Avamere Rehabilitation Of Issaquah

Based on observation, interview, and record review the facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for 2 of 5 (Residents 40 & 5) residents reviewed for activities. Failure to consistently implement meaningful individual activity plans left residents at risk for boredom, frustration, isolation, and a diminished quality of life. Findings included . <Facility policy> According to the facility's undated Activities policy the facility would provide an Activities program that would address the intellectual, social, spiritual, creative, and physical needs, capabilities, and interest of each resident. The activity program would promote each resident's self-respect by providing activities that support self-expression and choice. <Resident 40> According to the 02/19/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 40 had no speech, poor vision, and was dependent on staff for all daily activities including personal hygiene, toileting, bed mobility, and transfers. The MDS showed Resident 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess for the safety of and obtain and implement physician's orders to leave the facility independently for 1 (Resident 240) of 1 residents reviewed for safety, failed to ensure appropriate safety measures to prevent a fall were implemented for 1 (Resident 5) of 2 residents reviewed for falls, and, to ensure safe resident smoking and perform quarterly smoking assessments for 1 (Resident 6) of 1 resident reviewed for smoking. These failures placed all residents at risk for injury, harm, and continued falls. Findings included . Review of the facility policy, titled Safety and Supervision of Residents, revised 07/2017, showed the facility would strive to make the environment as free from hazards as possible. The interdisciplinary team would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The facility would have interventions to reduce 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 obtain timely laboratory services to meet the needs of 2 (Residents 5 & 8) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services. Findings included . <Resident 5> According to a 12/23/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex diagnoses including anemia (lack of healthy blood cells), heart failure, kidney, and lung disease. This MDS showed Resident 5 was at risk for pressure injuries. Review of a 02/06/2025 wound consult progress note showed Resident 5's wound was evaluated by the wound team and recommendations were given to obtain lab work. Review of Resident 5's February 2025 Treatment Administration Record (TAR) showed a 02/07/2025 physician order to obtain the recommended lab work, which included an ESR [Erythrocyte Sedimentation…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) provided at least eight hours of direct care supervision per day for 4 of 51 days reviewed. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the facility's Daily Nurse Staff Documentation showed on four days (12/16/2023, 12/30/2023, 01/13/2027, and 01/27/2024 - all Saturdays) from 12/16/2023 through 02/04/2024 there was no Registered Nurse on site for eight hours as required by federal regulations. In an interview on 02/05/2024 at 11:29 AM Staff II (Certified Nursing Assistant) stated they were responsible for the nurse staffing. Staff II stated when staff called out they were responsible for finding a substitute. Staff II stated they started with in-house staffing resources and used agency staffing if an in-house option was not available. Staff II stated call outs were most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a required form that outlined the transfer of financial liability from the nursing facility to the Medicare beneficiary) for 2 of 2 residents (Residents 66 & 26) and 1 closed record (Resident 75) reviewed for liability notices, who remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended. This failure placed the residents at risk for not being fully informed of the cost of continued SNF services necessary for decision-making. Findings included . <Facility Policy> According to the facility's 08/29/2022 ABN Policy, an ABN form was issued by the facility when the financial liability was being transferred from the nursing facility to the residents and/or their representative. The policy showed ABNs were issued to beneficiaries at least two days prior to the end of their Medicare Part A benefits and elected to remain 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 and interview, the facility failed to provide a home like environment on 4 of 4 halls (Halls 100, 200, 300, and 400). The failure to ensure resident rooms had window coverings that provided full privacy (Halls 200 & 300), free of wall gouges (Halls 200, 300, & 400), were cleaned thoroughly (300 Hall), and clean linen storage was free of dirt, stains and food waste placed residents at risk for compromised privacy, and a less-than-homelike environment. Findings included . <Blinds> Observation on 01/30/2024 at 9:33 AM showed room [ROOM NUMBER] was missing three vertical slats from the window blinds and staff were unable to fully closed the blinds for privacy. Observation on 01/30/2024 at 9:55 AM showed room [ROOM NUMBER] was missing three vertical slats from the window blinds and staff were unable to fully close the blinds for privacy. Observation on 01/30/24 at 1:24 PM showed two slats were missing from room [ROOM NUMBER]. The missing slats made it possible for to look into the room from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable, for 5 (Residents 35, 57, 13, 68, & 26) of 5 residents reviewed for hospitalization. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the March 2021 Transfer or Discharge Notice facility policy showed the resident and the resident's representative would be notified in writing the specific reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident was being transferred or discharged too, and an explanation to the resident their rights to appeal 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 observations, interview, and record review the facility failed to ensure 5 of 22 residents (Residents 1, 31, 25, 66, & 46) whose Minimum Data Sets (MDS- an assessment tool) were reviewed reflected the resident's condition accurately. This failure placed residents at risk for the lack of and/or inappropriate care planning, unidentified and/or unmet care needs, and a diminished quality of life. Findings included . <Facility Policy> The facility's October 2023 Resident Assessments policy showed residents and their representatives were encouraged to participate in the assessment process. The policy showed information in the MDS assessments would consistently reflect information in the progress notes, Care Plan (CP), and resident observations and interviews. <Resident 1> According to a 12/06/2023 Quarterly MDS, Resident 1 was assessed with a limitation in Range of Motion (ROM) to both lower legs and was dependent on staff for rolling in bed, sitting, and transfers. This MDS showed Resident 1 refused bathing but had no rejection of care. Review of December 2023 Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 5 of 22 sample residents (Residents 8, 1, 25, 35, & 46) whose CPs were reviewed. This failure left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's March 2022 Comprehensive Person-Centered Care Plans policy, CP interventions should be developed from thorough analysis of information gathered during the completion of resident assessments. The policy showed resident assessment was an ongoing process and CP revisions occurred as new information was identified. The policy showed CPs should be revised after significant changes in residents' condition, when a desired outcome was not met, after readmission, and at least quarterly. <Resident 8> According to the 10/26/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 8 had diagnoses including the need for personal assistance. The MDS showed…

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

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed and medications were given within ordered parameters for 6 (Residents 8, 68, 178, 1, 31, &10), POs were clarified as needed for 1 (Resident 8), nurses signed only for tasks completed for 1 (Resident 68), and POs were obtained to monitor skin issues for 1 (Resident 19) of 22 sample residents reviewed. These failures left residents at risk for unmet care needs, unneeded treatment, and other negative health outcomes. Findings included . <Medications Outside Parameters/Failure to Follow POs> <Resident 8> According to the 10/26/2023 Minimum Data Set (MDS - an assessment tool) Resident 8 used scheduled and as needed pain medications. The MDS showed Resident 8 had diagnoses including opioid dependence. The January 2024 Medication Administration Record (MAR) included two orders for the same narcotic pain medication. The 06/29/2023 PO showed to give 2 Milligrams (MG) as needed every four hours for moderate to severe pain of 7-10/10 and was discontinued on 01/20/2024. 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 provide assistance with Activities of Daily Living (ADLs) for 5 of 8 (Residents 45, 19, 35, 46, & 4) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> According to the 03/2018 ADL policy, residents unable to carry out ADLs independently would receive the support they required to maintain good nutrition, grooming and personal and oral hygiene. <Resident 45> According to the 01/16/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 45 had severe memory impairment, and diagnoses including stroke (brain injury), impaired vision, difficulty with speech, and muscle weakness. The MDS showed Resident 45 was totally dependent on staff for eating, using the toilet, and required substantial to maximal assistance with personal hygiene. The 01/09/2024 Resident has an ADL Self Care deficit Care Plan (CP)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review the facility failed to ensure 5 of 9 residents (Residents 46, 49, 61, 1, & 25) reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> The facility's July 2017 Restorative Nursing Services policy showed the residents would receive restorative nursing care to promote optimal safety and independence. The policy showed RNP goals and objectives were individualized and resident centered, and were outlined in the residents Care Plan (CP). The policy showed the resident and/or representative would be included in determining RNP goals and care planning. <Resident 46> According to the 12/13/2023 Annual Minimum Data Set (MDS - an assessment tool), Resident 46 was not capable of verbal communication and had medical conditions including 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 observation, interview, and record review the facility failed to ensure 3 of 5 residents (Residents 1, 19, & 40) reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to physician ordered flow rates (Resident 1, 19, & 40) and maintain oxygen equipment (Resident 1) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's October 2010 Oxygen Administration policy staff should ensure a Physician's Order (PO) was in place before providing oxygen treatment. The Policy showed nurses should review the PO for accuracy. <Resident 1> According to a 12/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 had multiple medically complex diagnoses including heart and lung failure and required the use of oxygen. This MDS showed Resident 1 had no memory impairment. 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 observation and interview, the facility failed to ensure food was distributed in a sanitary manner. The failure to ensure food was distributed in a fashion to prevent exposure to airborne pathogens left residents at risk for food borne illness, food contamination, less than palatable food, and other negative outcomes. Findings included . <Uncovered Food> Observation on 01/30/2024 at 11:52 AM of lunch service showed the meal cart parked in front of the Fireside Family Room in 100 Hall. Two resident rooms in the 100 Hall had isolation precautions signs posted due to active infections and/or open/exposed skin conditions. Staff N (Certified Nursing Assistant - CNA) was observed passing trays along 100 Hall while holding the meal tray for Resident 15. The dessert plate was left uncovered. At 11:55 AM, Staff N was observed delivering the meal tray for Resident 6. The dessert plate was uncovered. Observation on 02/02/2024 at 11:53 AM of lunch service in 100 Hall showed Staff V (CNA) delivering the meal tray for Resident 15. The dessert plate was left uncovered. In an interview on…

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

Based on observation, interview, and record review the facility failed to ensure 2 (Resident 62 & 26) of 2 residents noted with medications at bedside, were assessed by nursing staff to safely self-administer medications, prior to allowing the residents to do so. Failure to obtain required Physician's Orders (POs), complete a self-medication assessment to establish clinical appropriateness and safety for these residents, placed the residents at risk for medication errors and adverse medication interactions. Findings included . <Facility Policy> According to the February 2021 Self-Administration of Medications facility policy, the interdisciplinary team would assess each resident's cognitive and physical abilities to determine whether self-administration of medications was safe and clinically appropriate for the resident. <Resident 62> According to the 01/15/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 62 had moderate memory impairment. In an observation and interview on 01/30/2024 at 9:07 AM, a small medication cup containing four white round pills in varying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodations to ensure a Television (TV) was within visual reach for 2 of 2 residents (Resident 5, & 66) whose physical environment were reviewed. This failure caused unnecessary discomfort to Resident 5 and 66 and placed residents at risk for unmet psychosocial needs and a diminished quality of life. Findings included . <Facility policy> Review of the facility policy titled, Activities Policy, dated 02/2005, showed the facility would provide an activities program that would address intellectual needs to stimulate creative thinking by means of TV. The revised March 2021 Accommodation of Needs facility policy showed the resident's individual needs and preferences would be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The policy showed modifications to the resident's physical environment, including the resident's bedroom, were evaluated upon admission and reviewed in an ongoing basis. <Resident 5> According…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a written notification regarding a room change, including the reason for the move, was provided as required for 1 of 3 residents (Residents 66) reviewed for choices/room changes. This failure detracted Resident 66 and their representative's right to freely consent to the room move/change and placed residents and/or their representatives at risk for not being informed, feelings of powerlessness, and a diminished quality of life. Findings included . <Facility Policy> The facility's February 2021 Resident Rights policy showed all employees should treat residents with kindness, respect, and dignity. The policy showed Federal and State laws guaranteed certain basic rights to all residents residing in a nursing facility including the right to refuse a transfer from a distinct part within the institution. The facility's December 2016 Transfer, Room to Room policy showed part of the preparation process was to inform the resident and/or 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.

<Resident 26> Based on interview and record review the facility failed to ensure residents had the appropriate Advance Directive (AD) in place for 1 of 5 (Residents 26) reviewed for ADs. The facility failed to obtain a copy from residents (Resident 26) with an existing AD and make the documentation readily available in the medical records and accessible to facility staff. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The revised September 2022 Advance Directives facility policy showed the facility would determine if the resident had executed an AD upon admission. The policy showed if the resident had an AD, copies would be made and placed in the medical record and would be readily available to staff. <Resident 26> According to the 01/10/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 26 had moderate memory impairment. Review of Resident 26's medical records on 02/05/2024 showed they had contact information 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 interviews and record review, the facility failed to initiate and complete a thorough grievance investigation for 1 of 4 residents (Residents 66) reviewed for missing personal property. The facility failed to ensure there was resolution coming from the resident and/or the resident representative regarding their lost property and how the event would affect their quality of life if left unresolved. These failures placed residents at risk for frustration and a diminished quality of life. Findings included . <Facility Policy> The facility's undated Grievance - Skilled Nursing Facility policy showed the nursing facility would listen to and act promptly upon grievances received from residents and families. The policy showed the department manager would notify the concerned party to inform them of the resolution to their grieved concern. The September 2004 Lost Item Policy showed the facility would protect residents' items from theft or loss to the extent possible. The policy showed every effort would be made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identified skin issues for 1of 2 residents (Resident 35) reviewed for abuse/neglect. Facility failure to report multiple bruises of unknown origin to Resident 35's upper/middle/lower back, both breasts, and knee, placed Resident 35 at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> The facility's revised September 2022 Abuse, Neglect, Exploitation- Reporting and Investigating policy showed the facility would ensure all alleged violations involving abuse and neglect including injuries of unknown origin were reported to the facility administrator immediately and to the other officials as required by current regulations within two hours of an occurrence of an event/allegation and/or an allegation was made and resulted in serious bodily injury. The facility policy showed a thorough investigation would be completed by facility management within five working days and the final…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Significant Change Minimum Data Set (SCSA- an assessment tool) was initiated timely for 1 of 22 (Resident 5) reviewed for a significant change assessment. This failure placed residents at risk for unidentified and unmet care needs and, a diminished quality of life. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (RAI, a manual directing staff on requirements for completion of a Minimum Data Set - MDS) dated [DATE] showed a SCSA must be completed within 14 calendar days after the facility determined or should have determined there was a significant change in the resident's physical or mental condition. An SCSA was appropriate if there were consistent patterns of changes, with either two or more area of decline. Areas affected included an increase in the number of behavior symptoms or frequency of behaviors increased, a decline 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, observation, and record review the facility failed to ensure a Significant Change Minimum Data Set (MDS - an assessment tool) was completed as required for 1 (Resident 68) of 22 sample residents reviewed. The failure to identify the need to complete a Significant Change MDS left residents at risk for unassessed care needs, inappropriate care, and other negative health outcomes. Findings included . According to the October 2023 Resident Assessment Instrument Manual (a manual that directs staff on how to accurately assess the status of residents) a Significant Change MDS is a comprehensive assessment that must be completed when the interdisciplinary team has determined that a resident met the significant change guidelines for either major improvement or decline. Review of the guidelines showed, a Significant Change MDS was appropriate if there was a determination a significant change in a resident's condition from their baseline occurred and the resident's condition was not expected to return…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain and implement mental health interventions for 2 of 5 residents (Residents 5 & 8) reviewed for Pre-admission Screening and Resident Review (PASRR). This failure placed residents at risk for receiving inadequate mental health interventions, an increase in avoidable behaviors, and a diminished quality of life. Findings included . <Facility policy> The facility's 01/04/2021 Screening for Clinical Needs policy showed the facility would obtain a PASRR on all potential admits prior to their facility admission to ensure placement was appropriate and that the facility was capable to meet the residents' needs. <Resident 5> According to the 05/29/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 admitted to the facility on [DATE]. Resident 5 was dependent on others for decision making. Resident 5 had diagnoses of dementia, anxiety, and depression. Review of the 12/14/2023 Notice of Determination showed Resident 5 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 interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health needs/intellectual disability and required further assessment/treatment) assessment was obtained and/or accurate to reflect the residents' mental health conditions for 2 of 5 residents (Resident 31 & 8) and 1 supplemental resident (Resident 1) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> According to the facility's 01/04/2021 Screening fo Clinical Needs policy, a pre-admission screening would occur prior to admission for all potential residents in order to ensure appropriate placement. The policy did not address rescreening residents if their mental health status changed after admission, or give instructions to staff on what to do if 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 a person-centered comprehensive Care Plan (CP) was developed and implemented for 1 of 22 residents (Resident 46) whose CP was reviewed. Failure to address the individualized care needs for each resident with identified depression and signs and symptoms of mood problems placed residents at risk for inconsistent and/or inadequate care, worsening depression, and a decreased quality of life. Findings included . <Resident Assessment Instrument - RAI> The October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) showed for each Care Area Assessment (CAA) triggered during a Minimum Data Set (MDS - an assessment tool), the MDS coordinator should indicate whether a new CP, CP revision, or continuation of the current CP was necessary to address the problem(s) identified in the assessment. The manual showed Care Planning Decision must be completed within seven days of completing the assessment and to mark the CAAs triggered if they 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.

Based on observation, interview, and record review the facility failed to ensure 2 of 22 (Residents 45, & 19) sampled residents reviewed for non-pressure skin alterations and 1 of 1 (Resident 59) reviewed for hospice coordination. The failure to ensure residents skin was assessed and findings treated and/or monitored, and coordination between the facility and hospice services left residents at risk for unmet care needs, and decreased quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Hospice Program, dated 07/2017, showed the facility was responsible for collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. <Non-Pressure Skin> <Resident 45> According to the 01/16/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 45 had severe memory impairment and diagnoses including stroke, vision impairment, difficulty talking, muscle weakness, and high sodium levels. The MDS showed Resident 45 had one or more skin tears at 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 residents received necessary treatment and assistive devices to maintain hearing function for 1 of 2 (Resident 68) residents reviewed for hearing. The failure to respond timely after identifying adaptive devices were not functioning adequately left residents at risk for communication difficulty, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's July 2017 Care of the Hearing Impaired Resident policy, the facility would assist residents with hearing impairments with scheduling appointments and obtaining hearing services. The policy showed the facility would assist residents whose assistive devices were lost or damaged. <Resident 68> According to the 01/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 68 had moderate hearing difficulty and used Hearing Aids (HAs). The MDS showed Resident 68 usually understood others and was understood in conversation. The assessment showed Resident 68 had diagnoses including stroke,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 4 residents (Residents 35 & 46) whose physical environment reviewed was free from accident hazards. The facility failed to identify Resident 35's fall, provide supervision, and clear surroundings of clutter. The facility failed to position Resident 46's bed safely in their room. These failures placed the residents at risk for unidentified falls, bodily entrapment, and potential injuries that could affect the residents' quality of life and safety. Findings included . <Facility Policy> According to the revised March 2018 Falls and Fall risk Managing facility policy, a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level. The policy showed that unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. <Resident 35> The 10/12/2023 5-day/Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 35 had medical diagnoses including memory impairment, stroke (brain injury), vision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient staff to meet resident needs related to the Restorative Nursing Program (RNP) for 5 of 9 residents (Residents 1, 25, 46, 49, & 61) reviewed for RNP. These failures left residents at risk for unmet care needs, worsening Range of Motion (ROM), and other negative health outcomes. Findings included . <RNP Program> <Resident 1> The 09/19/2023 Activities of Daily Living Care Plan (CP) showed Resident 1 needed an RNP program related to a ROM issue. The CP showed Resident 1 required the program three to six times a week. In an interview on 01/31/2024 at 8:35 AM, Resident 1 stated they did not receive their restorative program three times a week as ordered. <Resident 25> The revised 09/28/2023 restorative CP showed directions to staff to provide an active ROM program for Resident 25 three to six times per week and to apply a left-hand splint daily. Review of November 2023 restorative documentation showed staff only provided the splint to Resident 25's left hand on 19 of 30 days, rather than daily as scheduled.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arbitration agreement was signed by the resident's Durable Power of Attorney (DPOA) for financial affairs as required for 1 of 3 residents (Resident 46) whose arbitration agreements were reviewed. This failure placed Resident 46 and residents at risk of forfeiture of their right to a jury or court trial and a diminished quality of life. Findings included . <Resident 46> According to the 12/13/2023 Annual Minimum Data Set (MDS - an assessment tool), Resident 46 was non-communicative, had severe memory impairment, and was incapable of daily decision-making. Review of Resident 46's medical records on 01/31/2024 at 12:05 PM showed the resident had DPOA for healthcare in place and this representative signed Resident 46's arbitration agreement. In an interview on 01/31/2024 at 12:31 PM, Staff A (Administrator) stated the arbitration agreement was offered to residents and their representatives during admission and was conducted by the facility's admissions coordinator. In an interview on 02/05/2024 at 10:33 AM, Staff W…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to consistently perform Hand Hygiene (HH) before and after resident care/contact and staff failed to ensure equipment was cleaned after use. These failures placed the residents and staff at risk for development of contagious, communicable infections and disease. Findings included . <Facility Equipment> Observations on 01/30/2024 at 9:15 AM and 01/31/2024 at 10:10 AM showed Resident 1 in their room wearing oxygen. The oxygen concentrator's (a device used to increase the concentration of oxygen inhaled) filter was dirty with debris. Observations on 01/30/2024 at 11:39 AM, 01/31/2024 at 2:32 PM, and 02/01/2024 at 10:10 AM showed Resident 19's oxygen concentrator in their room contained brown spots and the filter on the oxygen concentrator was dirty with debris. Observations on 01/30/2024 at 1:34 PM, 01/31/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided met professional standards for 2 of 3 residents (Resident 1 & 3) reviewed. The facility nursing staff failed to clarify physician's orders for 1 of 3 residents (Resident 3), and follow manufacturer's recommendations for 1 of 3 residents (Resident 1). These failures placed residents at risk for medication errors, delay in treatment, and adverse outcomes. Findings included . Review of the facility Medication Administration policy, revised 04/2019, showed medications were administered in a safe and timely manner. Medications were administered in accordance with the physicians orders and if the dosage was believed to be inappropriate or excessive for a resident, or a medication was identified as having a potential adverse consequence for the resident or suspected to be associated with consequences, the person preparing or administering the medication would contact the physician to discuss the concerns. Allergies and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs), related to showers for two of four residents (Resident 1 & 2) reviewed for showers. The facility's failure to provide residents who were dependent on staff to meet hygiene needs placed residents at risk for poor hygiene, embarrassment, and diminished quality of life. Findings included . Review of the facility Bathing policy, dated 02/2018, showed the purpose of the bathing procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the skin. The policy directed staff to document the date and time of the shower. If the resident refused the shower, staff would document the reason why the shower was refused and the intervention taken and staff would notify the supervisor of the resident refused the shower. <Resident 1> Review of a 07/14/2023 admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 was able to make their own…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review the facility failed to obtain and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 6 of 18 residents (Residents 50, 48, 19, 64, 47, & 78) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care. Findings included . Resident 50 According to the 08/23/2022 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 50 had severe memory impairment and a diagnosis of a progressive neurological condition. The MDS showed Resident 50 had a prognosis of less than 6 months to live and received hospice services. Review of Resident 50's record showed a Capacity for Medical Decisions form signed by the physician on 03/21/2021. The form showed Resident 50 chose a surrogate decision maker to assist with medical decision making. The form included 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 have a system in place that ensured grievances were identified, immediately investigated, documented, resolved promptly with notification to the resident of findings, and action taken to correct concerns for 1 of 1 resident (Resident 63) reviewed for a resident-to-resident verbal altercation and additional reports from multiple unidentified residents during Resident Council (RC) meetings for 2 of 3 months (July 2022 & September 2022) reviewed. This failure detracted from the facility's ability to protect resident rights and placed residents at risk for resident-to-resident altercations, unresolved concerns, feeling unheard, frustrated, diminished self-worth, and decreased quality of life. Findings included . Policy According to the undated Resident and Family Grievance Policy & Procedure the Administrator (or designee) was the Grievance Officer, and the facility would use the Concern/Grievance Form for any written or verbal concern expressed by a resident. The form includied time, date, name of person receiving the concern,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement a system to ensure residents were provided fluids within ordered parameters for 2 of 2 residents (Resident 78 & 38) reviewed for hydration and 1 supplemental resident (Resident 52). This failure placed residents at risk for medical complications, unmet needs, and diminished quality of life. Findings included . Resident 78 A 09/22/2022 admission Minimum Data Set (MDS - an assessment tool) showed Resident 78 had diagnoses including heart failure, kidney failure, low sodium level, and chronic respiratory failure. Resident 78 was assessed to require setup assistance with eating and was on a therapeutic diet. A 09/15/2022 PO showed Resident 78 was restricted to 2000 milliliter (ml) per day of fluids. The order directed dietary to provide 1500 ml, nursing to provide 350 ml on day shift and 150 ml on night shift. Review of the 09/19/2022 Care Plan (CP) showed Resident 78 was at risk for an altered hydration status related to a 2000 ml a day prescribed fluid restriction and use of a water pill medication.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess 5 of 20 residents (Residents 19, 64, 17, 52, & 48) reviewed for Minimum Data Set (MDS - an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 19 According to the 07/14/2022 admission MDS, Resident 19s admitted to the facility on [DATE] and had no decayed or broken teeth. Observation on 10/05/2022 at 9:47 AM, showed Resident 19 missing a front tooth which was broken at the root. Resident 19's revised 07/20/2022 oral/dental care plan stated, Report loose or broken teeth .to [nurse] immediately. Review of Resident 19's records showed no progress notes documenting a lost tooth in the facility. A 10/03/2022 dental visit note showed the presence of a decayed tooth and a broken/root tip tooth. In an interview on 10/11/2022 at 10:10 AM, Staff T (Certified Nursing Assistant) stated Resident 19 admitted with the broken tooth. In 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 obtain and/or ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 3 (Residents 19, 52, & 64) of 5 residents reviewed for unnecessary medications. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . Resident 64 According to the 09/02/2022 Minimum Data Set (MDS - an assessment tool), Resident 64 had multiple medically complex diagnoses including depression which required the use of antidepressant medications. Review of Resident 64's records on 10/10/2022 at 9:00 AM showed no Level 1 PASRR documentation. At 2:50 PM on 10/10/2022 facility staff provided a Level 1 PASRR dated 05/25/2022 that indicated Resident 64 had no Serious Mental Illness (SMI) indicators. Staff did not identify Resident 64 had a depression diagnosis and required the use 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 Resident 50 According to the 08/23/2022 Significant Change MDS, Resident 50 had severe cognitive impairment and diagnoses including a progressive neurological condition and muscle weakness. The MDS showed Resident 50 required extensive assistance with personal hygiene. Record Review showed Resident 50 had a revised 04/28/2021 Actual Self Care Deficit . CP. The CP indicated Resident 50 had a self care deficit related to personal hygiene and directed staff to provide extensive assistance for personal hygiene. Observation on 10/06/2022 9:18 AM showed Resident 50 had considerable nose hair growing in [NAME] extending from both nostrils. Resident 50's nose hair was observed to remain untrimmed on 10/07/2022 at 12:56 PM, 10/10/2022 at 8:07 AM, and on 10/11/2022 at 8:25 AM. In an interview on 10/11/2022 at 9:41 AM, Staff E (RCM, Licensed Practical Nurse) stated they expected staff to assist with nose hair trimming if it was care planned. On 10/11/2022 at 9:41 AM, Staff E was observed to enter Resident 50's room. Staff…

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

Based on observation, interview, and record review the facility failed to ensure the residents enviornment was free of accident hazards by implementing their system for securing and storing hazardous toxic chemicals in 1 of 4 shower rooms, 1 of 2 soiled utility rooms, and 1 of 1 tub room. This failure placed residents at risk for injury. Findings included . Shower Room A 10/05/2022 12:36 PM observation of the unattended and unoccupied shower room on the 400 Hall showed the door was unlocked. Inside the shower room was an unlocked cabinet that contained 4 bottles of hazardous sanitizing cleansers. Three of the four bottles had a warning on the label stating DANGER Keep out of reach of Children and one bottle had a label warning that said, DANGER! CAUSES SEVERE SKIN BURNS AND EYE DAMAGE. Stored with the hazardous chemicals was one bottle of skin moisturizing cream, an energy drink, and an apple pie. In a 10/05/2022 12:43 PM interview Staff P (Nursing Aide Orderly) stated the apple pie and Starbucks drink belonged to them and should not be stored in the cabinet. Staff P stated they…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 3 of 3 nurses (Staff P, Q, & I) to properly administer 3 of 25 medications for 3 of 4 residents (Residents 84, 48, and 38) observed during medication pass, resulted in a medication error rate of 12%. These failures placed the residents at risk for adverse side effects and/or reduced medication effectiveness due to improper administration. Findings included . Resident 84 Observation of medication pass on 10/06/2022 at 9:34 AM showed Staff P (Registered Nurse) administered Artificial Tears solution 1 drop in each eye. Review of Resident 84's Physician's Orders (PO) showed instructions to instill two drops of Artificial Tears solution to both eyes. In an interview on 10/06/2022 at 9:41 AM, Staff P validated they only administered one drop of Artificial Tears solution to each eye of Resident 84 and not two drops as specified in the PO. Resident 48 Observation of medication pass on 10/07/2022 at 11:34 AM showed Staff Q (Licensed Practical Nurse -…

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

Based on observation, interview and record review, the facility failed: to ensure drugs and biologicals were secured and stored at the appropriate temperature; expired medications and biologicals were disposed of timely in accordance with professional standards for 1 of 4 medication carts and 1 of 2 medication rooms reviewed; and ensure medications were secured for 3 of 3 residents (Residents 48, 78, & 69) observed with medications at the bedside. These failures placed residents at risk for receiving expired medications, medication errors, and non-assessed, self-administration of medications by residents. Findings included . Unsecured medications at bedside Resident 48 Observations on 10/05/2022 at 9:53 AM showed Resident 48 had a medication cup filled with several unidentified pills and a second medication cup that had two tablets of an antacid medication. In an interview at this time, Resident 48 stated the nurse left the medications in their room for them to take. Review of Resident 48's records revealed no Physician's Order (PO) for medications at bedside and 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 interview and record review, the facility failed to ensure pneumococcal vaccines were provided for 1 of 5 residents (Residents 64) reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease. Findings included . Review of Centers for Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have only received a PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends you . may give 1 dose of PCV15 or PCV20 [Pneumococcal conjugate vaccine] . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination . The CDC guidelines went into effect on 10/21/2021 per recommendations from the Advisory Committee on Immunization…

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