Crystal Cove Post Acute

Based on observation, interview, and record review, the facility failed to ensure medication was stored in manners that met professional standards of practice, for 1 of 1 medication storage rooms (A&B Medication Room) and 2 of 2 medication carts (Halls C &B) reviewed. This failure placed residents at risk of receiving expired medications, cross-contamination, and a diminished quality of life. Findings included.During an observation of the A&B Medication Room on 01/06/2026 at 9:26 AM, Staff C, Infection Preventionist/ Licensed Practical Nurse (LPN), was present for review of the medications. A purified protein derivative (PPD, a test for Tuberculosis) multiuse vial was missing an open date. Staff C confirmed this and said it looked empty (had been used). An emergency kit, with medication in it, had an expiration date listed of 12/2025. Staff C confirmed this. The posted medication refrigerator log for January 2026, had columns that specified staff were to check temperature in the morning and at night due to the Centers of Disease Control and Prevention recommendation for if vaccines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents approved of a 15-hour mealtime gap and were served a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased to 15 hours. This failure placed residents at risk of feelings of hunger and inadequate nutrition.Findings included.Review of the Resident Council (a self-governed, resident-led group) Minutes, dated 08/07/2025, included the following mealtime schedule:a) The Main Dining room was served dinner at 4:30 PM and breakfast at 7:30 AM (for a total of 15 hours in between meals).b) The A Hall was served dinner at 5:00 PM and breakfast at 8:00 AM (15 hours in between meals).c) The B Hall was served dinner at 5:20 PM and breakfast at 8:20 AM (15 hours in between meals).d) The C Hall was served dinner at 5:40 PM and breakfast at 8:40 AM (15 hours in between meals).e) The D hall was served dinner at 6:00 PM and breakfast at 9:00 AM (15 hours in between meals).Further review of the Resident Council Minutes, dated 08/07/2025, showed the dining time had been changed, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a system that ensured residents were screened, educated and offered the COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccine for 2 of 5 residents (Residents 15 & 7) when reviewed for immunizations. This failure precluded residents from the opportunity to make an informed decision regarding receiving Covid-19 vaccines. Findings included . Review of the facility's undated Infection Prevention and Control Program policy showed residents would be screened to see if they were prior immunized or had medical contraindications prior to being offered the COVID-19 vaccination. Once screened, education about the vaccine, risks, benefits, and potential side effects would be given to the resident/resident representative and the COVID vaccination offered. If the resident/resident representative consented, the COVID vaccination would be administered. The resident's electronic health record (EHR) would include documentation that indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity was provided to 2 of 2 Residents (6 & 79) reviewed for resident rights during a meeting with Resident Counsel. This failure placed the residents at risk for diminished self-worth and a decreased quality of life.Findings Included.Resident 6Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS-an assessment tool), dated 12/16/2025, documented Resident 6 was cognitively intact. On 01/07/2026 at 11:00 AM Resident 6 said they felt harassed when Staff R, Business Office Manager, asked them why aren't you paying your bill? Resident 6 said if your bill is not paid [Staff R] will hassle you. Resident 79Resident 79 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 79 was cognitively intact.On 01/07/2026 at 11:00 AM Resident 79 said they also felt harassed by Staff R, Business Office Manager, when they had asked about a bill not being paid one month. On 01/07/2026 at 3:14 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.

Based on interview and record review, the facility failed to communicate resolutions about the concerns brought forward by the resident council (RC) for 6 of 6 months (July, August, September, October, November and December 2025) of RC minutes reviewed. These failures resulted in RC members feeling frustrated, unheard and powerless to affect their care.Findings included .Review of the facility's Resident and Family Grievances policy, dated 2025, showed In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:i. The date the grievance was received. ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s).iv. A statement as to whether the grievance was confirmed or not confirmed.v. Any corrective action taken or to be taken by the facility as a result of the grievance.vi.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received their personal funds (money kept for the resident by the facility) within 30 days of discharge for 1 of 1 residents (Resident 107) reviewed for personal funds with discharge. This failure placed residents at risk of delay in access to their money and a diminished quality of life. Findings included .Review of the facility policy titled Resident Personal Funds, dated 2025, showed upon discharge, eviction, or death, a resident with personal funds deposited with the facility, would receive from the facility within 30 days, their funds and a final account of those funds. Review of the refund request form for Resident 107, showed they were discharged on 06/24/2025. Review of the facility's copy of the check they provided Resident 107 to return their money after discharge, showed the check was written on 07/29/2025. During an interview on 01/07/2026 at 9:38 AM, Staff R, Business Office Manager, confirmed Resident 107 was discharged on 06/24/2025 and was not written a check within 30 days, until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate a fall with injury for 1 of 2 residents (Resident 52) reviewed for falls. The facility's failure to identify and assess the location where a fall occurred, to identify and consider what environmental factors such as uneven surfaces, and insufficient lighting, were present at the time of the fall and to interview all residents and staff with knowledge about the incident, prevented facility staff from identifying the external factors that were present and led to the residents fall. These failures detracted from the ability to identify what interventions needed to be implemented to prevent reoccurrence and placed residents at risk for continued falls and injuries. Findings included . Resident 52 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident was cognitively intact, was independent with activities of daily living, able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 21 sampled residents (Resident 33 & 6) reviewed. This failure placed residents at risk of a lack of care or services related to the assessments, and a diminished quality of life. Findings included .Resident 33 Resident 33 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 33 was cognitively intact and relied on staff for all cares. The MDS documented Resident 33 did not complain, have difficulty and or pain with swallowing or chewing food. On 01/05/2026 at 3:10 PM, Resident 33 reported they had missing and broken teeth and a number of their teeth had fallen out. Resident 33 said it had been almost a year since they had been to a dentist and they wanted to get their teeth fixed, because it was causing pain when they ate. Resident 33 said they could not chew meat, it had to be cut up very small, or sugar, due to causing pain and missing fillings,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 6 of 21 sample residents (Resident 22, 87, 21, 8, 12 & 72) reviewed. The failure to obtain, follow and/or clarify physician's orders when indicated, and to only sign for tasks they completed, placed residents at risk for medication errors, respiratory infections, unmet care needs and other adverse health outcomes.Findings included Resident 22 Resident 22 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated10/16/2025, showed the resident was cognitively intact, had a diagnosis of chronic lung disease and received oxygen therapy during the assessment period. On 01/05/2026 at 2:38 PM, Resident 22 was observed lying in bed receiving O2 at 3L(liters)/min (minute) via NC (nasal cannula). Record review showed Resident 22 had an order for continuous oxygen at 2L/min via NC, dated 2/08/2025, and a 10/08/2024 order that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure interventions to prevent development or promote pressure ulcer healing were implemented as ordered for 1 of 3 residents (Resident 72) reviewed for pressure ulcers. This failure placed residents at risk of worsening wounds, delay in care, and a diminished quality of life. Findings included.Review of the facility policy titled, Pressure Injury Prevention and Management, dated 03/19/2025, showed the facility were to implement interventions for preventing/managing pressure ulcers which included: pressure redistribution (including redistribution support surfaces [mattresses]), minimizing exposure to moisture, and maintaining or improving nutrition status when applicable.Resident 72 was admitted to the facility on [DATE] with diagnoses of malnutrition (body gets too few nutrients), spinal stenosis (narrowing within the spinal canal), anemia (abnormally low level of red blood cells, impacting oxygen delivery), paraplegia (loss of motor and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure cigarettes and failed to complete a smoking assessment for 1 of 3 residents (8) reviewed for accident hazards. The facility also failed to maintain an environment with adequate lighting (the lights were turned off) related to resident safety for 31 for 31 residents utilizing the smoking area. These failures placed residents at risk for accidents, injury and a diminished quality of life. Findings included .Resident 8 Resident 8 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 11/07/2025, documented the resident was cognitively intact and had current tobacco use. Unsecured Cigarettes On 01/05/2026 at 12:11 PM, Resident 8 said I have my cigarettes in my drawer. Cigarettes were observed in the top drawer of the cabinet by Resident 8's bed. On 01/06/2026 at 12:59 PM, Staff Q, Licensed Practical Nurse, went into Resident 8's room and collected the cigarettes from the drawer by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a prescribed therapeutic diet or offer alternatives to residents on a therapeutic diet and monitor and document fluid restrictions (a diet which limits the amount of daily fluid intake) for 2 of 3 sampled residents (Resident 12 & 94), reviewed for nutrition/hydration. This failure placed the residents at risk of inadequate diet, fluid overload, medical complications, and a diminished quality of life. Findings included.Resident 12-Renal Diet Resident 12 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 11/18/2025, documented Resident 12 was cognitively intact and was placed on a renal diet (designed to support kidney health by limiting certain nutrients, particularly sodium, potassium, phosphorus, and protein, to help manage kidney disease and prevent further damage). Review of Resident 12's Nutritional Assessment, dated 11/17/2025, under food preferences documented, see food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Peripherally Inserted Central Cather (PICC) line Intravenous (IV) treatments were provided consistent with professional standards of practice for 1 of 1 resident (Resident 76) reviewed. These failures placed the resident who required IV services at risk for loss of vascular access and complications related to IV therapy.Findings included .A review of the facility policy titled, Peripherally Inserted Central Catheter Flushing, Locking, Removal, dated 2025, stated, It is the policy of this facility to ensure that peripherally inserted central catheters (PlCC) are flushed, locked and removed with current standards if practice. And under the Flushing heading it documented 7. Slowly aspirate [withdraw fluid] for a blood return to confirm device patency.Resident 76Resident 76 was admitted to the facility on [DATE] with a diagnosis of Methicillin Resistant Staphylococcus Aureus Infection (a staph infection resistant to common antibiotics).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 1 resident (Resident 22) reviewed for respiratory care. Facility staffs' failure to administer oxygen at the physician ordered rate and to change oxygen tubing as the frequency ordered, placed residents at risk for respiratory infections and unmet respiratory needs. Findings included .Review of the facility's Oxygen Administration policy, copyright 2025, O2 (oxygen) would be administered to residents who needed it. O2 would be administered in accordance with physician's orders except in the case of an emergency. In such case, O2 would be administered and orders for the oxygen/rate would be obtained as soon as practicable and staff would document the initial and ongoing assessment of the resident's condition that warranted O2 administration and the resident's response. O2 tubing/NC (nasal cannula) would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with Hemodialysis (dialysis, a machine that is used to remove waste and extra fluid from blood and return the filtered blood into the body), receive/obtain dialysis communication documentation including resident's plan of care and post dialysis communication, and/or follow up on dialysis recommendations for 2 of 3 sampled residents (Resident 15 &12) reviewed for dialysis. This failure placed residents at risk for medical complications, missed dialysis treatments and a decreased quality of life. Findings included.Review of the facility polity titled, Hemodialysis, dated 2024, showed the facility was to communicate with the dialysis facility, such as using a dialysis communication form or other form, that would include: bloodwork results, vital signs, nutritional/fluid management (including resident compliance with food/fluid restrictions, and monitoring fluid intake and output measurements as ordered),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 complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 1 sampled veteran staff (Staff BB) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.Findings included .Review of Staff BB's, Nursing Assistant personnel file showed they were hired on 07/18/2023. Review of Staff BBs personnel file showed no annual performance review had been completed from July 2024 - July 2025On 01/12/2026 at 12:50 PM, Staff A, Administrator, said there was not a performance review for Staff BB as required. Reference WAC 388-97-1680 (1), (2)(a-c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 2 of 2 sampled residents (Residents 33 &11) reviewed for dental services. This failure placed residents at risk for difficulty chewing, pain/discomfort due to unmet dental needs, and a diminished quality of life. Findings included .Resident 33 Resident 33 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/09/2025, documented Resident 33 was cognitively intact and relied on staff for all cares. On 01/05/2026 at 3:10 PM, Resident 33 reported they had missing, and broken teeth and a number of their teeth had fallen out. Resident 33 said it had been almost a year since they had been to a dentist and they wanted to get their teeth fixed, because it was causing pain when they ate. Resident 33 said they could not chew meat, it had to be cut up very small, or sugar, due to causing pain and missing fillings, and this had been going on for months…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foods that accommodated the residents' preferences, diet types and tolerances for 3 of 8 sampled residents (Resident 12, 66 & 15) reviewed for preferences. This failure placed residents at risk for meal dissatisfaction, nutrition at risk, and a diminished quality of life.Findings included .Resident 12 Resident 12 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 11/18/2025, documented Resident 12 was cognitively intact and was placed on a renal diet (designed to support kidney health by limiting certain nutrients, particularly sodium, potassium, phosphorus, and protein, to help manage kidney disease and prevent further damage). On 01/06/2026 at 9:42 AM, Resident 12 said the dialysis meal sent every dialysis day was a turkey sandwich (only two pieces of turkey, nothing else on the sandwich), some type of crackers or cereal bar, a Nutri grain bar, a cup of Jello…

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

Based on observation and interview, the facility failed to ensure food was stored under sanitary conditions by not ensuring a resident refrigerator maintained cold food at or below 41 degrees Fahrenheit. This failure created the potential to expose residents to improperly stored food and increased risk of foodborne illness.Findings included .During an observation of the dining room resident refrigerator on 01/06/2026 at 11:09 AM, the refrigerator thermometer red indicator line showed a reading of 51 degrees, Staff G confirmed that the reading was 51 degrees. When asked what steps she would take now that it had been identified the refrigerator was above 41 degrees, Staff G said she would throw everything away and began removing food items from the refrigerator. On 01/07/2026 at 2:20 PM, Staff G showed there was a new resident refrigerator saying it had been placed on 01/06/2026. When asked to see the thermometer, Staff G was unable to locate it in the refrigerator and said it had been there in the morning. Staff G then asked Staff I, Admissions Director, about the thermometer 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 the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Resident 46, 60 & 79) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included .On 01/12/2026 at 2:16 PM, when asked what their understanding of the arbitration process was, Resident 46 stated, what is that? Resident 46 said they did not know they were giving up their right to pursue litigation in a court proceeding or that they could terminate the arbitration agreement within 30 days. When it was explained they had signed the facility's arbitration agreement when they admitted to the building, Resident 46 stated, when I was admitted I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 resident (Resident 87) reviewed for hospice services.The facility failed to designate a staff member to be responsible for coordinating care with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/ documentation of what hospice staff had visited (e.g., registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care was provided. These failures detracted from staffs' ability to effectively communicate collaborate and coordinate care with the Hospice provider, and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included .Resident 87 was admitted to the facility on [DATE]. Review of a Significant Change Minimum Data Set (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 observation, interview and record review, the facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when facility staff failed: to performed required hand hygiene and gloves changes with wound care; to ensure urinals were emptied/rinsed after use; to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions used when someone has confirmed or suspected infections) for 2 of 3 (Residents 66 & 72) and reviewed for infection control. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications and a decreased quality of life. Findings included .WOUND…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance and adverse side effects for 3 of 5 residents (Residents 74, 25 & 32) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and a decreased quality of life.Findings included . 1) Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's electronic health record (EHR) showed a urinalysis, dated 11/05/2025, that documented Resident 74's urine was positive for Many! bacteria. The lab did not include a culture and sensitivity (C&S, identifies the specific bacteria or fungi causing an infection and identifies which antibiotics or antifungal drugs will effectively kill or inhibit them.) On 11/08/2025 Resident 74 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 interview and record review the facility failed to ensure Nursing Assistants (NA) received a minimum of 12 hours of required in-service training per year which was to include dementia management, abuse prevention, and caring for individuals with cognitive impairment for 1 of 1 sampled veteran NA, (Staff BB), reviewed for staff training. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff. Findings included .Review of the personnel file for Staff BB, NA, showed they were hired on 07/18/2023. Review of Staff BB's training records showed she received 6 hours of in-service training from July 2024 - July 2025 and it did not include abuse prevention.On 01/12/2026 at 12:50 PM, Staff A, Administrator, said Staff BB only received 6 of the 12 required in-service hours from July 2024 - July 2025.Reference WAC 388-97-1680 (2)(a-c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comfortable homelike environment by not providing adequate heat in resident rooms in 3 of 4 hallways reviewed for comfortable temperature. This failure placed residents at risk for diminished quality of life.Findings included.Review of facility documentation titled, Logbook Documentation showed All buildings are required to maintain an ambient temperature throughout resident and patient care areas in a temperature range of 71 to 81 degrees Fahrenheit [F] or at a more restrictive range required by state or local requirements.During a telephone interview on 12/5/2025 at 11:00 AM, Collateral Contact 1 said they placed a digital thermometer in Resident 7's room and installed a temperature app on their phone so they could monitor the temperature of the resident's room as the room had been cold. They said Resident 11's room temperatures were as follows:10/14/2025 12:05 PM - 62 degrees F10/15/2025 2:20 PM - 61.7 degrees F10/16/2025 5:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wound and indwelling catheter (flexible tube inserted into the bladder to drain urine) cares were provided to 1 of 3 residents (Resident 3) reviewed for quality of care. This failure placed residents at risk for developing infection and diminished quality of lifeFindings included .Review of the facility policy, titled Wound Treatment Management, undated, showed, wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing [NAME]. In absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record.Review of the facility policy, titled Catheter Care, undated, showed, catheter care will be performed every shift and as needed by nursing personnel.Resident 8 was admitted to the facility on [DATE] with diagnoses of…

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

Based on observation, interview and record review the facility failed to ensure sufficient dietary staff were trained and competent in recognizing and documenting appropriate food temperatures, appropriate chemical sanitation of the dishwasher, sanitizer bucket and three compartment sink, and providing meals at the established mealtimes for 1 of 1 kitchen. This failure placed residents at risk of food born illness and decreased quality of life.Findings included.Food TemperaturesFacility Policy Review of facility policy, titled, Food Safety Requirements undated showed, staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed. Reheating - food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 FReview of facility policy titled Record of Food Temperatures, undated, included the following, Food temperatures will be checked on all items prepared in the…

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

Based on observations, interviews and record reviews, the facility failed to ensure food temperatures were taken and documented, failed to ensure foods were cooked and served at the appropriate temperatures, failed to ensure food was stored and prepared in a sanitary manner, failed to ensure chemical solutions and water temperatures were maintained and documented and failed to ensure staff utilized proper handwashing during meal preparation and serving in 1 of 1 kitchen. This failure placed residents at risk for food borne illness.Findings included.Food TemperaturesFacility Policy Review of facility policy, titled, Food Safety Requirements undated showed, staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed. Reheating - food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 FReview of facility policy titled Record of Food Temperatures, undated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Administration failed to ensure there was active and engaged oversight and a monitoring system in place to correct findings from an internal audit related to treatment and service to prevent/heal pressure ulcers, food procurement, sufficient dietary support personnel and a sanitary kitchen. This failure placed residents at risk for development or worsening pressure ulcers, food borne illness and a diminished quality of life. Findings included .Review of a facility document titled Mock Survey, dated 07/28/2025 and 07/29/2025 included the following:The facility failed to ensure a resident receives care consistent with professional standards of practice, to prevent pressure injuries and does not does not develop pressure injuries.skin checks not completed every 7 days.no measurements of this wound were taken other than the measurements taken upon admission.Infection Prevention/Control.follow enhanced barrier precautions for residents.standing/pooled water on the floor between the walk-in fridge and freezer.Towels on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure adequate care and services were provided to promote wound healing and prevent pressure ulcers from developing or worsening by assessing wounds timely, and following physicians' s orders timely for 2 of 3 sampled residents (Resident 1 and 4) reviewed for pressure ulcers. This failure placed residents at risk for worsening pressure ulcers, infections and medical complications.Findings included .Facility PolicyReview of facility policy, titled Skin Assessment, effective 03/03/2025 showed A full body, or head-to-toe assessment, will be conducted upon admission/readmission, weekly, and with any change of condition or after any newly identified pressure injuryReview of facility policy, titled Wound Treatment Management, undated, showed, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the Treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescribed nutritional supplements with meals for 2 of 2 residents (Resident 1 and 5) reviewed for nutrition. This failure placed residents at risk for decreased quality of life and weight loss. Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (neurological condition), cellulitis (skin infection) and a pressure ulcer to the left buttocks. The admission Minimum Data Set (MDS), an assessment dated [DATE], documented Resident 1 was cognitively intact and required supervision to eat. Review of Resident 1's physician's order, dated 06/25/2025, showed an order for regular diet, regular texture and thin consistency.Review of Resident 1's physician's order, dated 06/30/2025, showed an order for mighty shakes (high calorie, high protein nutritional supplement) for wounds with lunch and dinner.During observation on 08/06/2025 at 9:10 AM, showed Resident 1 with his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of observation, interview and record review the facility failed to follow infection control practices for transmission-based precautions for 1 of 1 resident (Resident 6) reviewed for infection control. This failure placed residents at risk for spread of infection, health complications, and a diminished quality of life. Findings included .Facility PolicyReview of the facility policy, titled Transmission-based Precautions undated showed, Signage that includes instructions for use of specific PPE [personal protective equipment] will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. Contact Precautions: The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident 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 obtain weights and failed to provide a recommended nutritional supplement for 1 of 3 (Resident 1) residents reviewed for nutrition. The facility's failure placed residents at risk for weight loss and decreased quality of life.Findings included.Review of the facility's policy, titled, Nutritional Management, undated, showed nutritional recommendations may be made by the dietician based on the resident's preferences, goals, clinical condition and other factors and followed up with the physician/practitioner for orders as per facility policy.Resident 1 was admitted to the facility on [DATE] with diagnoses including non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cerebral aneurysm (weakness in the blood vessel in the brain that balloons and fills with blood), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body) and dysphagia (difficulty in swallowing). 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 ensure accurate acquiring and receiving of all drugs and biologicals to meet the needs of 2 of 4 residents (6 and 9) reviewed. Failure to ensure ordered medications were received from pharmacy placed residents at risk for experiencing increased pain and a decreased quality of life. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS), an assessment tool, Resident 6 was cognitively intact, assessed with medically complex conditions including spinal stenosis and fractures of the thoracic vertebrae, received scheduled pain medication and was assessed with pain frequently. Review of the May 2025 Medication Administration Records (MARs) showed an order for Morphine Extended Release (ER), (narcotic pain medication) 30 milligrams to be administered every 12 hours for pain. Resident 6 did not receive three consecutive doses on 05/06/2025 at 8:00 PM, 05/07/2025 at 8:00 AM and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to assess gastrostomy tube (surgically placed tube through the abdominal wall into the stomach to provide nutrition) placement prior to initiating an enteral feeding (feeding through tube) and failed to follow the prescribed orders for hydration for 1 of 2 residents (Resident 7) reviewed for tube feeding management. This failure placed residents at risk for alteration in nutrition and decreased quality of life. Findings included . Review of the facility policy, titled, Verifying Placement of Feeding Tube, undated, showed before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. The policy then went on to describe the various methods of confirming proper placement. <Resident 7> Resident 7 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (serious condition that occurs when blood flow to the brain is disrupted),…

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

Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 4 residents (Residents 1, 7, 71 & 12) interviewed, and 5 staff (Staff T, X, OO, N & PP) interviewed. The facility had insufficient staff to ensure residents received assistance with activities of daily living, restorative services and staff documentation. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNPs not being done for 3 of 4 residents (Residents 42, 1 & 32) reviewed for RNP. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Interviews> On 01/22/2025 at 11:18 AM, Resident 1 said it took a long time to get help. At 2:16 PM, Resident 7 said it took a long time to get help. Resident 7 said they had currently been waiting an hour and a half or close…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurses and nursing aides had the appropriate competencies/skill sets to provide nursing services that included appropriate transmission-based precaution (TBP) identification, staff correctly identifying which residents were on enhanced barrier precautions (EBP) and failed to implement correct usage of personal protective equipment (PPE) for residents on EBPs. The facility also failed to implement policies for orientation of agency/contracted staff, provide updated trainings for EBPs, ensure licensed staff were trained and competent in the management and monitoring of central venous catheters (centrally inserted access to veins), and to provide oversight of the Restorative Nursing Program (RNP). These failures placed residents at risk for facility acquired or healthcare-associated infections, related complications, unmet care needs and a decreased quality of life. Findings included . <Infection Control> Review of the facility policy titled Enhanced Barrier Precautions, undated, described that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the governing body acted with disregard to the well-being of the residents of the facility by not ensuring adequate oversight and monitoring of appointed Administration and/or Directors of Nursing to ensure clinical systems were in place and followed and staffing levels were appropriate for the care required by the residents admitted to their facility. The governing body failed to ensure the facility was staffed sufficiently to meet the needs of the residents, so they received showers and other activities of daily living (ADLs) such as grooming and nailcare timely, that restorative programs were completed, and meals were delivered timely and accurately and that residents could access their personal funds. The governing body failed to ensure staff were adequately trained and had proper oversight for infection control practices, intravenous therapy and restorative nursing. The governing body's failure to provide oversight and support to ensure all policies 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 the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, when asked if they had reviewed the [NAME] report (a report with previously cited deficiencies) to identify any repeat deficiencies that needed to be addressed, Staff A, Administrator, said no, they had only been in the facility since January 13th 2025, so was unable to speak to last year's survey. Staff A said she had 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 operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when the facility failed to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions (used when someone has confirmed or suspected infections) related to lack of prompt isolation and use of precautions when several residents and staff had vomiting and diarrhea and a suspected gastrointestinal outbreak. The facility also failed to ensure the consitent hand hygiene, personal protective equipment (PPE) use and or cross contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one…

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

Based on interview and record review, the facility failed to address, respond to and/or resolve concerns and/or suggestions brought forward by the resident council (RC) for 3 of 3 months (October, November and December 2024) of RC minutes reviewed. These failures resulted in the same unresolved/unaddressed concerns being brought forward for consecutive months without resolution, and resulted in RC members feeling frustrated, unheard and powerless to affect the care they receive and/or their environment. Findings included . Review of the facility's Resident Council policy, dated 2024, showed the purpose of RC was to provide a forum for residents and families to have input in the operation of the facility; to discuss concerns and make suggestions for improvement; and consensus building and improving communication between residents and staff. The council was encouraged to elect a president to act as a liaison and facilitate communication between the RC and the designated staff person chosen by the RC. A Resident Council Response Form would be utilized to track issues and 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 ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 12 of 12 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE]. The quarterly minimum data set, an assessment tool, dated 01/08/2025 documented the resident was cognitively intact. On 01/23/2025 at 9:33 AM, Resident 4 said they could not withdraw money from their account on the weekends. On 01/28/2025 at 12:24 PM, Staff K, Business Office Manager said residents could not withdraw money from their accounts after hours or on the weekends until a couple of weeks ago. Now if a resident wants to withdraw money the nurse will contact the administrator, and she will come in and help the residents make a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 3 of 3 sampled residents (Residents 4, 32, and 5) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . Resident 4 was admitted to the facility on [DATE]. The quarterly minimum data set, an assessment tool, dated 01/08/2025 documented the resident was cognitively intact. On 01/23/2025 at 9:33 AM, Resident 4 said they did not receive statements from their personal funds account, and would like a statement every month. On 01/28/2025 at 12:24 PM, Staff K, Business Office Manager said they were not sure if the residents received their statements before they started working in October 2024, but they would be receiving them now. Staff K showed a printed pile of statements sitting on the desk and said they would be distributing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment for 4 of 4 Wings (A Wing, B Wing, C Wing and D Wing) observed. The failure to ensure doorways were free from gouges, blue decorative coverings over resident doors were secured to doors, light fixtures and resident medical equipment and shower rooms were clean and in good condition, left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . On 01/22/2025 at 10:14 AM and 01/30/2025 at 10:02 AM, room [ROOM NUMBER]'s overhead light was out. On 01/28/2025 at 12:18 PM, the overhead light in front of Nurses station had 10 dead bugs. room [ROOM NUMBER]'s door blue decorative covering was peeling off the door and there were multiple gouges ranging from 3 & ½ inch to and 1-inch gouges in the paint exposing wood beneath. On A Wing, the last overhead light at the emergency exit was broken and a section was missing out of the light covering. room [ROOM…

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

Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, timely addressed, and resolved in response to residents' verbal conveyance of concerns during Resident Council for 3 of 3 months (October, November and December 2024) of resident council minutes reviewed. The failure to identify the initiate, log, investigate and timely resolve reported complaints/concerns, and inform residents of the findings and actions taken to correct the issues, placed residents at risk of feelings of frustration, unimportance, diminished self-worth, and quality of life. Findings included . Review of the facility's Resident and Family Grievance policy, dated 2024, showed the Grievance Officer was responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining confidentiality; and issuing written grievance decisions to residents. A resident or family member could voice a grievances in the following forums: a) Verbal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to obtain assessments, orders, consent, and/or develop a care plan for the use of potential restraints for 4 of 5 residents (Resident 4, 1, 65, and 6) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy, titled, Proper Use of Bed Rails, undated, showed the facility was to assess the resident's risk from using bed rails, risk of entrapment, and risk of potential restraint. The policy listed alternatives that were to be attempted prior to installing or using bed rails. 1) Resident 4 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS-an assessment tool), dated 01/08/2025, documented the resident was cognitively intact. On 01/27/2025 at 7:29 AM, Resident 4 was sitting up in bed watching TV and their bed was against the wall. On 02/03/2025 at 2:21 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 provide a written transfer/discharge notice to the resident and/or their representative for 5 of 6 sampled resident (Residents 4, 11, 42, 57 & 58), failed to provide the Ombudsman notification for 6 of 6 sampled residents (Residents 3, 4, 11, 42, 57 & 58), and failed to update a resident representative for 1 of 6 sampled residents (Resident 11) reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . The facility policy titled, Transfer and Discharge, dated 2023, documented the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner in which they could understand. The notice would include all of the following at the time it is provided that facility would maintain evidence that the notice was sent to the Ombudsman.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 4 of 6 sampled residents (Resident 4, 11, 42 & 57) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . The facility policy, titled, Bed hold Notice Upon Transfer, dated 2023, documented, 1. Before a resident is transferred to the house or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies . 2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated in the State's plan . 5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1) Resident 4 was 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 record review and interview, the facility failed to ensure the Minimum Data Set Assessments (MDS) were complete and accurate for 9 of 23 sampled residents (Residents 27, 11, 12, 42, 1, 65, 16, 32 & 57). This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life. Findings included . Review of the October 2024 Resident Assessment Instrument (RAI, a manual that provides instruction on how to accurately code a MDS assessment) showed the following criteria must be met to code restorative services on the MDS: a) Measurable and objective interventions must be documented in the care plan. b) Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record, which should include reassessment of progress, goal, and duration/frequency of the program(s). c) Range of motion (ROM) exercise programs must be individualized to the resident's needs, planned, monitored, evaluated and documented in the resident's medical record. 1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to review and revise a comprehensive plan of care to include resident specific interventions for 7 of 23 sampled residents (Residents 65, 4, 6, 11, 27, 12 and 61) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . 1) Resident 65 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke) affecting left non-dominant side. The quarterly Minimum Data Set (MDS/an assessment tool), dated 12/30/2024, documented the resident was moderately cognitively impaired. On 01/27/2025 at 7:34 AM, Resident 65 was in bed and appeared asleep. The bed was observed against the wall and window. On 02/03/2025 at 2:23 PM, Resident 65 was sitting up in bed watching TV. Their bed was observed against 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 ensure care plans were consistently reviewed and revised to meet residents' current needs for 7 of 23 sampled residents (Residents 65, 27, 58, 51, 7, 18 & 32) reviewed for care plans. This failure to revise care plans placed residents at risk for unmet care needs. Findings included . 1) Resident 65 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction affecting left non-dominant side. The quarterly MDS dated [DATE] documented the resident was moderately cognitively impaired and was on a pain medication regimen and the resident reported they had not had pain or hurting in the last 5 days. A review of Resident 65's care plan listed a focused intervention initiated on 09/27/2024 that said they have a history of chronic sores in their mouth making it painful to chew their food and they have an oral suspension for pain control. On 01/30/2025 at 12:42 PM Staff B, Director of Nursing (DNS), said I don't see that Resident 65 is on an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4) Resident 55 had an order for lisinipril (blood pressure medication) daily, with direction to hold the medication for a systolic blood pressure (SBP) less than 100 or a pulse (P) less than 60. Review of the January 2025 MARs showed on the following dates facility nurses failed to hold the medication as ordered: - 01/13/2025- SBP 98; P 58 - 01/18/2025- P 58 A 01/09/2025 order for hydrochlorothiazide (hctz, a diuretic) daily, with direction to hold the medication for a SBP less than 100 or P less than 60. Review of the January 2025 MARs showed on the following dates facility nurses failed to hold the medication as ordered: - 01/09/2025- SBP 98; P 43 - 01/13/2025- SBP 97; P 58 - 01/18/2025- P 58 On 02/03/2025 at 2:18 PM, Staff C, Resident Care Manager (RCM), said on the above referenced occasions facility nurses administered the hctz and lisinipril outside of the physician ordered parameters, when the medications should have been held. 5) Resident 42 had a 01/05/2025 order for oxygen (O2) at two liters per minute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 of 8 residents (Residents 124, 32 and 27) reviewed for ADLs. The failure to assist dependent residents with oral care, shaving and meals, placed residents at risk for decreased nutritional intake, weight loss, poor hygiene, feelings of embarrassment, diminished self-worth and a decreased quality of life. Findings included . 1) Resident 124 admitted to the facility on [DATE]. An Admit/Readmit Assessment, dated 01/24/2025, documented the resident required extensive assistance with personal hygiene. During a meeting with the Resident Council on 01/30/2025 at 10:00 AM, Resident 124 stated, I have not had my teeth brushed since I got here [7 days]. They reported a toothbrush was requested from staff on multiple occasions but had not been provided. On 01/30/2025 at 11:46 AM, Resident 124 opened their drawers and showed that there was not a toothbrush or toothpaste present in 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 ensure bowel management interventions were implemented for 3 of 8 residents (Residents 32, 65 & 3) reviewed for quality of care. This failure placed residents at risk for discomfort, further complications, and a diminished quality of life. Findings included . The facilities bowel protocol policy, undated, had the following instructions: FOR PATIENTS WITH CONSTIPATION; 1. lf no bowel movement (BM) within 72hrs, may give MOM (Mild of Magnesia, a laxative) 30cc (cubic centimeter) po (by mouth). 2. lf no results after MOM 30cc, may give Miralax (a laxative) 17gm (grams) po qd (daily) prn (as needed) or . 3. May add Bisacodyl (a laxative) 5mg (milligrams) i to ii (1 to 2) tablets po qd or suppository, NTE (not to exceed) 30mg in a 24hr period 4. May add Fleets (bowel stimulant) enema prn if constipation persists. 1) Resident 32 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 1/8/2025, showed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide restorative services at the frequency residents were assessed to require for 5 of 6 sample residents (1, 42, 61, 69, and 32) reviewed with restorative nursing programs (RNPs). These failures placed residents at risk for decrease in Range of Motion (ROM/movement of a joint through the range of motion with no effort from the patient), increased dependance on staff for care needs and a diminished quality of life. Findings included . <Facility Policy> Review of the facilty's undated Restorative Nursing Documentation policy, showed the need for restorative nursing services would be documented in the medical record, and indicated on the resident's plan of care. Documentation would include: The problem, need, or strength that was being addressed. A measurable goal with target date. The specific interventions/treatments to be provided. The frequency and duration of interventions/treatments. Restorative aide documentation would include the treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Peripherally Inserted Central Catheters (PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart.), were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 55 & 12) reviewed for intravenous (IV) therapy. The failure to ensure IV orders included: the type and location of IV access, the method of delivery, the infusion rate and duration, monitoring of the insertion site, flush orders, changes of needleless injection caps, and initial and weekly external catheter measurements, placed residents at risk for loss of vascular access, infection, and other potential complications and negative outcomes. Findings included . <Facility Policy> Review of the facility's undated Care and Maintenance of Central Venous Catheter policy, showed nurses would: a) Document the indication for use, insertion date, and type 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 ensure freedom from unnecessary medications for 4 of 6 sampled residents (Resident 1, 32, 27, and 42) when reviewed for unnecessary medications. The failure to assess, monitor, and evaluate the need for medications ongoing use, and administration of medications without clinical indication resulted in residents receiving unnecessary medications and placed them at risk of experiencing avoidable adverse side affects to medications, and other potential negative health outcomes. Findings included . 1) Resident 1 was admitted to the facility on [DATE] with a cerebral infarction (stroke/a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting their right dominant side. The Quarterly Minimum Data Set, (MDS, an assesment tool) dated 01/02/2025, documented the resident was cognitively intact and they reported no pain or hurting at any time in the previous five days. A review of the electronic medical record (EHR) 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 that residents receiving psychotropic (used for treating mental health conditions) medications had specific target behaviors identified for there use, behavior and adverse side effect monitoring were in place, non-pharmacological (non-medication) interventions were identified and documented, informed consent was obtained prior to administering the medication, and resident specific care plans and interventions were developed and implemented for 4 of 5 sampled residents (Residents 12, 27, 3, & 40) reviewed for unnecessary medications. These failures detracted from staffs' ability to monitor the effectiveness and need for continued use of psychotropic medications and placed residents at risk of medication complications, unidentified adverse effects, unmet care needs, and a diminished quality of life. Findings included . 1) Resident 12 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), showed…

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

Based on observation, interview and record review, the facility failed to ensure the medication storage room and medication carts were free from expired medication for 1 of 1 medication rooms (A and B Medication Nursing Station Room) and 2 of 2 medication storage carts (C Wing Cart & B Wing Cart) reviewed for medication storage and labeling. The facility failed to ensure that medications of different routes were safely stored in medication carts, that medication was appropriately labeled, that medication was not stored with possible items of contamination, and that controlled substances were appropriately stored, recorded, and wasted in a timely manner. The facility also failed to ensure that medication was stored inside the medication carts or with nursing present, for 1 of 3 medication carts (A Wing Cart) reviewed. This failure placed residents at risk for receiving expired medications, taking unattended medication, cross contamination, and a diminished quality of life. Findings included . <A and B Medication Nursing Station Room> During an observation and interview on 01/24/2025…

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 observation, interview, and record review the facility failed to ensure residents who were prescribed therapeutic diets (as ordered by a physician or a dietician) received the correct foods/drinks that would fulfill the unique properties of each diet. This failure placed residents at risk for nutritional compromise and related negative health outcomes. On 01/28/2025 at 12:08 PM, staff began to plate the noon meal. The main meal consisted of roasted pork, cooked spinach, stuffing with apples, rolls, and pumpkin pie. Alternatives to the main meal were cold sandwiches, grilled cheese sandwiches, salads, and chicken noodle or tomato soup. Each plate was dished up the same way with the same food, unless the ticket said there was an allergy or a dislike. At 12:18 PM, a plate of food was placed on a tray with a ticket that said 'controlled carbohydrates.' Another plate of food was set on a tray with a ticket that said 'low calorie.' At 12:19 PM, Staff W, Cook, said the only therapeutic diet they served was Renal (for residents with kidney issues). They did not know what the 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 facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) included necessary wording of resident rights, and failed to explain to residents what a binding arbitration agreement was in a manner to allow them to understand, for 2 of 3 sampled residents (Residents 53 and 18) reviewed for binding arbitration agreements. This failure placed residents at risk for legal complications and a diminished quality of life. Findings included . The facility's blank Arbitration Agreement was reviewed on 01/27/2025 and found to be missing wording that: 1. The resident or their representative had the right to communicate with federal, state, or local officials such as federal or state surveyors, other federal or state health department employees and representative of the State Long Term Care Ombudsman 2. That a neutral arbitrator would be agreed upon by both parties 3. That the selection of a venue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP) and the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities. This failure detracted from the effectiveness of the QAA committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life. Findings included . On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff A reviewed the QAPI/QAA required attendees for the past year of QAPI/QAA meetings. QAPI meeting attendance sheet documented: May 24th, 2024: No IP in attendance. August 29th, 2024: No IP or Medical Director in attendance. September 11th, 2024: No IP or Medical Director in attendance. December 20th, 2024: No IP in attendance. Staff A, Administrator, said they had only been in the facility since January 13th, 2025, so was unable to speak to last year's QAPI/QAA attendees.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy for 1 of 3 sampled residents (Resident 1) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, diminished self-worth, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The quarterly minimum data set, an assessment tool, dated 01/2/2025 documented the resident was cognitively intact and needed substantial to maximal assistance with showers and bathing. On 01/23/2025 at 10:23 AM, Resident 1 was observed being transported down the hallway in a shower chair with blankets draped over their abdomen only, exposing their left side and buttocks. On 01/23/2025 at 10:45 AM, Staff X, Certified Nursing Assistant, was asked about transporting Resident 1 down the hallway after their shower and Staff X said she did not see their bottom exposed. On 01/30/2025 at 12:32 PM, Staff B, Director of Nursing said her expectation was that residents be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to offer and/or honor bathing choices for 3 of 8 residents (Residents 124, 42 and 51) reviewed for choices. The failure to promote and facilitate resident choice related to type and frequency of bathing, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life. Findings included . 1) Resident 124 admitted to the facility on [DATE]. In an interview on 02/05/2025 at 1:08 PM, the resident said staff had informed them that their shower days were Wednesdays and Saturdays, but reported staff didn't always show up. Resident 12 said they had only been provided one shower since admission. An activities of daily living (ADL) care plan, initiated 01/24/2025, documented Resident 124 required extensive assistance bathing, and would be showered on Wednesdays and Saturdays on evening shift. Review of the January and February 2025 bathing records showed there was no documentation to show the resident had been offered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the transfer of funds, from a resident trust account, was completed within 30 days following their discharge for 1 of 4 residents (Resident 177) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated. Findings included . A review of the electronic medical record showed Resident 177 deceased on [DATE] and a review of their account showed it contained a balance of $314.35. On [DATE] at 12:24 PM, Staff K, Business Office Manager confirmed Resident 177's account had not been closed within 30 days. On [DATE] at 12:43 PM, Staff A, Administrator said she was aware that Resident 177's account had not been closed and they had contacted the Department of Social and Health Services to close out the account properly. She said the expectation was that the accounts be closed within 30 days moving forward. Reference WAC 388-97-0340 .

Based on observation and interview, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 1 of 1 sampled resident (Resident 60) reviewed for privacy and confidentiality. These failures placed residents at risk for loss of confidential medical information and a diminished quality of life. Finding included . On 01/29/2025 at 2:03 PM, D Wing Medication cart had a laptop open and unsecured, displaying Resident 60's personal medical information. Seven feet away stood Staff L, Infection Preventionist, who was talking to contractor staff. Staff L then walked away a minute later. At 2:05 PM, Staff D, Resident Care Manager (RCM), walked past the open computer. At 2:07 PM, Staff M, Lead Restorative Nursing Assistant (RNA) walked past the open compute with a resident. At 2:08 PM, Staff N, Certified Nursing Assistant (CNA), walked past open computer. At 2:09 PM, Staff M, Lead RNA and Staff N, CNA walked by open computer. At 2:14 PM, Staff D, RCM, observed the open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation during transfer or discharge of the residents was complete with appropriate information provided to the receiving health care institution or provider, for 1 of 2 residents reviewed (Resident 11) for closed records. This failure placed residents at risk of unidentified and unmet medical needs, and a diminished qualify of life. Findings included . Resident 11 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety. Review of the Electronic Health Record (EHR) showed Resident 11 was transferred and discharged to the hospital on [DATE]. The EHR showed it was a facility initiated discharge, as the facility called the police to transfer Resident 11 to the hospital for inappropriate behaviors. Review of the EHR showed the facility was missing documentation. The facility did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for 2 of 7 sampled residents (Residents 11 & 12) reviewed for PASRR. This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life. Findings included . 1) Resident 11 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety. Review of the Electronic Health Record (EHR) showed Resident 11 had a Level II PASRR uploaded in their record, dated 03/03/2023, and a Level I PASRR, dated 05/02/2024. Resident 11's Level II PASRR was completed in 2023 and only addressed their diagnosis of PTSD. Resident 11's Level I PASRR, completed 05/02/2024 prior to their admission, only had PTSD selected. Resident 11's diagnosis list was updated on admission, 05/02/2024, with 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 2) Resident 61 admitted to the facility on [DATE]. Review of the 11/24/2024 Quarterly MDS showed the resident was cognitively intact, and identified that being around animals such as pets, keeping up on the news, and getting fresh air when the weather was nice were somewhat important to them, while listening to music they liked was Very important. On 01/22/2025 at 9:40 AM, 01/23/2025 at 10:19 AM, 01/27/2025 at 02/03/2025 at 9:57 AM and 10:26 AM, and 02/05/2025 at 10:57 AM, Resident 61 was observed lying in bed without their television on or music playing. An activity care plan, revised 11/12/2024, documented the following goals: will have opportunities to watch TV or listen to music and will socialize in a one-to-one setting with a volunteer/visitor/activity staff two to three times a week. The care plan did not address getting fresh air or being around animals. Review of the Kardex showed under Activities it was documented one to one visits with family, one to one visits with staff and watching television.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 1 resident (Resident 27) reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life. Findings included . Resident 61 admitted to the facility on [DATE]. Review of the 11/24/2024 Quarterly Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, and required substantial to maximal assistance with hygiene and lower body care. On 01/23/2025 at 9:40 AM, Resident 61's toenails were observed to long, yellow, thick and untrimmed. The second through fourth digits on the right foot and first, third and fifth digits on the left foot were starting to curve around the end of the resident's toes. At 10:35 AM, Resident 61 said that staff had not offered or provided toenail care since admission. The resident indicated they went to a podiatrist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to consistently implement fall prevention interventions for 1 of 3 residents (Resident 27) reviewed for falls. This failure placed residents at risk of falling, injury, and a diminished quality of life. Findings included . Resident 27 was admitted to the facility on [DATE] with diagnoses of dementia and anxiety. Review of the Quarterly Minimum Data Set Assessment, dated 01/11/2025, showed Resident 27 had severe cognitive impairment, was receiving psychotropic medication (used for treating mental health conditions, can increase risk of falls), required staff assistance for using the restroom, and had a history of falls. Review of the Electronic Health Record showed that Resident 27's most recent fall was on 10/11/2024, which resulted in a broken nose. Review of Resident 27's fall and nutrition care plans, listed interventions that included: -Fall mat to the right side of bed to prevent injury -Keep call-light and things of interest within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) without a documented justification for use, were assessed for catheter removal as soon as possible, that catheter tubing properly positioned and secured to prevent trauma, and urology referrals were made when ordered for 1 of 3 residents (Resident 42) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, decreased bladder tone, urethral erosion and a decreased quality of life. Findings included . Resident 42 admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had an indwelling urinary catheter but no diagnoses of neurogenic bladder, obstructive uropathy, urinary retention or kidney disease. An alteration in elimination related to indwelling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) Resident 42 admitted to the facility on [DATE]. Review of the 01/12/2025 Quarterly MDS showed the resident was cognitively intact, had a diagnosis of lung disease and required supplemental oxygen during the assessment period. Review of Resident 42's orders showed a 01/05/2025 order for O2 at 2 Liters/minute (how much oxygen flowed in per minute) via NC to maintain O2 saturation (SpO2) above 90%. On 01/22/2025 at 10:05 AM, Resident 42 was lying in bed receiving 02 at 1.5L/min via NC. The O2 tubing and humidifier bottle were undated, and the humidifier bottle was empty. On 01/23/2025 at 10:36 AM, Resident 42 was in bed receiving O2 via NC at 4L/min. The humidifier bottle and O2 tubing had been replaced and were dated 01/22/2025. 01/23/2025 at 11:40 AM, Staff L, Infection Preventionist, observed Resident 42 and confirmed they were receiving O2 via NC at 4L/min. Review of the January 2025 Medication Administration Record (MAR) showed the nurse signed that they administered Resident 42 O2 at 2L/min as ordered. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify, plan, and implement interventions for the individual needs of 1 of 2 residents (Resident 57) reviewed for dialysis. This failure placed residents at risk for unmet care needs, rehospitalizations, and further medical complications. Findings included . The facility's Dialysis Policy, undated, stated the following, Residents receiving hemodialysis have a Plan of Care (POC) specific to meet their needs, which is developed by [facility] in conjunction with the dialysis center providing hemodialysis. It said the facility was responsible for completing/sending; and receiving back, the Dialysis Transfer Form which contained information about vitals, weights, medications, psychosocial changes/needs, and labs. In addition, the policy said the facility would provide ongoing monitoring and as needed interventions for the dialysis access site. Resident 57 initially admitted to the facility on [DATE], was hospitalized on [DATE], and was readmitted 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 follow up on pharmacy recommendations for 1 of 5 sampled residents (Resident 65) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . Resident 65 was admitted to the facility on [DATE] with multiple diagnoses including diabetes (a chronic metabolic disorder characterized by high blood sugar levels). The Quarterly Minimum Data Set, an assessment tool, dated 12/30/2024, documented the resident was moderately cognitively impaired. A review of the monthly pharmacy review (MMR) for Resident 65, dated 11/30/2024, showed the physician agreed with the pharmacist's recommendation to discontinue the blood sugar checks four times a day. The physician ordered Resident 65's blood sugar to be checked weekly and an A1C (a blood test that measures the average blood sugar level over the previous 2-3 months) in three months. The MMR was signed by the physician on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of 5% or greater, with an error rate of 16% with errors observed for 2 of 7 sampled residents (Residents 69 and 1) reviewed for medication administration observation. This failure placed residents at risk for medical device complications, delay in medication, and a diminished quality of life. Findings included . Review of the facility policy, titled Medication Administration via Enteral Tube, undated, showed staff were to administer each medication separately, not combined, and not add to a formula feed. The feeding tube was to be flushed with 15 milliliters (ml) of water after each medication. For medications substituted with pill form, they should have been crushed and mixed with water. 1) Resident 69 was admitted to the facility on [DATE] and had a feeding tube (gastric tube, G-tube). Resident 69 had four medications to be given: 1. A liquid Multivitamin 15 ml via G-tube AM 2. A stool…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure that 2 of 10 sampled residents (Resident 12 & 51) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life. Findings included . 1) Resident 12 was admitted to the facility on [DATE]. On 01/23/2025 at 10:03AM, Resident 12 said they did not like the food, it often gets stuck going down. Resident 12 said they did not like milk or apple juice but continual get it on the meal tray. Resident 12's ordered diet was CCHO (Controlled Carbohydrate Diet), Regular texture, thin liquids. The electronic health records (EHR) documented Resident 12 disliked the following foods/beverages: Cottage cheese, milk, Acidic foods, apple juice, seafood, fish, wild rice, pickles, and onions. The EHR documented Resident 12 was lactose intolerant. On 01/31/2025 at 8:16 AM, Resident 12 was laying in bed, with breakfast meal tray…

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

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP) for three of three months (October 2024, November 2024 and December 2023) reviewed. This failure placed residents at risk for adverse outcomes associated with inappropriate and/or unnecessary use of antibiotics, including for Multi Drug Resistant Organisms (MDRO: germs that are resistant to many antibiotics), and a diminished quality of life. Findings included . On 02/05/2025 at 2:09 PM, when asked which residents should be included in the Antibiotic Line Listing (a list that tracks antibiotic use, patterns, or infection cases to track trends and identify inappropriate use of antibiotics) Staff L, Infection Preventionist, said any resident who was on antibiotics should be on the Antibiotic Line Listing. When Staff L was made aware that Resident 32, who had been taking antibiotics since 10/2023 but was not found on the 10/2024, 11/2024, or 12/2024 Antibiotic Line Listing, Staff L said she did not track indefinite antibiotics (antibiotics that are prescribed for…

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

Based on interview and record review, the facility failed to maintain documentation of staff COVID 19 (an infectious respiratory disease caused by a virus) vaccination status. This failure placed residents at risk of contracting COVID 19, medical complications and a decreased quality of life. Findings included . On 01/28/2025 at 9:16 AM, when asked if there was documentation of staffs COVID-19 vaccination status, Staff L, Infection Preventionist (IP) and Registered Nurse said it's was not a requirement, it was not part their hiring process and it was not being done. On 01/29/2025 at 2:07 PM, when clarifying that keeping documentation of staff COVID-19 vaccination was a requirement Staff L, IP, said, I was told that it was not a requirement, that it is not mandated. I was keeping a record when it was a mandated requirement. Staff L said, I don't yet have a staff list of vaccination status. No associated WAC .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to ensure staff followed the facility policy for safe use of dryers for 1 of 2 dryers (dryer 2) and the facility failed to provide the necessary monitoring and supervision for 3 of 4 residents (Resident 1, 3 and 4) with wandering behaviors reviewed for accidents, hazards, and supervision. These failures contributed to a fire in dryer 2 and Resident 1 eloping from the facility and placed resident at risk for injury and a diminished quality of care. Findings included . <Dryer Use> Review of the facility policy, titled laundry, dated 06/01/2024, showed laundry will be removed from washers and dryers promptly and will not be left in the machines overnight Review of counseling/disciplinary/termination notice for Laundry Attendant, Staff G, dated 10/07/2024 showed Staff G has been counseled on the lint traps not being clean out or documented that they'd been clean out and documented, you must clean out the lint traps every three hours and at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to ensure safe food preparation by documenting food temperatures for 1 of 1 kitchen. This failure placed residents at risk for food-borne illness. Findings included . Review of the facility policy, titled Record of Food Temperatures, undated, included the following: - Food temperatures will be checked on all items prepared in the dietary department - Hot foods will be held at 135 degrees Fahrenheit or greater - Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log On 11/27/2024 at 11:55 AM, Kitchen Staff, Staff F, was asked if they were responsible for taking food temperatures. Staff F said yes she completed food temperatures but doesn't write the temperatures down but can remember them and said temperature logs should be in the kitchen somewhere. At 12:05 PM, the Dietary Manager, Staff E, acknowledged during review of the food temperature logs that food temperatures drop after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate acquiring and receiving off all drugs and biologicals to meet the needs of 3 of 4 residents (Resident 3, 5 and 6) reviewed for medications and pharmacy services. Failure to ensure ordered medications were received from the pharmacy placed residents at risk for pain and decreased quality of life. Findings included . <Resident 3> Resident 3 was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage from impaired blood flow), osteoarthritis (bone inflammation) and pain. The admission Minimum Data Set (MDS/an assessment tool), dated [DATE], the resident was cognitively impaired and received scheduled pain medication, as needed pain medication for pain and antipsychotic medications (medications that treat psychosis symptoms such as delusions, hallucinations or paranoia). Resident 3's physicians order, dated [DATE], showed an order for oxycodone (narcotic pain medication to treat pain)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 4 residents (Resident 10) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life. Findings included . The facility policy titled, Notification of Changes, undated, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status .Competent individuals .The facility must still contact the resident's physician and notify resident's representative . Resident 10 was admitted to the facility on [DATE] with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 condom catheter care for 1 of 1 resident (Resident 6) reviewed for condom catheter care. Findings included . Resident 6 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Sepsis (life threatening response to infection) and diabetes. The resident had a history of a Penile Skin Graft and an Orchiectomy (surgical procedure where one or more testicles are removed). The admission Minimum Data Set (MDS), an assessment tool, dated 04/17/2024, showed the resident had no internal or external catheter or pressure ulcers. Review of the facility policy, titled Condom Catheter Care Policy, undated, showed it is the policy of this facility to ensure that condom catheters are applied appropriately, cared for and removed consistent with current standards of practice. Caring for these devices includes proper sizing and observation of the skin to ensure that signs of breakdown are 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 interview and record review the facility failed to ensure transfer discharge documentation was completed including physician's order and necessity for transfer for facility-initiated transfer/discharge for 1 of 3 sampled residents (Resident 1) reviewed for transfer/discharge. This failure placed residents at risk for un-met care needs and decreased quality of life. Findings included . Review of facility policy, undated, titled Transfer and Discharge (including AMA [Against Medical Advice], showed for non-emergency transfers or discharges initiated by the facility, they would document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and when the resident's needs could not be met in the facility, they would document the specific resident needs that could not be met and what attempts the facility made to meet the those needs. They would document any danger to the health or safety of the resident or other resident 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 observation, interview, and record review, the facility failed to ensure policies to promote smoking safety were established in accordance with state and local laws for 3 of 3 (Residents 1, 7 & 8) sampled residents reviewed for smoking. These failures placed residents, staff, and visitors at risk for ignition of combustible material. Findings included . Review of the facility policy titled, Non-Smoking/Tobacco and Marijuana Free Notice and Agreement, undated, showed smoking cigarettes, marijuana, and the use of any/all tobacco products as well as electronic cigarettes and vaping devices anywhere on the premises by residents was strictly prohibited. All residents admitted after 10/15/2021 were to smoke off facility premises under direct supervision of family, guardian, power of attorney (POA) or an individual acting as responsible party. All smoking materials were to be held outside by family, guardian, POA or the responsible party. <Resident 1> Resident 1 was 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 ensure an allegation of financial exploitation was reported timely for 1 of 4 residents (Resident 2) reviewed for abuse. This failure placed residents at risk for abuse, neglect and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and major depressive disorder. The admission Minimum Data Set (MDS), an assessment tool, dated 01/10/2024, showed the resident was cognitively impaired, did not exhibit behaviors, and was frequently incontinent of bladder and bowel during the look back/review period. Review of the facility accident and incident log, dated 1/3/2024 through 3/31/2024 showed no documentation of an unusual incident or event related to misappropriation of resident funds. Review of a Social Services progress note for Resident 2, dated 03/28/2024, showed Staff C, Social Services Director (SSD), submitted a report to a state agency related to a potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to develop and implement interventions to address dementia care needs for 1 of 3 residents (Resident 4) reviewed for dementia care. This failure placed residents at risk for diminished quality of life. Findings included . Review of the facility policy, titled Dementia Care, dated 2023, documented care and services will be person-centered .individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities .if needed, the environment will be modified to accommodate individual resident care needs . <Resident Information> <Resident 4> Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and anxiety disorder. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 02/13/2024, showed the resident was cognitively impaired, exhibited physical behaviors towards others during the look back/review period and exhibited wandering behaviors. <Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to promote and facilitate resident choices related to frequency of bathing for 3 of 7 residents (Residents 5, 64 & 37) reviewed for choices related to bathing. This failure placed residents at risk for feelings of un-cleanliness, powerlessness and diminished a quality of life. Findings included . 1) Resident 5 admitted to the facility on [DATE]. Review of the 12/26/2023 quarterly Minimum Data Set (MDS, an assessment tool) showed the resident was cognitively intact and choices related to bathing were very important. On 03/05/2024 at 10:31 AM, Resident 5 said they did not get to choose their bathing frequency and stated, [staff] assign you one shower per week. My doctor called and questioned them about bathing because I was having such itching problems only being bathed once per week. Now I am supposed to get two per week. Review of Resident 5's bathing flowsheet for February and March 2024 showed the resident was to be bathed twice weekly on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to provide a clean, comfortable and homelike environment in 1 of 1 dining rooms (Main Dining) review for homelike environment, 2 of 10 resident rooms (room [ROOM NUMBER] & 15) observed for cleanliness and 1 of 9 resident rooms observed for odors. This failure placed residents at risk of feeling unclean, undignified, and diminished self-worth and/or quality of life. Findings included . <Dining> Observation of the lunch meal in the main dining room on 03/04/2024, showed the dining room tables had no tablecloths or centerpieces. Staff served all 18 residents in the dining room their meals on cafeteria style trays, rather than placing residents' plates and beverages directly on the table. Similar observations were made on 03/06/2024 at 1:47 PM and on 03/08/2024 at 12:03 PM. On 03/08/2024 at 2:12 PM, Staff B, Director of Nursing, said it was the expectation that staff remove resident meals from the trays and place them directly on the tables in the dining room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 of 24 residents (Residents 56, 90, 292, 12 & 64) reviewed for Minimum Data Set (MDS), an assessment tool, were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . 1) Resident 56 admitted to the facility on [DATE]. The admission MDS, dated [DATE], the resident had a diagnosis of anxiety disorder and did not receive antipsychotic medications. Review of October 2023 Medication Administration Records (MARs) showed the resident received the antipsychotic medication, Abilify, as an added medication to treat depression. In an interview on 03/06/2024 at 1:50 PM, Staff B, Director of Nursing Services (DNS), confirmed the 10/10/2023 MDS did not, but should have reflected the use of an antipsychotic. According to the 01/14/2024 Quarterly MDS, the resident had no falls since admission/entry or reentry or the prior assessment. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the Care Plan (CP) for 5 of 6 residents (Residents 12, 11, 56, 5 & 47) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . 1) Resident 12 was admitted to the facility on [DATE]. According to a Level 1 PASRR, dated 09/11/2023, Resident 12 had a Serious Mental Illness (SMI) of schizophrenic disorder and Post Traumatic Stress Syndrome (PTSD). A second PASRR Level 1, dated 10/27/2023, showed facility staff identified the resident with mood disorder, anxiety disorders, and an Intellectual Disability and referred for a Level 2 evaluation. Record review on 03/08/2024 showed no indication a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide residents and/or their representatives with a summary of the baseline care plan for 3 of 3 residents (90, 66 & 292) reviewed for newly admitted residents. Failure to provide baseline care plans placed residents at risk to be uninformed of their healthcare goals, treatments, and services. Findings included . 1) Resident 90 admitted to the facility on [DATE] and according to the 02/13/2024 admission Minimum Data Set (MDS, an assessment tool) had multiple medically complex diagnoses including cancer, sepsis and malnutrition. In an interview on 03/05/2024 at 8:15 AM, the resident said he did not recall receiving a copy of the baseline care plan. Record review showed no indication the resident and/or representative received a written summary of the baseline care plan he/she was able to understand. 2) Resident 66 readmitted to the facility on [DATE] following a hospitalization. In an interview on 03/05/2024 at 10:03 AM, Resident 66 indicated they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to review and revise care plans for 6 of 24 residents (Residents 56, 12, 66, 21, 5 & 37) reviewed for care plans. The failure to review and revise care plans, by the interdisciplinary team, after each assessment, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 56 admitted to the facility on [DATE] with multiple medically and psychologically complex diagnoses. Care Plan (CP) documents showed Resident 12 had an Activities of Daily Living (ADL) Self-Care-Performance deficit related to anxiety. Resident 56's Pre-admission Screening Record Review (PASRR) Level 2, dated 12/18/2023, documented the resident had experienced both sexual and personal trauma. Review of the CP documents showed no indication of these issues. The 12/18/2023 PASRR Level 2 made recommendations for Resident 12 to have Mental Health (MH) Counseling and psychiatry medication management, which was not reflected in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 8 of 24 residents (Residents 84, 11, 56, 90, 79, 21, 5 & 8) reviewed. The failure of nursing staff to obtain, follow or clarify physicians' orders when indicated, and to document for only those tasks completed, placed residents at risk for medication errors, delayed treatment, and other adverse outcomes. Findings included . 1) Review of Resident 84's physician's orders showed orders for Cozaar and metoprolol (blood pressure medications) with instruction to hold the medication if the Systolic Blood Pressure (SBP) was less than 110. Review of the March 2024 Medication Administration Record (MAR) showed on 03/01/2024 and 03/06/2024 the SBP was less than 110, but nursing staff administered both the Cozaar and metoprolol instead of holding the medications as ordered. Observation of medication pass on 03/07/2024 at 8:01 AM, showed Staff I, Licensed Practical Nurse, administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 4 of 7 residents (Residents 21, 5, 37 & 47) reviewed for bowel management and 1 of 1 resident (Resident 5) reviewed for a fluid restriction. The failure to initiate bowel care in accordance with physician's orders and to accurately document, total, and assess fluid intake placed residents at risk for fluid volume overload, pain/discomfort, and other health complications. Findings included . <Bowel Management> Review of the facility's For Patients with Constipation policy, dated 11/05/2023, showed if a resident went 72 hours (3 days) without a bowel movement (BM), the nurse may administer the following: a) If 72 hours without a BM may administer Milk of Magnesia (MOM) 30 milliliters. b) If no results after MOM, may administer Miralax 17 grams. c) May administer bisacodyl one to two tabs or a suppository. d) May administer a Fleets enema if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate acquiring and receiving off all drugs and biologicals to meet the needs of 3 of 4 residents (Resident 292, 90 & 79) reviewed. Failure to ensure ordered medications were received from the pharmacy placed residents at risk for pain and nutritional deficit. Findings included . 1) Resident 292 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS), an assessment tool, the resident was cognitively intact, assessed with medically complex conditions and received as needed pain medication for pain that occasionally interfered with therapy and day to day activities. The resident rated their pain as a 5 on a scale of 1-10. Observation during medication pass on 03/05/2024 at 8:14 AM showed Resident 292 requested an as needed (PRN) narcotic pain medication. Resident 292 said he hadn't received the pain medication since 03/03/2024 and the Tylenol being administered in it's place was not effective.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 residents (Resident 11, 56, 21 & 34) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications related to the failure to: adequately monitor, ensure adequate indications for use, or identify non-pharmacological (non-drug) interventions for behaviors. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings included . 1) Resident 11 admitted to the facility on [DATE]. The resident's Medicare five day/ admission Minimum Data Set (MDS - an assessment tool), dated 01/20/2024, showed the resident had an anxiety disorder, but no depression. The associated Care Area Assessment (CAA) documented the resident received routine Zoloft (an antidepressant) for depression. Review of Resident 11's February and March 2024 Medication Administration Records (MARs) showed staff monitored for adverse side effects of the Zoloft but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 when 2 of 4 nurses (Staff E and G) failed to properly administer 4 of 30 medications for 3 of 9 sampled residents (Resident 69, 292 & 53) observed during medication pass resulting in a medication error rate of 13.3 percent. These failures placed residents at risk to not receive the therapeutic effects of medications prescribed by the physician. Findings included . 1) Observation of medication pass on 03/06/2024 at 12:06 PM showed Staff E, Registered Nurse (RN), prepare a Lispro insulin KwickPen (Diabetic Medication) for administration to Resident 69. Staff E failed to prime the insulin pen prior to dialing up the 4 units of insulin ordered for Resident 69. According to manufacturer directions, prior to insulin injections, the pen should be primed before each injection and directs, Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 insulin was dated when opened, drugs and biologicals were removed when expired, medications were stored at proper temperatures, and medication carts and rooms were secured, in accordance with currently accepted professional standards in 2 of 4 medication carts and 1 of 2 medication rooms reviewed. The facility failed to ensure medications were secured in locked storage for 2 of 2 sampled residents (Residents 90 and 56) observed with medications in their rooms. This placed residents at risk to receive expired medications and biologicals. Findings included . UNSECURED MEDICATIONS D wing Medication Cart Observations on 03/05/24 at 8:59 AM showed the D Wing Medication cart was observed unlocked. Staff [NAME] Licensed Practical Nurse(LPN) came out of room [ROOM NUMBER] grabbed something out of the cart and went back into room [ROOM NUMBER] leaving the D wing Medication Cart unlocked again. Unlocked A/B Hall Medication Room Observations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt dental services were provided for 3 of 5 residents (Residents 66, 5 & 21) reviewed for dental services. This failure placed residents at risk for difficulty chewing, pain discomfort due to unmet dental needs, and a diminished quality of life. Findings included . 1) Resident 66 admitted to the facility on [DATE]. According to the 01/18/2024 Quarterly Minimum Data Set (MDS), an assessment tool, and the 02/13/2024 Medicare 5 Day MDS Resident 66 was identified Resident 66 complained of difficulty or discomfort with chewing. In an interview on 03/05/2024 at 9:51 AM, Resident 66 stated he had problems chewing and needed dentures. Observation at this time showed the resident had tooth stubs/broken carious teeth on both the top and bottom gumline. In an interview on 03/07/2024 at 3:19 PM, Resident 66 stated he had difficulty chewing food secondary to his broken/missing teeth. He stated he wanted to see a dentist. Record review…

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

Based on interview, observation and record review, the facility failed to provide appetizing and palatable food to residents. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life. Findings included . RESIDENT INTERVIEWS 1. On 03/04/2024 at 11:50 AM, Resident 47 said the food was cold and did not taste good. 2. On 03/04/2024 at 12:10 PM, Resident 46 said the food was cold by the time it got to them and it was not savory like the instant potatoes. 3. On 03/04/2024 at 12:20 PM, Resident 90 said the food was cold and not good. 4. On 03/04/2024 at 1:31 PM, Resident 56 said the food didn't look good or taste appetizing, and was cold sometimes. Resident 56 also said it didn't look good and sometimes they couldn't tell what it was. 5. On 03/05/2024 at 9:59 AM, Resident 66 said the food was over cooked; they had fried eggs, but the egg was hard cooked. 6. On 03/05/2024 at 11:07 AM, Resident 64 said the food was cold when they got it. RESIDENT COUNCIL MINUTES November 2023 minutes documented, Room services food cold and milk warm.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff provided meal service according to the facility's posted meal service schedule for 2 of 2 (Lunch meals on 03/04/2024 and 03/06/2024) reviewed for meal service. These failures placed residents at risk for not receiving their meals as scheduled, medical complications and a diminished quality of life. Findings included . Facility posted mealtimes as followed: Breakfast: 7:30 AM-8:30 AM, Lunch: 11:30 AM-12:30 PM and Dinner 4:30 PM-5:30 PM On 03/04/2024 at 12:41 PM, B Wing staff started passing out meal trays, 11 minutes after the end of mealtime. At 12:46 PM, D Wing meal cart arrived on the hall, 16 minutes after the end of mealtime. On 03/06/2024 at 12:24 PM, Staff A, Administrator, came into the kitchen inquiring why lunch meal was behind schedule and then left the kitchen. At 12:37 PM, Staff A, returned to the kitchen, again inquiring about the meal being behind schedule. At 12:52 PM, kitchen staff started plating 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 ensure the kitchen followed proper safe food preparation/storage for 1 of 1 kitchen reviewed for food safety. The facility failed to discard rusted and dented dry food storage cans, identify expiration dates on dry food storage cans, maintain temperature logs for 3 of 3 refrigerators/freezers, and maintain walk in freezer in appropriate working conditions. These failures contributed to an unsanitary kitchen environment and placed residents at risk for food-borne illness. Findings included . <Food Storage> On 03/04/2024 at 9:19 AM, during Initial Kitchen tour observation, 4 6-pound cans of stewed tomatoes were observed to be covered in rust (on the top of the can). Two of 4 stewed tomatoes cans were observed with large dents on the top and side of the cans. None of the stewed tomatoes had expiration dates. At 9:36 AM, when asked about the expiration dates on the stewed tomatoes, Staff T, Cook, said the cans were in the box and the expiration date was on the box. Staff T said the cans were removed from the box.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infections control standards were followed related to use of required Personal Protective Equipment (PPE) with residents on Transmission Based Precautions (TBP), use of barriers and sanitization of glucometers, prevention of cross-contamination during administration of eye drops and handling of laundry to prevent spread of infection. These failures paced residents at risk of spreading and/or contracting infectious diseases. Findings included . LAUNDRY SERVICES On [DATE] at 1:43 PM, the door between the dirty laundry staging room (Room where contaminated linen is brought to be separated) and the main laundry area was propped open. Additionally, observation of the exhaust vent showed it was heavily soiled with brown stringy debris and was non-operational. On [DATE] at 1:48 PM, Staff Z, Environmental Services Director, said the door between the dirty laundry staging room and the main laundry area should remain closed except when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a manner that promoted resident dignity for 3 of 18 residents (Residents 11, 57 & 9) observed in the dining room. The facility also failed to respect and value residents' private space by knocking and/or announcing themselves prior to entering a resident's room for 4 of 9 rooms (Rooms 32, 33, 29 & 31) reviewed for dignity. These failures placed residents at risk for being treated with a lack of dignity and respect and a diminished quality of life. Findings included . <Dinning Observation> 1) Resident 57 admitted to the facility on [DATE]. Review of the 02/09/2024 quarterly Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment and a diagnoses including dementia. On 03/04/2024 at 11:27 AM, during lunch meal service, Staff V, Certified Nursing Assistant (CNA), danced up to Resident 57's wheelchair and stated, hey girl and continued to dance. An 'improving mental health and enhancing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address the required documentation for advanced directives (AD) for 1 of 2 residents (67) reviewed for AD. This failure placed residents at risk of losing their right to have their preferences/decisions regarding end-of-life care followed. Findings included . Resident 67 was admitted to the facility on [DATE] with diagnoses of diabetes, hypertension, lower extremity ulcers and congestive heart failure. The Quarterly Minimum Data Set, an assessment tool, dated 02/05/2024, indicated the resident had moderately impaired cognition. A review of Resident 67's electronic health records showed no documentation of an AD. A record review of Resident 67's care plan showed no documentation of an AD. A review of the Care Conference notes on 08/15/2023, said the resident did not want to fill out advance care directives at that time. On 03/07/2024 at 8:40 AM Staff D, Social Services Director, said they should have followed up again with Resident 67 and asked them…

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

Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) was completed as required for 1 of 3 residents (Resident 59) reviewed for Beneficiary Notification. This failure placed residents at risk of not being allowed to make informed choices about further treatment or services as required by the Medicare Program and of not being informed of their appeal rights prior to the end of Medicare covered services. Findings included . Review of Resident 59's SNF ABN, completed on 03/11/2024, showed, Question 1: Was an SNF ABN, form CMS-10055 provided to the resident? was left blank. This form did not show a check mark for any of the three available options. On 03/11/2024 at 2:48 PM, Staff A, Administrator (with Staff C, Chief Executive Officer, present for interview), said they could not find the SNF ABN for Resident 59…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate, log, promptly respond to and resolve grievances for 2 of 6 residents (Residents 21 & 46) reviewed for missing property. The failure to initiate, log, and promptly address resident grievances prevented staff from identifying care trends and ensuring resident concerns were timely and effectively addressed. This placed residents at risk of feelings of frustration, unimportance, decreased self-worth and quality of life. Findings included . Review of the facility's undated Resident and Family Grievances policy, showed the facility would make prompt efforts to resolve grievances. Staff members taking a grievance would record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form and forward it to the grievance official as soon as practicable. The grievance official would take steps to resolve the grievance, and record information about the grievance, and actions taken, on the grievance form. Prompt efforts included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 2 of 6 residents (Residents 66 & 56) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . According to the facility policy on Bed Hold Notice Upon Transfer (undated): 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. bathe reserve bed payment policy in the state plan policy, if any. cither facility policies regarding bed-hold periods 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 ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 2 of 6 residents (Residents 11 & 21) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . 1) Resident 11 was admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS, an assessment tool), dated 01/20/2024, the resident had multiple diagnoses which including anxiety disorder but no indication of depression. Resident 11's January Medication Administration Records (MARs), showed the resident was admitted to the facility with orders for the antidepressant, Zoloft, but with no associated diagnosis. A provider note, dated 01/30/2024, documented the resident was taking the Zoloft to treat depression. Review of the Electronic Health Record (EHR) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 2 of 6 residents (Residents 66 & 50) reviewed for ADL care for dependent residents. This failure to provide dependent residents with nail care and overall grooming placed them at risk for poor hygiene, embarrassment, and a diminished quality of life. Findings included . 1) Resident 66 admitted to the facility on [DATE] and according to the 02/13/2024 Medicare 5 Day Minimum Data Set (MDS), an assessment tool, Resident 66 was identified with diagnoses including acute respiratory failure, peripheral vascular disease, diabetes, and multiple chronic ulcers of the lower extremity. This MDS also indicated the resident had bilateral lower extremity range of motion impairment. On 03/04/2024 at 2:20 PM and 03/05/2024 at 10:03 AM, Resident 66 was observed with long, jagged fingernails with dark brown debris under the nails. In an interview on 03/05/2024 at 10:03 AM, Resident 66…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to follow pressure ulcer orders and prevention measures for 1 of 4 residents (Resident 50) reviewed for pressure injuries. This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life. Findings included . Resident 50 was admitted to the facility on [DATE]. The annual Minimum Data Set, an assessment tool, dated 02/15/2024, documented Resident 50 was cognitively intact. Resident 50 admitted to the facility with one Stage 4 pressure ulcer on their sacrum (tail bone) and three unstageable pressure ulcers located on left and right heels. A physician's order, dated 11/08/2023, documented: Wound Care: Sacral [triangular area at base of spine) wound Cleanse with wound cleanser Pack with 1/4 strength Dakins (diluted bleach water) soaked gauze Cover with sacral foam dressing Change daily and PRN every day and evening shift every Mon, Wed, Fri for wound care related to PRESSURE ULCER OF SACRAL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary foot care and treatment in accordance with professional standards, including provision of nail care for 2 of 6 residents (Resident 12 & 666) reviewed for nail care. This failure to provide timely foot/nail care, placed residents at risk for decreased quality of life and negative health outcomes. Findings included . 1) Resident 12 admitted to the facility on [DATE]. The 12/16/2023 Quarterly Minimum Data Set assessment (MDS), documented the resident had care needs related to high blood pressure, infection, and cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture). Care plan documents, dated 09/12/2023, showed Resident 12 had an Activities of Daily Living (ADL) /Mobility Self-Care Performance Deficit related to decreased activity tolerance and generalized weakness. Interventions included check nails every shift. Trim & clean PRN. Report any changes to the case manager.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision, thorough accident investigations to determine the circumstances of resident accidents and implementation of measures to prevent reoccurrence for 1 of 8 residents (Resident 56) reviewed for accidents. These failures placed residents at risk for avoidable accidents and injury. Findings included . Resident 56 admitted to the facility on [DATE] with multiple medically and psychologically complex diagnoses, including diabetes and depression. In an interview on 03/04/2024 at 1:39 PM , Resident 56 stated, I fell three times, that's why I have the walker, I got dizzy and fell. I have seizures . the walker is helpful. Care Plan (CP) documents, dated 01/09/2024, showed Resident 56 was identified as high risk for falls related to often refuses to wear proper foot wear .seizures, overactive bladder. Interventions included a four wheeled walker (FWW) for stability with ambulation, call light within reach, medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents (Resident 5) reviewed for respiratory care, were provided such care, in accordance with professional standards of practice. Failure of the facility to maintain and monitor oxygen equipment, obtain the prescribed pressure settings and care and maintenance orders for continuous positive airway pressure (CPAP/an external device that provides a fixed pressure to keep breathing airways open while you sleep) therapy, placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . According to the undated facility policy for Oxygen Administration: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for…

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

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage for at least 8 hours for 1 of 30 days reviewed for staffing. This failure placed residents at risk for unmet care needs. Findings included . A record review of the staffing pattern from 01/28/2024 through 03/03/2024 showed on 02/04/2024 there was no RN working during all 3 shifts. A record review of the daily staff posting showed there were no RNs working the day, evening, or night shift on 02/04/2024. On 03/11/2024 at 10:57 AM, Staff A, Administrator, said while looking at the staffing pattern there were no RNs working on 02/04/2024. At 11:37 AM Staff B, Director of Nursing Services, said while looking at the daily staff posting for 02/04/2024, it was a Sunday and there were no RNs working that day. WAC 388-97-1080(3)(a) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to fully inform in advance 1 of 1 sampled residents (Resident 2) reviewed for the use of a ankle wander guard alarm (sounds alarm when an at-risk wanderer approaches a monitored door ). This failure placed residents at risk for not knowing treatment risks, benefits, options, and alternatives. Findings included . Resident 2 was re-admitted to the facility on [DATE] with diagnoses including high blood pressure, pneumonia, and hip fracture. The Minimum Data Set, an assessment tool, dated 10/01/2023, showed Resident 2 had moderate cognitive impairment and no wandering behaviors. On 10/12/2023 at 3:00 PM, Resident 2 was observed resting in his bed with a wander guard attached to his left ankle. Review of resident 2's medical record on 10/12/2023 showed no consent documentation for the use of the wander guard. On 10/18/2023 at 2:30 PM, Staff A, Director of Nursing Services, said the facility obtained the consent after the concern was brought 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 ensure a safe discharge for 1 of 3 sampled residents (Resident 1) reviewed for discharges. This failure led to Resident 1 utilizing emergency services on the day of discharge, re-hospitalization and placed residents at risk for psychosocial distress and medical complications. Findings included . Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure, diabetes, and heart failure. The resident discharged from the nursing facility on 09/22/2023 to an Adult Family Home (AFH) in the community. On 10/18/2023 at 8:53 AM, a collateral contact (CC1), stated the resident arrived in the emergency room on the day of discharge from the nursing facility, 09/22/2023. CC 1 said the resident was discharged from the nursing facility to the AFH without oxygen services or medications. CC1 said hospital staff set up oxygen services, the AFH provider arranged medications, and the resident was discharged back to the AFH the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a person-centered care plan to address the use of a wander guard (sounds alarm when an at-risk wanderer approaches a monitored door) and potential elopement for 1 of 9 sampled residents (Resident 2) reviewed for care planning. This failure placed residents at risk of receiving inappropriate and inadequate care to meet their individualized safety needs. Findings included . Resident 2 was re-admitted to the facility on [DATE] with diagnoses including high blood pressure, pneumonia, and hip fracture. The Minimum Data Set, an assessment tool, dated 10/01/2023, showed Resident 2 had moderate cognitive impairment and no wandering behaviors. Resident 2's September 2023 nurse progress notes showed Resident 2 had elopement behaviors and wore a functioning wander guard alarm on his left ankle. The notes showed prior to Resident 2's re-admission he had made several attempts to leave the building and facility grounds. On 10/12/2023 at 3:00…

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