Clarkston Health And Rehab Of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 sampled residents (Resident 1), reviewed for smoking. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included.Review of the facility policy titled, Care Plans revised October 2024, showed a comprehensive person-centered care plan was developed and implemented consistent with the resident's specific conditions, risks, needs, behaviors, and preferences within seven days after the completion of the comprehensive assessment. According to the 06/21/2025 admission assessment, Resident 1 admitted to the facility on [DATE] with diagnoses including respiratory failure (inability to effectively exchange oxygen and carbon dioxide). Resident 1 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 the periodic review and monitoring of splint and/or brace wear and effectively address refusals of the Restorative Nursing Program (RNP) for 2 of 2 sampled residents (Residents 22 and 81) reviewed for limited range of motion (ROM, the full movement potential of a joint or series of joints). These failures placed the resident at risk of worsening contractures (a medical condition where muscle, tendon, or other soft tissue becomes abnormally tight and shortened, limiting the ROM at a joint) and diminished quality of life.Findings included.Review of a revised 01/20/2025 facility policy titled Restorative Nursing showed that RNPs, to include splint or brace (a custom or prefabricated device that provided support, immobilized or assisted movement in the hand, wrist, or fingers to heal injuries, correct deformities, prevent stiffness, or manage contractures) assistance programs, required measurable objectives and interventions that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate care and services to minimize the risk of associated urinary tract infections for 1 of 1 sampled residents (Resident 8), reviewed for catheter (a flexible tube inserted into the bladder to drain urine) care. This failure placed the resident at risk for urinary tract infections. Findings included. Per the Lippincott Manual of Nursing Practice 10th Ed. ([NAME], 2014), infectious organisms can move into the bladder along the outside of any urinary catheter, and the catheter bag (a urine collection bag attached to the catheter) should be kept off the floor (and other unclean surfaces), to prevent bacteria from entering the bladder (pg. 781-782). The 07/02/2025 quarterly assessment documented Resident 8 had diagnoses which included benign prostatic hyperplasia (BPH, prostate gland enlargement that blocks the flow of urine out of the bladder), obstructive uropathy (a urinary tract disorder that occurs when…

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

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 1 of 5 sampled residents (Resident 70) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted. Findings included . The 07/09/2025 quarterly assessment documented Resident 70 had diagnoses which included arthritis, migraines and a neck fracture, and had severe cognitive impairments. The 04/06/2023 care plan documented Resident 70 was at risk for pain. Staff were instructed to give medications as ordered. A review of the August 2025 Medication Administration Record (MAR) documented medication orders and omissions:-Pregabalin 150 milligrams (mg) three times a day for neuropathy (weakness, numbness, and pain from nerve damage). The entry on 08/10/2025 and 08/11/2025 said the medication was not available. There was a progress note on 03/11/2025 that stated the medication was reordered. -Humalog insulin inject…

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 coordinated follow-up appointments with the denturist (a person who made dentures) for 1 of 1 sampled resident (Resident 5) reviewed for dental needs. This failure placed Resident 5 at risk of discomfort or pain from ill-fitting dentures, weight loss and decreased self-esteem. Findings included. Review of an 08/13/2025 annual assessment showed Resident 5 admitted to the facility on [DATE] with medically complex conditions and was cognitively intact. This assessment showed the resident had no natural teeth or tooth fragments or abnormal mouth tissue. A care area assessment worksheet associated with the 08/13/2025 annual assessment showed Resident 5 was, having a sore on gum line that is being treated/monitored. Resident is at risk for weight changes and chewing problems. The note also showed, dental appointments as ordered or requested PRN [as needed]. In an interview and observation on 08/11/2025 at 8:45 AM, Resident 5 said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 2 of 3 medication administration observations. Additionally, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or colonized with antibiotic resistant bacteria) were implemented and followed when indicated or ensure PPE was readily available for 2 of 3 sampled residents (Residents 1 and 6), reviewed for infection control. This failure placed residents at risk for potential unintended health consequences, the potential spread of infectious diseases or organisms resistant to antibiotics, and diminished quality of life.Findings included.According to The Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE- gloves, disposable gowns, eye protection or masks) Use in Nursing Homes to prevent Spread 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 the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) was properly monitored to ensure it was functioning for 2 of 2 sampled residents (Residents 1 & 3), reviewed for urinary catheters. This failure placed the residents at risk for complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Indwelling Catheters, revised 04/12/2022, showed if an indwelling catheter was in use, the facility provided appropriate care for the catheter in accordance with current professional standards of practice and staff were to monitor for changes in condition related to potential catheter-associated urinary tract infections. <Resident 1> Review of the admission assessment dated [DATE] showed Resident 1 was admitted to the facility with multiple diagnoses to include neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or…

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

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), reviewed for medication administration, received medications appropriately, in accordance with the physician's order. This failure resulted in a pattern of significant medication errors which placed the resident at risk for medical decline, discomfort, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Errors, revised 08/01/2024, showed a medication error occurred when a medication was not administered in accordance with the prescriber's orders. Review of the September 2024 Medication Administration Record (MAR) showed Resident 1 had an order for a narcotic pain medication, hydrocodone-acetaminophen, to be given every 6 hours as needed. The resident could take 1 tablet for mild to moderate pain and 2 tablets for moderate to severe pain. The order included instructions not to administer more than four tablets every 24 hours. Further review showed the resident was administered more than 4 tablets on 15 occasions: 09/07/2024,…

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 interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 3 sampled residents (Resident 1), reviewed for abuse/misappropriation. This failure placed the resident and other residents at risk for abuse/misappropriation. Findings included . Review of the facility's policy titled Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, revised 08/01/2023, showed staff were to report any form of alleged abuse to the SA immediately, but not later than two hours after the allegation is made if abuse was alleged and there was serious bodily injury. All other allegations were to be reported within 24 hours. Additionally, the facility would investigate the allegation and document evidence of the investigation. Review of the September and October 2024 facility incident logs showed no reported incidents for Resident 1. 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 facility failed to inform the Resident Representative (RR) of changes to the resident's weight, treatments, wound status, medication changes, refusals of treatments, and changes in condition for one (1) of 4 residents reviewed for the right to be informed of care for a span of five months. This failure precluded the RR from the opportunity to contribute to help Resident 1 make an informed decision related to medication and treatment changes and move forward with the treatment options being proposed. Findings included . Review of an 11/28/2017 facility policy titled Resident Change in Condition, described a change in condition as a change from the resident's normal status or whenever there was a change in the resident's medical condition. Some of the examples of a change in condition included, new or increasing confusion, newly identified incontinence, weight loss of more than 5 % (percent) of body weight, behavior changes, and potentially life-threatening conditions due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) reviewed for dental services received adequate pain management and timely dental services for an impacted wisdom tooth and abscess. This failure placed residents at increased risk of pain, unmet dental needs, and a diminished quality of life. Findings included . Review of an 11/28/2017 facility policy titled Dental Services showed the facility provided the assistance needed or requested to obtain dental services and if a referral did not occur within 3 business days, the facility would ensure the resident would drink and eat adequately while awaiting dental services. The policy defined emergency dental services as services needed to treat an episode of acute pain in teeth, gums, or palate, broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. <Resident 1> Review of a 09/17/2024 assessment showed Resident 1 re-admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to monitor the temperature of food being served, failed to ensure a resident's meal tray (9) was discarded timely, and failed to prepare food in a sanitary manner. These failures placed the residents at risk for food borne illnesses and decreased quality of life. Findings included . <Resident 9> A progress note dated 01/06/2024 at 10:40 PM, documented Resident 9's dinner tray was being left at bedside and resident would eat items from the tray and that was concerning since it had been sitting on the bedside table for quite awhile. On 01/21/2024, breakfast had been served at 7:45 AM. During an observation at 9:05 AM, Resident 9's breakfast tray was observed sitting untouched on their bedside tray table. At 10:07 AM, it was observed that the breakfast tray had been removed except for the hot cereal and orange juice. At 12:20 PM, the hot cereal and orange juice still remained on the bedside table untouched and the lunch tray had been delivered. At 1:04 PM,…

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 4 of 5 sampled residents (117, 53, 2, and 55), 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 and/or include necessary information about the medication such as reasons for taking and benefits resulted in the resident and/or representative not being fully informed. Findings included . <Resident 117> Per the 01/22/2024 admission assessment, Resident 117 had diagnoses which included anxiety, depression, and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, and perceives reality) and received psychotropic medications daily. A review of the Order Summary Report showed on 01/17/2024, Resident 117 was prescribed psychotropic medication (Trazodone and Venlafaxine) to treat depression, and Risperidone to treat the symptoms associated with Schizophrenia. In addition,…

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 1 of 5 sample residents (56), reviewed for medication management, received adequate monitoring to ensure appropriate administration of a high-risk medication. Failure to monitor edema (excess fluid in the tissues) placed the residents at risk for compromised heart health. In addition, the facility failed to ensure timely bowel care was provided for 3 of 3 sample residents (9,10, and 55) reviewed for constipation which placed the residents at risk for constipation and unmet care needs. Findings included . According to the article Loop Diuretics published by the National Library of Medicine on 05/22/2023, Loop diuretics (such as Furosemide) included a black box warning (the highest safety-related warning that has been assigned by the Food and Drug Administration to inform consumers of the medications potential and serious side effects) and careful medical supervision was necessary to monitor the patient's response (blood pressure,…

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 medication boxes/kits which contained controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenic) and stored in the medication refrigerators were affixed as required for 2 of 2 medication rooms reviewed for medication storage. In addition, the facility failed to consistently monitor the medication refrigerator temperatures to ensure they were at safe storage levels. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . Per the 01/20/2023 article titled Storage and Handling of Immunobiologics published by the Center for Disease Control, 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)…

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

Based on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate, in accordance with accepted professional standards and practices, for 2 of 2 sampled residents (1, 50) reviewed for abuse, 1 of 1 sampled resident reviewed for activities (2), and 1 of 1 sampled resident (12) reviewed for care planning. Failure to document pertinent resident information placed the residents at risk for unmet care needs, decreased continuity of care, and diminished quality of life. In addition, the facility failed to provide access timely to resident records for 15 of 17 sampled residents (169, 62, 1, 16, 2, 53, 167, 33, 55, 58, 3, 117, 25, 18, and 56) reviewed for Advance Directives, and failed to timely provide the facility staffing documentation that had been requested for review of the sufficient staffing task. Findings included . <Resident 1> The 12/05/2023 quarterly assessment showed Resident 1 had no cognitive impairment and was able to make decisions regarding their care. In addition, the assessment showed the resident 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 and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 3 dining rooms, and during wound care for 1 of 1 sampled residents (58) reviewed for non-pressure wounds. These failures placed the residents at risk for infections and unmet care needs. Findings included . <Dining Room> During a lunch observation in the [NAME] unit dining room on 01/18/2024 at 11:53 AM, Staff O, Nursing Assistant, cut up a resident's turkey, without gloves and touched the prongs of fork with their hands and gave it to the resident to eat with. Staff O, then pushed a resident up to the table, did not perform hand hygiene and continued to pass meal trays. During an observation at 12:13 PM, Staff O passed out meal trays to residents who did not eat in the dining room. Staff O entered room [ROOM NUMBER] with a meal tray and placed it on resident's tray table and left the room without performing hand hygiene. Staff O then went to the dining room, grabbed another…

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 investigations related to allegations of abuse/neglect were initiated, thorough, and completed timely for 2 of 2 sampled residents (1, 50), reviewed for abuse. These failures placed the residents at risk for repeated incidents and potential abuse. Findings included Review of the 08/01/2023 Freedom from Abuse, Neglect, and Exploitation facility policy showed allegations of abuse were to be reported to the CEO (Chief Executive Officer) or designee immediately and the state agency within 2 hours if there was alleged abuse or serious bodily injury as a result of an event, and within 24 hours if the event that caused the injury did not involve abuse or did not result in serious bodily injury. The policy also showed a thorough investigation of an alleged violation would be completed and would include conducting interviews and an assessment of the alleged victim as appropriate. The policy also showed the results of all investigations would be reported to the State agency in accordance with State and Federal law within 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], was completed for 2 of 5 sampled residents (50, 55), reviewed for PASARR services. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included . <Resident 55> According to the 11/07/2023 quarterly assessment, Resident 55 was admitted on [DATE] with diagnoses which included dementia and received psychotropic medication, (medications that affect the mind, emotions, and behavior). Review of Resident 55s's Level I PASARR showed it was completed and signed by Staff F, Social Services, on 09/02/2023, 35 days after the resident's admission to the facility, and not prior to admission as required. In an interview on 01/24/2024 at 5:13 PM Staff F,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 3 sampled residents (53, 12) reviewed for activities of daily living, received assistance with grooming and maintaining clean glasses. These failures placed residents at risk for poor hygiene and impaired vision. Findings included . <Resident 53> According to Resident 53's quarterly assessment dated [DATE], they required assistance with activities of daily living, including transferring, dressing, personal hygiene, and bathing. Resident 53's care plan dated 05/02/2023, directed nursing staff to assist them with personal hygiene, such as trimming facial hair and shaving. During an observation on 01/18/2024 at 10:21 AM, Resident 53 was sitting in their wheelchair and had nasal hair that protruded out of their nose. Subsequent observations made on 01/20/2024 at 8:10 AM, 01/21/2024 at 9:02 AM, 1/21/2024 at 1:02 PM, 01/22/2024 at 9:19 AM, 01/22/2024 at 11:18 AM, and 01/23/2024 at 8:57 AM, all showed Resident 53's nasal hair…

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 1 of 1 sampled residents (2) reviewed for activities, received an ongoing program of activities that met their interests. Failure to assess the resident's activity preferences placed the resident at risk for boredom and diminished quality of life. Findings included Review of the 12/26/2023 quarterly assessment showed Resident 2 had severe cognitive impairment, was able to direct their care, and had diagnoses which included dementia and depression. The assessment showed the resident was independent with activities of daily living, including moving around the facility in their wheelchair, and it was very important to the resident to be involved in activities that included: reading materials, pets, news, and doing favorite activities. Review of Resident 2's 08/22/2023 care plan showed a quarterly and annual assessment would be done to ensure resident's activity preferences were accurate. Review of resident's record from 12/14/2021 through 01/20/2024 showed no activity assessments had been completed as care…

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

Based on observation, interview, and record review, the facility failed to ensure nutritional supplements were offered as ordered for 1 of 5 sampled residents (9), reviewed for nutrition. This failure placed the resident, who had experienced significant weight loss, at risk for further loss. Findings included . The 11/28/2017 Nutritional Assessment facility policy, last revised on 08/01/2023, defined nutritional supplements as products that are used to complement a resident's dietary needs. A review of the record showed Resident 9 had diagnoses including diabetes (a disease in which your body does not make enough insulin), kidney failure and depression. According to a 01/16/2024 annual assessment, Resident 9 was cognitively intact, did not reject care, was able to eat independently, weighed 143 pounds (lbs.) and had lost 5% of their weight in one month or 10% in six months, and was not on a prescribed diet. A 01/12/2024 Nutrition at Risk assessment by Staff J, Registered Dietitian (RD,) documented Resident 9 weighed 170.4 lbs on 07/06/2023 and had lost 15.8% of their weight. Staff J…

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 performance reviews at least once every 12 months, and provide in-service education based on the outcome of the reviews as required, for 1 of 5 sampled staff (L), whose records were reviewed. This failure placed residents at risk for receiving care from inadequately trained staff. Findings included . Per review of Staff L, Nursing Assistant's file, they had a performance evaluation that was last completed on 06/16/2021, not yearly as required. During an interview on 01/26/2024 at 3:08 PM, Staff M, Staff Development Coordinator, stated they were unsure how often performance evaluations were completed. Staff M stated they had a workshop last year in which certain skills had been performed by nursing staff. During an interview on 01/26/2024 at 3:42 PM, Staff B, Director of Nursing, stated they completed performance evaluations yearly and were aware that some employees did not have theirs completed or updated. Reference: WAC 388-97-1680 (1)(2)(a-c)

<Resident 16> Per the 12/26/2023 quarterly assessment, Resident 16 had diagnoses including kidney failure and diabetes (a disease in which your body does not make enough insulin). Review of the physciain orders showed on 07/03/2023, Resident 16 was presecribed Lispro (sliding scale insulin, a hormone used to treat diabetes and given based on blood glucose levels). The July, August, and September 2023 Monthly Medication Review (MMR) documented a recommendation to discontinue the sliding scale insulin as mentioned above and no response was obtained. The October 2023 MMR documented a recommendation to discontinue the Lispro insulin sliding scale and the physician responded on 11/10/23, nearly four months since the recommendation was first made. Reference: WAC 388-07-1300 (4)(c) Based on interview and record review, the facility failed to follow-up on pharmacist recommendations for medication changes, and to implement recommended changes in a timely fashion for 2 of 5 sampled residents (16, 55), reviewed for unnecessary medications. This failure placed the residents at risk 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 ensure that orders for as needed (PRN) psychotropic medication (a type of medication used to affect mood, behavior, and perceptions) was limited to14 days, and was given for an appropriate diagnosis for 1 of 5 sampled residents (55). These failures placed the residents at risk for unintended medication side effects and a decreased quality of life. Findings included . <Resident 55> A review of records showed Resident 55 had diagnoses including dementia without behavioral disturbance, depression, and anxiety. A quarterly assessment completed on 11/07/2023 showed Resident 55 had moderate cognitive impairment and was not able to make needs known. Review of physician orders showed on 08/08/2023, Resident 55 was prescribed and received Lorazepam as needed for anxiety. Review of the Order Summary Report documented the last 14 day stop date as required for the as needed Lorazepam was obtained on 08/11/2023. A review of the resident's Medication Administration Records (MAR) for August 2023 through October 17, 2023, documented 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 employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 68 residents. Failure to ensure Staff J, Registered Dietician (RD) had a license to practice in Washington State placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain. Findings included . On [DATE], a review of the Washington State Department of Health Provider Credential database showed Staff J's license to practice as a dietitian had been expired since [DATE], and they were no longer licensed to practice as a dietician in Washington State as of that date. In an interview on [DATE], Staff J confirmed their license had expired on [DATE], and stated they were not aware it had expired until Staff B, Director of Nursing, had called and asked for it. Upon learning it was expired, Staff J immediately called the licensing board and paid the fees to renew the license. Review of an email…

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 dietary staff had the required qualifications (current Food Worker Cards) for one dietary staff (W). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed no Washington State Food Workers card for Staff W (hire date 2/18/2023). Staff W did have a certificate dated 1/25/2024 from Food Handler Solutions for completing the food handler's course. Review of Food Handler Solutions website, foodhandlersolutions.com/[NAME]-food-handler-card/ showed, the Food Handler Solutions Program is currently not approved in the state of [NAME]. This program is only intended to be used for personal development and preparation for the state provided training. A review of the staffing schedules showed Staff W had worked in the kitchen the following dates/times: 1/18/2024 1:04pm - 6:32pm 1/20/2024 8:05am -…

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 an injury of unknown origin was reported to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 1), reviewed for abuse. Failure to report potential abuse placed Resident 1 and additional residents in the facility at risk for uninvestigated abuse, mistreatment, and poor quality of life. Findings included . Review of 09/28/2023 admission assessment showed Resident was unable to make themself understood and required substantial staff assistance for activities of daily living. Review of the facility incident log for October and November 2023 showed Resident 1 had a fall on 10/08/2023 that resulted in superficial skin injuries and a fall on 10/16/2023 with no injuries. No additional entries for Resident 1 were found on the logs. In an interview on 01/12/2024 at 4:44 PM, a representative for Resident 1 stated the resident was admitted to the facility September 2023 after a surgery to repair a fractured hip. Per the representative, they received a phone call from unidentified facility staff 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.

Based on interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 1 sample residents (Resident 2) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Review of the 10/14/2023 admission assessment for Resident 2 showed they received IV antibiotics. Per the assessment, the resident was cognitively intact and did not refuse care. Review of the home care instructions dated 10/13/2023 showed Resident 2 had a dual lumen (two separate working…

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

Based on interview and record review, the facility failed to ensure the resident and/or the resident's representative was informed of and consented to a new medication for 1 of 3 residents (Resident 1), reviewed for care planning. This failure disallowed the resident and/or the resident representative to make an informed decision regarding treatment, and placed the resident at risk of diminished quality of life. Findings included Review of the 07/31/2023 admission assessment showed Resident 1 was severely cognitively impaired and needed assistance with decision making. Per the assessment the resident had diagnoses of fractures to their spine and anxiety. Review of a Durable Power of Attorney (DPOA; document that establishes who is in charge of a person's health or financial decisions), dated 12/16/2019, showed Resident 1 had a personal representative appointed to assist in their health care planning. Review of the 07/2023 and 08/2023 Medication Administration Records (MARs) showed an order for Depakote sprinkles (an anticonvulsant medication used to treat seizures, bipolar 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.

Based on interview and record review the facility failed to provide the necessary care and services for 1 of 2 residents (Resident 6), reviewed for non-pressure skin wounds. Failure to perform wound treatments as ordered placed the resident at risk for delayed wound healing, worsening of wounds, and/or potential infection and a diminished quality of life. Findings included . Review of the skilled nursing transfer report, dated 08/07/2023, showed Resident 6 admitted to the facility from the hospital with a surgical wound to their lower leg, and had a specialty dressing that was not to be removed for 14 days. Review of the August 2023 progress notes showed on 08/13/2023 the skin below Resident 6's incision was red and had large fluid filled blisters. New wound care orders were given by an orthopedic specialist. Review of the August 2023 Treatment Administration Record (TAR) showed beginning on 08/13/2023 Resident 6 was to have daily wound care and and dressings. Further review showed no documentation that the ordered wound care was provided on 08/14/2023, 08/15/2023, 08/17/2023,…

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 multiple food items in the kitchen were properly labeled, and that out-of-date foods were identified and discarded. In addition, the facility failed to ensure unpasteurized eggs were not used for foods not fully cooked. The failure to properly label foods, ensure the visibility of Best By dates, and use pasteurized eggs, placed residents at risk for consuming expired/spoiled foods and exposure to food borne illness. Findings included . Observations of the kitchen showed: Unlabeled and expired food items Refrigerator observations on 10/24/2022 at 2:07 PM showed: 1. Three large unlabeled and undated items wrapped in aluminum foil on the lower shelf of the refrigerator. On 10/24/2022 at 2:09 PM, Staff I, Dietary Manager, stated that they were just cooked turkey meat and acknowledged the food items needed a Use By date. 2. An unopened large bag of unlabeled and undated greens. 3. Three bags of six English muffins per bag, with a Best By date of 08/2022, for a total of 18 expired muffins. Staff I stated, I'll throw it away…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' records had complete and readily accessible Advance Directives and Vaccination Consents for 6 residents (6, 12, 25, 26, 33, and 47) of 15 residents whose records were reviewed for Advance Directives and immunizations. This failure placed the residents at risk for unmet care needs. Findings included . Advance Directives Resident 12 Review of an 08/13/2022 comprehensive admission assessment showed Resident 12 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the staff assessed Resident 12's cognition as moderately impaired. Review of an 08/10/2022 admission Care Conference note showed Resident 12 and their representative attended the care conference. This note showed the facility conducted a Review of Advance Directive and concluded the review was Accurate. Review of an 08/12/2022 Psychosocial History form showed the staff identified Resident 12 had a POA [Power of Attorney]/Living Will, and who…

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 thorough policies, and implement abuse and neglect prevention policies and procedures including, identifying, reporting, and investigating abuse, and protection of residents after verbal reports of rough handling during care were made, for 2 of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . A revised 07/13/2018 facility policy and procedure titled Preventing Abuse showed: Procedure - Prevention - (2) (c) Observe residents, visitors and staff to identify inappropriate behaviors, such as using derogatory language, rough handling, taking or using photographs or recording in any manner that would demeanor humiliate a resident(s), etc. The policy and procedure showed instructions to the staff regarding the observation of rough handling. Further review of the policy showed no instruction to staff on how to address verbal…

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 report resident verbal reports of rough handling during care as an allegations of abuse for 2 of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . RESIDENT 39 Review of the 09/24/2022 admission assessment showed that Resident 39 had severe cognitive impairment but was able to make their needs known. Resident 39 reported to surveyor, during the initial interview on 10/25/2022 at 9:42 AM, that one staff member was rough during care. RESIDENT 31 Review of the 09/15/2022 admission assessment showed that Resident 31 had no cognitive deficits and made decisions regarding their care. Resident 31 reported to the surveyor, during the initial interview on 10/25/2022 at 11:04 AM, that two staff members were rough during an assessment. On 10/25/2022 at 11:44 AM, Staff A, Administrator, was informed of the allegations of rough handling during care, from Residents 39 and 31. On 10/27/2022 at 8:30 AM, a review of the State…

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

Based on interview and record review, the facility failed to thoroughly investigate resident verbal reports of rough handling during care as allegations of abuse for 2 residents of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . RESIDENT 39 Review of the 09/24/2022 admission assessment showed that Resident 39 had severe cognitive impairment but was able to make their needs known. Resident 39 reported to surveyor during initial interview on 10/25/2022 at 9:42 AM that that one staff was rough during care. RESIDENT 31 Review of the 09/15/2022 admission assessment showed that Resident 31 had no cognitive deficits and made decisions regarding their care. Resident 31 reported to surveyor during initial interview on 10/25/2022 at 11:04 AM, that two staff members were rough during an assessment. On 10/25/2022 the facility was made aware of Resident 31 and 39's allegations. The allegations were reported to Staff A, Administrator, by the surveyors. In a follow-up interview with…

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

Based on observation, interview, and record review, the facility failed to provide grooming for 1 of 3 sampled residents (40), reviewed for activities of daily living. This failure placed the resident at risk for poor personal hygiene and a diminished quality of life. Findings included . According to the 09/20/2022 quarterly assessment, Resident 40 had severe cognitive impairment and needed assistance from one staff to complete activities of daily living, such as grooming. Observations of Resident 40 while sitting in their wheelchair with unshaved facial stubble were made on 10/24/2022 at 3:30 PM, 10/24/2022 at 4:41 PM, 10/25/2022 at 8:49 AM, and 10/26/2022 at 9:16 AM. In an interview on 10/27/2022 at 10:13 AM, Staff N, Nursing Assistant, stated residents were shaved on their bath days. Staff N further stated if the resident refused, then they would re-approach, and any refusals were documented in the resident's record. Review of Resident 40's bathing and grooming records from 10/24/2022 through 10/26/2022 showed the resident was bathed on 10/24/2022, and no refusals for assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement bowel protocol orders as instructed for 1 of 5 sampled residents (25), reviewed for unnecessary medications. In addition, the facility failed to ensure care and services were provided for 2 of 4 sampled residents (43, 267) reviewed for non-pressure skin conditions. Failure to treat Resident 25's constipation, consistently monitor blood pressure for Resident 43, and obtain wound care orders for Resident 267 placed the residents at risk for clinical complications and unmet care needs. Findings included . RESIDENT 43 Per the 09/20/2022 annual assessment, Resident 43 had diagnoses of high blood pressure and took a diuretic (a medication used to help the body get rid of excess fluid by producing more urine), daily. Observations on 10/24/2022 at 3:44 PM, 10/25/2022 at 8:51 AM, 10/26/2022 at 9:18 AM and 10:59 AM showed the resident sitting in their wheelchair beside their bed; both feet were without shoes, socks and were edematous…

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 show adequate indication for the use of a seizure medication for 1 of 5 sampled residents (25), reviewed for unnecessary medications. This failure placed the resident at risk for receiving an unnecessary medication, and its adverse outcomes. Findings included . Review of an 08/30/2022 quarterly assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions, to include cardiac diagnoses, dementia, and psychiatric disorders. The assessment showed Resident 25 had severe cognitive impairment. Review of the October 2022 Medication Administration Record (MAR) showed an order for Gabapentin (a seizure medication) Tablet, by mouth at bedtime for -. The Gabapentin order showed a start date of 05/28/2022, the day of Resident 25's admission to the facility, and no indication for its use. The MAR showed the staff administered the Gabapentin every night at bedtime. Review of a 09/06/2022 physician progress note showed no mention…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. Three medication errors were identified for 2 of 3 sampled residents (78,16), observed during 29 medication opportunities, resulting in a medication error rate of 10.34 percent. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication. Findings included: RESIDENT 78 On 10/25/2022 at 9:17 AM Staff P, Licensed Practical Nurse, was observed to administer one 450 milligram (mg) Cranberry tablet and one 81 mg. enteric coated aspirin (a medication which had a special coating that prevents release and absorption of contents until it reaches the small intestine) to the resident. On 10/26/2022 at 10:45 AM Staff Q, Registered Nurse, was observed to administer one 81 mg. enteric coated aspirin to the resident. When the order for the Cranberry tablet was reviewed by the nurse, they recognized they did not have the correct dose per the physician order and spoke with Staff R,…

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 maintain a clean, comfortable, homelike, and safe environment for 3 of 17 rooms (211, 213, 106), sampled for a safe and sanitary environment. Failure to ensure that the facility was free from damaged walls and a broken door, placed the residents (25, 33, 38) at risk for injury and a decreased quality of life. Findings included . room [ROOM NUMBER]-A Observations on 10/24/2022 at 3:12 PM showed Resident 33 sitting between the bed and the wall. The wall showed areas of chipped paint. Resident 33 stated, The door can't close. It's broken. It gets worse each time they mess with it. It's been over a week now. That's a safety issue, it's a fire door. Observation of the door showed it closed half of the way. room [ROOM NUMBER]-B Observations on 10/24/2022 at 4:26 PM showed two unfinished and rough-to-touch white patches to the wall, next to an empty bed in Resident 25's room. The size of each of the identified areas was approximately 1 to 1 ½ feet by 4 inches.…

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.