Gig Harbor Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a baseline care plan for 2 of 19 sampled residents (Residents 8 and 6) when reviewed for baseline care plans. Failure to timely initiate a dental or bathing care plan for resident 8 and/or a skin risk care plan for Resident 6 placed the residents at risk for unmet care needs and a decreased quality of life. Findings included . Resident 8Review of the electronic health record (EHR) showed Resident 8 admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and malnutrition. The resident was able to make needs known. Observation and interview on 12/02/2025 at 2:20 PM showed Resident 8 laid in bed and had no teeth. Resident 8 stated they had dentures but did not wear them often and staff did not assist them to put them in regularly. Resident 8 stated they did not get showers often enough and they had itchy skin because of it. Review of the progress notes dated 09/30/2025 showed an entry by the registered dietitian…

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 timely care conferences with the resident/responsible party for 3 of 22 sampled residents (Residents 45, 11, and 6) when reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and a diminished quality of life. Findings included .Resident 45 Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), unsteadiness on feet, and major depressive disorder. Resident 45 was able to make needs known. During an interview on 12/03/2025 at 9:51 AM, Resident 45 stated they could not recall when they last attended a care conference. Review of Resident 45's medical record showed care conferences were conducted on 03/26/2025 and 09/19/2025. Resident 11 Review of the EHR showed Resident 11 readmitted to the facility on [DATE] with…

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 in accordance with professional standards of practice and the comprehensive person-centered care plan for 4 of 22 residents (Residents 96, 24, 11, and 14) when reviewed for quality of care and/or Hospice services. Failure to provide bowel management for Resident 14, to obtain and review hospice services notes for Residents 96, 24, and 11, and to develop a collaborative comprehensive care plan involving Hospice service for Residents 24 and 11, placed the residents at risk for unmet needs, clinical complications and a diminished quality of life. Findings included.<Hospice Services Visit Notes> Resident 96 Review of the electronic health record (EHR) showed Resident 96 admitted to the facility on [DATE] with diagnoses to include kidney failure, depression, and dementia (a group of thinking and social symptoms that interfere with daily functioning). Resident 96 received hospice services and was able to make needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for 2 of 2 sampled residents (Residents 86 and 14) when reviewed for fluid restrictions. This failure placed the residents at risk for medical complications and a diminished quality of life. Findings included.Findings included. Resident 86 Review of the electronic health record (EHR) showed Resident 86 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (kidneys cannot filter blood waste), renal dialysis (treatment that filters waste, salt, and fluid from the body), anxiety, depression, and hypertension (elevated blood pressure). Resident 86 was able to communicate needs. During an interview on 12/02/2025 at 1:31 PM, Resident 86 stated they were allowed to consume 1200 milliliters (ml) of fluids a day. Review of medication administration record (MAR) for December 2025 showed Resident 86 had consumed 240 ml of fluids for daytime and 240 ml for…

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

Based on observation, interview, and record review, the facility failed to maintain safe food storage in 3 of 3 resident refrigerators (100 Hall, 300 Hall, and Serenity Unit Refrigerators) and failed to ensure safe food re-heating for 1 of 2 re-heating microwaves (300 Hall Microwave) when reviewed for kitchen. This failure placed residents at risk of eating expired and/or contaminated foods, foodborne illness, and a diminished quality of life. Findings included.RefrigeratorsObservation on 12/03/2025 at 1:21 PM showed the Serenity Unit Refrigerator with a gallon jug of milk with a best by date of 11/27, a plastic container with an unidentifiable yellow food item with white growth on top, and a pitcher of facility made juice without a date label. Observation on 12/03/2025 at 1:26 PM showed the 300 Hall Refrigerator with an unopened bottle of brewed tea labeled as placed in the refrigerator on 11/15 and with a use by date of 11/04/2025. Observation and record review on 12/03/2025 at 1:31 PM showed the 100 Hall Refrigerator with a jar of salsa with a worn off use by date and labeled…

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 infection control program to monitor for and manage infections for 2 of 3 months (September and October 2025) and 2 of 22 residents (Residents 73 and 12) when reviewed for infection control. Failure to collect and analyze the infection control data and implement measures to reduce infections for the months of September and October 2025 and failure to provide infection prevention measures for an indwelling urinary device and abdominal drain for Residents 12 and 73 placed the residents at risk for infections, poor clinical outcomes, and a decreased quality of life. Findings included.Findings included. Review of the facility policy titled Infection Control Surveillance, undated, showed the infection preventionist would collect and analyze the infection control data to identify trends by comparing the rates to previous months in the current year and to the same month in previous years, to identify trends and implement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccines for 3 of 5 sampled residents (Residents 6, 15, and 23) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included.Review of the facility policy titled Pneumococcal Vaccine, dated 05/02/2025, showed, Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Review of the facility policy titled Influenza Vaccination, undated, showed the facility would educate, offer and obtain consent…

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 offer, educate, and obtain consent for Covid-19 vaccines for 3 of 5 sampled residents (Residents 6, 15 and 23) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included.Review of the facility document titled Clinical Protocol for SARS COV-2, undated, showed All Residents to be offered resources and counseled about receiving the COVID-19 vaccine. Resident 6Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with a diagnosis of adult failure to thrive. The resident was able to make needs known. Review of the Vaccine Consent Form dated 03/25/2025 showed the resident had requested any vaccine that is due. Review of the EHR on 12/08/2025 showed no documentation that the facility…

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

Based on observation, interview and record review, the facility failed to ensure mechanical lifts were in safe working order for 2 of 2 mechanical lifts (Free Spirit and Tenor) when reviewed for activities of daily leaving. This failure placed the residents at risk of avoidable injuries, falls and diminished quality of life. Findings included.Observation on 12/04/2025 at 2:25 PM showed Resident 1 being transferred via mechanical lift from bed to wheelchair. The mechanical lift had no safety pins on the prongs where the resident's sling was attached. Observation on 12/05/2025 at 9:15 AM showed two lifts called Free Spirit and Tenor with missing safety clips. During an interview on 12/05/2025 at 9:50 AM, Staff Z, Maintenance Director, stated the clips were replaced on November 18, 2025, but had disappeared one week after. Staff Z stated they did the monthly maintenance inspecting and were aware of the issue and were looking to order clips. Review of the inspection reports from November and December 2025 showed no safety clips on the two mechanical lifts. 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 and interview, the facility failed to provide necessary housekeeping in resident rooms for 3 of 4 halls (Halls 100, 200 and 300) reviewed for safe, clean, functional and comfortable environment. These failures placed residents at risk for unsanitary conditions, less than a homelike environment and a diminished quality of life.Findings included . Observation on 12/04/2025 at 2:07 PM showed Resident 95 overhead asking Staff M, Housekeeping Aide, if they were able to clean the resident's bathroom. Staff M stated they had three other rooms to clean and would try to get to the bathroom on their next scheduled shift (three days later). During an interview on 12/05/2025 at 1:34 PM, Resident 95 stated their bathroom had not been cleaned in a week. Observation of the toilet bowl showed brown and orange stains on the toilet seat and in the toilet bowl. During an interview and observation on 12/05/2025 at 11:19 AM, Resident 83 stated, My bathroom hasn't been cleaned since Tuesday. Housekeeping is short staffed. Observation showed dried red matter on the bathroom floor.…

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 assess and provide appropriately sized wheelchairs for 1 of 3 sampled residents (Resident 1) when reviewed for accommodation of needs. This failure placed the Resident at risk for skin breakdown, pain in lower back and hips, inability to use the wheelchair for an extended time, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 1 was admitted to the facility on [DATE] with diagnoses to include spondylolisthesis lumbar region (condition when one vertebra [spine bone] slips forward onto vertebra below causing pain and nerve damage), atrial fibrillation (irregular heartbeat), bipolar disorder (brain disorder causing extreme mood swings from manic highs to depressive lows) and heart failure. Resident 1 was able to communicate needs. Observation and interview on 12/02/2025 at 09:01 AM showed Resident 1 in bed. Resident 1 stated they did not get out of bed as often, and the mechanical…

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 resident choices for 1 of 22 sampled residents (Resident 78) when reviewed for choices. Failure to accommodate Resident 78's choice for ice water when requested placed the resident at risk for decreased quality of life and diminished self-worth.Findings included. Review of the electronic health record (EHR) showed Resident 78 readmitted to the facility on [DATE] and was able to make needs known. The annual minimum data set assessment (MDS, a required assessment tool) dated 11/12/2025 showed Resident 78 had diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), anxiety disorder, and diabetes (too much sugar in the blood). During an interview on 12/02/2025 at 9:43 AM, Resident 78 stated they would like to have ice water with lunch. Resident 78 stated that if they wanted ice water, they would have to ask for it, but, even then, they would just get a glass of water but would prefer ice…

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 a residents advanced directive for 1 of 4 sampled residents (Resident 96) when reviewed for advanced directive. This failure placed the residents at risk of not being able to designate a healthcare designee and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 96 admitted to the facility on [DATE] with diagnoses of end stage renal disease (kidneys permanently fail), dementia (severe cognitive decline affecting memory, thinking, language, and problem-solving), and encounter for palliative care (specialized medical support for people with serious illnesses). Resident 96 was unable to make needs known. Review of a Multidisciplinary Care Conference assessment, dated 07/28/2025, showed the Advanced Directives Reviewed/Offered was blank. Review of a Multidisciplinary Care Conference assessment, dated 10/16/2025, showed the Advanced Directives Reviewed/Offered was blank. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and/or implement thorough investigations to rule out abuse or neglect related to falls for 1 of 3 sampled residents (Resident 11) when reviewed for accidents/falls. These failures placed Resident 11 at risk for unidentified abuse or neglect, continued exposure to abuse and/or neglect, and a diminished quality of life.Findings included. According to the Nursing Home Guidelines also known as the Purple Book, sixth edition, dated October 2015, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated . A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on a Preadmission Screening and Resident Review (PASRR, a mental health screening tool) for 1 of 7 sampled residents (Resident 4) when reviewed for PASRR. This failure placed residents at risk for unmet needs and a decreased quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 14 admitted to the facility of 05/30/2025 with diagnoses of anxiety and depression. The resident was able to make needs known. Review of the EHR showed Resident 4 was screened for PASRR on 04/17/2025 and determined to require a level 2 PASRR for mood disorders. No level 2 PASRR was found in the EHR. During an interview on 12/04/2025 at 11:21 AM, Staff F, Social Services Director, stated Resident 4 transferred from another skilled nursing facility and they were told it was sent for review but on 12/02/2025 they reached out to the PASRR review team and learned it was never sent/received. Staff W stated they should have followed…

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 initiate comprehensive care plans for 2 of 22 sampled residents (Residents 4 and 78) when reviewed for comprehensive care plans. Failure to initiate a plan of care for epilepsy for Resident 4 and ensure the care plan was accurate and included monitoring behaviors and side effects for use of antidepressant and antianxiety medication use for Resident 78 placed the residents at risk for unmet needs and a decreased quality of life. Findings included .Resident 78 Review of the electronic health record (EHR) showed Resident 78 readmitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder, and depression. Resident 78 was able to make needs known. Review of the medication administration record (MAR) dated December 2025 showed Resident 78 was prescribed and received an antidepressant and antianxiety medication and was not prescribed nor…

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 provider's orders to monitor orthostatic blood pressure was followed for 1 of 5 sampled residents (Resident 5) when reviewed for unnecessary medications. This failure placed the resident at risk for dizziness when laying and sitting, avoidable falls, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorders affecting movement, posture, and muscle tone), bipolar disorder (a brain disorder causing extreme shifts in mood, energy, and activity levels), schizoaffective disorder (a chronic mental illness blending symptoms of schizophrenia [like hallucinations, delusions, disorganized thinking] with symptoms of a mood disorder [depression or mania], and general anxiety disorder (GAD). Resident 5 was able to make needs known. Review of the provider's orders showed Resident 5 was to have orthostatic…

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 the necessary care and services to maintain physical and psychosocial well-being for 1 of 22 sampled residents (Resident 14) when reviewed for quality of life. Failure to provide an escort/caregiver for a dependent resident when going to a doctor's appointment placed the resident at risk for unmet care needs, diminished self-worth, and decreased quality of life. Findings included. Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses of hemiplegia (weakness on one side of the body), anxiety, and cognitive deficit. The resident was able to make needs known. During an interview on 12/02/2025 at 2:40 PM, Resident 14 stated they had gone out to a doctor's appointment that morning and did not have an escort. Resident 14 stated the driver dropped them off and left them there. Resident 14 was not able to navigate the doctor's office and missed their appointment. They then had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure a resident's ability to participate in activities of daily living did not diminish for 1 of 22 sampled resident (Resident 45) reviewed for activities of daily living (ADLs) and therapy services. Residents 45 experienced harm when they had a decline in mobility in the areas of sit to stand, toilet transfers and ambulation. This failure placed residents at risk of decreased mobility and a diminished quality of life.Findings included .Review of a facility policy titled, Activities of Daily Living (ADLs), dated 10/01/2021, showed Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.Resident 45 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung condition…

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 treatment and services to maintain vision for 1 of 3 sampled residents (Resident 15) when reviewed for communication/sensory. This failure placed the resident at risk for unmet needs, continued visual impairment, and a diminished quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 15 readmitted to the facility on [DATE] with diagnoses to include high blood pressure, stroke (blood flow to a part of the brain is blocked causing brain cells to die), and anemia (lack of healthy red blood cells). Resident 15 was able to make needs known. During an interview on 12/02/2025 at 12:18 PM, Resident 15 stated they had asked to see an eye doctor because their vision had declined and when they tried to read it was blurry. During a follow-up interview on 12/04/2025 at 11:05 AM, Resident 15 stated they had told a social worker that they wanted to see an eye doctor but that social worker no longer…

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 the root cause of a fall, ensure new interventions were developed or timely initiated, and/or referrals/screenings were completed to minimize falls for 1 of 3 sampled residents (Resident 11) when reviewed for accidents/falls. This failure placed Resident 11 at risk for falls, injuries, medical complications and a diminished quality of life.Findings included. Review of the electronic health record (EHR) showed Resident 11 readmitted to the facility on [DATE] with diagnoses to include unsteadiness on feet, Alzheimer's disease (a progressive brain disorder causing difficulty with daily activities), anxiety disorder, and bipolar disorder (a brain condition causing extreme mood swings). Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 11 had two or more falls since admission or prior assessment, received hospice care services (end of life care), and was able to make needs known. Review of the incident report…

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 behavioral health provider's recommendations for changes in mental health medications were considered/implemented for 1 of 5 sampled residents (Resident 5) when reviewed for unnecessary medications. This failure placed the resident at risk of ineffective mental health medication regimen, increase of avoidable behaviors, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorders affecting movement, posture, and muscle tone), bipolar disorder (a brain disorder causing extreme shifts in mood, energy, and activity levels), schizoaffective disorder (a chronic mental illness blending symptoms of schizophrenia [like hallucinations, delusions, disorganized thinking] with symptoms of a mood disorder [depression or mania], and general anxiety disorder (GAD). Resident 5 was able to make needs known.…

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 medically related social services, including follow up, monitoring and assessment of intervention effectiveness, were provided for a resident with a mental health diagnosis and a history of making negative statements for 1 of 22 sampled residents (Resident 30) when reviewed for medically related social services. This failure placed residents at risk for unwanted behaviors, unmet care needs, and a diminished quality of life.Findings included . Review of the electronic health record showed Resident 30 admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental illness causing extreme shifts in mood alternating between high and low periods), depression, and chronic pain. Resident 30 was able to make needs known. Review of a progress note dated 11/29/2025 showed nursing staff documented Resident 30 stated they were so sad that their family did not come to visit they felt like dying. Review of Resident 30's mental health care plan,…

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 pharmaceutical services (including providing medication without a dosage and not following a prescribed order) to meet the needs of 2 out of 3 sampled residents (Residents 51 and 37) when reviewed for medication administration. Failure to timely remove a medicated topical patch for Resident 51 and to provide medication without a dosage to Resident 37, placed residents at risk for medical complications and a poor quality of life.Findings included. Resident 51Review of the electronic health record (EHR) showed Resident 51 admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), gout (painful inflammation/swelling of the joints), and diabetes (too much sugar in the blood). Resident 51 was able to make needs known. Observation and interview on 12/05/2025 at 9:15 AM showed Staff G, Licensed Practical Nurse (LPN), pulled off a lidocaine…

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 consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 2 of 5 sampled residents (Residents 5 and 78) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included.Resident 5 Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorders affecting movement, posture, and muscle tone), bipolar disorder (a brain disorder causing extreme shifts in mood, energy, and activity levels), schizoaffective disorder (a chronic mental illness blending symptoms of schizophrenia [like hallucinations, delusions, disorganized thinking] with symptoms of a mood disorder [depression or mania], and general anxiety disorder (GAD). Resident 5 was able to make needs…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 3 medication carts (Run Four Medication Cart) and 1 of 2 medication rooms (Peak Medication Room) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and diminished quality of life. Findings included.Observation on 12/05/2025 at 12:35 PM, with Staff C, Assistant Director of Nursing, showed Peak Medication Room refrigerator with missing temperature logs for the evening time on 12/03/2025 and 12/04/2025. The medication refrigerator stored medications and tuberculin testing supplies (a skin test to help diagnose tuberculosis [TB] infection). Staff C stated the expectation was for Licensed Nurses to document the temperature twice a day, morning and evening. Staff C could not provide temperature logs for November 2025. Observation and interview on 12/08/2025 at 10:56 AM showed the Run Four Medication cart with expired medication slow magnesium chloride with calcium tablets dated…

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 2 sampled residents (Resident 1) reviewed for dental needs. This failure placed the resident at risk of having discomfort, difficulties eating, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 1 was admitted to the facility on [DATE] with diagnoses to include spondylolisthesis lumbar region (condition when one vertebra [spine bone] slips forward onto vertebra below causing pain and nerve damage), atrial fibrillation (irregular heartbeat), bipolar disorder (brain disorder causing extreme mood swings from manic highs to depressive lows) and heart failure. Resident 1 was able to communicate needs. Observation and interview on 12/02/2025 at 11:59 AM showed Resident 1 in bed with missing upper teeth. Resident 1 stated they had problems with their teeth and need a denture. Review of the EHR showed Resident 1 was seen by a dental hygienist on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide necessary supplies for toileting needs for 2 of 3 residents (Residents 5 and 6) reviewed for Activities of Daily Living. This failure placed residents at risk for increased discomfort and a diminished quality of life. RESIDENT 5Resident 5 admitted to the facility on [DATE] with multiple diagnoses. The admission minimum data set (MDS, an assessment tool), dated 06/17/2025 showed Resident 5 had moderate cognitive impairment, but was able to make their needs known and was moderately dependent on staff for toileting hygiene. During an interview on 07/24/2025 at 2:02 PM, Resident 5 said the facility had run out of briefs three times since their admission to the facility. Resident 5 said it could take the facility between 3-5 days to get their size of brief in the building. Resident 5 said when the facility ran out of briefs, the staff would put a smaller size brief on them until they were able to get the right size.…

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 infection control standards were followed related to not following the Centers for Disease Control and Prevention (CDC) by implementing droplet precautions with residents suspected of having Tuberculosis (TB: an infectious disease caused by bacteria called Mycobacterium tuberculosis, primarily affecting the lungs but potentially impacting other parts of the body) for 1 of 5 residents (Resident 1), reviewed for infection control. This failure placed residents, staff and visitors at risk for possibly contracting and spreading infections. Findings included . Review of the facility's policy titled, 'Tuberculosis Screening-Nursing Facility Residents,' undated, states the definition for Tuberculosis (TB): is a disease caused by the bacterium Mycobacterium tuberculosis that is spread person-to-person through the air. TB usually attacks the lungs but can affect other parts of the body. Under the subtitle Specific Procedures/Guidance .2. (e.) 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 sufficient staff were available to provide assistance with activities of daily living and prevent falls for 3 of 4 halls (100, 200 & 300) reviewed for sufficient staffing. This failure placed residents at risk for unmet care needs, risk if increased falls and a diminished quality of life. Findings included . Review of a policy titled, 'Staffing' dated 10/01/2021, documented Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Review of facility assessment, revised 02/26/2025, showed 78 percent of residents required bathing assistance (assist and dependent) from staff, 73 percent required dressing assistance, 73 percent required transfer assistance and 73 percent required assistance with toileting. The assessment identified the facility utilized 40 contracted licensed staff. Staffing as described above is adequate as evidenced by: Staffing is reviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 1 of 8 sample residents (Resident 1) reviewed for medication errors. This placed residents at risk for adverse medical conditions, changes in health conditions, and a diminished quality of life. Findings included . Review of the policy titled 'Medication Orders', undated, notes under the subtitle Recording Orders . 2. Medication Orders-When recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered . Review of the policy titled 'Medication and Treatment Orders', dated 10/01/2021, notes under the subtitle Specific Procedures / Guidance . 7. Verbal orders must be recorded immediately in the resident's medical record by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order . 9. Orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to conduct a prompt and thorough investigation that included immediate interventions and reporting for 1 of 8 sample residents (Resident 1) reviewed for falls. The failure to implement the facility's accidents and incident policy and procedure, placed residents at risk for further exposure to falls/injuries, unmet care needs, and diminished quality of life. Findings included . Review of the Washington State Department of Social & Health Services Nursing Home Guidelines -The Purple Book (guidelines to assist nursing homes with compliance of the State and Federal requirements for the prevention, identification, reporting, and investigating incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, exploitation, and misappropriation of nursing home residents), dated October 2015, showed the facility must begin an immediate investigation of alleged violations in order to collect accurate data. Review of the facility policy,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 6 sample residents (Resident 1) reviewed for abuse. Resident 1 experienced physical harm when the resident was moved out of the way abruptly while sitting in their wheelchair causing injury to their knee. This failure placed residents at risk for ongoing abuse and a diminished quality of life. Findings included . The facility's Abuse policy dated 10/01/2021 and revised on 10/20/2022, states This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. Definitions: 'Abuse'-is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in…

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 pain medications were available and failed to obtain provider's orders for an alternate pain medication of similar strength, for 1 of 3 sampled residents (Resident 1) reviewed for pain management. This failure placed residents at risk for increased pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including chronic pain due to lumbar spine stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and nerves) and degenerative disc disease (cushioning in the spine wears away). The Minimum Data Set, an assessment tool, dated 07/26/2024, documented Resident 1 was alert and oriented, and required assistance with activities of daily living. Resident 1's care plan, dated 12/19/2024 for management of acute/chronic pain, stated staff were to administer analgesia as per orders, monitor/record/report resident complaints of pain or requests for pain…

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 that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . During an interview on 12/12/2024 at 10:33 AM, Staff B, Director of Nursing Services (DNS), stated they took over the DNS position in July 2024 and had been informed of issues related to infection control; however, the systems were supposed to have been fixed by the time they took over the DNS position. Staff B stated they could do a better job with the QAPI process to decrease repeated deficiencies. During an interview on 12/12/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 2 of 2 sampled residents (Residents 14 and 66) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic obstructive pulmonary disease (COPD, a progressive lung disease causing obstructed airflow and breathing difficulties). Resident 14 was able to make needs known. During an interview on 12/06/2024 at 1:30 PM, Resident 14 stated they informed staff that their roommate constantly disrupted their sleep and increased their anxiety. Resident 14 stated they were offered ear plugs as a resolution, but stated they were still unhappy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party of discharges to the hospital for 2 of 2 sampled residents (Residents 38 and 66) reviewed for hospitalization. This failure denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility. Findings included . Resident 38 Review of the electronic health records (EHR) showed Resident 38 readmitted to the facility on [DATE] with diagnoses to include a stroke, high blood pressure, and paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs in brief episodes). Resident 8 was able to make needs known. Review of form titled, SNF -NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 11/29/2024 showed Resident 38 was transferred to the hospital on [DATE]. Review of Resident 38's EHR showed no documentation a written notice of transfer/discharge was provided 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 Resident 5 Review of the EHR showed Resident 5 readmitted to the facility on [DATE] with diagnoses to included anxiety disorder, depression, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Resident 5 was able to make needs known. Review of the PASRR level one, dated 05/18/2022, showed Resident 5 had mood disorder- depressive, bipolar disorder and anxiety disorder; however, it showed No Level II [two] evaluation indicated. During an interview on 12/09/2024 at 9:22 AM, Staff F, SSD, stated Resident 5's PASRR level one dated 05/09/2024 showed the resident had serious mental illness indicators marked and should have had a referral for a PASRR level two evaluation. During an interview on 12/09/2024 at 9:33 AM Staff A, Administrator, stated Resident 5's PASRR level one dated 05/09/2024 did not meet expectations and should have been referred for a PASRR level two evaluation. Resident 8 Review of the EHR showed Resident 8 readmitted to the facility on [DATE] with diagnoses to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to conduct timely care conferences with the resident/responsible party for 4 of 17 sampled residents (Residents 17, 35, 47, and 65) when reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care, and a diminished quality of life. Findings included . Resident 17 Review of the electronic health record (EHR) showed Resident 17 readmitted on [DATE]. Resident 17 was able to make their needs known. During an interview on 12/04/2024 at 2:56 PM, Resident 17 stated, I don't remember going to a care conference. Review of Resident 17's EHR showed the most recent care conference occurred 07/22/2024. Resident 35 Review of the EHR showed Resident 35 readmitted on [DATE]. Resident 35 was able to make their needs known. During an interview on 12/05/2024 at 9:30 AM, Resident 35 stated, I went to a care conference a long time ago. I don't remember going to one recently. 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 observation, interview, and record review, the facility failed to ensure care and services to ensure residents increased or maintained range of motion (ROM) were provided for 3 of 5 sampled residents (Resident 17, 35, and 20) reviewed for position, range of motion/mobility. This failure placed the residents at risk for worsening mobility, developing of contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life. Findings included . Resident 17 Review of the electronic health record (EHR) showed Resident 17 readmitted on [DATE] with diagnoses to include arthritis (swelling of the joints), muscle weakness, and spinal stenosis of the lower back with neurogenic claudication (a condition when the spinal canal narrows in the lower back putting pressure on the spinal cord and nerves). Resident 17 was able to make needs known. Review of the annual minimum data set assessment (MDS), an assessment tool, dated 10/08/2024, showed Resident 17 utilized 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 interview and record review, the facility failed to consistently conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 2 of 2 sampled residents (Residents 65 and 66) reviewed for dialysis. This failure placed the residents at risk for unmet care needs and medical complications. Findings included . Resident 65 Review of the electronic health record (EHR) showed Resident 65 readmitted to the facility on [DATE] with diagnoses to include stroke, diabetes (too much sugar in the blood), kidney failure and required dialysis. Resident 65 was able to make needs known. Review of the provider's order dated 05/16/2024 showed Resident 65 was to receive dialysis treatment at a dialysis center on Mondays, Wednesdays, and Fridays. Review of Resident 65's dialysis binder on 12/10/2024 showed forms titled, Hemodialysis [also known as…

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 use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 3 of 5 sampled residents (Residents 53, 14, and 66) when reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life. Findings included . Resident 53 Review of the electronic health record (EHR) showed Resident 53 admitted to the facility on [DATE] with diagnoses of acquired absence of right leg above knee and depression. Resident 53 was able to make needs known. Review of the medication list showed Resident 53 was prescribed a pain medication PRN. Review showed an order for NPI to be used before PRN pain medications and document effectiveness. Review of the medication administration record (MAR) for November 2024 showed Resident 53 received the PRN pain medication 14 times and was provided with no NPI.…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of 13 errors were made in 31 opportunities during a medication administration for 1 of 3 sampled residents (Resident 396) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life. Findings included . Observation of medication administration on 12/06/2024 at 9:19 AM showed Staff V, Licensed Practical Nurse (LPN), prepared and administered metoclopramide (a medication to treat stomach problems) and 12 other medications to Resident 396. Review of provider's orders for Resident 396 showed the order for metoclopramide have a specific time and instructions to be given at 7:00 AM with meals and the orders for the 12 other medications had a specific time to be given at 8:00 AM. During an interview on 12/11/2024 at 9:34 AM, Staff B, Director of Nursing Services, stated the expectation was for nurses to follow orders including the correct…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 3 of 3 medication carts (Run 3, Peak 1, and Run 4) and 2 of 2 medication rooms (South and North) when reviewed for medication storage. The facility failed to have prescription medications locked in the medication room for 1 of 2 nurses' stations (North Nurses' Station). This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life. Findings included . Observation on 12/04/2024 at 10:40 AM showed medications belonging to Resident 3 left unsupervised on the North Nurses' Station counter. Observation showed the medications were 8 packets (bingo) cards of the medication Seroquel (medication used to treat mental illness), and 4 bingo cards of Tamsulosin (medication prescribed to treat kidney stones). During an interview on 12/04/2024 at 10:51 AM, Staff X, Licensed Practical Nurse (LPN), stated they should have been locked away, and took the medications to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed explain and ensure residents understood the arbitration agreement for 3 of 3 residents (Residents 75, 14, and 31) when reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a jury trial, inability to seek restitution for errors made by the facility, and a diminished quality of life. Findings included . Resident 75 Review of the electronic health record (EHR) showed Resident 75 admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness on one side of the body) and cognitive communication deficit (difficulty with communication). Review showed Resident 75 was able to sign their own documents and make needs know. Review of the arbitration agreement showed Resident 75 signed the document but did not date it. During an interview on 12/06/2024 at 11:24 AM, Resident 75 stated they did not know what an arbitration agreement was and did not recall anyone explaining it to them.…

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

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of antibiotic resistance by not ensuring criteria were met for the use of antibiotics and an indication for use/type of infection was included in the provider orders for 6 of 10 sampled residents (Residents 9, 45, 15, 14 , 63 and 26) when reviewed for antibiotic stewardship. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics, and a decreased quality of life. Findings included . Review of the facility policy titled Antibiotic Stewardship, dated 04/2023, showed the infection preventionist (IP) would review antibiotic utilization daily to identify inappropriate use of antibiotics to include: indications for use that do not meet the criteria for clinical definition of an active infection, and if an antibiotic is indicated, prescribers will provide complete antibiotic…

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 risks/benefits and obtain consent for the use of an antidepressant for 1 of 5 sampled residents (Resident 53) when reviewed for unnecessary medication. This failure placed the resident at risk of unknown side effects of the medication, lack of decision-making power in treatment decisions, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 53 admitted to the facility on [DATE] with diagnoses of acquired absence of right leg above knee and depression. Resident 53 was able to make needs known. Review of the medication list showed Resident 53 received duloxetine (an antidepressant) for depression daily. Review of the EHR showed no risks/benefits for the use of duloxetine was provided to Resident 53 and consent to receive this medication was not obtained. During an interview on 12/10/2024 at 11:02 AM, Staff G, Unit Manager, stated before starting a resident on an antidepressant…

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 an environment free from verbal abuse for 1 of 3 sampled residents (Resident 45) reviewed for abuse. This failure placed residents at risk for ongoing abuse and neglect, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse Prevention Program, dated April 2023, showed, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff . Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body) and cognitive communication deficit (difficulty communicating). Resident 45 was able to make needs known. During an interview on 12/05/2024 at 10:18 AM, Resident 45 stated there was an incident where an unnamed staff member accused them of buying out all the potato chips from 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 identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 45) reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect, or mistreatment, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse Prevention Program, dated April 2023 showed, As part of the resident abuse prevention, the administration will . identify and assess all possible incidents of abuse . report any allegations of abuse within timeframes as required by federal requirements. Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body) and cognitive communication deficit. Resident 45 was able to make needs known. During an interview on 12/05/2024 at 10:18 AM, Resident 45 stated there was an incident where an unnamed staff member accused them of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to thoroughly report allegations of abuse for 1 of 3 sampled residents (Residents 85) reviewed for abuse. This failure placed residents at risk repeated potential abuse, neglect, or mistreatment, and a diminished quality of life. Findings included . Resident 85 Review of the EHR showed Resident 85 was admitted to the facility on [DATE] with diagnoses of fracture of right lower leg, injury of right ankle, and diabetes (too much sugar in the blood). Resident 85 was able to make needs known and needed assistance to get up from bed. Observation and interview on 12/04/2024 at 9:56 AM, showed Resident 85 laid in bed with a worried facial expression. Resident 85 stated, I don't feel safe in here. Resident 85 stated early in the morning a male resident was walking towards the room in the hallway, and they could hear the footsteps coming close. Resident 85 stated they started yelling for everyone to get up. Resident 85 stated they reported this to Staff U.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 20 sampled residents (Residents 69 and 346) reviewed for accuracy of assessments. Failure to accurately code Resident 69's use of corrective lenses, and Resident 346's antibiotic therapy and continuous oxygen therapy, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 69 Review of the electronic health record (EHR) showed Resident 69 admitted to the facility on [DATE] with diagnoses to include systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs), depression, and was able to make needs known. Review of the quarterly minimum data set (MDS), an assessment tool, dated 09/03/2024, showed Resident 69 had adequate vision with no corrective lenses. During an interview on 12/11/2024 at 10:30 AM, Staff F, Social Services Director (SSD), 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 develop and/or implement a comprehensive care plan for 4 of 20 sampled residents (Residents 17, 35, 20, and 346) when reviewed for care plan. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to, limited range of motion/impaired mobility, restorative nursing services, palm guard and/or splint application, peripherally inserted central catheter (PICC, a tube inserted through the arm and into the heart), antibiotic therapy, and sepsis (a life-threatening complication of an infection), placed residents at risk for unmet care needs and potential negative outcomes. Findings included . Resident 17 Review of the electronic health record (EHR) showed Resident 17 readmitted on [DATE] with diagnoses to include arthritis (swelling of the joints), muscle weakness, spinal stenosis of the lower back with neurogenic claudication (a condition when the spinal canal narrows in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide and accurately document the necessary care and services to ensure that a resident received showers as scheduled and had facial hair removed for 1 of 4 sampled residents (Resident 35) reviewed for activities of daily living (ADLs). This failure placed the resident at risk for continued unmet needs and a poor quality of life. Findings included . Review of Resident 35's electronic health records (EHR) showed Resident 35 readmitted to the facility on [DATE] with diagnoses to include contracture of the right hand (permanent tightening of muscle, tendons and skin, leading to deformity), muscle weakness, and difficulty in walking. The quarterly minimum data set, an assessment tool, dated 10/29/2024, showed Resident 35 required partial/moderate assistance with shower/bathing and was able to make needs known. Observations on 12/04/2024, 12/05/2024, 12/06/2024, 12/09/2024, and 12/10/2024 showed Residet 35 with multiple long (approximately…

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 follow provider's orders for 2 of 7 sampled residents (Residents 66 and 8) when reviewed for non-pressure related skin conditions and unnecessary medications and failed to evaluate wheelchair positioning for 1 of 5 residents (Resident 17) when reviewed for positioning/mobility. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life. Findings included . Resident 66 Review of the EHR showed Resident 66 admitted to the facility on [DATE] with diagnoses of left below knee amputation, infection, and diabetes. The resident was able to make needs known. During an interview and observation on 12/05/2024 at 9:37 AM, Resident 66 stated they had wounds on their right foot and calf and on the left leg amputation site. There was a bandage present on both lower extremities. Resident 66 stated the dressing was not changed on 12/04/2024, and they had to ask staff to change it multiple times, but staff 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 interview and record review, the facility failed to provide services to maintain vision for 1 of 3 residents (Resident 65) reviewed for communication sensory. This failure placed the resident at risk of unmet vision needs, inability to perform activities of daily living, inability to participate in leisure activities and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 65 readmitted to the facility on [DATE] with diagnoses to include stroke, diabetes (too much sugar in the blood), and kidney failure. Resident 65 was able to make needs known. During an interview on 12/05/2024 at 8:45 AM, Resident 65 stated they needed new glasses because they were nearsighted, and they had told staff about a month ago. Review of Resident 65's document titled, Attending Physician Request for Services and/or Consultation, dated 03/25/2024, showed the form for eye care/referral was completed and signed by the provider on 03/25/2024. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and assistance to maintain continence for 1 of 6 sampled residents (Resident 394) reviewed for bowel and bladder incontinence, and unnecessary medications. This failure placed the resident at risk for incontinence, skin injuries, and diminished quality of life. Findings included . Review of electronic health record (EHR) showed Resident 394 was admitted to the facility on [DATE] with diagnoses of fracture of left leg, asthma, and muscle weakness. Resident 394 was able to make needs known and needed assistance to move out of bed. Observation and interview on 12/04/2024 at 11:22 AM showed Resident 394 in bed with a device on their left leg. Resident 394 stated they needed assistance to go to bathroom and by the time the staff came, they were fully soiled. Resident 394 stated therapy had assisted them to use the toilet on 11/28/2024 and told them two strong staff could assist and transfer them 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 residents received the correct amounts of supplemental nutrition for 2 of 2 sampled residents (Residents 34 and 81) and failed ensure diet recomendations and fluid restrictions were implemented for 2 of 5 sampled residents (Residents 19 and 74) reviewed for nutrition. These failures placed residents at risk for medical complications, unmet care needs, and a diminished quality of life. Findings included . Resident 19 Review of the electronic health record (EHR) showed Resident 19 admitted to the facility on [DATE] with diagnoses that included kidney disease, heart failure, and depression. Resident 19 was able to make needs known. During an interview on 12/05/2024 at 9:58 AM, Resident 19 stated the facility did not follow the recommendations of their provider related to their diet and fluids. Resident 19 stated they were offered cinnamon rolls for breakfast and foods high in sodium. Review of a provider's order, dated 05/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide respiratory care according to professional standards of practice for 1 of 3 sampled residents (Resident 74) reviewed for respiratory care. This failure placed the resident at risk for infection, unmet needs, and diminished quality of life. Findings included . Review of the EHR showed Resident 74 was admitted to the facility on [DATE] with diagnoses of heart failure, endocarditis (infection of the heart), and kidney failure with dependance of kidney dialysis (medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do). Resident 74 was able to make needs known. Observation and interview on 12/05/2024 at 9:00 AM showed Resident 74 laid in bed with a continuous positive airway pressure machine (CPAP, device to keep airway open while a person sleeps) next to them. Resident 74 stated, My only problem is, the aids do not want to add water in my machine, and it takes a long time 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 provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 3 sampled residents (Resident 85) reviewed for abuse. The facility failed to recognize and follow-up on a resident after a traumatic experience in their room. This failure placed the residents at risk for unmet needs, continued emotional disturbance, and diminished quality of life. Findings included . Review of a policy titled, Social Services Policy, undated, showed medically related social services were provided to maintain or improve each's resident's ability to control everyday physical needs and mental and psychosocial needs. It described in detail how social services was responsible for identifying emotional needs, providing corrective action, maintaining individualized care plans, and making regular progress notes. Review of the electronic health record (EHR) showed Resident 85 was admitted…

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 monitor for behaviors for 2 of 5 sampled residents (Residents 57 and 8) review for use of psychotropic medications (medications that affect a person's mental status). This failure placed the residents at risk for adverse side effects, unknown behaviors, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 57 was admitted to the facility on [DATE] with diagnoses including anxiety and post-traumatic stress disorder. Resident 57 was able to make needs known. Observation and interview on 12/04/2024 at 1:40 PM showed Resident 57 sat in a dark room on the bed. They stated, I have night terrors and don't like to be awaken or touched. Review of Resident 57's medication administration record for November 2024 and December 2024 showed the resident was administered multiple antidepressant medications and an antianxiety medication. There was no behavior monitor to monitor what behaviors…

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 monitored refrigerator temperatures and take corrective action as needed for 1 of 3 resident refrigerators (South Clean Utility Fridge) when reviewed for kitchen. This failure placed residents at risk of consuming spoiled food goods, avoidable foodborne illnesses, and a diminished quality of life. Findings included . Observation of the South Clean Utility Fridge on 12/10/2024 showed temperature logs for November 2024 and December 2024 hung to the front. Review of the temperature logs showed spaces for AM and PM temperatures to be recorded and written at the bottom was, NOTE: [ .] Refrigerator temperature should not exceed 40 [degrees]. Notify supervisor if temperature exceeds these guidelines. Review showed a space for comments to be written. Review of the November 2024 South Clean Utility Fridge temperature log showed 11 of 31 AM temperatures and 16 of 31 PM temperatures were recorded as above 40 degrees. Review showed no comments had been made for these temperatures. Review of the December 2024 South Clean…

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 resident was free from physical restraints for 1 of 3 sampled residents (Resident 1) reviewed for Abuse. This failure placed the resident at risk for injury, limited freedom of movement and a decreased quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of the facility's Abuse Prevention Program policy, dated 10/01/2021, documented residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included free from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.…

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 care and services were provided timely for one of three residents (Resident 1) reviewed for falls. The facility's failure to obtain immediate medical care placed Resident 1 at risk for distress and delay in evaluation and treatment when the resident sustained a head injury after a fall. Findings included . Facility Policy, Managing Falls and Fall Risk, dated 5/10/2023, documented that after a fall, if there was evidence of injury, appropriate first aid should be provided and/or medical treatment obtained immediately. Resident 1 was admitted to the facility on [DATE] with diagnoses including heart disease. Nursing Progress Note, dated 4/17/2024 at 8:04 AM, documented Resident 1 fell, struck the back of the head and sustained a 3 centimeter (slightly more than 1 inch) vertical wound that, per Progress Note, bled profusely. Progress Note documented that first aid was administered by a Registered Nurse (RN) and that the guardian and provider 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 reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when 3 of 3 residents' (Residents 1, 2, 3) physician recommendations or orders were not carried out timely, assessment and monitoring of wounds and changes in condition were not done, and coordination of care with providers was incomplete. These failures placed residents at risk for harm from worsening or potential infections and wounds and placed residents at risk for unmet care needs and diminished quality of life. Findings included . < Resident 1 > Resident 1 was admitted [DATE] with diagnoses including heart failure, osteomyelitis (bone infection) and an infection that developed after a coronary artery bypass graft (surgery to help restore blood supply to the heart) in the surgical wound site at the sternum (breastbone). admission Orders, dated 01/29/2024, documented Resident 1 was to receive 39 days of intravenous (IV) Zosyn…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure 2 of 3 residents (Resident 1 and 2), reviewed for accidents, were assessed or re-assessed for elopement risk and care plans were revised to include interventions to migitate risk for or prevent elopement. In addition, facility failed to ensure staff received education regarding prevention of elopement. These failures placed Resident 1 at risk for injury when the resident eloped to a potentially unsafe home setting and interventions to prevent elopement were not in place; and placed Resident 2 at risk for injury when the resident was not re-assessed for elopement risk and care plan was not revised after being moved from an alarmed unit to an unalarmed unit upon a change in medical condition and the resident was found attempting to leave the facility through an employee exit. Findings included . Facility policy, Elopement Prevention Guideline, dated April 2023, documented that residents would be evaluated by a licensed nurse for risk for…

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

Based on observation, interview, and record review, the facility failed to maintain a kitchen environment which allowed each resident to receive nourishing, palatable, and well-balanced meals when reviewed for kitchen. This failure placed residents at risk of decreased mood, feelings of worthlessness, lack of nutritional intake, avoidable weight loss, foodborne illness, and a diminished quality of life. Findings included . <Staff Competency> During an interview on 02/26/2024 at 11:14 AM, Staff A, Administrator (ADM), stated Staff H, Dietary Manager (DM), had no formal training to serve as director of food and nutrition services and Staff P, Registered Dietician (RD), oversaw the kitchen. During an interview on 02/26/2024 at 12:31 PM, Staff P stated they did not have any management responsibilities in the kitchen and that was the responsibility of Staff H. <Kitchen Staffing> Observation on 02/22/2024 showed Staff H asked for additional staff in the kitchen to complete meal service. Observation on 02/22/2024 showed the kitchen utilized Staff Y, Director of Rehabilitation (DOR), in the…

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

Based on interview, the facility failed to ensure the dietary manager (DM) was qualified for food and nutrition services for 1 of 1 DM (Staff P) reviewed for qualified dietary staff. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . During an interview 02/26/2024 at 11:14 AM, Staff A, Administrator (ADM), stated Staff H, Dietary Manager (DM), had no formal training to serve as director of food and nutrition services and Staff P, Registered Dietician (RD), served as the facility's director of food and nutrition services. During an interview on 02/26/2024 at 12:31 PM, Staff P said they did general oversight of the kitchen monthly through a sanitation and tray accuracy audit. Staff P stated the results of this audit were provided to Staff H and Staff A. Staff P stated they had concerns with the facility's food storage and had asked a few times for support, such as training, to increase the kitchen staff's competency. Staff P stated they did not have any management responsibilities in the kitchen and…

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

Based on observation and interview, the facility failed to ensure the kitchen had sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 facility kitchen. This failure placed residents at risk of delayed mealtimes, lack of sanitation in the kitchen, foodborne illness, and a diminished quality of life. Findings included . Observation on 02/22/2024 at 12:15 PM, showed Staff H, Dietary Manager (DM), stated to another staff the kitchen needed more staff to finish the lunch service. Observation on 02/22/2024 at 12:24 PM, showed Staff W, Receptionist, entered the kitchen and was directed to assist on tray line by Staff H. Staff W stated they had previously never worked on tray line, had previously received a food handler's permit about two years ago, and was unsure if it was still valid. Staff H stated the facility did not have a food handler's permit on record for Staff W. Observation on 02/22/2024 at 12:29 PM, showed Staff Y, Director of Rehabilitation (DOR), entered the kitchen and was directed to wash…

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 prepare meals that were palatable and appetizing for 8 of 8 sampled residents (64, 71, 30, 82, 36, 25, 77 & 17) reviewed for food value and palatability. This failure placed residents at risk of decreased nutritional intake, depressed mood, and a diminished quality of life. Findings included . <Kitchen> Observation on 02/20/2024 at 9:26 AM, showed Staff X, Cook, had long hair in a ponytail which hung down the back and was uncovered. Observation of Dry Storage on 02/22/2024 at 11:08 AM, showed one box of small containers of beef base with label refrigerate for optimum flavors, two bags of pasta left open to the air in original packaging, a bin of lentils with the lid ajar, a stack of banana pudding mix bags with a variety of best by dates including January 2024, a box of barley left open to the air, and a box of ham base with label refrigerate for optimum flavors. Review of the Bread Shelves on 02/22/2024 at 11:27 AM, showed two bags of hot dog buns without use by date, two bags of wheat bread with use by date of 02/20, one…

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

Based on observation, interview, and record review, the facility failed to provide food that accommodated resident preferences for 1 of 6 sampled residents (Resident 64) reviewed for food preferences. This failure placed residents at risk of reduced nutritional intake, decreased mood, and a diminished quality of life. Findings included . During an interview on 02/20/2024 at 11:39 AM, Resident 64's durable power of attorney (DPOA) stated the facility's speech therapist (ST) had evaluated the resident to require a pureed texture. The DPOA stated Resident 64 did not want pureed food, that the DPOA had asked the facility's ST to contact them, and the DPOA had not heard back regarding the issue. Observation on 02/20/2024 at 12:19 PM, showed Resident 64 with pureed meat on their meal tray. Observation on 02/22/2024 at 8:46 AM, showed Resident 64 with pureed food on their meal tray. Review of Resident 64's meal tray card, undated, showed the resident was to receive soft and bite sized food. Review of Resident 64's February 2024 physician's orders showed the resident had a soft and…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared, served and stored, in a sanitary manner for 3 of 3 kitchen refrigerators (Refrigerator #1, Refrigerator #2, and Walk-in Refrigerator), 3 of 3 resident use refrigerators (North Hall Refrigerator, South Hall Refrigerator, and Minifridge) and 5 of 5 other food storage areas (Dry Storage, Bread Shelves, Back Preparation Area, Spice Shelf, and Under Preparation Table) reviewed for sanitary food preparation, service and storage. This failure placed residents at risk of consuming expired food items, foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . <Main Kitchen> Observation on 02/20/2024 at 9:21 AM, showed Refrigerator #1 with a temperature monitoring log which had no recorded temperatures from 02/14/2024 through 02/19/2024. Observation on 02/20/2024 at 9:22 AM, showed the Walk-in Refrigerator/Freezer with temperature logs for the refrigerator and freezer which had no recorded temperatures from 02/14/2024 to 02/19/2024. Observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to control and prevent the transmission of communicable diseases by ensuring the proper application of transmission-based precautions (TBP) to ensure the proper use of personal protective equipment (PPE) by staff during a respiratory virus outbreak on 2 of 4 sampled hallways (100 & 200) and the facility failed to track infectious organisms present in the facility for 3 of 3 sampled months (November 2023, December 2023 & January 2024) reviewed for infection prevention and control. These failures placed residents, visitors and staff at risk for communicable diseases, infections, and decreased quality of life. Findings included . Outbreak management and Transmission Based Precautions Review of the facility document entitled Infection Control Program, dated 10/24/2022, showed the facility would develop isolation precaution protocols for when control of an infectious or communicable disease…

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 infection prevention and control program (IPCP) was overseen by a qualified individual with the time and training necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as Quality Assurance and Performance Improvement for 1 of 1 infection control preventionist (ICP) (Staff U) reviewed for infection preventionist qualifications. This failure placed residents, family members and staff at risk of contracting communicable diseases and a decreased quality of life. Findings included . Review of the facility document entitled Infection Control Program, dated 10/24/2022, showed the IPCP would be overseen by the infection preventionist and be consistent with the guidelines from the Center for Disease Control (CDC). Review of the CDC document entitled CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/2022, showed core practices included: 1.…

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 ensure kitchen equipment, that was powered by a gas line, was maintained to prevent a grease build-up which could create a fire hazard and placed residents at risk for smoke inhalation in 1 of 1 kitchen reviewed for safe operating equipment. Findings included . Observation of the Griddle/Oven Combo Unit, on 02/22/2024 at 12:48 PM, showed a black substance dripping from the bottom of the oven door and forming a line of grease approximately six inches long on the floor. Observation of the interior of the oven showed a large bulb of grease approximately two inches in diameter stuck to the inside of the oven door with accompanying runoff which was dripping down onto the floor. The grease from the griddle was draining down into the oven compartment and causing the grease bulb. A muffin tin of cupcakes on the top rack of the oven were hard to the touch. Staff H, Dietary Manager, said the facility did not use the oven and was unsure why cupcakes were placed in the oven. Observation on 02/22/2024 at 1:42 PM showed Staff H, Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 10> Review of the quarterly MDS, dated [DATE], showed Resident 10 admitted on [DATE] with diagnoses including heart and lung disease, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the inability to carry out simple tasks), and depression. In addition, the resident's EHR showed diagnoses of dementia with psychotic disturbances, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety. The MDS further showed that the resident was able to make needs known. Review of Resident 36's providers orders for January and February 2024 MAR showed multiple orders for staff to administer several psychotropic medication to include: risperidone (an antipsychotic medication to be administered for dementia with psychotic disturbances and bipolar disorder), dated 11/13/2023, sertraline (a medication used to treat depression) dated 06/23/2023 and lorazepam (a medication used to treat anxiety)…

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 or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 4 of 5 residents (Residents 10, 17, 31 and 71) reviewed for AD. This failure placed the residents at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences. Findings included . An AD is a written instruction, such as a living will or durable power of attorney [DPOA] for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. <Resident 10> Resident 10 readmitted to the facility on [DATE] and was usually able to make needs known; however, had some difficulty communicating some words or finishing thoughts. Review of a progress note, dated 10/13/2023, showed Resident 10's family member was going to email a copy of 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 report allegations of abuse for 2 of 6 residents (Residents 82 and 13) reviewed for abuse and neglect. This failure placed residents at risk of repeated abuse, injury, unmet needs, and a diminished quality of life. Findings included . <Resident 82> Review of the admission Minimum Data Set assessment (MDS) showed Resident 82 admitted to the facility on [DATE] and was able to make their needs known. Review of a progress note, dated 02/16/2024, showed Resident 82 had said everyone was trying to kill me and that staff had not assisted with incontinence (loss of bladder control) care. Review of the facility's incident log did not show that this incident had been logged or investigated. During an interview on 02/21/2024 at 12:18 PM, Staff C, MDS Coordinator/Registered Nurse (MDS/RN), said the facility responded to allegations of abuse or neglect by protecting the resident from further abuse or neglect and initiate an investigation. Staff C…

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 a baseline care plan (CP), within 48 hours of admission, which provided the minimum healthcare information necessary to meet the immediate care needs for 3 of 19 residents (Residents 30, 55 and 85) reviewed for care planning. This failure placed the residents at risk for medical complications and unmet care needs. <Resident 30> Review of Resident 30's Minimum Data Set assessment (MDS, an assessment tool) showed the resident admitted on [DATE] with diagnoses including pneumonia (a lung infection), respiratory failure, and cancer, The MDS showed the resident required assistance with showering/bathing, was receiving scheduled and as needed pain medications and was receiving continuous oxygen therapy. During an observation and interview on 02/20/2024 at 1:27 PM, Resident 30 was in bed, there was a tube in their nose connected to an oxygen concentrator set at 3 liters per minute, the resident said staff changed the tubing for 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 resident care plans were reviewed, revised, and accurately reflected residents' care needs for 1 out of 4 residents (Residents 28) reviewed for falls and 1 of 3 residents (Resident 71) reviewed for non-pressure skin conditions and failed to provide quarterly care conferences in a timely manner and included the resident and/or their representative for 3 of 19 residents (Residents 7, 13, and 36) reviewed for care planning. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . <Care Plan Review, Revision and Accuracy> <Resident 28> Review of the quarterly Minimum Data Set assessment (MDS, an assessment tool), dated 12/19/2023, showed Resident 28 admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), repeated falls, and was able to make needs known. Observation and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from unnecessary pain medication and ensure provider orders were followed (blood pressure parameters) prior to medication administration for 2 of 5 sampled residents (17 & 71) reviewed for unnecessary medications. These failures placed residents at risk for side-effects, medical complications, and a diminished quality of life. Findings included . <Blood Pressure Parameters> 1) Review of the entry Minimum Data Set (MDS), an assessment tool, dated 01/18/2024, showed Resident 17 was admitted on [DATE] with diagnoses including heart, lung and kidney disease, hemiplegia (paralysis of one side of the body), diabetes, and depression. The MDS showed the resident was able to make needs known. Review of Resident 17's January 2024 and February 2024 Medication Administration Record (MAR) showed a provider had ordered metoprolol (a medication used to treat high blood pressure) every day with orders to hold for a systolic blood pressure…

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 monitoring of potential side effects, conducting Abnormal Involuntary Movement Scale (AIMS) at least every six months and monitoring orthostatic blood pressures (blood pressures while lying, sitting and standing), related to the use of psychoactive medications was completed for 6 of 6 sampled residents (Residents 36, 10, 17, 71, 7, and 25) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for adverse side effects, medical complications, and a diminished quality of life. Findings included . Review of a document entitled, Antipsychotic Medication Use, undated, showed, The attending physician/practitioner and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. In addition, nursing staff shall monitor for and report any of the following side effects and adverse consequences…

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 offer, educate, and obtain consent for and administer influenza and pneumococcal vaccines for 5 of 5 sampled residents (Residents 11, 32, 48, 55 & 79) reviewed for influenza and pneumococcal immunizations. These failures placed residents at risk for not having the opportunity to make an informed decision regarding receiving immunizations, exposure to communicable diseases, health complications, and a decreased quality of life. Findings included . 1) Review of Resident 11's Electronic Health Record (EHR) showed the resident was admitted on [DATE] and had not received the influenza or pneumococcal vaccines. There was no documentation that education was provided on the risks and benefits or the resident was offered the vaccines. 2) Review of Resident 32's EHR showed the resident was admitted on [DATE]. The resident received a dose of the Pneumococcal Vaccine pcv23 on 09/22/2021. There was no documentation the follow up pneumococcal vaccine was offered.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents or resident representatives were provided education regarding the benefits and potential side effects of the COVID-19 vaccine and were offered the vaccine for 5 of 5 sampled residents (11, 32, 48, 55 & 79) reviewed for COVID-19 immunizations. This failure placed residents and their representatives at risk of not being given the opportunity to make an informed decision regarding their medical care, of potential complications of a communicable disease, and a decreased quality of life. Findings included . 1) Review of Resident 11's Electronic Health Record (EHR) showed the resident was admitted on [DATE] and had not received the COVID-19 immunization. There was no documentation education was provided on the risks and benefits or the vaccine was offered in the EHR. 2) Review of Resident 32's EHR showed the resident was admitted on [DATE] and had received COVID-19 immunization doses on 09/14/2021 and 10/16/2021. There was no documentation…

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 provide necessary housekeeping and maintenance to maintain resident rooms and common areas for 2 of 4 halls (Halls 400 & 200) reviewed for safe, clean, functional and comfortable environment. These failures placed residents at risk for unsanitary conditions, less than a homelike environment and a diminished quality of life. Findings included . <Housekeeping> Observation on 02/22/2024 at 11:31 AM, showed the 400 Hall Dining/Activity Room floor had food particles, spiders and webs on the baseboards and in all corners, multiple orange stains, black scuffs and dried substances and scrapes around the entire perimeter of the lower wall panels. Observation and interview on 02/20/2024 at 9:37 AM, showed room [ROOM NUMBER] (on 200 Hall) had multiple stains and crumbs on the carpet, and the garbage was overflowing. Resident 13 stated their room was cleaned once a week. Observation on 02/23/2024 at 1:42 PM, room [ROOM NUMBER] showed the floor had numerous yellow…

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

Based on interview and record review, the facility failed to identify, initiate, thoroughly investigate and promptly resolve a grievance for one of one resident (Resident 13) reviewed for concerns/grievances. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . During an interview on 02/20/2024 at 12:53 PM, Resident 13 said there had been incident last month regarding their medication; however, nothing was ever done about it because staff at the facility didn't follow through on things. Resident 13 said they informed the dietician that they did not receive their dinner or medications; however, no one ever got back to them about the situation. Review of Resident 13's electronic health record (EHR) showed a progress note, dated 01/17/2024, from Staff P, Registered Dietician, indicating that Resident 13 had reported they did not receive the previous evenings medications nor did the resident receive dinner. Staff P said the information was reported to the Director of Nursing. Review of Resident 13's Medication Administration…

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 respond timely to allegations, thoroughly investigate and/or follow up on identified interventions for incidents of skin impairment or fall and allegations of abuse or neglect for 1 of 4 residents (Residents 94) reviewed for abuse or neglect and 1 of 4 residents (Resident 28) reviewed for falls. Thes failures placed residents at risk for potential ongoing abuse/neglect, continued falls, unmet needs, and a decrease quality of life. Findings included . <Skin Impairment Incident> Review of the admission Minimum Data Set assessment (MDS, an assessment tool), dated 01/17/2024, showed Resident 94 admitted to the facility on [DATE] with diagnoses including acute (sudden) respiratory failure with hypoxia (low levels of oxygen in the body tissues), heart failure, diabetes (a condition in which blood sugar levels are too high), and chronic kidney disease (damaged kidneys that cannot filter blood the way they should) and was able to make 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 interview and record review, the facility failed to implement identified mental health interventions for 1 of 6 residents (Resident 25) reviewed for Pre-admission Screening and Resident Review (PASRR). This failure placed residents at risk of anxiety, depressed mood, emotional distress, and a diminished quality of life. Findings included . Resident 25 admitted to the facility on [DATE] with diagnoses of bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), suicidal ideation (thinking about or planning suicide), anxiety, and depression. Review of Resident 25's PASRR Level 2 assessment, dated 08/01/2022, showed recommendations to include the addition of mood disorder diagnosis, re-evaluation by a psychiatrist to reassess the resident's current diagnoses, and referral to counseling. Review of Resident 25's 07/29/2022 initiated care plan showed a referral for a PASRR Level 2 evaluation on 08/04/2022 but did not show recommended interventions or referral…

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 accurately completed for 2 of 5 residents (Resident 10 and 17) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . <Resident 10> Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 01/17/2024 showed that Resident 10 admitted on [DATE] with diagnoses to included heart and lung disease, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the inability to carry out simple tasks), and depression. In addition, the resident's electronic health record (EHR) showed diagnoses of dementia with psychotic disturbances, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety. The MDS further showed that the resident was able to make…

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 discharge plan that included special precautions and instructions for ongoing care to the receiving facility for 1 of 1 resident (Resident 294) reviewed for discharge planning. This failure placed the resident at risk for unmet needs, medical complications, and poor adjustment at the receiving long term care nursing facility. Findings included . Review of the discharge Minimum Data Set (MDS, a required assessment tool) dated 02/05/2024, showed Resident 294 re-admitted on [DATE] with diagnoses including a neurogenic bladder (a condition which results in lack of bladder control due to a brain, spinal cord or nerve problem), obstructive uropathy (a disorder of the urinary tract that results due to an obstructed urinary flow either structural or functional), and chronic kidney disease. The resident's electronic health record (EHR) showed they had an indwelling urinary catheter. The MDS showed the resident was able to make needs known. Review…

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 the necessary care and services to ensure residents received their showers as scheduled for 2 of 4 residents (Resident 17 and 30) reviewed for activities of daily living (ADLs). This failure placed the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . <Resident 17> Review of the entry Minimum Data Set assessment (MDS, an assessment tool), dated 01/18/2024, showed Resident 17 admitted on [DATE] with diagnoses including heart, lung and kidney disease, hemiplegia (a loss of function of one side of the body due to paralysis) diabetes and depression. The MDS showed the resident was able to make needs known and required substantial/maximal assistance with activities of daily living to include shower/bathing. On 02/20/2024 at 10:19 AM, Resident 17 was observed wearing a hospital gown and said they had not had a shower for quite some time while in the facility. 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.

Based on interview and record review, the facility failed to provide services and devices to maintain vision and/or hearing for 1 of 3 residents (Residents 13) reviewed for communication/sensory. This failure placed residents at risk for decreased visual acuity, inability to perform activities of daily living and a diminished quality of life. Findings included . Review of a Progress Note dated 12/29/2023 showed that Resident 13 accidentally rolled over their glasses with their power wheelchair. During an interview on 02/20/2024 at 9:49 AM, Resident 13 said they missed their scheduled vision appointment on 01/25/2024 due to the staff not getting them up and dressed on time. During an interview on 02/22/2024 at 12:22 PM, Staff E, Licensed Practical Nurse/Unit Manager, said they were responsible for scheduling appointments for Resident 13. Staff E said Resident 13 did have a scheduled vision appointment; however, the transportation service did not show up and Resident 13 did not make it to the appointment. Staff E said they had not rescheduled the appointment; however, they should…

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 and prevention measures for 1 of 3 residents (Resident 55) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life. Findings included . Review of resident 55's electronic health record (EHR) showed the resident admitted on [DATE] with diagnoses including pneumonia (lung infection), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and polyneuropathy (when multiple limb nerves become damaged causing problems with sensation), required moderate assistance with bed mobility, had no pressure injuries on admission and had a high risk for developing pressure injuries. During an observation on 02/20/2024 at 11:17 AM, Resident 55 was in bed and was rubbing their heel on the bed and said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to maintain an environment free of accidents by providing supervision/assistance during toilet transfers, assistance needed for walking, and self-medication administration for 2 of 5 sampled residents (Residents 28 and 295) reviewed for accident hazards. This failure placed residents at risk for falls, injuries, medical complications and a diminished quality of life. Findings included . <Resident 28> Review of the quarterly Minimum Data Set assessment (MDS), dated [DATE], showed Resident 28 was admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), repeated falls, and was able to make needs known. Review of the incident report, dated 01/30/2024, showed Resident 28 had a fall while trying to pick up a noodle from the floor during meal service resulting in a laceration (cut) to the back of the left hand. The report showed the care plan was updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) had orders for the presence of the catheter and provided catheter care and management that minimized the risk for complications for 1 of 1 sampled resident (Resident 294) reviewed for catheter care. This failure placed residents at risk for catheter associated urinarty tract infections, dislodgement and other complications. Findings included . Review of the discharge summary Minimum Data Set (MDS, a required assessment tool) dated 02/05/2024, showed Resident 294 re-admitted on [DATE] with diagnoses including neurogenic bladder (a condition which results in lack of bladder control due to a brain, spinal cord or nerve problem), obstructive uropathy (a disorder of the urinary tract that results due to an obstructed urinary flow either structural or functional), and chronic kidney disease and was able 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 monitor and accurately document fluids consumed for a resident on dialysis (treatment to filter wastes and water from the blood) to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for 1 of 1 sampled resident (Residents 71) reviewed for hydration status maintenance. This failure placed residents at risk for medical complications and a decreased quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS), dated [DATE], showed Resident 71 was readmitted on [DATE] with diagnoses including kidney failure (damaged kidneys that cannot filter blood the way they should), received dialysis services, and was able to make needs known. Observation and interview on 02/20/2024 at 11:26 AM, showed Resident 71 with a cup of clear fluid at the bedside. Resident 71 stated the nurse gave water with their medications, and they had not finished drinking…

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 monitor and provide oxygen services to meet professional standard for 2 of 2 sampled residents (Residents 25 and 30) reviewed for respiratory services. This failure placed residents at risk of oxygen toxicity, injury, infection, and a diminished quality of life. Findings included . 1) Resident 25 was admitted to the facility on [DATE] with diagnoses including pneumonia (lung infection), chronic obstructive pulmonary disease (a lung diseases that blocks airflow and makes it difficult to breathe), respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide), and obstructive sleep apnea (airflow blockage during sleep). Review of Resident 25's physician's orders showed the resident was to receive oxygen at two to three liters per minute (L/min). Observation on 02/20/2024 at 11:22 AM, showed Resident 25 in bed with their oxygen on their face. Resident 25's oxygen concentrator was set to five…

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 assess the need for and administer pain relief medications in a timely manner for 2 of 3 sampled residents (Residents 1 and 30) reviewed for pain. This failure placed residents at risk for unrelieved pain, lack of participation in therapy and a decreased quality of life. Findings included . <Resident 1> During an interview and observation on 02/21/2024 at 9:00 AM, Resident 1 laid in bed, the resident's body was curled to the right side of the bed hanging onto the mobility bars, the resident groaned and grimaced while repositioning. Resident 1 stated they had pain related to their wounds that sometimes was nine out of ten on a scale of one to ten. Resident 1 said they take Gabapentin (a medication for nerve pain) for the pain, but it did not help. The resident said they also took oxycodone (a narcotic pain medication) and that worked pretty well to relieve the pain, but they only took it once a day. Resident 1 stated they felt they should…

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 conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis center regarding dialysis care and services to include medications provided at dialysis and maintaining dialysis communication forms in the residents medical record for 1 of 1 sampled resident (Resident 71) reviewed for dialysis. These failures placed residents at risk for unmet care needs, not having a record of dialysis communication forms, medical complications and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment, dated 01/24/2024, showed Resident 71 readmitted on [DATE] with diagnoses including bacteremia (bacteria in the blood), kidney failure (damaged kidneys that cannot filter blood the way they should), received dialysis services, and was able to make needs known. Observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to act on and/or consistently follow the pharmacy consultant's Medication Regimen Review (MRR) recommendations in a timely manner and maintain MRR documentation for 1 of 5 sampled residents (Resident 71) reviewed for drug regimen review. This failure placed residents at risk for not having all MRR documentation in the medical record, experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the facility's policy and procedure entitled, Medication Regimen Review and Reporting, dated 2007, showed, A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. Review of the quarterly…

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

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance and adverse side effects for 2 of 2 sampled residents (73 & 347) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and a decreased quality of life. Findings included . Review of the facility policy entitled Antibiotic Stewardship Program, dated 04/01/2023 showed the goals of the program included: Ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use. A standard of criteria for defining various infections (McGeers Criteria) will be adopted and utilized. <Resident 73> Review of Resident 73's electronic health record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews and record reviews, facility failed to ensure safe, sanitary and homelike environment for residents on 2 of 4 units (300 Hall and 400 Hall) when needed maintenance repairs and resident comfort and safety concerns were not identified in supervision of the environment and maintenance requests were not followed up upon. Failure to ensure resident care environment was safe, sanitary and homelike placed residents at risk for harm and a diminished quality of life. Findings included . Maintenance Repair Request Logs, reviewed on 08/18/2023, showed the following repairs and requests were made of maintenance staff and were not signed off as completed: 08/09/2023 room [ROOM NUMBER]B footboard on resident's bed broken 08/10/2023 room [ROOM NUMBER] remote control for TV missing, handrail detaching in bathroom, need new blinds, automatic bed control, bathroom lock, wheelchair arms < Shower room [ROOM NUMBER] Hall > On 08/18/2023 at 1:55 PM, the first shower stall was observed to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews and record reviews, the facility failed to ensure arrangements were made for timely laboratory services for 7 of 23 residents (Residents 2,3,5,6,7,9,10) reviewed for current physician orders for lab tests and failed to notify the provider for 6 of 7 late laboratory orders that they had not been carried out. These failures placed residents at risk for delay in treatment, decline in medical conditions and a diminished quality of life. Findings included . Facility policy, Laboratory Services, undated, documented the facility would have contracts and agreements to ensure that appropriate clinical laboratory testing was available to residents as ordered by the physician / practitioner. If the facility staff obtained a specimen for laboratory testing, the specimen would be stored in a manner to preserve the specimen for transport or until the specimen was picked up for testing by the laboratory. Should the laboratory test not be obtained, the physician/practitioner 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.