properly, and those with an abnormal appearance were not served. The policy showed bare hands should never touch raw food directly. The policy showed leftovers must be dated, labeled, and discarded within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and facility equipment was maintained and in safe operating conditions for 2 of 20 residents (Residents 7 & 60) whose mobility devices and environment were observed for safety. The facility failed to ensure: The call light cord remained intact (Resident 7); the Wheelchair (WC) tires were functional and properly inflated (Resident 20); and the dishwasher in the facility's main kitchen operated at the correct wash temperature it was specified to clean/sanitize resident dishes with according to manufacturer specifications. These failures left residents at risk for accidents, isolation, and other negative health outcomes. Failure to ensure the dishwasher maintained the appropriate temperature placed residents at risk for eating from unclean and/or inappropriately sanitized dishes. Findings included . <Facility Policy> According to the facility's policy titled, Internal Environmental Services, revised October 2010, the staff would ensure the facility was well-maintained through a preventative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 (Residents 77, 68, 17, 66, 10, 44, & 33) of 7 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the 03/2021 Transfer or Discharge Notice facility policy showed when a resident was transferred or discharged from the facility, the resident and/or the resident's representative would be notified in writing in a language or manner they understood, the specific reason or the transfer or discharge, the effective date of the transfer or discharge, and the location to which the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 10 of 20 residents (Resident's 31, 60, 80, 7, 32, 85, 44, 33, 66, & 10) whose CPs were reviewed. Failure to address the individualized care needs for each resident placed residents at risk for inconsistent and/or inadequate care, and a decreased quality of life. Findings included . <Facility Policy> Review of a facility policy titled, [CPs],Comprehensive Person-Centered dated March 2022, showed a comprehensive, person-centered CP that included measurable goals and timeframes to meet the residents needs would be implemented for each resident. The policy showed the comprehensive person-centered CP was developed within seven days of the completion of the Minimum Data Set (MDS - an assessment tool) assessment and no more than 21 days after the resident admits to the facility. <Resident 31> According to the 01/24/2024 admission 5 Day MDS, Resident 31…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 11 of 20 (Residents 31, 77, 29, 60, 32, 7, 17, 190, 191, 44, & 83) sample residents whose CPs were reviewed. The failure to update and/or revise CPs left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's policy titled [CPs], Comprehensive Person Centered revised March 2022 showed a comprehensive, person centered CP included measurable objectives and timeframe's to meet each resident's physical, psychosocial, and functional needs. The policy showed all residents had the right to participate in the planning process, request CP meetings, and were provided advanced notice of CP meetings. The policy showed interventions would address the underlying source of problem areas, not just symptoms and/or triggers and assessments of all residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist residents with Activities of Daily Living (ADLs) for 8 of 11 residents (Residents 32, 67, 85, 60, 29, 77, 10, & 44) reviewed who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled Activities of Daily Living, Supporting dated 03/2018 showed residents who were unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This policy showed if residents with impaired ability to think or memory loss disorders resisted care, staff would attempt to identify the underlying cause of the problem and not assume the resident was refusing care. This policy showed staff should reapproach the resident or have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate for 10 of 20 sample residents (Residents 190, 191, 83, 77, 49, 67, 85, 7, 75, & 31) whose resident records were reviewed. The facility failed to ensure the presence/use of medical devices were captured during initial admission assessment (Residents 190, 191, & 7), skin and wound evaluations identified the location of wounds (Residents 190), accurately document a resident's Activities of Daily Living (ADL) performance/ability (Resident 77), and complete daily skilled charting for Medicare (a type of payer source that provide skilled care benefits) residents as required (Residents 49, 190, 191, 67, 85, 7, 83, 75, & 31). These failures placed residents at risk for unidentified and/or unmet care needs, missed care planning, other negative health outcomes, and denial of coverage of their skilled care benefits. Findings included . <Facility Policy> Review of the facility's policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in a manner that promoted resident respect and dignity for 1 of 1 residents (Resident 7) reviewed for dignity concerns. This failure left Resident 7 with feelings of invalidity, and placed residents at risk for having low self-esteem, diminished self-worth, and a decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled, Dignity, revised February 2021, each resident should be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy showed the facility culture supported resident dignity and respect by honoring resident goals, choices, and preferences. The policy showed demeaning practices and standards of care that compromised resident dignity were prohibited. <Resident 7> According to the 01/09/2024 admission MDS, Resident 7 was cognitively intact, capable of understanding others, and had clear speech during communication. The MDS showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 3 (Residents 190, 191, & 29) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, and offered assistance to formulate an AD (Resident 190 & 29), obtain a copy of AD paperwork and have it readily available in the resident's record (Resident 191), and follow up to obtain guardianship (Resident 29). These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The 09/2022 Advanced Directives facility policy showed the resident and/or the resident's representative would be provided with written information regarding the resident's right to refuse or accept assistance with formulating an AD and this information would be provided in a manner the resident could understand. Nursing…

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

Based on interview and record review, the facility failed to ensure injuries of unknown origin was reported to the State Survey Agency (SSA) within the required timeframe for 2 of 6 sampled residents (Residents 10 & 66) reviewed for abuse/neglect. Failure to complete required reporting of incidents placed Resident's 10 & 66 at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Prevention Policy and Procedure, Revised 07/01/2020, showed all incidents, accidents, and injuries of unknown origins would have an incident report completed to initiate an investigation. This policy showed that mandated reporters were to immediately report to the SSA and any injury of unknown origin would be reported to State Officials per regulations. Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, revised September 2022, showed all reports of resident abuse (including injuries of unknown origin) would be reported to local, state, and federal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 or thoroughly investigate incidents for a facility acquired pressure injury and unwitnessed falls with major injuries for 3 of 6 sampled residents (Resident 10, 66, & 31) reviewed for abuse/neglect. Facility failure to initiate an investigation for the pressure injury of unknown origin to Resident 10's toe, and failure to thoroughly investigate Resident's 66 and 31's falls with fractures placed all residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Prevention Policy and Procedure, Revised 07/01/2020, showed all incidents, accidents, and injuries of unknown origins would have an incident report completed to initiate an investigation. Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, revised September 2022, showed all reports of resident abuse (including injuries 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 interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 1 of 7 sample residents (Resident 77) and 1 closed record (Resident 68) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> The facility's revised October 2022 Bed-Holds and Returns policy showed all residents/representatives were provided written information regarding the facility and state bed-hold policies that addressed holding or reserving a resident's bed during periods of absence including hospitalization. The policy showed residents were provided the written notice at the time of transfer or, if the transfer was an emergency, within 24 hours. <Resident 77> According…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Sets (MDS - an assessment tool) were accurate and complete for 1 of 20 residents (Resident 7) whose MDS and Care Area Assessments (CAA) were reviewed. This failure placed residents at risk for unidentified and/or unmet care needs. Findings included . <Facility Policy> The facility's 01/02/2024 MDS Completion and Submission Timeframes policy showed the assessment coordinator or designee was responsible for ensuring that the resident MDS assessments were scheduled, completed, and submitted in accordance with current state and federal guidelines. The policy showed MDS completion requirements follow the guidance outlined under the Resident Assessment Instrument (RAI) User's Manual. < RAI Manual> The October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) showed the MDS coordinator should examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices were present, and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a screening process for residents who have indicators of intellectual disability (ID), related disability (RD), or serious mental illness) assessments were accurate and revised for 2 (Residents 31 & 32) of 5 residents reviewed for PASRR. The failure to ensure PASRR screening was accurate and revised timely placed residents at risk for not receiving timely and necessary services to meet their mental health care needs and placed them at risk for diminished quality of life. Findings included . <Facility Policy> Review of the 03/2019 facility policy admission Criteria, showed the facility conducted a Level I PASRR screen for all potential admissions. If the Level I screen indicated the resident may meet the criteria for MD or RD, they would be referred to the state PASRR authority for the Level II screening process. The facility policy showed Social Services staff would be responsible for making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline Care Plan (CP) within 48 hours of admission as required that documented resident-specific initial goals and treatment plans for 2 of 2 newly admitted residents (Residents 190 & 191) reviewed to ensure continuity of care upon admission. Failure to develop baseline CPs that identified the presence/use medical devices including an indwelling urianry catheter (a device that drained urine from the bladder) and non-removable splint/cast (Resident 191) placed the residents at risk for unmet care needs, potential complications, and a decreased quality of life. Findings included . <Facility Policy> The facility's revised March 2022 Care Plans - Baseline policy showed a baseline CP was developed for each resident within forty-eight (48) hours of admission to meet the resident's immediate health and safety needs. The policy showed the baseline CP must include the minimum healthcare information necessary to properly care for the resident.…

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

Based on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were obtained for a Gastric tube (tube inserted through the abdomen into the stomach) and a medicated topical cream for 2 of 20 sampled residents (Resident 44 & 77) reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled medication therapy, revised April 2007, showed the residents clinical records would contain a written Physician Order (PO) for all prescriptions and over the counter medications taken by the resident. <Resident 44> According to the 12/27/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 44 had complex medical conditions including difficulty swallowing, and Diabetes Mellitus (unstable blood sugar levels). The MDS showed Resident 44 had a Gastric tube during the assessment period. Record review of Resident 44's 12/29/2023 Enhanced Barrier precautions (staff to wear protective equipment to protect the resident from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 (Residents 17, 63, & 44) of 9 residents reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> Review of the 07/2017 Restorative Nursing Services facility policy showed residents would receive restorative nursing care to promote optimal safety and independence. <Resident 63> According to the 02/07/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 63 admitted to the facility on [DATE] with impairment to both legs. This assessment showed Resident 63 participated in Active Range of Motion (AROM), Passive Range of Motion (PROM), and a splinting RNP five days during the seven-day look-back period. Observations on 02/20/2024 at 10:21 AM, 02/21/2024 at 12:33 PM, 02/23/2024 at 10:04…

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

Based on observation, interview, and record review, the facility failed to ensure residents with indwelling urinary catheters (a device that drained urine from the bladder and into a collection bag) were provided catheter care consistent with professional standards of practice and post-catheter use monitoring was implemented for 2 of 3 residents (Residents 190 & 7) reviewed for indwelling urinary catheters and bladder function. These failures placed residents at risk for Urinary Tract Infection (UTI), undiagnosed urinary retention, dignity issues, and a decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled, Catheter Care - Urinary, revised August 2022, staff were instructed to ensure the catheter tubing and drainage collection bag were kept off the floor for infection control. The policy showed the collection bag was emptied at least every eight hours and the resident checked frequently to ensure the catheter and tubing were free of kinks. The policy showed residents should be observed for complications associated with urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement personalized nutritional interventions that met resident needs or ensured residents consistently received supplemental fluids they were assessed to require for 1 of 2 residents (Resident 77) reviewed for hydration. These failures placed the residents at risk for dehydration, worsened nutritional status, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's policy titled, Hydration - Clinical Protocol, revised September 2017, the physician and staff would help define the resident's hydration status and identify significant risk for subsequent fluid and electrolyte imbalance (a condition of either too much or not enough of certain minerals in the body). The policy showed the staff would provide supportive measures such as supplemental fluids where indicated. <Resident 77> According to the 01/14/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 77 was not proficient in English and had unclear speech/mumbled words during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 3 residents (Residents 83 & 67) reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to physician ordered flow rates (Resident 83 & 67) and maintain oxygen equipment (Resident 83) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life. Findings included . <Resident 83> According to the 01/31/2024 admission Minimum Data Set (MDS- an assessment tool), Resident 83 had clear speech during communication, their memory was intact, and had medical conditions including respiratory and heart failure. The MDS showed Resident 83 was administered supplemental oxygen during the assessment period. Review of Resident 83's Care Plan (CP) showed a 01/31/2024 intervention directing the nursing staff to administer 2 Liters Per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 5 residents (Resident 190) reviewed for mood/behavior. The facility's failure to assess trauma history, develop, and implement nursing interventions placed Resident 14 and other residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . <Facility Policy> The facility's revised August 2022 Trauma-Informed and Culturally Competent Care policy showed all staff were provided in-service training about trauma, trauma-informed care, and cultural competency as an aspect of resident-centered care. The policy showed traumatic events could affect residents during their lifetime including a serious injury. The policy showed resident care planning involved the development of individualized Care Plans (CP) that address past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their policy and procedures to ensure residents were assessed to be safe to use Bed Rails (BR) for 3 (Residents 60, 44, & 66) of 3 residents reviewed for BR's. Facility failure to attempt alternatives before implementing BR's, assess residents for safe use of BR's, or obtain informed consent for the use of BR's placed all residents at risk for harm or injury and other negative health outcomes. Findings included . <Facility Policy> Review of the November 2015 Restraint and Device Guideline facility policy showed when a safety device was determined to be needed for a resident, facility staff would complete or update the resident's safety device assessment. Facility staff would initiate a Care Plan (CP) and update the resident's Kardex (directions to care staff on how to provide care for a specific resident). This policy showed the risks and benefits of the device were to be explained to the resident and informed consent would be obtained. <Resident 60> According to Resident 60's 11/27/2023 Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social service intervention for 1 of 5 residents (Resident 32) reviewed for unnecessary medications and 5 (Residents 63, 17, 44, 60, & 31) of 5 residents reviewed who demonstrated the behavior of refusals. The failure to initiate further assessment and appropriate interventions when the resident answered positively to a self-harm question, placed the resident at risk for unmet care needs and self-harm. Failure to have a process for resident refusals and identify and seek ways to support residents needs related to refusals, placed residents at risk of unmet care needs. Findings included . <Resident 32> According to the 01/18/2024 Admission/5-day Minimum Data Set (MDS- an assessment tool), Resident 32 admitted to the facility on [DATE], had no memory impairment and had a diagnosis of depression. The MDS showed Resident 32 received Antidepressant (AD) medications on seven of seven days during the assessment period. Part of the 01/18/2024 MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 altered consistency liquids were provided and consistent with the resident's Care Plan (CP) for 1 of 2 residents (Resident 77) reviewed for hydration. This failure placed the resident at risk for aspiration (accidental inhalation of food or liquid into the airways), dehydration, and a decreased quality of life. Findings included . <Facility Policy> The facility's revised December 2011 Nutrition Assessment policy showed a nutritional assessment, including current nutritional status and risk factors would be conducted for each resident. The policy showed information derived from the nutritional assessment, including the presence of chewing and swallowing abnormalities, should be identified by the staff. <Resident 77> According to the 01/14/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 77 had medical conditions including a traumatic brain injury, malnutrition, and adult failure to thrive and was dependent on staff for their Activities of Daily Living (ADLs) including eating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 2 garbage dumpsters and 1 of 1 recycling dumpster reviewed and inspected for outdoor garbage storage area were properly covered with a lid and the surrounding areas were kept clean as required. This failure placed the facility at risk of attracting bugs, rodents, and other disease-carrying germs/bacteria that could reproduce and grow and placed the residents at risk for acquiring these diseases. Findings included . <Facility Policy> The facility's October 2010 Internal Environmental Services policy showed the facility would be kept clean and well-maintained. The policy showed staff would walk the building every morning to determine environmental needs and attempts should be made to pick up any trash that may be on the floor. A joint observation and interview on 02/26/2024 at 2:17 PM with Staff U (Dietary Manger) showed three dumpsters located at the back end of the facility: The recycling dumpster lid was open and was full of boxes/recyclable materials; the middle garbage dumpster was overflowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 1 of 3 residents (Resident 31) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's 01/13/2022 Arbitration Agreement (AA) policy showed the admissions coordinator would review the arbitration agreement with the resident upon admission to the facility. The policy showed the admissions coordinator was responsible for any questions the resident may have about the contract. <Resident 31> According to the 01/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 31 was alert and oriented, their memory was intact, and had clear speech during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to follow Transmission Based Precautions (TBP) recommendations for 2 (Medicare and North) of 5 units reviewed, failed to consistently perform Hand Hygiene (HH) before and after resident care/contact, and failed to ensure residents' surrounding environment were maintained clean and sanitary (Resident 190). These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <TBP> <room [ROOM NUMBER]> Observation on 02/20/2024 at 9:04 AM showed room [ROOM NUMBER] had an Aerosol Precautions (AP - a type of isolation applied to residents with known or suspected to be infected with microorganisms transmitted by airborne particles or droplets in the air)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implementation and staff compliance with the facility's infection prevention and control program to prevent the transmission of communicable diseases, including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) during an active COVID-19 outbreak and global pandemic. The facility failed to ensure staff and visitors followed posted Transmission Based Precautions (TBP - a set of guidelines used with certain infectious diseases to prevent transmission) for residents who had COVID-19; ensure staff and visitors were wearing the required personal protective equipment (PPE) during close contact with a resident who was COVID-19 positive; ensure staff wore the appropriate, fit-tested N95 respirator correctly; ensure consistent hand hygiene before and after resident care; ensure staff implemented safe infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a system to ensure all staff were tested for COVID-19 at the frequency set forth by the Secretary and the Local Health Jurisdiction (LHJ) during an active COVID-19 outbreak, causing a delay in the identification and isolation of new cases, and failed to maintain proper infection control using recommended personal protective equipment (PPE) during specimen collection and testing for COVID-19. This failure placed residents, visitors, and staff at risk for contracting COVID-19 during an active outbreak and global pandemic. Findings included . According to the revised 09/23/2022 CMS QSO-20-38-NH memo, facilities must conduct testing at the required frequency, consistent with professional standards, and for each instance of testing must document that testing was completed. The memo directed facilities to handle specimens correctly and safely to ensure the accuracy of test results and prevent any unnecessary exposures. The memo directed facilities to use recommended personal protective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interdisciplinary care conferences were completed for 1 (Resident 51) of 2 residents reviewed for care conferences. This had the potential for missed concerns the resident may have and for the resident to participate in her plan of care. Findings included . Review of the facility's undated Care planning/Interdisciplinary Team (IDT) Care Planning Conference policy showed all residents will have a comprehensive care plan to meet their individual needs that is prepared by an interdisciplinary team within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family .IDT meetings may take place face-to-face in a conference room or in resident's room . may involve teleconference or written communications with family and physicians .Care planning shall include 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 the necessary treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers (PUs) and promote healing for 1 of 2 Residents (Resident 82) reviewed for PUs. The facility's failure to thoroughly assess, monitor, treat, and implement pressure relieving interventions placed the residents at risk for further skin breakdown, delayed healing, unnecessary discomfort, infection, and diminished quality of life. Findings Included . According to the undated National Pressure Injury Advisory Panel (NPIAP) PU/PI staging definitions include: a Stage 2 PU was defined as a partial-thickness wound where the wound bed was viable, pink or red, moist, and may also present as an intact or ruptured blister; an Unstageable PU was defined as a full thickness skin and tissue loss where the base of the wound was obscured by slough (dead skin cells) and/or eschar (dead tissue) where until sufficient slough and/or eschar could be removed to expose the base of the wound, 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 monitor and address a resident's significant weight loss for 1 (Resident 6) of 3 residents reviewed for nutritional status. This failure left the resident at risk for further weight loss, other negative health outcomes and a diminshed quality of life. Findings included . Review of the facility's updated 05/07/21 Nutrition and Hydration Monitoring policy showed all residents admitted to the facility will be weighed for the next three (3) days of admission and then weekly thereafter to establish a baseline weight. The policy showed the Nutrition at Risk (NAR) committee met weekly to review residents at risk for altered nutrition and hydration and would review all weights to identify trends. The policy showed criteria for review included any residents with: 5% +/- weight change in the previous 30 days, 7.5% +/- weight change in the previous 90 days, 10% +/- weight change in the previous 180 days, residents with average meal intake of <50%, residents 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 residents received ongoing communication and collaboration with the dialysis (a process to filter the blood when kidneys so not function as they should) clinic for 1 (Resident 6) of 1 residents reviewed for dialysis services. Facility failure to communicate and collaborate with the center as required leftthe residenty at risk for significant changes in their health status going unnoticed and not addressed in a timely manner, and other health risks. Findings included . Review of the facility's revised 11/14/2017 Dialysis Management policy, showed coordination of care between the facility and the dialyisis clinic should include: the day(s), date(s) and times(s) of dialysis therapy; transportation arrangements; timing of medication administration around the dialysis schedule; communication of useful and necessary information; communication of significant changes in the resident's clinical condition by the Resident Care Manager (RCM) or primary care…

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