Wesley Homes Des Moines Health Center

Based on interview and record review the facility failed to ensure nurse and nurse aide staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 7 of 7 staff (Staff H, I, J & K - Nurse Aids and Staff E, G, & R - Licensed Nurses) reviewed for competency. The failure to develop and implement a process to evaluate staff's competency and skills to perform job expectations, including medication pass evaluation of competency, placed residents at risk for medication errors, accidents, injuries, infections, diminished quality of life, and diminished quality of care. Findings included . The 2024 Facility Assessment review date 09/08/2024 showed training/education and competencies of nurses and nurse aides that were necessary to provide support and care to the residents of the facility. Registered Nurse (RN) training and…

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

Based on interview and record review, the facility failed to implement a facility-wide system for Antibiotic (ABO) Stewardship (a program to improve how ABO medications are prescribed, treating bacterial infections, and reduce the inappropriate use of ABO medications). The facility failed to implement an accurate surveillance method to track all resident infections, identify the source of infections, collect diagnostic data for organisms and ensure correct ABO treatment, identify residents' symptoms and use nationally recognized assessment criteria for prescribing ABO medications, monitor isolation precaution timelines, identifying trends in types infections or similar organisms, analyze data collected to provide ABO and infection reports to the prescribers of antibiotics. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and an increased risk for ABO resistant organisms. Findings included . Review of the facility policy Antibiotic Stewardship Program dated 07/10/2024 showed the facility implemented an ABO…

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

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 5 (Residents 2, 3, 24, 35, & 37) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with showers, shaving, and nail care, placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Activities of Daily Living, revised 07/26/2024, the facility would provide ADLs in accordance with resident's comprehensive assessment, Care Plan (CP), and resident's needs and choices to ensure a resident's ADL abilities would not deteriorate unless deterioration in function was unavoidable. <Resident 2> According to the 07/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 2 had weakness on right side of the body related to a stroke and required maximal assistance with personal hygiene including showers. The 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 implement an infection prevention and control program to prevent, identify, report, investigate, and control infections and communicable diseases according to national standards. The failure to implement a system of surveillance designed to identify possible communicable diseases and infections before they could spread to other persons in the facility, implement Enhanced Barrier Precautions (EBP) to prevent the spread of infections for 2 of 5 residents (Residents 33 & 212), and ensure staff used Personal Protective Equipment (PPE) as required placed all residents at risk for facility-acquired or healthcare-associated infections and related complications. Findings included . <Infection Prevention and Control Program (IPCP)> Review of the Facility Assessment, revised 09/08/2024, showed the facility infection prevention and control (IPC) program would effectively prevent, identify, report, investigate, and control infections and 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 interview and record review, the facility failed to develop, implement and maintain an in-service training program that ensured 4 of 4 Nursing Aides (Staff H, I, J & K) completed the required training, including dementia care management and training for special needs of residents, to ensure continued competency when providing resident care. The failure to provide nurse aides the required training on hire, provide no less than 12 hours of continuing education annually, and perform annual performance evaluations to address weak areas for additional training placed residents at risk for less than competent care and services from nurse aide staff. Findings included . The 2024 Facility Assessment (FA), review date 09/08/2024, showed Nurse Aides (NA) would require training/education and competency to provide support and care needed to the resident population. The FA listed the following training/ education needs: basic personal care skills, vital signs monitoring, safety and mobility, communication and empathy, infection control, emergency protocols, and cultural competency. 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 ensure informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 3 of 5 residents (Resident 53, 212, & 213) reviewed for unnecessary medications. This placed residents at risk for unwanted treatment. Findings included . <Facility Policy> According to a facility policy titled, Use of Psychotropic Medication, revised 07/02/2024, the facility would develop psychotropic medication regimens in collaboration with residents/resident representatives. The policy showed residents/resident representatives would be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/nonpharmacological interventions. According to a facility policy titled Promoting/Maintaining Resident Self-Determination, revised 07/29/2024, the facility would ensure each resident had the opportunity to exercise their autonomy. The policy showed the residents rights to determine what, if anything, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and rule out abuse/neglect for 1 of 1 sampled resident (Resident 31) reviewed for abuse investigations. Facility's failure to complete a thorough investigation and provide feedback regarding the resident's concerns placed residents at risk for potential abuse and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled, Abuse, Neglect and Exploitation, revised June 10 2024, showed the facility would implement processes to prevent and prohibit all types of abuse or neglect and establish a safe environment. The facility would rule out abuse and neglect by use of identification, assessments, and care planning for appropriate interventions. The policy showed the facility would monitor residents with needs and behaviors which might lead to conflict, and the facility would provide information to staff and residents on how and to whom concerns would be reported. The policy also 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.

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/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 16, 35, & 46) 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. Findings included . <Facility Policy> A facility policy titled, Transfer, and Discharge (including AMA) revised on 08/08/2024, showed a notice of transfer/discharge must be provided to the resident/representative when an emergency transfer to an acute care facility is ordered. The policy showed the notice would include the specific reason and basis for transfer, date of transfer, and name of the hospital to which the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process (a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings), was followed for 1 of 4 residents (Resident 213) sampled for PASRR review. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life. Findings included . <Resident 213> According to the 10/05/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 213 admitted to the facility on [DATE] with multiple complex conditions that included psychiatric mood disorder and confusion. Review of Care Area assessment dated [DATE] showed resident had confusion, behavior and mood disorder. Review of 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 interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition for 1 of 3 (Resident's 14) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 14> According to a 09/19/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 14 admitted to the facility on [DATE]. The assessment showed Resident 14 had diagnoses of, but not limited to, non-Alzheimer's dementia, Seizure disorder, Psychotic disorder, delusional disorders, and unspecified mental disorder due to unknown physiological condition. The MDS showed Resident 14 received antipsychotic medications…

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/or implement a comprehensive Care Plan (CP) for 2 of 18 sampled residents (Residents 53, 2 ) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Resident 53> According to a 09/13/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 53 admitted to the facility on [DATE]. The assessment showed Resident 53 was severely cognitively impaired and had a diagnosis of, but not limited to, pain in right hip and other chronic pain. The MDS showed Resident 53 received scheduled and as needed pain medication and was observed to express symptoms of pain three to four days during the seven-day assessment period. Review of Resident 53's records showed a physician order for scheduled pain medication to be administered routinely In an…

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 (CPs) were accurately reviewed and revised to reflect current resident status and needs as required for 3 (Residents 24, 213, & 212) of 17 residents reviewed for CP's. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 24> According to the 09/23/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 24 had a Pressure Ulcer (PU) on their sacrum (triangular bone at base of spine, upper buttocks). The MDS showed Resident 24 required maximal assistance with bed mobility and toileting needs. Review of the 08/09/2024 Skin CP showed Resident 24 had a sacrum PU and was at risk for new PU development. Nursing interventions included Resident 24 needed to be repositioned at least every two hours and more often with two staff members. Observations on 10/22/2024 at 8:33 AM and 11:12 AM, on 10/23/2024 at 8:24 AM and 12:33 PM, and on 10/24/2024 at 8:55…

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 resident environment was free of accident hazards for 2 of 2 residents sampled for accidents (Resident 213, & 212). The failure to ensure supervision of wandering residents and safety of transfer pole device was accurately assessed for safety placed residents at risk for accidents, injury, and negative health outcomes. Findings included . <Facility Policy> According to a facility policy titled, Elopements and Wandering Residents, revised 07/26/2024, the facility would ensure that residents who exhibit wandering behavior or were at risk for elopement received adequate supervision to prevent accidents in accordance with their person-centered plan of care to address the factors contributing to wandering. The policy showed staff would develop interventions to increase staff awareness of resident's risk, all risks would be added to the resident's Care Plan (CP) and communicated to the staff. The effectiveness of interventions would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1 of 3 sampled residents (Residents 212) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure of the facility to ensure physician orders with a supporting diagnosis, routine catheter care and monitoring was provided, placed the residents at risk for infections, skin breakdown, and diminished quality of care. Findings included . <Facility Policy> Review of the facility policy titled, Catheter Care, dated 07/26/2024, showed the purpose of the policy was to ensure that residents with indwelling catheters received appropriate catheter care when indwelling catheters was in use. <Resident 212> Review of the admission Minimum Data Set (an assessment tool) dated 10/10/2024 showed that Resident 212 was admitted to the facility on [DATE] with muscle weakness, Parkinson's disease (movement disorder), lack of coordination,and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 33) reviewed for pain management received the necessary treatment, services, and follow-up care to manage their pain during wound care. This failure placed residents at risk for avoidable pain, refusal of wound treatments and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Pressure Injury Prevention and Management, revised 08/09/2024, showed the facility would utilize a systematic approach for pressure injury prevention and management, including using evidence-based treatments with current standards of process for treatment decisions based on condition of the wound, including the presence of pain. Modifications of interventions would be considered for resident's non-compliance to treatment. <Resident 33> According to the 07/26/2024 admission Minimum Data Set (an assessment tool), Resident 33 admitted to the facility on [DATE] with loss of…

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

Based on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) certificate completed a Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire for 2 of 2 NAR staff (Staff J & L) reviewed for CNA licensure. This failure placed residents at risk to receive care from unlicensed staff. Findings included . The facility staff list provided on 10/21/2024 showed Staff J & L were both hired as NARs on 04/09/2024. Review of the 10/28/2024 the Washington State Provider Credential Search website showed Staff L was currently a NAR, not a CNA. The verification showed Staff L was first credentialed as a NAR on 08/05/2021 with renewal on 01/02/2024. Review of the 10/28/2024 the Washington State Provider Credential Search website showed Staff J was currently a NAR, not a CNA. The website showed Staff J was first credentialed on 08/07/2023 and last renewal was on 01/10/2024. Review of the daily schedules for 10/2024 showed Staff J and Staff L both were scheduled and worked with residents as NARs. In an…

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 (Residents 3, 35, & 53) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Use of Psychotropic Medication policy revised 07/08/2024, showed the facility would not give psychotropic medications to their residents unless the medication was necessary to treat a specific condition and the indications for use would be documented in resident's medical record. The policy showed supportive documentation included non-pharmacological interventions addressed prior to initiating a psychotropic medication. <Resident 3> According to the 07/11/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 3 had diagnoses of Schizophrenia (disorder…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 28 of 35 medications for 4 of 6 residents (Resident 54, 6, 44 and 163) observed during medication pass resulted in a medication error rate of 68 %. This failure placed residents at risk for not receiving the correct dose at the correct time or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> Review of the 01/2024 facility, Medication Administration policy showed medications should be administered in accordance with written orders of the prescriber. The six rights of medication administration were to be followed that included the right time and right documentation. Staff were to administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Staff were to report and document discrepancies and report to the nurse manager. Observations of medication pass on 10/23/2024 at 1:37 PM, showed Staff G…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dietary orders pertaining to the consistency of foods were implemented for 3 of 6 (Residents 34, 37, & 45) residents whose dietary intake was reviewed. This failure placed residents at risk for choking, poor nutritional intake, and weight loss. Findings included . <Facility Policy> According to a facility policy titled, Resident Food Services - Special Food Needs, Swallowing/Chewing Difficulties, and Food Allergies, revised 01/2024, showed all foods and beverages would be assessed and determined safe for residents with special dietary needs, including those with food allergies, cultural and religious dietary preferences, and/or swallowing/chewing difficulty. The policy showed nursing would communicate diet orders, dietary staff would ensure diet information was transferred to meal ticket identifying residents diet order, food allergies, and special instructions. The policy showed dining staff would follow diet orders, allergies,…

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 store, prepare and serve food in accordance with food service safety standards. The failure to cover, label and date stored foods, maintain clean ceiling vents, and perform standard hand hygiene and glove use to prevent cross-contamination placed residents at risk of foodborne illness and diminished quality of life. Findings included . <Food Preparation> Observation on 10/25/2024 at 9:31 AM showed Staff AA (Cook) wearing plastic gloves over knitted safety gloves and washing raw chicken at the prep sink. Staff AA left the sink, did not remove the contaminated gloves or wash their hands, then touched a large spoon to stir the soup on the stovetop, left the spoon in the soup, turned and touched the three soup warming pans on a cart by the stove, picked up a plastic bag of frozen corn and placed it in a pan on the prep table, walked to the other side of the kitchen and returned to the sink, still wearing the same contaminated gloves. In an interview on 10/25/2024 at 9:36 AM, Staff AA was still wearing the plastic…

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 2 of 3 garbage dumpsters and 1 of 2 recycling dumpsters were properly covered, the surrounding areas were kept clean, and free of trash/debris and food scraps. These failures placed the facility at risk of attracting bugs, rodents, birds, and other disease-carrying germs/bacteria that could reproduce, grow, and place the residents at risk for acquiring these diseases. Findings included . Observations on 10/21/2024, 10/22/2024, 10/23/2024, 10/24/2024, 10/25/2024, 10/28/2024 and 10/29/2024 showed the outside refuse area with uncovered garbage dumpsters and uncovered recycle dumpsters. Observations on these dates showed sea gulls (birds) flying over the dumpsters, opening the garbage bags for food scraps. These observations showed trash such as plastic, paper, gloves, food scraps, and other debris on the concrete surrounding the dumpsters. In an observation and interview on 10/29/2024 at 11:18 AM, Staff P (Director of Environmental Services) observed the refuse area and stated the dumpsters should be covered, the ground…

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 stored, prepared, and transported in a sanitary manner, and in accordance with professional standards of food safety. The failure to ensure food was stored appropriately, discarded when expired, and covered as required left residents at risk of food contamination and food-borne illness. Findings included . <Policy> According to the facility's revised January 2023 Food and Supply Storage Policy, staff should cover, label, and date unused food and open packages of food. The policy directed staff to complete all sections of the label including a use-by date. <Dry Food Storage, 1st Kitchen> During initial kitchen rounds on 08/01/2023 from 8:54 AM until 9:42 AM with Staff GG (Director of Culinary Services) the following was observed: -One open 32-ounce bag of dry roasted peanut topping with no open date, marked as received 08/10/2022. Staff GG stated staff should label open packages with the date the item was opened. -Two cans of chili with beans marked by facility as received 05/29/2022 and a third…

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 update the Facility Assessment (FA - a required document that comprehensively assesses the levels and types of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff) to accurately reflect the resources the facility determined were necessary for day-to-day and emergency operations. This failure placed the residents at risk for not receiving needed care, services, and resources. Findings included . Review of the updated 09/07/2022 FA provided by the facility during the entrance conference showed the FA included outdated information, including the following: - The FA showed the facility had 5 halls: the 100, 200, 300, 400, and 500 halls, and described the 400 Hall as a secured unit. The FA did not reflect that the 300 and 400 halls were now closed. - The resident demographic information gathered using data from 05/01/2022 to 07/31/2022 showed the only language spoken by the resident population was English and did not reflect the facility had current 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.

Observations on 08/04/2023 at 10:23 AM, showed Staff X (CNA) providing incontinence care for Resident 47 in the resident's shared bathroom. Staff X wore gloves and used a wet, soapy washcloth to assist with cleaning the resident's bottom area. After completing incontinence care, Staff X picked up a new brief and put it on the resident while wearing the same soiled gloves. Staff X continued wearing the same soiled gloves to pull up Resident 47's pants, then touched the door handle to the bathroom to open the door, locked the brakes on the resident's wheelchair, touched the handle of a walker, adjusted the footrests for the wheelchair, and then emptied the basin that was used for the soapy water prior to removing the soiled gloves. Staff X, without performing HH, was observed picking up Resident 47's toothbrush, applied toothpaste and handed it to the resident. Staff X did not perform HH until they went to exit Resident 47's room. In an interview on 08/04/2023 at 10:39 AM, Staff X confirmed they did not perform HH after assisting with incontinence care and stated, I should have. In an…

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 there was a designated Infection Preventionist (IP) who worked at least part-time at the facility responsible for the facility's effective Infection Control and Prevention Program (IPCP) including early detection of infections, analysis of evidence-based infection surveillance data, implementation of infection prevention measures, and management of healthcare associated infections such as Antibiotic (ABO) Stewardship and Infection Surveillance including Legionella (a severe form of lung inflammation caused by a bacterial infection). These failures and the lack of leadership without a fully functional IPCP placed residents at risk for unmet care needs and a decreased quality of life. Findings included . In an interview on 08/03/2023 at 12:42 PM, Staff B (Director of Nursing - DON) stated they were hired as the full-time DON. Staff B stated they were also the acting IP in the facility and were responsible for the facility's IPCP as described in their job description to perform other duties assigned by the Corporate…

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

Based on observation, interview, and record review the facility failed to provide privacy during personal care for 1 of 19 (Resident 1) residents and to cover Foley Catheter bags (FC- a tube placed in the bladder to drain urine into urinary bag), to ensure dignity for 3 of 5 (Resident 3, 1, and 59) residents. Failure to provide personal privacy placed residents at risk of feelings of institutionalization and a diminished quality of life. <Facility Policy> The facility's undated Resident Rights policy showed residents should be treated with dignity and respect and had a right to personal privacy that included their medical treatment. <Catheter Bag Privacy Cover> <Resident 3> Review of the 06/13/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 3 had a diagnosis of obstructive uropathy (obstructed urinary flow) and was admitted to the facility with a FC. Observation on 08/03/2023 at 5:28 PM showed Resident 3 had a FC in place and urinary bag hooked on the bed without a privacy bag cover in place. Record review on 08/07/2023 Physician Orders (PO) 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 observation and interview, the facility failed to ensure resident rooms had access to fresh air, were clean, free of clutter, and provided a homelike environment for 2 of 3 units (200 Hall and 500 Hall). These failures left residents at risk for feelings of institutionalization, decreased quality of life, and a less than homelike environment. Findings include . <Windows> Observations on 08/01/2023 at 9:38 AM showed room [ROOM NUMBER] had a torn window screen, and the left window did not latch. On 08/01/2023 at 9:59 AM, observation showed room [ROOM NUMBER], 214, and 216 windows bolted closed, residents were unable to open them for fresh air. <Cleanliness> Observation on 08/01/2023 at 9:38 AM showed light fixtures with globes contained dead bugs in rooms 208, 209, 210, 211, 212, 213, 214, 215, and 216. The sconce lights and florescent lighting on the 200-hall showed they contained dead bugs in every fixture. room [ROOM NUMBER] had brown splats on the ceiling above the residents' beds.…

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 3 of 6 (Residents 59,12 & 33) residents reviewed for Restorative Nursing Programs (RNP) received the care and services they were assessed to require. These failures placed residents at risks for declines in Range of Motion (ROM) or functional status, and other negative health outcomes. Findings included . <Resident 59> According to the 07/05/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 59 admitted to the facility on [DATE] and had multiple medical diagnoses including weakness and deconditioning from a bladder infection. The MDS showed Resident 59 had intact memory and was able to communicate and understand effectively. Review of Resident 59's rehabilitation documentation showed Resident 59 received skilled Physical Therapy (PT) and Occupational Therapy (OT) services from 06/28/2023 until 07/20/2023. A 07/20/2023 Restorative Program referral form showed Resident 59 was placed on a RNP to maintain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the environment was free of accident hazards on 3 (100 Hall, 200 Hall & 500 Hall) of 3 units. The failure to ensure chemicals and razors were safely secured left residents at risk for accidents with a potential for injuries. Findings included . Observation on the 100 Hall on 08/01/2023 at 1:03 PM showed an unnamed storage room across from room [ROOM NUMBER] had a keypad lock and handle installed. The door freely opened without a code being entered. Inside the storage room [ROOM NUMBER] chlorine wipe dispensers, 8 germicidal wipe dispensers, and a bottle of a solution used to dispose of medications were observed. The medication-disposal solution included a warning that read Ingestion of this product will induce vomiting. In an interview and observation on 08/01/2023 at 1:11 PM, Staff A (Administrator) and Staff B (Director of Nursing) noted the presence of the wipes and the medication-disposal solution, confirmed they represented a potential hazard,…

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 put into practice protocols necessary to optimize the treatment of infections that ensured Residents 2, 42, & 7, who required the use of an antibiotic (ABO), were prescribed the appropriate ABO. The facility failed to implement a facility-wide system that monitored the use of ABOs. These failures placed residents at risk of adverse events and the development of ABO-resistant organisms from unnecessary or inappropriate ABO use. Findings included . <Facility Policy> According to the facility's 04/2021 ABO Stewardship Program policy, the Infection Preventionist (IP), with oversight from the Director of Nursing (DON), served as the leader of the ABO Stewardship Program and received support from the Administrator and other governing officials of the facility. The policy outlined the use of protocols and systems to monitor ABO use including a communication process for physician notification, laboratory testing in accordance with the current standards of…

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

Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 317 & 316) of 4 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required. Findings included . According to an undated facility, Resident Personal Funds policy, upon the discharge or death of a resident with personal funds deposited with the facility, the facility would, within 30 days, send the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State Law. <Resident 317> Record review showed Resident 317 passed away and was discharged from the facility on 11/28/2022. Review of Resident 317's January 2023 trust statement showed the resident's balance of $232.76 was not transferred to the OFR until 01/17/2023, almost two months after discharge. <Resident 316> Record review showed 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 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 resident's wishes if they became incapacitated) for 4 (Residents 9, 12, 7, & 10) of 19 residents 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 . <Facility Policy> Review of the revised December 2016 Advance Directives facility policy showed upon admission, residents were provided with written information concerning the right to formulate an AD. The policy stated facility staff would offer assistance with formulating an AD, the resident would be given the option to accept or decline the assistance, and nursing staff would document in the medical record the offer to…

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

Based on observation, interview, and record review the facility failed to notify State Survey Agency (SA) of an unwitnessed fall with injury in an area not generally vulnerable to trauma for 1 of (Resident 1) residents reviewed for falls. Failure to notify SA of unwitnessed injury put residents at risk for uninvestigated potential abuse. Findings included . <Abuse Policy> The revised 10/05/2022 facility abuse policy showed possible indicators of abuse included physical injury of a resident with no known cause. The policy showed the facility would report all alleged violations of potential abuse to the SA immediately, but no later than two hours after an event with serious bodily injury. <Resident1> Observation on 08/04/2023 at 8:04 AM showed Resident 1 with a forehead laceration and yellow bruising to corner of left eye. Review of a 07/19/2023 facility incident report showed Resident 1 had an unwitnessed fall and sustained an injury to their face. This report showed the SA was not notified. In an interview on 08/07/2023 at 1:50 PM Staff B (Director of Nursing) stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO) received required resident transfer information for 1 of 1 (Resident 3) residents reviewed for hospitalization. Failure to ensure required notification was completed, prevented the LTCO from educating and advocating for residents regarding their rights. Findings included . In an interview on 08/02/2023 at 9:50 AM, Resident 3 stated they were sent to the hospital about one month ago. Record review showed Resident 3 was sent to the hospital on [DATE]. In an interview on 08/08/2023 at 11:50 AM, Staff A (Administrator) stated social services should be notifying the LTCO monthly of all facility-initiated transfers or discharges. In an interview on 08/08/2023 at 11:58 AM, Staff D (Social Worker) stated they were not notifying the LTCO of any facility-initiated discharges since they started working at the facility in June 2023. REFERENCE: WAC 388-97-0120 (2)(a-d), -1040…

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 baseline Care Plans (Baseline CP - individualized instructions for resident care nursing homes are required to complete for each resident within 48 hours of admission) were developed for 1 (Resident 65) of 1 residents reviewed for discharge. The failure to develop a baseline CP left the resident at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Resident 65> According to the 06/23/2023 Entry Tracking Minimum Data Set (MDS - an assessment tool) Resident 65 admitted to the facility on [DATE]. According to a 06/23/2023 progress note, Resident 65 admitted to the facility on [DATE] at 3:00 PM. According to 06/26/2023 progress note Resident 65 discharged against medical advice that on 06/26/2023 at 3:24 PM. The discharge occurred over 72 hours after admission, and more than 24 hours after the Baseline CP was required to be complete. Resident 65's record included a 06/23/2023 Baseline CP. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed for 2 of 19 (Residents 24 & 47) sample residents whose CPs were reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes. Findings included . <Resident 24> According to the 05/09/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 24 admitted to the facility on [DATE]. The MDS showed Resident 24 had diagnoses including heart failure and malnutrition. Review of the April 2017 Medication Administration Record (MAR) showed Resident 24 tested positive for Tuberculosis (TB - a highly infectious respiratory disease) skin test on 04/11/2017. Record review showed the facility obtained a chest x-ray on 04/12/2017 that demonstrated there was no evidence of an active TB infection for Resident 24. The 04/12/2017 TB symptom screener showed Resident 24 did not show any signs or symptoms of an active TB infection. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure care planning meetings were conducted routinely and Care Plans (CP) were maintained, revised, and updated as required for 3 (Residents 47, 9, & 12) of 19 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 47> According to a 07/03/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 47 had multiple medically complex diagnoses including a history of falling, fractures, and lung disease. This MDS showed staff assessed Resident 47 with falls and a fracture prior to admission and the resident was always incontinent of bladder. In an interview on 08/01/2023 at 11:53 AM, Resident 47 stated they fell at home before admission to the facility. According to a 07/07/2023 Fall Care Area Assessment, staff documented Resident 47 was at risk for falls and this would be addressed on the resident's CP. Review of Resident 47's 07/07/2023 risk for…

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

Based on observation, interview, and record review the facility failed to provide services according to professional standards; ensure Physician's Orders (POs) were followed for 2 of 16 sample residents (Residents 47 & 7), or clarified for 1 of 16 sample residents (Resident 47), monitor the behaviors for a new diagnosis for 1 of 16 residents (Resident 9) whose care was reviewed, monitor an alteration in skin integrity for 1 of 4 (Resident 1) residents and ensure proper settings and function of air mattresses for 3 of 4 (Residents 1, 3, and 41) residents. These failures left residents at risk for not receiving the care they required, infection, accidents with potential for injuries, and other negative health outcomes. Findings included . <Clarifying Physician Orders> <Resident 47> According to a 07/03/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 47 had multiple medically complex diagnoses including fractures and required the use of a narcotic pain medication during the assessment period. Review of June 2023 Medication Administration Records (MAR) 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 Activities of Daily Living (ADLs) were provided as residents were assessed to require for 3 of 19 (Residents 33, 9 & 41) dependent residents reviewed for ADLs. Facility failure to provide bathing (Resident 33 & 9) and communication (Resident 41) assistance left residents at risk for poor hygiene, and frustration. Findings included . <Resident 33> According to the 07/07/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 33 was assessed with severely impaired cognition, and had diagnoses including heart failure, arthritis, Alzheimer's disease, and functional quadriplegia (paralysis of all four limbs). The MDS showed Resident 33 was assessed with unclear speech, and to rarely be understood or to understand others. The MDS showed Resident 33 did not receive bathing assistance during the 7-day lookback period. The revised 10/25/2022 ADL self-care performance deficit . Care Plan (CP) showed Resident 33 preferred showers two times a week, and as needed. The CP directed staff to provide a sponge…

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 assess for bladder needs to alert and oriented residents for a toileting program for 1 of 4 (Resident 12) residents. The facility failed to ensure residents with Foley Catheters (FC- a tube placed in the bladder to drain urine) received appropriate care and services for 1 of 5 (Resident 59) residents reviewed for indwelling FCs. The failure to assess the residents for toileting programs and obtain and follow Physician Orders (PO) for FCs care placed residents at risk for infection and diminished quality of life. Findings included . <Resident 12> According to the 05/15/2023 Annual Minimum Data Set (MDS - an assessment tool), Resident 12 admitted to the facility on [DATE], was assessed to make their own decision, was understood, and able to understand the conversation. The MDS showed Resident 12 required two-person extensive assistance from staff for bed mobility, transfers, and toilet use. The MDS showed Resident 12 was always incontinent…

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 drugs and biologicals were secured, dated when opened, and expired medications and biologicals were disposed of timely for 2 of 4 medication carts, 1 of 2 medication rooms, and 1 of 64 resident rooms reviewed. This failure placed residents at risk for receiving expired medications, medication errors, adverse side effects of medications, or not receiving the full effect of their medications. Findings included . <Facility Policy> According to a revised 11/10/2022 Medication Storage facility policy, all drugs and biologicals would be stored in locked compartments. Medications would be under the direct supervision of the person administering the medications. The policy showed medications for external use would be stored separately from medications administered internally and medications administered by mouth would be stored separately from medications administered by other routes such as eye drops or injectables. All medication rooms…

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

Based on observation, interview, and record review the facility failed to ensure resident dietary preferences and food allergies were honored for 2 (Residents 59 and 41) of 19 sample residents. This failure left residents at risk for frustration, allergic reactions to food, and weight loss. Findings included . <Resident 59> According to the 07/05/2023 admission MDS, Resident 59 had intact memory and was able to communicate and understand effectively. The MDS showed Resident 59 did not have any chewing or swallowing difficulty and was on a therapeutic diet (a meal plan that controlled the intake of certain foods or nutrients). The 06/30/2023 Nutrition Care Plan (CP) identified Resident 59 as at risk for altered nutrition and instructed staff to honor Resident 59's food preferences within the resident's diet regimen. The 06/30/2023 Nutrition Assessment showed Resident 59's food preferences were obtained by staff. On 08/01/2023 at 12:57 PM, Resident 59 was observed eating lunch in their room. Resident 59's plate had vegetable salad and pushed on one side were sliced fresh tomatoes.…

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.