Judson Park Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure activity programs met the needs for 5 (Residents 1, 54, 2, 9, & 20) of 7 residents reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life. Findings included.<Facility Policy>According to the facility's revised 2018 Activity Evaluation policy, an activity evaluation would be completed for each resident and the results incorporated into the resident's Care Plan (CP). This CP would facilitate the resident's participation in the activities of their choice.<Resident 1> According to the 07/13/2025 admission Minimum Data Set (MDS – an assessment tool) it was very important to Resident 1 to listen to music, be around pets, participate in group and favorite activities, and attend religious services. Review of the 07/16/2025 “somewhat dependent on staff for meeting emotional, intellectual, physical, and social needs…” CP Resident 1 had a goal to participate 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.

Based on observation, interview, and record review the facility failed to ensure 1 of 23 sample residents (Resident 54) and one supplementary resident (Resident 1) reviewed for pressure injuries (injuries to the skin and underlying tissue caused by prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to complete weekly skin assessments, implement interventions, and describe and measure wounds placed residents at risk for skin deterioration, increased discomfort, new pressure injuries, and a diminished quality of lifeFindings included.<Facility Policy>According to the facility's revised April 2018 Pressure Ulcers/Skin Breakdown. policy the facility would assess residents' risk for pressure injuries and obtain orders from the physician for wound treatment. The policy showed the physician would identify pertinent medical interventions and during wound rounds evaluate and document the progress of wound healing.<Resident 54>According to a 07/07/2025…

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.

Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 (Resident 43) of 8 residents reviewed for accidents, and failed to ensure the potential risks of an air mattress were assessed prior to implementation for 1 supplemental resident (Resident 1). These failures placed residents at risk for falls, injury, discomfort, and frustration. Findings included. <Facility Policy>According to the facility's revised March 2018 Falls - Clinical Protocol Policy, after assessing a resident was at risk for falls, the facility would identify pertinent interventions to try to prevent future falls.<Resident 43>According to a 05/21/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 43 had multiple medically complex diagnoses and had a recent history of falls, one with major injury. This MDS showed Resident 43 had limitations in functional Range of Motion (ROM) to one of their arms and both sides of their legs, and required partial assistance from staff to roll side to side in bed.In an interview on 08/22/2025 at 10:20…

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 effective pain management was provided to residents, consistent with professional standards of practice. The failure to offer non-pharmacological interventions to residents experiencing pain or investigate causes of pain for 3 of 5 sampled residents (Residents 6, 49 & 40) reviewed for pain management, placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.Findings included .<Facility Policy>Review of the facility's revised April 2025 Pain Assessment and Management policy showed procedures that helped staff identify pain in residents, helped with development of interventions consistent with the resident's goals and needs, and helped to address the underlying causes of pain. The policy shows staff were to conduct a comprehensive pain assessment whenever there was a need or significant change in condition and when there was an onset of new or worsening pain and to offer pain management interventions along with non-pharmacological intervention in conjunction…

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 identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 1 residents (Resident 67) reviewed for trauma informed care (a framework for understanding and responding to the effects of trauma). This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life.Findings included .<Facility Policy>Review of a revised August 2022 Trauma-Informed Care policy showed an individualized Care Plan (CP) would be developed that addressed past trauma, triggers identified to decrease exposure that may re-traumatize the resident, and establish resident-care strategies.<Resident 67>According to an 08/18/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 67 had a diagnosis of depression, moderate memory impairment, and no behavioral symptoms.Review of an 08/21/2025 care conference progress note showed Resident 67 reported being punched by staff during 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 proper storage and labeling of medications in 1 of 1 medication storage rooms (Cascade Hall), 2 of 3 medication carts (Cascade Hall and Shoreline Hall), and ensure medications were secured for 1 of 1 residents (Resident 2) reviewed for medication storage. These failures placed residents at risk of receiving expired medications, ineffective treatment, missing medications, and a diminished quality of life.Findings included.<Facility Policy>According to the facility's Medication Labeling and Storage policy, revised 02/2023, all medications would be labeled with an expiration date. The policy showed multi-dose vials that were opened would be dated and discarded within 28 days.<Cascade Hall Medication Room>Observation on 08/21/2025 at 9:11 AM of the Cascade Hall medication storage room showed an open bottle of tuberculosis (infectious, airborne disease affecting the lungs) testing solution with an open date of 07/08/2025. The bottle was not discarded after 28 days. Observation at that time showed a box…

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 prompt dental services were provided for 1 (Resident 43) of 1 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.Findings included .<Resident 43> According to a 11/25/2024 admission Minimum Data Set (an assessment tool) Resident 43 had clear speech, was able to understand others, and make themselves understood. This MDS showed Resident 43 was assessed with obvious or likely tooth decay or broken teeth and had mouth or facial pain and discomfort or difficulty with chewing. In an interview on 08/22/2025 at 10:09 AM, Resident 43 stated they needed to see a dentist for their “really bad teeth.” Resident 43 stated they had some teeth that were cracked down to the gum which caused discomfort at times when eating. Resident 43 stated they had one tooth with a hole and they had to pick food out of their tooth every time they ate. Resident 43 stated they saw a dentist when they first admitted at the facility and did not…

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 properly stored and labeled for 2 of 2 kitchens reviewed for kitchen safety. These failures left residents at risk for spoiled or contaminated foods, and food-borne illness.Findings included .<Facility Policy>According to the facility's revised 01/2025 Food Storage policy and Resident Food Services policy, all food, non-food items, and supplies used in food preparation would be stored in a manner to prevent contamination and maintain the safety and wholesomeness of the food. Food items would be labeled with a manufacturer's expiration date or the date of receipt. This policy showed staff would restrain all facial hair with a beard/hair net restraint. <Skilled Nursing kitchen >Observation of the facility's dry food storage on 08/21/2025 at 8:45 AM showed opened boxes of snacks containing nacho chips, cheese crackers, and popcorn packages. These packages did not have a label with an expiration date on the box or individual packages. Three cartons of unopened frozen orange juice were observed 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.

Based on interview and record review, the facility failed to ensure nurses signed timely for the care provided for 1 (Resident 1) of 20 sample residents reviewed, and failed to ensure provider notes were added timely to the resident's record for 1 (Residents 9) of 1 resident reviewed for hospice and one supplemental resident (Resident 54). These failures placed residents at risk for an incomplete record of their care, unmet care needs, and delays in treatment. Findings included.<Resident 1>According to a 07/13/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 had multiple medically complex conditions including a thyroid (an organ that helps regulate metabolism) disorder.Review of the August 2025 Medication Administration Record (MAR) showed Resident 1 had a thyroid medication scheduled to be administered every day by staff at 6:30 AM. This MAR showed nurses left the boxes blank with no initials indicating the medications were administered as ordered on 08/20/2025 and 08/21/2025.In an interview on 08/28/2025 at 10:56 AM, Staff Y (Medical Records) stated it 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 staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 2 of 2 residents (Resident 27 & 6) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff used appropriate Hand Hygiene (HH) during resident care for 4 of 4 residents (Resident 27, 6, 37 & 54) who were observed for care; ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 of 1 resident (Resident 37) reviewed for TBP; and ensure the facility was free of uncleanable surfaces for 1 of 1 residents (Resident 2). These failures placed residents and staff at risk for exposure to and development of contagious, communicable…

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 contact information of all pertinent State regulatory and informational agencies and advocacy groups were provided and/or posted in areas accessible to residents in a format and a language the residents understood for 8 of 8 residents (Residents 2, 22, 32, 25, 7, 38, 53, & 21) reviewed during Resident Council. This failure placed residents at risk for not being fully informed of their rights, potential abuse and/or neglect, and a decreased quality of life. Findings included . Review of the facility's admission packet on 05/06/2024 showed a Supplement To Health Facility admission Agreement outlining Resident rights. The packet showed information and contact information for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman (LTCO) program were furnished to residents and/or their representatives. On 05/06/2024 at 2:18 PM during Resident Council meeting, the attendees stated they did not know the State and/or LTCO contact number or where to find…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the information was documented showing the facility communicated necessary resident information to the receiving health care institution or provider for 3 of 5 sampled residents (Residents 56, 2, & 51) reviewed for hospitalizations. Failure to ensure necessary resident information was communicated to the hospital placed residents at risk for decreased quality of care, inadequate care/treatment, and decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled Transfer or Discharge, Facility -Initiated, dated October 2022, the facility would provide the receiving provider/hospital the basis for the transfer, contact information of the practitioner responsible for the care of the resident, resident representative contact information, advanced directive information, all special instructions or precautions, comprehensive care plan, and all other information necessary to meet the resident's needs. <Resident…

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 by which residents received required written notices at the time of transfer/discharge and notify the Office of the State Long Term Care Ombudsman (LTCO) of transfer/discharge for 5 of 5 sampled resident's (Residents 54, 28, 51, 56, & 2) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure required notification of LTCO prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Facility Policy> According to the facility policy titled Transfer or Discharge, Facility -Initiated, dated October 2022, the facility would give the resident or resident…

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 the resident and/or the resident's representative a written notice of the facility's bed hold (a process allowing residents who transfer from a facility temporarily to return to the same bed) policy, at the time of transfer or within 24 hours, for 5 of 5 sample residents (Resident 54, 28,51, 56 & 2) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> According to the facility policy titled, Bed- Hold and Returns, revised October 2022, showed the facility would provide a copy of their bed hold paperwork to residents at time of emergent transfer or within 24 hours which would include the reserve bed payment information and agreement. <Resident 54> According to a 03/27/2024 nursing progress note, Resident 54 was out 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 Care Plans (CP) were updated and/or revised as needed for 3 of 18 sampled residents (Residents 20, 54, & 18) reviewed, and failed to ensure residents were provided an opportunity for a Care Conference (CC) for 1 of 18 sampled residents (Resident 40). Failure to ensure CPs were updated to reflect current care needs and residents were given the opportunity to participate in CCs left residents at risk for unmet care needs, lessened participation in care planning, and a diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, assessments of residents were ongoing and residents' CPs would be revised as information about residents and their conditions changed. The policy showed the interdisciplinary team, including residents and/or resident's representative, would participate in the development and implementation of the residents…

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 administer the medications as ordered and to communicate with the provider to adjust the time for those medications while residents were out of the facility for dialysis (a procedure to clean and filter the body's waste products) treatment for 2 of 2 sampled residents (Resident 28 & 54) reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Resident 28> According to the 04/02/2024 Quarterly Minimum Data Set (an assessment tool - MDS), Resident 28 had an intact memory, clear speech, and medical conditions including end-stage kidney failure. The MDS showed Resident 28 received dialysis during the assessment period. On 05/02/2024 at 9:52 AM, Resident 28 stated they were hospitalized on [DATE] due to increased confusion related to kidney disease. Resident 28 stated the physician prescribed a medication that facilitated their…

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

Based on observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions for 1 of 1 kitchen observed. Facility staff failed to: Label and date food; discard damaged/spoiled food; and perform Hand Hygiene (HH) during food preparation. The facility failed to ensure 1 of 2 resident refrigerators in the nursing units (Cascadia Neighborhood) were monitored for food brought in from outside sources. These failures contributed to an unsanitary and unsafe storage and preparation of food, and placed residents at risk for food-borne illness and a decreased quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Use and Storage of Foods Brought to Residents from Home, revised January 2019, showed if the prepared food was not served immediately to the resident, the food must be stored in stored in a container with a tight-fitting lid, clearly labeled with the resident's name and room number, dated when the food was brought in for the resident, and indicate the use-by date. The policy showed outside foods should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to initiate and thoroughly investigate incidents in a timely manner for Pressure Ulcer (PU) and unwitnessed falls for 2 of 3 sampled residents (Resident 40 & 54) reviewed for incident reports to rule out abuse and/or neglect. Facility failure to initiate an investigation for the cause of Resident 40's PU and Resident 54's falls within five days left residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> Review of the facility policy titled, Elder Abuse Prevention, Identification, Response, and Reporting Policy and Procedure, revised 10/18/2022, showed all incidents including unusual bruising, wounds, injury of unknown origin, and incident reports would be thoroughly investigated to rule out abuse and neglect and report the result of all investigations within five working days to the administrator and to other officials including to the State survey agency. <Resident 40>…

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 the Minimum Data Set (MDS - an assessment tool) of 2 of 18 residents (Residents 40 & 7) were completed accurately to reflect the resident's condition and overall health status. The facility failed to identify Resident 40's bilateral hand contractures and failed to capture Resident 7's active use of a wander guard device for elopement (to elope). These failures placed Residents 40, 7, and other residents at risk for unidentified and/or unmet care needs and continued unnecessary device use. Findings included . <Facility Policy> Review of the facility policy titled, Comprehensive Assessments, revised October 2023, showed the comprehensive assessment process included direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members. The policy showed comprehensive MDS assessments were conducted to assist in developing person-centered Care Plans (CP). <Resident 40> According to the 03/04/2024 Quarterly Minimum Data Set (MDS - an assessment…

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

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with their Activities of Daily Living (ADLs) received the assistance they were assessed to require for 2 of 7 residents (Residents 18 & 40) reviewed for ADLs. The failure to provide clean-up care after eating assistance (Residents 18) and personal grooming care (Resident 40) left residents at risk for unmet care needs and a decreased self-worth, dignity or quality of life. Findings included . <Facility Policy> Review of the facility policy titled, ADLs, Supporting, revised March 2018, showed the residents who were unable to carry out ADLs independently would be provided by the facility with the necessary care, services, and assistance to maintain grooming and personal hygiene in accordance with the resident's Care Plan (CP). <Resident 18> According to the 03/27/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 18 had clear speech, understood others during communication, and had medical conditions including heart failure,…

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 4 residents (Resident 40) was provided physician ordered pressure relief interventions. Failure to implement use of off-loading boots, in accordance with the wound care team's recommendation, placed residents at risk for PU development, worsening of PU, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed the nursing staff and practitioner would assess and document a resident's significant risk factors for developing PUs including immobility. The policy showed when new wounds develop despite existing interventions, the current approaches should be reviewed and the physician would order pertinent wound treatments including pressure reduction surfaces for PU treatment and management. Review of the facility policy titled, Pressure Injuries Overview, revised March 2020, showed the facility used the National Pressure Injury Advisory Panel Classification System for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were dependent on facility staff for bowel and bladder (B/B) needs were accurately assessed to require for 1 of 4 residents (Resident 54) reviewed for B/B incontinence. Failure to accurately assess and provide care for Resident 54's B/B needs placed the resident at risk for unmet care needs and diminished quality of life. Findings include . <Resident 54> According to the 03/13/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 54 was admitted to the facility on [DATE] for a fall with hip fracture and was assessed with memory impairment. The MDS showed Resident 55 was incontinent of B/B and required total assistance for toileting needs. Review of the 04/01/2024 B/B assessment showed Resident 54 was occasionally incontinent of B/B and unable to get to the bathroom physically and mentally. Observation on 05/03/2024 at 9:32 AM showed Resident 54 was trying to get out of bed and stated bathroom.…

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 attempts to use appropriate alternatives prior to installing side rails were conducted and residents with side rails installed on their beds were: (1) assessed, evaluated, and did not pose as an entrapment risk, (2) risk and benefits were reviewed with the resident and/or their representative, and (3) an informed consent was obtained prior to device installation to ensure the device was and remained safe and appropriate to use for 3 of 4 sampled residents (Residents 40, 28, & 51) reviewed for accident hazards. This failure placed residents at risk for harm and significant injury. Findings included . <Facility Policy> Review of the facility policy titled, Bed Safety and Bed Rails, revised August 2022, showed the use of bed side rails (including temporarily raising the side rails for episodic use during care) was prohibited unless the criteria for use of bed rails was met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy showed…

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 (%). Failure to properly administer 2 of 25 medications for 2 of 6 residents (Resident 70 & 9) observed during medication pass resulted in a medication error rate of 8%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered (PO) medication. Findings included . <Resident 70> Observation of medication pass on 05/03/2024 at 9:31 AM, showed Staff BB (Registered Nurse -RN), training with Staff S (RN), enter Resident 70's room and administered the resident's morning medication's crushed in applesauce to include a blood pressure medication. Review of resident 70's records on 05/03/2024 showed a PO for a blood pressure (BP) medication with parameters to hold the medication for a heart rate (HR) of less than 60 beats per minute (BPM). These records showed Resident 70 had a HR of 56 BPM prior to medication administration. In an interview on 05/03/2024 at 9:49 AM, Staff 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.

Based on observation and record review, the facility failed to ensure residents were provided the correct meal portion size by dietary staff as part of the prescribed therapeutic diet for 1 of 4 residents (Residents 7) reviewed for food concerns and 1 additional sample resident (Resident 1) identified during meal service observation. Failure to ensure residents were provided food as ordered in their diet placed residents at risk for nutritional compromise and related negative health outcomes. Findings included . <Facility Policy> Review of the Resident Food Services policy titled, Special Food Needs, revised January 2024, showed all food and beverages served would be assessed and determined by the Food and Nutrition staff to be safe for residents with special dietary needs. The policy showed all staff were in-serviced on therapeutic diets orders. Review of the Resident Food Services policy titled, Resident Dining Profile And Food Preferences, revised January 2024, showed a nutrition file was used to maintain accurate records of resident diets including individualized meal plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident records were complete, accurate, and readily accessible for 2 of 18 sampled residents (Resident 1& 21) whose records were reviewed. The facility failed to ensure current legal guardianship documents were accurate, accessible to staff, and in resident records. These failures placed residents at risk for unidentified and/or unmet care needs. Findings included . <Facility Policy> According to the facility policy titled, Advance Directives, revised [DATE], showed information regarding advanced directives/Legal guardianship would be displayed prominently in the resident's medical record that was retrievable by any staff. The policy showed interdisciplinary staff would review annually and be recorded in the resident's medical records. <Resident 1> According to a [DATE] Annual Minimum Data Set (MDS - an assessment tool) Resident 1 had memory impairment. The assessment showed Resident 1 admitted to the facility on [DATE]. Review of Resident 1'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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to consistently perform Hand Hygiene (HH) before and after resident care/contact. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Hand Hygiene> <Resident 52> Observation on 05/03/2024 at 10:04 AM showed Staff T (Certified Nursing Assistant - CNA) provided peri care to Resident 52 in the bed and put clean slacks on the resident. Staff T did not change their dirty gloves before touched the clean areas. Staff EE (Licensed Practical Nurse) started changing the wound dressing for Resident 52's wound on their back and Staff T was assisting the Staff EE by holding the resident with the same contaminated gloves. After Staff EE changed the wound dressing for Resident 52, Staff T fixed the resident's shirt with the same…

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 food was stored, prepared, and served in a sanitary manner and in accordance with professional standards of food safety. The failure to ensure food was stored appropriately, the dishwasher reached the required temperature necessary to sanitize dishes, ensure the clean area of the dishwashing area was free of food debris, hand hygiene was performed as required, and food preparation surfaces were free of contaminants left residents at risk of food contamination and food-borne illness. Findings included . Food Storage During initial rounds of the facility's main kitchen on 01/04/2023 at 9:00 AM open containers of dried parsley, poppy seeds and rice were observed in the dried food storage area. The containers were not labeled to indicate when they were open or when staff should dispose of the contents. In an interview on 01/04/2023 at 9:04 AM Staff E (Executive Chef) stated the containers should have been but were not labeled with dates…

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, monitor, and maintain their infection control practices providing a safe and sanitary environment to help prevent the transmission of communicable disease. The failure to ensure staff performed hand hygiene when required, implemented correct Transmission Based Precautions (TBP) for a contagious infection for 1 of 2 residents (Resident 280) reviewed for TBP, ensured staff received education and proper fit testing for N95 respirators, used standard infection control practices during medication pass (Resident 14 and 288) placed residents, staff, and visitors at risk for development of contagious communicable infections and disease. Findings included . Hand Hygiene U According to the Centers for Disease Control (CDC) reviewed January 30, 2020 guidance for Hand Hygiene in Healthcare Settings, alcohol-based hand sanitizer (ABHS) for hand hygiene is the preferred method for cleaning the hands in most clinical situations. Washing hands…

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 their COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing, pneumonia, hospitalization, and even death) staff testing procedures were conducted in a manner consistent with current standards of practice for COVID-19 testing, followed proper infection control guidance for safe testing, and was performed according to the Named brand COVID-19 Point-of-Care manufacturers recommendations to ensure accurate test results. The failure to adequately educate, validate staff understood the directions by return demonstration, and monitor the testing process for compliance of manufacturer's instructions and infection control practices placed residents, visitors, and staff at risk for transmission and/or contracting COVID-19 or other communicable disease during an active facility COVID-19 outbreak and global pandemic. Findings included . Policy A 09/04/2020 facility COVID-19 Testing Policy showed the facility would follow the Centers for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a system to ensure residents were offered assistance to formulate an Advance Directive (AD) for 5 of 18 sampled residents (Resident 9, 34, 15, 20 & 25) who did not have one. The facility failed to obtain the AD from residents who had one and make the documentation readily available in the record for 12 of 18 residents (Resident 9, 34, 15, 20, 21, 43, 12, 25, 17, 63, 225 & 50). Failure to help formulate an AD, document in the medical record that assistance was offered, and have existing AD accessible to facility staff placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . Facility Policy According to a revised September 2022 Advance Directives facility policy, an AD was a written instruction such as a Living Will, or Durable Power of Attorney (DPOA) recognized by state law and related to the provisions of health 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 interview and record review, the facility failed to implement their abuse policy and procedure for 4 of 5 staff (Staff FF, GG, II & JJ) reviewed. The facility failed to conduct a criminal background check and/or re-check for 2 of 5 staff (Staff FF & GG) and failed to obtain reference checks for 4 of 5 staff (Staff FF, GG, II & JJ) that placed residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings include . Facility Policy The revised 02/06/2021 revised Background and Pre-Screening policy outlined the facility's pre-employment, annual, and ongoing requirements for staff including the Criminal Background Reports. The policy showed all staff must complete a background check prior to their first day of employment and abide by the Washington State's requirements for conducting background re-checks (every two years). Staff FF Review of Staff FF's (Personnel Scheduler/Certified Nursing Assistant- CNA) personnel file showed a hire date of 03/20/2019. There was no evidence an initial Background Inquiry (BGI) was conducted by the facility prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident Care Plans (CP) were reviewed and revised to accurately reflect residents' care needs for 4 of 18 sampled residents (Resident 9, 6, 17, & 25) and failed to timely conduct a CP conference for 2 of 18 residents (Resident 50 & 63) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, diminished quality of life, and deprived residents and their representatives the opportunity to participate in the care and discharge planning process. Findings included . CP Revision Resident 9 According to the 12/06/2022 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 9 had medically complex diagnoses including respiratory failure. The MDS showed Resident 9 required oxygen therapy while at the facility. Observation on 01/04/2023 at 2:28 PM showed Resident 9 in bed, receiving oxygen therapy via an oxygen concentrator (a medical device that provided extra oxygen) set to two liters per…

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 implement their policy and procedures to ensure residents were assessed to be safe to use side rails (SR) or assist bars (AB) and ABs and SRs were installed correctly for 9 of 18 sampled residents (Resident 284, 275, 21, 12, 63, 9, 34, 20, 17 & 25) who had bed rails (BRs - SRs or ABs). Facility failure to attempt alternatives before implementing SRs, identify the necessity for SRs, assess the safety of SRs, and provide informed consent prior to use of SRs placed the residents at risk for harm or significant personal injury up to and including potential for death due to strangulation. Facility failure to correctly install ABs according to the manufacturer's specifications for 54 of 54 beds observed with ABs and have a system for initial and routine maintenance and monitoring of the devices placed the residents at risk for harm or significant personal injury up to and including potential for death due to strangulation. Findings included . Facility Policy & Procedure According to the November 2016 BRs 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.

Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of a resident's discharge or death, for 1 of 1 (Resident 229) discharged residents reviewed. This failure caused a delay in reconciling resident accounts within 30 days as required. Findings included . Resident 229 Record review showed Resident 229 passed away on 05/31/2022. Review of trust records showed on 07/01/2022 Resident 229 had a balance of $2762.05 that was not transferred to the OFR until 07/28/2022, almost two months after discharge. In an interview on 01/12/2023 at 12:01 PM, Staff A (Administrator) stated Resident 229's money should have, but was not sent to the OFR within 30 days of the resident's discharge. REFERENCE: WAC 388-97-0340(5). .

Based on interview and record review, the facility failed to ensure 3 of 8 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . Record review of the facility's monthly Trust Account Reconciliation report for 2022 showed the following account balances: January- $12,815.31; February- $13,010.93; March- $12,541.53; April- $12,300.00; May- $13,121.83; June- $13,577.50; July- $10,512.22; August- $10, 214.83; September- $10,345.57; October- $10,658.24; November- $10,211.13; and December- $10,423.72. Review of the facility's surety bond, effective July 12, 2009, showed the bond amount only covered a trust account balance of $10,000 and did not cover the total monthly trust account balances in 2022. In an interview on 01/12/2023 at 12:01 PM, Staff A (Administrator) stated having a surety bond that covered the resident trust account amounts was important to protect the resident's assets. Staff A confirmed 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 failed to provide the required liability notice for a sample of 2 of 4 residents (Resident 53 & 39) reviewed for liability notices, who remained in the facility after skilled services ended. This failure placed the residents at risk of not being fully informed of the cost of continued services. Findings included . Resident 53 Review of Resident 53's records showed a Notice of Medicare Non-Coverage (NOMNC - a required form) was issued and signed by the resident on 09/12/2022, which informed the resident their skilled nursing services would end on 09/14/2022. There was no Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) provided to Resident 53 that would include information regarding the payment amount the resident was responsible for, should they elect to continue with skilled services that would not be covered by Medicare. Resident 39 Similar findings were applicable to Resident 39. Review of Resident 39's records showed a NOMNC was issued and signed by the resident on 08/16/2022, which informed 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 system was in place by which the Office of the State Long-Term Care Ombuds (LTCO) received required notification of emergent resident discharges for 3 of 5 residents (Resident 9, 34 & 63) reviewed for discharge to the hospital. Failure to ensure required notifications were completed prevented the Ombud's office the opportunity to educate residents and advocate for them through the discharge process. Findings included . Resident 9 According to the 12/06/2022 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 9 had medically complex diagnoses including respiratory failure with hypoxia (low blood oxygen saturation levels) and stomach problems. The MDS indicated Resident 9 readmitted to the facility from the hospital on [DATE] after an initial admission on [DATE]. Review of the progress notes showed Resident 9 was admitted to the hospital emergently on 11/12/2022 for uncontrolled nausea. Progress notes showed Resident 9 left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to conduct a Significant Change in Status Assessment (SCSA) including Care Area Assessments (CAAs) within 14 days after the significant change was identified (or should have been identified) for 2 of 2 residents (Resident 284 & 21) reviewed for significant changes from baseline status and or/function and a terminal prognosis with subsequent hospice services. These failures placed the residents at risk for unmet care needs, diminished quality of life, and quality of care. Findings included . Facility Policy Review of a revised February 2021 Change in a Resident's Condition or Status policy, if a change in a resident's physical or mental condition occurred, the facility would conduct a comprehensive assessment of the resident's condition. The SCSA would be conducted in accordance with the current OBRA regulations governing resident assessments. Resident 284 A 10/14/2022 admission Minimum Data Set (MDS - an assessment tool) showed Resident 284…

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 284 A 10/14/2022 admission MDS showed Resident 284 had moderate to severe cognitive impairment. The resident had depressed mood (felt down/hopeless). Resident 284 weighed 116 pounds and was 61 inches tall (5-foot 1 inch). The resident was assessed to have occasional pain. A 12/05/2022 provider progress note showed Resident 284 was evaluated for continued foot pain and was prescribed routine and as needed pain medications. Review of a 12/06/2022 Physical Therapy (PT) evaluation showed Resident 284 was referred to PT after hospitalization for change in alertness, cognition, functional mobility, low activity tolerance, and unsafe ambulation related to multiple severe infections and malignant cancer. A 12/08/2022 facility Physician History and Physical note showed Resident 284 was hospitalized from [DATE] to 12/02/2022 for a severe systemic infection from an antibiotic resistant bacteria and was found to have cancer. The resident had complained to the physician about continued pain. A 12/08/2022 5-Day MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan, to address pain and discomfort, respiratory compromise after hospitalization, and nutritional status risks for 3 of 18 sample residents (Resident's 50, 63 & 284) reviewed for comprehensive Care Plans (CP). These failures placed the residents at risk for medical complications, unmet care needs, continued decline of nutritional status, and diminished quality of life/quality of care. Findings included . Resident 50 The 12/14/2022 Nursing admission Evaluation showed Resident 50 had right shoulder pain. The assessment showed Resident 50 could communicate their pain and discomfort to staff. A 12/27/2022 physician progress note showed Resident 50 was seen for complaints of back pain and was prescribed routine pain medications. The 01/05/2023 nursing progress note indicated Resident 50 complained of increased back pain despite the prescribed pain medications. The 01/05/2023 physician…

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 nursing services were provided within professional standards of nursing for 9 of 18 residents (Resident 17, 9, 25, 21, 6, 50, 12, 34 & 9) reviewed. Facility failure to ensure: Physician's Orders (POs) were followed (Resident 17) and clarified (Residents 9, 17, & 25); POs were obtained prior to treatment (Resident 21); staff only signed for tasks they completed (Resident 6); POs included an associated diagnosis (Residents 34, 9 & 12); the physician was notified when required (Resident 50), placed residents at risk for medication and treatment errors and adverse health outcomes. Findings included . Follow Physician Orders According to a revised April 2019 facility Administering Medications policy, medications should be administered in a safe and timely manner, and as prescribed. This policy stated medications should be administered in accordance with the prescriber orders, including any time frame. Resident 17 According to the…

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

Based on observation, interview, and record review the facility failed to implement a system to timely, accurately, and consistently: assess nutritional status; identify, implement, monitor, and modify personalized nutritional interventions that met the resident's needs, choices, and cultural preferences to prevent avoidable significant weight loss for 1 of 1 Resident (Resident 284) who experienced a significant weight loss; and failed to ensure residents consistently received the nutritional supplements they were assessed to require to help prevent weight loss for 2 of 6 Residents (Resident 284 & Resident 225) reviewed for nutrition. These failures placed the residents at risk for worsened nutritional status, continued weight loss, and diminished quality of life/quality of care. Findings included . Facility Policy A 1/22 revised Nutrition Alert Committee Policy showed the facility would use a set of criteria to determine if a resident qualified for a Nutritional Alert which included: a significant weight loss/gain of 2 % in one week, 5 % in one month, 7.5 % in three months;…

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 artificial nutrition was provided as ordered for residents requiring artificial nutrition, for 2 of 2 residents (Residents 34 & 12) reviewed for enteral tube feeding (nutrition provided via a tube directly to the digestive system). Failure to ensure artificial nutrition was provided as ordered left residents at risk for weight loss, malnutrition, dehydration, and other negative health outcomes. Findings included . Facility Policy According to the facility's revised November 2018 Enteral Tube Feeding via Continuous Pump policy, whoever performed the procedure should document the date and time the procedure was performed. The policy directed staff to document the amount and type of artificial nutrition provided. Resident 34 According to the 12/12/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 34 had medically complex diagnoses including dementia and a history of stroke. The MDS showed Resident 34 received nutrition via a feeding tube. Resident 34's January 2023 Medication…

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 recognize and treat 1 of 4 residents (Resident 50) who were reviewed for pain management. Failure to assess and implement interventions to relieve pain, including physician notification for newly identified pain, resulted in Resident 50 experiencing episodes of untreated pain, and placed the resident at risk for a decreased quality of life. Findings included . Resident 50 According to the 12/14/2022 Nursing admission Evaluation, Resident 50 had right shoulder pain. The assessment showed Resident 50 was capable of communicating their pain to staff. Review of the 12/20/2022 admission Minimum Data Set (MDS- an assessment tool) showed Resident 50 did not have pain during the resident-directed interview. The assessment showed Resident 50 did not take any routine or as needed pain medications during the assessment period. A 12/27/2022 physician progress note showed Resident 50 complained of back pain. On 12/27/2022, routine pain medication was ordered three times a day. Review of a 01/05/2023 nursing progress note…

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 (%). Failure of 2 of 4 nurses (Staff K and Staff MM) to properly administer 3 of 26 medications for 2 of 6 residents (Resident 288 & 16) observed during medication pass resulted in a medication error rate of 11.54%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . According to a revised April 2019 facility Administering Medications policy, medications should be administered in a safe and timely manner, and as prescribed. This policy stated the individual administering the medication, should check the label THREE times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. Resident 288 Observation of medication pass on 01/12/2023 at 8:21 AM showed Staff K (Registered Nurse) prepare and administer multiple medications by mouth to Resident 288,…

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 implement their COVID-19 Vaccination Policy and Procedures. The failure to ensure 3 of 3 (Staff AA (Activity Assistant), Staff BB (Certified Nursing Assistant), & Staff OO(Certified Nursing Assistant)) unvaccinated staff implemented the additional precautions the facility would follow to prevent the transmission of COVID-19 placed residents, visitors, and staff at risk for contracting a highly transmissible, communicable disease. Findings included . Facility Policy According to the 01/25/2022 COVID-19 SNF Vaccination of Team Members Policy, Section G, unvaccinated team members would be required to follow precautions intended to mitigate (lessen the likelihood of) the transmission and spread of COVID-19, including, by way of example and not limitation, wearing appropriate PPE and submitting to COVID-19 testing (before providing care, treatment or services for the facility and/or residents). Review of the 04/01/2022 Notification of COVID-19 Vaccination Exemption Determination provided to Staff BB after they 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.