Bethany At Pacific

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 44) reviewed for use and care of a catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. This failure placed residents at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications.Findings included . Review of the facility policy titled, Catheter Care, reviewed 03/2026 documented the facility would ensure residents with indwelling catheters received appropriate catheter care. Resident 44 admitted to the facility on [DATE] with diagnoses to include acute prostatitis (severe bacterial infection in the prostate gland) and urine retention (inability to completely empty the bladder).Review of Resident 44's care plan, dated 04/29/2026, documented they had a catheter related to urinary retention with the goal for them not to have any catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 1 of 1 resident (Resident 55) reviewed for respiratory care received their physician ordered Continuous Positive Airway Pressure machine (CPAP -a machine that sends a steady flow of pressurized air into the nose and mouth to keep the airways open and helps you breath normally while sleeping). This failed practice placed the residents at risk of respiratory distress, lack of restful sleep and diminished quality of life.Findings included. According to facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) with revised date of 07/2025 documented, document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s).Resident 55 was admitted to the facility on [DATE] with diagnosis to include obstructive sleep apnea (disruption of breathing during sleep due to airway blockages).Review of Resident 55's physician orders documented CPAP to be on at bedtime and off in the morning, 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 provide medically related social services and to advocate for 1 of 4 cognitively impaired residents (Resident 81) reviewed for advanced directives. The facility failed to advocate and educate the resident of legal options for an advanced directive and failed to identify other family that may be an alternative decision maker per state law which placed the resident at risk of not having their rights and wishes honored.Findings included.Resident 81 admitted to the facility on [DATE] with diagnoses to include fall with wedge compression fracture (spinal break where the front part the vertebrae collapse while the back remains intact) of the upper/middle back.Review of Resident 81's care plan dated 05/08/2026 documented they were primary language was Mandarin.Review of Resident 81's admission documents dated 05/01/2026, to include advanced directive options/information, showed they were all signed by their Collateral Contact 4 (CC 4) as 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 speech therapy services were provided for 1 of 2 residents (Resident 91) reviewed for specialized rehabilitative services. This failure prevented residents from attaining and maintaining their highest practicable level of physical, functional and psycho-social well-being.Findings included.Resident 91 was admitted to the facility on [DATE] with diagnoses to include stroke. According to the admission Minimum Data Set (an assessment tool) dated 05/14/2026, the resident had intact cognition.In an interview on 05/12/2026 at 9:52 AM, Resident 91 stated they had not seen a speech therapist since they were admitted to the facility. According to the resident, they had to wait for the speech therapist to evaluate them first before they could upgrade the diet texture of their meals.Review of Resident 91's orders documented Speech Therapy evaluation and treatment for swallow and cognitive evaluation, order date 05/07/2026.Review of Resident 91's therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordinate Home Health (HH) services, provide a medication list, and complete discharge instructions for 1 of 3 sampled residents (Resident 1) reviewed for discharges. Failure to arrange HH services and provide a medication list placed residents at risk of unmet care needs, and diminished quality of life. Findings included . Review of a facility policy titled DISCHARGE OF A RESIDENT, last reviewed on January 25th, 2025, showed: Discharge to lesser level of care (home/ALF/AFH) 3. Nurse manager and social services will complete Discharge Instruction Form in PCC to include: any follow up appointments, pharmacy to pick up prescriptions, DME ordered, HH services ordered, any special instructions for the patient after discharge and a summary of their stay. Additionally, a complete list of their medications will be provided. -On the day of the patient's discharge: a. Discharge Instruction Form and completed medication list will be reviewed by a licensed nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to ensure medically related social services were provided for 8 of 8 residents (Residents 20, 28, 39, 277, 278, 324, 325, and 329) reviewed for social services. The facility failed to ensure residents received support with care planning process (Residents 28, 39, 325, and 329), failed to ensure residents were provided support to formulate their advanced directive options (Residents 325, and 329), failed to ensure residents received support with discharge planning (Residents 277, and 278), and failed to ensure referrals and recommendations for appropriate mental health services were completed (Residents 20 and 324). This failure placed residents at risk of unmet social service needs, unsafe care, psychosocial decline, and a diminished quality of life. Findings included . <RESIDENT 20> Resident 20 admitted to the facility on [DATE] with diagnoses that included depression, and insomnia. The admission Minimum Data Set (MDS- an assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences (a collaborative care plan meeting where a resident's care is discussed and coordinated by a team of health care providers, family members and residents) for 2 of 6 sampled residents (Residents 325 and 329) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included . Review of the facility policy titled, Care Planning-Resident Participation, revised date January 2025, documented the facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including initial decisions about treatment .The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 3 of 24 residents (Residents 325, 329 and 55), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility policy titled, Advance Directive Policy and Procedure, dated 2017, showed the Social Services, at the time of admission, will ask if there are any current Advance Directives. If so, copies will be obtained and placed in the resident's chart under the admission tab and scanned into PC documents. <RESIDENT 325> Resident 325…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed in writing of their potential liability for payment related to Medicare services ending for 1 of 3 sampled residents (Resident 45) reviewed for Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). This failure placed the residents at risk of not having adequate information to make care and financial decisions during their continued stay. Findings included . Resident 45 was admitted to the facility and was receiving skilled services under their Medicare Part A benefit. Review of the most recent Minimum Data Set assessment (a required assessment tool) dated 03/09/2025 (end of Med A stay) showed the resident had mild cognitive impairment. The resident record showed they had an Advance Directive in place designating Collateral Contact 5 (CC5) as their representative. Review of Resident 45's record documented a Notice of Medicare Non-Coverage (NOMNC) was communicated by phone to CC5 on 03/07/2025, which informed the resident and the representative that skilled nursing services would end…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 2 of 3 resident council's (February and March 2025), who verbalized complaints during a Resident Council (RC) meeting and failed to follow the grievance process for 2 of 2 residents (Resident 12 and 35) who voiced grievances. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings Included . Review of the facility policy titled Resident and Family Grievances dated October 2024 showed the social services director was designated as the Grievance Official and was responsible for overseeing the grievance process. The grievance procedure showed staff members who received the grievance would record the nature and specifics of the grievance on the designated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that potential restraints were appropriately assessed for safety, consented, and care planned for 1 of 2 residents (Resident 28) reviewed for physical restraints. This failure placed residents at risk for unidentified risks and care needs, and for a diminished quality of life. Findings included . Review of the facility policy titled, Restraint Free Environment, reviewed 04/2025 a physical restraint refers to any manual methods of physical or mechanical device, mater, or equipment attach or adjacent to the the residents body that the individual cannot remove which restricts freedom of movement .facility was responsible for the appropriateness of the physical restraint . medical symptoms warranting the use of restraints should be documented in the medical record . care plan updated accordingly to include development and implementation of interventions. Resident 28 admitted to the facility on [DATE], they have diagnoses that include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review the facility failed to identify and report an allegation of abuse and/or neglect for 3 of 5 sampled residents (Residents 28, 54, and 276) when reviewed for abuse/neglect. This failure placed the residents at risk of further abuse, psychological distress, and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect, and Exploitation, reviewed 05/01/2024 stated will develop and implement policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident's property staff will be able to identify different types of abuse an immediate investigation will be completed when there is suspicion of any type of abuse and or neglect all allegations will be reported immediately, but not later than two hours. <RESIDENT 28> Resident 28 admitted to the facility on [DATE], diagnoses that include Alzheimer's, and cognitive communication deficit. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct a thorough investigation for 3 of 5 resident investigations (Resident 28, 44 and 54) reviewed for accidents and allegations of potential abuse and/or neglect. The facility failed to identify the root cause, and all contributing factors related to allegations of abuse and/or neglect placed residents at risk for injury, and additional abuse/neglect. Findings included . Review of the facility policy titled, Abuse, Neglect, and Exploitation, reviewed 05/01/2024, stated the facility will investigate and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .provide complete and thorough documentation of the investigations .provide emotional support and counselling to the resident during and after the investigation. <RESIDENT 44> Resident 44 admitted to the facility on [DATE] with diagnoses to include fracture of surgical neck of left humerus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident 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) Level I was completed for 1 of 5 residents (Resident 324), reviewed for PASARR screening. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, Resident assessment-Coordination with PASARR program, reviewed in October 2024, showed that all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. PASARR level I-initial pre-screening that is completed prior to admission .The facility will only admit individuals with a mental disorder or intellectual disability who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASRR) assessments were completed for residents following significant change in status or with newly evident or possible serious mental disorders for 1 of 5 residents (Resident 55) reviewed. This failure resulted in a potential delay in access to level 2 PASSR services and decreased quality of life. Findings include . PASSR - a federally required screening of all individuals who has both an intellectual disability or related condition and a serious mental illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition. According to the facility policy titled Resident Assessment- Coordination with PASSR Program review date 10/2024 documented: Any resident who exhibits a newly evident or possible serious mental disorder will be referred promptly to the state mental health or a level II resident review. Examples include: A resident who exhibits behavioral,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice were implemented for 3 or 3 residents (Residents 278, 328, and 329) reviewed for oxygen therapy. Failure to obtain a doctor's order prior to administering oxygen placed residents at risk for potential adverse outcomes. Findings include . Review of the facility policy titled Oxygen Administration, review date 10/2024 documented: Oxygen is administered under orders of a physician, change oxygen tubing and mask/cannula weekly and as needed. <RESIDENT 278> Resident 278 was admitted to the facility on [DATE] with admitting diagnoses to include Chronic Obstructive Pulmonary Disease (COPD - a type of progressive lung disease). According to the admission Minimum Date Set (MDS - an assessment tool) assessment dated [DATE], the resident had moderately impaired cognition and was on oxygen therapy. In an observation on 04/15/2025 at 2:05 PM, Resident 278's oxygen tubing was on the floor under the left side 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 interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 20) reviewed for mood and behavior. The facility failed to ensure a psychiatric evaluation was reviewed, and implementation of mental health recommendations for treatment of depression. These failures placed the residents at risk for declining their mental health and diminished quality of life. Findings included . Resident 20 admitted to the facility on [DATE] with diagnoses that included depression, and insomnia. The admission Minimum Data Set (MDS- an assessment tool) dated 03/04/2025 showed the resident had moderately impaired cognition, with moderate depression. Review of Resident 20's care plan showed a focus area dated 03/04/2025 that the resident had a behavior problem of refusal of care related to their depression and anxiety. Interventions included administering medications as ordered and documenting effectiveness. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative therapy services (a personalized training program to help people maintain or regain their ability to do everyday tasks, like walking, dressing, and eating) were implemented to prevent avoidable reduction of range of motion (ROM, how far you can move a joint in any direction) for 1 of 1 residents (Resident 35), reviewed for restorative therapy and limited ROM. This failure placed residents at risk for loss of ROM, deconditioning, and loss of independence. Findings included . Review of the facility policy titled, Restorative Nursing Programs dated 07/01/2024 showed the interdisciplinary team, with the support and guidance from the physician, would assure ongoing review, evaluation, and decision making regarding the services needed to maintain or improve a resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. Resident 35 admitted to the facility on [DATE] with diagnoses to include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety interventions were developed and implemented for 2 of 3 residents (Resident 234 and 328) who had dysphasia (difficulty swallowing) and were at risk for aspiration (inhalation of food). This failure placed residents at risk for aspiration, increased health complications and a diminished quality of life. Findings Included . Review of the facility policy titled, Refusal of Medications, and Treatment Refusal or Non-compliance with Care, dated 08/22/2011, showed: Documentation pertaining to a resident's refusal of treatment shall include each time the resident refused his or her treatment and resident's condition and any adverse effects due to such refusal. The date and time the physician was notified as well as the physician's response. All pertinent observations and the signature and title of the person recording data. Resident's legal representative must be notified of the resident's refusal. Referral must also 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 interviews and record reviews, the facility failed to ensure that 1 of 1 residents (Resident 35) who were incontinent of bladder and continent of bowel received appropriate treatment and services to restore continence to the extent possible. This failure placed residents at an increased risk of urinary tract infections, discomfort, loss of dignity, and decreased quality of life. Findings included . Resident 35 admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease (circulatory condition involving narrowing of the blood vessels), high blood pressure, and atrial fibrillation (rapid/irregular heartbeat). In an interview on 04/16/2025 at 9:54 AM Resident 35 stated they had been getting therapy and was able to use the toilet to have bowel movements, but was told the insurance would not cover anymore therapy and was moved to the third floor, at which time they were told there was no bathroom, and they would need to use their brief to urinate and defecate. In a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 5 residents (Resident 55) reviewed for unnecessary medication were free from unnecessary psychotropic medications (drugs that affect mental processes, emotions and behaviors). The facility failed to ensure valid diagnosis for the use of psychotropic medication, they failed to obtain consent for the antidepressant medication and failed to monitor for any adverse side effects (ASE) for the psychotropic medications. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse side effects and diminished quality of life. Findings include . According to the FDA Boxed Warning: Elderly patients with dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities)-related psychosis (symptoms that happen when a person is disconnected from reality) are at an increased risk of death. Seroquel or Quetiapine Fumarate is not approved for elderly with dementia related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment cart (containing prescribed topicals, ointments, and wound cleaning agents) was secured in a locked storage area and inaccessible to unauthorized staff and residents for 1 of 4 treatment carts (3 South Unit) observed for medication cart review. These failures placed residents at risk for unauthorized access to medications and treatments that should be securely stored. Findings included . Review of the facility policy titled, Storage of Medications, dated 01/2023, medications, and other biologicals are stored properly the supply shall be only accessible to licensed nursing personnel supplies should remain locked when not in use or unattended. In an observation on 04/18/2025 at 10:38 AM, the treatment cart on unit 3 South was observed to be unlocked, and no licensed staff around. The drawers were accessible to anyone that walked by, observed in some of the drawers was a tube of topical pain gel (that must be prescribed by a doctor), three 16 ounce bottles of Dakin's solution (a prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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> RESIDENT 422 Resident 422 admitted to the facility on [DATE]. In an observation/interview on 06/07/2024 at 7:43 AM, Staff M, Licensed Practical Nurse/Resident Care Manager, was observed performing wound care on Resident 422's left heel pressure injury and did not perform hand hygiene after removing their gloves and donning a new pair of gloves during the procedure. In an interview Staff M was unable to provide any information about their lack of hand hygiene. Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and national standards of practice for 1 of 1 resident (Resident 14) reviewed for transmission-based precautions (TBP) of a resident that had tested positive for Coronavirus Disease 2019 (COVID-19 -an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices. Findings included . Review of the facility policy titled, Infection Surveillance, revised 05/29/2024, The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. Review of the facility's Staff Key Personnel document, updated 06/05/2024, showed Staff C, Registered Nurse (RN), was designated Infection Preventionist (IP) with a date of hire as 05/06/2024. On 06/05/2024 at 9:14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, provide, and/or assist with completing Advance Directives for 4 of 5 sampled residents (Residents 22, 32, 62, and 65) reviewed for Advance Directives. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . <RESIDENT 32> Resident 32 was admitted to the facility on [DATE] with diagnoses including fall at home resulting in left tibia fracture, and infection at left tibia surgical site. Resident 32's profile information records showed they were self-responsible in making their own decisions. Review of Resident 32's current medical record on 06/05/2024 and 06/10/2024, showed no Advance Directives had been formulated. Review of the resident's medical record did not show documentation that the resident had been informed of their right to formulate an Advance Directive. In a joint interview on 06/07/2024 at 12:15 PM, with Staff A, Administrator, and Staff V, Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clean, comfortable, and homelike environment for 1 of 2 floors (3rd floor). The failure to ensure resident's floors were clean and free of debris, and utility and housekeeping rooms were secured left residents at risk for a diminished quality of life, and a less than homelike environment. Findings included . <UNSECURED MAINTENANCE AND HOUSEKEEPING EQUIPMENT> In an observation on 06/05/2024 at 11:01 AM, the maintenance room door and the housekeeping room doors near room [ROOM NUMBER] were unlocked and unsecured. The maintenance room had paint, caulk, tools, various equipment, television (TV) screens and other clutter were stored all over the room and floor. The housekeeping room had chemicals to include Aromazyne drain and grease trap maintenance odor eliminator that was labeled to keep out of reach of children. In an interview on 06/05/2024 at 11:14 AM, Staff U, Maintenance Assistant, stated those rooms were supposed to 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 interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and receive the services they need in those settings), was followed for 4 of 8 sampled residents (Resident 7, 42, 21 and 26). Failure to coordinate Resident 7, 42, 21, and 26 for Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) services as indicated placed residents at risk for not receiving care and services in the most integrated setting appropriate to their needs. Findings included . <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses including anxiety, depression, and bi-polar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs and preferences for 2 of 8 sample residents (Resident 32 and 6) reviewed for Level II PASRR (an in-depth evaluation to determine if a resident has a serious mental illness [SMI], Intellectual Disability [ID] or Related Condition [RC]and is completed by a representative from the state intellectual disability authority), 1 of 3 sampled residents (Resident 65) reviewed for discharge planning, 1 of 3 sampled residents (Resident 42) reviewed for emotion/behaviors, 1 of 3 sampled residents (Resident 26) reviewed for dental, and 1 of 3 sample residents (Resident 422) reviewed for accidents care plans. This failure placed residents at risk for not receiving needed and preferred care and services and a decreased quality of life. Findings include . <LEVEL II PASRR> RESIDENT 32 Resident 32 admitted to the facility on [DATE] with diagnoses to include depression 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 revise comprehensive care plans for 4 of 18 sampled residents (Residents 8, 21, 26 and 58), reviewed for care plan revision. The failure to revise care plans for hospice services, resident caregiver preference, edema management, and use of psychotropic medication placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <RESIDENT 8> Resident 8 admitted to the facility on [DATE] with diagnoses that included stroke, anxiety disorder and high blood pressure. Review of Resident 8's electronic medical record showed they were admitted to hospice services on 03/14/2024. Observation on 06/06/2024 at 9:09 AM, an oxygen (O2) concentrator (a medical device that provides pure O2) was located next Resident 8's bedside table. There was green O2 tubing laying on the floor. Review of hospice binder, located at the nurse's station, on 06/11/2024 at 8:40 AM, showed a facility/hospice care coordination-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist conducted thorough monthly medication regimen reviews (MRRs), identified and reported medication-related irregularities for 3 of 5 sampled residents (Resident 18, 21 and 26) reviewed. The failure to act on irregularities identified by the consulting pharmacist placed residents at risk for medication-related adverse consequences and for receiving unnecessary psychotropic medications. Findings included . Six months of the prior pharmacy consultant reviews were requested from the facility on 06/07/2024. The facility provided consultant pharmacy reviews for December 2023, January 2024, February 2024, and May of 2024. In an interview on 06/07/24 at 1:22 PM, Staff B, Registered Nurse (RN)/Director of Nursing Services, stated they did not have March 2024 or April 2024 pharmacy reviews. Staff B stated the consultant pharmacist changed and no pharmacy reviews had been done for March or April. On 06/12/2024 at 10:00 AM, Staff B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, and interview, the facility failed to ensure 3 of 3 Certified Nursing Assistants (NACs) (Staff G, H and I) reviewed for training, had the required 12 hours per year of in-services. This failure placed residents at risk of less than competent care and services from staff. Findings included . Review of Staff G, NAC's, employee file showed their date of hire was 05/19/2019. Review of the in-service education provided did not show evidence of the required 12 hours of in-service education for the prior year. Review of Staff H, NAC's, employee file showed their date of hire was 03/10/2020. Review of the in-service education provided did not show evidence of the required 12 hours of in-service education for the prior year. Review of Staff I, NAC's, employee file showed their date of hire was 12/03/2022. Review of the in-service education provided did not show evidence of the required 12 hours of in-service education for the prior year. In an interview on 06/10/2024 at 8:02 AM, Staff B, Director of Nursing Services stated the education logs from their computer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident was evaluated, assessed and a physician order was obtained for safe administration of medications for 1 of 1 resident (Resident 46) reviewed for clinically appropriate self-administration of medications. This failed practice placed the resident at risk for adverse medication interactions, complications, and a diminished quality of life. Findings included . Review of the facility policy titled Medication Administration Self-Administration by Resident: Self-Administration by Resident, dated 11/2017, showed: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. Resident 46 admitted on [DATE]. According to the admission Minimum Data Set Assessment (an assessment tool) dated 05/05/2024, the resident had 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 complete accurate assessments for 1 of 3 sampled residents (Resident 58) reviewed for dental concerns, and 2 of 8 sampled residents (Resident 6 and 32 ), reviewed for Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability [ID] or Related Condition [RC] and a serious mental illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition). These failures placed residents at risk for unmet care needs. Findings included . <DENTAL> Resident 58 admitted to the facility on [DATE] with diagnoses that included kidney failure, urinary tract infection, and atrial fibrillation (an irregular heart rate). Review of Resident 58's Minimum Data Set (MDS-an assessment tool) assessment, dated 05/02/2024, showed they did not have any missing or broken teeth, abnormal mouth tissue, obvious or likely cavities, no teeth,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals identified with an Intellectual Disability [ID] or Related Condition [RC] or a serious mental illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed according to the guidelines specified for 3 of 8 sampled residents (Residents 2, 6 and 32) reviewed for unnecessary medications. Incomplete or inaccurate PASRRs placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified serious mental health indicators or intellectual disability. Findings included . Review of Washington State's exempted hospital requirement (42 CFR 483.106(b)(2)(ii)), showed if an individual who entered a nursing facility as an exception (an exempted hospital discharge) was later found to require more than 30 days of nursing 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 observation, interview, and record review the facility failed to ensure 1 of 2 sampled residents (Resident 30) reviewed for Pressure Ulcers (PU) were provided care planned interventions they required for the prevention or worsening of PU. This failure to implement pressure reducing devices in accordance with physician's orders placed residents at risk for PU development, worsening of PU, pain, and a diminished quality of life. Findings included . Resident 30 admitted to the facility on [DATE] with diagnoses that included stroke, high blood pressure, spinal stenosis (the spaces inside the backbones of the spine get too small), and right rotator cuff tear (injury to the group of muscles and tendons that hold the shoulder joint in place). In a review of Resident 30's Care Area Assessment (CAA- a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), dated 11/10/2023, showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received the necessary services to maintain their level of functioning and/or prevent decline for 2 of 2 sample residents (Residents 14 and 26) reviewed for limited range of motion. This failure placed the residents at risk for decreased ROM and diminished quality of life. Findings included . Review of the facility policy titled, Restorative Nursing Programs, dated 05/01/2024, showed the interdisciplinary team would assure the ongoing review, evaluation, and decision-making regarding the services needed to maintain or improve the residents' abilities in accordance with their comprehensive assessment, goals and preferences. The policy also indicated the restorative nursing plan would include the frequency of the restorative activities. The policy indicated the restorative nurse would provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate 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 interviews and record review, the facility failed to obtain needed services from an outside entity for 1 of 2 sampled resident's (Resident 26) reviewed for medically related social services. The facility failed to coordinate and schedule a dermatology appointment after a referral was made for Resident 26 which placed residents at risk for unmet care needs and decrease in their mental, physical, and psychosocial wellbeing. Findings included . Resident 26 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), depression, and cancer. In an interview on 06/05/2024 at 10:28 AM, Resident 26 stated they wanted a second opinion about the rash on his legs. Resident 26 stated the rash on their legs itched and the nurse practitioner had told them that they could not be seen by a skin specialist. In a review of Resident 26's progress note, dated 01/18/2024, showed they had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a written notice to the resident, resident's representative(s), and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 3 of 5 residents' (Resident's1, 2, and 3) reviewed for hospitalizations. This failure did not afford residents and/or their representatives to make informed decisions about transfers and prohibited access to an advocate who could inform the resident/representative of their options and rights. Findings included . Review of facility policy titled, Transfer and Discharge, revised on 05/01/2024, showed It is the policy of this facility to permit each resident to remain in the facility, and not initiated transfer or discharge for the resident from the facility, except in limited circumstances. The policy showed Emergency Transfers/Discharges are initiated by the facility for medical reasons to an acute care setting such as hospital, for the immediate safety and welfare of a resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a bed hold notice in writing at the time of a resident transfer to the hospital or within 24 hours of transfer to the hospital for 3 of 5 residents (Residents 1, 2, and 3) reviewed for hospitalizations. This failed practice placed residents or their representative at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings included . Review of the facility's policy titled, Bed Hold Policy, dated 05/01/2024, stated the facility will provide written information to the resident and/or representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. <RESIDENT 1> A review of Resident 1's hospital admission information showed the resident discharged from facility to the hospital on [DATE]. <RESIDENT 2> A review of Resident 2's current nursing progress notes and admission/discharge history, showed the resident discharged from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, and interview, the facility failed to complete and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 1 of 5 residents (Resident 1) whose Minimum Data Set (MDS - an assessment tool) assessments were reviewed for timeliness in transmission/submission. The facility's lack of an effective system in ensuring the MDS assessments and tracking records are completed and transmitted timely as required placed all residents of the facility at risk for unmet care needs and diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses that included altered mental status, dementia, anxiety, and Chronic Obstructive Pulmonary Disease (lung disease). Review of the MDS tracking record on 05/15/2024 at 12:45 PM, showed an Entry or Discharge MDS assessment had not been completed for Resident 1. In an interview on 05/15/2024 at 2:35 PM, Staff D, Licensed Practical Nurse (LPN)/admission Nurse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a homelike environment in resident rooms for 2 of 3 sampled residents (Resident 4, and 7) reviewed. The failure to have functioning lights over the sinks in resident rooms and to ensure the soap dispenser had soap placed residents at risk for diminished quality of life. Findings included . <RESIDENT 4> Resident 4 admitted to the facility on [DATE]. In a phone interview on 04/16/2024 at 2:43 PM, Resident 4 stated the room they had stayed in at the facility was not maintained in a clean condition and there were lights in the room that did not work. <RESIDENT 7> Resident 7 admitted to the facility on [DATE]. In an observation/interview on 04/17/2024 at 11:50 AM, Resident 7 stated the light over the sink was not working and they had notified staff who had not responded yet. Resident 7 stated the soap dispenser by the sink was empty and it had been like that, and they had notified staff, but they never refilled it. In an 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 Based on observation, interview, and record review, the facility failed to resolve resident grievances for 1 of 2 sampled residents (Resident 2) reviewed for grievances. The failure to resolve resident grievances placed residents at risk for ongoing unmet care needs, missed activities, and unresolved missing property. Findings included . Review of the facility policy titled, Resident and Family Grievances, dated 07/01/2023, showed: -Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. -A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished . -Grievances may be voiced verbally, written, by telephone by the Ombudsman programs, and by verbal complaint of the resident. -The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for 2 of 4 sampled residents (Residents 1 and 2) reviewed. The failure to obtain necessary physician progress notes and orders, and to revise the resident's medications accordingly, and to provide necessary transfer assistance placed residents at risk for unmet care needs, adverse medication-related outcomes, missed activities, and for diminished quality of life. Findings included . <RESIDENT 1> Resident 1 resided in the facility from [DATE] - 02/26/2024. The resident had diagnoses to include a stroke, heart failure, pneumonia, and breathing difficulties. Review of a nursing progress note, dated 02/21/2024, showed Resident 1 had an appointment with their physician that day. On 04/17/2024 a review of Resident 1's clinical record showed there were no physician progress notes found for their 02/21/2024 doctor appointment. In an interview on 04/17/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and file clinical laboratory reports for 1 of 1 sampled resident (Resident 1) reviewed for lab results. The failure to ensure resident's laboratory results were filed in the resident's clinical record placed them at risk for unmet care needs. Findings included . Resident 1 resided in the facility from [DATE] - 02/26/2024. Review of Resident 1's nursing progress note, dated 02/21/2024 at 7:29 PM, showed Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager, authored a note that indicated the resident had a doctor appointment that day and two lab tests were done. On 04/17/2024, Resident 1's clinical record was reviewed. There were no laboratory results filed in the resident's clinical record from their doctor appointment on 02/21/2024. In an interview on 04/17/2024 at 3:50 PM, Staff F and Staff C, LPN/Assistant Director of Nursing Services, were unable to provide any information about the lack of documentation in Resident 1's clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and file a radiology report for 1 of 1 sampled resident (Resident 1) reviewed for radiology results. The failure to ensure residents radiology results were filed in their clinical record placed them at risk for unmet care needs. Findings included . Resident 1 resided in the facility from [DATE] - 02/26/2024. Review of Resident 1's nursing progress note, dated 02/21/2024 at 7:29 PM, showed Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager, authored a note that indicated the resident had a doctor appointment that day and a chest X-Ray was done. A review of Resident 1's clinical record on 04/17/2024, showed no chest X-Ray report was filed in the resident's clinical record from their doctor appointment on 02/21/2024. In an interview on 04/17/2024 at 3:50 PM, Staff F and Staff C, LPN/Assistant Director of Nursing Services, were unable to provide any information about the lack of the results of the chest X-ray in the resident's clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete, accurate, and accessible clinical records for 3 of 4 sampled residents (Resident 1, 2, and 4) reviewed for care and services. The failure to maintain clinical records in accordance with professional standards of practice placed residents at risk for unmet care needs and diminished quality of life. Findings included . <RESIDENT 1> Resident 1 resided in the facility from [DATE] - 02/26/2024. The resident had diagnoses to include a stroke, heart failure, pneumonia, and breathing difficulties. A review of Resident 1's clinical record on 04/17/2024, showed there were no physician progress notes found for their doctor appointment on 02/21/2024. In an interview on 04/17/2024 at 2:47 PM, Staff C, Licensed Practical Nurse (LPN)/Assistant Director of Nursing Services (ADNS), and Staff J, Medical Records Director, stated they did not have the progress notes from Resident 1's doctor appointment on 02/21/2024. Staff J stated they would call 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.