Benson Heights Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure food and drinks served to residents were prepared and distributed under sanitary conditions for 1 of 1 facility kitchens. The failure to maintain an effective system for sanitizing counters and monitor refrigerator temperatures placed residents at risk for contaminated/spoiled food, foodborne illness, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 07/2018 Food and Nutrition Services - Food and Drink policy, the facility would be provided food and drink prepared using methods to preserve the nutritive value, flavor, and appearance of the food. <Facility Kitchen> During initial rounds of the facility kitchen on 02/18/2025 from 8:54 AM to 9:08 AM no log documenting facility staff monitored the kitchen's sanitizing solution was at an effective concentration was found. Staff S (Dining Services Director) asked the kitchen staff if anyone knew where the log was, and no staff could provide an answer. At that time Staff S stated the daytime dietary 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 3 residents (Residents 22, 63, & 82) reviewed for hospitalizations and 1 supplemental resident (Resident 20) reviewed. The failure to ensure written transfer notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make an informed decision about the transfer/discharge. Findings included . <Policy> According to the facility policy titled, Notice Requirements Before Transfer/Discharge, dated 07/2018, the facility would provide the resident and/or their representative, in writing, the reasons for the move in a language and manner they understood prior to the transfer/discharge. The policy showed the written notice would include the reason for transfer/discharge, the effective date, the location, a statement of the resident's…

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

Based on observation, record review, and interview, the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits were provided) for the use of bed rails and/or the bed against a wall for 3 of 6 residents (Residents 63, 4, & 70) reviewed for bed rails/bed against the wall. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options. Findings included . <Policy> According to a facility policy titled, Bed Rails, dated 02/2018, showed the facility would inform the resident or resident representative of the risks and benefits of bed rails prior to installation of the rails and obtain consent from the resident or the resident representative. <Resident 63> Review of a 01/10/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 63 had no bed rails installed on their bed. The MDS showed Resident 63 had no memory impairment. The MDS showed Resident 63 had diagnoses of, but not limited to, general muscle weakness, unsteadiness on feet, 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 ensure a level II Preadmission Screening and Resident Review (PASRR- a mental health screening required prior to nursing home admission) evaluation was completed and/or incorporated into the Care Plan (CP) for 4 of 6 residents (Residents 61, 22, 82, & 20) reviewed for PASRR. This failure placed residents at risk for unmet mental health care needs. Findings included: <Facility Policy> According to the facility's 11/2017 PASRR policy, a PASRR screening must be completed prior to admission. The policy showed for residents assessed to need Level II services, the facility would incorporate the recommendations into the resident's CP. <Resident 61> According to the 11/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 61 admitted to the facility from the hospital on [DATE] and was assessed with a severe memory impairment. The MDS showed Resident 61 had diagnoses including dementia and three mental health diagnoses, and needed to use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and/or implement a comprehensive Care Plan (CP) for 6 of 18 residents (Residents 34, 10, 4, 63, 70 & 38). This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Resident 34> According to the 11/20/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 34 had intact memory and medically complex diagnoses including a history of stroke, but no seizure/epilepsy diagnosis. The MDS showed Resident 34 used an anticonvulsant (anti-seizure) medication. According to a 12/02/2024 physician's progress note, Resident 34 had metabolic encephalopathy (a change in how the brain works due to an underlying condition) in part due to a seizure disorder. Record review showed a 02/15/2025 physician's order for an anticonvulsant medication at 750 Milligrams (MG) twice a day for a seizure disorder, and a prior 11/13/2024 order for the same medication with the same schedule for spinal injuries. Review of Resident 34's comprehensive 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.

<Resident 34> According to the 11/20/2024 admission MDS, Resident 34 had medically complex diagnoses including a spinal fracture and a history of falling. The MDS showed Resident 34 had frequent pain that affected their sleep and ability to participate in activities and therapy. Record review showed two physician orders for a pain medication patch: a 02/18/2025 physician's order for a pain medication patch to be placed on Resident 34's lower back in the evening and removed at bedtime for pain, and a 02/19/2025 physician's order for the same pain medication patch to be applied in the morning and removed in the afternoon. The orders did not include the strength of the painkiller required. In an interview on 02/25/2025 at 9:32 AM, Staff B (Director of Nursing) stated they expected orders to be clarified when unclear. In the same interview at 9:45 AM, Staff B reviewed the pain medication patch orders and stated they should include the strength of the medication but did not. Based on record review and interview the facility failed to ensure physician orders for 3 of 3 residents…

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

Based on observation, interview, and record review the facility failed to implement skin breakdown interventions for 1 of 6 residents (Resident 61) reviewed for positioning/mobility and failed to provide weight monitoring for 1 of 1 resident (Resident 82) reviewed for edema. The failure to ensure palm protectors were used as ordered (Resident 61) and weights monitored as required (Resident 82) placed residents at risk for skin breakdown, weight loss, weight gain, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Care -policy, for residents with non-pressure-related skin impairments, the facility would provide care and services consistent with professional standards to prevent skin breakdown. The policy showed the facility would provide preventative measures as needed to maintain skin integrity. According to an undated facility policy titled, Edema Management, interventions for heart failure may include monitoring weights. <Resident 61> According to the 11/14/2024 Quarterly Minimum Data Set (MDS - an 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, record review, and interview, the facility failed to ensure safety assessments were completed for 3 of 6 residents (Residents 4, 63, & 70) reviewed for bed against the wall/bed rails, failed to store chemicals and razors for 1 of 2 utility rooms (North Utility Room) and failed to supervise the leave of absence for 1 of 2 residents (Resident 90) reviewed for leave from the facility. Failure to complete safety assessments for the beds against the wall, store chemicals and razors safely, and supervise a resident at risk for safety while on a leave of absence placed residents at risk of entrapment and injury. Findings included . <Policy> According to a facility policy titled, Accident Hazards/Supervision/Devices, dated 07/2018, the facility would implement systems that addressed residents risk and environmental hazards to minimize the likelihood of accidents. The policy showed a potentially hazardous item or situations that was accessible to vulnerable residents would be considered hazardous. The policy showed hazardous materials would be contained to protect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 sampled residents (Residents 38 & 22) reviewed for Oxygen (O2) administration were provided care consistent with professional standards of practice. Failure to provide oxygen monitoring and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, infection, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's July 2018, Quality of Care Respiratory Care Policy, the facility would assure respiratory care was provided to residents in need of such care. The care would be consistent with professional stands standards of practice, the comprehensive person-centered care plan and resident's goals. The facility would have procedures for response to adverse reactions to respiratory interventions, for respiratory assessments and should include when and how the assessment would be conducted and the type of documentation required. <Providing Oygen Level Monitoring> <Resident 38> According to the 01/07/2025 Annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain management was provided to residents consistent with professional standards of practice including the failure to follow parameters for administration of as needed (PRN) pain medications for 1 of 3 residents (Resident 74) reviewed for pain management and monitor for side effects to pain medications for 1 of 5 residents (Resident 22) reviewed for unnecessary medications. These failures placed residents at risk for experiencing untreated pain, possible side effects, and a decreased quality of life. Findings included <Facility Policy> According to the facility's 11/2017 Pain Management policy, the facility would conduct an evaluation of pain based on professional standards of practice. An evaluation included current medical conditions and medication and satisfaction with current level of pain control. The facility would implement both pharmacological and non-pharmacological interventions and approaches to pain management. The policy showed the facility would conduct ongoing clinical assessments and…

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

Based on interview and record review the facility failed to ensure medically-related social services were provided for 2 of 2 residents (Residents 10 & 21) reviewed for Pressure Ulcers (PU). The failure to provide assistance to residents demonstrating behaviors of rejection of care placed residents at risk for worsening skin and other negative health outcomes. Findings included . <Policy> According to the facility's 2018 Quality of Care - Skin Integrity policy, the facility would provide the necessary care to prevent the development of new PU. The policy showed certain risk factors for PU development could not be modified including resident refusals of care and treatment. <Resident 10> According to the 12/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 10 had diagnoses including a condition hindering urinary flow, dementia, a mental health diagnosis, and muscle weakness. The MDS showed Resident 10 had a moderate memory impairment and refused care on one-to-three days of the MDS lookback period. The MDS showed Resident 10 had three full thickness tissue loss…

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

Based on record review and interview, the facility failed to ensure freedom from unnecessary medications for 1 of 2 residents (Resident 63) reviewed for antibiotic use. The failure to ensure an order for antibiotic therapy was transcribed accurately per physician order resulted in Resident 63 receiving an unnecessary medication for an excessive duration and placed them at risk of experiencing avoidable adverse side effects to the medication and other potential negative health outcomes. Findings included . <Resident 63> According to a 01/10/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 63 had no memory impairment. The MDS showed Resident 63 required use of a continuous positive airway pressure (non-invasive mechanical ventilator or respirator) machine while sleeping. In an interview on 02/18/2025 at 9:59 AM Resident 63 stated they took an antibiotic for a sinus infection. Review of Resident 63's health records showed a 01/15/2025 physician order for an antibiotic for a sinus infection. The antibiotic order was to be a 14-day course. Resident 63's 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 residents requiring specialized diets were provided the diets required for 1 of 4 residents (Resident 64) reviewed for food. The failure to provide specialized diets residents were assessed to require placed residents at risk for unmet nutritional needs and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 07/2018 Food and Nutrition Services policy, the facility would provide for the nutritional wellbeing of all residents. The policy showed the facility would provide residents with a nourishing, palatable, and well balanced diet to meet daily nutritional and special dietary needs. <Resident 64> According to 12/14/2024 Quarterly Minimum Data Set, Resident 64 had intact memory and required a specialized (therapeutic) diet. The MDS showed Resident 64 had medically complex diagnoses including stage-2 kidney disease, diabetes mellitus (a condition impairing the ability to manage blood glucose), and morbid obesity. The MDS showed Resident 64 required an altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 60> According to 10/12/2023 progress note Resident 60 discharged emergently to the hospital. The note showed the facility called 911 after the resident was observed to be lethargic and flushed. A 10/18/2023 provider progress note showed Resident 60 remained in the hospital from [DATE] to 10/18/2023 before returning to the facility. Review of Resident 60's record showed no documentation to demonstrate the LTCO was notified as required. In an interview on 11/16/2023 at 1:12 PM, Staff I stated they were unaware of the ombudsman notification requirements and did not have a system in place to track resident hospitalizations. Based on interview and record review, the facility failed to ensure a system was in place by which the Office of the State Long-Term Care Ombudsman (LTCO) received required notification of emergent resident discharges for 3 of 3 residents (Residents 41, 60 & 68) reviewed for discharge to the hospital. Failure to ensure required notifications were completed prevented the LTCO office 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/follow breakout menus for therapeutic diets, follow measurement tool/conversion tables when preparing modified consistency diets. This failure put residents at risk for receiving foods that exacerbated potential life-threatening diagnoses, choking or aspiration (inhaling food contents into lungs), developing lung infections, and decreased quality of life. Findings included . On 11/15/2023 at 1:38 PM Staff A (Administrator) provided two weeks of facility breakout menus. Review of these breakout menus provided, only addressed a Regular Diet and what to serve for the different levels of consistency but did not address therapeutic diets. Observation on 11/13/2023 at 11:18 AM showed Staff H (Cook) and Staff N preparing foods without any adjustments or consideration for therapeutic diets. Observation and interview on 11/15/2023 at 10:05 AM Staff H was preparing pureed meats and vegetables. Staff H stated they had no template providing what ratio of water to use when preparing pureed foods. Observation 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 interview and record review, the facility failed to ensure that, unless the facility employed a full-time Registered Dietitian (RD), the Director of Food and Nutrition services (Staff N) met Washington State requirements including the completion of an academic program in nutrition or dietetics (the practical application of the science of diet and nutrition in relation to health and/or diseases) approved by the American Dietetic Association/Dietary Manager Association. This failure compromised residents' nutritional status and placed residents at risk for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services management. Findings included . <Staff N> In an interview on 11/15/2023 at 3:02 PM Staff R (RD) stated they were employed part-time and came into the building only once a week on Wednesdays. Staff R stated their only involvement in the kitchen was doing the monthly sanitization reports. On 11/17/2023 at 8:08 AM, Staff N's credentials were requested from Staff A (Administrator). The facility was…

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

Based on observation, interview, and record review the facility failed to follow menus, provide menus to residents, or have menus reviewed/approved by a qualified nutrition professional. This failure placed residents at risk of dissatisfaction with meals, residents not being able to have choices, and unmet nutritional needs. Findings included . Review of the Week 3 cycle menu provided by the facility showed lunch for 11/16/2023 was fish, rice, asparagus, dinner roll, and lemon meringue pie with an alternative entrée of orange chicken. In an interview on 11/15/2023 at 10:05 AM Staff H (Cook) stated they did not follow a template providing what measurements of water to use when preparing pureed foods. Staff H stated that they add water until there's no lumps. Observation and interview on 11/16/2023 at 10:41 AM showed Staff H cooking sausage. Staff H stated that they were supposed to provide fish, but Staff N (Food Services Manager) stated that they did not have enough and to cook sausage instead. Staff H stated the dietary department did not furnish menus to residents in the last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was procured, stored, prepared, and served in accordance with professional standards of safety. The facility failed to ensure: (1) Foods were at a safe temperature before serving to residents, (2) open foods were covered and dated, (3) dietary staff practiced good hygiene and sanitization methods, (4) menu ingredients were ordered and readily available as per menu cycle, (5) meal ticket accuracy to ensure all residents were provided with meals, (6) outside foods undated and not stored properly. These failures placed residents at risk of developing food borne illnesses, ingesting expired foods, not receiving preferred foods, and the potential to not receive a meal. Findings included . <Facility Policy> The facility's 07/2018 Food and Nutrition Services Food Safety policy showed the facility will prepare and serve food in a manner to minimize contamination regarding time and temperature control of the foods. This policy also…

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

Based on interview and record review, the facility failed to provide 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 194 & 195) 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. Findings included . <Facility Policy> According to the facility's 09/20/2022 Medicaid/Medicare Coverage/Liability Notice policy, the issuance of the SNF ABN or one of the uniform Denial Letters at the initiation, reduction, or termination of Medicare Part A benefits constituted the facility meeting its obligation to inform the beneficiary of their potential financial liability for payment and related standard claim appeal rights. <Resident 194> Review of Resident 194's records showed a Notice of Medicare Non-Coverage (NOMNC - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were revised as needed to reflect resident needs for 7 (Residents 72, 21, 41, 29, 22, 38, & 68) reviewed for CPs and failed to ensure residents were given the opportunity to participate in Care Conferences (CCs) for 20 (Residents 60 & 8) of 5 residents reviewed for CCs. These failures left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Policy> The 11/2017 Comprehensive Care Plans facility policy showed the purpose of the CP was to provide each resident with a person-centered, comprehensive CP to identify each resident's medical, nursing, physical, mental, and psychosocial needs. This policy showed the CP would have measurable objectives, interventions, and time frames. It would address goals, preferences, needs, and strengths of the resident. The CP process would be on-going. The facility would notify the resident and/or the resident's representative in advance 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 observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 3 of 3 residents (Residents 3, 13, & 41) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to the facility's revised 06/2018 Quality of Care- Restorative Nursing Programs [RNPs] policy, residents were routinely assessed for the need of a formalized RNP. The policy outlined the RNPs assisted residents in obtaining and maintaining their highest practicable functional levels and prevented unnecessary decline, including residents with limited range of motion and mobility. <Resident 3> According to the 08/22/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 3 had clear speech, can make themself understand, and understood others during communication. The MDS showed Resident 3 had a medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 2 (Residents 54 & 67) of 2 residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> Review of the 04/2018 facility policy titled Dialysis showed the facility and the dialysis center will collaborate to assure that the resident's needs related to dialysis treatments are being met. The facility will assess the resident's condition and monitor for complications before and after dialysis treatments received at a dialysis facility. <Resident 54> According to the 05/31/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 54 admitted to the facility on [DATE]. Resident 54 made their own decisions and utilized their sister…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 3 (Staff H, T, & U) dietary employees reviewed for sufficient support and competent kitchen personnel had Food Handler's card. This failure placed residents at risk for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . Review of the facility's staff roster dated 11/13/2023 showed a list of dietary personnel currently working in the facility from which three random dietary staff's, Staff H (Cook), T, and U's (Dietary Aides), Food Handler's cards were requested from Staff N (Food Services Manager). In an interview on 11/13/2023 at 2:28 PM, Staff N provided a dietary staff schedule dated for the week of 10/22/2023 to 10/28/2023. Staff N stated the dietary staff's schedule stayed the same every week. <Staff H> Observations on 11/13/2023 at 8:50 AM, 11/14/2023 at 9:38 AM, 11/15/2023 at 9:01 AM ,11/16/2023 at 8:23 AM, and 11/17/2023 at 9:12 AM showed Staff H was preparing meals in the kitchen. <Staff T> Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 4 residents (Residents 72, 54, 67, & 21) reviewed who required a therapeutic diet (a specialty diet ordered by a physician or dietician) received the prescribed diet. Failure to ensure residents received their diet as ordered, placed residents at risk for an inappropriate diet and related negative health outcomes. Findings included . <Resident 72> According to the 10/18/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 72 was assessed with intact memory/thinking, and had complex medical diagnoses including Diabetes Mellitus (a condition that makes blood sugar levels harder to manage), kidney problems, thyroid issues, and obesity. The 10/18/2023 Care Area Assessment (CAA) showed the Registered Dietician was following Resident 72 to ensure the resident was provided the proper diet and/or interventions. Record review showed Resident 72 had a 10/11/2023 Physician's Order (PO) for a Controlled Carbohydrate (CCD) diet. Resident…

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

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Residents 24, 42 & 49) reviewed for arbitration agreement. The facility failed to ensure the arbitration agreement for 2 of 3 residents (Resident 42 & 49) whose arbitration agreement contracts were reviewed contained language that did not prohibit or discourage the resident and/or their representative from communicating with federal, state, or local officials. These failures placed residents at risk of lacking understanding of the legal document signed, forfeiture of the right to trial, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 10/11/2022 Resident Arbitration Agreements- Entering into Binding Arbitration Agreements policy, the facility would ensure an agreement to arbitrate (a process used to reach an authoritative judgement or settlement using an independent person or body) was explained to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain and/or offer assistance to residents or their representatives to formulate Advance Directives (AD) for 6 (Resident 72, 29, 54, 68, 56, & 83) of 20 residents reviewed for ADs. 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> Review of an 11/2017 Resident Rights, Advance Directives facility policy showed upon admission, the facility would determine if the resident had an AD in place and this information would be available in the resident's record. The facility would inform the resident of their right to establish ADs and provide assistance to the resident. The resident would accept or decline assistance with formulating an AD. The resident's record would reflect the discussion of ADs and whether the resident accepted or declined assistance with formulating an AD. <Resident 72> According 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.

Based on observation, interview, and record review the facility failed to ensure 3 of 20 residents (Residents 3, 13, & 72) whose Minimum Data Set (MDS- an assessment tool) were completed accurately reflected the resident's condition. The MDS did not identify the presence of loose dentures (Resident 3), did not capture the provision of wound care treatment (Resident 13), and did not determine the degree of vision loss (Resident 72). These failures placed residents at risk for not meeting individualized care needs and a decreased quality of life. Findings included . <Facility Policy> According to the facility's 11/2017 Resident Assessment policy, the facility utilized the Resident Assessment Instrument (a manual/guide directing staff on how to accurately assess residents) to conduct assessments that reflected the resident's status. The policy showed the results of the assessment would be used to develop, review, and revise the resident's comprehensive care plan. <Resident 3> According to the 08/22/2023 Quarterly MDS Resident 3 had clear speech, could make themselves understood, and…

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

Based on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed, implemented, resident-specific for 3 (Residents 72, 13, & 41) of 20 sample residents reviewed. Facility failure to develop and/or implement CPs placed residents at risk for unmet care needs and other negative health outcomes. Findings included . <Resident 72> According to the 10/18/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 72 was assessed with intact memory/thinking, and had medically complex conditions including . Review of Resident 72's comprehensive CP showed the following: - the facility initiated an 11/01/2023 resident is resistive to care (SPECIFY) r/t [does not say] CP. The CP included no goals. - the facility developed a 10/11/2023 resident has a communication problem CP. This CP did not identify the nature of the communication problem and included no interventions directing staff how to direct Resident 72 with their communication problem. - the facility developed a 10/11/2023 resident has altered cardiovascular status CP.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed and clarified for 4 of 20 residents (Residents 29, 8, 6, & 41) and ensure medications were given within parameters for 2 of 20 residents (Residents 29 & 72) reviewed. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes. <POs Given Outside of Parameters> <Resident 29> Review of Resident 29's 11/15/2023 order summary showed a 10/08/2023 PO for an over-the-counter pain-relieving medication to be administered to Resident 29 every four hours as needed for pain. This summary showed two 10/08/2023 POs for a narcotic pain-relieving medication. One PO directed staff to administer one tablet of the narcotic medication every four hours as needed for pain and the second PO directed staff to administer two tablets of the narcotic medication every four hours as needed for pain. The three POs did not give instructions to staff indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 onservation, interview, and record review the facility failed to ensure assistance for Activities of Daily Living (ADLs) provided for 3 of 9 residents (Residents 21, 3, & 13) reviewed for ADLs. The failure to provide assistance with dressing (Resident 21 &13) and nail care (Residents 3 &13) left residents at risk for unmet care needs, an undignified appearance, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Life- Activities of Daily Living [ADLs]/Maintain Abilities policy, the facility provided the necessary care and services to support the resident's needs and choices. The policy outlined that a resident who was unable to carry out ADLs including self-care received the necessary services to maintain good grooming and personal hygiene. <Resident 21> According to the 08/10/2023 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 21 admitted to the facility on [DATE]. Resident 21 made their own decisions. Resident 21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and provide resident-centered care and services for 4 of 20 residents (Residents 41, 67, 68, & 69) reviewed for quality of care in accordance with the resident's preferences, goals for care, and professional standards of practice. The facility failed to provide treatment and care to address positioning (Resident 41) and failed to identify skin conditions and perform the necessary assessment and monitoring (Residents 67, 68, & 69). These failures placed residents at risk for discomfort, pain, skin breakdown, and contractures from improper positioning, development and worsening of skin issues, and a diminished quality of life. Findings included . <Positioning> <Facility Policy> According to the facility's 07/2018 Quality of Care - Accident Hazards/Supervision/Devices policy, assistive devices would be of a size and fit for the resident to minimize the risk of an accident. The policy showed the use of devices would be reflected 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 observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 3 of 6 sample residents (Residents 60, 41, & 69) reviewed for accident hazards. The failure to assess bolstering (established matress boundaries) devices such as wedges (Residents 41 & 69) and the failure to ensure extension cords were not used in resident rooms (Resident 60) placed residents at risk for accidents, injury, and other negative outcomes. Findings included . <Resident 60> According to the 10/25/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 60 had adequate vision with glasses and used a manual wheelchair. The MDS showed Resident 60 required some help with indoor mobility such as moving from room to room. The MDS showed Resident 60 had progressive neurological conditions including a nervous system disorder that affected movements and caused tremors, and muscle weakness. Observation on 11/14/2023 at 9:38 AM showed an extension cord being used 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.

Based on observation, interview, and record review the facility failed to provide adaptive equipment with meals for 1 of 1 resident (Resident 41) who was assessed to require assistive devices-eating equipment/utensils. Failure to provide and/or set-up the adaptive eating utensils during meals placed the resident at risk for decreased independence with their Activities of Daily Living (ADLs), decline and/or loss of residual functional mobility, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Life- Activities of Daily Living [ADLs]/Maintain Abilities policy, the facility would provide the necessary care and services to support the resident's abilities in ADLs that ensured their abilities did not diminish, unless they were due to unavoidable circumstances. The policy showed a resident was given appropriate treatment and services to maintain and/or improve their ability to carry out ADLs including dining/eating. <Resident 41> According to the 10/25/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident…

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