Cashmere Post Acute

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of transfer to the hospital for 1 of 3 residents (Resident 10) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility.Findings included. Review of a policy titled, Bed Hold Notice, dated 2025, showed the facility would provide written information to the resident and/or their representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization or therapeutic leave (a planned temporary absence from the facility for non-medical reasons). Review of the medical record showed Resident 10 was admitted to the facility with diagnoses including end stage renal disease (permanent kidney failure where kidney function is less than 10% and they can no longer function on their own), diabetes (a condition of having too much…

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 Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission for 1 of 5 residents (Resident 81 ) and updated when new SMIs were identified. and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 1 of 5 residents (Resident 3) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings Included . Review of the facility policy titled Coordination with PASRR Program, dated 2025, showed all applicants to the facility would have a Level I PASAAR for SMI, ID/DD, and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure fluids were readily available and provided to 1 of 3 residents (Resident 88) and to identify and monitor skin bruising for 1 of 4 residents (Resident 79) reviewed for quality of care. This failure placed the residents at risk for excessive thirst, dehydration, further skin injury and serious adverse health conditions. Findings included . Review of a policy titled, Provision of Quality Care, dated 2025, showed the facility would ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Resident 88 Review of the medical record showed Resident 88 was admitted to the facility with diagnoses including hemiplegia and hemiparesis (complete paralysis and weakness on one side of the body) following a stroke (a medical emergency that occurs when blood flow to the brain is blocked or a vessel bursts, causing rapid brain cell…

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 that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding a resident history of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event) for 1 of 5 residents (Resident 81) reviewed for trauma-informed care .This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Record review of the facility policy titled Trauma-Informed Care, dated 2026, showed: .The facility will recognize how trauma affects individuals through evaluation and identification of triggers during the admissions process. The facility will develop an appropriate plan of care and interventions based upon the residents' triggers and will modify the plan of care for any changes in behavior . Review of 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 observation, interview, and record review, the facility failed to ensure expired medications were destroyed in 1 of 1 medication room and failed to ensure refrigerated medications were stored at proper temperatures in 1 of 1 medication refrigerator. These failures placed residents at risk of receiving medications that could cause unintended outcomes due to improper storage and compromised efficacy. Findings Included. Review of the facility's undated policy titled, Medication Storage, showed to ensure all medications would be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. During an observation on 04/01/2026 at 9:37 AM, the facility medication room showed the following expired supplies and medications were identified: Three port access kits (sterile, all-in-one kit that contains all necessary components to safely access an implanted venous access device [port] for medications 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.

Based on interview and record review, the facility failed to ensure there was a designated Infection Preventionist (IP) who worked at least part-time at the facility and was responsible for the facility's Infection Control and Prevention Program (IPCP), including implementation of infection prevention measures to prevent the spread of communicable diseases. These failures placed the residents at risk for transmission of infectious disease and unmet care needs. Findings included . Review of the undated policy titled, Infection Preventionist, showed the infection preventionist was employed on site and at least part time. They were scheduled with enough time to properly assess, develop, implement, monitor, and manage the IPCP, address training requirements, and participate in required committees such as Quality Improvement and Performance Improvement (QAPI). Review of the Facility Assessment (FA), dated 09/20/2024, showed the need for an IP to develop and regularly update infection control protocols, personal protective equipment availability, and vaccination availability. The FA did…

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, within 48 hours of admission, that documented resident-specific goals and treatment plans for 3 of 4 residents (Residents 48, 196, and 9) reviewed for baseline care plan. Failure to develop a baseline care plan placed the residents at risk of not receiving continuity of care and resident centered care needs. Findings included . Review of an undated policy titled Baseline Care Plan, showed the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care. The baseline care plan would be developed within 48 hours of a resident's admission and it was to include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) and dry goods that did not have the proper labels and dates for food safety tracking for 1 of 1 kitchen reviewed, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses. Findings included . Review of the Washington State Retail Food Code [PHONE NUMBER]6(1)(2)(a,b)(3)(4), dated March 1, 2022 showed ready-to-eat or refrigerated, time/temperature control for food safety must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises. Prepared foods must have the date or day of preparation, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident's right to choose important aspects of their life, including frequency of showers and meal preferences for 2 of 3 residents (Residents 87 and 22) reviewed for choices. This failure disallowed Resident 87 the opportunity to increase their weekly showers and Resident 22 the right to dietary preferences. Findings included . Review of an undated policy titled, Resident Rights, showed the resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <Resident 87> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include bi-polar disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking and behavior), and personality disorder (long-term patterns or behaviors and inner experiences that differ significantly from what is expected). The 11/20/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain confidentiality of medical conditions through posting of signs in a Resident's room for 1 of 7 residents (Resident 84) reviewed for resident's rights. Posting a sign that identified a medical condition, prevented protection of residents' right to privacy of a medical condition. Findings included . Review of the resident's medical records showed they admitted on [DATE] with diagnoses to include schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). The 11/29/2024 comprehensive assessment showed Resident 84 ' s cognition was severely impaired. An observation on 01/06/25 at 2:31 PM, showed a laminated sign with bold black lettering on the wall above Resident 84's bed that stated, I have schizophrenia, I come in and out of reality (not from drugs), I'm also blind feed me half meals, I love my room cool and love tons of water. During an interview on 01/09/2025 at 1:23 PM, Staff I,…

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

Based on observation and interview, the facility failed to ensure a sanitary and homelike environment for 1 of 1 shower room reviewed for environment. This failure placed residents at risk for not having a comfortable and homelike experience during showers. Findings included . Review of the undated policy titled, Resident Rights, showed the resident had the right to a safe, clean, comfortable and homelike environment, including treatment and support for safe daily living. <Shower Room> An observation and interview on 01/09/2025 at 8:50 AM, showed the shower room had a staff desk, desk chair, and cabinet across from the entrance door, against the adjacent wall. The top of the desk had a laptop and computer tablet, a clipboard of resident names for bathing/showering, tape dispenser, and a pen. The cabinet top contained a notebook, a personal large pink jug, half full of clear fluid, and a black shaker cup. The top shelf of the cabinet had a pink cell phone, an Apple watch, a personal large silver drink tumbler, a small red and white gift bag, and an open box of tissues. The wall above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 4 residents (Residents 27 and 58), reviewed for hospitalization. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and monetary charges associated with the bed hold while in the hospital. Findings included . Review of the undated facility policy titled Bed Hold Prior to Transfer, showed the facility would provide written information to the resident/resident representative prior to transferring to the hospital. The written information would include the duration of the bed-hold, reserve bed payment, and facility policies regarding bed-hold periods to include permitting residents to return to the facility. <Resident 27> Review of Resident 27's medical record showed the resident admitted to the facility on [DATE] with diagnoses including 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] assessment accurately reflected residents' mental health conditions for 3 of 6 residents (Resident 51, 55, and 84) reviewed for unnecessary medications. Additionally, the facility failed to ensure a PASARR was completed prior to admission for 1 of 6 residents (Resident 9) reviewed for PASARR screening on admissions. These failures placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . Record review of an undated policy titled, Resident Assessment - Coordination with PASARR Program, showed the Social Services Director (SSD) was responsible to ensure all applicants to the facility were screened for serious mental disorders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive Care Plans (CPs) for one of seven residents (Resident 27) whose CPs were reviewed. The failure to develop and/or implement comprehensive CP interventions left residents at risk for unmet care needs and other negative health outcomes. Findings included . <Resident 27> Review of Resident 27's medical record showed the resident was admitted to the facility on [DATE]. The resident had medically complex diagnoses including a heart condition that could cause fluid in the lungs. The comprehensive assessment dated [DATE], showed Resident 27's cognition was intact and able to make decisions regarding their care. During a concurrent observation and interview on 1/08/2025 at 2:24 PM, Resident 27 stated he had not worn their pulmonary vest in a long time and staff had not asked them about it nor documenting the use of their inhaler. Review of the medical record showed an 11/18/2024 physician's order directing staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a process of monitoring daily fluid intake for residents with a physician's order for daily fluid restriction for 1 of 2 residents (Resident 196) reviewed for quality of care. Additionally, the facility failed to identify and provide needed care and services for 1 of 2 residents (Resident 4) reviewed for positioning. These failures placed the residents at risk for health complications and poor clinical outcomes. Findings included . Review of an undated policy titled, Fluid Restriction, showed the nurse would obtain and verify the physician's order for a fluid restriction that included the breakdown of the amount of fluid per 24 hours, to be divided between the food and nutrition department and the nursing department. The fluid intake would be recorded on the medication record. Water would not be provided at the bedside unless calculated into the daily total fluid restriction. <Fluid Restriction> <Resident 196> Review…

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 an effective pain management program for 1 of 3 residents (Resident 51) reviewed for pain management. This failed practice placed the residents at risk for unmanaged pain and emotional distress. Findings included . Review of an undated policy titled, Pain Management, showed the facility must ensure a pain management program was provided to residents that was consistent with professional standards of practice, in accordance with the comprehensive, person-centered care plan, and the resident's goals and preferences. Pharmacological interventions would follow a systemic approach for selecting medications to treat pain. The facility would consider administering medication around the clock instead of as needed (PRN) or combining longer acting medications with PRN medications for breakthrough pain. Opioids (prescription pain medications like oxycodone) would be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their…

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 a medication error rate of less than five percent. Two medication errors were identified for 2 of 10 residents (Residents 345 and 8) observed during 26 medication administration opportunities that resulted in an error rate of 7.69%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . Review of the undated policy titled, Insulin Pen, [a pre-filled disposable device containing (insulin - medication to control blood sugar in the blood)] showed when the insulin pen needle was inserted into the skin, the plunger (button) was to be depressed and held into the skin for six to 10 seconds and then removed from the skin. Review of the Instructions for use for an insulin pen by the U.S. Food and Drug Administration revised 07/2023 stated to insert the needle into the skin, press plunger all the way down, and continue to hold the plunger and slowly count to six prior…

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 expired medications were removed from use for 2 of 4 medication carts (South and North) and 1 of 4 medication carts (East), and 1 of 2 wound carts were secured when unsupervised. Additionally, the facility failed to follow Centers for Disease Control (CDC) guidance for temperature monitoring of vaccines in 1 of 1 medication storage refrigerator located in the medication storage room. These failures placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications and vaccines and access to potentially harmful medications and negative health outcomes. Findings included . Review of the undated policy titled, Medication Storage, showed all medications and biological's would be stored and locked and under proper temperature control. The policy also showed the medication carts, when not under direct supervision, must be locked. Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, 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 implement an effective Infection Control and Prevention Program (IPCP) including implementation of infection prevention measures to mitigate the spread of infection in the areas of hand hygiene for 1 of 1 staff (Staff Q) during dining service, cleaning of equipment for 8 of 8 staff (Staff W, Y, S, V, T, U, AA, and BB) during transfers with a mechanical lift, wound care for 1 of 1 staff (Staff C) while performing a dressing change, enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) for 7 of 7 staff (Staff EE, L, CC, FF, GG, HH, and N) during high contact resident care, transmission-based precautions (additional infection control precautions used in healthcare to prevent the spread of disease) for 2 of 2 staff (Staff U, and AA) while in an isolation room, and food service for 4 of 4 meal carts (Main, North, East, and West) during meal service. These failures…

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 thoroughly investigate an incident involving a missing resident for 1 of 3 residents (Resident 1) reviewed for elopement (when a resident leaves the premises or a safe area without authorization or appropriate supervision). The failure to complete a thorough investigation placed the resident at risk for re-elopement and other negative health outcomes. Findings included . <Resident 1> Review of the resident's medical records showed they were admitted to the facility with diagnoses to include an infection to their right lower extremity and a substance use disorder (a medical condition that is defined by the inability to control the use of a particular substance or substances despite harmful consequences). The 11/27/2024 comprehensive assessment showed Resident 1's cognition was intact and they were independent for transfers and walking. Review of Resident 1's 12/04/2024 incident investigation showed Resident 1 left the facility at around 8:00 AM unsupervised and without the staff's knowledge, nor did the resident sign out.…

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 received substance use disorder (SUD, a medical condition that is defined by the inability to control the use of a particular substance or substances despite harmful consequences) assessments and interventions for 3 of 3 residents (Residents 1, 2, and 3) reviewed for elopement (when a resident leaves the premises without authorization or necessary supervision to do so). Additionally, the facility failed to timely implement all aspects of their elopement process when Resident 1 eloped from the facility twice. These failed practices placed residents at risk for unidentified risk factors and preventable accidents. Findings included . Review of a policy titled, Safety for Residents with Substance Use Disorder, dated 2024, showed residents would be assessed for risks, including the potential to leave the facility without notification, and use of illegal/prescription drugs to include a Care Plan (CP) with increased monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 1) and/or their representative was informed of an increase in their monthly financial responsibility before charging the debit card on file. This deficient practice placed residents at risk of financial hardship and potential loss of other benefits. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of left hip fracture, osteoporosis, and severe obesity. Review of the comprehensive assessment, dated 07/03/2024, showed Resident 1 had intact cognition, required the assistance of two people for bed mobility, personal cares and required the use of a mechanical lift for transfers. Review of the admission Agreement, signed by Resident 1 on 04/21/2022, showed residents .will be notified about any rate changes at least thirty (30) days in advance. Review of the medical record showed the facility received written notification, dated 11/25/2023, 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.

Based on observation, interview, and record review, the facility failed to ensure 5 of 5 nursing assistants registered (P, Q, R, S and T) met competency requirements defined under State Law, for license and certification. This failure placed residents at risk to receive care from an unlicensed staff. Findings included . Record review of Staff P's employee files, showed they were hired on 10/24/2022 as a hospitality assistant. Documentation in the employee file showed Staff P had completed their competency course for the nursing assistant certified (NAC) class on 03/01/2023 and began working in the facility as a Nursing Assistant Registered (NAR). However, they had not completed the nursing assistant competency test for certification within the required four months as per the regulation. Record review of Staff Q's employee files, showed they were hired on 10/24/2022 as a hospitality assistant. Documentation in the employee file showed Staff Q had completed their competency course for the NAC class on 03/01/2023 and began working in the facility as a NAR. Staff P did not complete 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 observation, interview, and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 4 of 5 residents (Residents 22, 35, 24, and 188) reviewed for unnecessary psychotropic medications. The facility failed to monitor targeted behaviors and adverse side effects (unwanted, uncomfortable or dangerous effects from medications), ensured there were valid indications/conditions diagnosed for resident psychotropic medication use, document rationale for the continuous use of as needed (PRN) psychotropic medication, consistently attempt non-pharmacological interventions (alternative treatment of a resident's symptoms that do not involve medications and directed toward understanding, preventing and relieving a resident's distress or loss of abilities) prior to psychotropic medication use. These failures placed residents at an increased risk for falls, experiencing medication-related…

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 the resident, Resident Representative (RR), or payee were notified when their personal funds account reached a balance that was below $200 of the Social Security Income (SSI, a monthly Social Security benefit for people with low incomes, limited resources and who are blind, disabled or 65 or older) resource limit of $2000, for 1 of 5 residents (Resident 24) reviewed for personal funds. This failed practice placed the resident at risk of losing their Medicaid (a federal system of health insurance for those requiring financial assistance) or SSI eligibility. Findings included . Review of the facility's undated policy, titled Resident Personal Funds showed, residents who received Medicaid benefits would be notified when their personal funds account reached less than $200 of the resource limit for one person. The policy further showed if the account reached the resource limit for one person, the resident could lose eligibility for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a process to assist residents and/or their representatives in the development and periodic review of Advanced Directives (AD) for 2 of 3 residents (Resident 60 and 19) reviewed for AD. This deficient practice denied the residents and/or their representatives the opportunity to make their choices known, regarding end-of-life care. Findings included . Review of the facility's undated policy titled, Resident's Rights Regarding Treatment and Advanced Directives, showed that: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate one. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. Any decision making regarding the resident's choices will be documented in the resident's medical…

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 required liability notice for 1 of 3 residents (Resident 77) reviewed for liability notices, who was discharged from the facility and had skilled benefit days remaining. This failure placed the resident at risk for not fully understanding their Medicare benefits. Findings included . Review of the form titled Form instructions for the Notice of Medicare Non-coverage, dated 12/31/2011 showed that the Medicare provider or health plan must give an advanced, completed copy of the Notice of Medicare Non-Coverage (NOMNOC) to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services not later than two days (48 hours) before the termination of services. <Resident 77> Review of the comprehensive assessment, dated 10/03/2023, showed Resident 77 was admitted on [DATE] with diagnoses to include fracture of spine, muscle weakness and chronic pain. The comprehensive assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement a system for notifying residents of the grievance process or how to report a grievance (verbally, in writing or anonymously) for 16 of 16 residents (Residents 5, 243, 15, 18, 19, 37, 38, 45, 47, 60, 65, 66, 81, 82, 239 and 241) reviewed during resident council. Additionally, the facility failed to consistently follow up on missing items and concerns voiced during resident council meetings. This failure placed residents at an increased risk for unresolved concerns, their right to express their concerns and unmet care needs. Findings included . Review of the undated facility policy titled, Resident and Family Grievance, showed grievances may be expressed, anonymously, verbally or in writing to facility staff, the grievance official, during resident or family council meetings, and through the customer service line. The policy showed that a grievance form would be filled out, by facility staff, with detailed specifics of the concerns. 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, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident's freedom of movement) when applying foam wedges under the resident's bed linen which prevented the resident from getting out of bed, for 1 of 1 resident (Resident 42) reviewed for physical restraints. This failure placed the resident at risk for the inhibition of free movement and/or activity and unmet care needs. Findings included . <Resident 42> Review of Resident 42's medical record showed they were admitted on [DATE] with diagnoses including Alzheimer's (an impairment of brain function, which causes memory loss, forgetfulness and thinking abilities) and a history of falls. Review of the most recent comprehensive assessment, dated 10/13/2023, showed Resident 42's cognition was severely impaired and was dependent on facility staff for eating, oral hygiene, bathing, dressing, personal hygiene, rolling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the state agency for 1 of 6 residents (Resident 55) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential for ongoing abuse and/or neglect. Findings included . Review of facility's undated policy titled, Abuse, neglect and exploitation, showed, .reporting of all alleged violations to the Administrator, state agency .and to all other required agencies within specified timeframes .Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. <Resident 55> Review of Resident 55's medical record showed the resident re-admitted to the facility on [DATE] after a two day stay in the hospital for assessment and evaluation for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct a thorough or complete investigation following allegations of rape and/or abuse for 1 of 6 residents (Residents 55) reviewed for abuse. This failure placed the resident at risk for unidentified abuse, unmet care needs, and the potential continued exposure to abuse. Findings included . Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, showed, when abuse, neglect, or exploitation was suspected, or reported, an immediate investigation would be started. The policy further showed the facility would ensure residents were protected from physical and psychosocial harm or further abuse during and after the investigation. <Resident 55> Review of Resident 55's medical record showed the resident readmitted to the facility on [DATE] after a two day stay at the hospital related to a fall. Resident 55 admitted with diagnoses to include depression and dementia (a group of symptoms affecting memory, thinking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) to address anticoagulant (a high-risk, blood thinning medication) use for 1 of 6 residents (Resident 26) reviewed for activities of daily living. This failure placed the resident at risk for unrecognized adverse side effects (ASE) and unmet care needs. Findings included . <Resident 26> Review of Resident 26's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include a blood clotting disorder in the lungs and a left arm fracture. Review of the comprehensive assessment, dated 10/04/2023 showed the resident was cognitively intact, had weakness to their left arm that remained after recovery from the fracture, and required staff assistance with sitting to standing, showering, and walking. The assessment further showed the resident received an anticoagulant on 7 days during the lookback period. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that 2 of 2 residents (Resident 27 and 55) reviewed for constipation were assessed daily for frequency of bowel movements, and signs and symptoms of impaction or obstruction, in accordance with professional standards of practice. Additionally, the facility failed to develop an integrated comprehensive care plan for 1 of 1 resident (Resident 246) reviewed for Hospice. These failures placed residents at risk for medical complications and unmet care needs. Finding included . <Bowels> <Resident 27> Review of Resident 27's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include respiratory failure and heart failure. Review of the significant change assessment, dated 11/06/2023, showed the resident's cognition was intact and required staff assistance for their bed mobility, transfers, toileting, and personal hygiene. During a concurrent observation and interview on 11/08/2023 at 12:08 PM, showed Resident 27 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 1 resident (Resident 54), reviewed for urinary catheter care. This placed the resident at risk of developing medical complications, secondary to an infection in the bladder. Findings included . Review of Lippincott Nursing Procedures 8th edition, dated 2019, showed when performing IUC care (cleaning of the IUC tubing and urinary meatus), .to avoid contaminating the urinary tract, always clean by wiping away from, never towards, the urinary meatus .keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases 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 medications were adequately monitored and/or administered within the physician ordered parameters (instructions to ensure medications are properly given and may prevent unwanted effects) for 2 of 7 residents (Residents 22 and 29) reviewed for unnecessary medications. These failures placed residents at an increased risk for adverse side effects, unintended medical complications, and unmet care needs. Findings included . <Resident 22> Review of the resident's medical record showed they were admitted on [DATE] with diagnosis including heart failure, long-term kidney disease and orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down). Review of Resident 22's comprehensive assessment, dated 10/05/2023, showed they were cognitively intact and able to make their needs known. Review of Resident 22's physician orders, dated 10/04/2023, showed Midodrine (a medication used for treatment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled, dated, or discarded in accordance with currently accepted professional standards for 1 of 1 medication room and 2 of 4 medication carts (West and East carts). This deficient practice placed residents at risk of receiving compromised or inaccurate medications and had the potential for misappropriation of residents' property. Findings included . Review of the undated facility policy titled Medication Storage showed medication rooms were routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications were to be destroyed in accordance with the Destruction of Unused Drugs policy. Review of the undated facility policy titled Destruction of Unused Drugs showed all unused, unwanted, and non-returnable medications should be removed from the storage area and destroyed and disposed of in compliance with all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices for 4 of 4 residents (Resident 246, 189, 190 and 54 ) were implemented related to hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment and during wound care dressing changes). These failures placed the residents at an increased risk for exposure to cross-contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of Centers for Disease Control and Prevention (CDC) guidance, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/2022, showed; Healthcare personnel should use an alcohol-based hand rub or wash with soap and water after they touched a resident or their environment; After contact with contaminated surfaces; Immediately after glove removal; Wash hands for at least 15 seconds; Do not use the same pair of gloves for care 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.