Lacey Post Acute & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented on 1 of 4 (Resident 2) residents reviewed for infection control. This failure placed the facility at risk of exposing staff and other residents to multidrug-resistant organisms (MDROs) and a diminished quality of life.Findings included.Review of the facility's Enhanced Barrier Precaution (EBP), policy, dated 03/28/2024 documented The purpose of this policy is to outline the guidelines for implementing Enhanced Barrier Precautions (EBP) in order to reduce the transmission of multidrug-resistant organisms (MDROs) within our facility. EBP will be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities.Resident 2 admitted to the facility on [DATE] for rehabilitation after hospitalization. The 5-day Minimum Data Set (MDS, an assessment tool) assessment, dated 09/26/2025, indicated Resident 2 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 observation, interview and record review, the facility failed to develop a comprehensive care plan for 3 of 4 sampled residents (44, 32, & 83) reviewed for smoking, position/mobility, and anticoagulants (often called a blood thinner, a medication that inhibits blood clotting). This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Smoking> Resident 44 was admitted to the facility on [DATE] with multiple diagnoses to include Chronic Obstructive Pulmonary Disease (COPD, a lung disease blocking the airflow, making it difficult to breathe). The Quarterly Minimum Data Set (MDS) assessment, dated 04/09/2025, documented Resident 44 was alert and oriented. Facility policy, entitled Smoking Prohibited, dated 10/01/2021, documented: Evaluation of resident for ability to safely smoke without staff assistance / supervision in a location out of the facility and off the facility grounds. Evaluation will be maintained in the resident's record and the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 220 was admitted to the facility on [DATE]. The admission note, dated 05/22/2025 at 3:08 PM, showed Resident 220 was alert and oriented. Resident 220's admission care plan dated 05/29/2025 documented: SKIN IMPAIRMENT UPON ADMISSION/readmission - The resident has an area of impaired skin integrity. Left hip abrasion Left vascular wound to toes Left lower extremity vascular wound Left heel diabetic foot ulcer (DFU) stage 3 Right heel DFU unstageable Left lateral DFU unstageable. Resident 220's physician orders, dated 05/29/205, documented: Left hip abrasion clean with normal saline, pat dry, apply medihoney [wound treatment], and skin prep [skin protectant]. Cover with foam dressing. Change every other day until resolved. On 06/03/2025 at 11:43 AM, Resident 220 was observed sitting in his wheelchair with therapeutic cushion in place. He had bandages with kerlix wraps (gauze wrapping) covering both lower extremities. He informed me he was admitted with wounds to his heels. He said he also had a wound 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 residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 1 of 5 sampled residents (56) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life. Findings included . Resident 56 was admitted to the facility on [DATE]. The Annual Minimum Data Set assessment, dated 04/25/2025, documented Resident 56 was severely cognitively impaired, had multiple diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression (a mood disorder characterized by persistent sadness and loss of interest) and was taking an antipsychotic (a class of psychotropic medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident funds were conveyed to the resident's representative and/or to the state office of financial recovery (OFR) within 30 days of death or discharge for 1 of 1 discharged resident (311) reviewed for Trust Funds. This failure placed residents and/or their representatives at risk for delayed reconciliation of resident trust funds. Findings included . Review of Resident 311's Discharge Minimum Data Set assessment, dated 11/06/2024, showed resident 311 was discharged on 11/06/2024 with return anticipated. Resident 311's trust account statement showed Resident 311 had a balance of $1032.42 after a credit of $.45 on 01/02/2025, 57 days after discharge. Resident 311's trust account statement showed Resident 311 had a balance of $1135.62 after a credit of $103.20 on 01/08/2025, 63 days after discharge. Resident 311's trust account statement showed Resident 311 had a balance of $1135.97 after a credit of $.35 on 01/23/2025, 78 days after discharge. Resident 311's trust account statement showed, on 01/23/2025, 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 obtain and/or maintain Advance Directives (AD) for 1 of 7 sampled residents (83) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 83 was admitted to the facility on [DATE], discharged with return anticipated on 04/16/2025, and re-admitted on [DATE]. The Quarterly Minimum Data Set assessment, dated 03/20/2025, documented Resident 83 was alert and oriented. The Social Service Initial Evaluation, dated 12/16/2024, showed in Section A.18., Resident 83 had a Health Care durable power of attorney (DPOA). A progress note, dated 01/15/2025, showed DPOA paperwork was supposed to be brought to the facility on [DATE]. The Social Services Quarterly Note, dated 03/06/2025, documented in section I. Advanced Directives, No change in status. Review of Resident 83's care plan did not document a Focus area addressing an AD. Review of Resident 83's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to obtain an evaluation assessment, consent, and/or physician's order for 2 of 2 sampled residents (56 & 86) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy entitled, Bed Rail Risk and Safety, revised 10/19/2022, documented: .Assess the Resident 1. Any resident being considered for using a bed with bed rail(s) is evaluated by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of bed rail(s), to identify any bed rail that might constitute physical restraint, and to identify individual characteristics that may increase the risk of entrapment by bed rails or mattress . 3. If the resident's evaluation identifies him or her as appropriate for the use of bed rail(s), the following procedures will be followed: a. Educate 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 the Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected mental health diagnoses for 2 of 6 sampled residents (409 & 410) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings Included . Review of facility policy, entitled Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy, documented, 1) Prior to an individual's admission, The Social Worker, Admissions Coordinator, or designee will review the completed screening forms via e-PAS and obtain a copy for placement in the electronic medical record . 1) Resident 409 was admitted to the facility on [DATE] with diagnoses including depression and anxiety. The admission Minimum Data Set (MDS) assessment, dated 05/30/2025, documented Resident 409 was alert and oriented. Record review of Resident 409's Level 1 PASRR, dated 05/26/2025, did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation, and record review, the facility failed to document completion and/or refusal of weights for 1 of 3 residents (223) reviewed for nutrition. This failure placed residents at risk for unplanned weight loss and decreased quality of life. Findings included . Resident 223 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 04/13/2025, showed Resident 223 was alert and oriented. Review of Resident 223's care plan showed no potential problems or goals related to nutrition or hydration were developed. Resident 223's electronic health record (EHR) showed the following weights: On 04/04/2025 admission weight showed 113.4 pounds On 04/06/2025 weight showed 111.0 pounds On 05/13/2025 weight showed 105.8 pounds On 06/05/2025 weight showed 104.6 pounds On 06/06/2025 at 9:14 AM, Staff H, Certified Nursing Assistant, said when residents were admitted they were weighed every day for four days, and then every week unless otherwise directed. Weights were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure drugs, biologicals, and medical equipment were dated upon opening and discarded once expired for one of two medications rooms (2nd floor) and one of two treatment carts (1st floor) reviewed for medication and equipment storage. This failure placed the residents at risk for receiving compromised or ineffective medication and receiving treatment with outdated equipment. Findings included . <Medication Storage room [ROOM NUMBER]nd Floor> On [DATE] at 10:35 AM, a concurrent observation with Staff C, Unit Manager and Licensed Practical Nurse, showed as follows: 1. Medication Storage Room Refrigerator: One Vial of Tuberculin Purified Protein Derivative PPD (a solution used to test for tuberculosis) was observed opened with no date for when it was opened for use, and no date for when it should be disposed of. Two boxes of Bisacodyl Suppositories (rectal suppositories used to relieve constipation) with expiration date of [DATE]. 2. Medication Storage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 training was provided to family resulting in an unsafe discharge for 1 of 3 sample residents (1) reviewed for discharge process. This failure placed residents at risk for an unsafe discharge into the community and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitative services. The 5-day Minimum Data Set Assessment, dated 02/29/2025, indicated that Resident 1 was cognitively intact and required moderate assistance from staff for transfers. Review of the hospital Physical Therapy (PT) note, dated 02/22/2025, indicated that Resident 1 was independent with all mobility using a 4 wheeled walker prior to hospitalization. On 04/29/2025 at 12:15 PM, Staff D, Social Services Director, said that the last covered day for stay depends on insurance. Staff D said that the insurance case manager decides when the resident no longer qualifies for therapy services. Staff D was unable 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 interviews and record review, the facility failed to ensure that advance directives were implemented on admission for 1 of 7 (1) residents reviewed for advance directives. This failure placed residents at risk for not having advanced directives honored and a diminished quality of life. Findings included . Corporate entity policy/document titled, Advance Directives, dated [DATE], showed, upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. In addition, facility staff will verify the residents' wishes with regard to urgent or emergency care, including the use of cardiopulmonary resuscitation (CPR). Washington State requires the facility to use CPR with nursing home residents unless the resident's guidelines state 'No CPR. Resident 1 admitted to the facility on [DATE] for rehab services. The 5-day Minimum data set assessment, dated [DATE], 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 interviews and record reviews, the facility failed to establish a wound plan of care for 1 of 4 sampled residents (Resident 1) reviewed for comprehensive care plans. This failure placed residents at risk of unmet care needs and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set assessment, dated 12/30/2024, documented the resident was moderately cognitively impaired and had a Stage II pressure ulcer (an open wound on the skin caused by prolonged pressure to a specific area of the body) upon admission. An admission note, dated 12/28/2024, documented, New admission from [local hospital] . Stage 2 pressure injury to sacrum [lower back above the buttocks] . Resident resting in bed. Resident 1's comprehensive care plan, dated 12/28/2024, did not have documentation of wound plan of care for the resident's pressure ulcer. On 01/13/2025 at 2:57 PM, Staff C, Assistant Director of Nursing Services and Registered Nurse (RN), said Resident 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 interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) for 1 of 11 sampled residents (157) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 157 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 08/15/2024, documented Resident 157 was alert and oriented. Record review of Resident 157's Social Service Initial Evaluation, dated 08/12/2024, documented, 18a .POA [Power of Attorney] is [Proper Name]. Record review of Resident 157's Multidisciplinary Care Conference, dated 08/12/2024, documented, K.1 . Son is POA. Record review of Resident 157's Electronic Health Record (EHR) did not show AD paperwork documentation, or that AD documents were requested. On 08/22/2024 at 2:01 PM, Staff C, Director of Social Services, said when a resident was admitted , if they had an AD or Power of Attorney,…

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

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 1 of 3 sampled residents (42) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk for not having adequate information to make financial decisions related to the residents' stay in the facility. Findings included . The Notice of Medicare Non-Coverage, dated 04/10/2024, documented Resident 42's representative was contacted on 04/09/2024 and informed Resident 42's services were ending on 04/11/2024. The SNF ABN was not provided to inform the representative of the potential financial liability. On 08/23/2024 at 11:25 AM, Staff N, Business Office Manager, said the SNF ABN for Resident 42 was not completed. At 11:40 AM, Staff C, Social Services Director, said she had a conversation with Staff N and she was not sure who was supposed to cover the SNF ABN with residents or their representatives. Staff C said Resident 42 should have had the SNF ABN because he remained in the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 1 of 1 sampled resident (105) reviewed for bed hold notification. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 105 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 06/14/2024, documented Resident 105 was moderately cognitively impaired. The Electronic Health Record (EHR) showed Resident 105 was hospitalized on [DATE]. The EHR did not show documentation of a written Bed-Hold notice, nor that contact was made to the resident or resident's representative regarding a Bed-Hold. On 08/22/2024 at 10:06 AM, Staff E, Admissions Liaison, said when a resident was transferred to the hospital, admissions contacted the resident or the resident representative and offered a bed-hold. Staff E said she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's condition at the time of assessment for 1 of 27 sampled residents (75) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs. Findings included . Resident 75 was admitted to the facility on [DATE] with diagnoses including history of strokes (when the brain's blood supply is cut off, which can damage or kill brain tissue). The MDS, dated [DATE], documented the resident was alert and oriented and was able to make care needs known. The MDS did not reflect the resident's visual deficit. On 08/08/09/2024 at 2:47 PM, Resident 75 stated, Strokes have taken a big chunk of my vision. It is very difficult for me to see. It is difficult to read the activity calendar and get into the bathroom. Resident 75 said she needed assistance with most Activities of Daily Living (ADLs) related to her poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview and record review, the facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II for 1 of 7 sampled residents (14) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health services and a diminished quality of life. Findings included . Resident 14 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (chronic, long-term brain disorder that affects the nervous system and causes involuntary movements) and Depression. The quarterly Minimum Data Set (MDS) assessment, dated 08/07/2024, indicated Resident 14 experienced hallucinate and experience delusions, and was severely cognitively impaired. The PASARR, dated 06/25/2024, indicated Level II services were appropriate for new behaviors of a psychotic disorder. The Notice of Determination, dated 07/16/2024, documented Resident 14 had been identified as having a mental health condition that required specialized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and Resident Review (PASARR) assessment was completed correctly for 2 of 9 sampled residents (38 & 100) reviewed for PASARR. This failure placed residents at risk for not receiving the necessary mental health services and a diminished quality of life. Findings included . 1) Resident 38 was admitted to the facility on [DATE] with diagnoses including depression. The admissions Minimum Data Set (MDS) assessment, dated 07/22/2024, indicated Resident 38 was alert and oriented. The PASARR, dated 07/12/2024, indicated Resident 38 had a Mood Disorder. The recommendation was No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. On 08/21/2024 at 2:20 PM, Staff A, Administrator, said they should review the PASARR for accuracy for new admits. Staff A said she did not understand the exemption issue and would reach out to the PASARR. At 3:17 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 observation, interview, and record review, the facility failed to ensure a care plan was updated to reflect changing needs for 1 of 27 sampled residents (67) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of care. Findings included . Resident 67 was admitted to the facility on [DATE] with diagnoses including falls with a fracture of one rib right side, fracture of T5-T6 vertebra, Dysphagia (difficulty swallowing), Aphasia (a language disorder that affects a person's ability to communicate, caused by damage to the parts of the brain that control language) and Dementia. The 5- day Minimum Data Set (MDS) assessment, dated 08/07/2024, documented Resident 76 was moderately cognitively impaired and required moderate assistance with toileting. The MDS showed the resident was at risk of injury from falls due to new admission and deconditioning with resulting lack of balance and endurance; and Resident 67 had an indwelling foley catheter (a thin,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 toilet assistance was provided consistently, in accordance with the resident's preferences and current abilities for 1 of 6 sampled residents (67) reviewed for activities of daily living (ADLs) for dependent residents. This failure placed residents at risk for embarrassment, poor hygiene, potential falls, and a diminished quality of life. Findings included . Resident 67 was admitted to the facility on [DATE] with diagnoses including falls and Aphasia (a language disorder that affects a person's ability to communicate, caused by damage to the parts of the brain that control language). The 5-Day Minimum Data Set (MDS)assessment, dated 08/07/2024, documented Resident 67 had moderate cognitive impairment, was able to make care needs known and required moderate assistance with toileting. The MDS documented Resident 67 was at risk of injury from falls due to new admission and deconditioning with resulting lack of balance and endurance;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services were provided to maintain residents' abilities in range of motion and activities of daily living, and provide preventative range of motion (ROM) services for 4 of 5 sampled residents (64, 82,15 & 67) reviewed ROM services. This failure placed residents at risk for an avoidable decline and diminished quality of life. Findings included . 1) Resident 64 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, unspecified affecting left non-dominant side (Partial paralysis on one side of the body). The quarterly Minimum Data Set (MDS) assessment, dated 07/31/2024, showed Resident 64 was severely cognitively impaired, and no restorative therapy services were completed. The care plan, dated 01/06/2024, indicated resident required extensive assistance x2 for bed mobility, and repositioning. No restorative services was noted in the care plan. On 08/20/2024 at 10:00 AM, Resident 64 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 administered Tuberculin (TB) Solution to a resident allergic to the TB solution for 1 of 5 sampled residents (100) reviewed for Tuberculin testing. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . Resident 100 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set assessment, dated 08/08/2024, indicated Resident 100 was severely cognitively impaired. The local hospital H&P (history & physical) Note, dated 07/26/2024, indicated Resident 100 had an allergy to Tuberculin. A progress note, dated 08/03/2024 at 7:19 PM, documented, chest x-ray done r/t (related to) unable to take the TB solution, results came back negative . The August 2024 Medication Administration Record (MAR) documented Resident 100 was administered the first step Tuberculin on 08/08/2024. The MAR documented Resident 100 was administered the second step on 08/16/2024. On 08/22/2024 at 2:54 PM, Staff O, Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, the facility failed to ensure medication was secured in 1 of 4 medication carts (100 hall medication cart) reviewed for medication administration. This failure placed resident at risk for medications being accessible to unauthorized staff and residents. Findings included . On 08/22/2024 at 9:08 AM, Staff K, Licensed Practical Nurse, was observed standing near the 100 hall medication cart. When asked if they were available to be observed for medication administration, Staff K said they had completed their morning medication pass. Staff K went into room [ROOM NUMBER] and was speaking to the resident in bed one. A medication cup with clear yellow liquid was observed on the 100 medication cart when Staff K walked away. At 9:12 AM, Staff K came out of room [ROOM NUMBER] and proceeded to answer the call light in room [ROOM NUMBER]. She returned to the medication cart and then walked back into room [ROOM NUMBER]. At 9:14 AM, Staff K walked back to the medication cart and discarded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, the facility failed to ensure patient care equipment was maintained in safe operating condition for 1 of 1 suction machines (2nd Floor Crash Cart Suction Machine) reviewed for equipment in safe operating condition. This failure placed residents at risk for not having their care needs met. Findings included . On 08/20/2024 at 12:18 PM, while reviewing the 2nd Floor crash cart, Staff L, Licensed Practical Nurse, said the crash cart was checked every night shift. Staff L was asked to turn on the suction machine on the crash cart. When the suction machine was turned on, the suction machine had no suction to it. When asked what the sign off forms on the cart were for, Staff L said they were not sure what the staff were checking, and the crash cart was checked by the night shift nurse every evening. At 12:24 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said staff checked the crash cart every night. At 3:20 PM, Staff M, RN, said the suction machine on the crash cart was used to clear a resident's airway in the event they 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 consents for wanderguards, a device used for residents at-risk of elopement, were in place for 2 of 3 sampled residents (Residents 1 & 2) reviewed for informed consents regarding wanderguards. This failure placed residents and resident representatives at risk of inadequate knowledge of wanderguard use, decreased freedom of movement, and a decreased quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 03/13/2024, documented the resident was cognitively intact and did not exhibit wandering behavior during the lookback period. A physician's order, dated 03/15/2024 and discontinued 03/19/2024, documented, Check placement of wander bracelet every shift. A review of Resident 1's electronic medical record (EMR) did not show an informed consent was completed for the wanderguard. On 04/08/2024 at 2:44 PM, Resident 1 said after her hospital stay she would walk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wanderguard, a device used for residents at-risk of elopement, assessments were completed and in place for 3 of 3 sampled residents (Residents 1, 2 & 3) reviewed for accident hazards related to wanderguards. This failure placed residents at risk of improper wanderguard use, decreased freedom of movement, and a decreased quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 03/13/2024, documented the resident was cognitively intact and did not exhibit wandering behavior during the lookback period. A physician's order, dated 03/15/2024 and discontinued 03/19/2024, documented, Check placement of wander bracelet every shift. A resident safety evaluation, dated 03/07/2024, documented, Not at risk for elopement at this time. No other safety evaluations were found in Resident 1's EMR (Electronic Medical Record). On 04/08/2024 at 2:44 PM, Resident 1 said 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 interview and record review, the facility failed to ensure residents and/or resident representatives were able to give an informed consent before psychotropic medications (mind altering) administration for 2 of 5 sampled residents (34 & 79) reviewed for right to be informed and make decisions about treatment. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . 1) Resident 34 was admitted to the facility on [DATE] with diagnoses including depression (persistent feeling of sadness and loss of interest). The 5-Day/admission Minimum Data Set (MDS), an assessment tool, dated 08/21/2023, documented Resident 34 was severely cognitively impaired. A physician's order, dated 08/16/2023, documented Resident 34 was prescribed Citalopram (an antidepressant). Resident 34's Electronic Medical Record (EMR) did not show documentation of an informed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dependent residents were provided scheduled bathing/showering opportunities for 1 of 3 sampled residents (Resident 34) reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . Resident 34 was admitted to the facility on [DATE]. The 5-Day/admission Minimum Data Set, an assessment tool, dated 08/21/2023, documented Resident 34 was severely cognitively impaired, required extensive assistance with ADLs, and Wednesdays and Saturdays were the resident's scheduled bathing/shower days during dayshift. Resident 34's bathing/showering record, dated 08/06/2023 to 09/06/2023, documented no bathing activity was documented from 08/19/2023 until 09/03/2023, for 16 days. Resident 34's Shower record, dated 08/06/2023 to 09/06/2023, documented no bathing activity was documented from 08/19/2023 until 09/02/2023, for 15 days. On 09/07/2023 at 3:11 PM, Staff K, Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview, and record review, the facility failed to ensure compression socks were applied per physician orders and failed to obtain resident weights per physician orders for 2 of 5 sampled residents (82 & 33) reviewed for quality of care related to following physician orders. This failure placed residents at risk of poor circulation, weight loss, unmet care needs and a decreased quality of life. Findings included . 1) Resident 33 was re-admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 08/21/2023, documented the resident was moderately cognitively impaired. A physician order, dated 08/25/2023, documented, Weight MWF [Monday, Wednesday, Friday] every day shift every Mon, Wed, Fri for monitoring. Resident 33's electronic medical record, dated 08/25/2023 to 09/06/2023, documented two weights were obtained out of five opportunities. No weights were documented after 08/30/2023. A progress note, dated 09/06/2023, documented, Pt [patient] left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weight loss for 1 of 4 sampled residents (Resident 34) reviewed for nutrition. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life. Findings included . Resident 34 was admitted to the facility on [DATE] with diagnoses including a femur (long bone of leg) fracture and dysphagia (swallowing difficulties). The 5-Day/admission Minimum Data Set, an assessment tool, dated 08/21/2023, documented Resident 34 was severely cognitively impaired, required extensive assistance with activities of daily living including eating, was not on a documented weight loss program and was not on a diuretic medication during the review period. A Medical Nutrition Therapy Follow-Up Note, dated 08/14/2023, documented Resident 34 weighed 141.5 lbs upon discharge from the hospital. A Registered Nurse and Medical Doctor Note, dated 08/14/2023, documented upon discharge Resident 34 weighed 144.2 lbs. on 08/14/2023.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and target behaviors for 1 of 5 sampled residents (Resident 34) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 34 was admitted to the facility on [DATE] with diagnoses including depression (persistent feeling of sadness and loss of interest). The 5-Day/admission Minimum Data Set, an assessment tool, dated 08/21/2023, documented Resident 34 was severely cognitively impaired. A Physician's order, dated 08/16/2023, documented Resident 34 was prescribed Citalopram (an antidepressant). Resident 34's Depression Care Plan, revised 08/25/2023, documented the intervention to administer medications as ordered. Monitor/document for side effects and…

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

Based on observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 1 of 2 sampled medication rooms (1st floor) reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications with unknown potency. Findings included . On 09/07/2023 at 6:05 PM, the medication rooms on the first floor were observed. In the IV (intravenous) medication room, there was a fridge used to store medications including vaccines. The Refrigerator/Freezer Temperature Log was reviewed and showed the following: --The July 2023 Log showed the refrigerator temperature was not documented 22 of 31 AM (morning) checks. --The August 2023 Log showed the refrigerator temperature was not documented 18 of 31 AM checks. --The September 2023 Log showed the refrigerator temperature was not documented 4 of 7 AM checks. On 09/07/2023 at 6:18 PM, Staff A, Administrator, said fridge temperatures should be obtained twice a day if vaccines were stored in the refrigerator. After reviewing 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.