Life Care Center Of Kennewick

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medications were monitored for effectiveness using individualized, resident-specific targeted behaviors for 3 of 5 residents (Resident 9, 43, and 31) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects and unmet care needs.Findings included . Review of a policy titled, Psychotropic Medication, Informed Consent Policy, dated 04/22/2025, showed behavior interventions were to be individualized, non-pharmaceutical approaches to care that were provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating residents' distress, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. Resident 9 Review of…

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

Based on interview and record review, the facility failed to follow professional standards of practice related to adding a new mental health diagnosis for 1 of 5 residents (Resident 31) reviewed for psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medication use. This deficient practice placed residents at risk for unnecessary medications and unmet care needs.Findings included . Resident 31Review of the medical record showed Resident 31 admitted to the facility, on 09/09/2025, with diagnoses of dementia (a disease that causes the loss of thinking, remembering, and reasoning skills) and affective disorder (a mental health condition characterized by prolonged and extreme shifts in mood, such as persistent sadness or excessive elation). Review of the comprehensive assessment, dated 09/15/2025, showed Resident 31 had severe cognitive impairment and required the assistance of one staff member for grooming, dressing, incontinent care, bathing and mobility. Review of Resident 31's admission orders dated 09/09/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician ordered physical therapy (PT) was received in a timely manner for 1 of 3 residents (Resident 34) reviewed for specialized rehabilitation services. This failure placed the resident at risk for decline in function and/or not achieving the highest practicable level of physical, mental, and functional well-being. Findings included . Review of a policy titled, Specialized Rehabilitative Services, revised 09/04/2025, showed the facility would ensure that each resident received specialized rehabilitative services to assist them to attain, maintain, or restore their highest level of physical, mental, functional and psychosocial well-being. Resident 34 Review of the medical record showed Resident 34 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial infection of the skin and underlying tissues) of the right lower leg, muscle weakness, and difficulty walking. The 10/08/2025 comprehensive assessment showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and/or provide an influenza (a common viral infection that attacks the lungs, nose, and throat) immunization for 1 of 5 residents (Resident 58) reviewed for immunizations and infection control. This failure placed the residents at risk for illness and transmission of communicable diseases. Findings included . Review of a policy titled, Influenza Vaccine Policy for Residents, revised 09/23/2025, showed residents would be offered an influenza immunization between October 1st through March 31st annually, unless the immunization was medically contraindicated or the resident had already been immunized during that period. The resident's medical record would include documentation that the resident or their representative was provided education regarding the benefits and potential side effects of the immunization and that the resident either received or refused the immunization. Resident 58 Review of the medical record showed Resident 58 was admitted to…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program that ensured insects (flies) were not congregating in rooms or on persons for 1 of 4 residents (Resident 73) reviewed for environment. This deficient practice placed residents at risk of infection and contributed to a less than homelike environment.Findings included. Review of the facility policy, Pest Control, revised on 07/09/2025, showed the facility's pest control program would provide frequent treatments to keep the facility free of pests, the facility's staff would monitor the environment for potential concerns, and all pest control problems would be reported to the Director of Maintenance promptly. Resident 73Review of the medical record showed Resident 73 admitted to the facility with diagnoses of hemiplegia (paralysis of one side of the body) of the right side and aphasia (brain disorder that affects how you speak and understand language). Review of the comprehensive assessment, dated 11/13/2025, showed Resident 73 had moderate cognitive impairment 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 provide notification of discharge to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notifications. This failure placed the residents at risk of not having their representatives involved in their health care decisions, and a delay in care and services. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including follow-up care for a surgical procedure, heart failure and dementia (a progressive disease that destroys memory and other important mental functions). The cognitive assessment dated [DATE] showed Resident 1 had a severely impaired cognition. Record review of a discharge summary progress note dated 08/31/2025, showed Resident 1 was discharged to another facility. During an interview on 09/11/2025 at 2:45 PM, Staff A, Licensed Practical Nurse, stated they had Resident 1 sign the discharge/transfer documentation for their transfer. Staff A 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.

Based on interview and record review, the facility failed to ensure staff implemented fall prevention interventions identified on the resident's care plan for 1 of 3 residents (Resident 1) reviewed for falls. This failure placed the residents at risk for repeated falls and injuries.Findings included. Review of a policy titled, Person Centered Care Planning, dated 09/05/2024, showed each resident would have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, that addresses the resident's medical, physical, mental, and psychosocial needs. The care plan would be developed and implemented to ensure consistency with implementation across all shifts. <Resident 1>Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a brain injury with loss of consciousness, stroke (damage to the brain from an interruption of blood flow), and history of falling. The 06/30/2025 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living. The…

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

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for 1 of 3 residents (Resident 1) reviewed for abuse/neglect. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress. Findings included . Review of the Washington State guidance titled, Nursing Home Guidelines - The Purple Book, dated October 2015, showed verbal abuse was the use of oral, written or gestured language that willfully includes threats .within hearing distance of any resident regardless of their age, ability to comprehend, or disability; threats of harm; saying things to frighten a resident. Review of a policy titled, Abuse - Identification of Types, reviewed 05/06/2025, showed verbal abuse included the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse included threatening residents, depriving a resident of care or withholding a resident from contact with family and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure visitation rights were protected for 1 of 1 resident (Resident 2) when an immediate family member was limited to specific visitation hours indefinitely. This failure placed residents at risk of isolation, depression, and a diminished quality of life. Findings included . <Resident 2> Review of the resident's medical record showed they admitted to the facility with diagnoses of a stroke (when something prevents your brain from getting enough blood flow) with a deficit to their left side and heart failure. The 04/16/2025 comprehensive assessment showed Resident 2's cognition was intact, and they were dependent on staff assistance for their activities of daily living (essential tasks that individuals perform regularly to care for their bodies and maintain overall well-being). A concurrent observation and interview on 05/21/2025 at 1:26 PM, showed Resident 2 and their Resident Representative (RR) were both visibly upset. Resident 2 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.

Based on observation, interview, and record review the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 4 residents (Residents 3 and 4) reviewed for grievances. This failed practice placed residents at risk for not receiving care and services and unidentified and on-going abuse and/or neglect. Findings included . Review of the policy dated 11/19/2024, titled Abuse and Neglect, showed the facility would report alleged violations of abuse, neglect, exploitation, or mistreatment no later than two hours if there was abuse or serious bodily injury and no later than 24 hours if the allegation did not involve abuse and did not result in bodily injury. The policy showed the report was to be made to .the administrator of the facility and .to the state agency. <Resident 3> Review of the resident's medical records showed they admitted with diagnoses to include bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows) and epilepsy (a brain condition that causes recurring seizures [sudden…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection control interventions intended to mitigate the risk for transmission of COVID-19 [an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise (a general feeling of discomfort/uneasiness), headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death] for 3 of 4 staff (Staff D, E, and F) reviewed for personal protective equipment [(PPE) clothing and devices that protect workers from exposure to injury or infection]. Additionally, the facility failed to ensure COVID-19 testing was completed every three days as directed by the Local Health Jurisdiction for 3 of 5 residents (Resident 1, 2, and 3) reviewed for COVID-19 testing. These failures placed the residents at risk for transmission of communicable diseases, illness, and death. Findings included . Review 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.

Based on observations, interviews and record review, the facility failed to ensure staff followed acceptable standards of practice regarding medication administration for 1 of 3 residents (Resident 1), reviewed for narcotic pain medication. Resident 1's narcotic pain medication was not available to administer to the resident as it was not ordered timely by staff when the supply became low. In addition, scheduled agency staff and newly hired staff did not have authorization codes to use the Omnicell (emergency dispensing machine for medications). Administrative staff made no attempt to call the pharmacy to determine an action plan based on scheduled staff not having access to the Omnicell, nor did any LNs come to the facility to obtain the narcotic medication for the resident. As a result, the same narcotic pain medication belonging to different residents, was administered twice to Resident 1 and the resident was transferred to the emergency room (ER) for pain management. This placed the resident at risk for increased pain due to a delay in the administration of their narcotic 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 report a fall with significant injury to the State Agency as required, experienced by 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed the residents at risk for harm and diminished protection and oversight from the State Agency. Findings included . Review of a policy titled, Abuse - Reporting and Response - No Crime Suspected, reviewed 06/17/2024, showed the facility would report alleged violations to the State Agency, if the incident that caused the allegation resulted in serious bodily injury. Additionally, the report should be made immediately but not later than two hours after the allegation was made. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a stroke with left arm paralysis (loss of muscle function), muscle weakness, and heart failure. The 07/24/2024 comprehensive assessment showed Resident 1 was dependent on two staff members for bed mobility (the ability to move in bed) and transfers between surfaces. The assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative nursing services programs including the consistent use of braces/splints were implemented for 2 of 3 residents (Resident 22 and 31), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Review of a policy titled, Restorative Nursing, revised 08/20/2024 showed the goal of the Restorative Program was to maintain or improve functioning, . Restorative program to include but not limited to ROM (Active and Passive), applying, and removing splint or braces . <Resident 22> Review of the resident's medical record showed Resident 22 admitted to the facility with diagnoses including muscle weakness and need for assistance with personal care. The 06/13/2024 comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dialysis services met professional standards of care for 2 of 2 residents (Residents 9 and 44) reviewed for dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream). The facility did not have an effective or coordinated process for communication between the facility and the offsite dialysis center for continuity of care. This failure placed residents receiving dialysis at risk for complications and unmet care needs. Findings included . Review of a facility policy titled, Hemodialysis Offsite, dated 08/2023, showed The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. The communication process and responses will be documented in the medical record. <Resident 9> Review of the resident's medical record showed they were re-admitted to the facility on [DATE] with diagnoses…

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

The facility failed to coordinate a referral for denture services for 1 of 1 resident (Resident 33), reviewed for dental services. This failure placed the resident at risk for altered self-image and weight loss. Findings included . <Resident 33> Review of the medical record showed Resident 33 was admitted to the facility with diagnoses including a stroke (loss of blood flow to part of the brain, which damages brain tissue), malnutrition (lack of sufficient nutrients in the body), and depression. The 07/19/2024 comprehensive assessment showed Resident 33 required setup/cleanup assistance of one staff member for oral care and had an intact cognition. Record review of the care plan dated 10/21/2022, showed Resident 33 was edentulous (lacking teeth), with interventions that included coordinating arrangements for dental care, transportation as needed/as ordered. During an interview on 08/21/2024 at 11:36 AM, Resident 33 stated they wanted dentures and had not seen a dentist since their admission to the facility. Resident 33 stated it kind of bums you out when you don't have teeth. During…

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

Based on observation, interview, and record review, the facility failed to maintain essential equipment in working condition, including 1 of 1 washing machine (Washer 2) and 1 of 1 kitchen exhaust fan (janitor closet fan), reviewed for functional essential equipment. The failure to ensure Washer 2 was in working condition placed the residents at risk for ineffective cleaning of laundry, lack of clean laundry, and cross contamination of infectious disease. Additionally, the failure to ensure the janitor closet fan was in working condition placed residents and staff at risk for inhalation of chemical fumes that could cause illness or breathing issues. Findings included . <Washer 2> A concurrent observation and interview on 08/25/2024 at 9:59 AM, showed Staff D, Laundry Assistant in the soiled laundry area in the laundry room. There were two yellow bins of laundry that were filled to the top. Staff D stated the laundry was soiled resident laundry. The observation and interview continued to the main washing area. There were three large commercial size washing machines. There was a piece…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 incident of neglect was reported to the State Agency in a timely manner as required for 1 of 3 residents (Resident 1) reviewed for neglect. Failure to report to the State Agency placed residents at risk for additional neglect. Findings included . Review of the facility's undated policy titled, Abuse - Conducting an Investigation, showed the results of all investigations were to be reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident. If it was determined that alleged abuse and/or neglect had occurred, the Administrator, Director of Nursing, or his/her designee would promptly notify officials in accordance with state and federal regulations. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (space around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate incidents of neglect for 1 of 3 residents (Resident 1) reviewed for investigations. This failed practice placed all residents at risk for not identifying corrective actions to prevent further neglect. Findings included . Review of the facility's undated policy titled, Abuse - Conducting an Investigation, reviewed on 07/18/2023, showed it was the policy of the facility that allegations of abuse and neglect were promptly and thoroughly investigated. The facility would prevent further abuse and neglect from occurring while the investigation was in progress, and take appropriate corrective action, as a result of the investigation findings. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (space around the spinal cord became too narrow which occurred most often in the lower back and neck), diabetes and urinary retention (bladder did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure 1 of 1 Licensed Nurse (Staff B), reviewed for competency, demonstrated competency in caring for Resident 1, who was experiencing a change of condition. In addition, the facility failed to ensure Staff B was evaluated by the facility for competency with skills and techniques prior to working. This failure placed Resident 1 at risk for clinical complications. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (space around the spinal cord became too narrow which occurred most often in the lower back and neck), diabetes and urinary retention (bladder did not empty completely or at all). Resident 1 was hospitalized between 05/24/2024 to 06/07/2024 and had laminectomy surgery (created space by removal of bony growth on the edge of a bone and tissues associated with arthritis of the spine) on 05/26/2024. Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure appropriate interventions were thoroughly implemented to prevent avoidable accidents for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced leg wounds while using their motorized wheelchair (w/c). This failure placed Resident 1 at risk for medical complications from the repeated leg wounds. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses of cervical disc displacement (an injury to a disc [cushion] between the spinal bones, that resulted in pain, loss of sensation in arms and hands, and stiffness of the neck), rheumatoid arthritis (a chronic disorder that could cause pain, swelling, stiffness and loss of function in the joints of the body), anxiety, and muscle weakness. The 04/05/2024 comprehensive assessment showed the resident was independent using their motorized w/c and had 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 monitor blood glucose levels [a measurement of the amount of glucose (sugar) in the blood] for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed the resident at risk for worsening of their diabetes mellitus [(DM) a disease that occurs when the amount of sugar in the blood is too high], unidentified care needs, and poor clinical outcomes. Findings included . Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including DM and heart failure. Review of the 03/13/2024 comprehensive assessment showed Resident 1 required moderate to substantial assistance of one staff member for activities of daily living. The assessment also showed the resident had an intact cognition. Resident 1's diagnosis of DM was documented on the comprehensive assessment. Record review of Resident 1's hospital discharge orders dated 03/11/2024 at 1:33 PM, showed the resident had physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify the resident's responsible party of significant changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the responsible party placed the resident at risk of not having them involved in the heatlh care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart problems and pneumonia (infection that affects one or both lungs). Review of Resident 1's comprehensive assessment, dated 01/29/2024, showed they had moderately impaired cognition. Progress Notes (PNs), dated 02/02/2024 at 7:54 AM, showed at 5:55 AM it was reported to Staff A, Director of Nursing, Resident 1 had a bloody nose. Despite interventions of squeezing the bridge of Resident 1's nose, gauze dressing to the nose and ice pack to the back of their neck 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 interviews and record review the facility failed to ensure the medical records were accurate for 1 of 5 residents (Resident 1) reviewed for complete medical records. This failure placed Resident 1 at risk for not having accurate information and possible harm if inaccurate information was used to make medical decisions. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart problems and pneumonia (infection that affects one or both lungs). Review of Resident 1's comprehensive assessment, dated 01/29/2024, showed they had moderately impaired cognition. Review of physician orders for Resident 1 showed Plavix (a blood thinner that increased the risk for bleeding and bruising) was ordered on 01/25/2024 to be administered to the resident on a daily basis. Review of Progress Notes (PNs), dated 02/02/2024, showed Resident 1 developed a nose bleed at 5:55 AM. Despite several interventions staff was unable to stop…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement written abuse policies and procedures relative to the required identification, abuse reporting, investigation and protection for 1 of 1 resident (Resident 1) reviewed for abuse. These failures placed all residents at risk for potential and/or further abuse. Findings included . Review of the facility policy titled, Abuse - Identification of Type, dated 07/18/2023, showed it was the policy of the facility to identify abuse and understand the different types of abuse and possible indicators. If it was determined that alleged abuse had occurred, the administrator, director of nursing, or their designee would promptly notify officials in accordance with state and federal regulations. Review of the facility policy titled, Abuse - Conducting an Investigation, dated 07/18/2023, showed it was the policy of the facility that allegations of abuse are promptly and thoroughly investigated. Review of the facility policy titled, Abuse - Protection 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 interviews and record review the facility failed to ensure allegations of verbal abuse were reported to the State survey agency in a timely manner for 1 of 1 (Resident1) reviewed for abuse reporting. This failure placed Resident 1 at risk for unidentified verbal abuse and lack of protection due to prolonged, unrecognized abuse by their representative (RR). Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), a nursing home employee (or other mandated reporter) is required to make a report if they had reasonal cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations. Review of Resident 1's medical record showed they were admitted 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 interviews and record review the facility failed to conduct thorough investigations on multiple witnessed incidents of verbal abuse to 1 of 1 resident (Resident 1) reviewed for abuse. This placed the resident at risk for repeated incidents of abuse. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), 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 systemic 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 prevent further occurrences. Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications, biologicals, and testing supplies were stored, labeled, dated, or discarded when expired for 2 of 3 medication rooms (Team 2 and Team 3), and 1 of 3 (Transitional Care Unit, cart B - TCU B) medication/treatment carts reviewed. Additionally, the facility failed to consistently monitor temperatures for the storage of vaccines (A preparation that is used to stimulate the body's immune response against diseases) for 2 of 2 medication refrigerators (Team 2 and Team 3) reviewed. These failures placed residents at risk of receiving compromised or ineffective medications. Findings included . Review of the [DATE] facility policy, titled Storage and Expiration Dating of Medications, Bioligicals, showed, .medications with an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy, or supplier .medications that were missing labels or cautionary instructions should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice to ensure that physician ordered parameters for narcotic pain medications were followed and documented accurately by licensed nurses (LNs) for 5 of 6 residents (202, 207, 208, 209, and 210) reviewed for following physician orders. This failed practice placed residents at risk for medication errors, a delay in treatment, and adverse outcomes. Findings included . Review of the facility's policy, titled Administration of Medications, dated 02/13/2023 (revised), showed during medication administration the Licensed Nurses (LN's) will follow the .10 Rights of Medication Administration.3. Right Dose .6. Right Documentation. Resident 202. Review of Resident 202's admission record showed the resident admitted to the facility on [DATE] with diagnoses to include a fracture of their left leg. The record further showed the resident's cognition was intact. Review of the resident's May 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that resident's who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice by not assessing, monitoring, or treating past experiences of post traumatic stress disorder (PTSD, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) and sexual assault for 2 of 3 residents (Residents 7 and 202), reviewed for mood and behavior. This placed the residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . Review of the facility's policy, titled Trauma-Informed Care, revised on10/04/2022, showed upon admission and with a change of condition, the facility would have completed an assessment to identify residents with PTSD or a history of trauma. If a resident was identified to have had past trauma history or PTSD the assessment would have been 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.