Regency Coupeville Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of six of eight residents (Residents 4, 8, 10, 21, 70 and 72) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and follow up of laboratory results along with a risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.Findings included.<RESIDENT 70> Resident 70 admitted on [DATE] with diagnoses which included sepsis (serious complication of infection causing inflammatory response throughout the entire body and can potentially lead to organ failure). Review of Resident 70’s admission orders showed several labs to be done twice weekly to monitor the status of the resident’s sepsis: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), ESR, CRP,…

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 system in which resident records were complete, accurate, accessible, and that documentation was in accordance with state law for 6 residents (Residents 3,8,10,30,32,and 43), and on one of two resident units. Failure to ensure records included accurate and timely entries and prohibit the use of stamped signatures on medical records, placed residents at risk for records that did not accurately reflect their care, and placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, General Documentation Guidelines, dated 3/2013, showed the procedure for completing and correcting clinical records was:- Every entry shall be recorded promptly as the events or observations occur. - All entries should be complete, concise, descriptive and accurate- Record pertinent observations, psychosocial and physical manifestations, incidents, unusual occurrences and abnormal behavior. -All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to incorporate the recommendations from the Level II Preadmission Screening and Resident Review (PASRR, a federally required screening of all individuals who have a serious mental illness (SMI) report into the resident's assessment, and care planning for 1 of 1 resident (Resident 8) reviewed for PASRR. Facility failure to incorporate the PASRR recommendations into the residents' assessment and care plan delayed the implementation of recommendations and left the residents at risk for unmet mental health and activity needs and a diminished quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) dated 11/2016 directed the interdisciplinary team to incorporate level II recommendations into the resident's care plan. Resident 8 was re-admitted to the facility on [DATE] with diagnoses to include a history of depression and moderate dementia with anxiety. Review of the clinical record showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were completed timely following a significant change in status for 2 of 5 residents (Residents 10 and 21) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASRR services for Residents 10 and 21, and placed other residents at risk for unmet mental health needs and a decreased quality of life. Findings included .Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), dated 11/2016, showed the PASRR would be reviewed and updated as indicated with significant changes in residents' physical or mental condition. The state mental health authority would be notified of the changes affecting the residents' physical or mental condition. <RESIDENT 10>Resident 10 admitted to the facility on [DATE] with diagnoses to include post-traumatic stress disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for 1 of 5 residents (Resident 13) reviewed for medication management. Failure to obtain a doctor's order and failure to monitor residents use of their own medical equipment, placed residents at risk for injuries and potential adverse outcomes.Findings include.Resident 13 was admitted to the facility on [DATE] with diagnoses to include lower extremity cellulitis (bacterial infection of the deeper layers of the skin) and polyneuropathy (nerve damage in multiple areas of the body). According to the admission Minimum Data Set (MDS - an assessment tool) dated 07/15/2025, the resident was cognitively intact.In an observation and interview on 07/25/2025 at 9:58 AM, Resident 13 stated that the rectangular white machine that was on their table and was plugged in the electrical socket in the wall was a machine called Therma Zone (pain management device that provides heating and cooling…

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 pharmacy services were provided to meet the needs of 2 of 3 residents (Resident 70 and 72) reviewed for Admission/Discharge planning. Failure to ensure medications were acquired and administered as ordered, and to follow facility processes for medications not available, placed residents at risk for adverse events related to missing medications. Findings included .<Resident 70>Resident 70 admitted to the facility on [DATE] with diagnoses to include hypomagnesemia (low magnesium levels in the body). Review of Resident 70’s physician orders showed an order for Magnesium with calcium (a supplement for magnesium and calcium), three times a day for a daily supplement with a start date of 05/01/2025 at 6:00 PM. Resident 70’s physician orders showed an order for Magnesium Oxide three times a day for Hypomagnesemia with a start date of 05/06/2025 at 12:00 PM. Review of Resident 70’s electronic medication administration record (EMAR) for May 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure staff recognize and report timely allegations of abuse/neglect for 2 of 2 residents (Resident 1 and 2) reviewed for allegations of abuse/neglect. These failures to timely report and investigate allegations of abuse/neglect and unexpected death placed residents at risk for potential abuse/neglect. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated [DATE], showed Unexpected Death, possibly related to abuse or neglect, Not related to abuse/neglect but suspicious needed to be reported to the State Hotline, Law enforcement agency as needed if a crime was suspected, Coroner or Medical Examiner and must be logged within 5 days of the event/incident. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include left femur fracture, malnutrition (lack of sufficient nutrients in the body) and dysphagia (difficulty or inability to swallow). Review of the facility…

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 thorough investigations were completed for 3 of 3 residents (Residents 1, 2, and 3) reviewed for allegations of abuse and/or neglect. Failure to conduct thorough investigations to identify root cause(s) and all contributing factors related to allegations of abuse and/or neglect placed all residents at risk for unidentified abuse or neglect, unidentified corrective actions, potential harm and decreased quality of life. Findings included . Review of the facility provided policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised 10/2022 documented during the investigation, the data collection involved interview of the alleged resident victim, interview caregivers, family, visitors, roommates and the alleged perpetrator. The policy also documented that after an investigation was complete, action to correct the reasonable cause of the incident and prevent further recurrences must be taken. According to the Washington State Reporting…

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 thorough investigations were completed for 2 of 4 residents (Resident 1 and 2) reviewed for allegations of abuse/neglect. Failure to conduct thorough investigations to identify root cause and all contributing factors related to allegations of abuse/neglect placed all residents at risk for unidentified abuse, unidentified corrective actions, and potential harm and decreased quality of life. Findings included . Review of the facility provided policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised 10/2022 showed during the investigation, the data collection involved interview of the alleged resident victim, interview caregivers, family, visitors, roommates and the alleged perpetrator. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include sepsis (chemicals released into the bloodstream to fight infection trigger inflammation throughout the body), acute cystitis (inflammation 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.

Based on interview and record review, the facility administration failed to ensure the facility maintained substantial compliance with federal and state regulatory requirements and to meet the significant needs of the residents. The administration failed to provide sorely needed administrative oversight and monitoring of facility personnel, systems, policies and practices related to residents' care plan timing and revision, professional standards of care, ensuring competency of nursing staff and completion of required nursing assistants performance reviews, psychotropic medication management, infection control and coordination of dental services. This failed practice placed all residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the facility Administrator position description, dated May 2015, showed the administrator was responsible for the daily operation of the facility and they were to utilize resources effectively and efficiently to attain and maintain the highest level of care for residents in accordance with regulatory…

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 nursing assistant competencies were assessed and completed yearly, for 5 of 5 staff (L, N, O, P and Q) employee files reviewed. This failed practice had the potential to negatively affect the competency of the nursing assistants and impact the quality of care provided to residents. Findings included . Staff L, Nursing Assistant Certified (NAC) was hired 09/29/2023. Review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. In an interview on 10/28/2024 at 11:41 AM, Staff L, NAC, confirmed they had been at the facility over a year and had not had competencies or skill checks done other than someone watched them do hand hygiene a couple months back. Staff N, NAC, was hired 05/12/2023. Review of the employee file showed no documentation of a yearly skills checklist having been performed. Staff O, NAC, was hired 07/17/2023. Review of the employee file showed no documentation of a yearly…

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 annual Nurse Aide Certified (NAC) performance reviews were completed for 5 of 5 employees (Staff L, N, O, P, and Q ) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents. Findings included . Review of the facility handbook dated May 2023, showed the performance management system is designed to provide employees with specific feedback on their job performance for the previous evaluation periodm and to establish new objectives and goals for the upcoming review period. Employees and supervisors are encourged to provide mutual feedback and communication about performance, expectations, and other work issues on a regualr basis. You also may request performance feedback from your supervisor at any time. Staff L was hired on 09/29/2023. Review of Staff L's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation…

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 food was prepared and stored under sanitary conditions in 2 of 2 nourishment rooms (East and [NAME] units) and 1 of 1 facility kitchens. The failure to ensure overhead light fixtures, toasters, microwave ovens and refrigerator/freezer units were sanitary placed residents at risk for foodborne illnesses and diminished quality of life. Findings included . <UNIT NOURISHMENT ROOMS/REFRIGERATORS/FREEZERS/MICROWAVE OVENS/TOASTERS> In an observation on 10/23/2024 at 11:09 AM, the East unit nourishment room refrigerator/freezer units in the clean utility room were soiled with food matter and spillage. The microwave oven in the nourishment room was very soiled with food splattering and debris inside and out. In an observation on 10/23/2024 at 11:16 AM, the [NAME] unit nourishment refrigerator/freezer units with very soiled with spilled food matter, and the freezer unit had lots of ice buildup. The microwave oven was very soiled. In an observation/interview on 10/23/2024 at 1:40 PM, the toasters in the East 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 observations and interviews, the facility failed to ensure the residents environment was clean and sanitary, and failed to identify and provide the necessary housekeeping services to ensure privacy curtains were laundered or replaced in resident (Residents 4 and 7) rooms on 1 of 2 units. These failures placed residents at risk for infectious disease and diminished quality of life. Findings included . <RESIDENT 4> In an interview and observation on 10/22/2024 at 11:43 AM, Resident 4 was in bed with both privacy curtains pulled around them. Both privacy curtains were heavily soiled with an 18 inch by 2-inch vertical brown stain on the left curtain and multiple brown and black areas on the right curtain. In multiple observations the privacy curtains remained unchanged on 10/23/2024 at 1:07 PM, 10/24/2024 at 9:55 AM, 10/25/2024 at 8:23 AM and 10/28/2024 at 9:30 AM. In an interview and observation on 10/29/2024 at 9:00 AM, Resident 4 was observed in bed behind both privacy curtains that remained soiled. Resident 4 stated they did not know when their privacy curtains 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 promptly resolve and document resident grievances for 2 of 3 sampled residents (Residents 67 and 4) reviewed for grievance resolution. The failure of staff to document, investigate, and resolve resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing clothing, and placed residents at risk for frustration and diminished quality of life. Findings included . Review of the facility policy titled Grievance Procedure, revised date of October 2021, showed the facility would have a process in place for identification, investigation, and follow-up of resident grievances in a timely manner. The policy indicated they facility would identify a Grievance Officer to oversee the grievance procedure and coordinate the facility system for collecting, tracking, and responding to grievances. The policy indicated staff were trained on the facility's grievance procedure including the need…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a Significant Change in Status (SCSA) Minimum Data Set (MDS- an assessment tool) was completed for 1 of 3 sampled residents (Resident 12) reviewed for decline in Activity of daily living (ADL). This failed practice placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, stated a Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date and no later than 14 days from the determination date of the significant change in status. (For purpose of this section, a significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of a resident's health…

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 accurately assess 2 of 3 sample residents (Residents 67 and 65) reviewed for devices and 1 of 2 residents (Resident 4) reviewed for pressure injuries. This failure placed the residents at risk for not receiving the care and service required to meet the residents' needs and for inaccuracies in care planning of the residents' care. Findings included . <RESIDENT 67> Resident 67 admitted to the facility 09/07/2024 with diagnoses to include a colostomy (colostomy - a surgery to create an opening for the colon (large intestine) through the abdominal wall). According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/11/2024, the resident had no cognitive impairment, and they had no ostomy, and they were coded they were always continent of bowels. In an observation/interview on 10/24/2024 at 1:10 PM, Resident 67 stated they had a colostomy that was used for them to have their bowel movements, and they 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 a Level II Preadmission Screening and Resident Review (PASRR) screening for residents for a serious mental illness (SMI), intellectual disability (ID) or a related condition was completed if the scheduled discharge did not occur for 1 of 5 sampled residents (Resident 18) reviewed. Additionally, the facility failed to ensure a resident with a Level 1 PASRR screening form was accurate prior to admission to the nursing facility for 1 of 5 sample residents (Resident 38) reviewed. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or intellectual disability care needs. Findings included . <RESIDENT 18> Resident 18 was admitted to the facility on [DATE] with diagnoses to include depression, anxiety disorder and a history of delirium (a serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) 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, interview and record review, the facility failed to ensure that care plans were revised to reflect changes or current status of 3 of 7 sample resident (Residents 4, 7, and 17) reviewed for care plans. These failures placed residents at risk of less-than-optimal care, staff not knowing how to properly care for a resident, a decreased quality of life with potential for harm. Findings included . <RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Accident (CVA, a condition that affects blood flow to the brain) with hemiparesis (weakness on one side of the body), hemiplegia (paralysis on one side of the body) and mild cognitive impairment. In a review of Resident 4's care plan dated [DATE] and most recently updated [DATE] showed a care plan focus of potential alteration in skin integrity related to decreased mobility following CVA with hemiparesis. The care plan showed Resident 4 preferred to remain up in their wheelchair throughout the day…

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 staff followed professional standards of practice for 2 of 2 sampled residents (Residents 7, 17) reviewed for physician's orders on medication parameters and 1 of 1 sample residents (Resident 38) reviewed for admission orders. The failure to implement and follow physician prescribed orders placed residents at risk for adverse effects, unmet care needs and diminished quality of life. Findings included . <RESIDENT 38> Resident 38 was admitted to the facility on [DATE] with diagnoses to include dislocation of right hip prosthesis and dementia unspecified with behavioral disturbance. Resident 38 was sent to the emergency room (ER) on 09/08/2024 for hip dislocation. In a record review on 10/28/2024 at 9:14 AM, Resident 38's hospital discharge note, dated 09/09/2024, the Emergency Department (ED) note stated, the ED provider recommended palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to advocate and assist 1 of 1 sampled residents (Resident 38) with their rights within the facility. The failure to assist the resident in having care planning meetings to ensure their voice was heard regarding their care and preferences placed residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled: Interdisciplinary Care Conference Revised date 11/2016 stated, the Interdisciplinary Care Conference is completed upon admission, quarterly and following a significant change in condition. The resident and/resident representative will be invited to care conference. Resident 38 was admitted to the facility on [DATE] with diagnoses to include dislocation of right hip prosthesis and dementia unspecified with behavioral disturbance. Review of Resident 38's quarterly Minimum Date Set (MDS -an assessment tool) assessment dated [DATE] showed the resident rarely/nevererstood, has short-term and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure 2 of 5 sampled residents (Resident 38 and Resident 58) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behaviors). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, behavior monitoring and to attempt gradual dose reductions (GDR). These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of life. Findings included . According to the FDA Boxed Warning: Elderly patients with dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities)-related psychosis (symptoms that happen when a person is disconnected from reality) treated with antipsychotic drugs (prescribed medication to treat psychosis) are at an increased risk of death. Seroquel is not approved for elderly 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 interviews, observations, and record review, the facility failed to assist with access to preventative (and emergency) dental services for 2 of 3 sampled residents (Residents 44 and 15) reviewed for dental services. Failure to follow up on dental referrals and ensure the coordination of dental services for residents who had missing, and broken teeth placed the residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life. Findings included . <RESIDENT 44> Resident 44 admitted to the facility on [DATE], with diagnoses including heart failure, history of stroke, and difficulty swallowing. The Annual Minimum Data Set (MDS - an assessment tool) assessment, dated 09/04/2024 showed the resident had intact cognition, and required substantial to maximum assistance for oral hygiene care assistance. The dental section was documented as unable to examine. Review of Resident 44's current care plan showed a focus area initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigations for 3 of 7 sample residents (Residents 1, 6, and 7) reviewed for accidents/incidents. Failure to conduct a thorough investigation to identify root cause(s) and consistently consider all potential contributing factors, such as last time checked on, last time toileted/changed, and other factors placed the residents at risk for unidentified abuse and/or neglect, inappropriate corrective actions, and ineffective care planning that potentially impacted the overall well-being of the residents. Findings included . Review of the facility policy titled Incident Documentation and Investigation revised date 10/2022, showed the policy of this facility was to document and investigate investigations in order to protect residents from further incidents and a thorough investigation may require 2 phases of fact gathering. The policy showed that an incident report would be completed for falls, witnessed, unwitnessed or staff lowered…

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 maintain complete and accurate clinical records for 3 of 7 residents (Residents 1, 6, and 7) reviewed for incidents and care and services. The failure to ensure thorough documentation of incidents, care and services, and food preferences placed residents at risk for unmet needs, repeat occurrences of incidents, and diminished quality of life. The failure to obtain witness statements for incidents resulted in lost evidence regarding incidents that occurred in the facility making it impossible to ascertain what occurred. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), aftercare and rehabilitation after spinal fusion surgery. According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/05/2024, the resident had severe cognitive impairment and needed supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include providing oral care of 1 of 3 sample residents (Resident 1) reviewed for ADL's. The failure to provide oral care placed residents at risk for poor hygiene, unmet needs and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/05/2024, the resident had severe cognitive impairment and needed supervision or touching assistance with oral hygiene. In a phone interview on 09/26/2024 at 2:52 PM, Collateral Contact 1 stated staff were not brushing Resident 1's teeth, so they had to do it. Review of Resident 1's care plan, print date 09/26/2024, showed they were care planned to receive oral care twice daily, in the morning and at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision, update and consistently implement the care plan to prevent accidents/falls for 1 of 3 residents (Resident 1) reviewed for accidents. The facility failure to provide adequate supervision and implement appropriate interventions placed residents at risk for future falls, injury, and diminished quality of life. Findings included . Review of a facility policy titled Fall Risk Overview, revised date 02/2020, showed it was the policy of this facility to evaluate each resident's fall risk in order to develop and implement care plan interventions that create a safe and secure environment where falls and injuries are minimized. The facility fall risk program included identification of residents at risk for falls, development of care plan interventions to minimize fall risk, implementation of fall risk interventions and evaluation of effectiveness of fall risk interventions. The policy indicated an individualized care plan was to be…

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, facility staff failed to use appropriate standards of infection control practice for 2 of 2 residents (Residents 2 and 3) observed during resident care. Failure to utilize appropriate hand hygiene and to provide incontinent care without staff contaminating the resident's environment placed residents at risk for cross-contamination and for living in a contaminated environment. Findings included . <RESIDENT 2> Resident 2 was admitted at the facility on 01/11/2023. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], showed the resident was cognitively intact, and was incontinent of urine and bowels. In an observation on 09/26/2024 at 12:50 PM, Staff C, Certified Nursing Assistant (CNA) was completing peri care (the process of washing the genital and rectal area) on Resident 2 and with the gloves they used to wash the resident's peri area (area in the body between the genital and rectal), which were contaminated gloves, staff touched 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 [NAME] Based on interview and record review, the facility failed to provide resident focused care through consistent monitoring, assessment and evaluation of the resident's condition to identify a change in condition for a suspected urinary tract infection (UTI) and to implement physician orders for 1 of 5 residents (Resident 1) reviewed for quality of care. This failed practice placed residents at risk for unmet needs, hospitalization, and diminished quality of life. Findings included . Review of McGreer's criteria (set of surveillance definitions used to identify infections in long-term care settings) showed the constitutional criteria for a UTI (a set of signs and symptoms that indicate a patient may have an infection, even if diagnostic testing has not confirmed it) included fever, acute change in mental and/or functional status and leukocytosis (high white blood cell count). Resident 1 admitted to the facility on [DATE] with diagnoses to include low back pain, chronic pain, cardiomyopathy (disease 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 interviews and record review the facility failed to ensure timely physician visits (once every 30 days for the first 90 days after admission) were completed for 1 of 4 residents (Resident 1) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being. Findings included . Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include low back pain, chronic pain, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and spondylosis (a condition that causes the spine to degenerate, resulting in abnormal wear on the cartilage and bones in the spine). Review of Resident 1's electronic health record (EHR) showed they were seen by a physician on [DATE], [DATE], [DATE], and [DATE]. Resident 1 was not seen by a physician again until [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that an allegation of abuse was reported immediately, not longer than 2 hours after the allegation of abuse was made for 1 of 3 (Resident 1) residents reviewed for abuse allegations or injury of unknown source. This failure placed Resident 1 and other residents at risk for potential continued abuse, unrecognized abuse, and a decreased quality of life. Findings included . Review of the facility provided policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised date of 10/2022, showed a mandated reporter include facility employees, and mandated reporters must immediately report to the Abuse Hotline. Resident 1 admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), oxygen dependence, and schizophrenia (a serious mental condition of a type involving a breakdown in 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 residents were protected during the facility's investigation phase to prevent further potential abuse or mistreatment for 1 of 3 residents (Resident 1) investigations reviewed for abuse when they allowed the staff member to continue to work with Resident 1 and other residents after an allegation of abuse. This failure placed all residents at risk for continued potential abuse from Staff E, Nursing Assistant Certified (NAC), and a decreased quality of life. Findings included . Review of the facility policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised date of 10/2022, showed that all alleged incidents of abuse and injuries of unknown source are thoroughly investigated to determine what occurred and make necessary changes to the provision of care and services to prevent reoccurrences. The policy also showed that protecting the resident from further harm means keeping the resident safe by immediate suspension of the alleged…

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

Based on observation, and interview, the facility failed to provide a dignified and homelike dining experience in 1 of 3 dining rooms (East) during 1 of 3 dining observations for dignity witnessed when a resident was in respiratory distress (an abrupt change in a resident's breathing abilities) in the East dining room observed by other residents. These failures placed residents at risk for feelings of anxiety, fear, and concern. Findings included . In a continuous observation on 11/19/2023 from 12:56 PM until 1:04 PM, Resident 37 was seated in the dining room when a persistent coughing episode began. The resident was red faced and unable to stop coughing. Residents 7, 16, 52 and 119 were present at the same table eating their lunch. Staff AA, Registered Nurse (RN), came into the dining room to assess the resident and administer their inhaler (a device to administer a drug which is to be breathed in). At 1:15 PM, Resident 37 was asked how they were and when they went to answer, they began coughing continuously and a long thick clear secretion came out of their mouth. Resident 16 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 interview and record review, the facility failed to ensure residents were informed and provided written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a wide range of healthcare decisions and includes resident's wishes if they became incapacitated) for 4 of 6 residents (Resident 54, 172, 6, and 13) reviewed for ADs. The failure to offer assistance or choose to refuse to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions. Findings included . <RESIDENT 54> Resident 54 was admitted to the facility on [DATE] with diagnosis to include dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 54's Electronic Medical Record (EMR) on 11/14/2023, showed the resident did not have an AD or documentation written information on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure written notification of facility initiated transfer and/or discharge was completed for 5 of 5 sampled residents (Residents 37, 59, 68, 219 and 44) reviewed for hospitalizations. The facility failed to ensure the transfer/discharge notice with all the required information was provided in a timely, practical manner upon an emergent transfer to the hospital. This failure placed residents and their representatives at risk of not receiving accurate information related to resident's discharge, and potential for diminished quality of life. Findings included . <RESIDENT 37> Resident 37 was admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE]. Review of the Resident 37's electronic medical record (EMR), showed no documentation the resident or to the Office of the State Long-Term Care Ombudsman (Ombudsman - a resident advocate) received written notification of the resident's transfer to the hospital. In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a bed hold notification for transfer to the hospital for 5 of 5 sampled residents (Residents 37, 59, 68, 219 and 44) reviewed for hospitalizations. This failed practice placed the resident or the resident's representative at risk for a lack of knowledge regarding the facility's bed hold policy a resident was admitted to the hospital and did not allow an opportunity to the resident or their representative from making an informed bed hold decision. Findings included . <RESIDENT 37> Resident 37 was admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE]. Review of Resident 37's electronic medical record (EMR), showed no documentation the resident was offered or received a written notification of a bed hold. In an interview on 11/20/2023 at 8:43 AM, Staff B, Director of Nursing Services, stated there was no written notification of a bed hold was provided to Resident 37. <RESIDENT 59> Resident 59 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <RESIDENT 4> Resident 4 admitted on [DATE] with diagnosis to include paraplegia. According to the Quarterly MDS assessment, dated 11/01/2023, they had limited range of motion (ROM) on one side of upper extremities (UE) and both sides of lower extremities (LE). They required extensive assistance with grooming and bathing. Review of the facility shower schedule, showed Resident 4 was to receive showers on Mondays and Thursdays. Review of Resident 4's 10/01/2023 to 10/20/2023, showed the resident received four showers in October (on 10/02/2023, 10/09/2023, 10/26/2023 and 10/30/2023), and four showers in November (on 11/09/2023, 11/13/2023 and 11/16/2023, and 11/20/2023). Resident 4 did not received showers as they preferred. In an interview on 11/22/2023 at 9:25AM, Staff W, NAC, stated showers were provided depending on the residents wishes and some residents wanted two to three times a week. Staff W said if a resident refuses bathing, it was documented and brought to the nurse's attention. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly provide professional standards of care and services for 5 of 6 residents (16, 21, 36 51, and 64) reviewed for unnecessary medications and 1 of 1 resident (Resident 36) reviewed for medication management. The facility failed to hold medications per physician orders, and to reassess abnormal blood pressure (BP) values, and notify the provider of abnormal findings, medication refusals and did not include, tubing maintenance, dressing changes, flushes on a peripherally inserted central catheter (PICC). This failed practice placed residents at risk for infection, medication complications, and a diminished quality of life. Findings included . Review of the facility's interact policy titled, Vital Signs, dated 2011, showed licensed nurses were responsible for immediately reporting Systolic blood pressures over 200 mmHG or less than 90 mmHG and diastolic blood pressures over 115 mmHG. <MEDICATION MANAGEMENT> RESIDENT 21 Resident 21 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 3 of 4 residents (Resident 3, 18, and 172) with limited range of motion (ROM) received appropriate treatment and services to increase their ROM or prevent further decrease in range of motion. This failed practice placed the residents at risk for further decline in their ROM. Findings Included . <RESIDENT 172> Resident 172 was admitted to the facility on [DATE] with diagnoses to include right femur fracture, dementia, fall, and abnormal gait and mobility. Review of Resident 172's provider orders showed that they were to have a wedge/hip abduction pillow to place between legs to prevent flexion and internal rotation of right knee, ordered on 11/15/2023. Review of Resident 172's Treatment Administration Record (TAR) dated November 2023 showed that the resident was to have wedge in place when resident was in bed and to document every shift, initiated 11/15/2023. Review of Resident 172's care plan showed that there were no focuses or interventions,…

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 have sufficient staff to provide and supervise care as evidenced by information provided by 14 resident interviews (1, 4, 11, 16, 18, 30, 31, 32, 33, 36, 49, 55 , 64 and 171), and two-family interviews (3 and 6) and as evidenced by failed practice in other identified quality of life and quality of care areas. These failures placed residents at risk for potential harm related to anxiety, feelings of frustration and vulnerability, unmet care needs, negative outcomes and a diminished quality of life. Findings included . <RESIDENT INTERVIEWS> RESIDENT 11 In an interview on 11/14/2023 at 10:04 AM, Resident 11 stated they have to wait up to an hour for help on weekends and evenings. RESIDENT 18 In an interview on 11/15/2023 at 10:40 AM, Resident 18 stated the facility needed more staff especially at night. The resident said when they want to get up, they have to wait to get out of bed and they felt like staff try to keep them in bed. The resident stated they have to wait longer because they are a mechanical lift.…

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 Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 5 of 5 sampled staff (Staff J, AA, BB, CC & DD) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1). Staff J, Licensed Practical Nurse (LPN), was hired by the facility on 03/17/2023. Staff J's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 2) Staff AA, Registered Nurse (RN), was hired by the facility on 10/08/2018. Staff AA's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 3) Staff BB's,…

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 adequate monitors were in place for psychotropic medication management for 4 of 6 residents (6, 21, 37, and 172)reviewed for psychotropic medications. These failures placed residents at risk to receive unnecessary medications, possible side effects, and a diminished quality of life. Findings included . Review of the facility policy titled 'Behavior Management/Psychotropic Medication Overview', revised 10/2022 showed that Step 6 of the policy was that 'Risks associated with psychotropic medications still exist regardless of the indication for their use, therefore the requirements pertaining to psychotropic medications apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety, and hypnotic) without exception. Step 13 showed that 'when a hypnotic [NAME] is ordered, resident's hours of sleep will be documented on the Medication Administration Record (MAR). When Trazodone is given for insomnia, hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible, and systematically organized for 8 of 8 residents (4, 10, 18, 21, 37, 44 and 64) reviewed for accurate Medication Administration Records (MAR) and Treatment Administration Records (TAR). Failure to ensure clinical records were complete and accurate made it impossible to determine what care and services were provided, or should have been provided, and placed residents at risk for medical complications, unmet care needs, undocumented/unresolved grievances, and for diminished quality of life. Findings included . Review of the facility staff job description titled, Medical Records, updated May 2015, showed the duties for medical records were. - to include chart audits on an ongoing basis for MDS assessment completion, summaries, weights, vital signs, physician orders using the facility audit form. - Evaluate medical records on an on-going basis for missing documents, charting…

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 staff were compliant with Infection Prevention and Control Guidelines and standards of practice for one of two hallways (West Hall) and one of one residents tube feeding (Resident 44). The facility failed to ensure the staff used appropriate hand hygiene practices during meal tray pass, and during meal preparation in the kitchen. This failed place all residents and staff at risk for potential infection. Findings included . Review of the facility policy titled, Hand Hygiene, revised October/2017 stated staff are required to use appropriate hand hygiene after each direct resident contact or contact with resident food. In a continuous observation and interview on 11/14/2023 at 12:00 PM, Staff H, Licensed Practical Nurse (LPN) was observed to remove a resident lunch tray from the meal cart without performing hand hygiene. Staff H was observed to enter the resident's room, touch with their bare hand, items on the residents over 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 responsible parties were notified timely for one of one resident (55) reviewed for incidents. This failure placed resident's representatives at risk of not being informed of resident status and potential for receiving less than optimal care. Findings included . Review of the facility policy titled 'Incident documentation and investigation', last revised 10/2022 showed that step 8 of their policy is that the physician (provider) and family notification is documented. Resident 55 was admitted to the facility on [DATE] with diagnoses to include prostate cancer, bone cancer, paraplegia (paralysis of legs and lower body), and hospice (end of life) care. Resident 55's admission Minimum Data Set (MDS) assessment dated [DATE] showed that the resident was cognitively intact and that the resident required moderate to maximum assist with activities of daily living (ADL). Review of Resident 55's progress note dated 11/04/2023 at 9:47 AM showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 6 sampled residents (Resident 221) reviewed for allegations of abuse and/or neglect. The facility failed to identify, report, and initiate timely interventions for an allegation of sexual abuse for eight hours after the allegation had been made by a resident. This failure to report to the required state agency, and law enforcement resulted in lack of timely investigations and placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . Review of the facility policy titled, Abuse/Neglect/Misappropriation/exploitation, revised 10/2022, showed all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, and must report to law enforcement if there was a suspected incident of sexual abuse.…

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 conduct a thorough investigation for 1 of 6 sampled residents (Resident 221) reviewed for allegations of abuse and/or neglect. The facility failed to initiate an investigation for an allegation of sexual abuse for eight hours after the allegation had been made by a resident and failed to complete a thorough investigation of sexual abuse. This failure to investigate timely and thoroughly placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . Review of the facility policy titled, Abuse/Neglect/Misappropriation/exploitation, revised 10/2022, showed the investigation should begin as soon as the allegation was identified. The investigation should include interviews with all staff that worked on the shifts in the allegation occurred and shift prior and collect as much data as possible. Resident 221 admitted to the facility on [DATE] with diagnoses to include post-surgical care for toe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 of 6 residents (Resident 172 and 44) reviewed for comprehensive care plans. The failure to develop and implement care plans for necessary supplies (a positioning wedge/pillow and pressure relieving boots) placed the residents at risk for possible adverse effects and related complications. Findings included . <RESIDENT 172> Resident 172 was admitted to the facility on [DATE] with diagnoses to include right femur (upper leg bone) fracture, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), fall and abnormal gait and mobility. Review of Resident 172's admission 5-day Minimum Data Set (MDS - an assessment tool) assessment, dated 11/12/2023, showed they were dependent on staff to complete Activities of Daily Living (ADL - dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that care plans were revised to reflect changes or current status of three of six (2, 18, and 23) residents reviewed for care plans. These failures placed residents at risk of less than optimal care, staff not knowing how to properly care for a resident, a decreased quality of life with potential for harm. Findings included . <RESIDENT 2> Resident 2 admitted to the facility on [DATE] diagnoses included congetive heart failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should), unspecified dementia, and supplemental oxygen use. In a review of Resident 2's care plan dated 12/19/2020 and most recently updated 09/23/2023 showed a care plan focus for alteration in respiratory status related to of CHF, Chronic Obstructive Pulmonary Disease, and dependence on oxygen. One of the interventions on the care plan included that Resident 2 preferred to have their oxygen condenser in the bathroom to minimize noise,…

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 professional standards were met for 1of 1 sampled residents (Resident 36) sampled for intravenous (IV - into the vein) medication administration. The facility failed to ensure the resident's antibiotic (medication to treat an infection) IV medication was administered by a nurse that had the appropriate certification to manage IV lines and IV medication administration. This failure placed the resident at risk for complications, a worsened infection, delay in healing, and adverse outcomes. Findings include . Review of the facility policy titled, Administration of an intermittent infusion (IV therapy), revised 06/01/2021, stated that IV therapy was only to be performed by a licensed nurse according to state law and facility policy. The nurse was responsible and accountable for obtaining and maintaining competency with IV therapy within their scope of practice. Review of the facility job description titled, Licensed Practical Nurse…

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 necessary assistive devices to maintain vision abilities for 1 of 1sampled residents (Resident 23) reviewed for vision. Failure to ensure the resident received assistance with obtaining corrective lenses left the resident at risk for unmet needs and a diminished quality of life. Findings included . Resident 23 most recently admitted to the facility on [DATE] diagnoses included hypertension (high blood pressure), unspecified urinary incontinence, and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Review of Resident 23's Minimum Data Set (MDS - an assessment tool) assessment, dated 10/29/2023, showed the resident's vision was adequate. Review of Resident 23's progress notes from 11/15/2022 through 11/16/2023, showed the resident complained of blurred vision on 12/22/2022, and an eye exam was scheduled on 1/17/2023. Resident 23 was referred for eye surgery on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two residents (13 and 37), reviewed for use and care of a 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. This failure placed the resident at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications. 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 facility's Indwelling Urinary Catheters Policy, most recently dated 04/2018, read, in pertinent part, It is the policy of the facility to ensure an indwelling catheter is not used for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they had an effective system in place for monitoring resident weights for 1 of 1 resident (Resident 64) reviewed for nutritional status and weight loss. The failure to accurately monitor, assess and document resident weights placed residents at risk for unrecognized weight loss, nutrition-related complications and for diminished quality of life. Findings included . Review of the facility's policy titled, Nutrition and Hydration, revised 07/2018, included: - Residents who showed an unexpected significant weight change were assessed by the facility dietician and Resident Care Manager (RCM). - The resident's weight would be monitored weekly until stable for four weeks following admission and monthly thereafter if stable. - The RCM would monitor weights and request a reweigh if the resident's weight varied by five pounds (lbs.) or more (plus or minus) from the previous weight. - Residents showing a significant weight variance (5% in 30…

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 2 residents (Resident 2) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the concentrator was set to the ordered dosage and failed to ensure oxygen tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life. Findings included . Resident 2 admitted to the facility on [DATE] diagnoses included congestive heart failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should), unspecified dementia, and supplemental oxygen use. In a review of Resident 2's care plan for oxygen use, most recently revised 09/25/2023, showed that resident used oxygen via nasal cannula (a device that gives you additional oxygen through your nose) at two liters continuously to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 44) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes. Findings included . Resident 44 most recently admitted to the facility on [DATE] with diagnoses included dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum), atrial fibrillation (a heart condition that makes your heartbeat irregular and hypertension (high blood pressure). In a review of Resident 44's dialysis care plan, revised 05/05/2023, showed the resident received HD on Tuesdays, Thursday.…

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 annual Nurse Aide Certified (NAC) performance reviews were completed for three of three employees (BB, CC, and DD ) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents. Findings included . Staff BB was hired on 08/26/2022. Review of Staff BB's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff BB. Staff CC was hired on 08/25/2022. Review of Staff CC's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff CC. Staff DD was hired on 08/25/2022. Review of Staff DD's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff DD. In…

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 pharmacy recommendations were timely followed up on for 2 of 3 sampled residents (Resident 37 and 64) reviewed. These failures placed residents at risk for receiving an inaccurate dosing of medication, adverse side effects, and the risk of receiving a medication longer than medically necessary. Findings included . <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with a diagnoses of depression, dementia with behavioral disturbance, anxiety and failure to thrive. Review of a pharmacy recommendation dated 09/21/2023, showed a recommendation to assess for a required gradual dose reduction of Diazepam 2.5 mg, an anti-anxiety medication that may cause sedation and contribute to falls. The resident's provider disagreed with the pharmacy recommendation and wrote no changes. The patient is (unintelligible word) stable. The provider provided no rationale as to why the recommendation was rejected. <RESIDENT 64> Resident 64 admitted on [DATE]…

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 prompt dental services were provided for 1 of 1 (Resident 10) residents reviewed for dental care. This failure placed Resident 10 and all other residents at risk for unmet dental needs, and a diminished quality of life. Findings included . Resident 10 admitted to the facility on [DATE] with diagnoses included hypertension, atrial fibrillation (a heart condition that makes your heartbeat irregular), and dental caries (loss of tooth substance (enamel and dentine). In a review of Resident 10's care plan, revised 08/16/2023, showed a care plan focus for dental care. The care plan showed that Resident 10 had dental caries, several missing teeth, and that resident had declined to have their remaining teeth removed. Interventions included to coordinate arrangements for dental care, transportation as needed and as ordered. In an interview and observation on 11/15/2023 at 12:53 PM Resident 10 stated their teeth did not bother them and they…

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

Based on record review and interview the facility failed to develop, implement and maintain an in-service training program ensure 3 of 3 Nursing Assistant's (BB,CC and DD) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs. Findings included: Review of Staff BB, CC, and DD's employee file showed each NAC did not have documented evidence of 12 hours of in-servicing. Review of the in-service records showed the facility failed to document how long the in-service lasted or the time it started. In an interview on 11/22/2023 at 10:29 AM, Staff A, Administrator stated they were aware the 12 hours were not completed for the NAC's but had not had the chance to put the issue through Quality Assurance Performance Improvement (QAPI) yet. The Administrator stated the facility would develop a plan to ensure the required in-service hours would occur. Refer to WAC 388-97-1680 (2)(a-c) .