Cheney Care Center

Based on observation, interview and record review, the facility failed to consistently monitor the medication refrigerator temperatures for 1 of 1 medication storage rooms to ensure they were at safe storage levels. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included.The 01/20/2023 article titled Storage and Handling of Immunobiologics published by the Center for Disease Control, documented failure to follow recommended storage and refrigerator temperatures for immunobiologics (a medicinal preparation made from living organisms and their products, such as a serum or vaccine) reduced or destroyed their potency which resulted in inadequate or no immune response in the recipient. Refrigerator storage temperatures needed to be kept between 36 through 46 degrees Fahrenheit and prompt immediate action needed to occur when the temperature was out of range. During the review of the medication storage room with Staff E, Infection Preventionist, on 08/20/2025 at 9:06 AM, the medication refrigerator temperature log form was observed to…

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

Based on observation and interview, the facility failed to serve food that was palatable and had an appetizing appearance, and temperature for 2 of 2 meals observed and 1 of 1 test tray sampled. This failure resulted in the potential for all residents to have decreased appetite and decreased quality of life.Findings included .In an interview on 08/11/2025 at 11:33 AM, Resident 34 stated the food was bad and did not look good.In an interview on 08/11/2025 at 11:55 AM, Resident 48 stated that the food was terrible. They said it had no seasoning, everything was bland, and the appearance was unappetizing.During an observation on 08/11/2025 at 12:00 PM, a lunch tray was delivered to Resident 16. After seeing the food, Resident 16 stated it did not look very appetizing, took a bite then requested a cheeseburger.During an observation of the lunch meal on 08/11/2025 at 12:14 PM, in the main dining room, the food served was light brown pasta and light brown meat in a light brown gravy, dull green peas or green beans, and brown apple juice. The food lacked bright and varied colors.The lunch…

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 label and date food products in 2 of 2 resident snack refrigerators. This failure placed the residents at risk for food borne illness and decreased quality of life. Findings included .During an observation on 08/15/2025 at 3:04 PM, the resident snack refrigerator in the nurses' main charting room, contained six hard-boiled eggs in a plastic bag which was not labeled with a name or date. During an observation on 08/15/2025 at 3:08 PM the resident snack refrigerator on the transitional care unit contained six hard-boiled eggs in a plastic bag, and a bottle of honey mustard dressing, which were not labeled with a name or date.In an interview on 08/20/2025 at 9:18 AM, Staff M, Dietary Manager, stated the resident snack refrigerators were checked daily by the prep cook for proper labeling of food items and expiration dates. Staff M stated it was important for food items to be labeled and dated so the staff knew how long the item had been in the refrigerator and to whom it belonged. They stated unlabeled/undated food items would…

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 assess, monitor, and notify the physician of a non-pressure related skin condition for 1 of 3 sampled residents (Resident 1), reviewed for skin integrity. This failure placed the residents at risk for potential worsening skin conditions and a decreased quality of life. Findings included . Review of the facility policy titled Wound and Skin, dated 07/23/2013, showed the facility policy was to identify all wound and skin issues upon admission, on an ongoing basis, and on the routine weekly skin check day using the skin assessment tool. Once a wound or skin issue was identified, the Licensed Nurse (LN) was to document the characteristics of the issue i.e. size, depth, color, drainage, and location in the chart and on an incident report. This information must be documented in the skin assessment on a weekly basis. The findings were to be reported to the MD and fax MD with plan for treatment. Staff were to record this on the electronic Medication Administration Record (eMAR) under treatments and was to be followed…

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 staff followed Contact Precautions, when indicated, for 1 of 1 sampled resident (Resident 1), during wound care. This failure placed the residents at risk for spread of infection, illnesses, and unintended health consequences. Findings included . Per the Center for Disease Control (CDC) guidelines, staff should wear a gown and gloves for residents on Contact Precautions. Additionally, if there is a chance for splashes or sprays of body fluid eye precaution and mask may be needed. According to a facility assessment, dated 03/02/2025, Resident 1 had a history of a stroke, anxiety and depression. The resident had some difficulty making their needs known. Review of a hospital discharge orders, dated 05/12/2025, showed the resident had abscesses that had been drained and tested positive for Methicillin-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics and highly contagious by skin to skin contact or contact with contaminated surfaces). Dressing changes were to be daily…

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 a bed-hold notice (a notice to inform residents of their right to pay the facility to hold their room/bed while they were hospitalized ), to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 4 of 4 sampled residents (Resident 1, 3, 6, and 7), reviewed for hospitalization. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included . <Resident 1> The 11/20/2024 quarterly assessment documented Resident 1 was admitted with a history of a stroke, anxiety and depression. The resident was able to make needs known. Review of nursing progress notes, dated 09/16/2024, showed Resident 1 was transferred to the hospital due to complaints of increased numbness to their lower legs and pain in their hand. Additional record review showed no documentation the resident had been provided a bed-hold notice. <Resident 3> The 12/20/2024 admission assessment documented Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a screening required to be completed prior to admission to a nursing home that looked for indicators that one may have a serious mental illness) were completed for 3 of 5 sampled residents (Resident 1, 3, and 7), reviewed for PASARR's. Resident 1 and 3 were not referred for a Level II evaluation (an assessment that made recommendations about specialized services needed to determine the best setting to meet a person's behavioral health needs) and Resident 7 did not have a PASARR completed prior to admission to the facility, as required. This failure placed the residents at risk for a decline in their mental health and a decreased quality of life. Findings included . <Resident 1> Review of the quarterly assessment, dated 11/20/2024, showed Resident 1 was admitted with a history of a stroke, anxiety and depression. The resident was able to make their needs known. Resident 1's mood…

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 consider re-admission for 1 of 4 sampled residents (Resident 3), reviewed for hospitalization. This failure placed the resident at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life. Findings included . Review of a facility form titled Transfer and Discharge ., revised on 12/24 documented emergency transfers/discharges were initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. The resident will be permitted to return to the facility upon discharge from the acute care setting. In a situation where the facility initiates discharge while the resident is in the hospital following emergency transfer, the facility will have evidence that the resident's status at the time the resident seeks to return to the facility . Review of the admission assessment, dated 12/20/2024, showed Resident 3 was admitted with diagnoses which included a stroke, Parkinson's Disease (a progressive…

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 behavioral health needs were identified and met for 2 of 4 sample residents (Resident 1 and 3), reviewed for behavioral-emotional health. Failure to assess residents behavioral needs, identify individual resident responses to stressors and develop person-centered interventions placed residents at risk for unidentified behavior triggers, unmet behavioral needs, and diminished quality of life. Findings included . <Resident 1> According to the admission assessment, dated 08/23/2024, Resident 1 had diagnoses to include a stroke with left sided weakness, anxiety and depression. Resident 1 had difficulty making their needs known. The resident had hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind). The resident's mood assessment showed they felt bad about themselves, felt down, depressed, or hopeless, and had little interest in doing things. The resident took antidepressant and antianxiety medication. Review of the Pre-admission Screening 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 upon observation, interview, and record review, the facility failed to ensure adequate disposition of personal belongings upon admission, throughout their stay at the facility, and at the time of discharge, for 6 of 6 sampled residents (Residents 1, 2, 3, 4, 5 and 6) reviewed for missing items. This failure placed the residents at risk for loss of personal belongings and a diminished quality of life. Findings included . Review of a 06/2024 facility policy titled Resident Personal Belongings showed, the facility assured the resident's belongings were rightfully returned to the resident or their representative in the event of a death or discharge from the facility. This policy instructed the staff to inventory all personal belongings at the time of admission and retain documentation in the medical record. Staff would add additional possessions brought in during the duration of the resident's stay to the existing Personal Belongings Inventory List. Following the discharge or death of a resident, all personal…

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 their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting or investigating an elopement and resident-to-resident altercation for 1 of 6 sampled residents (Resident 1) reviewed for accident hazards. This failure placed the resident and other residents at risk for repeated abuse and elopement and precluded the state agency (SA) from being aware of and investigating the circumstances surrounding the resident's elopement and resident-to-resident altercation. Findings included . Review of an undated facility policy titled Abuse, Neglect and Exploitation showed, the facility would immediately investigate when suspicion or reports of abuse, neglect or exploitation occurred. The policy directed the facility to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The policy instructed the facility to report 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.

Based on interview and record review, the facility failed to provide and document sufficient preparation or orientation for a safe discharge for 1 of 4 sampled residents (Resident 1) reviewed for discharge planning. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of a 01/2024 facility policy titled Transfer and Discharge showed, the nurse who cared for the resident would ensure a Discharge Summary was completed for anticipated or resident-initiated discharges. The summary would show a description of the resident's stay that included their diagnoses, the course of illness/treatment or therapy, any pertinent labs, radiology and consultation reports, and a final summary of the resident's status. In an interview of 11/15/2024 at 11:37 AM, Resident 1's Representative stated that when the resident was discharged to a community provider, the facility did not send with the resident their medical file and that the receiving provider had zero idea what was going on with [Resident 1]. Review of progress notes showed 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 the staff implemented recommendations to help prevent kidney stones for 1 of 6 sampled residents (Resident 1) reviewed for urinary tract infections (UTI). This failure placed the resident at risk for repeated kidney stone development and associated discomfort. Review of the medical record showed Resident 1 re-admitted to the facility on [DATE]. Review of the diagnoses list showed but was not limited to, dementia, a history of UTI, kidney stones, and chronic kidney disease. Review of a 04/10/2024 Urology (branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) Visit Summary showed Resident 1 was seen for kidney stones. In this visit, the provider removed a stent (tube that allows urine to flow from the kidneys into the bladder) and gave the following recommendations to help prevent kidney stones, Drink 8 - 10 cups (64 - 80 ounces) of water daily to maintain proper hydration, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the staff provided and monitored the required amount of fluids to ensure adequate hydration for 1 of 6 sampled residents (Resident 1) reviewed for hydration. This failure placed the resident at risk for outcomes associated with insufficient fluid intake, like dehydration and urinary tract infections (UTI). Findings included . Review of a 09/18/2024 annual comprehensive assessment showed Resident 1 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the staff assessed Resident 1 to have severe cognitive impairment and was independent with eating. In an interview on 11/14/2024 at 3:45 PM, a Collateral Contact stated that the staff, didn't hydrate [Resident 1] enough and that's why [the resident] ended up in the hospital with a urinary tract infection (UTI). Review of a 01/2024 facility Hydration policy showed, sufficient fluid was the amount needed to prevent dehydration and maintain health. The amount of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 2 residents (3, 11) had current and complete oxygen orders and failed to ensure that oxygen equipment was maintained in a clean manner for 5 of 5 residents (3, 11, 14, 17, 28) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . A facility policy, reviewed on 01/20/2024, titled Oxygen Administration documented that orders for oxygen should include the flow rate (level of oxygen, usually measured in liters/minute.) In addition, the policy documented to change the oxygen tubing and mask weekly and as needed, and to follow the manufacturer recommendation for cleaning the filters. <Resident 3> According to an annual assessment dated [DATE], Resident 3 made their needs known and had diagnoses that included dementia and chronic respiratory failure. A review of Resident 3's Electronic Medical Record (EMR) showed an order dated 07/28/2022, that…

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

Based on observation and interview the facility failed to ensure meals were served to residents at an appropriate and appetizing temperature. This failed practice resulted in the potential risk for decreased quality of life for all residents. Findings inculded . According to the Washington State Food Handlers Guide Website, The Washington State Department of Health, Safety and Licensing Division recommends that all potentially hazardous foods be held at a temperature of 41°F or below in commercial refrigerators and freezers. This includes meats, fish, poultry, eggs, dairy products, cooked vegetables, cooked rice and pasta, cut melons, and other perishable items. All frozen foods should be stored at 0°F or below. Hot food items should be held at a temperature of 140°F or above. On 06/04/2024 while the lunch meal was being served, it was observed that periodic checks of the temperature of the foods being held on the steam table was not completed. During an observation on 06/04/2024 at 12:10 PM, Staff CC, Cook, was heating up soup in the microwave oven, and when they removed the soup…

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 1 of 5 sampled residents (25), reviewed for unnecessary medications, were informed of the potential risks and benefits associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). Failure to obtain the informed consents resulted in the resident and/or representative not being informed. Findings included . <Resident 25> Per the 02/29/2024 quarterly assessment, Resident 25 had diagnoses which included hallucinations and received psychotropic medications daily. A review of the Order Summary Report documented on 11/24/2023, Resident 25 was prescribed psychotropic medication (Trazodone) to treat depression, and Seroquel to treat the hallucinations. Review of the November 2023 Medication Administration Record documented Resident 18 received the first doses of Trazodone on 11/24/2023 and Seroquel on 11/25/2023. Review of the Psychoactive Medication Informed Consent, a form used to provide education related to the potential risks and benefits of psychotropic…

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

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 2 sampled resident (25), reviewed for environment. This failure placed Resident 25 at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included . Resident 25 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A 02/29/2024 quarterly assessment documented Resident 25 was moderately cognitively impaired, required partial to maximum assistance for activities of daily living and used a wheelchair for mobility. On 05/28/2024 at 11:13 AM, Resident 25 was observed in the dining room sitting in the wheelchair. The wheelchair was unclean with food smeared on the sides of the chair. On 05/30/2024 at 9:48 AM, Resident 25 was observed in bed asleep. The wheelchair was unclean with food smeared on the sides and foot pedals of the wheelchair. Additional observations of the wheelchair being unclean were made on 05/30/2024 at 9:48…

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 complete a discharge summary, including a recapitulation of the resident's stay as required, for 1 of 1 sampled residents (40), reviewed for discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included . The 12/30/2023 admission assessment documented Resident 40 was cognitively intact to make decisions regarding care, needed moderate to maximum assistance from staff to complete activities of daily living, and had received physical therapy for four days during the assessment period. A discharge assessment dated [DATE] documented the resident had discharged and was expected to return to the facility. A progress note dated 03/16/2024 at 6:45 PM documented Resident 40 had informed a nursing assistant that they were looking for plastic bags so they could suffocate themselves. The resident was assessed for depression and safety interventions were implemented to include increased supervision. 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 interview and record review the facility failed to implement bowel management protocol when indicated for 3 of 7 sampled residents (2,18,193), reviewed for constipation. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Bowel Protocol, dated 05/10/2023, instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for two days. The policy documented nursing staff was to administer Milk of Magnesia (MOM) on day two of no BM, Miralax on day three, Senna on day four, a suppository on day five, and if no BM on day six, the provider was to be notified. <Resident 2> According to the 04/18/2024 quarterly assessment, Resident 2 required maximal to total assistance for most activities of daily living including dressing, transfers, and toileting. Resident 2 was incontinent of bowel. The assessment further documented Resident 2 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to document a detailed nutritional assessment at time of admission, for a resident identified as being at risk for compromised nutritional status. This failure resulted in potential impaired nutrition, and an increased risk of: mortality, impairment of anticipated wound healing, decline in function, fluid and electrolyte imbalance/dehydration, and unplanned weight change. Findings included . Review of undated nutritional management policy, a comprehensive nutritional assessment would be completed upon admission, and the dietitian would use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake was adequate to meet those needs. According to the 04/11/2024 assessment Resident 10 had cognitive impairment and was unable to direct their care. They required assistance for most activities of daily living (ADL's) including transfers, toileting, and mobility. Resident 10 had…

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

Based on observation, interview and record review, the facility failed to accurately reconcile all controlled medications in 1 of 2 medication carts (Cart 1), reviewed for medication storage. This failure placed residents at risk for misappropriation of their controlled medications and placed the facility at increased risk for controlled substance drug diversion. Findings included . During an inspection of the narcotic drawer on Cart One on 06/05/2024 at 10:49 AM with Staff D, Registered Nurse (RN), a bottle of narcotic pain pills labeled for a current facility resident, was observed. The cap of this bottle was wrapped in clear plastic tape, with the number 56 in black marker, half on the tape and half on the side of the bottle. Staff D stated that the medication was from the resident's home supply. Staff D further stated that the 56 was placed that way, so it would be noticeable if anyone removed the tape to access the medication. In addition, Staff D stated they had been going by the pill quantity written on the tape, rather than counting the actual pills, during the narcotic…

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 recommendations from the pharmacist were addressed, for 1 of 5 sample residents (25), reviewed for unnecessary medications. These failures placed residents at risk for receiving medications at inappropriate times and a diminished quality of life. Findings included . The Consultant Pharmacy Report, dated 04/2024, documented Resident 25 received Melatonin (a medication to assist with sleep) and it was recommended the time the medication was administered be changed to be given 60 to 90 minutes before the resident's bedtime. Review of the April and May 2024 medication administration records documented the medication was to be given at bedtime. Resident 25 received the Melatonin from 7:00 PM to 10:53 PM A review of Resident 25's record documented no response from the provider or nursing regarding the recommendation. During an interview on 06/04/2024 at 3:50 PM, Staff G, Nursing Assistant, stated Resident 25 went to bed after dinner, between six to seven o'clock. During an interview on 06/04/2024 at 3:29 PM, Staff B,…

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 dietary staff had the required qualifications (current Food Worker Cards) for 2 dietary staff (W, X). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Additionally, the facility failed to ensure there were enough staff in the dining room during meals to assist residents timely. This failure had the potential risk for residents being served food at unappetizing temperatures, decreased appetite and decreased quality of life. Findings included . <Dietary Staff> A review of the dietary cards on 06/04/2024 at 09:28am showed Staff W, dietary aide (hire date 01/30/2024) had a Washington State Food Workers card with an effective date of 06/04/2024 and Staff X, Prep [NAME] (hire date 05/01/2024) did not have a current Washington State Food Workers card. Observations were made of both Staff W and Staff X preparing and/or serving food on 05/29/2024 at 09:28AM and 06/04/2024 at 11:05AM. During an interview on 06/04/2024…

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 and interview the facility failed to ensure food in the snack/nourishment refrigerators was labelled and dated, expired foods were removed, and the snack/nourishment refrigerators were monitored routinely for proper temperature. This failure resulted in a potential risk of food borne illness for all residents. Findings included . During an observation on 06/04/2024 at 09:37 AM of the Snack/Nourishment refrigerator on the Transitional Care Unit (TCU), there was an open apple and open grape juice container with no opened date, a foil covered container labelled with a name and room number but not dated, an open half full gallon jug of Kikkoman soy sauce with date of 9/2 but no year, and sugar free coffee creamer with an expiration date of 05/22/2024. There was a temperature log for March, April and May 2024 taped to the front of the refrigerator with only 5 temperature readings recorded in March, no April temperature readings recorded, and only 1 temperature reading recorded in May. No temperature log was present for June 2024. Staff O, Nursing Assistant (NA) was…

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

Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene and wore gloves during the meal service when indicated, maintained a resident's nails in a sanitary manner prior to and after meals, and not cleansing a resident's skin prior to an injection. These failures placed the residents at risk for infection, transmission of communicable diseases and diminished quality of life. Findings included . Review of the facility policy titled, Handwashing/Hand Hygiene revised 01/20/2024, documented hand hygiene was the means to prevent the spread of infections. The policy instructed staff to perform hand hygiene with alcohol-based hand rub or soap and water before and after direct contact with residents; before performing any non-surgical invasive procedure; before and after handling an invasive device; before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care; after contact with object in the immediate vicinity of a resident; before and after handling food; before 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.

Based on interview and record review, the facility failed to timely evaluate and initiate treatment for 1 of 2 residents (Resident 1), reviewed for accidents. This failure placed the resident at risk for unmet care needs related to transfers, increased pain, and worsening condition. Findings included . Review of the facility's 07/28/2023 incident investigation and nursing progress notes showed Resident 1 sustained a fall in their room on 07/28/2023 and complained of pain to their right hip. The physician was notified, and an x-ray was ordered, which showed no fracture (fx). According to a physician progress note dated 08/16/2023, Staff E, Physician, was notified by Resident 1 that they were still in pain from the fall, and it was quite bothersome to them. Staff E ordered a second x-ray that same day, which showed the resident sustained a right hip fx. Additional record review showed prior to injury, the resident required extensive assistance of 1-2 people for transfers. After the injury was identified on 07/28/2023, Resident 1 had Morphine ordered for increased pain. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the failed to provide mandatory behavioral health training to 7 of 7 staff (Staff F, H, I, R, S, T and U), reviewed for staff training and competency. This deficient practice placed all residents with behavioral health diagnoses at risk for unmet care needs and a diminished quality of life. Findings included . According to the State Operations Manual (SOM) Appendix PP, .behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders . Review of the facility assessment dated [DATE] identified behavioral health care needs of the current residents included anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), depression (mood disorder that causes persistent feelings of sadness and loss of interest), and schizophrenia (serious mental disorder in which people interpret reality abnormally). Review of all the training…

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 their bowel protocol timely and accurately for 7 of 23 sampled residents (Residents 32, 28, 25, 39, 2, 145, and 20), reviewed for bowel maintenance and quality of care. This deficient practice placed the residents at risk for complications related to unmanaged constipation such as discomfort, nausea, vomiting, bowel obstruction (blockage) and an overall diminished quality of life. Findings included . Review of the undated facility policy, Bowel Monitoring, showed the facility was .to monitor resident bowels daily . Further review showed the process included the night shift licensed nurse (LN) was to run a bowel report from the electronic health record, the day shift LN was to implement the interventions, and the evening shift LN was to assess and document the effectiveness of the interventions. Review of the document Bowel Regime, last revised in 2019, showed the following orders for bowel care: *no bowel movement (BM) in six shifts (two…

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 appropriate infection control practices were maintained for hand hygiene during an observed medication pass and dining; failed to ensure sanitary handling of a lancet (a sharp-pointed two edged instrument used to prick the skin) to check a blood sugar; failed to maintain oxygen tubing in a sanitary manner; and failed to ensure a resident reviewed for use and care of a urinary catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. These failures placed residents at risk of infection and illnesses. Findings included . <Medication Pass> In an observation on 05/04/2023 at 8:05 AM, Staff V, Medication Assistant Certified, applied a pair of gloves and cleansed a resident's eyes with a Systane wipe (a premoistened wipe to remove oily residue and debris). Staff C, with the same pair of gloves, administered the resident's eye…

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 one of five sampled residents (Resident 2), reviewed for medication management, was fully informed of the potential risks associated with use of psychotropic medications (medications which alter thought processes). This failure placed the resident at risk to make decisions about medications while lacking relevant information, related to serious side effects. Findings included: According to the Nursing 2016 Drug Handbook (Wolters Kluwer, p. 40-41), antipsychotic medications (types of psychotropic medications intended to treat disorders which caused the individual to experience sensations, or hold beliefs, which were not consistent with reality) included a Black Box Warning: Elderly patients with dementia-related psychosis treated with antipsychotics are at increased risk for death. Serious adverse reactions to the medication included extrapyramidal symptoms (drug induced movement disorders, including tremors or involuntary movements). Additionally, the Drug Handbook (pg. 31-32) included a Black Box Warning 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.

Based on interview and record review, the facility failed to provide notification to the resident's representative of a change in condition for one of twenty sampled residents (Resident 24), reviewed for notification of change. This failure prevented the resident's representative from being informed of a skin condition, behaviors, refusal of medication, and participating in care decisions. Findings included . Resident 24 was admitted with diagnoses which included Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions). According to the 02/28/2023 assessment, Resident 24 had memory impairments and required extensive assistance with activities of daily living. During an interview on 05/08/2023 at 2:54 PM, the resident's representative stated they were not notified of Resident 24's change in skin condition, behaviors, or refusal of medications. They additionally added that it was in the care plan to notify them of behaviors. Per record review, a progress note dated 12/11/2022 at 8:30 PM showed that during the evening medication pass,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely and thoroughly investigate 2 incidents involving 1 of 2 sampled residents (Resident 19), reviewed for abuse/neglect. This deficient practice disallowed an opportunity for an evaluation of facility practices, to determine if appropriate care and services were being provided, and placed residents at risk for unidentified and ongoing abuse/neglect. Findings included . Review of the medical record showed Resident 19 admitted to the facility on [DATE] with diagnoses of congestive heart failure (a chronic condition that occurs when the heart can't pump blood adequtely), pulmonary hypertension (a disease in which the blood pressure in the lungs is higher than normal), and a blood clot in the left leg. Review of the comprehensive assessment completed on 04/26/2023 showed the resident was cognitively intact and required the extensive assistance of one person for bathing, transfers, dressing, toileting, personal hygiene, and mobility. Additionally, 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 complete an updated Pre-admission Screening and Resident Review (PASARR) for one of five sampled residents (Resident 28), reviewed for PASARR accuracy, who required a Level II evaluation due to a new mental health diagnoses. This deficient practice placed the resident at risk of not receiving specialized mental health services, unidentified needs, and a decrease in quality of life. Findings included . Review of the medical record showed Resident 28 admitted to the facility on [DATE] with diagnoses of stroke, high blood pressure, atrial fibrillation (irregular heartbeat), and anorexia (an abnormal loss of the appetite for food). Review of the comprehensive assessment completed on 02/12/2023 showed the resident had severe cognitive impairment. Review of the undated and unsigned PASARR form for Resident 28 showed that a Level II evaluation was not indicated prior to admission to the facility. Review of the 06/25/2020 provider note showed new diagnoses of…

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

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], and a Level II assessment [a more in-depth screening, to identify whether nursing home services were needed and if specialized mental health services were required] was completed for 1 of 5 sampled residents (Resident 2), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included: Resident 2's Level I PASARR dated 10/20/2022, showed it was completed and signed by social services staff, sixteen days after the resident's admission to the facility. The PASARR stated that no level II was indicated. A level II PASSAR must be completed if the resident has an intellectual disability or a serious mental illness. The resident had a diagnosis of schizophrenia (a disorder that affects a…

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

Based on interview and record review, the facility failed to complete a discharge summary, including a recapitulation of the resident's stay as required, for one of one sampled residents (Resident 44), reviewed for discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included: Per the 03/15/2023 discharge assessment, Resident 44 was cognitively intact to make decisions regarding care, needed minimal to no assistance for completion of activities of daily living, and had received physical therapy and occupational therapy for two days. Record review showed Resident 44 was admitted to the facility for physical and occupational therapy following back surgery, and discharged home against medical advice on 03/15/2023. A progress note on 03/15/2023 at 4:52 PM showed the resident had informed the staff they were going home to complete their recovery with help from family. The resident was provided education related to the risk of leaving prior to completion of healing and therapy, and continued to insist on being discharged . Further record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for the effectiveness of a sleep aid for one of five sampled residents (32), reviewed for unnecessary medications. This deficient practice placed the resident at risk of experiencing adverse side effects, and for receiving ineffective and/or unnecessary medications. Findings included . Review of the medical record showed Resident 32 admitted to the facility on [DATE] with diagnoses of compression fractures to the lumbar spine (back), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), diabetes, and insomnia. Review of the comprehensive assessment completed on 01/31/2023 showed the resident had severe cognitive impairment and needed the extensive assistance of one-person for dressing, hygiene, toileting, bathing, and transfers. Review of the Medication Administration Record (MAR) for May 2023 showed an order for Melatonin (a sleep aid) three…

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 disposed of timely, in accordance with currently accepted professional standards, in 1 medication storage room and 1 of 3 nursing carts (cart 2). This failure placed residents at risk for receiving compromised or ineffective medication. Findings included . Per observation of the medication storage room, located at the main nursing station on 05/04/2023 at 2:32 PM, with Staff O, Registered Nurse, showed a medication used to treat nausea expired on 03/16/2023, Tylenol suppositories (a medication used to treat fever or pain), expired on 03/23/2021, and three bottles of a medication used to treat constipation expired on 02/2023. Per observation of medication cart 2 with Staff P, Registered Nurse (the same day), showed an expired bottle of Lantus Insulin (a medication used to treat diabetes). The open date on the Lantus Insulin was 04/03/2023, and once opened it was good for 28 days. The insulin was administered to Resident 32 on 05/02/2023, 05/03/2023 and 05/04/2023. The insulin…

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 documented evidence of the required 12-hours of in-service training for 2 of 3 nursing assistants (Staff G and H), reviewed for staff competency. This deficient practice placed the residents at risk of being cared for by inadequately trained staff, and a decreased quality of life. Findings included . <Staff G> Review of the staff personnel file showed Staff G, Nursing Assistant (NA), was hired on 01/22/2020. Review of the facility's training records showed Staff G completed six hours of trainings and/or in-services between the dates of 08/24/2022 to 04/27/2023. <Staff H> Review of the staff personnel file showed Staff H, (NA), was hired on 03/04/2013. Review of the facility's training records showed Staff H completed eight hours of trainings and/or in-services between the dates of 08/24/2022 to 04/27/2023. During an interview on 05/10/2023 at 10:17 AM, Staff Q, Facility Operations Manager, stated there was not a current system in place to track NA annual training and in-servicing. Staff Q explained that 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.