Avalon Care Center Federal Way, L.L.C.

Based on observation, interview, and record review, the facility failed to implement pharmacy recommendations for 2 of 6 residents (Residents 8 & 69) reviewed for pharmacy recommendations. These failures placed residents at risk of medication errors and adverse health outcomes.Findings included .<Facility Policy>Record review of the facility's November 2017 Pharmacy Services Medication Regimen Review policy showed a pharmacist conducted medication regimen reviews at least monthly to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The facility was to act upon reported irregularities in order to minimize adverse consequences that might be associated with medications.<Resident 8> According to a 09/26/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 8 had recent major orthopedic surgery and required active care during their admission to the facility related to the surgery. Observations during medication pass on 11/19/2025 at 8:26 AM showed Staff G (Registered Nurse) administered one 5,000-unit capsule of…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 2 medication storage rooms (West Station Medication Room) and 1 of 3 medication carts (West Two Medication Cart) reviewed for medication storage. This failure placed residents at risk for medication errors or receiving expired medications.Findings included .<Facility Policy>According to the facility's November 2017 Pharmacy Services Labeling and Storage of Drugs and Biologicals policy, all medications would be labeled with an expiration date. The policy showed multi-dose vials would be dated with an open date and discarded within 28 days after opening, unless the manufacturer specified a shorter or longer date for that opened vial. <West Station Medication Room>Observation on 11/18/2025 at 9:17 AM of the [NAME] Station medication storage room showed a bottle of medication used to treat itching with an expiration date of 10/25/2025, and nine bags of IV (intravenous - injected directly into a patient's bloodstream) medications with an expiration date of…

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

Based on observation, interview, and record review the facility failed to assess and obtain consent prior to implementing bed rails for 2 (Residents 1 & 2) of 3 sample residents reviewed for bed rails. The failure to assess and obtain consent prior to implementing bed rails resulted in Resident 1 sustaining a cut to their eyebrow and placed Resident 2 at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes. Findings included . <Resident 1> According to the 10/30/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 1 had diagnoses including an acute condition affecting their brain function that could cause confusion, memory loss, and personality changes. The MDS showed Resident 1 had severe memory impairment. The MDS showed Resident 1 had severely impaired vision and did not use bed rails during the assessment period. The 10/31/24 discharge MDS showed the resident was discharged from the facility and not available for observation or interview. Review of Resident 1's evaluation and documentation tabs in their…

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

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of Antibiotics (ABO), reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 6 of 6 sample residents (Resident 204, 80, 77, 64, 47, & 3) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's. Findings included . <Facility Policy> According to a facility policy titled, Infection Prevention and Control ABO Stewardship, revised 03/2019, the program would validate that antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration. The policy showed the program would implement a data gathering system and analyze the collected data to ensure unnecessary ABO prescribing did not take place. The policy showed the facility would monitor the use of ABO's using the McGeer's (a set of signs and symptoms that verify active infection) and Loeb's (tool used to assess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 of 7 residents (Residents 94, 31, 1, 20, 26, 23, & 59) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> A facility policy titled, Admission, Transfer, and Discharge - Notice Requirements Before Transfer/Discharge, dated 07/2018, showed a notice of transfer must be provided to the resident/representative when an emergency transfer to an acute care facility is ordered. <Resident 94> Review of Resident 94's 05/10/2024 Discharge Minimum Data Set (MDS- an assessment tool) showed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 6> According to the 06/07/2024 Quarterly MDS Resident 6 was independent with lying to sitting on side of bed, sit to stand, chair-to-bed/bed-to-chair transfer, toilet transfer, and walked ten feet. This MDS showed Resident 6 had intact cognition. During an interview on 07/16/2024 at 9:07 AM Resident 6 stated they transferred from their bed to their wheelchair or walker and back to their bed independently. Review of Resident 6's Potential for Alteration in Activities of Daily Living CP on 07/18/2024 at 8:46 AM showed the CP had contradicting information. One intervention stated the resident required supervision or partial assistance of one staff for transferring. Another intervention stated Resident 6 was able to transfer on their own. Review of Resident 6's bedside Kardex on 07/18/2024 at 9:00 AM showed Resident 6 required substantial to maximal assistance by one staff to turn and reposition in bed, was independent with bed mobility, was able to transfer on their own, and required supervision 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 restorative/rehabilitative treatment/services for 7 of 8 residents (Residents 47, 20, 40, 41, 61, 32, & 59) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to a facility policy titled, Quality of Care Restorative Nursing Programs, revised 06/2018, showed Restorative Nursing Programs (RNP) would be developed and/or formalized by a supervising nurse. <Resident 47> According to a 05/31/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 47 had functional limitation in ROM to both arms and both legs. The assessment showed Resident 47 did not have any memory impairment. The MDS showed Resident 47 had medically complex conditions which included, but were not limited 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.

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, and served under sanitary conditions. Facility staff failed to: consistently perform hand hygiene when preparing resident meal trays; label food items and discard expired food items from unit refrigerators; keep the kitchen dishwasher machine free from grime and debris build up; and maintain accurate documentation for the dishwasher temperature and chlorine chemical logs. These failures contributed to an unsanitary kitchen environment, placed residents at risk for food borne illness, and/or contaminated food. Findings included . <Facility Policy> Review of the facility's Food and Nutrition Services - Food Safety policy dated 07/2018, showed facility staff would use good hygienic practices when handling food. This policy showed facility staff would follow manufacturer's guidelines based on the type of dishwasher used to sanitize dishware and chemical solutions would be checked for concentration levels at least once per shift. Review of the facility's Food's Brought 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently performed Hand Hygiene (HH) before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP- implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms; and implement interventions to prevent Legionnaires disease (a serious severe respiratory infection caused by inhalation of bacteria growing in the water system) within the facility. The facility was unable to provide documentation of completed McGeer's or Loeb's infection surveillance criteria forms for each resident with an infection who received, or was currently on, an antibiotic. These failures placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform residents or their assigned representatives in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 residents (Residents 61 & 34) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' and/or their representative's ability to exercise their right to make an informed decision about proposed treatments, and prevented the residents and their representative from exercising their right to decline the treatments/therapies. Findings included . <Facility Policy> The facility's revised 10/04/2022 Psychotropic Medication policy showed residents who used psychotropic drugs would be educated on the risks and benefits of psychotropic drug use. <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (MDS - an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the appropriate Advanced Directives (AD) in place for 2 (Residents 61 & 6) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, and offered assistance to formulate an AD (Resident 61 and 6), and to obtain guardianship for Resident 61. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The 11/2017 Advanced Directives facility policy showed the resident and/or the resident's representative would be provided with written information regarding the resident's right to refuse or accept assistance with formulating an AD, and this information would be provided in a manner the resident could understand. Nursing staff would document the resident's decision about formulating an AD in the resident's record. Information about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to initiate a grievance for 2 (Resident 1 & 47) of 2 resident's reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the resident of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the resident at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life. Findings included . <Facility Policy> According to facility policy titled, Resident Rights - Grievances, dated 08/2018, the facility would help residents/representatives file grievances and would investigate and take appropriate actions to address resident grievances. The policy showed grievances could be submitted in writing or orally. The policy showed the administrator has designated the Social Services representative in the facility as the Grievance Officer (GO). The policy showed the GO had the responsibility to oversee the grievance process, receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document they communicated necessary resident information to the receiving health care institution or provider for 2 of 7 residents (Resident 1 & 31) reviewed for hospitalizations. Failure to ensure necessary resident information was communicated to the hospital placed residents at risk for decreased quality of care, inadequate care/treatment, and decreased quality of life. Findings included . <Facility Policy> According to a facility policy titled, Admission, Transfer, & Discharge - Facility initiated Transfers, or Discharges, dated 11/2017, showed when the facility initiates a transfer or discharge of a resident, the facility would document in the resident's record appropriate information was communicated to the receiving health care institution or provider. The policy showed information would be provided to the receiving provider and will include the following: a. Contact information of the practitioner responsible for the care of the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system that ensured residents who were transferred to the hospital or went on therapeutic leave were provided a written notice of bed hold that specified the duration of the bed hold policy upon transfer or attempted to contact the resident and/or the resident representative within 24 hours from an emergency transfer for 2 (Resident 59 & 23) of 7 sampled residents reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while hospitalized . Findings included . <Facility Policy> According to the Admission, Transfer, and Discharge - Notice of Bed Hold Policy Before/Upon Transfer facility policy revised 11/2018, the facility would provide information regarding the resident's right to hold their bed at the time of transfer or within 24 hours of the transfer if the transfer was emergent. <Resident 59> According to the 05/29/2024 Annual Minimum Data Set (MDS - an…

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

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days from the date of determination for 1 (Resident 68) of 1 resident reviewed for significant changes in status. The failure to identify the need for a SCSA when Resident 68 had a decline in condition and was started on hospice services placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status is required) a .SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains in the nursing home. <Resident 68> Review of Resident 68's 04/05/2024 Hospice Certification and Plan of Care showed Resident 68 admitted to hospice services on 04/05/2024 for a diagnosis of protein - calorie malnutrition and the inability to absorb nutrients from food. This certification showed Resident 68 was terminally ill…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pre-admission Screening and Resident Review (PASRR) assessments were completed accurately for 1 (Resident 61) of 5 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's revised 08/2018 Resident Assessment - PASRR for Mental Disorder (MD) and Intellectual disability policy, all residents must have a PASRR screening prior to admission, and the facility would keep a copy of the screening in the resident's record. The policy showed the facility's Social Services department was responsible for ongoing maintenance of accurate PASRR screenings and PASRR screening should be updated as needed to reflect changes both positive and negative to a resident's mental health status. This policy showed if a PASRR level I was positive, with any MD or a related condition, 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 services provided met professional standards of practice for 4 (Residents 66, 32, 59, & 67) of 20 residents reviewed. The nursing staff's failure to follow and/or clarify Physician Orders (POs), and notify the provider of resident refusals of treatment, placed residents at risk for unmet care needs, and potential negative outcomes. Findings included . <Clarifying Physician Orders> <Resident 66> According to the 05/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 66 received nutrition through a feeding tube (a tube surgically placed in the stomach used to administer artificial nutrition). Review of Resident 66's order summary on 07/23/2024 at 12:45 PM showed Resident 66 had a 02/29/2024 diet order of NPO (nothing by mouth). Review of Resident 66's March 2024 through July 2024 Medication Administration Records (MARs) on 07/23/2024 at 12:45 PM showed Resident 66 had a 03/10/2024 PO for an anti nausea medication, a 03/26/2024…

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 observation, interview, and record review, the facility failed to ensure 1 (Resident 61) of 3 sampled residents reviewed for communication, including language and speech, were provided a functional system to address their communication needs. Failure to identify and provide services which enhanced and or ensured effective communication, placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being. Findings included . <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (an assessment tool), Resident 61 admitted to the facility on [DATE], had impaired memory, was never able to understand others, and had unclear speech. The assessment showed Resident 61 had no behavior or rejection of care during the assessment period. Observations on 07/16/2024 at 9:40 AM, and 07/17/2024 at 11:59 AM showed Resident 61 was lying in their bed in their room. During an interview on 07/17/2024 at 11:59 AM, Resident 61 mumbled and was unable to make themselves…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 2 (Residents 61 & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 61), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Life- Activities of Daily Living policy, the facility would provide ADLs in accordance with resident's comprehensive assessment, Care Plan (CP), and resident preferences to ensure a resident's ADL abilities do not diminish unless decline in function was unavoidable. <Shaving> <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 61 admitted to the facility on [DATE], had impaired memory, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 20 residents (Residents 41, 67, & 59) reviewed, received the necessary care and services in accordance with professional standards of practice, and the comprehensive person-centered care plan. The facility failed to complete weekly skin checks and provide the treatment for 2 of 4 residents (Residents 41 & 67) reviewed for non-pressure ulcers and failed to accurately set air mattress setting according to resident's weight for 1 of 4 residents (Resident 59) reviewed for air mattress setting. These failures placed residents at risk for decline in medical status, unmet care needs, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's revised 08/2018 Quality of Care policy, the facility would ensure care plans included resident care needs and described the services and care required; ensure residents with non-pressure-related skin ulcers/wounds were assessed by a clinician, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Resident 41) of 5 residents reviewed for Pressure Ulcers (PU's) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to consistently complete weekly skin assessment, assess skin integrity to identify PUs timely, and implement interventions to include updating the Care Plan (CP), placed Resident 41 at risk to develop new PU, and diminished quality of life. <Facility Policy> According to the facility's 08/2018 Quality of Care- Skin Integrity policy, the facility would assess residents upon admission and thereafter, to identify if the resident had existing PU's or was at risk for developing PUs. A resident at risk for developing PUs would have individualized interventions implemented to prevent new PUs from developing. The policy showed the resident's CP would reflect the treatment strategies for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 1 of 8 (Resident 68) sample residents reviewed for accident hazards. The failure to assess devices such as wedges placed Resident 68 at risk for accidents, injury, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's Quality of Care - Accident Hazards/Supervision/Devices policy dated 07/2018, the facility would provide an environment that was free from accident hazards. This policy showed risks and benefits of assistive devices that could pose an entrapment risk would be considered prior to implementing the device. <Resident 68> According to the 06/20/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 68 had severely impaired thought processes. The MDS showed Resident 68 had a progressive memory loss disorder and was receiving end-of-life services. This assessment showed Resident 68 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain consent for Bed Rails (BR) for 3 (Residents 1, 297, & 20) of 3 residents reviewed for BR's. Facility failure to attempt alternatives before implementing BR's, assess residents for safe use of BR's, or obtain informed consent for the use of BR's placed all residents at risk for harm or injury and other negative health outcomes. Findings included . <Facility Policy> According to a facility policy titled, Resident Rights Planning and Implementing Care, dated 11/2017, the residents had the right to be informed of their treatment and care. The policy stated staff would inform residents in advance of the treatment risks and benefits, options, and alternatives. According to a facility policy titled, Quality of Care - Bed Rails, the facility would attempt alternative measures prior to utilizing BR's and if it was determined the alternative measures were not effective, the facility would assess the resident for risks of entrapment. 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 licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and carried out in a timely manner for 3 of 5 residents (Residents 32, 67, & 34) whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes. Findings included . <Facility Policy> According to the facility's Pharmacy Services - [MRR] policy dated 11/2017, the facility would develop a system by which medication irregularities would be acted on in order to minimize adverse consequences to the resident. This policy showed the pharmacist would conduct monthly MRRs. Any irregularities would be provided in a separate report and reviewed by the physician, medical director, and director of nursing. The irregularities would be responded to in a timely manner dependant on the nature of the concern. 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 2 (Residents 24 & 32) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Pharmacy Services - Psychoactive Medication policy revised 10/04/2022, showed the facility implemented Gradual Dose Reductions (GDRs) unless contraindicated, prior to initiating, or instead of continuing a psychotropic medication. The policy showed supportive documentation included but was not limited to consideration of other factors addressed prior to initiating a psychotropic medication or in conjunctions with GDRs. <Resident 24> According to the 07/01/2024 Medicare 5 Day Minimum Data Set (MDS - an assessment tool), Resident 24 admitted to the facility on [DATE] and…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 5 nurses (Staff N - Licensed Practical Nurse) to properly administer 2 of 25 medications for 1 (Resident 203) of 8 residents observed during medication pass resulted in a medication error rate of 8%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered. Findings included . <Facility Policy> Review of the facility's General Dose Preparation and Medication Administration policy revised 01/01/2013 showed the facility staff administering the medication should ensure the resident's consumption of the medication. <Staff N> Observation on 07/18/2024 at 9:02 AM showed Staff N preparing to administer morning medications to Resident 203. Staff N brought Resident 203 their morning medications. As Resident 203 took their medications, 2 medication tablets dropped in the resident's lap. Staff N did not notice and started to leave the resident's room. At that time, the surveyor stopped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 drugs and biologicals were secured for 3 (Resident 90, 23, & 52) of 21 sample residents observed with medications in their rooms. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents. Findings included . <Facility Policy> According to the facility's Storage and Expiration of Medications, Biologicals, Syringes, and Needles policy revised 10/31/2016, the facility would store bedside medications or biologicals in a locked compartment within the resident's room. This policy showed the facility would not provide bedside medications or biologicals without a Physician's Order (PO). <Resident 52> Observation on 07/18//2024 at 8:38 AM showed Resident 52 in bed. The facility's contracted wound team entered Resident 52's room to provide a treatment to Resident 52's skin. Resident 52's windowsill contained several skin treatments and ointments including a tube of antibiotic ointment, wound cleansing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 out of 1 walk-in freezers was maintained in satisfactory working condition. The freezer temperature logs indicated the temperature was elevated for a month prior to the start of the survey and there was a leak in a pipe resulting in substantial ice buildup in the freezer. Although service visits were made a couple of weeks prior to the survey, the freezer continued to be out of temperature range and with significant ice buildup, without additional follow-up being implemented. This failure placed residents at risk for spoiled food. Findings included . Review of the 07/20/2023 Food and Nutrition Services Food Safety policy revealed, Food items would be stored, prepared, distributed and served in accordance with professional standards for food service safety .Frozen foods would be maintained at a temperature to keep the food frozen solid. In an initial kitchen inspection with Staff V (Dietary Manager) on 04/25/2023 at 9:12 AM, the…

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

Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 161 & 162) of 4 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Findings included . <Resident 161> Record review showed Resident 161 was discharged on 01/17/2023. Review of trust fund records showed the resident had a balance of $60.41, which was not transferred to the OFR until 12/12/2022, 11 months after discharge. <Resident 162> Record review showed Resident 162 was discharged on 05/22/2022. Review of trust fund records showed the resident had a balance of $431.52, which was not transferred to the OFR until 10/31/2022, five months after discharge. In an interview on 04/27/2023 at 2:48 PM, Staff P (Business Office Coordinator) stated trust funds should be dispersed to the OFR within 30 days of a resident's discharge. Staff P confirmed the funds for Resident 161 and 162 should have, but were not dispersed within 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written notice of transfer/discharge to the State Office of the Long-Term Care Ombudsman (LTCO) for 2 of 3 residents (Residents 110 & 109) reviewed for discharge. The failure to have an established system of discharge notification to the LTCO placed all discharged residents at risk for lack of information about discharge, access to an advocate who could inform them of their options and rights, and risk for a diminished quality of life. Findings included . <Resident 110> A [DATE] progress note showed Resident 110 had a resident-initiated discharge from the facility to a private home. A [DATE] release form showed Resident 110 left the facility against medical advice. <Resident 109> A [DATE] progress note showed Resident 109 was deceased . A [DATE] release form showed Resident 109 was discharged and transferred to a funeral home. In an interview on [DATE] at 8:21 AM, Collateral Contact (CC) from the LTCO stated there was no notification 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 provide the bed-hold notice (a document detailing the duration, cost, and conditions of return, when holding a bed while the resident was at the hospital) for 2 of 2 residents (Residents 57 & 62) reviewed for hospitalization. This failure placed residents at risk for being uninformed and unable to exercise the right to hold their bed while in the hospital. Findings included . The 11/2018 Facility Policy for Notice of Bed Hold showed residents were notified of the bed hold policy at the time of transfer or within 24 hours if the transfer was an emergency. The policy showed the bed hold notification was provided regardless of payment source, and included the reserve bed payment policy, and information related to the resident's ability to return to the facility. <Resident 57> Review of Resident 57's January 2023, February 2023 and April 2023 progress notes showed Resident 57 was transferred to the hospital on [DATE], 01/26/2023, 02/24/2023, and…

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

Based on observation, interview, and record review the facility failed to ensure food served to residents was palatable, attractive and at a safe and appetizing temperature for 8 of 34 sampled residents (Resident 23, 39, 37, 20, 54, 40, 65, & 35) and 22 residents who attended the food committee. The failure to obtain and act on feedback from residents regarding food and failure to ensure food temperatures were maintained during transport from the kitchen to the resident placed residents at risk for decreased intake, weight loss, and diminished quality of life. Findings included . The 07/2018 facility policy Food and Nutrition Services Food and Drink showed the facility will prepare food and drink in methods that conserve nutritive value, flavor, and appearance. Food and drink will be palatable, attractive and at a safe, appetizing temperature. On 04/25/2023 at 9:00 AM, Resident 23 stated the eggs were always lukewarm and burnt on the bottom. Resident 23 stated they had previously talked with a manager about the cold burnt eggs, and the manager wrote down the complaint and said 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.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and exiting staff as identified in the Facility Assessment. The failure to ensure new staff received orientation and were evaluated for skill sets within their scope of practice, evaluate staff skills annually, and provide annual training on abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, and behavioral health, for 9 of 10 (Staff J, K, L, M, N, BB, G, Z, and I) staff placed residents at risk for unmet needs, inadequate quality of care and diminished quality of life. Findings included . Review of the undated Facility Assessment (FA) showed the facility evaluated the resident care needs and identified staff training requirements to provide person-centered care and services the facility residents required. The FA showed staff would receive orientation upon hire and receive annual education on the topics of abuse/neglect, resident rights, dementia, mental health and behaviors, hospice care, 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 a Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) and/or a Notice to Medicare Provider Non-Coverage (NOMNC) for 2 of 3 residents (Resident 102 & 262) reviewed for SNF ABN and NOMNC notification. The failure to provide residents information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program. Findings included . The 09/20/2022 Resident Rights of Medicaid/Medicare Coverage Liability facility policy showed the facility will issue a NOMNC to the resident or representative at least two days before the end of a Medicare covered Part A stay or when all therapy services were ending. The policy showed a SNF-ABN will be issued to inform the resident or representative of potential liability for non-covered services if the resident decided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Resident 82) of 1 residents reviewed for positioning was positioned correctly in their wheelchair; ensure care was coordinated with hospice services for 1 (Resident 78) of 1 residents reviewed for hospice services. Facility failure to ensure correct positioning left Resident 82 at risk for discomfort, and negative health outcomes. The facility's failure to coordinate care with hospice left Resident 78 at risk for receiving unnecessary care. Findings included . <Resident 82> In an interview on 04/28/2023 at 11:22 AM, Staff A (Administrator) stated there was no facility policy addressing wheelchair positioning. Staff A stated the facility used the [NAME] (Nursing) Manual which contained a section titled Measure it: Proper Wheelchair Fit is Key to Ensuring Function while Protecting Skin Integrity dated December 2014. This section showed, Users remain seated in wheelchairs during a variety of functional activities. For these…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to ensure residents with urinary catheters received appropriate treatment and services for 2 of 4 (Residents 37 & 75) residents reviewed for indwelling urinary catheters. The failure to obtain and follow physician orders for catheter care placed residents at risk for infection and diminished quality of life. Findings included . The 04/2021 facility policy for Urinary Catheterization, showed a resident with an indwelling urinary catheter will have a rationale for use, monitor for changes, a care plan with interventions, and physician orders for changing catheters and drainage bags. <Resident 37> The 01/24/2023 admission Minimum Data Set (MDS, an assessment tool) showed Resident 37 admitted to the facility on [DATE] with the diagnosis of diabetes, pressure ulcers and a urinary tract infection. Resident 37 was assessed as cognitively intact, able to make daily decisions and had an indwelling urinary catheter. Review of a 01/17/2023 Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a system of records for accurate reconciliation of narcotic drugs for 1 of 3 medication carts. The failure to accurately count and verify the inventory of controlled substances - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion. Findings included . Review of the 01/01/2023 facility policy Inventory Control of Controlled Substances showed the facility would ensure the incoming and outgoing nurses counted all controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily, and document the results. In an observation and interview on 04/28/2023 at 11:35 AM, Staff S (Licensed Practical Nurse) was at the [NAME] Medication Cart when a random narcotic reconciliation was completed. The narcotic ledger book showed page 91 had two doses of oxycodone remaining on the card. There was no card of oxycodone for page 91 for Resident 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and monitor resident-specific behaviors for the use of Antipsychotic (AP) medication and document the rationale for the use of an as needed (PRN) AP medication. The facility failed to implement non-pharmacological interventions for 1 of 5 residents (Resident 361) reviewed for unnecessary medications. This failure placed residents at risk for unmet behavior needs and a diminished quality of life. Findings included . The 10/04/2022 facility policy Psychoactive Medications showed prior to initiating psychotropic medications (medication affecting mental function), the facility would identify rationale for use and implement non-pharmacological interventions. The policy showed PRN psychotropic medication use was limited and only used when the medication was required. The 04/17/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 361 had diagnoses of depression, dementia with behaviors and a nervous system disorder. Resident 361 was assessed with severe cognitive impairment for daily decision making…

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