Garden Terrace Healthcare Center Of Federal Way

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs - personal hygiene, grooming, and bathing) received the assistance they were assessed to require for 4 of 9 residents (Residents 36, 45, 166, & 167) reviewed for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's 02/12/2024 Activities of Daily Living policy showed the facility would provide all treatment and care based on the comprehensive assessment of the resident, person-centered Care Plan, and resident's choices. The policy showed residents who were unable to carry out their own ADLs would receive the necessary services to maintain good nutrition and personal hygiene including bathing, dressing, grooming, and oral care. The policy…

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 activity programs met the needs of each resident for 3 of 3 residents (Resident 264, 265 & 270) reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 09/2024 Activities policy, the facility would implement an ongoing activities program that incorporated residents' interests and created opportunities for each resident to have a meaningful life by supporting their wellness. The policy showed all residents who are unable or unwilling to participate in group programs would have consistent, goal oriented and individualized recreation opportunities. <Resident 264> According to the 06/02/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 264 had intact memory and had symptoms of feeling down or depressed. The MDS showed it was very important for Resident 264 to do their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 115> According to the 04/24/2025 admission MDS, Resident 115 had medical conditions including brain cancer. The MDS showed Resident 115 developed brain abscess (accumulation of pus within the tissues) while recovering from the surgical resection (the process of cutting out tissue or part of an organ) of their brain tumor. The 04/21/2025 pain CP showed Resident 115 expressed discomfort/pain related to their recent brain surgery, back pain, bilateral leg pain from having blood clots, and generalized deconditioning. The CP outlined interventions directing the nursing staff to administer pain medications to Resident 115 as ordered by the physician and to notify the physician if interventions were unsuccessful or if there was a significant change from the resident's past experience of pain. A 04/21/2025 physician's order instructed staff to administer an over-the-counter pain reliever every six hours as needed for a pain level of one-to-three on the zero-to-ten pain scale. An additional 04/21/2025 order…

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

Based on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 3 (Resident 264) residents reviewed for behavioral-emotional health. The failure to provide interventions to Resident 264 behavioral health concerns placed Resident 264 and other residents at risk for not receiving the services necessary to meet their mental health needs and a diminished quality of life. Findings included . <Resident 264> According to the 06/02/2025 admission Minimum Data Set (MDS- an assessment tool) Resident 264 had diagnoses including anxiety and depression. The MDS showed Resident 264 took medication for anxiety and had several days when they were feeling down or depressed. Review of 06/10/2025 Mood Care Plan (CP), showed Resident 264 was at risk for changes in their mood or behavior due to their medical conditions. The CP included interventions for staff to provide a psychological (psych) evaluation consult as indicated. Record review showed a 06/03/2025 progress note that showed Resident 264 requested to be referred to psych and the status 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 Observation of the the freezer in the Tea Garden Unit's nourishment pantry on 06/13/2025 at 10:41 AM showed an opened package of glycerine swabs. The packaging stated it contained three swabs and two remained in the packet. The packaging stated it was sterile. There was no date on the swab packet indicating when it was opened or for how long the swabs could safely be used. REFERENCE: WAC 388-97-1300(2), -2340. Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 4 unit nutrition pantry fridges (Tea Garden) and 1 of 4 medication carts ([NAME] Unit) and failed to account for missing signatures in the narcotic book for 1 of 4 medication carts ([NAME] Unit) reviewed for medication storage. These failures placed residents at risk of receiving expired medications, ineffective treatment, missing medications and a diminished quality of life. Findings included . <Policy> According to the facility's revised 08/01/2024 Storage and Expiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received timely specialized rehabilitative services for 1 of 4 residents reviewed for therapy services (Resident 113). The failure to timely complete a Speech Language Pathologist (SLP - a speech therapist) evaluation placed Resident 113 at risk for unnecessary diet restrictions, weight loss, and a diminished quality of life. Findings included . <Resident 113> According to the 06/06/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 113 had a moderate memory impairment and no signs and symptoms of a possible swallowing disorder. The MDS showed Resident 113 admitted to the facility on [DATE], received a mechanically altered diet on admission and while a resident at the facility, and received no SLP services during the MDS's lookback period. Record review showed Resident 113 had a 06/03/2025 dietary order for a regular diet with an easy to chew texture and chopped meats. According to the 06/03/2025 Nursing…

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 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) was provided the necessary treatment and services consistent with professional standards of practice to promote wound healing. This failure placed residents at risk for worsening skin conditions, skin breakdown, and a diminished quality of life. Findings included . <Facility Policy> The facility policy titled, Skin Integrity & PU/PI Prevention and Management, revised 07/09/2024, showed the facility would provide the necessary treatment and services, consistent with professional standards of practice, to a resident with PU/PI to promote healing, prevent infection, and prevent new ulcers from developing. The policy showed preventative measures identified to maintain and improve the resident's skin condition were implemented in the Care Plan (CP). The policy showed when skin breakdown occurred, it required attention and a change in the plan of care could be indicated to treat the resident. <Resident 1> According to the 01/21/2025 Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their abuse and neglect policies and procedures regarding prevention, identification, investigation, and reporting of abuse and/or neglect. The facility failed to thoroughly investigate the incident and allegation of physical abuse for 1 of 3 residents (Resident 1) reviewed for facility incidents. This failure placed residents at risk for abuse and/or neglect by caregivers, avoidable and unnecessary pain, and a diminished quality of life. Findings included . <Facility Policy> The 06/17/2024 Abuse - Protection of Residents facility policy showed the facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents. The policy showed the facility must have evidence that all alleged violations were thoroughly investigated, including examining the alleged victim for any sign of injury, both physical and psychosocial. <Resident 1> According to the 12/23/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written transfer/discharge notices as required for 3 of 3 residents (Resident 1, 6, & 7) reviewed for hospitalization. Failure to provide notification to the resident and/or the resident's representative of the reason(s) for the transfer or discharge in writing placed residents at risk for a discharge that did not meet the resident's and/or their representative's stated goals for care and preferences. Findings included . <Facility Policy> The Transfers and Discharges facility policy, revised 06/28/2024, showed the facility would provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations. The Notice of Transfers and Discharges facility policy, revised 10/29/2024, showed the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in language and manner they understood. The policy showed the written notice in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: Provide an environment that was free from accident hazards; and ensure each resident received adequate supervision and/or assistance to prevent accidents, for 1 of 2 residents (Resident 1) reviewed for falls. These failures placed residents at risk for injuries, avoidable accidents, and a decreased quality of life. Findings included . <Facility Policy> Review of the undated facility guidance, Lippincott procedures- Fall Prevention, long-term care showed the factors that contribute to falls among older adults included conditions that affect mobility, medication use, increasing physical disability, and impaired vision, hearing, or mental status. The guidelines showed preventing falls begin with identifying residents at greatest risk. The guidelines showed fall prevention care plans should be individualized and comprehensive for each resident. The guidelines showed documentation associated with fall prevention included measures taken to help prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the physical environment was kept clean and food stored under sanitary conditions for 1 of 1 kitchen observed. Facility staff failed to: Label and date food; discard damaged/spoiled food; keep kitchen vents free from dirt/dust build-up; and maintain cleanliness of handwashing sinks and garbage bins. The facility failed to ensure 2 of 4 resident refrigerators in the nursing units (Lily Garden & Tea Garden) were monitored for opened and undated food and liquids, partially-eaten and spoiled resident-owned food brought in from outside sources, and cleanliness. These failures contributed to an unsanitary kitchen environment and unsafe storage of food and drinks, and placed residents at risk for food-borne illness. Findings included . <Facility Policy> According to the facility policy, Sanitation and Maintenance, revised 04/26/2023, the Director of Food and Nutrition Services was responsible for ensuring the dietary department was maintained according…

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 residents and/or the resident's representative a written notice of the facility's bed hold policy at the time of transfer or within 24 hours, for 1 of 1 closed records (Resident 21) and 2 of 3 residents (Residents 43 & 41) reviewed for hospitalization. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> Review of the facility'spolicy titled, Bed Hold, revised 11/17/2022 showed the facility would provide the bed hold policy upon transfer of a resident to the hospital or within 24 hours of transfer to the hospital. The policy showed written information regarding bed holds and payment would be provided to the resident and/or the resident's representative and the facility would document multiple attempts to reach the resident/representative. <Resident 21> Review of the facility census showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop comprehensive Care Plans (CP) for 7 (Resident 43, 46, 264, 25, 163, 167, & 2) of 17 sampled residents whose comprehensive CPs were reviewed. Failure to establish individualized CPs with identified goals that accurately reflected the resident's condition, placed residents at risk for unmet care needs. Findings included . <Facility Policy> Review of the facility's Comprehensive [CP] & Revisions policy revised 08/22/2023 showed the facility would ensure the comprehensive CP was reviewed and revised. The revisions would include changes to care delivery such as additional interventions to existing problems, updating goal or problem statements, and adding short term problem, goal, and interventions to address a time limited condition. <264> According to the 04/11/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 264 admitted to the facility on [DATE] and was able to make themselves understood and understand others…

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 observations, interview, and record review, the facility failed to ensure pain management was provided to residents consistent with professional standards of practice including the failure to offer nonpharmacological interventions, identify parameters for administration of as needed (PRN) pain medications, and identify the location of residents' pain for 4 of 4 residents (Residents 18, 13, 213, & 167) reviewed for pain management. These failures left residents at risk for experiencing untreated pain and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's Pain Assessment and Management policy revised 09/12/2023 showed the facility must ensure pain management was provided to residents that aligned with the residents' Care Plan (CP) and resident goals. This policy showed the facility would address and/or treat the underlying causes of pain while implementing nonpharmacological and pharmacological (not involving the use of drug/medication) interventions to pain management. <Resident 167> According to the 04/01/2024 admission Minimum Data…

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 <TBP> <Resident 167> According to the 04/01/2024 admission MDS, Resident 167 had medical conditions including a bladder infection and was administered antibiotics during the assessment period. The MDS showed Resident 167 was frequently incontinent of their urine and was assessed to require substantial/maximal assistance from staff for their toileting hygiene. In an observation and interview on 04/09/2024 at 10:13 AM, a Contact Precaution sign was observed posted outside Resident 167's door and instructed all staff to perform HH and wear PPE at all times. Staff T (Registered Nurse - RN) confirmed Resident 167 had a contagious infection in their urine. At 10:15 AM, the TBP sign was observed different; it was replaced with Enhanced Barrier Precaution (EBP) and instructed staff to only wear PPE during high-contact resident activities. Staff T stated they did not know why the TBP was changed. On 04/10/2024 at 8:27 AM, the TBP sign outside Resident 167's door was switched back to Contact Precaution. In a joint…

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 encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe, for 1 of 1 residents (Resident 9) reviewed for timeliness in transmission. This failure placed residents at risk for inaccurate monitoring of decline or progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . <Resident Assessment Instrument - RAI> According to the October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), all Minimum Data Set (MDS - an assessment tool) assessments must be submitted within 14 days of the MDS Completion Date. The manual showed MDS transmission requirements applied to all MDS 3.0 records used to meet both federal and state requirements. <Resident 9> Review of the facility census showed Resident 9 discharged on 11/29/2023. The 11/29/2023 Discharge Return Not Anticipated MDS showed the assessment's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) of 2 of 17 residents (Residents 28 & 166) were completed accurately to reflect the resident's condition and overall health status. The facility failed to identify Resident 28's poor dental status and failed to capture Resident 166's active diagnosis of dementia (a memory problem). These failures placed Residents 28 and 166 and other residents at risk for unidentified and/or unmet care needs. Findings included . <Facility Policy> According to the facility policy titled, Certification of Accuracy of the MDS, revised 08/17/2023, the assessment must accurately reflect the resident's status. <Resident 28> The 03/21/2024 admission MDS showed Resident 28 had clear speech, their memory was intact, and had medical conditions including heart failure, renal failure, muscle weakness, and malnutrition. The MDS showed Resident 28 did not have any oral/dental issues during the assessment period. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 32> Review of the 03/07/2024 admission MDS showed Resident 32 was admitted to the facility following a hip fracture. This MDS showed Resident 32 was totally dependent on staff for personal hygiene and bathing needs. This MDS showed Resident 32 did not reject care during the look back period of the assessment. Review of Resident 32's March 2024 task documentation showed on 03/07/2024 staff documented bathing did not occur. The task documentation showed Resident 32 was not offered or provided a bath from 03/07/2024 to 03/31/2024, indicating the resident went 24 days without bathing. Review of a 04/10/2024 [NAME] (directions to care staff) showed Resident 32 preferred bathing on Monday and Wednesday evenings. In an observation and interview on 04/09/2024 at 11:55 AM, Resident 32 was lying in bed and had short facial hair stubble. At that time, Resident 32 stated it was a couple of weeks since their last bed bath and they preferred to be clean shaven. Similar observations were made on 04/12/2024 at 9:32 AM…

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 identify and provide care and services in accordance with the resident's goals and professional standards of practice for 1 of 2 residents (Resident 163) reviewed for Anticoagulation (AC - blood thinner) use and monitoring. This failure placed residents at risk for unidentified and/or worsening bleeding and a decreased quality of life. Findings included . <Facility Policy> According to the 11/28/2023 facility policy titled, Area of Focus: AC Management, residents who received an AC were at increased risk of bleeding and required additional monitoring to ensure safe resident-centered care. The policy showed the facility should ensure the Care Plan (CP) reflected AC use and was updated as needed. <Resident 163> Review of the 04/01/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 163 had clear speech, their memory was intact, and had medical conditions including a right hip fracture after a fall. The MDS showed Resident 163 was administered an AC during the assessment period. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice to prevent weight loss for 2 of 3 sampled residents (Residents 163 & 264) reviewed for nutrition. The facility failed to timely assess the residents' nutritional status after facility admission and failed to develop and implement a nutrition Care Plan (CP) with person-centered interventions. These failures placed residents at risk for unidentified nutritional needs and concerns, unplanned weight loss, and a decreased quality of life. Findings included . <Facility Policies> Review of the facility policy titled, Nutrition Assessment, revised 04/25/2023, each resident would receive a comprehensive assessment to determine nutritional needs on admission and when a resident became at risk for compromised nutritional status. The policy showed the Director of Food and Nutrition Services or designee would visit each resident within 72 hours of admission, review 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 implement care for 1 (Resident 43) of 1 resident reviewed for Tube Feeding (TF - nutrition delivered into the stomach by tube) management including documenting and tracking the rate of the TF orders, documenting the amount of TF nutrition and water infused. These failures placed Resident 43 at risk for inadequate calorie or protein intake and/or inadequate hydration. Findings included . <Facility Policy> According to the facility's Nutritional Intake policy revised 08/24/2023, the facility would document the nutritional intake on each individual resident. <Resident 43> According to the 03/04/2024 admission Minimum Data Set (an assessment tool), Resident 43 had diagnoses including inability to express speech, a brain bleed, weakness to one side of their body, malnutrition, and a swallowing disorder. This assessment showed Resident 43 received more than 51 percent of their total calories and fluid intake via TF. Review of a 03/13/2024…

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 2 of 2 residents (Residents 167 & 31) reviewed for respiratory care were provided care consistent with professional standards of practice. Failure to provide deep breathing treatments as ordered (Resident 167) and obtain Physician Orders (POs) for supplemental oxygen (Resident 31) left residents at risk for over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life. Findings included . <Resident 167> <Facility Policy> Review of the 09/27/2023 facility policy titled, Incentive Spirometry [IS], showed the facility would provide IS (a breathing exercise using a handheld medical device to help improve lung function) in accordance with professional standards of practice as outlined by [NAME] (a book used for medical references). According to the revised 05/22/2023 IS Lippincott procedures, documentation associated with incentive spirometry included: Assessment of the resident before and after 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 provide appropriate treatment and services for residents diagnosed with dementia to attain and/or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident 166) reviewed for dementia (a memory problem) care. Failure of the facility to identify, develop, and implement a person-centered Care Plan (CP) that addressed residents' dementia diagnosis and behaviors placed the residents at risk for having unidentified and/or unmet care needs, avoidable decline, and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Care of the Cognitively Impaired [Dementia Care], revised 08/22/2023, the facility would provide dementia treatment and services that were person-centered and reflected the resident's goals of care while maximizing dignity, privacy, socialization, and safety. The policy showed the facility would develop and implement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 2 (Resident 18 & 13) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to: provide non-pharmacological interventions prior to administering an as needed Antipsychotic (AP) medication, re-evaluate and document the specific condition being treated with the as needed AP medication, obtain consent prior to administering psychotropics, and identify target behaviors. These failures placed residents at risk to receive unnecessary psychotropic medications, experience adverse side effects, and detracted from the resident/resident representative's ability to exercise their right to decline treatment/therapies. Findings included . <Facility Policy> Review of the facility's Psychotropic Medication Informed Consent policy revised 10/04/2022 showed the facility would obtain consent or refusal to the use of psychotropic medications and the medication would not be started…

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 1 of 2 garbage dumpsters and 1 of 1 recycling dumpster reviewed and inspected for outdoor garbage and refuse disposal were properly covered and the surrounding areas were kept clean as required. These failures placed the facility at risk of attracting bugs, rodents, and other disease-carrying germs/bacteria that could reproduce, grow, and place the residents at risk for acquiring these diseases. Findings included . <Facility Policy> According to the 04/25/2024 facility policy titled, Disposal of Garbage and Refuse, the facility must dispose garbage and refuse properly per federal, state, and local requirements. The policy showed all waste should be properly contained in the dumpsters and were covered appropriately. The policy showed all areas, where garbage/refuse were located, were kept clean, free of debris, and maintained in a sanitary condition to prevent harborage and feeding of pests. A joint observation and interview on 04/12/2024 at 9:59 AM with Staff D (Dietary Manager) showed three dumpsters…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as assessed to be required for 1 of 2 sample residents (Residents 265) reviewed for rehabilitation with skilled therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. Findings included . <Resident 265> According to the 04/10/2024 admission Minimum Data Set (an assessment tool - MDS), Resident 265 admitted to the facility on [DATE] status post right hip fracture with surgical repair. The assessment showed Resident 265 was assessed to require specialized rehabilitative services to include Physical Therapy (PT) and Occupational Therapy (OT). The assessment showed Resident 265 utilized a walker and wheelchair for mobility devices. The MDS showed Resident 265 had diagnoses of a degenerative neurological disorder, generalized muscle weakness, unsteadiness on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident medical records were accurate and consistent for 2 of 17 sample residents (Residents 166 & 167) whose resident records were reviewed. The facility failed to ensure the correct type of active diagnosis was identified (Resident 166) and the correct Advance Directives (AD) status was represented (Resident 167) in the resident's records. These failures placed residents at risk for unidentified and/or unmet care needs, missed opportunities for care planning, and inaccessible health care instructions if/when needed. Findings included . <Resident 166> According to the 03/21/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 166 had no verbal communication, was rarely or never understood, had both short-term and long-term memory problems, and was severely impaired with their daily decision-making. Review of Resident 166's diagnosis list showed the resident had a diagnosis of dementia without behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer a pneumococcal vaccine for 1 (Resident 213) of 5 residents reviewed for vaccinations. This failure placed the resident at risk for contracting pneumonia (a potentially life threatening lung infection) and associated complications. Findings included . <Facility Policy> According to the facility's Influenza Vaccine & Pneumococcal Vaccine Policy for Residents revised 09/13/2023 showed each resident would be offered a pneumococcal vaccine. If the resident was eligible for the vaccine, the vaccine would be administered to the resident per Physician Orders (POs). <Resident 213> Review of the 04/03/2024 admission Minimum Data Set (an assessment tool) showed Resident 213 admitted to the facility on [DATE]. This assessment showed Resident 213 was not up to date on the pneumococcal vaccine. Review of an Informed Consent for Pneumococcal Vaccine showed Resident 213 consented to receive the pneumococcal vaccine on 03/27/2024. Review of Resident 213's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 9 According to the 03/01/2023 Admissions MDS Resident 9 had diagnoses including metabolic encephalopathy (a brain disease that can cause confusion), Deep Vein Thrombosis (DVT - a blood clotting condition), anemia (low red blood cell count), insomnia, and chronic pain. The MDS showed Resident 9 expected to discharge to the community and active discharge planning was already occurring. Review of the 03/01/2023 Discharge CP showed the goal was to develop and follow full discharge plan with comprehensive and showed Resident 9 wished to return home. The Discharge CP did not include specific and measurable goals for discharge. In an interview on 03/20/23 at 1:29 PM, Staff H (Unit Care Coordinator) stated the Discharge CPs the facility created for residents did not include measurable goals and this was something the facility probably should work on. In an interview on 03/21/2023 at 9:00 AM Staff B stated CPs required specific and measurable goals. Staff B stated they did not know what specifically was meant 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 ensure Care Plans (CP) were maintained, revised, and updated as required for 5 (Residents 26, 37, 20, 39, & 25) of 12 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 26 According to a 02/05/2023 admission Minimum Data Assessment (MDS - an assessment tool) Resident 26 was on isolation or quarantine for an active infectious disease during the observation period. Observations on 03/15/2023 at 10:29 AM showed no isolation or quarantine sign up on Resident 26's door. In an interview at this time, Resident 26 stated they were sick back in January with a respiratory infection and was feeling better. The resident indicated they were no longer on isolation. In an interview on 3/15/2023 at 12:41 PM, Staff L (Unit Care Coordinator) confirmed Resident 26 was not currently on isolation or quarantine precautions. Review of Resident 27's February Treatment…

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 stored and prepared in a sanitary manner and in accordance with professional standards of food safety. The failure to ensure food was stored appropriately, food and trays were free from contaminants, and kitchen staffs' hair was secured as required left residents at risk of food contamination and food-borne illness. Findings included . Facility Policy According to the facility's 12/17/2021 Food Safety policy, upon delivery food should be labeled with the date received. The policy showed if multiple items were packaged in the same box, each individual item should be labeled with a date of receipt. Food Storage Observation of the facility's kitchen on 03/15/2023 at 9:01 AM showed the kitchen's freezer contained one open bag of chicken patties. The bag of patties was not labeled to indicate when it was received or when it was opened and did not indicate for how long they were safe to eat. The freezer also contained two other unopened bags of frozen meats that were not labeled to indicate until…

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 and implement a system to ensure a copy of the Advance Directive (AD) was obtained from residents/representatives who have an AD in place and make the documentation readily available in the medical records for 2 of 12 residents (Resident 20 & 32) reviewed. The facility failed to perform family/representative follow up after providing AD information for 1 of 12 residents (Resident 39) determined to have cognitive limitations necessary for healthcare decision-making. Failure to have the AD accessible to facility staff and failure to follow up the formulation of an AD placed residents at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment including end-of-life care. Findings included . Resident 20 According to the 02/15/2023 Care Plan (CP), Resident 20 had an AD. Review of Resident 20's records showed a 02/15/2023 social services care conference note indicating Resident 20 had delegated a family representative as Durable Power of Attorney for Health Care…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) for 1 of 2 residents (Resident 26) reviewed for SNF beneficiary protection notification. This failure placed residents at risk of not being informed of their right to make choices about further treatment or services, as required by the Medicare Program. Findings included . Resident 26 According to the 02/05/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 26 started Medicare part A skilled services on 01/31/2023. The End of Medicare Stay MDS showed the last day of Resident 26's skilled services was 03/15/2023. On 03/17/2023 at 11:27 AM, Staff K (Business Office Manager) provided a Notice of Medicare Non-Coverage that was signed on 03/08/2023, with an identified last covered date (LCD) of 03/15/2023. According to the facility census information, Resident 26 remained in the facility as private payee effective 03/16/2023. There was no ABN form found in the medical records to show the information about charges for care and services…

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

Based on interview and record review, the facility failed to ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO) received required discharge information for 2 (Resident 41 & 25) of 2 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the LTCO office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . Review of a 08/16/2022 facility Notice of Transfers and Discharges policy showed the facility would provide notice to the resident and/or representative in situations where the facility initiates a transfer or discharge. This policy stated a copy of the notice of transfer/discharge would be sent to a representative of the office of the State LTCO for all facility-initiated transfers or discharges and the facility must maintain evidence the notice was sent to the LTCO. Resident 41 According to the 01/10/2023 Discharge Minimum Data Set (MDS - an assessment tool), Resident 41 was discharged on 01/10/2023 to an acute hospital with Return…

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 nursing services were provided within professional standards of nursing for 3 of 12 sample residents reviewed (Residents 9, 37 & 32). Facility failure to: ensure pain medications were not given outside parameters (Resident 9); ensure psychotropic medications were monitored for Target Behaviors (TBs - the behaviors the medication was prescribed to treat) and Adverse Side Effects (ASEs) (Resident 9); ensure nurses clarified Physician's Orders (POs) (Resident 37); nurses only sign for tasks completed (Resident 32); ensure dressings were changed timely (Resident 32) left residents at risk for negative health outcomes. Findings included . Resident 9 According to the 03/01/2023 Admissions Minimum Data Set (MDS - an assessment tool) Resident 9 had diagnoses including malnutrition, chronic pain syndrome, and insomnia. The MDS showed Resident 9 took pain medications as needed and a hypnotic medication (a class of medications used to induce and/or maintain sleep). The MDS showed Resident 9 had a history of falling in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 3 of 12 (Residents 9, 26, & 17) sample residents whose records were reviewed. Facility failure to document resident refusals and maintain complete and accurate medical records left residents at risk for unidentified patterns of refusals, inaccurate medical records, and other negative outcomes. Findings included . Resident 9 According to the 03/01/2023 Admissions Minimum Data Set (MDS - an assessment) Resident 9 admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy (a brain disease that can cause confusion), altered mental state, and malnutrition. The MDS showed Resident 9 demonstrated no rejection of care during the assessment period. The MDS showed Resident 9 required liquid nutrition through a feeding tube before admitting to the facility. Review of the physician's orders showed a 02/27/2023 order to weigh Resident 9 every day for 5 days starting 02/28/2023. 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.