South Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident medications ordered by a provider were administered for 1 of 5 sampled residents (Resident 1) reviewed for medication administration. This failure placed residents at risk of delayed healing, unmet care needs, and a diminished quality of life. Findings included. Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 10/22/2025, documented the resident had a wound infection and was cognitively intact. Record review of Resident 1's Antibiotic Medication Care Plan, dated 11/11/2025, documented the intervention, Administer medication as ordered. Record review of Resident 1's Providence Swedish Infectious Disease Clinic Provider Orders, dated 10/15/2025 at 10:05 AM, documented, Meropenem [an antibiotic] 1g [gram] IV [Intravenously] every 8 hours. Record review of Resident 1's Providence Swedish progress note, dated 10/07/2025 and sent to the facility on [DATE], documented, Recommended patient…

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 thoroughly investigate a fall for 1 of 3 sampled residents (Resident 1) reviewed for facility investigations. This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included.Resident 1 admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 06/25/2025, documented the resident was cognitively intact. Record review of Resident 1's smoking care plan, dated 07/10/2025, documented the intervention, Supervision provided while resident is smoking. Record review of Resident 1's smoking assessment, dated 07/10/2025, documented, Patient is unable to safely get to smoking area independently and has cognitive impairment. Patient is unable to safely smoke independently. Record review of Resident 1's fall investigation, dated 07/12/2025, documented, NAC [Nursing Assistant Certified] assisted resident outside to watch patient smoke. NAC witnessed resident slide out of wheelchair,…

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 vital signs were obtained upon admission to the facility and before administration of a blood pressure medication for 1 of 4 sampled residents (Resident 1) reviewed for vital signs monitoring. This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included. Record review of the facility policy, Admitting the Resident: Role of the Nursing Assistant, dated September 2013, documented, The following information should be recorded in the resident's medical record. The resident's vital signs. Resident 1 admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 06/15/2025, documented the resident was cognitively intact. The resident discharged from the facility on 06/15/2025. Record review of Resident 1's physician's order, dated 06/16/2025, documented, [check] Blood Pressure weekly prior to giving antihypertensive [blood pressure] medication. Notify MD [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 observation, interview, and record review, the facility failed to ensure it was in compliance with state and local laws and regulations when the facility allowed 2 of 2 sampled Nurse Technicians (Staff D and Staff E) to administer scheduled medications and IV (intravenous) medications. This failure placed residents at risk of medication errors, injury, and a diminished quality of life. Findings included . [NAME] Administrative Code 246-840-870 documented, The nursing technician is authorized only to perform specific nursing functions within the limits of their education, up to their skills and knowledge, as verified by their nursing program. The nursing technician . May not administer chemotherapy, blood or blood products, intravenous medications, scheduled drugs, nor carry out procedures on central lines. Staff D, Nurse Technician, was first credentialed as a nurse technician on [DATE]. Staff D's nurse technician credential expired on [DATE]. Staff E, Nurse Technician, was first credentialed as 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 obtain and/or maintain Advance Directives (AD) for 2 of 20 sampled residents (59 & 65) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Review of the facility's policy entitled, Advance Directives, dated September 2022, documented, .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 1) Resident 59 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment, dated 02/27/2025, documented Resident 59 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to obtain an assessment, consent, and/or physician's order regarding bed rails for 2 of 3 sampled residents (264 & 50) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy entitled, Physical Restraint Application, dated October 2010, documented, .Preparation 1. Verify physician's order for the use of restraints . 1) Resident 264 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set (MDS) assessment, dated 04/09/2025, documented Resident 264 was severely cognitively impaired. Review of Resident 264's Electronic Health Record (EHR) did not show an assessment, resident and/or representative consent, or physician's order related to bed rails. On 04/08/2025 at 10:53 AM, Resident 264's bed was observed with a padded covered bed rail, about one third length of the bed, on the upper…

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 coordinate the Preadmission Screen and Resident Review (PASARR) for Level II services for 2 of 7 sampled residents (36 & 54) reviewed for PASARR. This failure placed residents at risk of not receiving the necessary mental health services and diminished quality of life. Findings included . Per Facility policy, entitled [PASARR] Screening for Mental Disorder/Intellectual Disability, revised 01/22/2025, documented, A positive Level I Screen (PASARR Indicates that individual required PASARR Level II Referral) necessitates an in-depth evaluation of the individual by the state-designated authority PASARR Level II) which must be conducted prior to admission to a nursing facility OR upon identification that the individual may need a Level II PASARR Referral while at the Nursing Facility. 1) Resident 36 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 03/30/2025, indicated Resident 36 was moderately cognitively…

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) assessment was completed to reflect accurate mental health diagnoses for 1 of 7 sampled residents (94) reviewed for PASARR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life. Findings included . Per Facility policy, entitled [PASARR] Screening for Mental Disorder/Intellectual Disability, revised 01/22/2025, showed, 2. The PASARR process requires all individual be screened for possible serious mental disorders or intellectual disabilities and related conditions. The initial pre-screening [PASARR level I] should be completed prior to admission to facility. A negative level I requires no further action. Resident 94 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health condition characterized by symptoms of both schizophrenia, like delusions and hallucinations; and a mood disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a person-centered activities care plan for 1 of 6 sampled residents (97) reviewed for activities. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 97 was admitted to the facility on [DATE]. The admission Medicare - 5 Day Minimum Data Set assessment, dated 03/06/2025, documented Resident 97 was severely cognitively impaired. Review of Resident 97's electronic health record (EHR) did not show a care plan addressing activity preferences, goals or interventions. On 04/07/2025 at 11:00 AM, Resident 97 was observed lying in bed sleeping. At 12:38 PM, Resident 97 was observed lying in bed sleeping. At 2:35 PM, Resident 97 was observed lying in bed. On 04/09/2025 at 9:42 AM, Resident 97 was observed lying in bed. On 04/10/2025 at 11:21 AM, Resident 97 was observed lying in bed sleeping. At 1:01 PM, Resident 97 was observed lying in bed. On 04/11/2025 at 8:54 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice with inaccurate enteral nutrition (method of providing nutrition directly into the gastrointestinal tract via a feeding tube) pump settings and not documenting medication administration for 1 of 1 sampled residents (101) reviewed for professional standards of practice. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 101 was admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing). The admission Medicare - 5 day Minimum Data Set assessment, dated 03/23/2025, documented Resident 101 was moderately cognitively impaired and required extensive assistance with activities of daily living. <Enternal Nutrition Pump Settings> A review of Resident 101's electronic health record (EHR) showed a physician order dated 03/28/2025, Enteral Feed Order in the evening Enteral Feeding…

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 assistance was provided with shaving for 1 of 3 sampled residents (59) reviewed for Activities of Daily Living (ADL) for Dependent Residents. This failure placed residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life. Findings included . Resident 59 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set assessment, dated 02/27/2025, documented Resident 59 was severely cognitively impaired and was dependent on assistance for personal hygiene. On 04/07/2025 at 11:45 AM, Resident 59 was observed lying in bed with thick facial hair about one quarter inch long on her upper lip and chin. Resident 59 said it bothered her when she had hair on her chin and lip. On 04/08/2025 at 10:40 AM, Resident 59 was observed with thick upper lip and chin hair about one quarter inch long. On 04/09/2025 at 8:40 AM, Resident 59 was observed with thick upper lip and chin hair present 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 observation, interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 1 of 1 sampled resident (97) reviewed for activities. This failure placed residents at risk of a decreased quality of life. Findings included . Resident 97 was admitted to the facility on [DATE]. The admission Medicare - 5 Day Minimum Data Set assessment, dated 03/06/2025, documented Resident 97 was severely cognitively impaired. Review of Resident 97's electronic health record (EHR) did not show a care plan addressing activities preferences, goals or interventions. On 04/07/2025 at 11:00 AM, Resident 97 was observed lying in bed sleeping. At 12:38 PM, Resident 97 was observed lying in bed sleeping. At 2:35 PM, Resident 97 was observed lying in bed. On 04/09/2025 at 9:42 AM, Resident 97 was observed lying in bed. On 04/10/2025 at 11:21 AM, Resident 97 was observed lying in bed sleeping. At 1:01 PM, Resident 97 was observed lying in bed. On 04/11/2025 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 initiate bowel interventions for 6 of 7 sampled residents (37, 50, 86, 92, 102 & 105) reviewed for quality of care related to bowel management. This failure placed residents at risk for health complications and a diminished quality of life. Findings included . Review of facility's bowel policy entitled Bowel Protocol, revised on 09/2024, documented, .1. At the beginning of each shift (based on an eight-hour shift), the Licensed Nurse will pull the Resident Bowel Management Report and identify residents that have not had a BM (Bowel Movement) for 3 days. (please run the report for last 7 days and check the box Include residents regardless of Bowel Alert Status). 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. Bowel movements are charted every shift by CNA (Certified Nurse Assistant). 2. Unless resident is physically unable…

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 continuous supplemental oxygen (O2) was provided for 1 of 4 sampled residents (97) reviewed for respiratory care and services. This failure placed residents at risk of discomfort, medical decline and a diminished quality of life. Findings included . Review of the facility's policy entitled Oxygen Administration, revised October 2010, documented, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 3. The rate of oxygen flow, route, and rationale. 5. The reason for p.r.n. (as needed) administration . Resident 97 was admitted to the facility on [DATE]. The admission Medicare - 5 Day Minimum Data Set assessment, dated 03/06/2025, documented Resident 97 was severely cognitively impaired. Review of physician's order, dated 03/02/2025, noted, O2 @ 1-5 L(liters)/min(minute) per NC (Nasal Cannula) as needed SpO2 (oxygen saturation) < (less than) 88% as needed 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 interviews and record review, the facility failed to complete behavior monitoring and intervention assessments for 1 of 5 sampled residents (36) reviewed for psychotropic medications. This failure placed residents at risk for receiving unnecessary medications and a diminished quality of life. Findings included . Resident 36 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, dated 03/30/2025, indicated Resident 36 was moderately cognitively impaired. Resident 36's April 2025 physician orders showed Resident 36 was taking medications for anxiety, depression, and psychosis. The Electronic Health Record (EHR) for Resident 36 did not include monitoring of behavioral symptoms or intervention for psychotropic medication use. On 04/10/2025 at 9:10 AM, Staff O, Nursing Assistant said she would look at the [NAME] to find specific information about resident behaviors and interventions. Staff O was unable to find specific behavior monitoring or interventions for Resident 36 on 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 medications were properly stored and labeled in 1 of 4 medication carts (Middle South) reviewed for medication storage. This failure placed residents at risk for receiving the wrong medication, adverse outcome, and a diminished quality of life. Findings included . Review of the facility's policy entitled, Medication Labeling and Storage, undated, documented .Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medication of several residents. On 04/10/2025 at 11:11 AM, the Middle South medication cart was observed with Staff S, Licensed Practical Nurse. The top drawer of the medication cart contained about six or seven loose plastic medication cups with multiple unlabeled medications in each cup. The plastic medication cups had writing on them of a room number. Staff S quickly grabbed all the plastic medication cups…

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 they were compliant with infection prevention and control guidelines and practices when staff did not clean and disinfect shared medical equipment between resident use on 2 of 2 hallways (North & South) reviewed for infection prevention and control. This failure placed residents, staff and visitors at risk for potential infection. Findings included . On 04/09/2025 at 9:48 AM, a facility staff was observed removing a Hoyer lift (a device used to help caregivers safely transfer individuals with mobility limitations from surface to surface) from room [ROOM NUMBER] and placed it in the hallway. Staff did not disinfect the Hoyer lift. At 3:14 PM, Staff V, Nurse Assistant Registered (NAR), was observed leaving room [ROOM NUMBER] with a vital sign (VS) machine (takes blood pressure, pulse and oxygen) after using it on the resident in Bed 1. Staff V did not disinfect the machine. At 3:26 PM, Staff V was observed going back into room…

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 bed rails were securely fastened to the bed and without gaps between the mattress and bed rail for 1 of 3 sampled resident (264) reviewed for physical restraints. This failure placed residents at risk for injury and/or entrapment. Findings included . Resident 264 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 04/09/2025, documented Resident 264 was severely cognitively impaired. On 04/08/2025 at 10:53 AM, Resident 264's bed was observed with a padded covered bed rail, about one third length of the bed, on the upper right side of the bed. The bed rail was observed to be loose with about six to seven inches of movement back and forth, and leaning six to seven inches out from the mattress. The bracket attaching the bed rail to the bed frame was observed to be loose. On 04/09/2025 at 8:45 AM, Resident 264 was observed lying in bed. Resident 264's right side bed rail was observed to be loose.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure resident care plans were updated after a change in condition for 1 of 3 sampled residents (Resident 1) reviewed for care plan revisions. This failure placed residents at risk for unmet care needs and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The discharge return anticipated Minimum Data Set assessment, dated 02/19/2025, documented the resident was moderately cognitively impaired. Resident 1's skin care plan, initiated 11/05/2024 and revised 02/20/2025, documented, Skin: Resident is at risk for skin breakdown related to decreased mobility and activity level, length of time in dialysis chair, diabetes, and ESRD [end stage renal disease]. At risk of continued skin breakdown and infections related to multi system organ failure secondary to ESRD and Liver failure. The skin care plan did not reference a wound to the resident's genitalia (reproduction organs). A communication with provider…

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, after a planned hospitalization, the resident was readmitted to the facility for 1 of 1 sampled residents (Resident 1) reviewed for permitting residents to return to the facility. This failure placed residents at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life. Findings included . A facility policy, entitled Bed-Holds and Returns, revised October 2022, documented, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. The policy noted, If the facility determines that a resident cannot return, the facility must comply with the requirements of the facility-initiated discharge. Resident 1 was admitted to the facility on [DATE]. The discharge return anticipated Minimum Data Set, an assessment tool, dated 01/06/2025, documented the resident had a chronic ulcer to 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 resident was assessed after an unwitnessed fall for 1 of 2 sampled residents (Resident 1) reviewed for quality of care related to falls. This failure placed residents at risk of undiagnosed injuries, increased pain, and a decreased quality of life. Findings included . A facility policy, entitled Falls-Clinical Protocol, dated March 2018, documented, The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 11/26/2024, documented the resident was cognitively intact and required some assistance with Activities of Daily Living (ADLs). Resident 1's progress notes, dated 12/18/2024 through 01/17/2025, were reviewed for nurses notes and assessments related to a fall on 12/31/2024. No progress notes were found related to the 12/31/2024…

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.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in a clean, dry and sanitary manner and in accordance with professional standards of cleanliness and food safety for 1 of 1 dry storage rooms and 1 of 1 juice dispensing areas reviewed for cleanliness and food safety. The failure placed residents at risk for food borne illness, ingestion of contaminated food or beverages, cross contamination, and a diminished quality of life. Findings included . A facility policy entitled Food Receiving and Storage, undated, documented, Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage at all times. <Dry Storage Area> On 01/03/2025 at 10:55 AM, the dry storage area was observed with Staff C, Dietary Manager. There was a pink, wheeled cart in the corner of the storeroom. Under the pink cart was clear and brown liquid and approximately 2-3 square feet of a black, spotted substance on the floor and creeping up the baseboards. The floor underneath and behind the wheeled shelving, that stored food,…

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 provide repair and maintenance services for a safe and sanitary environment in 1 of 1 kitchen floors reviewed for safe and functional environment. This failure placed residents at risk for infection by not having cleanable and maintained surfaces. Findings included . On 01/03/2025 at 11:30 AM, the kitchen floor was observed with broken linoleum tiles near and around the dishwashing station and a handwashing station. Bare concrete was showing in these areas, approximately 5 square feet at the dishwashing station and approximately 2 square feet at the handwashing station. At 11:31 AM, Staff D, Maintenance Director, said he was aware of the need to replace the kitchen floor, and in the meantime placed mats down on the exposed area. On 01/07/2025 10:23 AM, Staff A, Administrator, said he had seen the broken tiles in the kitchen. Staff A said the building was purchased from the prior corporation in that condition. Staff A said the broken tiles were something that could be fixed as soon as possible. Reference WAC 388-97-3220 (1) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to maintain the cleanliness of the kitchen ice machine and vent fan covers; and failed to ensure stored food and reusable items in the refrigerator, freezers and dry storage were labeled and dated when opened. These failures placed residents at risk for foodborne illness and a diminished quality of life. Findings included . <Initial Brief Tour> On 05/20/2024 at 9:23 AM, the ice machine dispenser snout was observed to have dark residue on its lower rim. The walk-in freezer had an opened Ben & Jerry's ice cream container that was not labeled and dated when it was opened. The dry storage had an opened and undated container of [NAME] Egg Shade Food Coloring. Two overhead vents were observed to have lint hanging down from them in the kitchen prep area and behind on the tray line side. <Follow-Up Visit> On 05/23/2024 at 10:53 AM, seven items were found opened and not labeled or dated during a walk through the dry storage room. At 11:05 AM, Staff K, Dietary…

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 obtain a consent, evaluation assessment and physician order for 1 of 3 sampled residents (17) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . The facility's policy entitled, Physical Restraints and Enablers/Devices, revised 07/2023, documented .the Bed Rail/Bed Enabler/Device Evaluation is completed prior to the device being initiated, annually and on change of condition . Devices may include but are not limited to the following: i. Bed rails (quarter, ½, ¾ full) . The resident and/or resident representative is provided risks/benefits of restraint use or enabler/device use, and consent obtained prior to implementation of the device. Resident 17 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 03/31/2024, documented Resident 17 was severely cognitively impaired. On 05/20/2024, at 10:52 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 3 sampled residents (17) reviewed for physical restraints. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Record review of the facility's policy entitled, Physical Restraints and Enablers/Devices, revised 07/2023, documented .Devices may include but are not limited to the following: i. Bed rails (quarter, ½, ¾ full) . The care plan is updated for the device use with the goal for the least restrictive measures . The care plan is evaluated quarterly and as needed. Resident 17 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 03/31/2024, documented Resident 17 was severely cognitively impaired. Record review of Resident 17's Electronic Health Record Comprehensive Care Plan did not show documentation the care plan addressed padded quarter bed rails on the left and right side of the bed. 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 ensure preventative measures for contractures were provided, and failed to provide consistent restorative services for 2 of 3 sampled residents (30 & 17) reviewed for maintaining activities of daily living (ADLs) These failures placed residents at risk for further decline and a diminished quality of life. Findings included . 1) Resident 30 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 04/21/2024, indicated the resident was moderately cognitively impaired. The Care Plan, initiated 01/25/2020, documented, I have left side weakness to the UE (upper extremity) and LE (lower extremity) due to history of CVA (cerebral vascular accident - a stroke) with contractures to the left hand. On 05/23/2024 at 3:21 PM, Resident 30 said she was not able to open her left hand. Staff F, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), said she did not think Resident 30's nails were digging into…

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

Based on interview and record review, the facility failed to provide follow-up education for the Pneumococcal Conjugate Vaccine (PCV13) for 1 of 5 sampled resident (45) reviewed for immunizations. This failure placed resident at risk of exposure to contagious diseases and an increased risk of respiratory complications. Findings included . A Pneumococcal Vaccine Informed Consent, dated 08/11/2020, documented Resident 45 declined the PCV13. No reason for the declination was given and no other information about the pneumococcal vaccine were found in the electronic health record. On 05/23/2024 at 12:17 PM, Staff J, Infection Preventionist and Licensed Practical Nurse, she said she could only find the 08/11/2020 consent form. Staff J said she believed the PCV13 should be reviewed quarterly at the care conference. Staff J said the care plan indicated Resident 45 wanted to get the PCV13 with her granddaughter. Staff J said she was not sure if this was followed up. At 3:40 PM, Staff C, Assistant Director of Nursing and Registered Nurse, said if the Pneumococcal vaccine was declined, we…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to initiate a facility investigation after a resident was sent to the emergency room (ER) and was later admitted with a diagnosis of narcotic overdose for 1 of 4 sampled residents (1) reviewed for facility investigations. This failure placed residents at risk of medication errors, medication side effects, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 03/25/2024, documented the resident was moderately cognitively impaired. A physician order, dated 03/19/2024, documented, Morphine Sulfate ER [extended release] Oral Table Give 15 mg [milligrams] by mouth two times a day for pain. An alert note, dated 03/25/2024, documented, This LN [licensed nurse] went to check on pt [patient] . and patient alert and oriented x 1 only [alert to person, not place or time]. Patient had fall on 3/22 . [Resident] is only able to tell me I am [Resident 1]. R [Right] pupil…

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.