Enumclaw Health and Rehabilitation

Based on observation, interview, and record review the facility failed to ensure Narcotic Ledgers were accurate for 2 of 2 Narcotic Ledgers (500 cart & 200/300 cart) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances. Findings included . <Facility Policy> According to the facility policy titled, Controlled Substances, dated 01/2023, the facility would establish a system of records to ensure accurate reconciliation to account for all controlled drugs. The policy showed at each shift change, a physical inventory of controlled medications would be conducted by two licensed staff and documented on the record. The policy showed any discrepancies in controlled substances would immediately be reported to Staff B (Director of Nursing). The policy showed controlled medications removed from a Narcotic Ledger would include the signatures of the nurse releasing the medication and the nurse or resident receiving the card of medication.…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 5 of 28 medications for 2 of 5 residents (Resident 43 & 13) observed during medication pass resulted in a medication error rate of 17.86%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> Review of a 01/2023 facility Medication Administration General Guidelines policy showed the following: medications were to be administered in accordance with written orders of the prescriber; If necessary, the nurse contacts the prescriber for clarification. This policy showed prior to medication administration, the nurse would review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) with the medication label, if different, the prescriber's orders would be checked for the correct dosage schedule and labeled. <Resident 43> Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 <100 Unit> <Resident 44> Review of Resident 44's 06/09/2025 physician orders showed the resident did not have an order directing staff to keep medications at the resident's bedside. Observation on 06/08/2025 at 8:33 AM showed a topical pain-relieving patch on Resident 44's nightstand. Observation on 06/13/2025 at 10:32 AM showed the topical pain-relieving patch remained on Resident 44's nightstand. In an interview at that time, Staff P (Registered Nurse) stated the topical pain-relieving patch should not be left on the resident's nightstand. Staff P removed the unsecured patch from the resident's room. Reference: WAC 388-97-1300(2), -2340. Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 2 of 2 medication carts (Medication carts 200/300 & 500), 1 of 1 medication rooms (Medication room [ROOM NUMBER]), and 3 of 3 units (Units 500, 200/300, & 100), 3 of 3 residents (Resident 11, 32 & 44) observed for medication storage. This failure…

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

Based on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 2 (Resident 13 & 18) of 17 sample residents reviewed. The facility failed to provide privacy during medication pass for Resident 13 and have washcloths available for staff and residents to use for personal care for Resident 18. These failures placed residents at risk for feelings of diminished self-worth and embarrassment. Findings included . <Resident 13> Observations during medication pass on 06/12/2025 at 9:45 AM showed Staff Q (Licensed Practical Nurse) prepare medications for Resident 13. Another staff member from the activities department went into Resident 13's room and brought the resident out in a wheelchair to join an activity. Staff Q stopped the staff member and let them know they needed to administer Resident 13's medications first, and stated, you can leave [them] here. Staff Q put on gloves, administered the medications, and handed the resident an inhaler to use. Staff Q then administered eye drops while Resident 13 remained in the hallway and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 73 & 74) of 3 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required. Findings included . <Facility Policy> According to a revised facility [DATE] Resident Trust Fund policy, the facility would maintain resident trust fund accounts in accordance with state and federal regulations. This policy showed when a resident discharged or expired, the balance of the resident's personal funds would be returned to the resident, responsible party, or as directed by state regulation. <Resident 73> Record review showed Resident 73 discharged from the facility on [DATE]. Review of the facility's trust records showed the resident had a balance of $229.61 which was not transferred to the OFR until [DATE], over three months after Resident 73's discharge from 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 <Resident 24> According to a 02/10/2025 Annual MDS, Resident 24 had no areas of concern for their dental status. In an interview on 06/08/2025 at 12:06 PM, Resident 24 stated they had some broken teeth that needed to be fixed for a while. Review of Resident 24's revised 02/29/2024 dental health CP showed tooth decay was found on an oral assessment and gave instructions to staff to coordinate arrangements for dental care, transportation as needed. Record review showed Resident 24 was seen by dental on 05/05/2025 with documentation showing the resident had several decayed and broken teeth and required a referral for evaluation and extractions. In an interview on 06/13/2025 at 10:31 AM, Staff D stated it was important to have an accurate MDS to provide a proper picture of the resident and to CP appropriately. Staff D reviewed Resident 24's 02/10/2025 Annual MDS and stated the dental status section was coded inaccurately and needed to be modified. <Resident 26> According to a 04/16/2025 Significant Change MDS,…

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

Based on interview and record review, the facility failed to ensure the recommendation of a Level II Preadmission Screen and Resident Review (PASRR) evaluation was incorporated into the Care Plan (CP) upon receiving recommendations for 2 (Resident 46 & 32) of 5 sampled residents reviewed for coordination of PASRR and assessments. This failure placed residents at risk for unmet mental health care needs and a diminished quality of life. Findings included . <Facility Policy> Review of a revised 01/01/2025 PASRR Process Policy and Procedures, showed once the Level II evaluation was complete, the Social Services Director (SSD) would give the evaluation to medical records to be placed in the resident's records. This policy showed the SSD would additionally expand the CP to include recommended approaches noted on the Level II PASRR evaluation. <Resident 46> According to a Quarterly 05/22/2025 Minimum Data Set (MDS - an assessment tool), Resident 46 had multiple medically complex diagnoses including anxiety, depression, a mental illness characterized by extreme mood swings, and a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 <Medications Given Outside of Parameters> <Resident 45> According to a 05/27/2025 Significant Change Minimum Data Set (MDS- an assessment tool), Resident 45 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 45's May 2025 Medication Administration Records (MAR) showed the resident was receiving two different medications for high BP with directions to staff to hold doses if the Systolic BP (SBP - a measure of the pressure in your arteries when your heart beats) was less than 110. This MAR showed staff gave the medications outside of these parameters on three occasions. Review of Resident 45's June 2025 MAR showed staff administered these medications outside of parameters on two occasions. <Resident 26> According to a 04/16/2025 Significant Change MDS, Resident 26 had multiple medically complex diagnoses including high BP. Review of Resident 26's April 2025 MAR showed the resident was receiving three different medications for high BP with directions to hold doses if 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 ensure residents received proper assistive devices to maintain vision and hearing abilities for 1 (Resident 46) of 2 residents reviewed for hearing services. Failure to ensure Resident 46 received assistance in obtaining hearing devices placed this resident at risk for a decline in hearing abilities and frustration. Findings included . <Facility Policy> Review of an updated July 2015 Clinical and Support Services policy showed the social services department would assist residents in obtaining needed clinical and support services. This policy showed social services would coordinate services with the nursing department and maintain a list of individuals requiring hearing services. <Resident 46> According to a 07/05/2024 admission Minimum Data Set (an assessment tool) Resident 46 had adequate hearing with the use of a hearing aid. Review of a 05/30/2024 baseline care plan showed instructions to staff that Resident 46 was hard of hearing in both ears and had hearing aids for both ears. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 3> According to an 04/25/2025 Quarterly MDS, Resident 3 had multiple medically complex diagnoses, was dependent on staff for wheelchair mobility, and had a history of falling. In an interview on 06/09/2025 at 10:18 AM, Resident 3's family stated they were concerned about the resident having recent falls. Observations on 06/09/2025 at 12:38 PM, showed Resident 3 lying in bed with their call light in reach. Review of a 01/05/2025 12:00 PM facility incident report showed Resident 3 had a fall in their room. This report showed staff were educated not to leave Resident 3 in their room alone and an intervention was added to their CP to place the resident in a wheelchair near the nurse's station and to encourage them to participate in activities of choice. On 01/20/2025 at 6:30 PM, Resident 3 had another fall and was found on the floor in their room with their wheelchair behind them. This report showed staff were again educated that if Resident 3 was sitting in their wheelchair they, were to remain in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's orders for 1 (Resident 53) of 2 residents who were reviewed for position/mobility. This failure placed residents at risk for decline in physical and functional mobility, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's, Therapy Evaluation Time Line policy dated 06/2010, showed upon receiving the physician's order for a therapy evaluation, the resident would be seen and evaluated by the therapy department in a timely manner (within 48 hours .). <Resident 53> According to the 05/12/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 53 admitted to the facility from another long term care facility and had moderate cognitive impairment indicating some difficulties with thinking and processing. The MDS showed Resident 53 had a diagnosis of a brain bleed with severe weakness to the right side…

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

<Unit 500> Observation on 06/12/2025 at 9:50 AM showed a unit 500 nurse run sheet left unattended in view on the unit 500 medication cart. The unit 500 nurse run sheet included resident's names, room number, and diagnoses on it. In an interview on 06/12/2025 at 9:52 AM Staff W (Licensed Practical Nurse) stated the nurse run sheet should be protected and not visible for all. Staff W stated it was important to protect PHI for resident rights. In an interview on 06/13/2025 at 11:02 AM Staff A (Administrator), Staff B (Director of Nursing), and Staff G (Regional Director of Clinical Operations) stated they expected staff to protect residents PHI for residents rights to privacy. Reference: WAC 388-97-1720(1)(c), -0360(1-3). Based on observation, interview, and record review the facility failed to keep all Protected Health Information (PHI) out of view from unauthorized individuals for 2 of 3 units (Units 200/300 and 500). This failure placed residents at risk for a violation of their right to privacy. Findings included . <Facility Policy> Review of the facility's admission agreement,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 <Hand Hygiene> <Dining> Observations of meal tray pass on 06/08/2025 at 12:53 PM, showed Staff V delivering a lunch tray to a resident in room [ROOM NUMBER]. While in the room, Staff V touched items on the bedside table and exited the room without performing HH. Staff V then wiped their face with their hand, picked up another tray, delivered the tray to a resident in room [ROOM NUMBER], and exited the room without performing HH. At that time, Staff V approached a resident in a wheelchair and pushed them to room [ROOM NUMBER]. At 12:59 PM, Staff V picked up another tray to deliver to a resident in a room with TBP. Staff V did not perform HH since observations started at 12:53 PM. In an interview on 06/13/2025 at 10:42 AM, Staff H stated it was their expectation staff complete HH before entering resident rooms, after touching items in a resident's room, and after exiting rooms. Staff H stated HH was important in reducing the risk of spreading diseases. <Medication Pass> Continuous observations during a 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 2 of 6 residents (Residents 218 & 15) reviewed for nutrition and hydration, and one supplemental resident (Resident 57) maintained acceptable parameters of nutritional status. The failure to ensure residents were consistently provided required eating assistance, and ordered weights were obtained and analyzed to determine the need for new interventions as ordered placed residents at risk for unwanted weight loss, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 06/10/2021 Weights policy, residents should be weighed on the day of admission. The policy defined a significant weight loss as 5 % or more in 30 days, 7.5 % or more in 90 days, or 10 % or more in 180 days. The policy showed if a resident was identified with five pounds (lbs) or more weight loss since the last weight, the resident should be reweighed. <Resident 218> According to the 04/29/2024 admission Minimum Data Set (MDS…

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

Based on observation, interview, and record review the facility failed to consistently serve meals within the posted timeframe's for 2 of 3 hallways (100/200 Hall Dining Cart) for meals served to residents who ate in their rooms. Failure to serve meals in a timely manner placed residents at risk of nutritional concerns, food temperatures served outside the of the desired temperature range, and a decreased quality of life. Findings included . Review of the facilities posted dining times showed the 100/200 Hall Dining cart served breakfast at 8:00 AM, lunch at 12:30 PM, and dinner was served at 6:00 PM. <200 Hall Dining Cart> Observation on 05/10/2024 at 8:53 AM showed the 200 hall cart containing breakfast trays waiting to be delivered to the residents. Observation on 05/10/2024 at 9:14 AM showed Resident 57 receiving their breakfast tray, 74 minutes after the posted meal service time. <100 Hall Dining Cart> Observation on 05/10/2024 at 12:56 PM showed the 100 hall cart arrived to the hall, 26 minutes after the posted service time. Observation on 05/13/2024 at 12:57 PM showed the 100…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident meals were prepared or stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2 unit refrigerators. The failure to ensure staff hair was secured in food preparation areas, that all refrigerated food was dated and labeled as required, and food was covered when in the hall left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings included . <Facility Policies> According to the facility's October 2017 Food Storage policy showed all food should be labeled with the month and year of receipt unless the item had an expiration date of 30 days or less. The policy showed all open containers should have a use by date. The facility's June 2021 Personal Hygiene Standards (for Dietary Staff) policy showed all dietary staff must secure their hair with provided hairnets. The policy showed if staff wore a hat to secure their hair, any remaining exposed hair must still 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.

Based on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 3 of 18 residents (Resident 29, 5, & 12) reviewed for dining observations. This failure placed the resident at risk for a diminished self-worth and over-all well-being. Findings included . <Resident 29> According to a 04/11/2024 Quarterly MDS, Resident 29 had multiple medically complex diagnoses including cancer, anxiety, depression, and weakness. This MDS showed staff assessed Resident 29 to require substantial assistance from staff for eating and to roll from side to side in bed. Observations during meal services on 05/10/2024 starting at 8:29 AM showed staff delivered a breakfast tray to Resident 29 and placed it on their overbed table, out of the resident's reach, on the left side of the bed. At 8:33 AM, staff sat down to assist Resident 29's roommate to eat their breakfast. At 8:35 AM, Resident 29 was lying in bed watching staff feed their roommate, it was not until 8:54 AM, 25 minutes later, when…

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

Based on observation, interview, and record review the facility failed to provide a comfortable, appropriately sized bed for 1 of 1 resident (Resident 15) reviewed for accommodation of needs. This failed practice placed the resident at risk for discomfort and skin issues. Findings included . <Resident 15> According to a 05/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 15 had multiple medically complex diagnoses including a hip fracture and dementia. This MDS showed staff assessed Resident 15 to have a functional limitation in their range of motion to both their arms and legs, and required substantial assistance from staff to roll from side to side or sit up in bed. Observations on 05/08/2024 at 12:36 PM showed Resident 15 lying in bed, with both feet pushed up against the footboard of the bed. Similar observations were made on 05/09/2024 at 10:19 AM, 12:06 PM, and 2:49 PM. In an interview on 05/10/2024 at 8:20 AM, Resident 15 stated their knees were sore. In an observation at this time, Resident 15's feet were pressed against the footboard, and they were…

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

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge for 2 (Residents 23 & 28) of 2 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge, in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the facility's policy titled Transfer and Discharge updated October 2022, showed when a resident transfer of discharge was initiated, the resident would receive a written notice that included the reason for the transfer/discharge, where the resident was moving to, contact information for the State Long-Term Care Ombudsman (LTCO), and explanations of the resident's right to appeal the transfer/discharge. <Resident 23> According to the 04/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), was completed within 14 days for 1 of 1 resident (Resident 57) reviewed for a decline in nutritional intake and a change in skin integrity. Failure to identify Resident 57's change in status and complete a SCSA placed the resident at risk for unidentified and/or unmet care needs. Findings included . According to the October 2023 Resident Assessment Instrument Manual (a manual that directed staff on how to accurately assess the status of residents) a SCSA was a comprehensive assessment that must be completed when the interdisciplinary team determined that a resident met the significant change guidelines for either major improvement or decline. Review of the guidelines showed, a SCSA was appropriate if there was a significant change in a resident's condition from their baseline that occurred, and the resident's condition was not expected to return to baseline within two weeks. <Resident 57> According to a 02/14/2024 admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was obtained, accurate, and/or available in the resident's records to reflect the residents' mental health conditions for 2 of 6 (Resident 61 & 29) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 61> According to a 03/08/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 61 was admitted on [DATE] with multiple medically complex diagnoses and required the use of an antidepressant medication. Review of Resident 61's records showed no PASRR Level 1 was available in the resident's records. In an interview on 05/14/2024 at 11:51 AM, Staff M…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive Care Plans (CP) for 3 (Residents 5, 34, & 8) of 18 sampled residents whose comprehensive CPs were reviewed. Failure to establish individualized CPs with identified goals that accurately reflected the resident's condition, placed residents at risk for unmet care needs. Findings included . <Facility Policy> The facility used Centers for Medicare & Medicaid Services' (CMS's) October 2012 Resident Assessment Instrument Manual's Chapter 4: Care Are Assessment (CAA) Process and Care Planning, Table 2: Clinical Problem Solving and Decision Making Process Steps and Objectives to guide the care planning process. This manual showed CPs should reflect the resident or their representative's input and goals for health care, include measurable goals. <Resident 5> According to the 02/14/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 5 had intact memory, diagnoses including a traumatic spinal cord injury, paralysis from the neck down, and was totally dependent on staff for all self-care…

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

<Resident 53> Review of the 03/25/2024 Quarterly MDS, showed Resident 53 had no memory impairment and had diagnoses of a stroke with limited mobility to one side of their body. This assessment showed Resident 53 required staff assistance with set up and clean up of the resident's meal. Resident 53 did not require assistance from staff to feed themself. Review of Resident 53's 02/28/2024 revised Baseline CP, showed Resident 53 required moderate assistance and was dependent on staff to eat their meals. Observation on 05/09/2024 at 8:40 AM showed Resident 53 sitting up in bed feeding themself breakfast. Similar observations were made on 05/13/2024 at 1:45 PM and 05/14/2024 at 1:08 PM. In an interview on 05/16/2024 at 11:27 AM, Staff B stated Resident 53 was independent with eating and confirmed staff needed to updated Resident 53's CP but did not. <Resident 9> Review of the 02/09/2024 Quarterly MDS showed Resident 9 had moderate memory loss and did not participate in a restorative nursing program during the lookback period. Review of a 04/05/2024 nursing progress note showed 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.

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed and/or clarified for 4 (Residents 50, 19, 29, & 57) and nurses signed only for tasks completed for 2 (Residents 57 & 29) of 18 sample residents. These failures left residents at risk for unmet care needs, unnecessary treatment, and other negative health outcomes. Findings included . <Following and/or Clarifying POs> <Resident 50> According to the 04/05/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 50 had diagnoses including muscle spasms, an abdominal hernia, and back pain. The MDS showed Resident 50 received regularly scheduled and as-needed pain medications, including narcotic pain medications. The May 2024 Medication Administration Record (MAR) included a 02/20/2024 order for an as-needed narcotic pain medication, give 5 Milligrams (MG) as needed for severe back pain of seven or more on a scale of 1-10. The MAR showed on 05/03/2024 at 6:13 PM, and on 05/04/2024 at 6:58 AM Resident 50 was given the narcotic pain medication for a pain 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 provide assistance with Activities of Daily Living (ADLs) for 3 (Residents 25, 15, & 218) of 3 residents who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Resident 25> According to a 04/18/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 25 had multiple medically complex diagnoses including kidney failure, Alzheimer's disease, and required hospice services. This MDS showed Resident 25 was dependent on staff for personal hygiene. Review of a revised 04/25/2024 skin integrity Care Plan (CP) showed directions to staff to keep Resident 25's fingernails short. Review of Resident 25's Physician Orders (POs) showed staff were to perform fingernail care every week. Observations on 05/08/2024 at 10:13 AM and 05/13/2024 at 11:14 AM showed Resident 25 with long jagged nails that extended beyond the fingertips on both…

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

Based on observation, interview, and record review the facility failed to ensure residents with Diabetes Mellitus (DM - a condition making the regulation of Blood Glucose [BG] more difficult) received the care and services needed to manage their blood sugar for 1 of 1 residents (Resident 50) reviewed for administration of a BG lowering medication. The failure to notify the physician when the resident's BG fell below 80 milligrams per deciliter (mg/dl) left the resident at risk for blurred vision, fatigue, confusion, delirium, loss of consciousness, and other negative health outcomes. Findings included . <Facility Policy> The facility's October 2017 BG Monitoring protocol showed BG levels should be monitored per the Physician's Orders (POs). The policy showed the physician should be notified if the resident's BG dropped below 80 mg/dl or rose above 350 mg/dl unless otherwise specified by the physician. The policy showed if a resident's BG was measured below 80 mg/dl insulin should be held (not administered). <Resident 50> According to the 04/05/2024 Quarterly Minimum Data Set (MDS -…

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

Based on observation, interview, and record review the facility failed to ensure residents with hearing deficits were provided the assistance they were assessed to require for 1 of 1 residents (Resident 218) reviewed for hearing needs. These failures placed Resident 218 and other residents at risk for ineffective communication, unmet care needs, and a decreased quality of life. Findings included . <Facility Policy> The facility's Resident's Right policy, updated July 2015, showed residents should receive reasonable accommodation of individual needs and preferences. The policy showed residents had rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. <Resident 218> According to the 04/29/2024 Minimum Data Set (MDS - an assessment tool), Resident 218 had a hearing impairment and used a hearing aid. Review of the 05/01/2024 Care Area Assessment (CAA) showed Resident 218 used the hearing aids for communication and staff should ensure the resident used them. The CAA showed Resident 218 had an impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative program was provided for 4 of 5 (1, 29, 22, & 8) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's revised March 2019 Restorative Program policy showed the facility provided restorative programs to promote the resident's ability to adapt and adjust to living as independently and safely as possible. This policy showed the restorative referral form would be filled out by the skilled therapist and should include the recommended frequency the restorative program should be provided to the resident. <Resident 1> According to 03/22/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 had multiple medically complex diagnoses including a progressive neurological condition and was assessed with a functional limitation in…

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

Based on interview and record review the facility failed to ensure 2 (Residents 9 & 118) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic drugs. Failure to document rationale and identify a failed Gradual Dose Reduction (GDR) for Resident 9 and ensure informed consent was obtained prior to administration (Resident 118) placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings included . <Facility Policy> Review of the facility's October 2022 revised Psychotropic Drug policy showed a Gradual Dose Reduction (GDR) consisted of tapering a resident's dose of a psychotropic medication to determine if the resident's symptoms could be managed by a lower dose or determine if the dose could be eliminated altogether. This policy showed if the GDR had an adverse effect on the resident and the GDR attempt was discontinued, staff would document this decision and indications of the decision in the medical record. The policy showed the resident's physician would include justification in the medical record why 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 and interview, the facility failed to ensure expired medications were disposed of timely for 2 of 2 medication carts and 1 of 1 central supply room and medications were stored securely in accordance with professional standards for one supplementary treatment cart. This failure placed residents at risk for receiving expired medications and at risk for medication errors. Findings included . <Facility Policy> Review of a 01/2023 facility Medication Storage policy showed medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. This policy stated outdated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal. <Medication Carts> <100 Hall> Observations on 05/08/2024 at 1:50 PM showed the 100 Hall medication cart with one opened bottle of a non-narcotic pain medication with an expiration date of 04/2024. In an interview at this time, Staff S (Licensed Practical Nurse - LPN) stated the bottle expired the previous month and should…

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

Based on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 2 (Resident 45 & 35) of 6 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included . <Policy> According to the facility's October 2017 Dental Services - Dentures policy, the facility would assist residents as necessary upon notification of lost or damaged dentures. The facility would refer a resident within three days of being notified and confirming lost or damaged dentures for dental services. This referral would be documented in the medical record. This policy showed staff would assist residents with arranging transportation to and from dental service locations. <Resident 45> According to a 03/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had no memory impairment, had clear speech, was understood, and able to understand others. In an interview on 05/08/2024 at 3:20 PM, Resident 45 stated they had their teeth cleaned today, but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meals that accommodated resident food preferences for 2 (Resident 8 & 45) of 6 sample residents reviewed for preferences, and one supplementary resident (Resident 55). This failure placed residents at risk for weight loss, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the updated March 2016 Food Preference Record policy, the dietary manager should interview all residents regarding their food preferences (including likes and dislikes) and documents the resident's stated preferences, including cultural/religious food preferences, specialized diets, and foods frequently eaten/special requests. The dietary manager should then sign and date the form. The form should then be added to and remain in the resident's record. If a resident's food preferences changed significantly, a new form could be completed. <Resident 8> Review of the 02/26/2024 admission 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.

<Resident 25> According to a 04/18/2024 Annual MDS, Resident 25 was assessed to require hospice services. Review of Resident 25's records showed hospice notes from February, March, and April 2024 were not scanned into the resident's records by staff until May 2024. Review of a hospice binder located at the nurse's station on 05/10/2024 at 12:18 PM showed no hospice notes for Resident 25 after 11/08/2023. In an interview on 05/14/2024 at 11:39 AM, Staff M (Medical Records) stated they had some hospice notes that needed to be scanned for Resident 25 that were, put in my box within the last week. Staff M stated they expected the hospice records to be readily available in the resident records and stated hospice leaves their notes with the resident care manager. <Resident 29> According to a 04/11/2024 Quarterly MDS, Resident 29 had multiple medically complex diagnoses including psychosis, anxiety, and depression and required the use of antipsychotic, antianxiety, and antidepressant medications during the assessment period. Review of Resident 29's records revealed no pharmacy…

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

Based on observation, interview, and record review the facility failed to maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff followed the instructions as written on signs posted on resident doors requiring staff to wear Personal Protective Equipment (PPE) for 1 (Residents 36) of 4 residents reviewed and 1 supplemental (Resident 16) resident reviewed, properly store resident urinals for 2 (Residents 46 & 57) of 3 residents reviewed, and maintain clean resident equipment for 1 (Resident 29). These failures placed residents at risk for the development and transmission of communicable disease and infections. Findings included . <Facility Policy> Review of the facility's May 2015 Transmission-Based Precautions (Isolation) policy showed Transmission-Based Precautions (TBP) were used for caring for residents who were documented or suspected to have communicable diseases or infections that could be transmitted to others. This policy showed contact precautions 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 provide the Specialized Rehabilitative Services of Physical Therapy, (PT) , that 14 ( Residents 53, 15, 59, 7, 26, 12, 51, 45, 43, 35, 1, 36, 63, 10, ) of 22 residents reviewed for therapy services were assessed to require. Failure to provide PT placed residents at risk for decline in physical and functional mobility, deterioration of muscle strength, delay of discharge, non payment of Skilled Nursing Facility stay by their insurance companies, and diminished quality of life. Findings included Resident 53 Resident 53 was admitted [DATE] for skilled services. Review of 09/19/2023 Hospital Therapy Notes showed Resident 53 required mobility/transfer training, strengthening, and adaptive equipment. Prior functional status showed Resident 53 was independent with ADL and mobility, used a cane to go outside, and a recent fall. Review of Physician Orders (PO) dated 09/19/2023 showed PT orders for evaluation and treatment. Review of 09/24/2023 admission MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal regulatory requirements. The Administration failed to ensure residents received the Specialized Rehabilitation Services they were assessed to require, failed to ensure the facility could meet the needs of the resident population by not admitting residents with Specialized Rehabilitation Services needs and/or retaining residents whose needs the facility could not meet. In addition, the Administration failed to provide administrative oversight and monitoring of facility personnel, systems, practices, and policies related to infection control. These failures of Administration placed residents at risk of unmet needs, decline in function, diminished quality of life/quality of care, isolation and infections. Findings included . FACILITY ASSESSMENT Review of the Facility Assessment August 2023, showed the facility is 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to ensure infection control interventions, intended to mitigate the risk of COVID-19 were consistently implemented for 32 (Residents 31, 10, 26, 29, 32, 52, 62, 56, 24, 9, 54, 28, 37, 57, 18, 53, 60, 2, 3, 45, 42, 47, 6, 39, 11, 48, 13, 61, 49, 17, 44 & 43) of 36 sampled residents. The facility failed ensure timely implementation of transmission based precautions. The facility failed to ensure N95 Fit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered Care Plans (CP) for 6 (Residents 10, 13, 19, 39, 45 & 32) of 16 residents reviewed for COVID-19 Care Plans. Failure to develop comprehensive CPs for refusal to comply with infection control procedures (Resident 10, 13, 19, 39 & 45), or potential psychological adjustment to restrictions (Resident 13) left residents at risk for unmet care needs, and negative health outcomes. Findings included . During an interview on 10/27/2023 at 10:47 AM, Staff C, Registered Nurse (RN), Infection Preventionist (IP) stated that as a nurse, they never used PCC (Point Click Care), the facility's electronic medical records system before, so Staff B, Interim Director of Nursing entered the COVID-19 care plans. During an interview on 10/27/2023 at 12:14 PM, Staff B, stated the residents had COVID-19 care plans. <Resident 10> During an interview on 10/27/2023 at 9:55 AM, Staff B, stated that Resident 10 refused to be tested for COVID-19, but was in a COVID-19 positive room. Review of 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.

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information including the total number of and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and the number of current residents residing in the facility. The failure to post required nurse staffing information daily and failure to retain the daily posted documents for a minimum of 18 months. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility. Findings included . Upon entering the facility on 10/27/2023 at 9:30 AM, and 11/03/2023 at 10:20 AM, the investigators were unable to located the posted Nurse Staffing information. During an interview on 10/27/2023 at 10:12 AM, Staff B, Director of Nursing, stated they had not posted the nursing staffing levels. During an interview on 10/27/2023 at 3:28 PM, Staff A, Administrator, stated they did not post the staffing levels. During an interview on 11/03/2023 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a Quality Assurance and Performance Improvement program (QAPI) that identified deficiencies and implemented appropriate preventative or corrective actions. The facility's QAPI program failed to timely recognize noncompliance with facility systems that resulted in deficiencies in Rehabilitation Services, placing residents at risk of unmet care needs. Findings included . Review of the Facility Assessment August 2023, showed the facility had a QAPI program to ensure continuous quality review/improvement as needed related to multiple areas, including staffing, competencies and services provided. Areas for improvement or needed action are identified through grievance refuse, quality outcomes data tracking and review. The facility partners with contracted rehab for their rehabilitation servcies which provide adequate staffing levels to meet the needs of those needing therapy services in the facility. During an interview on 11/03/2023 at 1:39 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure notification of room change was consistently provided prior to room changes for 4 of 4 residents (Resident 26, 17, 3 & 35) reviewed. This failure created confusion and anxiety and placed residents at risk for a diminished quality of life when decisions were made without their input. Findings included . Resident 26 According to the 08/28/2020 admission Minimum Data Set (MDS- an assessment tool), Resident 26 was admitted to the facility on [DATE] and had complex medical diagnoses including a brain condition evidenced by confusion and dysfunction. The assessment showed Resident 26 had moderate cognitive impairment. In an interview on 01/31/2023 at 9:55 AM, Resident 26 stated, I started in room [ROOM NUMBER] and have been moved to this room [room [ROOM NUMBER]] and I don't know why they moved me . while shaking their head in disbelief. Resident 26 stated they had multiple room changes since their admission. Resident 26 was worried about receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a system that ensured residents who were transferred to the hospital or went on therapeutic leave were provided a written notice of bed hold that specified the duration of the bed-hold policy upon transfer or attempted to contact the resident and/or resident representative within 24 hours from an emergency transfer for 5 of 7 sampled residents (Resident 35, 37, 41, 18 & 5) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Facility Policy The updated October 2019 Bed Hold policy outlined whether or not the resident or responsible party chose to secure a bed hold, the information on the Bed Hold Agreement (BHA) is filled out and signed. The policy showed if nursing staff were unable to provide notification at the time of resident transfer or discharge, the Social Services Director or designee should contact 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 nursing services were provided within professional standards of nursing for 6 of 17 (Residents 28, 5, 30, 37, 15 & 35) residents reviewed. Nursing staff failed to follow physician orders (Residents 28), signed for tasks not performed (Residents 5 & 30), clarify physician orders (Residents 37 & 15), and notify a physician of elevated blood sugar levels according to order parameters (Resident 35). These failures placed the residents at risk for medication and treatment errors, and adverse outcomes. Findings included . According to a 01/2021 facility Medication Administration General Guidelines policy staff were directed to review and confirm medication orders for each individual resident prior to administration of medications. This policy stated medications were to be administered in accordance with written orders of the prescriber and if necessary, the nurse contacts the prescriber for clarification. Follow Physician Orders 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 3 (Residents 28, 3, & 10) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic drugs. Failure to attempt Gradual Dose Reductions (GDRs) for the administration of psychotropic medications. placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings included . According to a revised October 2022 Psychotropic Drugs facility policy, residents with orders for psychotropic medications (any drug affecting brain activity associated with mental processes and behaviors) were evaluated and appropriate interventions implemented. This policy stated a Gradual Dose Reduction (GDR) consisted of tapering a resident's daily dose of a psychotropic drug to determine if the resident's symptoms could be controlled by a lower dose or to determine if the medication could be eliminated altogether. A GDR was attempted in two separate quarters with at least one month between attempts within 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 establish and maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: followed the instructions as written on signs posted on resident doors requiring staff to wear Personal Protective Equipment (PPE) for 3 (Residents 37, 10, & 36) of 7 residents in accordance with the Centers for Disease Control (CDC) recommendations, cleaned equipment used for 2 (Resident 17 & 3) of 5 residents, and performed hand hygiene and changed gloves while providing care for 3 (Residents 9, 25, & 35) of 16 residents. These failures placed residents at risk for the development and transmission of communicable disease and infections. Findings included . The facility's revised January 2023 Infection Control Policies and Practices [ICPP] policy showed the ICPP was established to maintain and provide a safe, sanitary, and comfortable environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to notify 3 (Residents 3, 24, & 26) of 4 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. Findings included . Record review of the facility's Trust - Current Account Balance report showed, as of 02/01/2023, the following trust account balances: Resident 3 was $85,754.36; Resident 24 was $5,853.96; and Resident 26 was $2,843.59. These were over the resource limit beneficiaries could possess. In an interview on 02/06/2023 at 1:40 PM, Staff BB (Business office manager) stated they were unable to recall if they gave notification to Resident 3 or Resident 26 and stated they did not give notification to Resident 24 when their balances reached or exceeded the resource limit. Documentation of notification was requested for the identified residents, nothing further was provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 2 (Residents 37 and 36) of 16 residents reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed. Findings included . Resident 37 According to the 11/23/2022 admission Minimum Data Set (MDS - an assessment tool) Resident 37 admitted to the facility on [DATE], was cognitively intact, and able to make themselves understood and understood others. Review of Resident 37's record showed no AD documentation. In an interview on 02/02/2023 at 9:17 AM, Resident 37 stated no one from the facility spoke with them about formulating an AD. In an interview on 02/06/2023 at 11:12 AM, 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 interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable.) as required for 1 (Resident 450) of 3 residents, reviewed for SNF ABN, whose Medicare stay ended. This failure placed residents at risk for not having adequate information to make care and financial decisions during their continued stay. Findings included . According to the 09/13/2022 Significant Change Minimum Data Set (MDS - and assessment tool) Resident 450 admitted to the facility on [DATE] with Medicare Part A as the payment source. Record review showed Resident 450's last covered day on Medicaid Part A was 08/27/2022, and they received a Notice of Medicare Non-Coverage (NOMNC) on 08/24/2022. Review of the resident's record showed no documentation to demonstrate Resident 450 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 develop comprehensive Care Plans (CP) for 3 (Resident 41, 3 and 37) of 17 sampled residents whose comprehensive CPs were reviewed. Failure to establish individualized CPs with identified goals that accurately reflected the resident's condition, placed residents at risk for unmet care needs. Findings included . Resident 41 According to a 01/02/2023 Comprehensive Minimum Data Set (MDS - an assessment tool), Resident 41 received anticoagulant (blood thinner) injections. Resident 41 was assessed to have no memory impairment. Review of a 12/27/2022 Physician Order (PO) showed Resident 41 received an anticoagulant injection twice daily. Review of Resident 41's 01/31/2023 revised CP showed Resident 41 did not have a CP for anticoagulant medication, interventions, or goals associated with the medication, and possible complications related to use of the anticoagulant. During an interview on 01/31/2023 at 10:45 AM, Resident 41 stated they thought…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were reviewed and revised for 4 (Resident 5, 30, 15, & 7) of 17 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs. Findings included . Resident 5 In an interview on 01/31/2023 at 12:26 PM, Staff O (Certified Nursing Assistant - CNA) stated they obtained information regarding Resident 5's care from the resident's CPs. Review of a self-care performance CP showed a revised 07/14/2020 intervention directing staff to place a palm guard to Resident 5's left hand contracture (fixed tightening of muscle, tendon or ligaments preventing normal movement of the body part) every morning and to take off at night as the resident allowed. Observations on 01/31/2023 at 10:23 AM, 02/02/2023 at 11:23 AM, and 02/03/2023 at 12:41 PM showed Resident 5 did not have a palm guard on their left hand. In an interview on 02/06/2023 at 2:40 PM, Staff C (Resident Care Manager) stated Resident 5 no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative program was developed and initiated for 2 of 5 residents (Resident 3 & 18) identified by staff with mobility limitation and reviewed for Range of Motion (ROM). These failures placed residents at risk for decline in ROM, a reduction in mobility, increased dependence on staff, and decreased quality of life. Findings included . Facility Policy The updated March 2019 Restorative Program policy showed the facility provided restorative programs that promoted a resident's ability to adapt and adjust to living as independently and safely as possible. The policy showed residents identified and evaluated with needs and limitations upon admission appropriate for a restorative program were provided a restorative Care Plan (CP) with individualized, measurable goals and interventions. The policy identified the Director of Nursing (DNS) had the overall responsibility for the restorative program. Resident 3 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 and interview, the facility failed to ensure expired medications, liquid feeding supplement, medical supplies, and intravenous (IV) solution were disposed of timely for 1 of 1 central supply/medication room, 2 of 4 medication carts, and 1 of 1 Automated Medication Dispensing (AMD) system reviewed for medication storage. The facility failed to secure resident medications safely for 2 residents (Resident 20 & 37) and failed to label multi-dose medications with the open date for 3 residents (Resident 6, 37 & 299) in accordance with current accepted professional standards of practice. These failures placed residents at risk for accidental ingestion of medications, receiving medications with decreased or no potency, and use of medical supplies with compromised integrity. Findings included . Facility Policies The undated Medication Storage policy directed staff to write the date on the label for diabetic medication vials and pens (a medication that regulates the body's blood sugar level) when first used. The policy showed outdated medications were immediately removed…

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

Based on observation, interview, and record review, the facility failed to provide food that accommodated resident's identified food preferences and/or intolerances for 2 of 7 sampled residents (Residents 5 & 3) and 2 supplemental residents (Resident 20 & 16) reviewed for food preferences. The failure to provide food that met the resident's individual needs and preferences, placed residents at risk for weight loss and diminished quality of life. Findings included . Resident 5 Observations on 01/31/2023 at 12:29 PM showed Resident 5 was served a lunch tray by Staff FF (Certified Nursing Assistant). Staff FF described what food was on the tray to the resident. Resident 5 told staff they were not crazy about spaghetti, peas, or carrots, and stated, I'll eat it because I'm hungry. Staff FF started assisting Resident 5 to eat the spaghetti. Review of Resident 5's meal tray ticket showed Resident 5 had dislikes including spaghetti. Resident 20 Observations on 02/03/2023 at 12:53 PM showed staff coming out of Resident 20's room with an untouched lunch tray. On the tray was chicken, steamed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a Physician Order (PO) for hospice care, and to ensure the development of a coordinated Care Plan (CP) for 1 of 2 residents (Resident 15) reviewed for hospice care services. These failures placed the resident at risk for not receiving necessary hospice services, lack of continuity of care, and unmet care needs. Findings included . Facility Policy The September 2017 Hospice - Provision of Care by Outside Providers policy showed the facility collaborated with outside providers to coordinate the provision of hospice care services as directed by the resident's physician. The hospice and the facility should communicate, establish, and agree upon a coordinated CP based on the evaluation of the resident's individual needs. The policy showed hospice services should establish the CP that pertained to the resident's terminal illness, related conditions, directives for management of pain, and other uncomfortable symptoms. The policy stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 (Residents 37 & 10) of 5 residents reviewed for vaccinations, were offered the recommended Pneumonia vaccinations in accordance with the Centers for Disease Control (CDC) guidelines. This failure placed residents at risk for contracting pneumonia, with the associated complications of infection. Findings included . Review of the CDC Recommended Adult Immunization Schedule showed a person 65 or older should receive one dose of the Pneumococcal Polysaccharide 23 (PPSV23). If the PPSV23 was administered prior to age [AGE], administer one dose of PPSV23 at least five years after the previous dose. A person 65 years or older should receive one dose of the Pneumococcal conjugate 13 (PCV13) if previously not administered. The CDC recommended PCV15 or PCV20 for adults 19 through [AGE] years old with certain medical conditions or risk factors and should be given at least one year after the most recent PPSV23. Resident 37 Resident 37 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.