Life Care 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 comprehensively assess and monitor the needs of physical restraints for 1 of 3 residents (Resident 12) reviewed for physical restraints. This failure placed residents at risk for harm and diminished quality of life. Findings included.<Facility Policy>According to the facilities policy titled, Physical Restraint Use, dated 09/03/2025, the intent was for each resident to attain and maintain their highest practicable well-being in an environment that prohibited the use of physical restraints for discipline or convenience and prohibited the use of physical restraints to unnecessarily inhibit a resident's freedom of movement. The policy showed when alternatives to restraint use were not effective, the facility should evaluate the least restrictive restraint to promote safety for the residents and should have documentation including physician orders, informed consent, care plans, and reevaluation in resident's records.<Resident 12>Resident 12…

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 discharge summary that included a recap of the residents stay and reconciliation of all medications for 1 of 3 residents (Residents 4) reviewed for discharge process and offer a bed hold for 1 of 2 residents (Resident 86) reviewed for hospitalizations. Failure to properly prepare residents for discharge placed residents at risk of rehospitalization, negative health outcomes, and a break in continuity of care. Failure to offer/provide a bed hold to the resident/resident representative placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.Findings included .<Policy>According to the facility policy titled, Against Medical Advice (AMA) Discharges, dated 08/29/2025, the facility would conduct a safe AMA discharge for residents requesting to discharge earlier than outlined in their Care Plan (CP). The policy showed the facility would complete the required documentation and provide…

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 the Minimum Data Set (MDS - an assessment tool) of 1 of 20 residents (Resident 21) were completed accurately to reflect the resident's condition and health status. The facility failed to identify Resident 21's appropriate diet and Restorative Nursing Program (RNP) exercises. This failure placed Resident 21 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy>The facility policy titled, Certification of Accuracy of the MDS, reviewed 08/29/2025, showed the MDS assessment must accurately reflect the resident's status. The policy showed a registered nurse must conduct and coordinate each assessment with the appropriate participation of health professionals. The policy showed appropriate health professionals would correctly identify and document assessed needs necessary for care planning to maintain and/or improve the resident's medical status and functional abilities. <Resident 21>According to the 05/14/2026 Quarterly MDS, Resident 21 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct care conferences for residents and their representatives and the applicable Interdisciplinary Team (IDT) members for 2 of 3 sample residents (Residents 5 & 41) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, a diminished quality of care, unmet care needs, and other negative health outcomes.Findings included.<Facility Policy>Review of a 08/29/2025 Comprehensive Care Plans and Conferences policy showed the facility would ensure the timeliness of each resident's person-centered, comprehensive CP, ensure the CP was reviewed and revised by an IDT, and that each resident and their representative, if applicable, was involved in developing the care plan and making decisions about their care. Care plans were to be revised based on changing resident needs. The facility had the responsibility to assist residents to engage in the care planning process including care planning…

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 physician's orders were followed for 1 of 2 residents (Resident 8) reviewed for bowel care and 2 of 5 residents (Residents 83 & 12) reviewed for Unnecessary Medications. The failure to follow orders for oxygen administration, bowel protocols, and parameters for blood pressure (BP) medications placed residents at risk for medication errors, unmet care needs, and other negative health outcomes.Findings included.<Facility Policy>According to a Bowel Protocol policy, reviewed 09/15/2025, the facility would provide effective interventions for signs and symptoms of constipation that were consistent with current standards of practice. Nursing staff would record each time a resident had a bowel movement (BM), and implement physician orders to address the lack of a BM.<Bowel Protocol> <Resident 8> According to the 04/04/2026 admission Minimum Data Set (MDS – An assessment tool) Resident 8 admitted to the facility on [DATE] with diagnoses 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 observation, interview, and record review the facility failed to ensure residents' skin was assessed, documented, monitored, and treated as required for 2 of 5 residents (Residents 5 &11) reviewed for non-pressure skin issues. These failures placed all residents at risk for delay in treatment, worsening of condition, and decreased quality of life. Findings included.<Policy>According to the facility policy titled, Area of Focus: Basic Skin Management, dated 12/03/2024, the facility would ensure all residents had a weekly head to toe skin assessment documenting a thorough description of all skin alterations at the time of the assessment.<Resident 5> According to the 03/06/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 5 had no memory impairment. The MDS showed Resident 5 was at risk for skin injuries and required staff assistance with all Activities of Daily Living (ADL). The assessment showed Resident 5 had diagnoses of general muscle weakness and adult failure to thrive. Review of 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 ensure effective pain management was provided to residents, consistent with professional standards of practice, for 2 of 3 sampled residents (Residents 21 & 38) reviewed for pain management. The failure to offer non-pharmacological interventions to residents experiencing pain, investigate causes of pain, and notify the physician for appropriate pain management placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.Findings included .<Facility Policy>According to the facility's 12/02/2025 Pain Management policy, the facility would ensure pain management was provided to residents who needed it, consistent with professional standards of practice and the resident's comprehensive assessment and care plan. <Resident 21> According to the 05/14/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 21 was alert, capable of verbalizing their needs, and had medical conditions 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.

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded timely for 1 of 2 medication storage rooms (North Medication Room) and to ensure medications were labeled appropriately in 1 of 4 medication carts (200 Hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving incorrect or expired medications, ineffective treatment, and diminished quality of life. <North Medication Room> Observation on 05/29/2026 at 8:00 AM in the North Medication room showed the following: Three inhalers (portable handheld devices that deliver medication via a fine mist, spray, or powder to be inhaled orally) that were opened with no open date. Two boxes containing vials of nebulizer medication (liquid medicine that is converted into a fine, breathable mist by a machine called a nebulizer) with expiration dates of 07/10/2025 and 10/29/2025. Vaccines stored in the refrigerator with expiration dates of 02/12/2025, 05/02/2025, 07/31/2025, and 10/23/2025. Review of a 2024 Medication Storage Guidance…

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 Antibiotic Stewardship Program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 1 of 5 residents (Resident 91) reviewed for unnecessary medications and 1 of 1 supplemental residents (Resident 53). This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.Findings included. <Policy>According to the facility's 06/02/2025 Infection Prevention and Control Program (IPCP) and Plan policy, the facility would conduct antibiotic surveillance to review the appropriateness of antibiotics in the facility to prevent unnecessary antibiotic use.<Resident 91>Review of Resident 91's health records showed they were receiving an intravenous antibiotic starting on 05/27/2026 with no stop date.<Resident 53>Review of Resident 53's health records showed they received an oral antibiotic from 05/12/2026 through 05/19/2026.Review of the facility's May 2026 Line Listing showed Resident 53 and Resident 91 were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a policy and procedures to assess and manage pain for 1 of 3 Residents (Resident 1) reviewed for pain management. The failure to thoroughly assess resident pain on admission, develop an individualized care plan (CP) in collaboration with the resident, their representative and practitioner, implement the CP, monitor for adverse consequences, notify the resident representative of medication changes, and document resident conditions, placed residents at risk for untreated pain, medication overdose, hospitalization, and diminished quality of life.Findings included.<Facility Policy>Review of the 09/23/2025 revised Pain Assessment and Management Policy showed all residents would be assessed for pain indicators on admission, quarterly, and with any change in condition; an individualized pain management CP would be developed and initiated when pain indicators were identified. The policy showed the facility would collaborate with the prescriber, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents' Care Plans (CPs) were comprehensive and implemented for 6 of 18 (Residents 139, 63, 6, 8, 69, & 14) sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 09/11/2024 Comprehensive Care Plans and Revisions policy, the facility would develop a comprehensive CP for each resident within seven days of completion of a comprehensive assessment. <Resident 139> According to the 03/04/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 139 required substantial/maximal assistance with bathing and had a moderate memory impairment. The MDS showed Resident 139 admitted to the facility on [DATE]. The MDS showed Resident 139 had a highly transmissible gastrointestinal infection that required isolation. Review of the 02/27/2025 ADL Assistance . CP included a goal…

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 facilitate quarterly care conferences for 5 of 8 residents (Resident 63, 77, 8, 14, & 64) reviewed for care planning, and failed to ensure Care Plans (CPs) were revised as required for 1 of 19 samples residents (Resident 80). Theses failures placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 09/05/2024 Comprehensive Care Plans and Conferences policy, the facility would ensure each resident, and their representative if applicable, would be involved in developing the CP. The policy showed the facility had a responsibility to assist residents to engage in the care planning process by holding the care conference at the time of day when the resident functioned best, and to encourage the resident's representative to participate in the care planning and attend the care conference. The policy showed CPs should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician orders were clarified for 3 of 5 sampled residents (Residents 8, 14, & 13) reviewed for unnecessary medications, and failed to ensure residents with multiple as-needed (PRN) pain medications had parameters to their orders for 3 of 5 residents (Residents 13, 14, & 8) reviewed for pain. These failures placed residents at risk for ineffective treatments, unmet pain management needs, overmedication, medications errors, and delayed treatment. Findings included . <Clarifying Orders> <Resident 8> According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 8 had no memory impairment. The MDS showed Resident 8 admitted to the facility on [DATE]. The MDS showed Resident 8 had no bed rails in use on their bed. Review of Resident 8's health records showed a 01/23/2023 evaluation for use of bed rails documenting the use of bilateral quarter bed rails to Resident 8's bed. Resident 8's health records…

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 an environment free of accident hazards for 2 of 4 units (Units 100 & 200), ensure wheelchairs were assessed for safety prior to use for 1 of 9 residents (Resident 63) reviewed for positioning/mobility, and failed to ensure sharps and chemicals were stored safely for 1 of 4 shower rooms (100 Hall Shower Room) reviewed. The failure to ensure hot water was maintained within safe limits, wheelchairs were assessed for safety prior to use, and shower rooms were free of hazards placed residents at risk for burns, exposure to sharps and chemicals, wheelchair accidents, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 01/21/2025 Hot Water Temperature Inspection Policy, the facility would monitor temperatures weekly. The policy showed hot water temperatures could reach hazardous temperatures in hand sinks, showers, and tubs accessible to residents, and many residents in long-term 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 ensure the Dietary Manager (Staff J) had the required qualifications to perform their duties for 1 of 1 facility kitchens. The failure to ensure a Dietary Manager without the required certification had fulltime support from a Registered Dietician (RD) placed all residents at risk of receiving a menu prepared by staff without the required competencies and skills to provide food and nutrition services. Findings included . During kitchen rounds on 03/11/25 Staff J at 8:35 AM (Incoming Dietary Director) provided access to the kitchen and stated they were in charge. In an interview on 03/18/2025 at 11:14 AM Staff J stated they did not complete the required dietary manager training. Staff J stated the previous Dietary Director left sooner than anticipated. Staff J stated the facility's Registered Dietician (RD) did not work a fulltime schedule at the facility. In an interview on 03/18/2025 at 12:01 PM Staff Q (RD) stated they were also the dietician for a sister facility. Staff Q stated they worked at the facility on Tuesdays…

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 education for the influenza vaccination and administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 4 (Residents 8,14, 13, & 64) of 5 residents reviewed for vaccinations. This failure placed residents at risk of experiencing complications, not being able to make an informed decision, and contracting pneumonia, with its associated complications. Findings included . <Policy> According to a facility policy titled, Pneumococcal Vaccine Policy for Residents, revised 01/28/2025, each resident would be offered the pneumococcal vaccine. The policy showed there would be documentation in resident health records of historical pneumococcal vaccination. The policy showed the facility would readdress refusals annually and show documentation of doing so. The policy showed education would be provided to the residents regarding the benefits and potential side effects and consent would be obtained. According to the facility policy titled, Influenza Vaccine Policy for Residents, revised 01/28/2025, 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 record review and interview, the facility failed to provide education on the benefits and potential side effects of the Covid-19 (C19) vaccination for 4 of 5 sampled residents (Resident 8, 14, 13, & 64) and provide education on the benefits and potential side effects of the C19 vaccination for 1 of 1 sampled staff (Staff U - Restorative Aide) reviewed for vaccinations. This failure placed residents, their representatives, and staff at risk of not being given the opportunity to make an informed decision regarding their medical care, potential complications of a communicable disease, and a decreased quality of life. Findings included . <Policy> According to a facility policy titled, Covid-19 (SARS-CoV-2) Vaccination Program Policy for Associates, revised 11/27/2024, showed the facility would provide education regarding the benefits and potential side effects associated with the C19 vaccine and offer the vaccine unless it was medically contraindicated, or staff member had already been immunized. The policy showed the facility would maintain a copy of the education material…

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 a system to ensure 1 of 1 (Staff CC) nursing aides reviewed for training received the required training for continued competency of no less than 12 hours per year. The failure to implement a system to provide mandatory training on dementia management, abuse prevention, and other specialized resident needs placed residents at risk for abuse, neglect, emotional distress, and physical injury. Findings included . In an interview and record review on 03/17/2025 at 1:42 PM, Staff C (Regional Director of Clinical Services) reviewed the personnel file for Staff CC and found no training documents related to abuse, neglect, exploitation, infection control, communication, resident rights, or cultural competency after Staff CC's hire date of 08/05/2024. Staff C stated the facility currently had no staff development coordinator who tracked nursing assistants continuing education and annual training requirements for mandatory topics or the topics related to resident population's special needs. REFERENCE: WAC…

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 adequate care in a manner that promoted dignity for 1 of 2 (Resident 31) residents reviewed for dignity, and 1 supplemental resident (Resident 16) reviewed for care conference choices. The failure to provide adequate notice prior to a care conference and honor resident's preferences left residents at risk for feelings of diminished self-worth and embarrassment. Findings included . <Facility Policy> According to the facility's revised 09/26/2024 Dignity policy, each resident had the right to be treated with dignity and respect. Interactions and activities with residents by staff would focus on maintaining and enhancing the resident's self-esteem, and self-worth and incorporate the resident's goals preferences and choices. Staff must respect the resident's individuality as well as honor the value of their input. <Resident 31> According to a 02/18/2025 admission Minimum Data Set (MDS-an assessment tool), Resident 31 could make themselves understood and understood others in conversation. Resident 31 had a cognitive…

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 resident consent for the Covid-19 (C19) vaccination for 4 of 5 sampled residents (Residents 8, 14, 13, & 64) reviewed for vaccinations, obtain resident consent prior to administration of psychotropic medication for 1 of 5 residents (Resident 14) reviewed for unnecessary medications, and obtain consent prior to utilization of a tilt-in-space wheelchair for 1 of 9 residents (Resident 63) reviewed for positioning and mobility. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options. Findings included . <Policy> According to the facility's 09/10/2024 Resident Rights policy, residents had the right to be informed in advance of the care of the care to be furnished. The policy showed residents had the right to refuse treatment. According to the facility's 09/06/2024 Physical Restraint Use policy defined a physical restraint as any device that was attached…

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.

Base on record review, and interview, the facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 (Residents 63, 14, & 77) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure 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> According to the facility's 09/26/2024 AD Policy showed residents or their representatives would receive materials explaining their right to formulate an AD upon admission. The policy showed if a resident already had an AD, the facility's social worker would request a copy and and add it to the resident's record. <Resident 63> According to the 01/22/25 Annual Minimum Data Set (MDS - an assessment tool) Resident 63 had intact cognition and diagnoses including heart failure and a kidney condition. According to the Resident is [their] own decision maker . Care Plan (CP)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to keep rooms free of wall gouges, room furniture in good repair, and hot water at a comfortable temperature for 2 of 4 units (Units 400 & 100) left residents at risk for a less-than-homelike environment. Findings included . <Policy> According to a facility policy titled, Resident Belongings and Home Like Environment, revised 06/12/2024, the facility would provide a safe, clean, comfortable, and homelike environment. <room [ROOM NUMBER]> Observations on 3/11/2025 at 1:54 PM showed room [ROOM NUMBER] had deep gouges and exposed drywall on the wall behind the head of the resident bed. <room [ROOM NUMBER]> Observations on 03/17/2025 at 9:40 AM showed room [ROOM NUMBER] had deep gouges and exposed drywall on the wall behind the head of the resident bed. <room [ROOM NUMBER]> In an interview on 03/18/2025 at 10:00 AM Resident 43 stated they told the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notice at time of transfer/discharge, or as soon as soon as practicable and ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO - an advocacy group for individuals residing in nursing homes) received required resident transfer/discharge information for 2 of 3 residents (Residents 8 & 69) reviewed for hospitalizations. Failure to ensure written transfer notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make an informed decision about the transfer/discharge. The failure to ensure required notifications were completed, prevented the LTCO office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Policy> According to a facility policy titled, Notice of Transfers 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 record review and interview, the facility failed to provide the resident and/or the representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 3 of 3 residents (Residents 8, 69, & 64) reviewed for hospitalizations. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the residents bed while hospitalized that was necessary for decision making. Findings included . <Policy> According to a facility policy titled, Bed-Hold, revised 09/05/2024, the facility would give the resident a copy of the facilities bed hold policy upon transfer or within 24 hours of transfer. The policy showed documentation of providing the bed hold policy would be in the residents records for each transfer/discharge. <Resident 8> According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 had no memory impairment. The MDS showed Resident 8's most recent reentry into 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 a Level II Preadmission Screening and Resident Review (PASRR - a mental health screening required prior to nursing home admission) evaluation was completed and/or incorporated into the Care Plan (CP) for 2 of 8 residents (Residents 26, 43) reviewed for PASRR. This failure placed residents at risk for unmet mental health care needs, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 09/24/2024 PASRR policy the facility would ensure potential admissions were screened for possible Serious Mental Illness (SMI) or Intellectual Disabilities (ID). A positive Level I screening required an in-depth evaluation by the state authority, known as a PASRR Level II. The PASRR process required the facility to notify the appropriate state mental health authority when a resident with a mental disorder or intellectual disability had a significant change in their physical or mental condition. The policy showed recommendations from the PASRR Level II determination and PASARR…

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 Pre-admission Screening and Resident Review (PASRR) assessments were completed for 2 of 6 residents (Resident 64 & 69) 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 . <Policy> According to a facility policy titled, Pre-admission Screening and Resident Review, revised 09/26/2024, showed if a level I PASRR indicated Serious Mental Illness (SMI), a level II PASSR referral to the state designated authority would be made prior to admission to the facility. <Resident 64> According to a 12/13/2024 Annual Minimum Data Set (MDS- an assessment tool) Resident 64 admitted to the facility on [DATE]. The MDS showed Resident 64 had diagnoses of, but not limited to, anxiety disorder and depression. Review of Resident 64's health records showed they had SMI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary care and services for 1 of 1 resident (Resident 77) reviewed for communication. Failure to provide communication assistance for residents where English was a second language placed residents at risk of miscommunication, unmet care needs, and quality of care. Findings included . <Policy> According to a facility policy titled, Language Access Services and Effective Communication, revised 01/07/2025, the facility would ensure residents, where English was not their primary language, would have access to interpreters/translators and other aides needed without cost. <Resident 77> According to an 11/05/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 77 admitted to the facility on [DATE]. The MDS showed Resident 77's preferred language was their primary language. The assessment showed Resident 77 needed an interpreter to communicate with the doctor and health care staff. Review of an 11/08/2024 communication…

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 - bathing etc.) to residents dependent on staff assistance for 1 (Resident 139) of 5 residents reviewed for ADL. The failure to provide bathing assistance to residents placed residents at risk for poor hygiene, skin breakdown, and feelings of diminished self-worth. <Facility Policy> According to the facility's 09/10/2024 ADL policy showed residents unable to perform their own ADL would receive the necessary assistance to maintain good grooming, and personal hygiene. <Resident 139> According to the 03/04/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 139 required substantial/maximal assistance with bathing and had a moderate memory impairment. The MDS showed Resident 139 admitted to the facility on [DATE]. The MDS showed Resident 139 had a highly transmissible gastrointestinal infection that required isolation. According to the 02/27/2025 bathing preferences form…

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 a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were implemented for 2 of 22 sample residents (Residents 32 & 16) and one supplemental resident (Resident 60), related to lifesaving treatment orders. The failure to follow the POLST instructions for Cardiopulmonary Resuscitation (CPR) (Resident 32) or ensure the POLST was readily available (Residents 16 & 60) placed residents at risk for receiving unwanted CPR, avoidable trauma, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's [DATE] CPR policy, when a resident admitted to the facility, staff would verify if the resident had any Advanced Directives (legal documents that provide instructions for medical care when a resident cannot communicate their own wishes) and if not, verify if the resident did not wish to receive CPR. The policy showed if the resident did not want CPR, a physician's order would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure 3 of 3 residents (Resident 8, 13, & 64) reviewed for Edema (fluid retention in the body) received the necessary care and services they required in accordance with professional standards of practice. The facility failure to assess and monitor residents with edema placed residents at risk for complications, worsening conditions, and a diminished quality of life. Findings included . <Resident 8> According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 reentered the facility on 08/08/2024. The MDS showed Resident 8 had diagnoses of, but not limited to, heart failure with edema. The MDS showed Resident 8 received diuretic medication during the assessment period. Review of an 11/02/2023 diuretic therapy Care Plan (CP) showed Resident 8 received diuretic medication for edema. Review of Resident 8's health records showed a 08/08/2024 physician's order for a diuretic medication given daily for edema. Resident 8's health…

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 fresh water was offered for 5 of 5 residents (Residents 8, 14, 13, 69, & 64) reviewed for hydration. Failure to offer fresh water daily placed residents at risk of dehydration, potential risk for medical complications, and decreased quality of life. Findings included <Policy> According to a facility policy titled, Hydration and Nutrition, revised 09/10/2024, each resident would be offered fluids to maintain proper hydration. The policy showed fluids would always be available to residents and a hydration cart may be utilized. <Resident 8> According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 reentered the facility on 08/08/2024. The MDS showed Resident 8 had no memory impairment. In an observation and interview on 03/12/2025 at 1:30 PM Resident 8's water pitcher was empty. At this time Resident 8 stated the staff do not offer fresh water and they only get it if they ask. Observations on 03/13/2025 at 10:16 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 ensure 1 of 4 residents (Resident 43) reviewed for respiratory care, were provided the care they required, consistent with professional standards of practice. Failure to ensure oxygen delivery was provided according to physician ordered flow rates and failure to monitor oxygen equipment, placed residents at risk of respiratory discomfort, oxygen-related accidents, and a decreased quality of life. Findings Included . <Facility Policy> According to the revised 10/11/2024 Oxygen Administration Policy, the facility must ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice and the person-centered care plan. Oxygen orders should be written for a specific flow rate required by the resident. <Resident 43> According to the 12/03/2024 Annual Minimum data set (MDS - an assessment tool) Resident 43 had a diagnosis of chronic obstructive pulmonary disease (COPD) and required oxygen therapy. According to the 12/03/2024 COPD care plan (CP), staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain consent prior to implementing bed rails/bed against the wall for 2 of 3 residents (Resident 8 & 69) and complete a safety assessment for the bed against the wall for 1 of 3 residents (Resident 69) reviewed for accident hazards. The failure to obtain consent and complete a safety assessment prior to implementing bed rails/bed against the wall placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to facility policy titled, Bed Rails - Safe and Effective Use of Bed Rails, revised 09/06/2024, the facility would review the risks and benefits of bed rail use with the resident/representative prior to installation, complete a safety assessment, and obtain the resident/representatives consent. The policy showed a comprehensive care plan would be developed for the use of bed rails within 48 hours of installation. <Resident 8> According to a 12/24/2024 Annual 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.

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 80) reviewed for mood and behavior was evaluated for potential mental health services to address demonstrated ongoing behaviors and failed to notify the provider of changes in behavior. This failure placed Resident 80 at risk for untreated mental health issues and other negative health issues. Findings included . <Resident 80> According to the 01/28/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 80 had diagnoses including depression, a cognitive communication deficit, and failure to thrive and received an antidepressant medication. Review of the 02/04/2025 Antidepressant Care Plan (CP) showed staff were to report changes in behavior and mood. Review of a 01/24/2025 physician order showed staff were to monitor Resident 80's exhibited behavior including verbal abuse. Staff were to redirect the resident and provide one-on-one services and chart in the progress notes. Review of the progress notes showed nursing staff documented on 03/04/2025,…

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 medication refrigerator temperatures were monitored for 1 of 2 medication rooms (100/200 Unit); ensure expired medications and biologicals were disposed of appropriately for 1 of 2 medication rooms (300/400 Unit); and ensure medications and biologicals were secured for 1 of 6 Residents (Resident 31) reviewed for medication storage. These failures placed residents at risk for receiving the wrong medications, expired medications, and other negative health outcomes. Findings included . <Facility policy> According to the revised 09/13/2024 Medication Storage in Refrigerator/Freezer policy the facility would ensure all medications and biological were stored in the appropriate temperatures. Safe temperatures for refrigeration were between the range of 36 degrees to 46 degrees Fahrenheit. <Medication room [ROOM NUMBER]/200> Observation on 03/13/2025 at 2:33 PM of 100/200-unit medication room showed the medication refrigerator temperature…

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 confidentiality of resident records was maintained for 1 of 4 medication carts (100 hall medication cart) reviewed. This failure placed residents at risk for a violation of their rights to privacy. Findings included . <Policy> According to a facility policy titled, Resident Rights, revised 09/10/2024, the facility must protect and promote the rights of the residents. The policy showed residents had the right to privacy and confidentiality of their medical information. <100 hall medication cart> In an observation and interview on 03/11/2025 at 12:33 PM Staff O (Licensed Practical Nurse) walked away from their medication cart with a list of all residents on 100 hall with their health information unsecured and in view. Staff O stated they were expected to maintain confidentiality of all resident information but did not. Staff O stated it was important to maintain confidentiality of resident information for their rights. In an observation and interview on 03/12/2025 at 12:33 PM Staff P (Registered Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff and failed to implement and develop a coordinated Care Plan (CP) for 1 of 2 residents (Resident 25) reviewed for hospice services. The failure to implement a system by which consistent communication between the facility and hospice staff occurred placed residents at risk for not for receiving necessary care and services, avoidable discomfort, and other negative health outcomes. Findings included . <Facility Policy> According to facility's revised 11/19/2024 Hospice policy, the facility would ensure the resident's CP included the most recent hospice plan of care and a description of services provided by the facility to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. The facility must designate a member of the team to ensure the resident received quality care in collaboration with the facility staff and the hospice…

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 Implementation> <Resident 84> According to the 02/21/2025 admission MDS Resident 84 had a Multidrug-resistant Organism (MDRO - a difficult to treat infectious organism) infection and surgical wounds. The MDS showed Resident 84 used an antibiotic medication. According to a 02/17/2025 physician's order Resident 84 required contact precautions (a type of TBP requiring anyone who entered the room to utilize specified Person Protective Equipment (PPE) before entry) related to their MDRO infection. Observation on 03/12/25 at 12:28 PM showed Enhanced Barrier Precautions (a system of PPE usage required for certain conditions that only required facility staff to use PPE when close contact with the resident was anticipated) were in place instead of the contact precautions ordered. In an interview on 03/18/2025 at 1:07 PM Staff B stated the sign on the door should reflect the order but did not.Based on observation, interview, and record review the facility failed to appropriately store resident respiratory equipment…

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 qualified nursing staff were provided training and specialized training for 4 of 5 staff members (Staff I [Infection Preventionist], Staff K [Licensed Practical Nurse], Staff CC [Certified Nursing Assistant - CNA] and Staff S [CNA] sampled for staff training. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the undated Facility Assessment showed staff were to be trained upon hire, annually, and as needed in the areas of communication, resident rights-ensuring staff were educated on residents rights and to properly care for its residents, abuse and neglect, infection control, person centered care, resident changes in condition, cultural competency, and quality assurance and performance improvement. Review of staff training records did not show documentation (Staff I, Staff K & Staff CC) received training upon hire or annual training of facility assessment trainings. In an interview on 03/17/2025 at 12:18 PM Staff DD (Staffing…

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 written explanation to residents and/or their representative for a facility initiated room change for 4 of 7 residents (Residents 14, 13, 12, & 11) reviewed for room moves. The failure to discuss reasons for a room move, provide written notification, provide an opportunity for the resident to see the new location and meet the new roommate, or inform roommates of a new person moving into the room placed residents at risk for feeling frustrated, powerless, and a diminished quality of life. Findings included . <Policy> Review of the facility policy Resident Room Relocation revised 09/05/2024 showed when a resident was moved at the request of the facility, the resident and/or their representative would receive an explanation in writing of why the move was required. The policy showed the resident should be provided the opportunity to see the new location, meet the new roommate and ask questions about the move. The policy showed a resident receiving a new roommate should be given as much advanced notice as possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a system to assess resident's need for the use of an air mattress, determine required settings of the air mattress, recognize or assess risk factors of the use of an air mattress, inform and educate residents or their representatives of the risks of using an air mattress including falls and/or injury, obtain informed consent from the resident or their representative for the use of an air mattress, implement a resident-directed care plan for the use of an air mattress, monitor the mattress function, condition, and individualized pump settings, re-evaluate the ongoing use of air mattresses for each resident to ensure necessity of use, and train staff to use the air mattress and assessed settings during care to ensure resident safety for 7 of 7 residents (Residents 1, 2, 3, 4, 5, 6, & 7) reviewed for accidents and hazards. This failure placed 11 current residents observed using air mattresses at risk of falls, injury,…

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 incident reports were completely and thoroughly investigated for 2 of 3 residents (Residents 4 & 7) whose facility investigation reports were reviewed for injuries of unknown origin. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect, repeated incidents, and a decreased quality of life. Findings included . <Facility Policy> Review of the Abuse - Conducting an Investigation facility policy, revised 06/17/2024, showed allegations of abuse, including injuries of unknown source, were promptly and thoroughly investigated so the facility could take appropriate corrective action as a result of the investigation findings. The policy showed the facility must have evidence to support that all alleged violations were thoroughly investigated within five working days of the incident occurring. The policy showed the written summary of the investigation should include a review of all circumstances surrounding 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 one of four abuse allegations reviewed were identified as such and reported to the State Survey Agency as required. The facility failed to report an allegation of abuse by Resident 4 towards Resident 3. Failure of the facility to report allegations of abuse placed residents at risk for additional abuse. Findings included . Review of the facility Abuse - Reporting and Response policy, revised 10/13/2023 showed the facility would report alleged violations related to abuse and report the results of all investigations to the proper authories within prescribed timeframes. The facility would ensure that all alleged violations involving abuse, and/or neglect were reported immediately, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the facility administrator and other officials, including to the State Survey Agency in accordance with state law through established procedures. During an interview on 04/03/2024 at 11:42 AM 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 ensure allegations of abuse were thoroughly investigated for two of four abuse allegations reviewed. The facility failed to investigate an allegation of abuse by Resident 4 towards Resident 3, failed to conduct a thorough investigation of abuse of Resident 2 by Resident 1 and failed to identify or implement preventative measures. Failure of the facility placed residents at risk of continued abuse and a diminished quality of life. Findings included . <Residents 3 & 4> During an interview on 04/03/2024 at 11:42 AM Resident 3 stated the other night they were lying in bed and Resident 4 threw a plate and it hit them in the eye. Resident 3 stated they were hit on the toe the same time they were hit on the eye. Resident 3 stated if Resident 4 wanted something and did not get it they threw stuff, which hit them. Resident 3 stated one night Resident 4 threw a whole tray with food, silverware, etc. Resident 3 stated they try to get out of the way, they usually just get up and leave the room. Resident 3 stated they were afraid to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement an effective infection control program with monitoring to demonstrate ongoing analysis and trending of infectious organisms resulting in staffs inability to identify trends and implement interventions, placing residents at risk for facility acquired infections.1) The facility failed to ensure: Accurate notification was provided to the Department of Health (DOH) for 2 of 9 (Residents 74 & 244). 2) Ensure residents were monitored for symptoms of infection for 3 of 9 (Residents 48, 494, & 11). 3) Ensure Personal Protective Equipment (PPE) was utilized correctly for 1 of 9 (Resident 14). 4) Ensure Transmission Based Precaution (TBP) recommendations were followed (Resident 14). 5) Ensure Hand Hygiene (HH) principles were followed for 3 of 9 (Residents 19, 47, & 6). 6) Ensure areas for cross contamination were identified and corrected for 1 of 9 (Resident 10). 7) Ensure noncleanable surfaces were identified and removed from patient…

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 (CPs) were implemented and revised as needed for 8 of 19 sample residents (Residents 73, 34, 19, 47, 244, 84, 14, & 75) whose CPs were reviewed. The failure to ensure CPs were implemented or revised when necessary left residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 08/22/2023 Comprehensive Care Plans and Revisions policy, the facility would ensure all residents' CPs were comprehensive, reviewed and revised periodically, and completed timely. The policy showed each resident and/or their representative was involved in CP development as applicable. <Resident 73> According to the 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had intact memory and thinking, and had diagnoses including heart failure, muscle weakness, and a need for assistance with personal care. The MDS showed Resident 73 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 5 of 20 sample residents (Residents 16, 20, 69, 10, & 73) received the necessary care and services in accordance with their comprehensive person-centered plan of care. The failure to follow physicians' orders (Residents 16, & 20), provide treatment to non-pressure skin (Residents 69), provide less frequent blood sugar checks (Resident 10), assess Range of Motion (ROM) issues (Resident 73) left residents at risk for unfollowed physician orders, unmanaged skin impairment, discomfort, ongoing infection, high blood sugar, reduced hand ROM function, and other negative health outcomes. Findings included . <Facility Policy> The facility's 03/31/2023 Skin Integrity & Pressure Ulcer/Injury Prevention Management policy showed decreased mobility, heart failure, malnutrition, and peripheral venous insufficiency with edema increased a resident's susceptibility to develop pressure injuries. This policy showed all residents upon admission were at…

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

Based on observation, interview, and record review the facility failed to ensure 4 of 5 sample residents (Residents 10, 41, 20, & 84) and 2 supplemental residents (Residents 13 & 12) reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to physician ordered flow rates (Resident 10 & 84), monitor respiratory status while receiving supplemental oxygen (Resident 10 & 84), and maintain oxygen equipment (Residents 10, 84, 41, 20, 13, & 12) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life. Findings included . <Facility Policy> The facility's 09/26/2023 Oxygen Administration/Safety/Storage/Maintenance policy showed oxygen would be administered in accordance with the PO and current standards of practice. The policy outlined for the purpose of infection control, the staff would change oxygen supplies weekly and when visibly soiled; equipment should be dated when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 3 (Residents 73, 18, & 25) of 5 residents whose medication regimens were reviewed, and 2 supplemental residents (Residents 84 & 75) were free of unnecessary psychotropic medications. This failure left residents at risk for receiving unnecessary psychotropic medications, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's October 2022 Psychotropic Medication Use policy, psychotropic medications must be prescribed for a diagnosed condition. The policy showed the facility should not use psychotropic medications to address behaviors without first determining if there was a medical, physical, functional, psychological, social, or environmental cause. The policy showed psychotropic medications should only be used in non-pharmaceutical approaches and if interventions were unsuccessful. The policy showed psychotropic medications should only be prescribed as-needed (PRN) for 14 days.…

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 of the risks and benefits associated with psychotropic medication therapy (medications that affected the mind, emotions, and behavior), and obtain their consent for prescribed psychotropic medications for 2 of 7 residents (Residents 69 & 75) reviewed for psychotropic medications. These failures detracted from the residents' ability to exercise their right to make informed treatment decisions and their right to decline treatment. Findings included . <Resident 69 > According to an 11/02/2023 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 69 had no memory impairment and was taking an Antidepressant (AD) medication since admission to the facility. Review of Resident 69's order summary showed a 08/16/2023 order for an AD medication to be administered daily to Resident 69. Review of Resident 69's August 2023, September 2023, October 2023, November 2023, December 2023, and January 2024 medication administration records showed Resident 69 received the AD medication as ordered. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care which upheld their right to dignity. Facility staff failed to provide a dignified existence for 2 of 20 residents (Resident 75 & 51) reviewed for dignity. These failures placed residents at risk for invasion of privacy and had the potential to negatively impact the residents' quality of life. Findings included . <Resident 75> According to a 12/07/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 75 admitted to the facility on [DATE] and had severe memory impairment. This assessment showed Resident 75 had a urinary catheter (tubing to assist voiding urine) during the assessment period. Record review showed Resident 75 had an order for the catheter since admission to the facility on [DATE]. The 11/29/2023 catheter order directed staff to provide catheter care every shift. Observations on 01/03/2024 at 9:54 AM, 01/04/2024 at 11:12 AM, and 01/05/2024 at 7:26 AM showed Resident 75 with 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 Based on observation, interview, and record review the facility failed to honor residents' rights to make choices of bathing for 3 of 4 residents (Resident's 75, 18, & 57), and choices of hair length for 1 of 4 residents (Resident 75) reviewed for choices. Failure to honor resident choices placed residents at risk for impaired hygiene, lack of choice, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 09/25/2023 Resident Rights policy, all residents had the right to make choices about their schedule and health care. The policy showed residents had the right to self-determination. The policy directed staff to ensure each resident was treated in a manner that promoted maintenance or enhancement of their quality of life. <Bathing> <Resident 75> According to the 12/07/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 75 had severe memory impairment and required maximal assistance with bed mobility, transfers, and personal hygiene. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain, renew as needed, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 3 of 10 residents (Residents 19, 47, & 14) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care. Findings included . <Facility Policy> According to the facility's [DATE] Advance Directives and Advance Care Planning policy residents had the right to execute an AD. The policy showed residents would be educated on their right to formulate an AD, which was the responsibility of the facility's Social Services department. The policy showed residents' decisions on whether to formulate an AD should be documented in the record. The policy did not address how to manage an expired guardianship (a document granting legal responsibility to another party when a person 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.

Based on observation, interview, and record review the facility failed to timely complete, thoroughly investigate, and provide prompt resolutions for complaints brought forth by residents and their representatives for 3 of 19 sample residents (Residents 34, 57, & 14) reviewed for grievances. Failure to ensure concerns about missing property (Resident 34), room noise (Resident 57), and incontinent care (Resident 14) were addressed and resolved placed residents at risk for misappropriation, frustration, neglect, and a diminished quality of life. Findings included . <Facility Policy> The facility's 09/25/2023 Grievance Program showed the facility would ensure prompt resolution of all grievances regarding resident rights within a reasonable expected timeframe. The policy showed any associate could assist in the completion of a Concern & Comment Form if a resident, family member, or guest expressed a concern or comment. The policy showed recordkeeping was maintained for grievances including the date of the grievance, a summary statement, steps taken to investigate, a conclusion to show…

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 report allegations of abuse and/or neglect, including injury of unknown origin, within five working days of the incident for 1 of 1 closed records (Resident 93) reviewed for death in the facility. This failure placed residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> The facility's [DATE] Incident and Reportable Event Management policy showed the facility would ensure all alleged violations involving abuse and neglect including injuries of unknown source were reported immediately no later than two hours after an event/allegation happened and/or was made. The policy, under the heading External Notifications, showed the facility should immediately report injuries of unknown origin to officials in accordance with state law including state survey and certification agencies. The policy showed the final investigation report was due to state licensing and certification agencies…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to initiate and thoroughly investigate the occurrences of events for 1 of 1 closed records (Resident 93) reviewed for death in the facility and for 1 of 4 residents (Resident 25) reviewed for falls. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect, repeated incidents, and a decreased quality of life. Findings included . <Facility Policy> The facility's [DATE] Incident and Reportable Event Management policy showed the facility defined an accident as any unexpected or unintentional incident which resulted or could result in injury to a resident including a fall. The policy showed unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred and the licensed nurse should perform an investigation to determine the most likely cause of the event. The policy showed the Director of Nursing (DON)…

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 were comprehensively assessed using the Centers for Medicare and Medicaid (CMS) specified Resident Assessment Instrument (RAI - a guide directing staff on how to accurately assess the status of residents) process and/or complete a Significant Change Minimum Data Set (MDS - an assessment tool) for 1 of 1 residents (Resident 14) who experienced a significant change in their health status. Failure to identify a significant cognitive decline and an increased need for Activities of Daily Living (ADL) assistance placed Resident 14 and other residents at risk for delayed care planning, further ADL decline, unmet care needs, and a decreased quality of life. Findings included . <RAI process> The October 2023 RAI manual defined a significant change as a major decline in a resident's status that would not normally resolve itself or was not self-limiting; impacted more than one area of the resident's health status; and required…

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 accurately reflected residents' mental health conditions at the time of admission or were revised to reflect mental health changes for 2 of 5 sample residents (Residents 73 & 25) whose PASRRs were reviewed. These failures placed 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 09/25/2023 PASRR policy, all residents would be screened for serious mental illness, intellectual disability, and related conditions prior to admission. The policy showed all residents with newly evident or possible serious mental disorders . or intellectual disabilities would be referred back to the state PASRR agency for review. <Resident 73> According to the 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident had intact memory and demonstrated no alteration of mood or behaviors. The MDS showed Resident 73…

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: Physician's Orders (POs) were clarified for 2 (Residents 75 & 18) of 19 sample residents; Abnormal Involuntary Movement Scale (AIMS) assessments were completed as required for 1 (Resident 16) of 7 residents reviewed for behavior. These failures left residents at risk for unmet care needs, inappropriate treatment, abnormal movements, and other negative health outcomes. Findings included . <Clarifying Physician Orders> <Resident 75> According to a 12/07/2023 admission Minimum Data Set (an assessment tool - MDS) Resident 75 admitted to the facility on [DATE] and had severe memory impairment. This MDS showed Resident 75 had a catheter (tubing to assist the passing of urine) during the assessment period. The 11/29/2023 catheter Care Plan (CP) showed Resident 75 had a catheter. The CP did not show the type of catheter (indwelling - connected at the urethra, or suprapubic - connected directly to the bladder through a surgical hole), the…

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

Based on observation, interview, and record review the facility failed to ensure assistance for Activities of Daily Living (ADL - personal care such as bathing/showering, dressing, getting in and out of bed or a chair) were provided for 4 (Residents 87, 47, 34, & 19) of 14 sample residents assessed to require ADL assistance. The failure to ensure dressing and shaving (Resident 87), bathing (Resident 47 & 34), oral care (Resident 34), and nail care (Resident 19) was provided as needed left residents at risk for unmet ADL needs, odors, tooth decay, and other negative health outcomes. Findings included . <Facility Policy> The facility's 08/23/2023 ADL policy showed residents would receive assistance as needed to complete ADLs. The policy showed the facility staff must provide ADL care and services when needed. <Dressing and Shaving> <Resident 87> According to the 11/07/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 87 was assessed with memory impairment. This MDS showed Resident 87 had weakness on one side of their body and required one to two-person assistance…

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 were provided with a program of individualized activities for 3 of 5 sampled residents (Residents 19, 244, & 75) and 1 supplemental resident (Resident 51). The failure to consistently implement meaningful, individualized activity programs left residents at risk for boredom, frustration, isolation, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 09/21/2023 Activity Policy, the facility should implement an ongoing program of resident-centered activities that incorporated resident's interests, hobbies, and cultural preferences. The policy showed activities were integral to maintain and/or improving a resident's physical, mental and psychosocial well-being, and independence. The policy directed staff to create opportunities for each resident to have a meaningful life by supporting their needs including security, autonomy, growth, and connectedness. <Resident 19> According to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 2 of 4 residents (Residents 10 & 14) reviewed for communication and sensory needs received treatment and assistive devices (ADs) to maintain their vision and hearing abilities. Failure to ensure vision devices were repaired and out-of-facility eye consultations were obtained (Resident 10) placed residents at risk for unmet care needs. Failure to determine the presence of hearing aids (HAs) placed residents at risk for impaired communication and a decreased quality of life. Findings included . <Facility Policy> The facility's 09/08/2023 Vision and Hearing Assistive Devices showed the staff assessed the resident's use of assistive devices to maintain their vision and/or hearing upon admission. The policy showed the facility would assist as needed with making appointments and arranging transportation to obtain needed services. The policy outlined that in situations where the resident lost their AD, the facility would assist residents…

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

<Resident 69> According to the 11/02/2023 Significant Change MDS Resident 69 had no memory impairment and required moderate assistance with rolling side to side in bed, and maximal assistance with dressing and hygiene of their lower body. This assessment showed Resident 69 had diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), cerebral palsy (a brain disorder marked by muscle impairment with a loss or deficiency of motor control), heart failure with edema (swelling from fluid retention), generalized muscle weakness, malnutrition, and chronic peripheral venous insufficiency (poor blood circulation to lower extremities). The 10/23/2023 functional goal CP showed Resident 69 would receive restorative nursing services for both arms' and legs' ROM and an ambulation program three times a week. Review of Resident 69's RNP documentation showed Resident 69 only received RNP services three times for the two-week period starting on 12/03/2023 and ending on 12/16/2023, instead of the six times…

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 7 (Resident 10 & 6) residents reviewed were free from potential accidents and hazards. This failure placed residents at risk for accidents, injury, and other negative health outcomes. Findings included . <Resident Bed> <Facility Policy> The facility's revised 01/02/2024 Bed Inspection & Maintenance and Bed Rail Installation policy showed the facility would ensure the mattress was appropriately sized for the bed frame. The policy outlined that beds found with broken or missing parts, or were in need of repair would be taken out of use immediately and reported to the maintenance department for repair. <Resident 10> According to the 10/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 10 readmitted to the facility on [DATE] after hospitalization. The MDS showed Resident 10 was six feet tall, weighed 240 pounds, assessed to have an intact memory, and communicated with clear speech. The MDS outlined Resident…

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

Based on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Residents 295) reviewed for Tube Feeding (TF- tube to provide nutrition directly into stomach for people who cannot swallow safely) care during medication administration were provided with care according to the Physician Orders (POs) and the facility policy. The facility's failure to follow the directions to administer medications via TF, amount of water for flushing the TF, amount of water provided with medications, and the techniques to administer medications via syringe too fast, placed Resident 295 and other residents at risk for dehydration, discomfort, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's revised 09/22/2021 Medication Administration via Enteral (tube placed in stomach to provide nutrition and medications) Access Device Policy, staff would follow the POs and professional standards of practice. The policy instructed the facility to dilute the crushed medications with 30-60 milliliter (ml) of water unless otherwise…

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

Based on observation, interview, and record review the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 7 residents (Resident 14) reviewed for mood/behavior. The facility's failure to assess or involve collateral contacts to obtain trauma history placed Resident 14 and other residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . <Facility Policy> The facility's 08/22/2023 Trauma-Informed Care policy showed the facility would use a multi-pronged approach in identifying a resident's PTSD or history of trauma utilizing the facility's Trauma-Informed Care Assessment. The policy outlined that the facility should collaborate with the resident trauma survivors, and as applicable, the resident's family/representative to develop 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 provide behavioral health services for 1 of 7 (Resident 34) residents reviewed for behavioral-emotional health. The failure to provide intervention to Resident 34s behavioral health concerns placed Resident 34 and other residents at risk for not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings included . <Resident 34> According to the 10/10/2023 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 34 admitted to the facility on [DATE]. Resident 34 was able to make themselves understood and understood others during communication. Resident 34 had diagnoses including diabetes (difficulty controlling blood sugar), multiple sclerosis (a progressive neuromuscular disease), and depression. In an interview on 01/03/2024 at 9:30 AM Resident 34 stated that they were depressed and had feelings of missing out on connecting with other people. Resident 34 stated that they used 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 storage of drugs and biologicals on 2 (200 Wing and 400 Wing Cart) of 4 medication carts, and failed to ensure resident rooms were free of medications and treatments for 1 of 20 sample residents (Resident 73) reviewed. These failures placed residents at risk for receiving expired medications and non-assessed, self-administration of medications by residents, and other negative health outcomes. Findings included . <Facility Policy> Review of the 08/07/2023 revised Pharmacy Services and Procedures Manual showed medications with expired dates would be stored separately from other medications until the medication could be destroyed or returned to the pharmacy. This policy showed eye drop medications should have the open date and the date the medication expired once opened written on the container. The policy showed the facility would not provide bedside medications without a physician's order or approval by the facility. Medications stored at bedside would be locked in a compartment inside the resident'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 residents' medical records were complete, accurate, and readily accessible for 4 of 20 sample residents (Residents 73, 10, 14 & 84) whose resident records were reviewed. The failure to maintain complete, accurate, readily accessible records left residents at risk for incomplete medical records, unmet care needs, and other negative health outcomes. Findings included . <Facility Policy> The facility's 03/10/2023 Filing policy showed paper copy documents regarding resident care were filed/uploaded into the medical record to ensure the information was readily accessible. The policy outlined resident records including diagnostic test results must be filed at least weekly. <Resident 73> According to the 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 73 had diagnoses including unsteadiness on their feet and a need for assistance with personal care. The MDS showed Resident 73 did not receive therapy services at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer Influenza (Flu) and Pneumococcal (PNA) vaccinations within the recommended timeframe for 5 of 7 residents (Residents 69, 75, 18, 51 & 25) reviewed for immunization status. This failure placed residents at risk for contracting influenza or pneumonia, with its associated complications. Findings included . <Centers for Disease Control (CDC) Guidance> Review of the CDC's Pneumococcal Vaccination: Summary of Who and When to Vaccinate, website, last revised on 09/21/2023, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have only received a PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends you . may give 1 dose of PCV15 or PCV20 [Pneumococcal conjugate vaccine] . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination . The CDC guidelines went into effect on 10/21/2021…

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.