Edmonds Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain resident dignity for 3 of 29 residents (Resident 106, 121 & 60), reviewed for dignity. This failure placed the residents at risk for diminished self-worth, potential embarrassment, and diminished quality of life.Findings included. Review of the facility's policy titled, Privacy, revised in February 2021, showed the residents are to be always treated with dignity and respect. Staff are expected to knock and request permission before entering residents' rooms and explain procedures before they are performed. Review of the facility's policy titled, Dignity, revised in February 2021, showed, When assisting with care, residents are supported in exercising their rights. For example, resident are .provided with a dignified dining experience. RESIDENT 106Observations on 02/27/2026 at 9:13 AM, at 9:19 AM, and at 9:23 AM, showed Staff KK, Licensed Practical Nurse, walked into Resident 106's room shared with one other resident without…

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 privacy and confidentiality of resident's medical information were maintained for 1 of 3 Unit Resident List/Document (Midwest [MW] 2 Unit), reviewed for confidentiality of records. This failure placed the residents at risk of having their medical and personal information compromised and a diminished quality of life.Findings included.Review of the facility's policy titled, Confidentiality of information and personal privacy, revised October 2017, showed, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The policy further stated, access to resident personal and medical records will be limited to authorized staff and business associates.Observation on 02/27/2026 at 9:18 AM showed a paper document titled MW2 UNIT on top of the medication cart. The list contained residents' names and nursing notes regarding the medication pass (the process of preparing and administering medications) visible to anyone in the hallway.A joint observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate and resolve a grievance for 1 of 2 residents (Resident 52), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Grievance, dated in March 2025, showed, To assure that concerns are quickly and thoroughly evaluated and acted upon in order to resolve issues which affect the quality of life and care for residents in our facility. The policy further showed, When a concern is voiced to a facility employee, the resident, family, guest or fellow employee is directed to the appropriate department supervisor to evaluate and resolve the issue.Review of the quarterly Minimum Data Set (an assessment tool) dated 01/06/2026 showed that Resident 52 was readmitted to the facility on [DATE] and was cognitively intact.On 02/24/2026 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS-an assessment tool) was completed timely for 1 of 21 residents (Resident 4), reviewed for comprehensive assessments. This failure placed the resident at risk for delayed and/or unmet care needs and a diminished quality of life.Findings included .Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.20.1, revised in October 2025, showed that the admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day 1.Review of the facility's policy titled, MDS Assessment Coordinator, revised in November 2019, showed that the A Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment.The Resident Assessment Coordinator must date and sign each assessment to certify that the assessment has been…

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

Based on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 1 of 18 residents (Resident 25), reviewed for resident assessments. This failure placed the resident at risk for delayed care planning, unidentified care needs and services, and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI-instructional guidelines for MDS completion) 3.0 User's Manual Version 1.20.1, revised in October 2025, showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual change in a resident's status are monitored. The RAI further showed that the quarterly MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD-look back period).Review of Resident 25's quarterly/discharge MDS with an ARD of 08/09/2025, showed that it was completed on 05/25/2025 (three…

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

Based on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS-an assessment tool) to the Centers for Medicare & Medicaid Service within the required timeframe for 1 of 29 residents (Resident 14), reviewed for resident assessments. This failure placed the resident at risk for unmet care needs and diminished quality of life. Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument [RAI-instructional guidelines for MDS completion] 3.0 User's Manual Version 1.20.1, revised in October 2025, showed that a discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD-look back period), and it must be submitted/transmitted within 14 days of the MDS completion date to the database as required.Review of Resident 14's discharge MDS with an ARD of 01/17/2025 showed that it was completed on 02/03/2025 (three days late).Review of Resident 14's discharge MDS with an ARD of 05/03/2025 showed that it was completed on 05/20/2025 (three days late).In an interview and joint…

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 develop and/or implement care plans for 2 of 29 residents (Residents 7 & 121), reviewed for comprehensive care plans. The failure to develop/implement care plans for anticoagulant (medications that helps prevent blood clots) usage and Activities of Daily Living (ADL) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. RESIDENT 7Review of Resident 7's physician orders showed an order for rivaroxaban (anticoagulant medication) 20 milligrams (mg – a unit of measurement) by mouth for deep vein thrombosis (DVT – blood clot that forms in a deep vein), started on 01/17/2026. Review of Resident 7's January 2026 and February 2026 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to facilitate quarterly care conferences or care plan meetings for 1 of 1 resident (Resident 25), reviewed for care planning. In addition, the facility failed to ensure care plans were revised timely and accurately to reflect shower preferences for 1 of 5 residents (Resident 6), reviewed for Activities of Daily Living. These failures placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Care Planning-Interdisciplinary Team, revised in March 2022, showed, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The policy showed, Care plan meetings are scheduled at the best time of the day for the resident and family when possible. The policy further showed, If it is determined that participation of the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 2 of 6 residents (Residents 121 & 13), reviewed for ADLs. The failure to provide assistance with personal and oral hygiene placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. RESIDENT 121Review of the admission Minimum Data Set (MDS-an assessment tool), dated 12/26/2025, showed that Resident 121 was dependent (helper does all the effort) for personal hygiene. Review of Resident 121's ADL care plan, revised on 12/19/2025, showed that Resident 121 requires one person staff total assist with personal hygiene. It further 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 consistently monitor and manage constipation (passing fewer than three bowel movements a week or having a difficult time passing bowel movement) in accordance with professional standards of practice for 1 of 5 residents (Residents 52), reviewed for quality of care. In addition, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for 1 of 2 residents (Resident 121), reviewed for hospice services. These failures placed the residents at risk for unmet care needs, related complications, not receiving necessary comfort care, services and a diminished quality of life.Findings included . Review of the facility's policy titled, Bowel (Lower Gastrointestinal Tract [the final part of the digestive system, consisting of the large intestine and anus, and is responsible for water absorption and waste elimination]) Disorders- Clinical Protocol, revised in September 2017, showed, As part 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 observation, interview, and record review, the facility failed to ensure ongoing assessment, monitoring, and documentation of an identified pressure ulcer/injury (damage to the skin and underlying tissue, usually over a bony area, caused by prolonged pressure) were conducted for 1 of 4 residents (Resident 11), reviewed for pressure ulcer/injury. The failure to routinely assess and monitor pressure ulcer/injurie's characteristics and response to treatment placed the resident at risk for unidentified wound decline, delays in treatment, prolonged wound healing, and diminished quality of life.Findings included .Review of the facility's policy titled, Prevention of Pressure Injuries, revised in April 2020, stated that the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.Monitoring, evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness and on an ongoing basis.Review of Resident 11's comprehensive care plan printed…

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 smoking materials were properly stored for 1 of 4 residents (Resident 77), reviewed for accident hazards. This failure placed the resident at risk for injury and a diminished quality of life.Findings included.Review of the facility's policy titled, No Smoking Policy, signed by Resident 77 on 01/16/2026, showed that Residents who smoke can leave the facility and be off the property to smoke. It further showed that Individuals [residents] retaining their own smoking materials must keep items in a locked cabinet when not in use, with the key in possession of the resident.Review of the Smoking and Safety assessment dated [DATE], showed that Resident 77 used cigarettes.Observation on 02/23/2026 at 2:17 PM showed a lighter and pipe on Resident 77's bedside table. Resident 77 stated that they smoked and that they were allowed to have their smoking materials with them.In an interview and joint observation on 02/23/2026 at 2:42 PM, Staff…

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 properly store respiratory mask when not in use and ensure timely changing of oxygen (O2) tubing for 1 of 3 residents (Resident 27), reviewed for respiratory care. This failure placed the resident at risk of respiratory infection, related complications, and a diminished quality of life.Findings included.Review of the facility's policy, Oxygen Administration, revised in October 2010, showed, Oxygen therapy is administered by way of oxygen mask, nasal cannula (a small flexible tube used to deliver supplemental oxygen through the nose), and/or nasal catheter. The policy further showed that staff would check the tubing connection to the oxygen cylinder and ensure it is adjusted to the flow rate as prescribed.Review of a face sheet printed on 02/23/2026 showed Resident 27 was admitted to the facility on [DATE] with diagnoses that included Sleep Apnea (a disorder where breathing repeatedly stops and starts during sleep) and acute respiratory…

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 who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 2 residents (Resident 76), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a diminished quality of life.Findings included .Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care, revised in August 2022, showed, Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. The policy further showed, Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values.Review of Resident 76's admission Minimum Data Set (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 the daily nurse staffing was posted for 2 of 7 days (02/28/2026 and 03/01/2026), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members, and visitors, at risk of not being fully informed of the current staffing levels.Findings included.Review of the facility's policy titled, Daily Nurse Staffing Posting, revised in June 2024, showed that the Daily Nurse Staffing is completed at the beginning of each shift to post nurse-staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. It further showed, Daily Nurse Staffing Posting will include the following .Enter the actual number and shift (including split shifts) of licensed and unlicensed nursing staff directly responsible for the care of residents for that particular day on each shift .post each shift staff number very close to the beginning of the shift in order to ensure that the posted numbers are actual staff working the shift .if…

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 expired medications were discarded for 1 of 3 medication carts (Midwest [MW] 1 Cart), 1 of 2 medication rooms (West Medication Room), and failed to ensure medications were properly stored and secured for 1 of 1 residents (Resident 65), reviewed for medication storage. These failures placed the residents at risk of receiving compromised medications and unsafe storage practices.Findings included. Review of the facility's policy titled, Storage of Medication, revised in November 2020, showed that the facility would store all drugs in a safe, secure, and orderly manner. Drugs used in the facility are stored in locked compartments under proper temperature, light and humidity controls, and only persons authorized to prepare and administer medications have access to locked medications. The policy further showed that discontinued, outdated, or deteriorated drugs would be returned to the dispensing pharmacy or destroyed. MW 1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident records were accurate for 1 of 5 residents (Resident 88), reviewed for Activities of Daily Living (ADL). The failure to accurately document ADL care placed the resident at risk for unmet care needs, inaccurate monitoring, and a diminished quality of life. Findings included .Review of a face sheet printed on 02/26/2026 showed that Resident 88 was readmitted to the facility on [DATE] with diagnoses that included dementia (memory loss) with other behavior disturbance.Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 01/18/2026 showed that Resident 88 required setup or clean-up assistance for upper and lower body dressing.Observations on 02/25/2026 at 12:05 PM, on 03/02/2026 at 1:26 PM, on 03/03/2026 at 4:19 PM, and on 03/04/2026 at 8:24 AM, showed Resident 88 was wearing pink pants, a purple long sleeve shirt and a purple vest.Further observations on 02/26/2026 at 2:26 PM and on 02/27/2026 at 3:13 PM,…

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

Based on observation, interview, and record review, the facility failed to ensure essential equipment was in operating condition for 1 of 2 dryers (Uni-Dryer Model), reviewed for laundry equipment. This failure placed the residents at risk for shortage of clean linens, delay in laundry turnaround, and a diminished quality of life.Findings included.Review of the facility's policy titled, Maintenance Service, revised in December 2009, showed that Maintenance service shall be provided to all areas of the building, grounds, and equipment.In a joint observation and interview on 03/02/2026 at 1:11 PM with Staff DD, Housekeeper, and Staff E, Housekeeping Director, showed a pile of wet clothes placed on top of a rolling cart next to two dryers, with one dryer in use. Staff DD stated that the dryer [older Uni-Dryer Model] that was not in use was broken and had been for a while. Staff E stated that they were waiting for a motor.In an interview on 03/03/2026 at 11:35 AM, Staff D, Maintenance Director, stated that they were aware that one of the dryers had not been working for a long time.…

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 safe, comfortable and sanitary environment was maintained for 1 of 3 shower rooms (Southwest Hallway Shower Room), reviewed for environment. This failure placed residents at risk for infections, related complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Homelike Environment, revised in February 2021, showed that facility staff and management maximizes, to the extent possible, the characteristics of the facility which include a clean, sanitary and orderly environment.During a joint observation and interview on 02/26/2026 at 10:16 AM with Staff D, Maintenance Director, showed the Southwest Hallway Shower Room had a brownish red substance on the walls and ground around the shower area, dark grey spots on the ceiling above the shower, and hair on the ground throughout the shower room. It further showed a shower chair with a dark grey substance on the legs. Staff D stated that housekeeping was responsible for cleaning the shower rooms. Staff D stated…

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 Certified Nursing Assistants (CNAs) had the required 12 hours of training annually for 1 of 5 staff (Staff U). This failure placed the residents at risk for potential negative outcomes and unmet care needs.Findings included.Review of the facility's assessment, reviewed on 01/20/2026, showed required training for nurse aides must be sufficient to ensure the continuing competence of nurse aides and must be no less than 12 hours per year.Review of the facility's policy titled, Sufficient, Competent and Qualified Staff, revised in September 2024, showed that Nursing assistants will have a minimum of 12 hours of continuing education in a 12 month period.Review of the facility's employee record for Staff U, CNA, showed they were hired on 05/16/2023. It further showed no documentation that Staff U received the required 12 hours of annual training.In an interview on 03/03/2026 at 2:24 PM, Staff F, Staff Development, stated that CNAs needed 12 hours of training yearly. Staff F stated that Staff U had the required training,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was evaluated, assessed, and a physician order was obtained for safe administration of a medication for 1 of 1 resident (Resident 1), reviewed for self-medication administration. This failure placed the resident at risk for medication errors, adverse medication interactions, and complications. Findings included .Review of the facility's policy titled, Administering Medications, revised in April 2019, showed, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.Review of Resident 1's admission Minimum Data Set (MDS-an assessment tool) dated 01/20/2026 showed that they were admitted to the facility on [DATE] and that they were cognitively intact. Further review of the admission MDS showed that they had a diagnosis of Gastroesophageal Reflux Disease (GERD- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an appropriately sized bed for 1 of 1 resident (Resident 1), reviewed for accommodation of needs. This failure placed the resident at risk for discomfort, skin issues and a diminished quality of life.Findings included .Review of the facility's policy titled, Bed Safety and Bed Rails, revised in August 2022, showed, Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. The policy further showed, Bed dimensions are appropriate for the resident's size.Review of the admission Minimum Data Set (MDS-an assessment tool) dated 01/20/2026, showed that Resident 1 was admitted to the facility on [DATE] and that they were cognitively intact. Further review of the admission MDS showed that Resident 1's height was 78 inches (unit of measurement) and that they were dependent on staff with 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, interview, and record review, the facility failed to ensure a resident had reasonable access to a telephone and a place where calls could be made without being overheard by others for 1 of 3 residents (Resident 1), reviewed for telephone access. In addition, the facility failed to ensure mail was delivered unopened for 1 of 3 residents (Resident 2), reviewed for resident rights. These failures placed the residents at risk for decreased communication with others inside and outside of the facility, lack of privacy and a diminished quality of life.Findings included .Review of the facility's policy titled, Telephones, Resident Use of, revised in May 2017, showed, Residents shall have easy access to telephones. The policy showed, Telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative is available. Residents should use telephones at the nursing stations 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 make needed repairs to maintain a homelike environment for 2 of 3 resident rooms (Rooms 14 & 15) and failed to maintain a clean and comfortable environment for 1 of 3 resident rooms (room [ROOM NUMBER]), reviewed for environment. These failures placed residents at risk for unmet care needs, a less than homelike environment, and potential infection control issues.Findings included .Review of the facility's policy titled, Homelike Environment, revised in February 2021, showed, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.REPAIRSroom [ROOM NUMBER]Observations on 02/03/2026 at 11:26 AM showed that the baseboard below the sink in room [ROOM NUMBER] was coming off the wall. Resident 2 stated that housekeeping was aware of the baseboards coming off 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 neurological assessments (set of tests nurses do to check how well a person's brain, nerves and muscles are working) were completed post fall and to ensure a physician's order for every 15-minute (observation performed at 15-minute intervals) check was followed for 1 of 3 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk of potential delay of immediate care and a diminished quality of life. Findings included.Review of the facility's policy and procedure titled, Neurological Assessment, revised in October 2021, showed neurological assessments were indicated following a fall or when indicated by a resident's condition. Review of the facility's policy titled, Falls and Fall Risk, Managing, revised in March 2018, showed The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. It further showed, The staff will monitor and document…

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

Based on interview and record review the facility failed to thoroughly investigate and promptly resolve a grievance for 1 of 1 resident (Resident 1), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised in April 2017, showed All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The policy further showed upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations.Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 09/05/2025, showed Resident 1 was cognitively intact.On 11/05/2025 at 12:36 PM, Resident 1 stated that sometime towards the beginning of September 2025, staff (Staff C, Certified Nursing Assistant and another unknown staff) left them soiled, and dripping urine. Resident 1 stated that staff threatened to not answer 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, interview and record review, the facility failed to ensure infection prevention and control practices including proper use of Personal Protective Equipment (PPE-use of gown, gloves and respiratory/N95 respirator-mask) and closure of resident room doors with COVID-19 (an infectious virus causing respiratory illness) were followed to help prevent the transmission of disease during resident care and/or housekeeping for 4 of 5 staff (Staff D, E, F & G), reviewed for infection control. These failures placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications. Review of a policy tilted, COVID-19 Facility Policy and Procedure, revised in April 2024, showed, All staff and essential personnel must wear appropriate PPE are items worn to keep people safe from germs and other hazards, including masks, gloves, gowns and face shields] when interacting with residents. For example: Aerosol [tiny particles that travel through 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 care plan for 1 of 9 residents (Resident 1), reviewed for comprehensive care plans. The failure to implement a care plan for Activities of Daily Living (ADLs) placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of Resident 1's care plan for ADLs, initiated on 01/04/2024 showed, ADL Self Care Performance Deficit r/t [related to] Dementia [memory loss], Hemiplegia [paralysis/weakness on one side of the body], Limited ROM [Range of Motion], Stroke [occurs when blood flow to the brain is disrupted]. The care plan further showed an intervention initiated on 09/23/2024 for EATING: provide 1 [one] on 1 feeding assistance. An observation and interview on 04/15/2025 at 12:30 PM showed Collateral Contact 1 (CC1) assisting Resident 1 with her meal. CC1 stated that if they were in the facility to visit Resident 1, they would assist them with their meals (lunch and dinner). CC1 stated that they were typically at the facility from 9:00 AM to 7:00 PM. CC1…

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 allegation of abuse was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that all alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the facility's policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, updated in August 2022, showed that the facility would review and investigate all allegations of abuse, neglect, exploitation, mistreatment, injuries, of an unknown source, and misappropriation of resident property using the risk management electronic incident report. The policy further…

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

Based on interview and record review, the facility failed to report a communicable disease (infectious disease that can spread through direct or indirect contact) outbreak (two or more cases of a highly contagious disease) for 1 of 2 outbreak, reviewed for infection control. This failure placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Infection Prevention and Control Program, dated December 2023, showed, Outbreak management is a process that consists of reporting the information to appropriate public health authorities. It further stated that the facility would comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. Review of the facility's Antibiotic Line Listing dated March 2025, showed two residents (Resident 2 & 3) tested positive for influenza (a communicable disease cause by a virus). It further showed Resident 2 tested positive for influenza on 02/28/2025 and Resident 3 tested…

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 medications were administered by a trained and/or licensed nursing staff per professional standards of practice for 1 of 3 residents (Resident 1), reviewed for medication administration. This failure placed the resident at risk for unmet care needs, unrecognized medication adverse side effects, and a diminished quality of life. Findings included . Review of the significant change in status Minimum Data Set assessment (MDS-a required assessment) dated 12/30/2024 showed Resident 1 admitted to the facility on [DATE]. The MDS assessment also showed Resident 1 had intact thinking. In an interview on 01/31/2025 at 11:02 AM Resident 1 stated that Staff B, Director of Nursing Services (DNS) gave their medications to Staff D, Certified Nursing Assistant (CNA), to give to them. Resident 1 stated, I am not taking any medications from an aide [CNA], it had my narcotic pain medication [oxycodone] in the medication cup and all the rest of my morning…

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 designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for unmet infection control issues and lack of oversite of infection control practices. Findings included . Review of the facility's policy titled, Infection Preventionist, revised in September 2022, showed that the infection preventionist has obtained specialized IPC [Infection Prevention and Control] training beyond initial professional training or education prior to assuming the role and evidence of training is provided through a certificate of completion. It further stated that the infection preventionist is employed on site and at least part time. In an interview on 11/25/2024 at 11:49 AM, Staff D, Infection Preventionist, stated that they had not competed the test for their specialized training in infection prevention and control, so [I am] not certified yet. Staff D stated that there was a corporate infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate water temperature used for showers/bathing were maintained for 3 of 3 residents (Residents 4, 25 & 73), failed to ensure blinds in resident's rooms were maintained or replaced when broken for 2 of 2 rooms (Rooms 63 & 64), and failed to ensure oxygen equipment was stored appropriately for 1 of 1 resident (Resident 88), reviewed for environment. These failures placed the residents at risk for a less than homelike environment, unmet care needs, and a diminished quality of life. Findings included . WATER TEMPERATURE A review of the Resident Council Meeting minutes, dated 10/31/2024, showed that water temperature issues, lukewarm too cold at times. A review of the facility's grievance log from 10/26/2024 to 11/25/2024 showed no complaints regarding residents having to take cold showers/bed baths. In an interview on 11/18/2024 at 1:00 PM, Resident 4 stated that it took the facility three weeks to get the hot water fixed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 5 of 21 residents (Residents 61, 76, 62, 16 & 95), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding pressure ulcer/injury (wounds that occur from prolonged pressure on the skin), diagnosis, behavior, use of insulin (medication/hormone that regulates blood sugar levels) injections, hypoglycemic medication (drug that lowers blood sugar level) and discharge status placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure professional standards of practice were followed when administering medications for 1 of 5 residents (Resident 26) and failed to ensure physician orders were followed for 3 of 5 residents (Residents 50, 38 & 61), reviewed for medication and treatment management. The failure to administer the right dosage form of medication for Resident 26, hold medication as ordered for Residents 50 & 38, and provide wound care treatment for Resident 61 placed the residents at risk for adverse side effects, worsening of pressure ulcer, and diminished quality of life. Findings included . Review of the facility's policy titled, Medication Administration, updated in October 2022, showed that the licensed nurse would check the following prior to administering the medication: right medication, right dose, right dosage form, right route, right resident, and right time. The policy further showed that the nurse would read the Medication Administration Record (MAR) for…

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

Based on interview and record review, the facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked and actual hours worked for 6 of 31 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members, and visitors, at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's policy titled, Daily Nurse Staffing Posting, revised in June 2024, showed that the Daily Nurse Staffing is completed at the beginning of each shift to post nurse-staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. It further showed that the Daily Nurse Staffing Posting will include the following .Enter the actual number and shift (including split shifts) of licensed and unlicensed nursing staff directly responsible for the care of residents for that particular day on each shift .post each shift staff number very close to the beginning of the shift in order to ensure that…

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

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 refrigerators (East Medication Room Refrigerator), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's provided document titled, Omnicare Medication Storage Guidance, dated 2022, showed that tuberculin (purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [a serious illness caused by a type of bacteria that mainly affects the lungs]) vials should be dated when opened and discarded after 30 days. In a joint observation and interview on 11/20/2024 at 3:34 PM with Staff O, Licensed Practical Nurse, showed the refrigerator in the East Medication Room had one opened and undated multi-dose vial of tuberculin. Staff O stated that the tuberculin vial should have been dated when it was first opened. In an interview on…

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

Based on observation, interview, and record review, the facility failed to ensure food items were dated and discarded in accordance with professional standards for food safety for 1 of 2 unit refrigerators (West Nursing Station Unit Refrigerator and failed to ensure refrigerators' temperature were maintained for 2 of 2 unit refrigerators (West Nursing Station and East Nursing Station Refrigerators), reviewed for food services. In addition, the facility failed to ensure the dishwasher chemical solution was tested routinely in the Kitchen's dishwasher. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility policy titled, Preventing Foodborne Illness, revised in December 2022, showed that food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The policy further showed that Functioning of the refrigeration and food temperatures will be monitored .Federal standards require that refrigerated food…

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 facility's water management program included a written description and a flow diagram that assessed the potential growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease), failed to ensure appropriate catheter (a semi-flexible tube inserted into the bladder to drain urine) care was followed for Resident 36, and failed to ensure hand hygiene was performed during dining services for Resident 9, reviewed for infection control. In addition, the facility failed to ensure proper use of gloves and/or gown were followed for 2 of 5 residents (Residents 61 & 76) who were on Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]), and failed to ensure sharp containers were replaced when full for 1 of 2 shower rooms (Southeast…

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 dignity was maintained related to urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 3 residents (Resident 88), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Rights, dated August 2022, showed the purpose was to treat each resident with respect and dignity. Review of the admission minimum data set (an assessment tool), dated 11/01/2024, showed Resident 88 admitted to the facility on [DATE], and had an indwelling catheter. Review of Resident 88's catheter care plan, revised on 11/06/2024, showed to check catheter system every shift for patency and integrity. Observations on 11/21/2024 at 8:04 AM and 11/22/2024 at 9:18 AM, showed Resident 88 had an uncovered urinary catheter drainage bag (collects urine from the catheter) with yellow urine.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the resident and/or their designated representative before administering a psychotropic (mind altering) medication for 1 of 5 residents (Resident 78), reviewed for unnecessary medications. This failure placed the resident and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Review of the facility's undated document titled, Notification and Consent Form, showed that the Resident has the right to refuse any medical treatment, to the extent permitted by law, and to be informed of the consequences of refusing the treatment. Review of Resident 78's admission record showed Resident 78 admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (a mental disorder that causes people to experience excessive worry about everyday things) and major depressive disorder (a mood disorder that can affect how a person feels,…

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 safe self-administration of medication was clinically appropriate and/or an assessment or evaluation was done for 1 of 1 resident (Resident 56), reviewed for self-medication administration. This failure placed the resident at risk for inaccurate/unsafe medication administration, adverse side effects, and related medical complications. Findings included . A review of the facility's policy titled, Self-Medication Program and Evaluation, revised in September 2024, showed the facility would complete a Self-Medication Evaluation, determine if the resident was able to safely self-administer medications, discuss with physician any medications that may not be self- administered, determine location to store medications to ensure that the location is secure and clean (i.e., in resident room in locked cupboard/drawer), discuss with resident how medication will be tracked and monitored, and to document in nursing notes that the resident is self-medicating. Review of the quarterly Minimum Data Set (MDS-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 an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 2 of 5 residents (Residents 76 & 73), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility policy titled, Advance Directives, revised in May 2023, showed to Determine upon admission whether the resident has an Advance Directives .document in the resident's medical record whether or not an Advance Directive has been executed by…

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 initiate, investigate, log, and promptly resolve a grievance for 1 of 3 residents (Resident 76), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Grievances, revised in February 2024, showed, The center strives to complete the review of the grievance within five business days of receipt. The policy further showed, Initiate the Resident Grievance Report for all concerns . the employee . should assist the resident/resident representative as needed to complete the form. Immediately provide the completed Resident Grievance Report to the Grievance Officer/Executive Director and/or his or her designee . Review of the quarterly minimum data set (an assessment tool) dated 10/31/2024 showed Resident 76 had intact cognition. In an interview on 11/18/2024 at 9:43 AM, Resident 76 stated, I got [a] missing cell phone, Samsung [a brand name]. I reported it about three weeks ago. I don't [do 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated for 2 of 2 residents (Residents 92 & 25), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, updated in August 2022, showed that the facility would review and investigate all allegations of abuse, neglect, exploitation, mistreatment, injuries, of an unknown source, and misappropriation of resident property using the risk management electronic incident report. The policy further showed that the components of a thorough investigation were to include resident interview, resident observation, staff interviews, and other resident interviews. RESIDENT 92 Review of the admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 2 of 4 residents (Residents 76 & 61), reviewed for hospitalization. This failure placed the residents and/or their representatives at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility policy titled, Bed-Hold: Notification Notice of Bed Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, updated in September 2022, showed, The center requires that when a resident is transferred to a hospital or for a therapeutic leave all federal and state laws, rules and regulations will be followed. The policy further stated that at the time of transfer of a resident for hospitalization or therapeutic leave, the center must provide to the resident and the resident's representative written notice which specifies the . reasons for transfer or discharge. RESIDENT 76 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 bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 4 residents (Resident 61), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility policy titled, Bed-Hold: Notification Notice of Bed Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, updated in September 2022, showed, The center requires that when a resident is transferred to a hospital or for a therapeutic leave, a written notice will be provided to the resident, family member or responsible party regarding the resident's bed hold rights and the center's bed hold policy. Resident 61 admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (MDS- 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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 1 resident (Resident 16), reviewed for significant change in condition. The failure to complete a SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days). Review of the SCSA MDS Care Area assessment dated [DATE] showed Resident 16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions) and referral for Level II evaluation (a comprehensive evaluation for positive Level I screening) when a significant change in status occurred and new diagnoses of mental illness were identified for 2 of 7 residents (Residents 76 & 38), reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, PASRR Requirements, dated 04/26/2023, showed that Following admission of a resident, the nursing facility must review all level I am screening forms for accuracy. If at any time the facility finds that the previous level 1 screening was incomplete, erroneous, or is no longer accurate, the facility must immediately complete a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally required screening of all individuals who have an Intellectual Disability [ID], Related Condition [RC], or Serious Mental Illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form for 3 of 7 residents (Residents 50, 78 & 62), reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR Requirements, dated 04/23/2024, showed the nursing facility would review all Level I PASRR screening forms for accuracy. The policy further showed that if at any time the facility found that the previous Level I PASRR screening was incomplete, erroneous, or was no longer accurate, the facility would immediately complete a new screening using the department's standardized level I form, following 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 develop and implement care plans for 3 of 18 residents (Residents 78, 46 & 77), reviewed for comprehensive care plans. The failure to implement care plans for diuretic (medications that help move extra fluid out of the body) use, resident preferences, and antibiotic (medications to treat infections) use, put the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning Process, revised on 05/19/2023, showed that the care plan provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being. RESIDENT 78 Review of the physician progress note on 11/01/2024, showed that Resident 78 was on torsemide (a diuretic) for edema (swelling). Review of the November 2024 Medication Administration Record (MAR) showed that Resident 78 was on torsemide…

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 revise comprehensive care plan for 1 of 18 residents (Resident 38), reviewed for care plan revision. The failure to revise the care plan to include current dialysis (a treatment to remove extra fluid and waste when kidneys fail) services placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care Planning Process, revised on 05/19/2023, showed, The care plan must be reviewed and revised according to the RAI [Resident Assessment Instrument- a guide directing staff on how to accurately assess the status of residents] process at a minimum upon admission, quarterly and with significant change in condition and services provided or arranged must be consistent with each resident's written Care Plan. Review of the facility policy titled, Dialysis Management, dated August 2022, showed, Review and revise the appropriate Dialysis care plan as needed. Resident 38 admitted 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 interview and record review, the facility failed to ensure skin assessments were consistently evaluated for 1of 1 Resident (Resident 73), reviewed for quality of care. This failure placed the resident at risk for not receiving necessary care services, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Documentation-Skin Conditions, updated in February 2023, showed that weekly skin assessments would be documented weekly using the Total Body Skin Evaluation or PCC [Point Click Care - facility's electronic documentation software] Skin & Wound - Total Body Skin Assessment. Review of the skin assessment for November 2024 in the electronic clinical records under the evaluations tab, showed Resident 73 had one skin evaluation dated 11/18/2024. There were no other skin evaluations done for November 2024. In an interview on 11/26/2024 at 11:35 AM, Staff K, Licensed Practical Nurse, stated that residents' skin check evaluations were part or the physician orders for them to appear in the treatment administration records.…

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 pressure ulcer/pressure injury (wound that occur due to prolonged pressure on the skin) was provided the necessary treatment and services consistent with professional standards of practice for 1 of 2 residents (Resident 61), reviewed for pressure ulcer care. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life. Findings included . Review of the facility undated policy titled, Wound Prevention and Management, showed, A resident with pressure ulcers will receive continued preventive interventions and necessary treatment and services to promote healing and prevent infection. Review of Resident 61's annual Minimum Data Set (an assessment tool) dated 11/07/2024, showed Resident 61 had an intact cognition. In an interview on 11/19/2024 at 9:41 AM, Resident 61 stated that they had pressure ulcer to their left buttock. When asked if they had received wound care to their left buttock, Resident 61 stated, No. It [wound care to their left buttock]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate oxygen storage and use of respiratory equipment were maintained to include care of oxygen tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) in accordance with professional standards of practice for 2 of 3 residents (Residents 36 & 18), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and complications due to improper oxygen storage. Findings included . Review of the facility's policy titled, Oxygen Management, revised in August 2023, showed to place oxygen delivery device in plastic bag when not in use. OXYGEN TUBING/NASAL CANNULA CARE Review of the admission Minimum Data Set (MDS-an assessment tool), dated 10/22/2024, showed that Resident 36 admitted to the facility on [DATE]. It further showed that Resident 36 was on oxygen therapy. Observations on 11/18/2024 at 9:52 AM and on 11/20/2024 at 8:28 AM, showed Resident 36'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 interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 of 31 days (10/08/2024), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's document titled, Daily Nursing Staffing Report, dated 10/08/2024 showed that no RN worked on 10/08/2024. In an interview on 11/21/2024 at 3:28 PM, Staff BB, Medical Records/Staffing Coordinator, stated, I assume there should be one [RN] every shift, every day of the week. Staff BB further stated that on 10/08/2024, there was no RN coverage for that that day and there should have been. In an interview on 11/25/2024 at 2:16 PM, Staff B, Director of Nursing Services, stated that they were unsure about the RN coverage requirement and will look into that. In an interview on 11/26/2024 at 2:32 PM, Staff A, Administrator, stated, that's the expectation, to have at least 8 hours [of RN coverage] a day. Reference: (WAC) 388-97-1080…

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 free from unnecessary medications for 3 of 6 residents (Resident 77, 78 & 38), reviewed for unnecessary medications. The failure to monitor for adverse side effects for use of antibiotics (a medication to treat infections) and diuretics (a medication to move extra fluid out of the body) and follow insulin (medication/hormone that regulates blood sugar levels) parameters placed the residents at risk for unmet care needs, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Medication Administration, updated in October 2022, showed that the licensed nurse would check the following prior to administering the medication: right medication, right dose, right dosage form, right route, right resident, and right time. The policy further showed that the nurse would read the Medication Administration Record (MAR) for the ordered medication, dose, dose form, route, and time; verify…

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 residents received the ordered medication dosage for residents receiving psychotropic medications (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) for 1 of 5 residents (Residents 50), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Physician Orders, revised on 02/24/2024, showed that discontinue the original physician's order when the physician changes an order that is currently in place and ensure the new order is in place and reflects the change. Confirm accuracy of orders by leaving new or changed orders in the queue for a second licensed to verify; the second nurse would review transcription errors and errors of omission. Review of the facility's policy titled, Medication Administration, updated in October 2022, showed that the licensed nurse would check the following…

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 and/or their representatives were provided information about the influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]), including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record, and as to why the vaccine was refused for 2 of 5 residents (Residents 22 and 78), reviewed for immunizations and infection control. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease and denied the residents and/or their representative of the right to make informed decisions. Findings included . Review of the facility's policy titled, Vaccination of Residents, revised in October 2019, showed that all residents will be offered vaccines that aid in preventing infectious disease unless the vaccine is medically contraindicated, or the resident has already been…

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 and/or their representative were provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record, and as to why the vaccine was refused for 2 of 5 residents (Residents 22 and 78), reviewed for COVID-19 immunizations. This failure placed the residents at risk for a COVID-19 infection and denied the residents and/or their representative of the right to make informed decisions. Findings included . Review of the Centers for Disease Control and Prevention online document titled, Staying Up to Date with COVID-19 Vaccines, dated 10/03/2024, showed that everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. It showed that for people ages 12-64 years are up to date when they have received one dose of the 2024-2025 COVID-19 vaccine. It further showed that 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 document on the State Reporting form and complete an investigation for an allegation of neglect within the required time frame for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigations. These failures had the potential to cause unrecognized abuse/neglect, unmet care needs, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines for Investigation and Reporting dated October 2015, showed, Appendix D: staff to resident incidents of neglect should be logged on the Department of Social and Health Services (DSHS-State Reporting Log) within 5 days of the incident. Additional review of the Nursing Home Guidelines further showed Appendix J, Regulations Relevant to Resident Protections (c)(3): The facility must have evidence that all alleged violations are thoroughly investigated and (c)(4) The results of all investigations must be reported to the administrator within 5 working days of the incident. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall care plan intervention for 1 of 3 residents (Resident 2), reviewed for falls. This failure placed the resident at risk for falls, injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning Process, revised on 05/19/2023 showed, The center follows the CMS [Centers for Medicare and Medicaid Services - government federal agency that administers major health care programs) RAI [Resident Assessment Instrument- User's Manual- a guide directing staff on how to accurately assess the status of residents] philosophy and process on care planning. The comprehensive care plan should be an interdisciplinary communication tool that must have measurable objectives with time frames and describes the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. It further showed, Develops and implements 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 revise the comprehensive care plan for 1 of 3 residents (Resident 1), reviewed for care plan revision. The failure to revise care plan for fall placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning Process, revised on 05/19/2023, showed that the care plan must be reviewed and revised according to the RAI [Resident Assessment Instrument-a guide directing staff on how to accurately assess the status of residents] process at a minimum upon admission, quarterly and with significant change in condition and services provided or arranged must be consistent with each resident's written care plan. The policy further showed, Update needs/problems/strengths, goals and interventions at least quarterly or with significant change. Resident 1 admitted to the facility on [DATE] with a diagnosis of Osteoarthritis (a type of bone joint inflammation causing the joints…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 2) was free from physical abuse when Resident 1 wandered into Resident 2's room and hit them across the face when asked to leave. This failure placed the residents at increased risk for injury, emotional distress, and a diminished quality of life. Findings included . Review of the annual Minimum Data Set (MDS - a required assessment tool) dated 04/14/2024, showed Resident 1 was admitted to the facility on [DATE]. The MDS also showed the resident had impaired thinking, wandered daily and significantly intruded on the privacy or activities of others. Review of an incident investigation report dated 04/16/2024, showed Resident 1 entered the room of Resident 2 and when Resident 2 asked them to leave their room, Resident 1 hit Resident 2 on the face. The incident investigation showed Resident 2 was not injured. Further review of the investigation showed the facility substantiated the incident when Resident 1 hit Resident 2…

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 comprehensive person-centered care plan for 1 of 4 residents (Resident 1), reviewed for discharge care plans. The failure to develop a care plan to address necessary care and services for a planned discharge placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the discharge Minimum Data Set (MDS-an assessment tool) dated 02/29/2024 showed Resident 1 had a planned discharge from the facility on 02/29/2024. The MDS showed Resident 1 had diagnoses that included diabetes (a medical condition that caused increased levels of sugar in the blood) and congestive heart failure (the heart struggles to pump blood effectively leading to a reduces supply of oxygen and nutrients to the body). The MDS further showed Resident 1 required assistance with care. Review of a nursing progress note dated 02/29/2024 showed Resident 1 discharged from the facility to the community with 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 maintain a clean, comfortable, homelike, and safe environment for 2 of 4 rooms (Rooms 14 &15), reviewed for safe and sanitary environment. The failure to ensure rooms were free from odors and maintained in safe and sanitary conditions placed the residents at risk for infection, poor living conditions, and a diminished quality of life. Findings included . room [ROOM NUMBER] During an observation and interview on 04/08/2024 at 1:23 PM with Staff D, Housekeeping Supervisor, showed room [ROOM NUMBER]'s bed mattress closest to the window had a cracked surface that was stained yellow covering the middle of the mattress. The mattress had a strong, foul odor, and the floor in front of the bed had a dried, sticky substance stuck to it. Staff D stated that the resident urinated on the mattress and on the floor in front of the bed all the time and that was why this whole room and the hallway smelled like urine. Staff D stated, I told the administrative staff that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services as ordered by a provider (medical doctor or nurse practitioner) for 1 of 3 residents (Resident 1), reviewed for urinary (eliminate body waste in the form of urine) care. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Physician's Orders, revised on 02/24/2023, showed Ensure appropriate departments are aware of applicable orders. Resident 1 admitted to the facility on [DATE]. Review of the June 2023 Medication Administration Record (MAR) showed an order to refer Resident 1 to a urologist (a doctor that specializes in the treatment of the urinary system), which was signed on 06/28/2023 indicating that the order was carried out. Review of Staff A's (Medical Record Director) progress note dated 07/13/2023 stated that they had spoken to Resident 1 about going to the urologist appointment and was…

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

Based on observation, interview and record review, the facility failed to appropriately label and store drugs and/or biologicals for 1 of 2 medication storage rooms (West Medication Storage Room), and 2 of 5 medication carts (Southwest and [NAME] middle Medication Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and ineffective medications. Findings included . Review of the facility's policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, revised on 07/21/2022, showed the facility should ensure that medication and biologicals that have an expired date on the label have been retained longer than recommended by manufacturer or supplies guidelines .are stored separate from other medications until destroyed or returned to the pharmacy. WEST MEDICATION STORAGE ROOM Joint observation of the [NAME] Medication Storage Room on 08/29/2023 at 9:37 AM Staff G, Resident Care Manager, showed five bottles of AF Vital (Brand) tube feeding (a device that delivers liquid nutrition) supplements, expired…

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, record review, the facility failed to ensure there was sufficient dietary support personnel to serve meals and menus prepared on time. In addition, the facility failed to ensure sanitizing procedures were implemented in the kitchen. These failures placed the residents at risk for poor dining experience, poor nutrition, foodborne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life. Findings included . Review of the undated facility provided form titled, Facility Assessment Tool, showed the purpose was to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies . Total number needed or average or range . 1 per day (CDM [Certified Dietary Manager]) 5/7 days a week . Food and nutrition services staff 4-10 per shift per day . Review of the Dietary Schedule Sheet for the month of August 2023, showed that four out of 12 staff quit during the month and were scratched out on…

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

Based on observation, interview, and record review, the facility failed to ensure menus were adequate, followed, and met the nutritional needs for 10 of 84 residents (Residents 68, 73, 50, 187, 74, 39, 27, 188,189 & 42) reviewed for menus and food preferences. Specifically, the menus were revised resulting in menu repetition and unappetizing foods/food combinations, there was a lack of hot foods available for alternate menu selections, and the food options that residents selected from the menus were not served. This failure placed the residents at risk for not having their food choices honored, unmet nutritional needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Menu Development, showed, To ensure menus are developed to meet resident choices that use established nutritional guidelines .Cycle menus are initially reviewed by the Registered Dietitian to ensure they meet national guidelines . Intermittent menu change made during the cycle are reviewed by the Registered Dietitian or Nutritional Professional, using menu…

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 walk in freezer in the kitchen was maintained properly, and failed to ensure the sanitizing solution used to wipe kitchen surfaces had the proper amount of disinfectant in it. In addition, the facility failed to ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety, and failed to ensure the walk- in freezer temperature was maintained appropriately. These failures placed the residents at risk for food borne illness (an illness caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Preventing Foodborne Illness, dated December 2022 and showed that, Policy: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized . critical factors implicated in foodborne illness are .a) poor personal hygiene of foodservice employees; b. inadequate cooking and improper holding temperatures; c.…

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 pneumococcal vaccinations (vaccines use to prevent pneumonia [lung infection]) were offered for 5 of 5 residents (Residents 25, 39, 52, 58 & 88) reviewed for pneumococcal immunizations. This failure placed the resident at risk for acquiring, contracting, and/or experience potential avoidable complications of pneumonia. Findings included . Review of the facility's policy titled, IC [Infection Control], revised in December 2022, showed, To provide facilities with systems to support the safety and health of the residents . All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission. RESIDENT 25 Resident 25 admitted to the facility on [DATE]. Review of the Immunology [immunization] tab in the resident's Electronic Medical Record (EMR) showed that the pneumococcal vaccine had 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 essential operating equipment in the kitchen was maintained in satisfactory condition and fail to ensure the temperature was maintained for 1 of 1 walk-in freezer in the kitchen. This failure placed the residents at risk for decrease food quality, foodborne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life. Findings included . WALK-IN FREEZER During the initial tour of the kitchen on 08/27/2023 from 8:31 AM to 9:00 AM, showed the walk-in freezer had ice crystals with a significant amount of built-up ice up to three inches thick in some areas, covering the boxes of food, containers of food, ceiling, the floor, and the shelves. There was no internal thermometer located in the walk-in freezer. The external thermometer read -1 degrees Fahrenheit (F). Staff L, Maintenance Director, was in the kitchen during the inspection and was interviewed. Staff L stated they manually defrosted the freezer every few weeks and there was a service provider working with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure recommended equipment was provided in 1 of 1 resident (Resident 72), reviewed for reasonable accommodation of needs. The failure to provide recommended equipment in resident room placed the resident at risk for diminished independent functioning, unmet care needs, and a diminished quality of life. Findings included . Review of the undated admission record in the electronic medical record, showed Resident 72 was admitted to the facility on [DATE], with a diagnosis that included aftercare of left foot amputation (removal of a body part, usually a limb or extremity due to medical illness or trauma). Review of the quarterly Minimum Data Set assessment dated [DATE], showed Resident 72's cognition was intact. The MDS also showed, Resident 72 was unsteady and only able to stabilize with staff assistance for balance during transitions from seated to standing, turning around, moving on and off the toilet, and surface to surface transfers. An active…

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 written notices of transfer and failed to properly notify the Office of the State Long Term Care Ombudsman (an advocacy group for residents) of discharges to the hospital for 3 of 3 residents (Residents 34, 58 and 186) reviewed for hospitalization. This failure placed the residents at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights. Findings included . RESIDENT 34 Review of the electronic medical record (EMR) showed Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's progress notes, dated 07/27/2023 showed, the Resident has a witness fall. Around 0830 [8:30 AM] the Psychiatrist came to nurse's station to inform this RN [Registered Nurse] that resident was on the floor. This nurse found resident on the floor sitting leaning her back on the bed w/c [wheelchair] next to her. Res [resident] denies hitting head…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written bed-hold notification to the resident and/or their representative for 1 of 3 residents (Resident 34) reviewed for hospital transfers. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed-Hold: Notification Notice of Bed Hold and return (Voluntary Transfer to Hospital and Therapeutic Leave), dated 09/2022 showed, The center requires that when a resident is transferred to a hospital .a written notice will be provided to the resident, family member or responsible party regarding the resident's bed hold rights and the center's bed hold policy . Resident 34 admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (an assessment tool) dated of 08/15/2023, showed Resident 34's Brief Interview for Mental Status (BIMS) score was a 10 out 15, indicating Resident 34's cognition 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 baseline care plan was completed within 48 hours of admission and ensure a copy of the baseline care plan was provided to the resident or their representative for 1 of 5 residents (Resident 187) reviewed for baseline care plans. The written summary of the baseline care plan was not provided to the resident and/or family in a timely manner to ensure they were informed of the initial plan for delivery of care and services. Findings included . Review of the facility provided policy titled, Baseline Care Plan, dated 02/01/2023 showed, To develop a Baseline Care Plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services, that are to be furnished .Within 48-72 hours complete the Baseline Care Plan Summary/Evaluation review with the resident and/or responsible party and provide resident and or resident representative with a summary of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, and facility failed to ensure residents and/or their representatives were invited to participate in their care plan meetings/care conferences for 2 of 5 residents (Residents 27 & 68) reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident/Resident Representative Care Plan Conferences Policy, revised on 02/20/2023 showed, The center has designed and implemented process that strive to assure the resident and/or resident representative are part of the Interdisciplinary Team (IDT) and participate in the development and ongoing review of the Plan of Care. Each Social Service Director will encourage the resident and/or legal representative to attend the Resident/ Resident Representative Care Plan Conference, which will be scheduled with the appropriate Interdisciplinary Team members. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a discharge summary included a recapitulation (overview) of the resident's stay that reflected their course of treatment in the facility for 1 of 1 resident (Resident 85) reviewed for discharge planning. This failure had the potential to prevent the resident from having the necessary information to ensure continuity of care. Findings included . Resident 85 admitted to the facility on [DATE] and was discharged on 05/30/2023. Review of the medical records on 08/28/2023, showed there was no recapitulation of stay documented for Resident 85. On 08/28/2023 at 3:22 PM, Staff E, Social Services Director, stated that nursing completes the recapitulation of stay for residents when they discharge. Staff E also stated they were unable to find Resident 85's recapitulation of stay documentation. On 08/29/2023 at 1:20 PM, Staff B, Director of Nursing, stated that recapitulation of stay should have been completed as part of the discharge process and that it…

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 bathing/showers, meals, and toileting were consistently provided for 3 of 6 residents (Residents 82, 73 & 27) reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decrease self-esteem, and a diminished qualify of life. Findings included . Review of the undated facility's policy titled, Personal Needs showed, The center strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The center also provides the needed support when the resident performs their ADL .Personal care and ADL support will be provided according to the resident's care plan . Personal care and support includes but is not limited to the following: assistance with meals, bath/shower .peri care . toileting . transfers . RESIDENT 82 Resident 82 was admitted to the facility on [DATE]. Review of the admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutrition care and services was provided to address low body weight, low protein levels, and nutritional needs for healing of the pressure ulcer (bed sore) for 1 of 4 residents (Resident 21) reviewed for nutrition maintenance. This failure placed the resident at risk for medical complication, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Nutrition Assessment, revised in November 2022 showed, Purpose: The center strives to maintain or improve nutritional status of each individual understanding that is some cases the person's clinical condition demonstrates that this is not possible . Center clinicians . as the interdisciplinary Team [IDT] members in managing/improving the resident's nutritional status by identifying, monitoring, evaluation, a and/or treating risk factors affecting the resident's nutritional status . Develop and implement individualized interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper care of a Continued Positive Airway Pressure (CPAP- a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) machine for 1 of 1 resident (Resident 27) reviewed for respiratory services. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications. Findings included . Resident 27 admitted to the facility on [DATE] with a diagnosis of obstructive sleep apnea (repeated obstruction to the airway during sleep). Review of the annual Minimum Data Set (an assessment tool) dated 08/13/2023, Resident 27 had an intact cognition. Review of the physician's orders, showed an order dated 08/16/2023, CPAP settings 8.0 at bedtime for SOB [shortness of breath]/obstructive sleep apnea and as needed for SOB. On 08/27/2023 at 10:27 AM, Resident 27 stated, I have not seen the [CPAP] filters changed since I got here three years ago. On 08/30/2023 at…

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

Based on interview and record review, the facility failed to ensure new nurse aide (NA) received dementia training and/or the 12 hour NA training per year based on their date of hire for 1 of 1 staff (Staff W) reviewed for NA in-service training. This failure placed the residents at risk for not receiving adequate care and services and a diminished quality of life. Findings included . Review of the personnel record showed, Staff W, Nursing Assistant Registered, completed 2.36 hours of training from their date of hire (07/13/2022) through 08/30/2023. The documented training included training on abuse and neglect of residents but did not include training on dementia care for residents. On 08/30/2023 at 11:43 AM, Staff R, Human Resources Manager, confirmed there were no additional training hours completed by Staff W. Reference: (WAC) 399-97-1680 2(a-c) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate care plan interventions and follow safety measures after significant injuries related to broken bones, shoulder separation (from the joint) and falls for 3 of 7 residents (Residents 3, 5 and 8) reviewed for accidents. This failure placed the residents at risk for additional accidents with injuries, medical complications, and a diminished quality of life. Findings included . RESIDENT 3 Review of the quarterly Minimum Date Set (MDS - an assessment tool) dated 04/29/2023, showed Resident 3 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and history of falls. Review of the investigative summary report dated 07/27/2023, showed Resident 3 had a fall on 07/27/2023 and was transported to the hospital for an evaluation that day. Review of a nursing progress note dated 07/28/2023, showed the hospital reported that Resident 3 had a broken leg. The nursing progress note also showed Resident 3's care plan…

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.