Mountain View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident grievances were promptly followed up on by coming to a resolution of the grievance for 2 of 5 residents (Residents 5 and 4) reviewed for grievances. Additionally, the facility did not keep the residents updated on the progress of their grievances. This failure placed residents at risk for overall dissatisfaction with their lives and unresolved concerns. Findings included . Record review of a facility policy titled Grievances dated 08/2024 showed, each resident has the right to voice concerns/grievances. The facility will actively seek a resolution to concerns and keep residents updated on the progress. Resident 5 Review of the resident's medical record showed the resident was admitted to the facility with diagnoses which included heart failure (the heart can no longer keep up with the needs of the body), end stage renal disease with dialysis (the kidneys no longer work and require a machine to remove waste from the blood) and diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free of unnecessary psychotropic (drugs that change brain chemistry to alter a person's mood, thoughts, behavior, or perceptions) medications when they did not consistently attempt non-pharmacological (non-drug, strategies used first to manage mental health symptoms) interventions prior to medication use and failed to adhere to the 14-day limitation for PRN (as needed) psychotropic medications for 1 of 5 residents (Resident 35), reviewed for unnecessary medication. This failure placed residents at an increased risk for falls, medication-related adverse side effects, and unmet care needs. Findings included. Review of the policy titled, Psychotropic Medication, dated 08/01/2025, showed that non-pharmacological interventions would be attempted and documented prior to the use of any PRN psychotropic medication. Orders for such medications would expire in 14 days and would require an in-person assessment by a medical provider, along with supporting documentation, for the order to continue for an additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to ensure residents dependent on staff received consistent showers, incontinent care, oral care, and nail care for 2 of 5 residents (Residents 2 and 3) reviewed for activities of daily living (ADL). The failure to receive adequate showering and grooming care according to the residents' physician orders and care plan placed the residents at risk for unmet care needs, impaired skin integrity, and a potential decline in health. Findings included.Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, revised date March 2018, showed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining and communication. Resident 2 Review of the resident's medical 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 a resident received the necessary care and services to maintain their highest practicable physical well-being in accordance with professional standards of care by failing to ensure proper immobilization, and failing to consistently follow physician's orders to oversee the healing process for 1 of 3 resident (Resident 35) reviewed for falls with injury. This failure placed Resident 35 at risk for further injury, impaired healing, and a decline in range of motion (ROM). Findings included. Review of the medical record showed the resident was admitted to the facility with diagnoses including Parkinson's disease (a condition where the brain gradually loses the ability to control movement properly). The 01/03/2026 comprehensive assessment showed Resident 35's cognition was severely impaired and required the assistance of one-two staff members for Activities of Daily Living. Further review of the comprehensive assessment showed Resident 35 had no impairment with their ROM to their upper extremity (hand).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided for 1 of 4 residents (Resident 2) reviewed for positioning. There were no assessments, specific interventions to mitigate the risk of contractures (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) or Restorative nursing for Range of Motion (ROM) services to prevent further decrease in range of motion and hand contracture. This failure placed the residents at risk for a decrease in mobility, development/worsening of contractures and inability to maintain their current level of functioning. Findings included. Resident 2 Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or total loss of motor function on one side of the body) of the left side, dementia (loss of memory, thinking and the ability to perform daily activities), and need for…

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

Based on observation, record review, and interview, the facility failed to ensure drugs and biologicals were stored, labeled, and monitored in accordance with professional standards. The facility failed to discard expired or improperly labeled medications on one of three medication carts (East medication cart) and failed to document twice-daily temperature monitoring for 1 of 1 medication refrigerator in medication storage room. These failures placed residents at risk for receiving compromised or ineffective medications and vaccines and negative health outcomes.Review of the Centers of Disease Control and Prevention guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure routine and timely dental services were provided and failed to follow through on practitioner-ordered referrals for 3 of 5 residents (Resident 52, 53 and 41) reviewed for dental care. This failure placed the residents at risk for dental pain, nutritional compromise and unmet dental needs. Findings included. Resident 52 Review of the medical record showed the resident was admitted to the facility with diagnoses including heart failure and dementia (a decline in brain functions severe enough to interfere with daily life). The 12/21/2025 comprehensive assessment showed Resident 52 cognition was moderately impaired and required the assistance of one staff member for Activities of Daily Living (ADL)s. During an interview on 02/17/2026 at 10:49 AM, Resident 52 stated they wanted to go to the dentist because they had one tooth in the back on the right side that was worn out. Resident 52 stated they had not seen a dentist since 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 interview and record review, the facility failed to ensure residents/resident representatives (RR) were educated on the potential risk versus benefits when offering the pneumococcal and influenza immunization (specific vaccines that protects against pneumococcal bacteria and influenza viruses that can lead to lung, nose and throat infections) nor documentation that indicated vaccination were offered, accepted or refused for 2 of 5 residents (Resident 22 and 2) reviewed for immunizations with infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risk/benefits in order to make an informed decision.Findings included .Review of the facility's policy titled, Influenza and Pneumococcal Immunizations, dated 08/01/2024, showed the facility would provide residents with the opportunity to accept or refuse the influenza and pneumococcal vaccines. The policy stated that a resident or RR would complete an immunization informed consent document, were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or resident representative (RR) were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (a specific vaccine for the COVID-19 virus) benefits/risks and potential side effects for 2 of 5 sampled residents (Resident 22 and 2) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus.Findings included .Review of the facility's policy titled, COVID-19, dated 08/01/2024, showed that facility residents were offered the recommended COVID-19 immunization upon admission to the facility. The policy stated that an immunization informed consent would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to maintain Range of Motion (ROM) for 3 of 3 residents (Residents 1, 3, and 2) reviewed for Restorative Nursing programs. The lack of consistent processes in place for implementation of splints and providing ROM services placed residents at risk for not maintaining ROM in the affected areas of contractures (tightening of tendons and muscle), decreased function and pain.Findings included .Resident 1 Review of the medical record showed the resident was admitted to the facility with diagnoses including history of a stroke (blood flow to a part of the brain is interrupted) with paralysis (loss or impairment of voluntary movement) on the left side and heart failure. Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and was dependent on staff for dressing, grooming and mobility. During an observation on 09/29/2025 at 1:17 PM, Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure cleaning, disinfecting and/or storing of oxygen care equipment was maintained in a manner to prevent infectious diseases for 3 of 5 residents (Residents 4, 5 and 6 ) reviewed for cleanliness of oxygen concentrator (a device that pulls air out of the environment and concentrates into oxygen) filters and storage of oxygen tubing when not in use. This failure placed residents at risk for infectious disease transmission and illness in their respiratory system (lungs). Findings included .Resident 4Review of Resident 4's medical record showed they were admitted to the facility with diagnoses including obstructive sleep apnea (repeated episodes of upper airway obstruction during sleep) and dementia (ongoing cognitive decline). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively impaired and was dependent on staff for grooming, dressing, transfers and mobility. Review of Resident 4's physicians order 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 residents were free of chemical restraints for 1 of 3 residents (Resident 5) reviewed for unnecessary medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life. Findings included . Review of the facility policy Psychotropic Medication Use, revised February 2025, showed psychotropic medications were any medication that affected brain activity related to mental processes and behavior, and these medications were .never used to sedate or alter a resident's behavior for discipline or for the convenience of staff. Further review showed residents' medical record should show specific behaviors to monitor for, potential triggers for these behaviors, and non-pharmacological interventions to try for soothing before as needed psychotropic medication were administered. <Resident 5> Review of the medical record showed Resident 5 admitted to the facility, on 04/15/2025,…

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

Based on interview and record review, the facility failed to ensure the components for identification and reporting abuse/neglect from their abuse prohibition policy were implemented for 1 of 5 residents (Resident 5) reviewed for abuse and neglect. This deficient practice placed residents at an increased risk for unidentified abuse and neglect and unmet care needs. Findings included . Review of the facility policy, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated 08/01/2024, showed facility staff was expected to be able to identify abuse and neglect of residents and were mandated to report these incidents to the State Agency (SA). Further review of the facility policy showed the facility identified unauthorized chemical restraints as a form of abuse with the example .[(psychotropic) a substance that affects the mind or brain, causing changes in thinking, feeling, or perception] medication is administered in order to prevent a resident from displaying behaviors . or for staff convenience resulting in a changed behavior requiring a lesser…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of potential abuse and/or neglect to the State Agency (SA) as required for 1 of 5 residents (Resident 5) reviewed for abuse and neglect. This deficient practice placed residents at risk for unidentified abuse/neglect. Findings included . Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, showed all reports of abuse and neglect .are reported to local, state and federal agencies (as required by current regulations) . <Resident 5> Review of the medical record showed Resident 5 admitted to the facility, on 04/15/2025, with diagnoses of dementia (a disease that causes loss of memory, language, problem-solving and other thinking abilities), diabetes (a disease that affects the body's ability to process sugar in the blood), sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep), and anxiety (a mood disorder causing the feeling of fear, dread, and uneasiness). Review of the comprehensive assessment,…

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

Based on interview and record review, the facility failed to ensure medication administration practices were maintained in accordance with professional standards of nursing practice for 1 of 3 residents (Resident 5) reviewed for medication administration. This deficient practice resulted in Resident 5 receiving a chemical restraint and placed other residents at risk for receiving unnecessary medications. Findings included . Review of Lippincott Manual of Nursing Practice 10th edition, defined the following ethical areas: Informed consent was the patient's right to accept or decline treatment provided by the nurse, and in circumstances where the patient was incapable of fully understanding the treatment components, informed consent must be obtained trhough a responsible person such as a decision maker or guardian. Accountability required the professional nurse to be proactive and take all appropriate measures to ensure their professional practice was not lacking, remiss, or deficient in any area or way. Review of the facility policy, Psychotropic Medication Use, revised February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to ensure residents dependent on staff received consistent showers for 3 of 9 residents (Residents 1, 3, and 4) reviewed for activities of daily living (ADL) care provided for dependent residents. The failure to receive adequate showering and grooming care according to the residents' care plan placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment. Findings included . <Resident 1> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart failure, weakness, altered mental status, and unsteadiness on their feet. Review of Resident 1's most recent comprehensive assessment dated [DATE], showed the resident had moderate cognitive impairment, and had an ADL self-care performance deficit and required substantial/maximal assistance with showering, upper/lower body dressing, and moderate assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were bathed, free from odors and provided a dignified dining experience for 5 of 5 sampled residents (Residents 13, 14, 25, 27, and 7) reviewed for dignity. These failures placed residents at risk for feelings of embarrassment, helplessness, and a diminished self-worth. Findings included . <Resident 13> Review of the medical record showed the resident was alert, oriented, and able to make their needs known. The10/18/2024 comprehensive assessment showed the resident required assistance with transfers with a mechanical lift, turning in bed, nail care and bathing. Diagnoses included cancer of the prostate (gland at the base of the urethra (tube that urine exits the body), stroke with left sided paralysis, and urinary catheter use due to urinary retention. Resident 13 was incontinent of bowels. During a concurrent observation and interview on 01/06/2025 at 10:39 AM, Resident 13's fingernails were long and could be seen over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a prompt effort to resolve grievances (a concern that has happened or been done that you believed was unfair) was made regarding resident grievances discussed during Resident Council (RC, an independent group of nursing home residents who meet at a minimum of once a month to discuss concerns and suggestions and to plan activities that are important to them) meetings nor the residents right to file a grievance/grievance process for 4 of 5 residents (Residents 6, 12, 13, and 14) reviewed for grievances. This failed practice placed residents at risk for unmet care needs. Findings included . Review of a policy titled, Grievance, dated 03/2019, showed the Activities Director (AD) should have completed a grievance if a concern was brought up during the RC meeting. The policy showed the Social Services Director (SSD) would then review/log the concerns and forward the concerns to the department heads who would complete them with appropriate actions and follow-up. Then, the grievance would be returned to the SSD who would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were completed or correct on/after residents admission to the facility and had the required level two referral sent if residents had a positive level one PASARR for 4 of 7 residents (Resident 9, 263, 56, 4) 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 Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR) Level 1 Screening Process, dated 07/06/2024, showed that nursing facilities will ensure residents with a positive level 1 PASARR screen have 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 develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP upon completion of the comprehensive care plan to the resident or the resident ' s representative for 5 of 10 newly admitted residents (Residents 49, 62, 60, 263, and 48) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs. Findings included . <Resident 49> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnosis including a stroke, anxiety, dementia (a progressive disease that destroys the memory and other important mental functions) and end of life care. The comprehensive assessment dated [DATE] showed the resident preferred language was Spanish, cognition was severely impaired and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were consistently reviewed and revised to meet residents' current needs for 5 of 12 sample residents (25, 30, 13, 4, and 17) reviewed for care plans. Additionally, the facility failed to complete care conferences for 1 of 3 residents' (Resident 4) reviewed for resident/resident representative participation in care conferences. These failures to revise care plans and complete care conferences, define changes and allow resident participation in planning their care, placed residents at risk for unmet care needs. Findings included . <Resident 25> Review of the medical record showed the resident admitted to the facility on [DATE] with multiple diagnoses to include heart failure and hypoxia (low level of oxygen in body tissue), on continuous oxygen and a Bipap machine (a device that helps you breathe by pushing pressurize air into your lungs) to be worn. Review of the 12/24/2024 quarterly assessment showed Resident 25 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 obtain physician assistance for a resident with a mental health and substance use disorder (SUD, a medical condition that is defined by the inability to control the use of a particular substance or substances despite harmful consequences) history, provide ongoing assessment and monitoring of identified non-pressure skin conditions, and provide care for a peripheral IV line for 3 of 4 residents (Residents 263, 28, and 13) reviewed for quality of care.These failures placed residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Findings included . <Resident 263> Review of the resident's medical records showed they admitted to the facility with diagnoses to include a right foot ulcer, bi-polar disorder (a mental health condition that causes extreme mood swings), SUD, and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). The 01/02/2025 comprehensive assessment showed Resident 263's cognition was moderately impaired, had mild depression,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and services were provided to increase, maintain and/or prevent a decline in Range of Motion (ROM) mobility for of 4 of 6 residents (Residents 13, 14, 25 and 42) reviewed for limited ROM and restorative nursing services. The facility's failure to have a process in place that ensured timely processing of the program, assessment, and implementation of restorative nursing programs, placed residents at risk for not maintaining gains made while on skilled therapy, functional decline, increased dependence on staff for Activities of Daily Living. Findings included . Review of the July 2017 Restorative Nursing Services policy showed that restorative nursing may or may not accompany a formalized rehabilitative service (physical therapy, occupational, therapy or speech therapy) Restorative Assistance goals and objectives are to be individualized, resident centered and outlined in the resident's care plan. Restorative Assistance goal may include supporting and assisting residents in development and maintenance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of nursing staff to provide care and services for 12 of 13 residents (Residents 13, 14, 25, 27, 6, 22, 37, 28, 263, 30, and 42) as evidenced by failures related to Resident Rights, Grievances, Activities of Daily Living (ADLs, daily actions like dressing, transferring/getting a resident up out of bed, changing briefs/toileting), Quality of Care, Resident Mobility, and Facility Assessment. Additionally, resident interviews and staff interviews provided evidence of insufficient staff. These failures place residents at risk for unmet care needs and the inability to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included . Review of the facility's resident roster, dated 01/06/2025, showed a census of 62, of which more than half of the residents required transfer assistance via a mechanical lift or required assistance of one to two staff for ADL's.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure cleaning, disinfecting and/or storing of oxygen care equipment was maintained in a manner to prevent infectious diseases for 3 of 3 residents (Residents 1, 36, and 35)reviewed for cleanliness of oxygen concentrator (a device that pulls air out of the environment and concentrates oxygen for use) filters and 1 of 2 residents (Resident 25) reviewed for storage of oxygen tubing when not in use. These failures placed residents at risk for infectious disease transmission and illness in their respiratory system (lungs). Findings included . <Oxygen filters> <Resident 1> Review of the Resident 1's medical record showed they were admitted to the facility with diagnoses including, obstructive sleep apnea (repeated episodes of upper airway obstruction during sleep) and dementia. Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and was dependent for grooming, dressing, transfer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 1) 2 of 3 halls (East and West) flooring, 2) East dining room, 3) [NAME] Hall shower room, 4) rooms [ROOM NUMBERS], 5) Laundry room, 6) East clean/dirty utility room, and 7) Conference/activities room. These failures placed the residents, at risk for potential accidents and the exposure to contaminants from unclean surfaces. Findings included . <East Hall Resident Room Floors> Observations on the east hall on 01/06/2025 at 11:00 AM, 01/07/2025 at 10:30 AM, 01/08/2025 at 11:15 AM, 01/09/2025 at 12:00PM, 01/10/2025 at 9:00 AM and 01/14/2025 at 9:00 AM, showed a housekeeper swept and mopped the east hallway to include resident rooms, utility rooms, linen room and east dining room. The dark substances and dirt embedded into the floors and entry ways was not cleanable. All resident rooms on the east hallway Rooms (1-12) had uncleanable dirt embedded black dirt substances 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 observation, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident ' s freedom of movement) when a seat belt was applied during the resident use of their electric wheelchair, for 1 of 2 residents (Resident 17) reviewed for physical restraints. This failure placed the resident at risk for a restriction of their free movement and/or activity and at an increased risk for injury when in their electric wheelchair. Findings included . Review of the facility policy titled, Physical Restraints and Enablers/Devices, revised July 2023, showed that residents had the right to be free of physical restraints (any manual method or physical or mechanical device/equipment attached to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body) .imposed for purposes of discipline or staff convenience, and 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 implementation of their abuse prohibition policy/procedures components of resident protection, identification, reporting and investigating for 4 of 4 residents (Resident 41, 28, 42, and 27) reviewed for abuse/neglect. This failure placed the residents at an increased risk for unidentified abuse/neglect, retaliation from the alleged perpetrator and the potential for continued exposure to abuse and/or neglect. Findings included . Review of the State Operations Manual, Appendix PP, dated 08/08/2024, the Code of Federal Regulations 483.12 (b)(1), F607, the facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of residents property, and in order to .provide protections for the health, welfare and rights of each resident residing in the facility . the facility must develop and implement components of screening, training, prevention,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notice of transfer/discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for 1 of 2 residents (Residents 60) reviewed for transfer/discharge notice requirements. This failure placed the residents at risk for diminished protection from inappropriate transfers/discharges, a lack of access to an advocate that could inform them of their options/rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. Findings included . <Resident 60> Review of the resident ' s medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and Parkinson ' s (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves, causing shaking movements) and was transferred to the hospital on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of the resident ' s hospital transfer for 1 of 2 residents (Residents 60) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital. Findings included . <Resident 60> Review of the resident ' s medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and Parkinson ' s (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves, causing shaking movements) and was transferred to the hospital on [DATE]. The 10/09/2024 comprehensive assessment showed Resident 60 had a moderately impaired cognition. Review of the medical record showed a 10/09/2024 progress note documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive resident centered care plans for 2 of 6 residents (Residents 21 and 56) reviewed for care plan development. This failed practice put residents at risk for unmet care and/or safety needs. Findings included . <Resident 21> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include a urinary tract infection and urine retention. The 11/22/2024 comprehensive assessment showed Resident 21's cognition was severely impaired, they required the use of a retention catheter (R/C- a device used to drain urine from the bladder) and was dependent on staff for toileting hygiene. During an observation on 01/06/2025 at 10:16 AM, Resident 21 was sitting on the edge of their bed, the r/c tubing was hanging out of their right pant leg, with the end of the tubing touching the floor. Resident 21 had a white stretchy material wrapped around their ankle, the tubing, and the bag to secure them in place. Resident 21 had a r/c leg bag (a smaller…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to ensure residents dependent on staff received consistent showers for 2 of 5 residents (Residents 37 and 22) reviewed for activities of daily living (ADLs). The failure to receive adequate showering and grooming care according to the residents' care plan placed the resident at risk for unmet care needs, impaired skin integrity, and embarrassment. Findings included . <Resident 37> Review of the resident's medical record showed they admitted with diagnoses to include diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and asthma (a chronic respiratory condition which is caused by inflammation of the airway that causes narrowing of the airway). The 12/04/2024 comprehensive assessment showed Resident 37's cognition was intact and required the assistance of one staff for showering/bathing. During an interview on 01/06/2025 at 3:45 PM, Resident 37 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who used chewing tobacco was assessed for 1 of 3 sampled residents (Resident 30) reviewed for smoking/chewing tobacco. This failure placed the resident at risk for interaction of medications with ingredients in chewing tobacco and/or with current health concerns. Findings included . <Resident 30> Review of the medical record showed the resident admitted to the facility on [DATE] after surgery of an infection and partial amputation of the resident's foot. The 12/17/2024 comprehensive assessment showed the resident was alert and able to make their own decisions and required minimal assistance. Additionally, Resident 30 was on a psychoactive medication and an intravenous (IV) antibiotic medication. Resident 30's diagnosis includes nicotine dependence to chewing tobacco. During an observation and concurrent interview on 01/06/2025 at 11:20 AM, Resident 30 was chewing tobacco at their bedside in their room and stated he had…

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

Based on observation, interview and record review, the facility failed to ensure a resident on continuous oxygen that required a Bipap device (an external device that helps you breathe by pushing pressurized air into your lungs and provides a fixed pressure to keep breathing airways open while you sleep) was used for 1 of 2 residents (Resident 25) reviewed for respiratory care. The failure of staff to assess and document Resident 25's refusal to use their Bipap device placed Resident 25 at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . <Resident 25> Review of the medical record showed the resident admitted to the facility with diagnosis to include hypoxia (low level of oxygen in body tissue), on continuous oxygen and a Bipap device to be worn at night. Review of the 12/24/2024 quarterly assessment showed Resident 25 was alert and oriented and had shortness of breath. During an interview on 01/08/2025 at 9:45 AM, Resident 25 stated they had not used their Bipap device for sleep for about two months now. The Bipap device was observed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to identify and implement specific requirements for the timely administration of an immuno-suppressive medication Tacrolimus (used to prevent the body from rejecting a transplanted organ) for 1 of 5 residents (Resident 4) reviewed for high-risk medications. Additionally, the specific instructions for the medication were not included on the medication administration record (MAR) to ensure licensed nurses were aware of the importance with closely following the medication administration times to maintain steady levels of Tacrolimus in the blood. This failure placed Resident 4 at risk for low therapeutic blood levels of the immuno-suppressive medication and increased the risk for rejection of their transplant organ. Findings included . Record review of an undated patient pamphlet published by [NAME] Cancer Center titled Tacrolimus Reference Guide showed, Tacrolimus must be taken at the same time every day to keep steady levels of Tacrolimus in your blood. 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.

Based on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 21 and 263) reviewed for unnecessary medications. The facility failed to 1) consistently monitor individualized targeted behaviors, 2) attempt non-pharmacological (non-medication) interventions prior to psychotropic medication administration, 3) assess for abnormal involuntary movements (AIMS, assess the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia (abnormal and uncontrollable movements caused by antipsychotic [drugs that treat psychosis, a collection of symptoms that affect your ability to tell what's real and what isn't] medications) prior to starting a psychotropic medication and periodically thereafter. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Findings included . Review of a policy dated 2001,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide palatable, and warm meals at the proper temperature for 4 of 8 residents (4, 23, 41 and 48) reviewed for appetizing food and drink. This failure placed the residents at risk for less-than-adequate nutritional intake potentially leading to weight loss and dissatisfaction with their dining experience. Finding included . <Resident 4> Review of the resident's record showed they were admitted with diagnoses including diabetes (a disease that results in too much sugar in the blood) and malnutrition (when the body does not get enough nutrients). Review of the comprehensive assessment dated [DATE] showed Resident 4 was cognitively intact and was independent with eating after meal set up. During an interview on 01/06/2025 at 1:48 PM, Resident 4 stated the food is terrible here. Further stating it was often served cold which was unappetizing to them and made it difficult to eat. During a concurrent observation and interview on 01/07/2025 at 8:52 AM showed…

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

Based on interview and record review, the facility failed to A) update the assessment when a substantial change occurred when the facility experienced a change in ownership, and B) update the assessment when substantial changes occurred for sufficient staffing when the facility lost their access to a nursing assistant training program that helped fill nursing assistant vacancies. These failures placed residents at risk for unmet care needs. Findings included . Record review of the Facility Assessment Tool, dated 09/2023, for (former facility name) showed what resources were necessary to provide person-centered care for residents during both day-to-day operations and emergencies. The Facility assessment showed no change in ownership as of 08/01/2024. During an interview on 01/06/2025 at 8:50 AM, Staff B, Director of Nursing Services, stated they no longer had a nursing assistant program and that it had been suspended prior to Staff B becoming employed. During an interview on 01/09/2025 at 9:55 AM, Staff A, Administrator, stated the previous Administrator (from two weeks ago) was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the cognitive capacity to understand the nature and implication of entering into a binding arbitration agreement (an alternative means of settling disputes without a jury by trial) for 2 of 3 residents (Resident 52 and 21) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding of the legal contract they had signed and their right to make a choice for a jury trial in the event of a dispute with the facility. Findings included . <Resident 52> Review of the resident ' s medical records showed they were admitted to the facility on [DATE] with diagnosis including fracture of the right leg bone, stroke and dementia (a progressive disease that destroys the memory and other important mental functions). The 10/10/2024 comprehensive assessment showed the resident had a severely impaired cognition. Review of Resident 52 ' s arbitration agreement, dated 10/27/2024 showed the resident signed the legal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and/or resident representatives were educated on the risks and benefits of the influenza vaccine, and consent or declination were obtained for the vaccine for 2 of 5 sampled residents (Residents 14 and 27) reviewed for influenza immunization. This failure placed residents at risk of not being fully informed before making decisions regarding immunizations and receiving the vaccine. Findings included . <Resident 14> Review of the 11/22/2024 medical record showed the resident was alert, oriented and able to make their needs known. During an interview on 01/09/2025 at 1:00 PM, Resident14 stated they received a flu vaccine every year but had not been given the vaccine in 2024/2025 and would like to have the flu vaccine. Review of the 12/03/2024 informed consent for vaccine education, consent and/or declination showed Resident 14 declined the COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely complete, thoroughly investigate, and provide prompt resolutions for grievances filed for 5 of 9 residents (Resident 1, 2, 3, 4, and 5) reviewed for grievances. This deficient practice placed residents at risk for unmet care needs and the potential for unidentified abuse and/or neglect. Findings included . Review of the undated facility policy, titled Grievances/Complaints, Filing, showed the facility was to complete an investigation for any expressed concerns (verbally, in writing, or anonymously) within five working days of receipt, and the Grievance Office or Administrator would provide verbally (in writing upon request) the determined resolution to the resident and/or their representative. Review of the facility's documented grievances for August 2024, September 2024, and October 2024 showed 17 grievances were filed regarding 10 different residents. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility, on 11/14/2023, with diagnoses of heart disease, lower back inflammation and…

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

Based on observation, interview, and record review, the facility to maintain their Respiratory Protection Program (RPP) for N95 respirator masks (a respiratory protective device designed to filtrate airborne particles by achieving a very close facial fit) related to fit testing for 2 of 4 staff (Staff F and G) and appropriate wear for 3 of 6 staff (Staff E, H, and I) reviewed for infection control practices during a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. This deficient practice placed residents and staff at continued risk of exposure and spread of COVID-19 during an active outbreak. Findings included . Review of guidance from the Washington State Department of Health website (with no date to reference), titled Respiratory Protection Program for Long-term Care Facilities, showed the N95 respirator protected the user when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff compliance with current infection control guidelines and standards of practice by 1) incorrectly donning/doffing (to put on/to take off) personal protective equipment (PPE) for 4 of 7 staff (Staff K, F, T, and U), 2) not adhering to fit testing (to ensure a proper fit) guidelines for N-95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for 5 of 5 staff (Staff G, I, M, N, and O), and 3) improper hand hygiene and glove changes for 4 of 7 staff (Staff K, F, T, and U) between dirty and clean tasks when providing care and services to residents on transmission based precautions ([TBP], safeguards to prevent spread of diseases) during a COVID- 19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the provider of an elevated heart rate and a low blood pressure for 1 of 3 residents (Resident 4) reviewed for change in condition This failure placed the resident at risk of inappropriate medication dosages, health complications, and timely care of services from the physician, resulting in a delay of treatment. Findings included . Review of a policy titled, Managing Acute Condition Change, dated 07/11, showed: .Assess the resident experiencing an acute change including vital signs . Notify physician without delay . <Resident 4> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi), chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), and hypertension (high blood pressure - when your blood is pumping with more force than normal through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident representative a summary of the baseline care plan for 4 of 5 residents (Resident 33, 38, 149, and 43) reviewed for baseline care plans. This failure placed the residents at risk for an unsafe environment, a delay in care and services, and unmet care needs. Findings included . Review of the facility policy titled, Care Plan - [NAME] (an information system that is used for a quick reference for nurses)/Baseline Care Plan, revised February 2019, showed the [NAME] would be completed, printed, and reviewed with the resident and/or their representative. The resident would be asked to sign a copy of the [NAME], indicating they received the information, and that signed copy would be scanned into the electronic medical record. If the resident was unable to sign, a progress note would be entered into the resident's medical record to reflect that the [NAME] was reviewed with the resident and/or their representative.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive assessments and care plans prepared by the required members of the interdisciplinary team (a group of healthcare providers from different fields who work together for the best outcome for residents) for 4 of 4 residents (Residents 43, 44, 27, and 153) reviewed for comprehensive care planning. This failure placed the residents at risk of unmet care needs. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023 §483.21 (b) (ii) The interdisciplinary team (IDT) must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative. <Resident 43> Review of the electronic medical record showed Resident 43 was admitted to the facility on [DATE] with diagnoses including a left knee replacement and high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate of less than five percent. Five medication errors were identified for 3 of 9 residents (Residents 40, 19, and 249) observed during 31 medication administration opportunities, that resulted in an error rate of 16.13%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible and possible adverse side effects. Findings included . Review of the facility policy titled, Medication Administration, General Guidelines, dated 01/2023, showed staff that are allowed to administer medications, administer medications in accordance with manufacturers' instructions. Review of the Instructions for use (IFU) by the U.S. Food and Drug Administration (USFDA) revised 07/2023, stated to prime the insulin pen with a new needle prior to each injection administration. Priming was meant to remove air from the needle and the cartridge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection control interventions, intended to mitigate the risk for transmission of infectious diseases, were consistently implemented in the areas of: A) Transmission based precautions (TBP- standard precautions [minimum infection prevention practices that apply to all patient care] along with additional precautions for residents that may be infected with certain infectious diseases) for 2 of 2 residents (Residents 151, and 38) reviewed for TBP; B) Personal protective equipment (PPE) for 1 of 3 residents (Resident 38) reviewed for PPE in TBP rooms; C) Medication administration for 4 of 4 residents (Residents 38, 40, 42, and 32) reviewed for infection control practices during medication administration. These failures placed the residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the Washington State Hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that prompt efforts were made to resolve grievances for 1 of 2 sampled residents (Resident 6) reviewed for grievances. The failure to promptly attempt to resolve grievances disallowed the resident their right to a timely grievance resolution and placed the resident at risk for dignity and financial concerns. Findings included . Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure and a right knee fracture. The comprehensive assessment dated [DATE] showed the resident had intact cognition and required extensive assistance of two staff member for activities of daily living. During an interview on 12/12/2023 at 10:04 AM, Resident 6 stated their hearing aid charger was lost in February 2023 and was not replaced by the facility. During an interview on 12/14/2023 at 1:11 PM, Staff P, Social Service Director (SSD) stated they were not sure what happened to Resident 6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an incident involving an unwitnessed event with substantial (of considerable importance) injury was reported to the State Agency (SA) as required for 1 of 2 resident (Resident 26) reviewed for falls with injury. The failure to report an unwitnessed fall that resulted in a substantial bodily injury, placed the resident at risk for further injury, harm and potential neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, sixth edition, dated October 2015, showed substantial and substantial reasonably (good judgement) related incidents, were to be reported to the Department of Social and Health Services (DSHS) within 24 hours of the incident. <Resident 26> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 2 of 6 residents (Residents 27 and 19) reviewed for residents' dependent on staff for personal grooming and hygiene. The failure to provide the necessary care and services to dependent residents placed them at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 27> Review of the electronic medical records showed the resident was admitted to the facility on [DATE] with diagnoses including a recent urinary tract infection, Parkinson's disease (a condition that affects the brain and causes problems with movement, balance, and coordination), and onychomycosis (a nail fungus causing distorted, thickened, brittle, crumbling, yellowish color to the toenails and fingernails). The resident's most recent comprehensive assessment, dated 09/22/2023, showed they required extensive to total assistance of one to two caregivers for bathing, transfers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received proper treatment and assistive devices to maintain vision abilities for 1 of 2 residents (Resident 20), reviewed for vision. Failure to ensure residents received vision care and assistive devices placed the residents at risk for worsening vision. <Resident 20> Review of Resident 20's electronic medical record (EMR), showed they were admitted to the facility on [DATE] with diagnoses including depression, presbyopia (loss of the eye to focus on objects closely), diplopia (a condition of the eye that caused double vision), and cataracts (cloudy patches that covers the eye causes blurred vision). The 10/19/2023 comprehensive assessment showed Resident 20 required partial or substantial assistance of one staff member for activities of daily living (ADLs) and an intact cognition. During an observation and interview on 12/12/2023 at 10:31 AM, Resident 20 stated they should be wearing glasses because they have cataracts.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three medication carts (South and East Hall medication carts), reviewed for medication storage, were secured. This failure placed residents at risk for access to potentially harmful medications and negative health outcomes Findings included . Review of the facility policy titled, Medication Storage, Storage of Medication, dated 01/2023, showed medications were to be stored properly and accessible only to licensed nursing and pharmacy personnel, or staff members who were lawfully authorized to administer medications. Medication storage should remain locked when not in use or attended by staff with authorized access. Review of the facility policy titled, Medication Administration, General Guidelines, dated 01/2023, showed the medication cart was to be closed and locked when out of sight of the medication nurse and no medications were to be kept on top of the medication cart. During an observation on 12/15/2023 at 8:57 AM, showed Staff J, Registered Nurse (RN), obtained medications for Resident 38…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician and resident representative of an injury for 1 of 1 resident (Resident 1) reviewed for a change in condition. This failure placed the resident at risk for a delay in medical treatment and of not having a resident representative involved in health care decision making. Findings included . Record review of the facility's policy titled, Skin at Risk/Skin Breakdown, dated 09/2020, showed that newly identified skin impairment (abrasion, excoriation, pressure sore, rash, or skin tear), the licensed nurse will notify the physician and notify the resident representative. <Resident 1> Review of Resident 1's medical record showed they were admitted from another long term care nursing facility on 03/09/2022. Review of the 03/15/2022 comprehensive assessment showed Resident 1 was cognitively intact. Review of a nursing progress note, dated 09/15/2023 at 6:33 AM, showed Resident 1 was sent to the hospital and diagnosed with a urinary tract infection (an infection of any part of the urinary system) and sepsis (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.