Lacamas Creek Post Acute

Based on interview and record review, the facility failed to explain the arbitration agreement in a manner that residents understood for 2 of 3 sampled residents (28 & 46) reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a trial without consent, lack of adequate resolution of violation of rights and a diminished quality of life. Findings included . 1) Resident 28 signed the Alternative Dispute Resolution Agreement on 02/16/2024. On 09/27/2024 at 1:51 PM, Resident 28 said she did not recall signing the arbitration agreement document. Resident 28 said her daughter handled that kind of stuff. 2) Resident 46 signed the Alternative Dispute Resolution Agreement on 09/10/2024. On 09/27/2024 at 1:38 PM, Resident 46 said she did not recall signing such a document and said her sister was her Power of Attorney (POA). At 1:58 PM, Collateral Contact 1 (CC1), POA, said Resident 46 should not be signing legal documents because she did not know what she was signing. CC1 said Resident 46 had gotten herself into trouble because people had taken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed rails were securely fastened to the bed and without gaps between the mattress and bed rails for 1 of 3 sampled residents (22) reviewed resident beds. This failure placed residents at risk for injury. Findings included . Resident 22 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/28/2024, indicated Resident 22 was moderately cognitively impaired. The bed rail care plan, revised 08/29/2024, indicated, bilateral ¼ side rails to aid in bed mobility and to increase independence. On 09/23/2024 at 2:46 PM, Resident 22's left side bed rail was observed to be loose. The bed rail had approximately 9 to 10 inches of movement. On 09/27/2024 at 8:50 AM, Resident 22's left side bed rail was observed to be loose. The bed rail had approximately 9 to 10 inches of movement. At 8:57 AM, Staff I, Resident Care Manager and Registered Nurse, said the nursing assistants and floor nurses were supposed 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 interview and record review, the facility failed to ensure facility staff received Dementia training for 1 of 5 sampled staff (F) reviewed for staff in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff. Findings included . Staff G, Nursing Assistant, was hired on 03/29/2014. Provided training or in-service training records did not show Dementia training was completed over the past year. On 09/26/2024 at 2:51 PM, Staff H, Staff Training Coordinator, said dementia training was covered in the new employee orientation and then annually. An email from Staff A, Administrator, dated 09/30/2024 at 9:49 AM, noted, Staff G should've had it [dementia training] as she's been a long standing employee so that is an error on us. Reference WAC 388-97-1680(2)(b) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 2 of 6 sampled residents (Residents 1 & 2) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition and a diminished quality of life. Findings included . Review of the facility policy Medication Administration-Errors, dated 11/2004 and revised 02/2019, noted, Policy: It is the policy of this facility that practices will be in place to ensure . 2. Residents are free of any significant medication errors . Medications will be prepared and administered in accordance with: 1. Physicians orders . 3. Accepted professional standards and principles which apply to professionals providing services . 1) Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preparation dishes were properly cleaned and air dried to provide safe, sanitary food preparation when the kitchen was reviewed for sanitization and storage. This failure placed residents at risk of foodborne illness and a diminished quality of life. Findings included . On 10/23/2023 at 10:30 AM, observations showed a rack of food preparation dishes including wet quarter pans and wet 6-inch pans stacked on top of each other; stacking of the wet pans would not allow for required air drying. Additionally, two quarter pans were noted to have food debris in the bottom and on the sides of the dish. At 10:45 AM, Staff U, Food and Nutrition Services Manager, observed the stacked wet food preparation dishes and the food debris in the dishes and said that the dishes in the rack were supposed to be clean and dry. Staff U said that the dishes were quarter pans and 6-inch pans, and they were used for food preparation for resident meals. Reference WAC 388-97-1100 (3), -2980 .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 9 of 13 sampled residents (2, 4, 10, 26, 48, 316, 318, 319 & 320) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023 documented Resident 2 was moderately cognitively impaired. Resident 2's Electronic Medical Record (EMR) documented a transfer to an acute-care hospital on [DATE] and 08/11/2023. Resident 2's EMR did not show documentation a written notice of transfer was provided to Resident 2 or their representative for the 05/16/2023 and 08/11/2023 transfers. Resident 2's eINTERACT forms, 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 a written bed hold notice to the resident and/or the resident's representative at the time of transfer to the hospital for 9 of 13 sampled residents (2, 4, 10, 316, 318, 319, 320, 26 & 48) reviewed for bed hold notifications. This failure placed residents and/or their representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was moderately cognitively impaired. Resident 2's Electronic Medical Record (EMR) documented a transfer to an acute-care hospital on [DATE] and 08/11/2023. Resident 2's EMR did not show documentation a written bed hold was provided to Resident 2 or their representative for the transfers listed above. 2) Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure comprehensive care plans were individualized to promote the highest physical, emotional and psychosocial well-being and failed to ensure an anticoagulant care plan was in place for 4 of 7 sampled residents (2, 4, 8 & 45) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a negative impact on their quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was incontinent of bowel and bladder. Review of Resident 2's Care Plan, dated 09/26/2023, showed interventions requiring editing, as indicated by the word SPECIFY within the Care Plan, had not been edited with individualized resident information. The care plan did not show individualized interventions. 2) Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 4 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 3 of 3 sampled residents (26, 17 & 51) reviewed for activities. This failure placed residents at risk for becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life. Findings included . A facility policy, entitled Activity Assessment and Documentation, dated January 2012 and revised March 2019, documented, The AD [Activity Director]/designee assures that participation records are completed for each resident as well as level of engagement . All participation records will be kept according to state regulation. PCC [an electronic medical record program]: Participation records are recorded and stored in EHR [electronic health record]. 1) Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/25/2023, documented the resident was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to ensure the facility's activity program was directed by a trained and qualified activities professional for the ongoing assessment, development, and/or revision of individualized activity programs for the current activities scheduled in the facility for 1 of 1 Activity Directors (Staff G) reviewed for activities professional qualifications. This failure placed residents at risk for unmet recreation needs, boredom, and decreased quality of life. Findings included . The Activities Director Position Description, dated July 2022, documented, Qualifications and Experience: Must meet certification requirements by the local and state regulations. Minimum of two years' experience in social or recreation programming for seniors. The position description documented under educational requirements, Associates Degree or equivalent knowledge and skills obtained through a combination of education, training, and experience. Review of Staff G's (Activity Director) application for Activity Director, dated 02/01/2023, did not show…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 responded to call lights in a timely manner to provide necessary care and services for 1 of 5 halls (300). This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . On 10/24/2023 at 8:05 AM, Resident 31 said it had taken staff almost two hours to respond to his call light. At 8:26 AM, Resident 41 said it could take up to one hour on the day and night shift for staff to respond to call lights. On 10/25/2023 at 8:20 AM, the call light in room [ROOM NUMBER] Bed 1 was initiated. At 8:22 AM, the call light in room [ROOM NUMBER] Bed 2 was initiated. At 9:06 AM, an unidentified Laundry Aide was observed going into room [ROOM NUMBER], about 44 minutes after the call light was initiated. At 9:10 AM, an unidentified Nursing Assistant (NA) was observed going into room [ROOM NUMBER], about 50 minutes after the call light was initiated. When the NA came out of the room, she went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide daily nurse monitoring for side effects of anticoagulant use in 3 of 3 sampled residents (2, 8 & 46) reviewed for unnecessary medications related to anticoagulant use. This failure placed residents at risk of unidentified adverse side effects, poor outcomes and a diminished quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, showed Resident 2 was taking an anticoagulant daily. Review of anticoagulant care plan, dated 09/26/2023, showed Resident 2 started Eliquis (an anticoagulant) on 09/10/2022. Staff were to monitor for signs and symptoms of increased bleeding. Review of Resident 2's electronic medical record did not show daily nurse monitoring for side effects. 2) Resident 8 was re-admitted to the facility on [DATE] with diagnoses including stroke, difficulty expressing himself with verbal communication, and dementia. The…

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

Based on observation, interview, and record review, the facility failed to ensure medication refrigerator temperature logs were consistently maintained in 2 of 2 sampled medication rooms and failed to ensure a multi-dose vial of PPD (purified protein derivative, a medication used in a skin test to diagnose tuberculosis, a contagious disease) was labeled appropriately with an open date for 1 of 2 sampled medications refrigerators (100 Hall Med Room) reviewed for medication storage. These failures placed residents at risk for receiving compromised or ineffective medications with unknown potency. Findings included . The facility policy, entitled Storage of Medication, dated January 2023, documented, A temperature log or tracking mechanism is maintained to verify that temperature remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. The facility policy, entitled Medication Administration General Guidelines, dated January 2023, documented, the nurse shall place a 'date opened' sticker on the medication if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff properly wore N-95 masks for 1 of 4 nurses (Staff O) on the evening shift; preformed hand hygiene and implement hygienic use of gloves, and adhered to transmission-based precautions on 5 of 5 halls (Halls 100, 200, 300, 400 & 500) reviewed for infection control. These failures placed residents, staff and visitor at risk of contracting an infectious disease, developing infections and a decreased quality of life. Findings included . During the survey, 10/23/2023 to 10/27/2023, the facility was on outbreak status for COVID-19 (a highly contagious virus that can cause severe illness including death). A sign posted at the entrance of the facility documented staff were to wear a N-95 mask (respirator that protects against COVID-19). <Mask Usage> On 10/23/2023 at 10:17 AM, Staff B, Director of Nursing Services and Registered Nurse (RN), said they had eight residents in the facility who were positive for COVID. On 10/25/2023 at 6:57 PM, Staff O,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were provided a pest free environment for 1 of 5 halls (400 Hall) reviewed for a clean, comfortable and homelike environment. This failure placed residents at risk of infectious disease and a decreased quality of life. Findings included . On 10/23/2023 at 10:00 AM, during the screening of residents and general tour, black house flies were observed in two resident rooms on 400 Hall, on top of the residents' blankets that were covering un-named residents. On 10/26/2023 at 1:06 PM, five gnats were observed in/on/around a cup of grape juice in room [ROOM NUMBER]. Resident 51 said he sometimes tried to trap them on his meal tray to send them out of his room. Resident 51 said he would prefer to not have them in his room. Resident 51 said the gnats were on the window. At 1:07 PM, Staff K, Certified Nursing Assistant, said she saw gnats in room [ROOM NUMBER]. Staff K said she tried to get all the food out of resident rooms and wipe 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 electronic discharged Minimum Data Set (MDS), a required assessment tool, were submitted to the Center for Medicare & Medicaid Services (CMS) within the required time frame for 1 of 1 sampled resident (53) reviewed for resident assessment. This failure placed residents at risk of not have an accurate assessment in place. Findings included . The Electronic Medical Record (EMR), Census, showed Resident 53 discharged from the facility on 06/15/2023. The admission None PPS (prospective payment systems), MDS, dated [DATE], showed it was accepted. The discharged Return Not Anticipated/End of PPS Part A Stay, MDS, was completed on 06/15/2023; and did not show it was accepted by CMS. On 10/26/2023 at 3:31 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said the discharge MDS did not have to be transmitted to CMS because Resident 53 had an HMO (private insurance). Staff E said the MDS was done for the facility's records and thought 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 a Pre-admission Screening and Resident Review (PASARR, an assessment used to ensure individuals with serious mental illness, intellectual or developmental disabilities and/or related conditions receive appropriate placement and services) assessment was completed to reflect accurate mental health diagnoses and failed to obtain a Level 1 PASARR 30 days after an exempted hospital discharge for 2 of 5 sampled residents (41 & 26) reviewed for PASARR. These failures placed residents at risk for not receiving necessary mental health services and a diminished quality of life. Findings included . 1) Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated [DATE], documented the resident was severely cognitively impaired. Resident 26's PASARR, dated [DATE], documented, No Level II evaluation indicated at this time due to exempted hospital discharge; Level II must be completed if 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to include residents and/or their representative in care conferences and having input into care decisions for 1 of 7 sampled residents (Resident 51) reviewed for care plan revisions. This failure placed residents at risk of not being fully informed about care decisions, not being able to provide input about care and treatment, and a diminished quality of life. Findings included . Resident 51 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 09/11/2023, showed Resident 51 was moderately cognitively impaired, participated in the MDS assessment, and his representative did not participate. Review of electronic medical record showed the last documented care conference was 03/16/2023. Documentation was not available to show the resident or his representative were offered or declined the care conference for care plans created in June and September 2023. On 10/24/2023 at 9:45 AM, Resident 51 did not recall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care with activities of daily living (ADLs) for dependent residents including fingernail care for 1 of 4 sampled residents (26) reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves. Findings included . Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 08/25/2023, documented the resident was severely cognitively impaired and required extensive assistance with personal hygiene ADLs. Resident 26's fingernail care record, dated April 2023 to October 2023, did not show documentation of a fingernail trimming for over six months. On 10/23/2023 at 3:17 PM, Resident 26 was observed with fingernails approximately ½ inch long, with dark debris noted under the fingernails of the right hand. On 10/25/2023 at 1:01 PM, Staff F, Certified Nursing Assistant, said Resident 26 required a lot of assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bowel interventions were initiated and failed to ensure resident weight gain was reported to the physician as ordered for 2 of 6 sampled residents (60 & 4) reviewed for quality of care related to bowel management and weight gain. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. Finding included . 1) The facility's policy entitled Bowel Protocol, revised 02/19, documented, 1. At the beginning of each shift [eight-hour shift], the Licensed Nurse will pull the Resident Bowel Management Report and identify resident that have not had a BM [Bowel Movement] for 3 days . The Licensed Nurse will review the residents MAR [medication administration record] to determine if the PRN [as needed] Bowel Protocol had been initiated by the previous shift. Resident 60 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/10/2023, showed 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 implement strategies for pressure ulcer prevention including turning and repositioning, air mattress, and zinc cream for 1 of 3 sampled residents (Resident 51) reviewed for pressure ulcer care. This failure placed residents at a high risk for recurrence of a recently closed pressure ulcer. Findings included . Resident 51 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/11/2023, showed Resident 51 was moderately cognitively impaired, required extensive assistance by two staff for bed mobility, had not transferred out of bed during the look back period, and was assessed to be at risk for developing a pressure ulcer. Review of electronic medical records showed Resident 51 had a Stage 4 (a pressure injury that extends to muscle, tendon or bone) in April 2023. Treatment orders included an air mattress overlay and a topical zinc cream to be applied to the sacrum (low 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 observation and interview, the facility failed to ensure oxygen equipment was monitored and sanitary for 1 of 1 sampled resident (Resident 17) reviewed for respiratory services. This failure placed residents at risk for unsanitary oxygen equipment, respiratory infections and a poor quality of life. Findings included . Resident 17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (airflow blockage and breathing related problems). The annual Minimum Data Set, an assessment tool, dated 07/03/2023, showed Resident 17 was able to make needs know and utilized oxygen therapy. Review of respirator care plan, dated 08/24/2022, showed staff were to Change O2 tubing, humidifier water, and clean concentrator filter per facility procedure and Check with rounds on night shift and re-place oxygen PRN (as needed). On 10/23/2023 at 3:54 PM, Resident 17 said she had recently been sick with pneumonia. The resident was observed to be wearing oxygen via nasal cannula at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide behavioral health care and services for 1 of 1 sampled residents (41) reviewed for behavioral health services. This failure placed residents at risk for not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings included . Resident 41 was admitted to the facility on [DATE] with diagnoses including depression, psychotic disorder (mental disorders characterized by disconnection from reality which results in strange behavior often accompanied by disturbances of thought and perception), and PTSD (post-traumatic stress disorder, mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). The 5-day Minimum Data Set, an assessment tool, dated 07/24/2023, documented the resident was cognitively intact. A physician's order, dated 07/26/2023, documented, Psych…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for target behaviors for 1 of 5 sampled residents (Resident 4) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 10/20/2023, documented the resident was cognitively intact. A physicians' order, dated 07/13/2023, documented Resident 4 was prescribed Citalopram (an antidepressant). Resident 4's Electronic Medical Record (EMR) did not show documentation of antidepressant medication target behavior monitoring. A physicians' order, dated 08/31/2023, documented Resident 4 was prescribed Quetiapine (an antipsychotic). Resident 4's EHR did not show documentation 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 ensure the pneumococcal vaccine was offered in a timely manner to 1 of 5 sampled residents (26) reviewed for immunizations. This failure placed residents at risk for developing pneumonia with potential negative outcomes. Findings included . Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 08/25/2023, documented the resident was severely cognitively impaired. Resident 26's pneumococcal vaccine consent, dated 02/17/2023, documented the resident consented to the administration of the PPSV23 vaccine, a type of pneumococcal pneumonia vaccine. Resident 26's medical record did not document administration of any pneumococcal vaccine. On 10/26/2023 at 10:46 AM, Staff E, Residential Care Manager and Licensed Practical Nurse, said Resident 26 had a pneumonia vaccine that was set to be given on 10/27/2023, 252 days after consent for the vaccine was obtained. Staff E said usually vaccines were given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 8 of 11 sampled residents (1, 2, 3, 4, 5, 6, 7 & 8) reviewed for ADLs for dependent residents. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 07/27/2023, documented the resident required 1 to 2-person extensive assistance with ADLs including 1-person total dependence with bathing. The facility shower schedule, undated, documented Resident 1 was scheduled for 2 showers a week. On 09/07/2023 at 12:18 PM, Resident 1 said she gets an average of one bed bath a week. Resident 1 said she does not feel clean and feels undignified. Resident 1 said she would like to have at least 2 bed baths a week. The bath report documented Resident 1 received 6 of 8 bath or…

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