Cottesmore Of Life Care

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 (PASARR) assessments were accurately completed for 3 of 6 sampled residents (Residents 29, 49 and 40) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . Review of a document titled, Pre-admission Screening and Resident Review (PASARR), dated 09/26/2024, showed the facility would ensure that potential admissions were to be screened for possible mental disorders or intellectual disabilities and related conditions. A positive Level I screen necessitated an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. Resident 29 Review of Resident 29's admission minimum data set assessment (MDS, a required assessment), dated 07/29/2024, showed the resident admitted on [DATE] with multiple 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, interview, and record review, the facility failed to ensure care plans were reviewed and revised after each quarterly assessment for 3 of 4 sampled residents (Residents 32, 50, and 22) when reviewed for care planning. This failure placed residents at risk of not receiving required care, avoidable decrease in health status, and a diminished quality of life. Findings included . Resident 32 Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (too much sugar in the blood). Resident 32 was able to make needs known. Review of Resident 32's modified annual minimum data set assessment (MDS, a required assessment), dated 12/11/2024, showed the resident received dialysis (treatment to filter wastes and water from the blood) and received a mechanically altered and therapeutic diet (a meal plan that is designed to treat a medical condition or symptom). During an interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure there was a system to provide care and services consistent with standards of quality of care for 2 of 3 sampled residents (Residents 57 and 71) when reviewed for edema/heart failure, for 4 of 8 sampled residents (Residents 7, 40, 57 and 78) when reviewed for bowel management, for 1 of 1 sampled residents (Resident 40) when reviewed for hospice service, and for 1 of 3 sampled residents (Resident 32) when reviewed for hospitalization. The failure to develop and implement person-centered edema/heart failure care plans (CPs) that included notifying the provider of changes in condition, routine monitoring of weights and fluid status, implementing bowel program orders when required, including the hospice plan of care and to provide speech evaluation upon return from hospital per provider orders, placed the residents at risk for unmet needs, medical complications, constipation, and a diminished quality of life. Findings included .…

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 medications and biologicals were securely locked for 3 of 26 sampled residents (Residents 90, 9, and 64) when reviewed for environment. This failure placed the resident at risk for consuming non-prescribed medications, unintended side effects of medications, medical complications, and a diminished quality of life. Findings included . Review of the facility policy titled Storage and Expiration of Medications, Biologicals revised on 08/07/2023, showed under General Storage Procedures Store all drugs and biologicals in locked compartments. Resident 90 Review of the electronic health record (EHR) showed Resident 90 admitted to the facility on [DATE] with multiple diagnoses that included fracture of right leg, respiratory failure and muscle weakness. Resident 90 was able to make needs known. Observation and interview on 01/07/2024 at 11:10 AM showed Resident 90 had multiple medications in pill form, inhalers, and nebulizing…

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 periodically review residents advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) for 1 of 4 sampled residents (Resident 32) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure and kidney failure. Resident 32 was able to make needs known. Review of a document titled Attachment H showed Resident 32 received information regarding establishing an AD on 02/26/2024. During an interview on 01/08/2025 at 2:07 PM, Staff F, Social Services Director (SSD), stated the facility informed residents of their right to formulate an AD on admission and the residents signed Attachment H once…

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' personal items were safe for 1 of 5 sampled residents (Resident 64) when reviewed for Personal Property and failed to ensure residents' rooms were homelike for 1 of 6 sampled residents (Resident 50) when reviewed for environment. These failures placed residents at risk of financial exploitation, feelings of worthlessness, decreased mood, and a diminished quality of life. Findings included . Resident 64 Review of the electronic health record (EHR) showed Resident 64 admitted to the facility on [DATE] with diagnoses of dementia (a group of brain conditions that cause a decline in mental abilities) and cognitive communication deficit (difficulty in communicating). Review of the modification of quarterly minimum data set assessment (MDS), an assessment tool, dated 11/25/2024, showed Resident 64's vision was adequate with corrective lenses. During an interview and observation on 01/09/2025 at 10:57 AM, Resident 64 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to implement pressure ulcer care for 2 of 4 sampled residents (Residents 78 and 72) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at risk for worsening pressure injuries, pain, and a decreased quality of life. Findings included . Review of a policy titled, Skin Integrity and Pressure Ulcer/Injury Prevention and Management, dated 07/09/2024, showed staff were to provide treatment and care of the resident wounds utilizing professional standards of the National Pressure Injury Advisory Panel (NPIAP). The facility must ensure resident care was provided to pressure ulcers consistent with professional standards of practice to promote healing and prevent infection. Resident 78 Review of the admission minimum data set (MDS, a required assessment tool), dated 11/04/2024, showed Resident 78 admitted on [DATE] with multiple diagnoses to include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide adequate fluids to maintain hydration for 1 of 2 sampled residents (Resident 40) when reviewed for hydration and failed to monitor and accurately document fluids consumed to ensure fluid restrictions were implemented per provider's orders for 1 of 5 sampled residents (Residents 32) reviewed for nutrition and/or dialysis (treatment to filter wastes and water from the blood). This failure placed residents at risk for over hydration, avoidable discomfort, and a diminished quality of life. Resident 40 Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses to include dementia and traumatic subarachnoid hemorrhage (a bleed in the brain). Review of the care plan, dated 12/04/2024, showed the resident was at risk for dehydration and had a diet which included regular thin liquids. The resident required assistance of two staff for transfers out of bed. Observation on 01/07/2025 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 observation, interview, and record review, the facility failed to manage oxygen therapy consistent with professional standards of practice and the comprehensive person-centered care plan by not ensuring provider's orders and care plans were in place and/or followed for 2 of 4 sampled residents (Residents 71 and 72) when reviewed of respiratory care. These failures placed residents at risk for unmet needs and a decreased quality of life. Resident 71 Review of the electronic health record (EHR) showed Resident 71 admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF, when the heart is not able to pump enough blood causing fluid to build up in the lungs and/or limbs). The resident was able to make needs known. Review of the EHR on 01/08/2025 at 4:45 PM showed no care plan had been initiated for oxygen use. A provider order was found showing Resident 71 was ordered oxygen at two liters per minute continuously per nasal cannula (NC, a tube that inserts into the nose). During…

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 staff provided adequate pain management in a timely manner for 1 of 3 sampled residents (Resident 29) when reviewed for pain management. This failure had the potential for the resident to have a delay in treatment to receive the necessary pain medication as ordered, a diminished quality of life and unmet needs. Findings included . Review of a document titled, Pain Assessment and Management, dated 09/05/2024 showed the policy was based on the comprehensive assessment of a resident and the facility was to ensure the resident received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Review of Resident 29's admission minimum data set (MDS, a required assessment tool), dated 07/29/2024, showed the resident admitted on [DATE] with multiple health conditions including heart and kidney disease, osteoarthritis (a chronic…

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 an agreement/contract with a resident's dialysis provider to ensure all care and services necessary were being provided and coordinated for 1 of 1 sampled resident (Resident 32) reviewed for dialysis (treatment to filter waste and water from the blood). This failure placed the resident at risk for inadequate quality of care and decreased quality of life. Findings included . Resident 32 Review of the electronic health record (EHR) showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure and kidney failure. Resident 32 was able to make needs known. Review of Resident 32's modified annual minimum data set assessment (MDS, an assessment tool) dated 12/11/2024 showed the resident received dialysis. During an interview on 01/08/2025 at 8:45 AM, Resident 32 stated they went to a dialysis center three days a week. Review of the provider order dated 12/31/2024 showed that Resident 32 was to be sent to 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 consistently initiate non-pharmacological interventions prior to the administration of as needed pain medication for 2 of 5 sample residents (Residents 18 and 398) reviewed for unnecessary medications. These failures placed residents at risk for receiving unnecessary medications and a diminished quality of life. Findings included . Review of a facility document titled, Pain Assessment and Management, dated 09/06/2024 showed the facility must ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. In addition, the facility will address and treat the underlying causes of pain, to the extent possible by developing and implementing both non-pharmacological and pharmacological interventions and approaches to pain management whether the pain is episodic, continuous or both. Resident 18 Review of the admission minimum…

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 dental services for 1 of 3 sample residents (Resident 78) reviewed for dental. This failure placed the resident at risk of difficulty eating and a diminished quality of life. Findings included . Review of the admission minimum data set (MDS, a required assessment tool) dated 11/04/2024, showed Resident 78 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, muscle weakness, dysphagia (a condition related to difficulty or discomfort in swallowing) and constipation. The MDS showed the resident was able to make needs known, was dependent upon staff with activities of daily living (ADLs) and had obvious or likely cavity or broken natural teeth. Observation and interview on 01/07/2025 at 2:11 PM showed Resident 78 laid in bed and multiple lower teeth appeared broken or were shown missing. Resident 78 stated they had not seen a dentist since they had been admitted to the facility. Review of Resident 78's focus…

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 prompt dental services for 1 of 3 sample residents (Resident 50) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included . Review of Resident 50's electronic health records (EHR) showed the resident admitted to the facility on [DATE] with diagnoses to include protein-calorie malnutrition (a condition where the body does not get enough protein, calories, and other nutrients), diabetes (too much sugar in the blood), need for assistance with personal care, and depression. Resident 50 was able to make needs known. During an interview and observation on 01/07/2025 at 11:39 AM, Resident 50 stated their upper dentures were chipped on the top center of the dentures and caused some pain at times when putting them in and they would like to get some lower dentures. Resident 50 stated they had told staff about wanting to get upper dentures fixed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure resident's medical records were accurately documented according to professional standards of practice for 2 of 26 sampled residents (Residents 398 and 71) when reviewed for medical records. This failure placed the residents at risk for isolation, unmet care needs, and diminished quality of life. Findings included . Resident 398 Review of electronic health record (EHR) showed Resident 398 readmitted to the facility on [DATE] with diagnoses that included methicillin resistant staphylococcus aureus infection (MRSA, an infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections), retention of urine, and diabetes (too much sugar in the blood). Resident 398 was able to make needs known. Observations from 01/07/2025 until 01/09/2025 showed Resident 398 had enhanced barrier precautions (infection control interventions designed to reduce transmission of resistant organisms)…

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, facility failed to ensure professional standards were met for 2 of 2 sampled residents (Resident 1 & 2) reviewed for physicians orders and care of residents with peripherally inserted central catheter lines (PICC, lines placed through the upper arm in a large vein near the heart). Failure to follow physician orders and professional standards of care when assessing and performing PICC line dressing changes placed residents at risk for medical complications including bloodstream infections. Findings included . Facility policy, Nurses' Infusion Manual, dated 2021, documented that residents with PICC lines had potential for serious complications including bloodstream infections related to PICC line catheter migration (movement of the catheter from its proper place in vein to another area of body). According to the Nurses' Infusion Manual, approaches to prevention of PICC line catheter migration included: > Documentation of catheter tip placement verification prior…

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 and interview, the facility failed to maintain mechanical lifts in good repair for 3 of 3 mechanical lifts when reviewed for accident hazards. This failure placed residents at risk of falling when using the mechanical lift, avoidable injury, and a diminished quality of life. Findings included . Observation of a mechanical lift on 300 [NAME] Hall on 02/05/2024 showed that three of the four safety clips were missing. Observation of mechanical lift #102 on 02/05/2024 showed that one of four safety clips were missing. Further observation showed an instruction card attached to the mechanical lift which indicated that the safety clips should be used when using the mechanical lift. Observation of mechanical lift #9737 on 02/05/2024 showed that two of the four safety clips were missing. During an interview on 02/08/2024 at 11:58 AM, Staff H, Maintenance Director, stated that the facility did not have a program to inspect and repair the mechanical lifts. Staff H further stated that the facility's mechanical lifts were missing safety clips. During an interview on…

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

Based on observation, interview and record review, the facility failed to ensure 3 of 5 residents (Residents 49, 68 and 96) received their physician-ordered therapeutic diets to support the resident's plan of care. This failure placed residents at risk for medical complications, nutritional deficits, and weight gain. Findings included . Observation on 02/06/2024 of the lunch meal service showed that the regular diet (no dietary modification or restriction) lunch meal consisted of a hot dog on a bun, seasoned potato wedges or mashed potatoes, vegetable blend and Jello with whipped topping. Resident 49 Review of Resident 49's electronic health record (EHR) showed a physician's diet order dated 11/20/2023 for easy to chew texture, thin consistency and small portions at lunch and dinner. Observation on 02/06/2024 at 12:52 PM showed that Staff K, Cook, served Resident 49 the regular diet. Resident 68 Review of Resident 68's EHR showed a physician's diet order dated 01/24/2024 for regular texture, thin consistency, diet condiments and 1/2 starch portions. Observation on 02/26/2024 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 ensure 1 of 5 sampled residents (Resident 6), reviewed for unnecessary medications, and/or her representative, were fully informed of the potential risks associated with use of a psychotropic medication (medication which alters thought processes). This failure placed the resident at risk for adverse medication side effects, and the resident and/or their representative at risk for not being able to make an informed decision about a medication. Findings included . Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 01/15/2024 showed Resident 6 admitted on [DATE] with multiple diagnoses to include heart disease and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks). In addition, the resident had a cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory planning, problem-solving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services that met professional standards for 1 of 1 resident (Resident 12) reviewed for hydration. Failure to accurately monitor fluid intake for residents who required fluid restriction and failure to monitor daily weights for a resident with congestive heart failure (a disease were the heart can not pump blood well enough, and blood and fluids collect in the lungs and legs over time) placed the residents at risk for acute medical complications and a diminished quality of life. Findings included . Observation and interview on 02/05/2024 at 11:45 AM showed Resident 12 laid in bed, there was a fluid restriction symbol on door. The resident stated they were told they were on a fluid restriction and did not know why. Resident 12 further stated that staff still allow them to drink what they want. There was a cup of hot tan liquid, a full water pitcher, water cups and a cup of juice on the bedside table. Review on 02/06/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance and follow up on an appointment for dental care services for 1 of 3 Residents (Residents 64) reviewed for dental services. This failure placed the resident at potential risk for continued dental problems and decreased the quality of life. Findings included . Review of Resident 64's quarterly Minimum Data Set (MDS, a required assessment tool) dated 10/23/2023, showed that Resident 64 was admitted on [DATE] with multiple diagnoses to include heart disease, diabetes, malnutrition, and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). The MDS further showed Resident 64 was able to make needs known and had obvious or likely cavity or broken natural teeth and was assessed to have inflamed or bleeding gums or loose natural teeth. Review of Resident 64's care plan dated 10/03/2023 showed that the resident had oral/dental health problems, broken teeth, loose teeth, and that a local…

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

Based on interview and record review, the facility failed to obtain and incorporate a hospice plan of care into the resident's facility plan of care for 1 of 1 resident (Resident 4) when reviewed for hospice. This failure placed the resident at risk of a lack of needed services, discoordination of care, and a diminished quality of life. Findings included . Review of Resident 4's physician's orders showed that the resident was admitted to hospice services on 10/30/2023. Review of Resident 4's 10/31/2023 initiated care plan showed no information on what services were to be provided by the hospice provider. During an interview on 02/08/2024 at 11:12 AM, Staff G, Registered Nurse/Residential Care Manager, stated that a resident's care plan would be updated with information in the hospice plan of care after admission to hospice. Staff G stated that the facility had not received Resident 4's hospice plan of care after the resident admitted to hospice and this did not meet expectation. During an interview on 02/08/2024 at 11:42 AM, Staff B, Director of Nursing Services, stated that 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 report an identified significant injury of unknown source to the facility's Administrator, Director of Nursing Services (DNS), and the state agency, and failed to log the incident in the reporting log within five days as required for 1 of 5 sampled residents (Resident 1) reviewed for abuse/neglect. These failures placed residents at risk for unrecognized abuse or neglect and potential continued exposure to abuse and/or neglect. Findings included . According to the Nursing Home Guidelines also known as the Purple Book, sixth edition, dated October 2015, reporting requirements included that substantial injuries of unknown source were to be reported to the Department of Social and Health Services (DSHS) state hotline, and logged on the DSHS reporting log within five days. Review of Resident 1's 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that the resident readmitted on [DATE] with diagnoses to include dislocation of internal left hip…

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 investigate an identified significant injury of unknown source for 1 of 5 sampled residents (Resident 1) reviewed for abuse/neglect. This failure placed the resident at potential risk for continued exposure to abuse and neglect, unmet needs, and a diminished quality of life. Findings included . During an interview on 08/29/2023 at 12:01 PM when asked how they dislocated their left hip on 08/11/2023, Resident 1 stated, I don't know. When asked if the resident has had a fall, Resident 1 stated, Yes, however, was not sure when or where it occurred. Review of Resident 1's 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that the resident readmitted on [DATE] with diagnoses to include dislocation of internal left hip prosthesis (artificial hip joint) and altered mental status (changes in a person's alertness, attention, memory and/or awareness). It further showed that the resident had a fall within the last two to six months prior to admission or…

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