Everett Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, were completed within the required timeframes and/or included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for nine of sixteen residents (Residents 13, 58, 66, 67, 71, 73, 78, 80, and 334) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed: A comprehensive admission minimum data set (MDS- assessment tool) assessment was required to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 1of 5 residents (Resident 13) reviewed for unnecessary medications and 1 of 6 months (November) reviewed for timely completion. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the facility policy titled, Medication Monitoring, Medication Regimen Review and Reporting, revised 01/2024 stated the MRR was a thorough evaluation of the medication regimen of the residents with a goal to promote positive outcomes and minimize adverse consequences and potential risks .the consultant pharmacist will conduct the MRR at least monthly to monitor the medication regimen and that the resident receives medications that are clinically indicated .a report would be available to the facility within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were removed when expired in 3 of 5 medication carts. The facility failed to monitor daily temperatures for 2 of 3 refrigerators that stored medications. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe physical or psychological dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. The facility failed to ensure 1 of 1 resident (Resident 78) was assessed for self-medication program. These failures placed residents at risk for receiving expired medications and vaccines, and potential for drug diversion from not securely locking controlled medications. Findings included . According to facility policy titled Medication Storage dated 01/2025 showed: - . Controlled substances stored in a refrigerator should be secured such as separately locked, permanently affixed compartment. - . The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system in which residents' records were complete, accurate, accessible, and systematically organized for 4 of 5 residents (Residents 40, 52, 71 and 78) reviewed for unnecessary medication. This failure included incomplete assessments, restorative care and incomplete documentation involving resident incidents. This placed residents at risk for unmet needs, condition deterioration, unrecognized changes in condition and adverse outcomes. Findings included . Review of a facility policy titled, Charting and Documentation, revised 02/24/2025, showed the purpose to provide a complete account of the patient's total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. -Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the patient's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignified existence was maintained for 1 of 1 sampled resident (Resident 58) reviewed for resident rights. The facility failed to ensure Resident 58's dignity, based on reasonable person as their roommate (Resident 29) watched and listened to pornography video (sexually explicit) on their laptop that could be overheard in the hallway. This failure placed all residents at risk for a diminished self-worth and a diminished quality of life. Findings included . According to Center for Medicare and Medicaid (CMS), document titled, Psychosocial Outcome Severity Guide, revised October 2022, states reasonable person concept was used to determine whether an individual's actions or responses align with what a hypothetical reasonable person would do under similar circumstances. It defines the behavior expected of an ordinary, prudent, and rational individual. Review of the facility policy titled, Resident Rights, revised on 02/01/2023 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 3 of 4 residents (Residents 47, 71 and 78), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, anxiety and a diminished quality of life. Findings included . Review of the facility's policy titled, Call Light Policy, dated 02/01/2023 showed that patients will always have a call light or alternative communication device within their reach, when unattended. Staff will respond to call lights and communication devices promptly to ensure safety and communication between staff and patients. <RESIDENT 71> Resident 71 admitted to the facility on [DATE] with diagnoses that included hemiplegia (unable to move one side of the body) affecting their left side, depression, anxiety and Post Traumatic Stress Disorder. In a joint interview on 03/11/2025 at 1:26 PM, Resident 71 and their spouse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 74> Resident 74 admitted to the facility on [DATE] with diagnoses to include mild cognitive impairment and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 74's Level 1 PASRR, dated 1/15/2025, showed the resident had a diagnosis of bipolar disorder (a mood disorder). Sections IIA, IIB, and III were blank, and the PASRR was not signed by a physician as required for hospital exemption. Section IV was marked; No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. A review of Resident 74's records on 3/12/2025 at 1:02 PM showed there was no referral for Level II PASRR, and the resident had admitted on [DATE], 38 days prior. In an interview on 03/13/2025 at 11:28 AM, Staff F, Social Services, stated that they were responsible for PASRR's and worked with admissions to ensure accuracy. While reviewing resident records, Staff F stated that they had not yet contacted 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 professional standards were met for 1 of 3 nurses (Staff G) observed for medication administration and 1 of 5 residents (Resident 334) reviewed for blood pressure parameters prior to medication administration. This failure place residents at risk for adverse effects, complications and potential for drug diversion. Findings included . According to the facility policy titled: Medication Administration, dated 01/2025, showed: - Medications are to be given at the time they are prepared. - The person who prepares the dose for administration is the person who administers the dose. - If a dose of regularly scheduled medication is refused the nurse shall document in the Electronic Medication Administration Record that the dose with refused and enter and explanatory note. <RESIDENT 38> Resident 38 admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus (a long term condition which body has trouble controlling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident was assisted by staff with activities as outlined in the care plan for 1 of 4 residents (Resident 43) reviewed for activities. This failed practice placed the resident at risk for isolation and decreased opportunities for a meaningful life in their areas of wellness. <Resident 43> Resident 43 was a long-term resident of the facility. According to the Minimum Data Set assessment dated [DATE], showed the resident was severely cognitively impaired and requires extensive assistance with daily activities. Record review of policy titled Recreation Services Policies and Procedures dated 08/07/2023 stated the purpose of the policy was 'to provide individuals with a wide variety of experiences that are available on a regularly scheduled basis consistent with their assessed life routines, preferences, interests, and personal engagement styles'. Review of a document titled, PASARR level II dated 2/24/2022, showed Resident 43…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess and ensure 1 of 1 resident (Resident 28) received the necessary care and services in accordance with professional standards of practice and maintained the highest practicable level of well-being. Failure to ensure that Resident 28 received services related to a midline IV (an 8-12 cm catheter inserted in the upper arm with the tip located just below the armpit) was adequately managed potentially placed Resident 28 at risk for infection and unmet care needs. Findings include . <Resident 28> Resident 28 was a long-term care resident, with a diagnosis to include persistent vegetative state (lack of awareness of themselves or the surroundings), and was dependent on a ventilator (a machine to assist with breathing). Review of facilities policy titled, Dresing Change for Vascular Access Devices on 03/14/2025 showed, Sterile dressings are to be maintained on all peripheral and central vascular access devices to protect site, provide microbial barrier, and provide device securement. To prevent local…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 4 residents (Resident 284) reviewed for medically related social services. The Social Worker (SW) was out for an extended absence; a plan was not implemented to ensure continuous social service coverage. Failure to ensure residents were informed of their care, treatment, and services available to them and continuously monitor and thoroughly assess and advocate for residents' rights, placed resident at risk for harm, diminished quality of life and unmet care needs. Findings included . Resident 284 was admitted to the facility on [DATE] with diagnoses to include aphasia (language disorder that affects a person's ability to understand, use or produce language) following cerebral infarction (ischemic stroke - a condition where blood flow to the brain is interrupted, causing brain cells to die), dysphagia (difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 residents (Resident 71) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that consents were obtained prior to administration of psychotropic medications. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . As referenced in the Food and Drug Administration (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to replace sharps containers (a specialized, puncture-resistant, and leak-proof container designed for the safe disposal of sharp medical instruments, like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste handling) in 1 of 5 medication carts, 1 of 2 shower rooms, and 1 resident room at Station 2 when it reached the full line when the environment was reviewed for safe and comfortable environment. This failure placed residents and staff at risk for injury, and potential exposure to diseases. Findings included . In an observation on 03/12/2025 at 1:20 PM, the sharps container at the side of Medication Cart 5 located at Station 2 was full, it showed the things inside the sharp's container was above the full line. There were insulin pens and lancets almost to the level of the opening of the container. In an observation on 03/12/2025 at 2:05 PM, the sharps container in Resident room [ROOM NUMBER] was very full, it showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to immediately report to the state agency potential abuse and/or neglect for 3 of 5 residents (Residents 19, 61, and 62) reviewed for allegations of abuse and/or neglect. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life. Findings included . Review of the facility's policy titled; Abuse Prevention revised 10/24/2022 showed the facility would report to the state survey agency allegations of abuse/neglect that did not involve serious bodily injury no later than 24 hours after the allegation/suspicion of abuse/neglect. Review of the Nursing Home Guidelines, or The Purple Book, guidelines, dated October 2015, showed facilities were required to report to the Complaint Resolution Unit (CRU) immediately when there was reasonable cause to believe abuse, neglect, substantial injuries of unknown source or on the reporting log within 5 days of discovery.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly resolve grievances for 1 of 1 sampled residents (Resident #1) reviewed for missing property. The facility failed to replace the resident's missing electrolarynx (device that produces voice electronically) timely, and when the missing property was replaced, the replacement item was not given to the resident for four days. Failure to timely replace missing property placed residents at risk for a diminished quality of life. Findings included . Review of a facility policy, titled Grievance/Concern, revised on 01/08/2024, showed the administrator and department manager would be notified of the grievance. The department manager would investigate the grievance, take corrective action, and notify the person who filed the grievance of the resolution in a timely manner. Resident 1 was admitted to the facility on [DATE] with diagnosis to include larynx (portion of throat containing vocal cords) cancer with removal of the larynx. Review of Resident 1's…

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

Based on interview, and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had annual evaluations, appropriate skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 4 of 7 sampled staff (Staff C, E, F and H) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Staff C, Licensed Practical Nurse (LPN), was hired by the facility on 10/27/2020. Staff C's training records did not include documentation they were assessed annually to be competent to provide nursing services to the facility's resident population. Staff E, NAC, was hired by the facility on 10/07/2022. Staff E's training records did not include documentation they were assessed annually to be competent to provide nursing services to the facility's resident population. Staff F, NAC, was hired by…

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

Based on record review, and interview, the facility failed to ensure 2 of 5 employees, (Staff E and Staff F) reviewed for training, had the required 12 hours per year of in-services and required annual dementia training. This failure placed residents at risk of less than competent care and services from staff. Findings included . Review of facility employee records showed: Staff E, Nursing Assistant Certified (NAC), with a hire date of 10/07/2022. For the year of January 2023 to December 2023, the facility was unable to provide documentation that Staff E had completed the required 12 hours of annual in-services or dementia training. Staff F, NAC, with a hire date of 08/16/2022. For the year of January 2023 to December 2023, the facility was unable to provide documentation that Staff F had completed the required 12 hours of annual in-services or dementia training. During an interview on 02/02/2024 at 10:05 AM, Staff A, Administrator, stated the facility did not have a spreadsheet or log for each individual staff person at the facility. Staff A stated the facility used to contract…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff were available to respond to call lights timely and to meet the toileting, bathing, and repositioning needs for 5 of 6 sampled residents (Residents 1, 2, 3, 4, and 5) reviewed for sufficient nursing staff. This failure resulted in feelings of frustration and vulnerability, diminished quality of life and unmet care needs of the residents. Findings included . Review of a facility policy titled, Call lights, revised on 06/01/2021, showed staff would respond to call lights promptly. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnosis of anoxic brain injury (brain damage due to lack of oxygen) and myoclonus (involuntary muscle movements that appears as jerky movements or spasms). Review of Resident 1's Minimum Data Set, (MDS - an assessment of care needs) assessment, dated 11/01/2023, showed Resident 1 had cognitive deficits, did not refuse care, and required maximum assistance with rolling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records that were complete and accurate for 12 of 12 sampled residents (Residents 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) reviewed for late and/or missed medications. The failure to complete documentation of medication administration at the time they were administered had the potential for clinical decisions to be made on inaccurate information. Findings included . Review of a facility policy titled, Administering Medications, dated 2001, showed the individual administering the medication initialed the Medication Administration Sheet (MAR) before administering any other medications and the individual was to record the date and time the medication was provided in the medical record. During an interview and observation on 12/27/2023 at 10:32 AM, surveyor observed medication cart 3 near rooms [ROOM NUMBERS]. The screen on the monitor showed red boxes, signifying medications were overdue. Staff F, Registered 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 interview and record review, the facility failed to implement their Abuse Prohibition policy for 3 of 5 residents (276, 71, and 39) reviewed for incidents and by not ensuring reference checks were conducted prior to hire for four of five employees (Staff O, P, Y and KK ) reviewed for reference checks. Facility staff failed to log and report allegations, to investigate allegations staff had knowledge of and to conduct thorough and timely investigations These failures placed residents at risk for abuse, neglect, unmet care needs, mistreatment by staff and a diminished quality of life. Resident 71's investigation for an unexpected death was non-existent (did not occur). Findings included . The facility policy titled, Abuse Prohibition, revised [DATE], showed the facility would implement an abuse prohibition program to include identification of possible incidents or allegations which need investigation, reporting of incidents, and thorough investigation of incidents and allegations. The policy showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct thorough investigations for 30 of 30 residents (10, 12, 2, 56, 57, 44, 51, 45, 64, 36, 278, 68, 5, 276, 52, 66, 31, 13, 54, 27, 15, 275, 30, 376, 20, 47, 124, 28, 7, 43) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred, and there was a failure to preserve evidence necessary for thorough investigations. These failures placed residents at risk for repeat incidents and injury. Findings included . RESIDENT 10 The resident admitted to the facility on [DATE] with diagnoses to include a fracture of a thoracic vertebra (a fracture of a vertebra in the thoracic region of their back), and a fracture of their left radius (arm bone) sustained in a fall. According to their admission Minimum Data Set (MDS) assessment, dated 08/25/2022, they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure there was adequate supervision for 3 of 3 residents (Resident 10, 12 and 13) reviewed for falls with injury, and failed to ensure call lights were within reach for 7 of 7 residents (Resident 32, 56, 124, 375, 54, 27, and 39) reviewed after their call lights were observed not within their reach for dependent residents. The failure to provide adequate supervision need to ensure the environment is free of environmental hazards placed residents at risk for injuries and unmet care needs. Findings included . Review of the facility policy titled, Fall Management, dated 05/26/2021, showed the purpose was to reduce the risk for falls and minimize the actual occurrence of falls. The policy indicated patients (residents) would be assessed for falls risk as part of the nursing assessment process, and those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Review of the facility policy titled…

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