Life Care Center Of Kirkland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 1 of 21 residents (Resident 5), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessment was completed accurately on the MDS regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included.According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here 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 interview and record review, the facility failed to include the dialysis (a treatment to remove extra fluid and waste when kidneys fail) days, transportation arrangement and contact information of the dialysis center in the comprehensive care plan for 1 of 1 resident (Resident 31), reviewed for dialysis. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Area of Focus: Care Planning-Baseline, Comprehensive, and Routine Updates, reviewed on 11/25/2024, showed that after a completion of Minimum Data Set (MDS-an assessment tool), a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs would be developed and implemented for each resident. Review of a face sheet printed on 11/21/2025 showed Resident 31 was admitted to the facility on [DATE].Review of Resident 31's admission MDS dated [DATE] 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 ensure safety hazards such as a lighter and a box cutter were properly stored for 1 of 2 residents (Resident 13), reviewed for accident hazards. This failure placed the resident at risk for injury, and a diminished quality of life.Findings included.Review of the facility's policy titled, Area of Focus: Incident and Reportable Event Management, reviewed on 11/15/2025, showed, The facility must ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision . to prevent accidents.Review of a face sheet printed on 11/24/2025 showed Resident 13 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set (an assessment tool) dated 07/14/2025 showed Resident 13 had intact cognition.Review of the behavior/mood care plan initiated on 05/29/2025 showed Resident 13 keeps items in room that he is aware is against [facility] policy.An observation on 09/28/2025 at 12:43 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to administering as needed (PRN) pain medication for 1 of 1 resident (Resident 21), reviewed for pain management. This failure placed the resident at risk for unnecessary medications and incomplete pain control.Findings included.Review of the facility's policy titled, Pain Assessment and Management, revised on 11/11/2025, showed that all residents will be assessed for pain and based on the assessment, the facility in collaboration with the attending physician, other healthcare professionals, and the resident and/or resident representative would develop and implement both pharmacological and non-pharmacological intervention approaches to pain management.Review of the quarterly Minimum Data Set (an assessment tool) dated 09/25/2025 showed Resident 21 was admitted to the facility on [DATE] with diagnosis that included left knee osteoarthritis (a condition in which the protective…

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 controlled medications were accurately reconciled for 1 of 3 medication carts (Olympic Medication Cart), reviewed for controlled medication storage/reconciliation. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medication.Findings included .Review of the facility's policy titled, Management of Controlled Substances, reviewed on 09/16/2025 showed, The facility will maintain a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation, and the facility conduct a periodic reconciliation.The facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift. The policy further showed, .using the Shift Change Controlled Substance Inventory Count Sheet [the facility] reconcile the number of doses remaining in the package to the number of remaining…

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 influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 2 of 5 residents (Residents 6 & 10), reviewed for immunizations. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease.Findings included.Review of the facility's policy titled, Influenza Vaccine Policy for Residents, reviewed on 07/08/2025, showed, Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. It further showed, The resident's medical record included documentation that indicates.that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.RESIDENT 6Review of a face sheet printed on 11/25/2025…

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.

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, All alleged incidents of abuse, neglect.and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. It further showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences.Review of the facility's policy titled, Abuse-Protection of Residents, reviewed on 05/07/2025, showed, Have evidence that all alleged violations are thoroughly investigated.Review of the quarterly…

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

Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices and/or proper use of personal protective equipment (PPE-glove/gown use) were followed for 2 of 3 residents (Residents 1 & 2), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included .Review of the facility's policy titled, Enhanced Barrier Precautions [EBP-precaution to protect residents from multidrug-resistant organism [MDRO - a germ that is resistant to medications that treat infections]), revised on 08/19/2025, showed that the facility would use EBP for MDRO mitigation as a strategy for residents during high contact care activities that included wounds even if the resident was not known to be infected or colonized with a MDRO. It also showed that EBP would be done for chronic wounds such as pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure), diabetic foot ulcers (skin injury with full thickness skin loss on the foot in patients…

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 a written summary of the baseline care plan to the residents and/or their representatives for 4 of 4 residents (Residents 1, 2, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Baseline Care Plan, reviewed on 09/05/2024, showed staff would 4. Review the baseline care plan and physician orders with the resident and/or representative. 5. Provide the resident[s]and/or representative with copies of the baseline care plan and physician orders. 6. Have all care plan conference attendees sign the last page of the Baseline Care Plan form. RESIDENT 1 In a phone interview on 04/24/2025 at 9:51 AM, Collateral Contact 1 (CC1), stated they did not recall receiving a written summary of Resident 1's baseline care plan. Review of Resident 1's assessment titled, Baseline Care Plan 2, dated 03/10/2025, did not show…

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 staff used N95 masks (a device designed to protect the wearer against particles and help prevent the spread of germs) correctly for 4 of 4 staff (Staff G, F, E & H), and were fit-tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) timely for 2 of 4 staff (Staff F & G), reviewed for infection control. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism (a germ that is resistant to medications that treat infections) practices were followed for 1 of 3 residents (Resident 2), reviewed for infection control. These failures placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the Centers for Disease Control and Prevention online document titled, How to Use Your N95 Respirator, dated 05/16/2023, showed, Always inspect the N95 respirator for damage…

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 necessary assistance with Activities of Daily Living (ADL) for 1 of 4 residents (Resident 1), reviewed for ADLs. The failure to provide the resident who was dependent on staff for assistance with toileting placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, ADL, reviewed on 09/10/2024, showed, The resident will receive assistance as needed to complete activities of daily living (ADLs). Review of the face sheet printed on 04/08/2025, showed that Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, and need for assistance with personal care. Review of the 5-day Minimum Data Set (an assessment tool) dated 03/14/2025, showed Resident 1 was frequently incontinent of urine, dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident centered discharge plan was in place for 1 of 5 residents (Resident 1), reviewed for discharge planning. The failure to begin the discharge planning process at admission placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Plan, reviewed on 09/05/2024, showed that the discharge planning process included to identify the patient's needs and goals regarding discharge upon or as soon as practicable after admission. It showed that Social Services or Care management associates will complete the initial discharge plan evaluation form within 48 hours of admission. It further showed that The Discharge Plan .originates on the baseline care plan and will be included on the patient's [resident's] comprehensive care plan, once developed. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's baseline care plan, dated 02/08/2025,…

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 timely reporting of an allegation of neglect to the State Agency for 1 of 3 resident (Resident 1), reviewed for abuse/neglect reporting. This failure placed the resident at risk for potential unidentified and ongoing abuse/neglect and lack of protection from abuse/neglect. Findings included . Review of the facility's policy titled, Abuse- Reporting and Response- No Crime Suspected, reviewed on 06/17/2024, showed an individual (e.g., a resident, visitor, facility associate) who reports an alleged violation to facility staff does not have to explicitly characterize the situation as abuse or neglect to trigger the facility to investigate. The policy further showed alleged violations of neglect that do not result in serious bodily injury, must be reported by the facility no later than 24 hours. Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 10/15/2024, showed Resident 1 admitted to the facility on [DATE] with intact…

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 allegation of neglect was thoroughly investigated for 1 of 3 resident (Resident 1), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse and/or neglect, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse- Conducting an Investigation, reviewed on 06/17/2024, showed allegations of neglect would be promptly and thoroughly investigated by the facility. The policy showed that when an incident or suspected incident of resident neglect occurred the administrator/designee would investigate the occurrence and provide protection to the alleged victim and other residents, such as changing staff to protect the residents from the alleged perpetrator. The policy showed that the facility must thoroughly collect evidence to determine what actions are necessary (if any) for protection of the residents. It showed that it would be expected, but not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 1), reviewed for elopement. This failure allowed Resident 1 to exit the facility unnoticed and placed the resident at risk for serious injury and a diminished quality of life. Findings included . Review of the facility policy titled, Unsafe Wandering and Elopement Prevention, revised 08/22/2022, showed the facility must ensure that each resident receives adequate supervision .to prevent accidents. The policy further showed elopement is when a resident leaves a safe area without the necessary supervision to do so and places them at risk of heat/cold exposure, dehydration, and/or being struck by a motor vehicle. Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (a progressive condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life), muscle weakness, and unsteadiness on feet.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 5 of 21 residents (Residents 9, 65, 68, 3 and 54), reviewed for care plans. The failure to develop care plans for nutrition, pressure ulcer (bed sore), Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open), antiplatelet (a medications that prevent blood clots), communication, and oxygen placed the residents at risk for unmet care needs, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Person Centered Care Planning, reviewed on 08/22/2023, showed that each resident will have a person-centered care plan developed and implemented to meet residents' preferences and goals, and address the residents medical, physical, mental and psychological needs. RESIDENT 9 Resident 9 admitted to the facility on [DATE]. Review of the admission Minimum Data Set…

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 appropriately label and store drugs and/or biologicals for 2 of 2 medication carts (Cascade medication cart & [NAME] medication cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and/or ineffective medications. Findings included . Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals revised on 08/07/2023, showed, the Facility should ensure that medications and biologicals that have an expired date on the label .are store separate from other medication until destroyed. It further showed, Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels Review of the facility's policy titled, Insulin (medication for diabetes [a condition in which the body has high blood sugar levels for prolonged periods of time]) Pen Administration revised on 8/30/2023, showed, to verify the pen with name of the patient and other patient…

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 foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, and for 1 of 1 dining room (Baker Dining Room), reviewed for food services. The failure to label and date food items, perform hand hygiene between glove use, and use appropriate food handling when assisting residents placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's undated document titled, Proper use of Gloves to Handle Food, showed, We know that we should not touch ready-to-eat food with our bare hands, but it is also important not to use contaminated gloves when handling ready-to-eat food. It further showed to change gloves after touching any unsanitary or unclean item or surface such as an oven door, refrigerator handle, scoop handle, the bottom of a plate or pan, or the outside of a bread bag. Additionally, it showed, Wash your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light (an alerting device for staff to assist residents in need) was within reach for 1 of 6 residents (Resident 3), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Call System, revised on 01/15/2024, showed the facility must be adequately equipped to allow residents to call for assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. The policy further showed associates should answer call lights whether they are assigned to provide care to that resident and the call light should be positioned within reach of the resident. Resident 3 readmitted to the facility on [DATE] with diagnoses that included aphasia (a language disorder that makes it difficult for people…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report suspected allegations of abuse and/or neglect to the State Agency for 1 of 4 residents (Resident 75), reviewed for abuse/neglect reporting. This failure placed the residents at risk for potential unidentified and ongoing abuse/neglect and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse - Reporting and response - No Crime Suspected, reviewed on 06/17/2024, showed that the facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property and report the result of all investigations to the proper authorities within prescribed time frame. The facility will ensure that all staff are aware of reporting requirements and to support an environment in which staff and others report all alleged violations. Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed 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 interview and record review the facility failed to ensure allegations of abuse and/or neglect was thoroughly investigated for 1 of 4 residents (Residents 75), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse and/or neglect, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse - Reporting and response - No Crime Suspected, reviewed on 06/17/2024, showed that within five working days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that 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. Resident 75 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 interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative describing the reason for transfer for 1 of 1 resident (Resident 65), reviewed for hospitalization. This failure placed the resident at risk of not having the opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Notice of Transfers and Discharges, revised on 08/13/2024, showed that the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Review of the discharge Minimum Data Set (an assessment tool) dated 07/03/2024, showed Resident 65 readmitted to the facility on [DATE], and discharged to an acute hospital on [DATE]. Review of the nursing progress notes dated 07/03/2023, showed Resident 65 was transferred to the emergency room. Review of Resident 65's electronic…

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 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 3 residents (Resident 9), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed that a SCSA is a comprehensive assessment for a resident that must be completed when determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual showed a significant change is a major decline or improvement in a resident's status that impacts more than one area of the resident's health status. The RAI manual further showed emergence of unplanned weight loss problem (5% change in 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS- an assessment tool) timely within 14 days from the Assessment Reference Date (ARD or assessment period) for 1 of 7 residents (Resident 32), reviewed for Resident Assessments. This failure placed the resident at risk for delayed and/or unidentified care needs. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed a quarterly assessment was considered timely if the MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + [plus] 14 days). Review of an admission record printed on 08/27/2024, showed Resident 32 admitted to the facility on [DATE]. Review of Resident 32's quarterly MDS with an ARD of 10/08/2023, showed it was completed on 11/01/2023 (10 days late). In an interview and joint record review on 09/05/2024 at 3:22 PM, 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 interview and record review, the facility failed to accurately assess 4 of 21 residents (Residents 11, 3, 95 & 8), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding change in behavior, bladder/bowel continence status, discharge status, and use of insulin (medication/hormone that regulates blood sugar levels) injections placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other…

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 the Level I Pre-admission Screening and Resident Review (PASRR- an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facility for long term care) had the required referral for PASRR Level II evaluation (a comprehensive evaluation required as a result of a positive Level I screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I screening and to determine whether placement or continued stay in a nursing facility is appropriate) for 1 of 5 residents (Resident 11), reviewed for PASRR. In addition, the facility failed to ensure a new PASRR Level I was completed when Resident 11 had a significant change in condition. These failures placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet their behavioral…

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 clarify a physician's order for 1 of 4 residents (Resident 55) and failed to ensure staff documented medications in accordance with professional standards for 1 of 4 residents (Resident 2), reviewed for medication administration. In addition, the facility failed to ensure insulin (a hormone that regulates blood sugar level) administration was documented for 1 of 3 residents (Resident 3), reviewed for insulin administration. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, General Dose Preparation and Medication Administration, revised on 01/01/2022, showed, prior to administration of medications .facility staff should: verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident. It…

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 bathing/shower and personal hygiene were consistently provided according to plan of care for 1 of 4 residents (Resident 9), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living (ADL's), revised on 02/12/2024, showed, The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse. Resident 9 admitted to the facility on [DATE] with diagnosis that included muscle weakness and required assistance with personal care. Review of the admission Minimum Data Set (an assessment tool) dated 07/19/2024, showed Resident 9 had severe impairment in cognition and required substantial/maximal assistance (Helper [staff] does more than half the effort/lifts…

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 appropriate treatment and services related to enteral tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 1 resident (Resident 55), reviewed for tube feeding management. The failure to label/date and discard tube feeding syringes placed the resident at risk for infection and related complications. Findings included . Review of the facility's policy titled, Enteral tube feeding, gastric [stomach], revised on 12/11/2023, showed to clean and dry the enteral syringe used for flush administration. It further showed to store clean equipment away from potential sources of contamination. Review of the annual Minimum Data Set (MDS - an assessment tool) dated 07/10/2024, showed Resident 55 readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (the presence of a surgical opening in the stomach). Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary behavioral care and services for 1 of 1 resident (Resident 11), reviewed for behavioral health services. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . According to the facility's policy titled, Behavioral Health Services, reviewed on 08/22/2023, showed the facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs, and includes individualized approaches to care. It further stated, Complete the nursing assessment and Social Services assessment upon admission/readmission, quarterly, and as needed with change in condition. Through this assessment the facility should identify residents who develop decreased social interaction and/or increased withdrawn, angry, or depressive (persistent feeling of sadness and loss of interest) behaviors and may have…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). The failure to properly administer 2 of 31 medications for 2 of 4 residents (Residents 2 & 55), observed during medication pass resulted in a medication error rate of 6.45%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . Review of the facility's policy titled, General Dose Preparation and Medication Administration, revised on 01/01/2022, showed, prior to administration of medications .facility staff should: verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident. RESIDENT 2 Review of the September 2024 Medication Administration Record (MAR) showed Resident 2 had an order for aspirin 81 milligrams (mg-a unit of measurement) chewable tablet. Observation on 08/30/2024 at 1:18 PM, 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 observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP - precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 7 residents (Resident 55), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and medication administration for 2 of 12 staff (Staff EE & Staff M), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Hand Hygiene, reviewed on 06/03/2024, showed staff should perform hand hygiene (even if gloves are used) in the following situations: before and after contact with the resident and after removing Personal Protective Equipment (PPE-gloves, gown and mask).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted residents' dignity related to use of urinary catheter (a flexible tube inserted into the bladder, which drains urine into a collection/drainage bag outside the body) for 3 of 4 residents (Residents 4, 5 & 6), reviewed for resident rights. This failure placed the residents at risk for embarrassment, decreased self-worth, and a diminished quality of life. Findings included . RESIDENT 4 Resident 4 admitted to the facility on [DATE]. Review of Resident 4's physician's order with a start date of 04/08/2024, showed catheter care every shift. Observation on 04/23/2024 at 12:40 PM, showed Resident 4's urinary catheter drainage bag had amber colored urine, and it was visible from the hallway. Further observation showed Resident 4's urinary catheter drainage bag was not covered with a privacy bag. During a joint observation and interview on 04/23/2024 at 12:42 PM with Staff C,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure allegation of abuse was reported to the State Agency and/or law enforcement for 1 of 3 residents (Resident 1), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse-Reporting and Response-No Crime Suspected, revised on 10/13/2023, showed, The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within the prescribed timeframes. Further review of the policy showed, The facility will ensure that all staff are aware of reporting requirements and to support an environment in which staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries…

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 allegation of abuse was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (The Purple Book), dated October 2015, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the facility's policy titled, Abuse-Reporting and Response-No Crime Suspected, revised on 10/13/2023, showed An individual who reports an alleged violation to the facility staff does not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger the facility to investigate. Rather, if the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received skin care and treatments in accordance with professional standards of practice for 3 of 4 residents (Residents 1, 2 & 3), reviewed for skin conditions. This failure placed the residents at risk for not receiving the necessary skin care treatment, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Documentation & Assessment of Wounds, reviewed on 03/31/2023, showed that the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of Resident 1's skin assessment dated [DATE], showed right forearm skin tear [traumatic wounds that may result from a variety of mechanical forces such as shearing or frictional forces, including blunt trauma, falls, poor handling,…

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 urinary catheters (a flexible tube inserted into the bladder, which drains urine into a collection/drainage bag outside the body) were positioned off the floor for 2 of 4 residents (Resident 1 & 2), reviewed for urinary catheter use. This failure placed the residents at risk for urinary tract/bladder infections and related complications. Findings included . Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, reviewed on 08/24/2023, showed the general urinary catheter maintenance guidelines were to always keep the collecting bag below the level of the bladder and do not rest the bag on the floor. RESIDENT 4 Resident 4 admitted to the facility on [DATE]. Review of Resident 4's physician's order with a start date of 04/08/2024, showed urinary catheter care every shift. Observation on 04/23/2024 at 12:40 PM, showed Resident 4 was sitting on the edge of their bed with their urinary drainage bag lying…

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 designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for contracting COVID-19 (an infectious disease-causing respiratory illness) during a facility outbreak, unmet infection control issues, and lack of oversite of infection control practices. Findings included . Review of the facility document titled, Care List for Positive Individuals, dated 04/02/2024, showed 42 residents and 17 staff had tested positive with COVID-19 between the dates of 03/18/2024 and 04/01/2024. On 04/03/2024 at 12:45 PM, Staff A, Executive Director, stated that they did not have an IP at this time, but that Staff B was the interim [temporary] IP. On 04/03/2024 at 1:12 PM, Staff B stated that we don't have an IP, so I've been helping out. Staff B stated they were not IP certified. On 04/03/2024 at 2:36 PM, Staff A stated that they expected the designated IP to be certified and that Staff B was 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 observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed for 1 of 3 staff (Staff E), failed to appropriately disinfect medical equipment for 1of 2 staff (Staff E), and failed to do proper use and disinfection/disposal of personal protective equipment (PPE-gown, gloves, face shield, N95 respirators [a device/mask designed to protect the wearer against particles and help prevent the spread of germs]) for 2 of 7 staff (Staff E & F), reviewed for infection control. In addition, the facility failed to ensure staff were fit tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) for N95 masks for 13 of 18 staff (Staff E, F, D, G, J, K, L, M, N, O, H, I & P), reviewed for transmission based precautions (measures to prevent the spread of infection). These failures placed the residents at risk for facility acquired or healthcare-associated infection and related complications. Findings included . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate nutritional care and services including assessments and interventions to address significant weight loss for 1 of 3 residents (Resident 1), reviewed for nutrition/hydration. This failure placed the resident at risk for decline in nutritional status, nutrition related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident at Risk (RAR), revised on 04/25/2023, showed the facility conducts weekly resident at risk meeting to review residents identified with problems or concerns related to their nutritional status or have an unidentified risk factor that may lead to nutrition and hydration issues. Ensure the physician, resident and/or responsible party have been notified of any significant changes. Make recommendations to the resident's physician including but not be limited to frequency of monitoring weights, initiation and/or changes regarding food portions and meal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident was free from physical abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for serious harm and injury and a diminished quality of life. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. Additionally, the term 'willful' describes the deliberate or non-accidental action or inaction that resulted in the abuse of the resident. Review of the facility's policy titled, Abuse-Prevention, reviewed on 07/18/2023, showed it is the policy of this facility to prevent and prohibit all types of abuse and identify, correct, and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur.…

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 air dry drinking glasses before stacking and a fan was blowing over food being prepared on the tray line. These failures placed all the residents at risk for developing food borne illness (caused by ingestion of contaminated food and beverages). Findings included . Review of the facility's policy titled, Sanitation and Food Safety, dated 11/04/2022, stated, . All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. On 05/03/2023 at 11:45 AM, the following observations in the kitchen were made with and verified by Staff C, the Food Service Director: 1. A stand fan was blowing on the tray line and on clean dishes as staff were starting to set food on the tray line for lunch. 2. Eighty plastic drinking glasses ready for use on the tray line were stacked wet and had not been allowed to air dry. An interview on 05/03/2023 at 4:13 PM with Staff C stated, All kitchen employees need to follow the policies of the kitchen. A new employee also unloaded the plastic…

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 electronically transmit Minimum Data Set (MDS) data to the CMS [Center for Medicare and Medicaid] system within the required time frames for 4 of 24 residents (Residents 74, 15, 35 and 7) reviewed for timeliness in transmitting 5 day and/or discharge MDS assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument, dated October 2019 showed, Submission files are transmitted to the QIES ASAP [Quality Improvement Evaluation System Assessment Submission and Processing System] system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements . All other MDS…

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 recognize and ensure that injuries of unknown source were reported to the state agency for 1 of 4 residents (Resident 146) reviewed for closed record review. This failure placed the resident at risk for abuse and neglect. Findings included . Review of facility's policy titled, Incident and Reportable Event Management, revised in January 2023, showed, injuries of unknown source . are reported immediately . Injuries of unknown source is classified when both of the following criteria are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury . event management includes, but is not limited to, the following types of events: . skin related injuries, bruise. Resident 146 admitted to the facility on [DATE] with a diagnosis that included heart disease. Review of Resident 146's 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 interview and record review, the facility failed to investigate multiple bruises of unknown origin to determine the cause, rule out abuse, and implement interventions to prevent reoccurrence of incidents reported for 1 of 4 residents (Resident 146) reviewed for closed record review. The failure to initiate and/or conduct a thorough investigation placed the resident at risk for delayed identification of potential injury/harm, abuse and neglect, and a diminished quality of life. Findings included . Review of the facility policy titled, Protection of Residents: Reducing The Threat of Abuse & Neglect, revised August 2021 showed, . identifying and understanding the different types of abuse and possible indicators . Examples of injuries that could indicate abuse include, Injuries that are non-accidental or unexplained; Bruises, including those found in unusual locations such as the head, neck, lateral (side) locations on the arms, or posterior (back) torso and trunk, or bruises in shapes. It is the policy 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 record review, interview, and policy review, the facility failed to conduct a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 3 residents (Resident 29) reviewed for PASARR. This failure placed the resident at risk for not receiving timely specialized health services, unmet care needs, and a diminished quality of life. Findings included . Review of the policy provided by the facility titled, Pre-admission Screening and Resident Review (PASARR), dated 10/06/2022, showed The facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission to a nursing facility . A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility . When a Level II PASARR screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide appropriate services for administering medications via gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach) for 1 of 2 residents (Residents 69) reviewed for administration of G-tube medications. This failure placed the resident at risk for drug interactions and complications. Findings included . Review of an online document from the National Institute of Medicine titled, Medication administration through enteral feeding tubes, dated 12/15/2008, showed, . Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effect, or drug-formula incompatibilities. Review of the facility policy titled, Medication Administered through an Enteral Tube, dated 12/11/2019 showed, . Medications are administered as prescribed in accordance with standard nursing principles and practices . Facility should prepare one medication at a time . Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to 1 of 1 resident (Resident 5) reviewed for dementia care. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care of the Cognitively Impaired (Dementia Care), dated 08/29/2022 showed, The facility will provide dementia treatment and services which may include, but are not limited to: Ensuring adequate medical care, diagnosis, and supports based on diagnosis; Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety . Identify, address, and/or obtain necessary services for the dementia care needs of residents. Review of the electronic medical record under the face sheet tab, showed Resident 5 admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS - a test that rates involuntary muscle movements on residents who are administered antipsychotic [mind-altering] medications) assessment, upon admission for 1 of 5 residents (Residents 298) reviewed for unnecessary medications. This failure placed the resident at risk for unrecognized side effects and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Medication Use, dated 10/24/2022, revealed, . All medication used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: Efficacy, Risks, Benefits, and Harm or adverse consequences . Review of the admission record located in the profile tab of the electronic medical record (EMR) revealed, Resident 298 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.