Alderwood Post Acute & Rehabilitation

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices. Findings included . Review of the facility policy titled, Infection Prevention and Control Committee, undated the Infection Preventionist will oversee the Infection Prevention and Control Program and report to the Infection Prevention and Control Committee and/or Quality Assurance and Performance Improvement (QAPI) committee. The Administrator will be responsible for oversight of the Infection Prevention and Control Program. In an interview on 08/13/2025 at 9:30 AM, during entrance conference with Staff A, Administrator, they stated the facilities designated IP was Staff D, Licensed Practical Nurse (LPN)/IP. Staff A stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the facility environment was maintained in a clean, comfortable, homelike and safe environment, for one of two floors (2nd floor), 1 of 1 resident reviewed for missing property (Resident 26), and 2 of 2 residents reviewed for noise complaints (Residents 4 and 102). Failure to ensure the facility maintained comfortable noise levels, ensured security of resident property, maintained flooring and controlled odors placed residents at risk for a decreased quality of life.Findings included .<ODOR> In an observation on 08/12/2025 at 9:23 AM, there was a strong unpleasant odor in the hall for room's 228 to 239. Observation of an area of one-foot by one foot round dark color-stained spot on the carpet in the middle of the hallway. In an observation on 08/13/2025 at 11:36 AM, smelled odor which resembled the odor of mildewed clothes after being left in the washer in the hall for room 's 228 to 239. In an observation on 08/14/2025 at 11:39 AM, smelled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed holds and provide a written transfer notice upon transfer to the hospital and notify the Office of the State Long Term Care Ombudsman (LTCO) for 5 of 5 residents (10, 12, 82, 108 & 109) who were reviewed for hospitalization. Failure to offer bed holds placed 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 . Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for lack of advocacy, not having an opportunity to make informed decisions about their transfer/discharge rights and possible unidentified or unmet care needs.Findings included .According to the facility's Bed Hold policy, undated, prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 6 residents (Residents 3, 4, 33 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included .Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed the RAI consisted of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions 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.

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 - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 5 sampled residents (1,11, 22, 81, and 98) reviewed for PASRR. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included . Review of a facility policy titled Long-Term Services and Supports (LTSS), Preadmission Screening and Resident Review (PASRR) Policy, undated, showed the organization observed preadmission screening requirements to ensure that :Medicaid-eligible individuals meet required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 101) for dialysis management, 1 of 4 resident (Resident 26) for pain management, 1 of 3 resident (Resident 4) for mobility, 2 of 6 resident (Residents 1 and 22) for mood and behaviors, and 3 of 6 residents (Residents 3, 22, and 81) for nutrition. This failure placed residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life. Findings included . Review of the facility policy titled, Care Planning - Interdisciplinary Team, undated, facility was responsible for the development of an individualized comprehensive care plan for each resident. The comprehensive care plan within seven days of completion of the resident assessment. Review of the undated facility policy titled, Resident Mobility and Range of Motion, documented the care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise quarterly care plans accurately to reflect the resident's needs for 2 of 7 residents (Residents 12 and 72), reviewed for care planning. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Care Planning - Comprehensive Person-Centered, documents that the care planning/interdisciplinary team is responsible for the review and updating of care plans when goals, needs, and preferences change, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly and after each MDS assessment.<RESIDENT 12> Resident 12 was readmitted from the hospital on [DATE] with diagnoses to include right leg pain. In an observation on 08/13/2025, at 1:11 PM, a green boot for relieving pressure was observed on a chair in Resident 12's room. In an observation on 08/15/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 5 of 5 sampled dependent residents (Residents 1, 33, 81, 98, and 99) reviewed for ADLs. The facility failed to provide showers/bathing assistance to residents (Residents 1, 33, 81, and 98), who were dependent on staff for bathing, and failed to ensure Resident 99, who was dependent for splint placement was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Shower/Tub Bath, undated, documented general guidelines that qualified nursing staff would provide two full baths or showers per week, and at a minimum offer a bed bath as needed. Resident preferences would be considered and honored. Review of the facility policy titled, Resident Mobility and Range of Motion, undated, documented all residents will receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure that 3 of 3 residents (Residents 12, 40 and 81) reviewed for pressure ulcers (PU), were provided interventions that were required for the prevention of a PU. This failure to implement pressure reducing interventions in accordance with physician's orders placed residents at risk for PU development, prolonged wound healing, and a diminished quality of life.Findings included .Review of the undated facility policy titled, Pressure Injury Prevention and Management, documented that the facility would promote the prevention of PU development, promote healing of exiting PU, and prevent development of additional PU. Preventative interventions included frequent assistance with repositioning, use of pressure reducing devices, and encouragement for adequate nutrition. Treatment protocols outlined in the policy documented that treatments would be ordered by the physician and may include medications to promote healing, special wound dressings, use 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 3 of 6 medication carts (Yellow, Blue and Pink Carts) and 1 of 2 medication rooms (second floor medication room) had unexpired medications and/or biologicals, reviewed for medication storage. These failures placed residents at risk of receiving compromised or ineffective medications and biologicals. Findings included .Review of the undated facility policy titled, Medication Storage, showed the facility shall not use discontinued, outdate, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Review of the undated facility policy titled, Self-Administration of Medications and Treatments, showed residents will be assessed to determine whether self-administering medications and or treatment is clinically appropriate for the resident. Self-administered medications and or treatments supplies will be stored in a safe and secure place, not accessible to other residents. <MEDICATION SECURITY> In an observation on 08/13/2025 at 11:04 AM, the yellow med…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services were provided for 6 of 6 Medicaid residents (Residents 3, 12, 79, 81, 85, and 101) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to wear ill-fitting dentures. These failures placed residents at risk of difficulty chewing, oral pain, decreased self-image and diminished quality of life. Findings included .<RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition. Review of the admission transfer orders from the hospital on [DATE] directed staff to weigh Resident 81 daily and provide a pureed diet and nutritional supplements daily. Review of the initial nutritional at risk assessment dated [DATE], showed the diet was listed as regular texture rather than the ordered pureed texture. Review of the admission Minimum Data Set (MDS, an assessment tool) dated 07/29/2025,…

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 and interview, the facility failed to store food for residents in accordance with professional standards in 1 of 2 nourishment refrigerators (second floor) reviewed for food service safety. The failure to maintain safe refrigerator temperatures placed residents at risk of foodborne illness. Findings included .In an observation on 08/15/2025 at 9:39 AM, the second-floor nourishment refrigerator door was found to be ajar and the thermometer on the inside of the refrigerator door read 55 degrees. The refrigerator was observed to contain cheese, yogurts, milk, puddings, sandwiches, pitchers of fruit juices and a plastic container of sushi labeled 08/13/2025 and labeled with the name of a facility resident. The temperature log was already signed for the day (08/15/2025) with no time, and the temperature was documented as 39 degrees on the log. In a follow up observation and interview on 08/15/2025 at 10:52 AM, the second-floor nourishment refrigerator door was again found to be ajar and the temperature on the thermometer inside the door read 58 degrees. Items inside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system in which residents' records were complete, accurate, and accessible for 2 of 2 residents (Residents 9 and 85) reviewed for physician visits, 1 of 5 residents (Resident 72) reviewed for unnecessary medications, and 1 of 3 residents (Resident 82) for hospitalizations. The facility failed to ensure the residents' medical records were complete and accurate which placed the residents at risk for medical complications, unmet care needs, and diminished quality of life.Findings included .According to the facility's Transfer and Discharge policy, dated 10/01/2021, nursing services and/or social services are responsible for completing the discharge note in the medical record.In a review of facility policy, dated 10/01/2021, titled, Weight Assessment and Intervention, documented that weights will be recorded in the resident's medical record. <RESIDENT 82> Review of the progress note dated 08/14/2025 at 11:14 AM, documented Resident 82 returned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 5 residents (Resident's 2, 12 and 116) reviewed for transmission-based precautions (TBP), 2 of 2 staff (Staff AA, Nursing Assistant Certified - NAC and Staff CC, NAC) reviewed for environmental disinfection of equipment, 2 of 2 drainage bags (Resident's 82 and 96) were secured off the floor and 1 of 1 facility water management plan. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriately disinfecting reusable resident equipment, and failed to ensure an appropriate placement of urinary drainage tubing. The facility failed to establish a water management plan for the facility that could place the facility residents and staff at an increased risk for Legionella or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advance directive (AD-a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 4 of 21 sampled residents (Residents 3, 4, 22 and 82), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the undated facility policy titled, Advance Directives, documented the social services director or designee will inquire of the resident or family members or legal representatives about the existence of any written advance directives. Information about whether the resident had executed an advance directive shall be displayed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 5 residents (Resident's 22 and 81) were reviewed for unnecessary medications (a drug that affects brain activities associated with mental processes and behavior). The facility failed to provide a valid diagnosis for the use of psychotropic medications, ensure a consent was obtained, attempt non-pharmacological interventions, and monitor hours of sleep which placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life. Findings included .Review of the policy titled, Anti-psychotic Medication Use undated stated residents will only receive anti-psychotic medications when necessary and when necessary to treat specific conditions for which they are indicated and effective. Diagnosis of a specific condition for which anti-psychotic medications are necessary to treat will be based on a comprehensive assessment. Nursing staff shall monitor for and report adverse side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recommendation of the Level ll Preadmission Screen and Resident Review (PASRR - a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]) evaluation was submitted after a hospital exemption was no longer valid for 1 of 5 residents (Resident 72) reviewed for PASRR. This failure placed residents at risk of behavioral health needs not being met and a diminished quality of life.Findings included.Review of the undated facility policy titled, Long-Term Services and Supports Screening, PASRR Policy, documented that when a resident has a positive Level l screening, the facility will initiate the Level ll screening.<Resident 72> Resident 72 was admitted on [DATE] with diagnoses to include Major Depressive Disorder (MDD), severe with psychotic symptoms and anxiety. In a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an environment that was free from accident hazards over which the facility had control for 1 of 3 residents (Resident 5) reviewed for falls. Failure to identify hazards and implement safety interventions in the facility therapy courtyard, resulted in Resident 5 experiencing a fall and placed residents at risk for injury. Findings included.Resident 5 admitted on [DATE] following an orthopedic surgery. Resident 5 was alert and oriented, and was wheelchair bound. In an observation and interview on 08/14/2025 at 9:42 AM, Resident 5 stated they had fallen about a week prior while outside in the courtyard. Resident 5 stated they were in their wheelchair with their back facing what they believed was a paved ramp. Resident 5 stated they began to wheel themselves backwards, and then suddenly fell back off a step, landing on their back on the cement ground. Resident 5 stated they hit their head and were scratched up on their elbows. 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 ensure 2 of 6 sampled resident's (Residents 3 and 81) reviewed for nutrition, received adequate weight monitoring, and implemented effective interventions to maintain adequate nutrition and hydration. This failure placed residents at risk of ongoing weight loss, poor nutrition, and potential harm. Findings included.Review of the facility policy titled, Weight Assessment and Intervention, dated 10/01/2021, documented the nursing staff will measure resident weights as ordered by the physician/practitioner and recorded in the medical record . The dietary staff will review the weight records, and the treatment team will evaluate negative trends . Unplanned significant weight change will be investigated and analyzed by the interdisciplinary team . Care planning for unplanned wright changes or impaired nutrition risks will be an interdisciplinary effort, including causes of weight loss, goals, time frames and parameters for monitoring .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 1 resident (Resident 101) reviewed for dialysis services received accurate, specific care and monitoring and received coordinated communication and collaboration with the dialysis facility. These failures had the potential to cause unmet care needs and unrecognized medical complications. Findings included.Resident 101 was admitted in February of 2023 with a diagnosis of End Stage Renal Disease requiring hemodialysis (process to filter toxins from the blood). Review of Resident 101's medical record documented that the resident had an indwelling tunneled jugular (IJ) catheter (directly inserted into large vein creating a permanent access for dialysis) in the right upper chest as their dialysis access. The IJ catheter was utilized and accessed only by the kidney center. The facility was to monitor only. In an interview and observation on 08/14/2025 at 09:00 AM, Resident 101 stated they go to dialysis three days a week. Resident 101 pulled down the top right corner of their shirt to show their tunneled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nonpharmacological interventions prior to the use of as needed pain medications for 1 of 1 sampled residents (Resident 26) reviewed for pain medication use. The facility failed to provide nonpharmacological interventions These failures placed residents at risk for receiving unneeded mediations, related side effects of medications and a diminished quality of life.Findings included .Review of a facility policy titled Pain Management, undated showed;9. Various strategies and modalities may be utilized to assist the resident in achieving optimal comfort. Such strategies and modalities may include, but are not limited to: a. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: i. Environmental-adjusting the room temperature, smoothing he linens, providing a pressure reducing mattress, repositioning, etc; ii. Physical-ice packs, cool or warm compresses, baths,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 residents (Resident 44) remained free of significant medication errors during medication administration. This failure of administrating expired insulin injection placed residents at risk for unnecessary medication-related complications and diminished quality of life.Findings included. Resident 44 readmitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus (DM - a chronic metabolic disorder characterized by persistent high blood sugar). Review of Resident 44's physician orders dated 11/06/2024 documented to administer Humalog Solution (medication inserted into the body to help regulate blood sugar levels) subcutaneously three times a day for diabetes. In a medication administration observation and interview on 08/14/2025 at 4:24 PM, Staff KK, Registered Nurse (RN) withdrew the insulin vial and was about to administer to Resident 44. The insulin vial had a label with an open date of 07/10/2025. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of 1 of 3 residents (Resident 33) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and review of lab results. This failure had potential for risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.Findings included.Review of facility policy titled, Lab and Diagnostic Lab Results dated 10/01/2021 documented the facility will provide notification and follow up of practitioner recommendations regarding labs. <RESIDENT 33>Resident 33 was re-admitted on [DATE] with diagnoses to include iron deficiency anemia secondary to blood loss, a left hip pressure ulcer, cellulitis (infection of the skin) of their right leg and an open wound to their left lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food services met the individual food plans, nutritional needs and preferences for 1 of 2 sampled residents (Resident 102) reviewed for nutrition and preferences. The failure placed residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included.Review of the facility policy titled, Food and Nutrition Services, dated 10/01/2021, documented food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Resident 102 was admitted to the facility on [DATE]. According to the Annual Minimum Data Set (MDS-an assessment tool), dated 07/13/2025, the resident was cognitively intact. In an interview on 08/13/2025 at 10:27 AM, Resident 102 stated the food served did not match the tray card or what they ordered from the menu. In an observation, interview and record review on 08/13/2025 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 required specialized rehabilitative services for 1 of 2 residents (Resident 1), reviewed for rehabilitation services. This failure placed the residents at risk for the decline in function, unmet care needs and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE], with diagnoses that included a history of a stroke that affected mobility to the left side of their body, muscle weakness, limited activity due to disability, and depression. The admission Minimum Data Set (MDS - an assessment tool) dated 08/04/2025 showed the resident had no cognition impairment, and no refusal of care, and the resident was dependent for toileting care, and required substantial to maximum assistance for transfers. Review of Resident 1's hospital transfer orders dated 07/29/2025, documented orders for evaluation and management for Physical Therapy (PT), and Occupational Therapy (OT). Review of Resident 1's 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.

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to provide timely medication administration, provide care without residents having to wait a long time and licensed nursing staff were able to adequately monitor resident's conditions and supervise nursing assistants to ensure care was provided timely for 2 of 2 units (first floor, second floor) reviewed for sufficient staffing. Failures to ensure sufficient nursing staff resulted in delays in nursing staff response to residents' call lights, delays in administering medications, and placed residents at risk for unmet care needs, complications of medical condition and a diminished quality of life. Findings included . Review of an anonymous report to the state agency on 06/10/2025 at 2:01 PM documented a concern of sufficient nursing staff at facility. The report documented that residents were getting their medications late and call lights were not being answered timely. During an observation and interview on 06/24/2025 at 8:51 AM, Staff B, Registered Nurse (RN),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a patient-centered discharge planning by the interdisciplinary team, involved resident and/or representative in the discharge planning, direct communication with the resident and/or representative about discharge process, and document required discharge information for 2 of 4 sample residents (Resident 5 and 6) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress and decreased quality of life. Findings included . Review of the facility policy titled, Transfer or Discharge, preparing a Resident for, dated 10/01/2021, documented a post-discharge plan was developed for each resident prior to transfer or discharge and the plan would be reviewed with the resident, and/or family at least twenty-four hours before resident's discharge or transfer from the facility. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] and discharged home on [DATE]. According to the discharge Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five percent. 8 medication errors were identified out of 29 opportunities due to the failure of 2 of 2 nurses (Staff B and D) provided medications outside of the scheduled administration time. This resulted in a medication error rate of 27 percent. This failure placed residents at risk of reduced medication effectiveness, worsening of symptoms, and/or complications of medical condition. Findings included . <RESIDENT 1> In an observation on 06/24/2025 at 8:58 AM, Staff B, Registered Nurse, prepared medications to be administered to Resident 1. Staff B administered the medications below to the resident at 9:04 AM. Staff B reported that the medications scheduled for 7:00 AM were administered late. Review of the June 2025 Medication Administration Records (MAR) for Resident 1 showed the following orders: - Levothyroxine (thyroid medication) once a day. Dose scheduled at 7:00 AM. - Acetaminophen (pain reliever) three times a day. Doses scheduled at 7:00AM, 3:00PM 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 record review and interview, the facility failed to maintain a completed state reporting log for 2 of 3 (April and May 2025) months reviewed. The facility failed to ensure incidents were logged within 5 days of incident discovery. This failure placed residents at risk of unidentified patterns of alleged violations, which could include neglect, abuse and/or exploitation. Findings included . Review of the Nursing Home Guidelines, also known as the Purple Book, dated October 2015 showed the facility was to report to the state agency and one method of reporting was by the state reporting log. The incident was to be reported via the reporting log within 5 days of discovery. Review of the April 2025 state reporting log documented that twenty incidents were all logged on 04/30/2025. The dates of these incidents ranged from 04/19/2025 through 04/30/2025. Review of the May 2025 state reporting log documented thirty-one incidents were logged on 05/31/2025. The dates of these incidents ranged from 05/01/2025 through 05/25/2025. During an interview on 05/29/2025 at 3:18 PM, Staff 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.

Based on interview and record review, the facility failed to ensure there was a qualified Infection Preventionist (IP, responsible for the facility's infection control program that includes early detection, analysis of evidence-based surveillance of infection, implementation, and management of healthcare associated infections by ensuring sources of infections were tracked/managed to isolate/prevent the spread of infection) designated for the facility. The facility was currently in a viral respiratory disease outbreak and this failure placed the residents and staff at risk for transmission of an infectious disease and/or unmet care needs. Findings included . During an interview on 03/19/2025 at 9:55 AM, Staff C, Unit Manager, stated Staff B, IP/Staff Development /Assistant Director of Nursing, was working in the role of IP as the last IP no longer worked at the facility. During an interview on 03/19/2025 at 12:45 PM, Staff B, stated they were hired to do IP/SDC. During an interview on 3/19/2024 at 1:03 PM, Staff A, Administrator, stated that Staff B was the acting facility IP but had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the responsible party for 1 of 3 residents (Resident 1) reviewed for hospitalization. Failure to notify the resident representative of transfer to a hospital placed the resident at risk for not having their representative involved in their health care decision-making with timely care and services. Findings included . Review of an undated facility policy, titled, Change in a Resident's Condition, documented a nurse would notify the resident's representative when the resident was transferred to a hospital. Resident 1 was admitted to the facility on [DATE]. Review of Resident's 1's admission record documented a son as emergency contact #1 and Collateral Contact 1 (CC1), significant other, as emergency contact # 2. During an interview on 03/19/2025 at 9:29 AM, Collateral Contact 2 (CC2), Resident 1's family member, stated that the resident had been sent to the hospital on [DATE] but the family had not been notified. CC2 stated that CC1 had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 5 sampled staff (Staff B) had an active professional license. Failure to ensure the Director of Nursing had an active license placed all residents at risk of substandard quality of care as the Director of Nursing was responsible for all residents in the center. Findings included . Review of Staff B's job description, signed by Staff B on [DATE], showed they were the Director of Nursing and supervised the nursing department. Review of the facilities Key Personnel list provided by on the facility on [DATE], showed Staff B listed as the Director of Nursing. During an interview on [DATE] at 2:13 PM, Staff B introduced themselves as the new Director of Nursing to surveyor. During an interview on [DATE] at 3:50 PM, Resident 1 stated they had been notified by Staff A, Administrator, that Staff B was hired as the new Director of Nursing. During an interview on [DATE] at 4:39 PM, Staff C, Licensed Practical Nurse (LPN), stated they were notified 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.

Based on observation, interview and record review, the facility failed to complete a background check prior to employment for 1 of 5 sampled staff (Staff B) reviewed for staff qualifications. This failure placed residents at risk from interactions with staff who were not qualified to work with vulnerable adults and created the potential for abuse, neglect and exploitation. Findings included . Review of a facility policy titled, Abuse, revised date of 10/20/2022, showed the facility will screen potential employees for a history of abuse, neglect or mistreating residents by completing a background check. Review of Staff B's employment file showed a hire date of 02/25/2025. Review of a report for a background check application, dated 2/20/2025, showed that the background check could not be completed until additional information was received from Staff B, Director of Nursing. Review of Staff B's personnel file showed no further information of the background check being completed. During an observation on 03/04/2025 at 2:13 PM, Staff B approached surveyor in the hallway and introduced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's governing body failed to ensure that the facility's abuse policy was followed by ensuring the Director of Nursing (DNS) had a completed background check and failed to ensure the DNS had an active professional license prior to employment. This failure placed residents at risk of substandard quality care and placed residents at risk of abuse, neglect and/or exploitation. Findings included . Review of Staff B's, DNS, employment records showed a hire date of 02/25/2025. Review of Staff B's job description, signed by Staff B on 02/20/2025, showed they were the Director of Nursing. During an interview on 03/07/2025 at 10:05 AM, Staff E, Human Resources, stated that they processed the background check applications and verified professional licenses were active and current for potential employees. Staff E stated that Staff B's background check returned stating that the applicant needed to provide additional information prior to the background check being completed. Staff E stated they had reviewed Staff B's Registered Nurse license 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 administer services effectively and efficiently to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. The facility failed to ensure all allegations had a complete and thorough investigation and failed to maintain systems to prevent repeat citations throughout the last year. In addition, the facility failed to recognize and/or correct repeated concerns that had been documented on the Resident Council meeting minutes for long call light wait times. The administrator should have been aware of these issues and did not put corrective action into place to sustain these systems. These failures placed residents at risk for the potential for continued abuse, unmet care needs and decreased quality of life. Findings included . Review of a facility policy, titled, Administrator, dated 10/01/2021, showed the administrator was responsible for the day-to-day functions of the facility and they were responsible for implementing operational policies to remain in compliance with current laws and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the governing body failed to provide adequate active and engaged oversight and monitoring of the facility's appointed Administrator. The governing body failed to ensure the Administrator had clinical systems in place and that were followed related to Abuse/Neglect, Resident Rights, Grievances, Pressure Ulcers, Infection Control and Prevention, Social Services, Nutrition, Care Planning, Accidents and Supervision, Transfer and Discharge, Staffing, Medication Safety, Range of Motion program, and Infection Control Practices, failed to identify and correct their own identified deficiencies to ensure sustainability with compliance for state/federal regulations and previous deficiencies. The governing body also failed to ensure the Administrator had sufficient staff to meet the needs of the residents, i.e., personal care/grooming, restorative care, and an effective call light system. These failures placed residents at risk for less-than-optimal care and services for residents. The…

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

Based on interview and record review, the facility failed to act, respond, and resolve the organized resident group's concerns for 1 of 1 Resident Council groups. The facility administration's failure to respond to the organized group's concerns resulted in an extended period where reported resident care needs went uninvestigated, unidentified and unmet due to the facility's systemic failure to investigate the concerns reported during the Resident Council meetings from May, June, July and August 2024. Additional failed practice included the facility failure to maintain complete and accurate Resident Council meeting minutes that included all concerns and grievances voiced during Resident Council meetings, and failures to log, report, investigate, and resolve concerns voiced by the Resident Council. The non-responsive facility administration's pattern of inaction placed all residents at risk for unidentified, unmet care needs and diminished quality of life. Findings included . In an interview with Resident Council representatives on 11/07/2024 at 10:00 AM: -Resident 50, 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 recognize, record and promptly resolve grievances for 5 of 5 residents (Residents 2, 37, 45, 98 and 255) reviewed for grievances. Failure to implement their grievance process placed the residents at risk for anxiety, undue stress, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Grievances/Complaints-Staff Responsibility showed staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. The procedure showed staff members may inform the resident or the person acting on their resident behalf that he or she may file a grievance or complaint with the Administrator or other government agencies as noted on posting in the facility, without fear oof threat or any form of reprisal. <RESIDENT 98> Resident 98 admitted to the facility on [DATE]. In an interview on 11/04/2024 at 11:53 AM, Resident 98…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free from abuse and neglect due the facility failure to respond to and resolve nursing care, staffing and food services grievances voiced by 1 of 1 organized resident groups over a four-month period from May to August 2024. Facility administration chose to address only select grievances and opted not to address reported nursing staffing and food service concerns. The facility administration's systematic failure to investigate and act on residents' reported concerns deprived an unknown number of residents necessary nursing care and food service support, the extent of which could not be ascertained due to a gross lack of documentation and overt failures in the facility's Resident Council/Grievance procedures. The facility failure to ensure the necessary processes, procedures and structures were in place to prevent abuse and neglect placed all residents at risk for ongoing abuse and neglect, unmet needs, weight loss and diminished quality of life. Findings included . In an interview with Resident Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 systems were in place for staff following and implementing abuse and neglect policies & procedures for reporting, investigation, and protection for 3 of 11 residents (Residents 15, 50, and 84), reviewed for abuse and neglect. The failure to identify potential abuse, timely report allegations of potential abuse, complete timely and thorough investigations of the potential abuse, assess and monitor the residents for physical and psychosocial harm, notify responsible parties and providers, and to document the allegations and revise resident care plans placed residents at risk for injury, fearfulness, frustration, humiliation, and further potential abuse. Findings included . A review of the facility's policy titled, Abuse dated 10/01/2021, showed the organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. This includes, but is 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 conduct a thorough investigation for 17 of 20 resident investigations (6, 15, 46, 78, 84, 454, 58, 2, 80, 31, 11, 56, 19, 66, 62, 46, 12) and 1 of 1 organized resident group (the Resident Council) reviewed for accidents and allegations of potential abuse and/or neglect . The facility failed to identify the root cause, and all contributing factors related to allegations of abuse and/or neglect placed residents at risk for injury, and additional abuse/neglect. Findings included . <RESIDENT 15> Resident 15 admitted on [DATE] with diagnoses to include cardiac disease, right above the knee amputation (AKA), muscle weakness and diabetes. The resident was alert and oriented with no cognitive impairment and required two-person extensive assistance for toileting. In an interview on 11/05/2024 at 1:25 PM, Resident 15 was sitting in a wheelchair with their right stump on an elevating leg rest. Resident 15 said It takes too damn long to get your call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 4 residents (Resident14, 43, 88 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . The RAI consists of three basic components: the Minimum Data Set (MDS - a resident assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). The CAA process was designed to assist the assessor to systematically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive person-centered care plan for 3 of 8 residents (Resident 24, 43, and 98) reviewed for comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the residents highest practicable well-being placed the residents' at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Findings included . <RESIDENT 24> Resident 24 admitted to the facility on [DATE]. In an interview on 11/04/2024 at 10:17 AM, Resident 24 stated they had sciatica and pain in their right shoulder and the muscle was sore. The resident said they received Lidocaine patches and Gabapentin for pain. Review of the care plan showed Resident 24 was at risk for pain related to advanced age, recent hospitalizations and multiple cardiorespiratory conditions. The care plan did not include the resident's goals or nonpharmacological interventions for 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, observation, and record review, the facility failed to follow professional standards of practice for 4 of 29 residents (Resident 2, 5, 58, and 78) reviewed for medication administration. Failure to transcribe orders accurately upon admission and pre-signing medications in the Medication Administration Record (MAR) ahead of adminsitration placed residents at risk for medication errors and acute medical problems. Findings included . According to the facility policy titled: Medication Administration: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination and infection. Review Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. Sign MAR after administered. <RESIDENT 78> Resident 78…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and provide necessary treatment and services consistent with professional standards of practice for 3 of 4 residents (Resident 14, 43, and 98) reviewed for Pressure Ulcers. This failure placed the resident at risk for increased pressure ulcers, pain, discomfort and diminished quality of life. Findings included . Review of the facility policy dated 10/01/2021, titled Pressure Injury Prevention and Management, showed that the nursing staff will develop and maintain systems and processes to ensure that the facility provides care and services consistent with professional standards of practice to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers. <Resident 98> Resident 98 admitted on [DATE] with diagnoses to include a right heel deep tissue injury. Review of Resident 98's physician's orders showed the resident had a right heel pressure ulcer and nurses were to check daily and apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative/rehabilitative treatment and services for 4 of 4 residents (Residents 2, 41, 46, 88) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function. Findings included . Review of the undated facility policy titled: Restorative Nursing Services, showed that the residents would receive restorative nursing care as needed to help promote optimal safety and independence. <RESIDENT 2> Resident 2 admitted [DATE] and was a long term resident with diagnoses which included weakness and spinal stenosis. According to the Annual Minimum Data Set (MDS) assessment dated [DATE], the resident had impaired lower extremity range of motion on one side and required extensive or total assistance with mobility. Review of the care plan with revision dated 08/25/2023 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 <RESIDENT 54> Resident 54 admitted to the facility on [DATE]. According to the admission MDS assessment, dated 07/17/2024, the resident had no cognitive impairment. Review of Resident 54's weight history showed weights to include: 07/11/2024 no documented weight found (day of admit) 07/14/2024 - 182.0 lbs. 08/08/2024 - 157.2 lbs. This was significant weight loss of 13.6% in less than 30 days. There was no documented re-weight found in the electronic health record. 08/16/2024 - 154.2 lbs. 11/07/2024 - 150.4 lbs. Review of a hospital Discharge summary, dated [DATE], showed Resident 54's weight was 186 lbs. 11 ounces on discharge from the hospital. Review of a nursing progress note, dated 10/09/2024, showed staff documented the resident had no significant weight changes. Review of a nutrition/dietary note, dated 08/27/2024, showed the resident's weight loss was categorized as unplanned/undesired, and the 07/14/2024 weight may be an outlier. The note indicated the dietitian was unable to communicate 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 Based on observation, interview and record review, the facility failed to provide sufficient numbers of adequately supervised nursing staff to provide care and services for 5 of 9 residents (Residents 5, 2, 43, 36, 15) and 1 of 1 organized resident groups (Resident Council) reviewed for nursing staffing and nursing care and services. Failures to ensure sufficient nursing staff and nursing staff supervision resulted in delays in nursing staff response to resident call lights, failures in administering nutritional supplements as ordered by physicians, missed bathing, cold food and not-accurate medical records. Findings included . <RESIDENT COUNCIL> In a group interview with Resident Council representatives on 11/07/2024 at 10:00 AM, Resident 50 stated overnight call light response times were sometimes slower than they should be, and they thought it was due to a shortage of staff. Resident 50 stated the facility was short of staff when it came time to pass out meal trays. Resident 50 stated it took staff only five…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five percent (%), there were 29 opportunities for error observed and resulted in 68.97% medication error rate. Failure to administer the right dose of medication for 1 of 8 residents (Resident 43), failure to administer medication by the correct route for 1 of 8 residents (Resident 78), and failure to administer medications at the right time for 7 of 8 residents (Resident 2, 5, 34, 43, 58, 75, 78) placed residents at risk for adverse side effects, medical complications and diminished quality of life. Findings included . According to the facility policy titled Medication Administration: Medications administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician in accordance with professional standards of practice. Review Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 7 of 10 residents (Residents 5, 2, 58, 78, 24, 98, 453) remained free of significant medication errors when administering and documenting medication administration. The failure to administer medications within the required time frame of one hour before/after the scheduled time resulted in countless timing and/or documentation errors including breakfast and lunch insulin administrations given within minutes of each other. The facility's failed medication management practices placed residents at risk for adverse medication-related complications, diminished quality of life, and for having inadequate medical records being used to make medical decisions. Additional failed practice included lack of sorely needed nursing supervision and administrative oversight of medication management practices and systemic failures in reporting, documenting and investigating medication errors. Findings included . Review of the facility policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were secured for 4 of 4 residents (Resident 47, 78, 453 and 454) observed with medications at bedside. Further, the facility failed to discard expired in three of four medication carts reviewed. This failure placed the residents at risk for receiving compromised or ineffective medications This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life. Findings included . Review of the undated facility policy titled, Medication Storage showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdate, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed. <RESIDENT 453> In an observation and interview on 11/04/2024 at 10:30 AM, Resident 453 was resting in bed with Normal Saline Spray in a clear cup, Artificial…

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

Based on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and were palatable for 6 of 7 residents (Resident 75, 81, 84, 95, 98 and 454) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings included . <RESIDENT INTERVIEWS> <RESIDENT 84> In an interview on 11/04/2024 at 11:27 AM, Resident 84 said they hate cooked spinach and they serve it to them. Resident 84 said the food could be served hotter. In an interview on 11/05/2024 at 8:41 AM, Resident 84 said they forgot my coffee. The resident said they just don't like spinach and they write in a lot of stuff on their tray card. Resident 84 said they must hate me in the kitchen. They do a lot of canned fruit. Lots of fruit cocktail, mostly canned. I would like fresh berries. Food is lukewarm at best. Maybe those carts are not insulated well. Food needs to be hotter. 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.

Based on observation, interview and record review, the facility failed to ensure residents' menus and individual food plans met the nutritional needs and preferences of 5 of 9 residents (Residents 2, 19, 50, 5, 81) and 1 of 1 organized resident groups (Resident Council) reviewed for food services. The failure to ensure residents received foods that met their nutritional needs, and their individual preferences placed residents at risk for weight loss, dissatisfaction with their food and diminished quality of life. Findings included . <RESIDENT COUNCIL> In a group interview with Resident Council representatives on 11/07/2024 at 10:00 AM, Resident 50 stated they can't always get alternative foods if they don't like the food they get, they stated they know there were alternatives, but to find staff to get them was limited. Resident 19 stated there was a lot of not getting foods they had requested as they were not following their menu. Resident 50 stated the tray cards (documentation for each meal what the resident had requested and what they were to receive for each meal) didn't usually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and/or provide a nutritional snack when ordered or requested for 4 of 6 (Resident 2, 24, 84, and 50) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition. Findings included . <BEDTIME SNACKS> <RESIDENT 2> In an interview and observation on 11/04/2024 at 1:55 PM, Resident 2 stated. We used to get snacks but now it is like pulling teeth or they will say there is nothing. I get low blood sugar and they don't get me the right snacks, I need protein. They will bring potato chips and say that is all there is. <RESIDENT COUNCIL> In an interview with resident council representatives on 11/07/2024 at 10:00 AM, Resident 50, Resident Council Representative, stated they used to get snacks at bedtime, but not anymore. Resident 50 stated when they returned from dialysis every Monday, Wednesday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 5 of 5 residents (Resident 6, 14, 46, 54, and 81) observed during cares. Failure to wear personal protective equipment (PPE) prior to entering a precaution room(first floor) and failure to do hand hygiene between glove changes during wound care and peri care placed residents and staff at risk for potential infections. Findings included . Review of an undated facility policy titled Hand Hygiene, all staff are responsible for following hand hygiene procedures: when hands move from a contaminated-body site to clean body site during resident care and before and after wearing gloves. Review of facility policy titled, Infection Control Program, stated the facility has an infection control program and committee that addresses the surveillance, prevention and control of disease and infection that was consistant with the guidelines from 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 and interview, the facility failed to ensure call lights were consistently operational and functioning appropriately on 2 of 2 floors, including 6 residents (Residents 24, 50, 53, 78, 98,and 454 ) and potentially any of the residents who used a call light throughout the facility. The failed practice placed residents at risk of not having their needs met and psychosocial harm. Findings included . <RESIDENT 50> Review of the resident record showed the resident made an allegation on 10/27/2024 that a nursing assistant had not responded to their call light for over an hour. The nursing assistant denied that the call light was on and was alleged by the resident to be rude. Review of the facility incident investigation showed that the resident was not interviewed regarding the incident until 10/31/2024 and it was determined that the resident's call light was, in fact, not functioning. Review of the facility audit documentation following the incident showed that the facility was conducting audits…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff were educated on all required topics that were identified on the facility assessment for 5 of 5 sampled staff (Staff DD, CC, EE, K, X) reviewed for education and training. Failure to ensure staff received required trainings placed residents at risk of not receiving competent care, unmet care needs, and a diminished quality of life. Findings included . Review of the facility assessment, review date 07/29/2024, showed the identified trainings to be provided to staff on hire and annually included: • Culture change/person-centered care. • Special needs of residents. • Identification of resident changes in condition. • QAPI (Quality Assurance Process Improvement) • Emergency Preparedness. • Dementia <STAFF DD> Review of Staff DD, Nursing Assistant Certified's (NAC) education log for the past year showed they had not received education on Culture change/person-centered care, Special needs of residents, Identification of resident changes in condition, QAPI, or Emergency preparedness. <Staff CC> 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff treated 2 of 2 residents (Residents 84 and 98) in a dignified and respectful manner. This failure placed the residents at risk for experiencing a high level of frustration, embarrassment, and the need to constantly advocate for their care. Findings included . The Cambridge English Dictionary, dated April 28, 1995, defines Dignity as The quality of a person that makes him/her deserving of respect, sometimes shown in behavior or appearance. According to Washington State Long-Term Care Ombudsman Program website 12/15/2023, People who live in long-term care facilities are more vulnerable than people who live independently. In 1987, the U. S. Congress recognized this fact and passed The Nursing Home Reform Act that gave nursing home residents additional legal protections, including a set of Resident Rights. Resident rights include the right to a dignified existence and to be treated with consideration, respect, and dignity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor a residents' representative's request to schedule a care meeting for 1 of 3 residents' (Resident 5) representative. The failure to honor the resident's representative's request to schedule a care meeting placed the resident at risk for unmet needs and for the resident's representative being unable to advocate for the resident. Findings included . Resident 5 admitted to the facility on [DATE]. In an interview on 11/05/2024 at 11:27 AM, Collateral Contact 2 (CC2), family member of Resident 5, stated they set up an appointment today at 10:00 AM for a care meeting, but it still had not happened. They stated they tried to talk to Staff X, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), but when they tried to talk to them, they just stuck their arm out to them like they weren't going to talk to them. CC2 stated they could have called them and let them know the meeting wasn't going to happen and they would have rescheduled. CC2 stated 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 ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (Resident 46) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included . According to facility policy titled: Resident Participation-Assessment/Care Plans, the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. An advance notice of the care planning conference is provided to the resident and his/her representative. Such notices are made by mail, telephone, and/or electronically. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's right to be free from involuntary seclusion for 1 of 1 resident (Resident 253). Failure to prevent involuntary seclusion placed the resident at risk for psychological harm. Findings included . Resident 253 was admitted to the facility on [DATE] with diagnoses that included acute cystitis (a bladder infection that begins suddenly and is usually caused by bacteria). In an interview on 11/04/2024 at 3:02 PM, Resident 253 stated they were not allowed to leave their room and they had to stay in their room. Resident 253 stated they get lonely because they were not able to leave their room. Resident 253 stated the nursing staff had informed them they had to stay in their room because of their infection. Review of Resident 253's Minimum Data Set (MDS-an assessment tool) showed resident was interviewed about their preferences for customary routine and activities and reported it was very important to them to do things with groups…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 14 and 78) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options. Findings included . Review of an undated facility policy titled, Facility Initiated Transfer and Discharge showed that before a facility transfers or discharges a resident, the facility will notify the resident and the residents representatives of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. The written notice will include a statement of the resident appeal rights, including the name, address (mailing and email) , and telephone number of the entity which received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, at the time of transfer or within 24 hours of transfer to the hospital, for 1 of 2 residents (Resident 78), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the undated facility policy titled Bed Hold showed that prior to initiated transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy showed residents and or representatives will be provided information on the facility's bed hold policy at the time of admission. A second written notice will be provided to the resident, and if applicable the residents representative, at the time of transfer, or in cases of emergency transfer, withing 24 hours. <RESIDENT 78> Resident 78 admitted to the facility 09/20/2024. According to the admission Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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)(a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings) was completed as required and that Level two comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 2 of 5 (Resident 43 and 74) residents reviewed for PASRR services. This failure placed residents at risk for not receiving necessary mental health care and services in the most integrated setting appropriate to their needs Findings included . <RESIDENT 74> Resident 74 admitted [DATE] with diagnoses which included anxiety, depression, post traumatic stress disorder and substance abuse disorder. Review of Resident 74's level one PASRR completed on 04/11/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement, review and revise care plans for 1 of 14 residents (Resident 46) reviewed for care planning. These failures placed residents at risk for unmet care needs, adverse health effects and diminished quality of life. <RESIDENT 46> Resident 46 admitted to the facility on [DATE]. Diagnosis to include Multiple Sclerosis (a disease that causes the breakdown of the protective covering of the nerves). According to the Minimum Date Set (MDS - an assessment tool) assessment, dated 10/17/2024 Resident 46 showed severe cognitive impairment. Resident was able to verbalize needs and responded appropriately when questions were asked. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and requires total assist with care. <RANGE OF MOTION (ROM -is a term used to describe how far you can move a joint or muscle in various directions) EXERCISES> Review of Resident 46's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary activities of daily living care and services for 2 of 4 residents (Residents 5, and 54) reviewed for bathing. The failure to bathe residents per their bathing care plans placed residents at risk for hygiene issues and for diminished quality of life. Findings included . <RESIDENT 5> Resident 5 admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment, dated 08/07/2024, they had no cognitive impairment, and they needed substantial/maximal assistance with bathing, and they were dependent on staff for tub/shower transfers. In an interview on 11/04/2024 at 10:47 AM, Resident 5 stated they had problems with bathing as the nursing assistant gave them a bed bath using the same soapy water to wash their body, then they used the same soapy water to rinse their hair and they felt itchy after. The resident stated they wanted different water to rinse. In an interview on 11/15/2024 at 9:42 AM, Resident 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for 1 of 3 residents reviewed for non-pressure skin conditions (Resident 2), 1 of 2 residents reviewed for falls (Resident 37) and 2 of 4 residents reviewed for medication management (Residents 24 and 88) The failure to provide monitoring and assessment related to wounds, medication management, fluid restrictions and fall prevention placed residents at risk for adverse outcomes and diminished quality of life. Findings included . <SKIN ASSESSMENT> <RESIDENT 2> Resident 2 admitted [DATE] and was a long term resident with diagnoses which included diabetes and chronic ulcer of the lower leg. Review of Resident 2's physician's orders on 11/14/2024 9:31 AM showed the resident received dressing changes to a wound on the left posterior calf (present since admission) twice per week and an order showed wound/measurement by the licensed nurse once per week. Record review Resident 2's care plan on 11/07/2024 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen (O2) tubing was appropriately maintained, changed regularly, and dated consistently according to with professional standards of practice for 1 of 1 sampled resident (Resident 43) reviewed for O2 tubing. Additionally, the facility failed to ensure 1 of 1 sample resident (Resident 43) physician's orders were followed related to O2. These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress. Findings included . Review of the facility policy titled, Oxygen Administration, undated, showed the procedure for O2 administration included verification of physician orders and review of the resident's care plan. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (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 ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 43) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes. Findings included . In a review of the facility's policy titled, End Stage Renal Disease-Care of Resident undated, showed the facility would care residents with end stage renal disease (ESRD) according to recognized standards of care including the immediate monitoring and documentation of the residents condition and access site upon return from the dialysis treatment center. Additionally, the policy outlined agreements between 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 ensure 1 of 5 Residents (Resident 74) reviewed for unnecessary medications were free from unnecessary psychotropic medications. Failure to provide complete and accurate informed consent for medications and identify/monitor target behaviors for as needed antipsychotic medication placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects. Findings included . Resident 74 admitted [DATE] with diagnoses to include anxiety and depression. Review of the admission Minimum Data Set, dated [DATE] showed Resident 74 was their own decision maker. Review of Resident 74's physician's on 11/12/2024 orders showed: An order for Trazodone (an antidepressant medication) dated 04/12/2024. The informed consent provided and signed by the resident on 04/12/2024 failed to include the category of medication or potential side effects. An order for Duloxetine (an antidepressant) dated 08/10/2024. No informed consent was found 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 observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 1-unit refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, the maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . <WALK IN REFRIGERATOR> During an observation 11/04/2024 at 9:48 AM the main refrigerator located in the kitchen had a temperature log on the front door showed no logged temperatures for the PM for 10/28/2024, 10/29/2024, 10/30/2024 and AM and PM for 10/31/2024. During a walk through of walk-in refrigerator on 11/04/2024 at 9:48 AM showed several undated and expired food items: - balsamic vinegar with a use by date 08/25/24 -bag of everything bagels opened not dated -pickle chips opened with a month and day, but no year documented -a container labeled applesauce with 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 maintain complete and accurate clinical records for 4 of 4 residents (Residents 41,5,14 and 253) reviewed for care and services. The failure to ensure thorough and consistent documentation of care and services placed residents at risk for unmet needs and diminished quality of life. Findings included . <RESIDENT 41> Resident 41 re-admitted to the facility on [DATE]. Review of Resident 41's September 2024 Medication Administration Records showed an order dated 09/19/2024 for daily weights for three days, and a licensed nurse had signed off they had done the daily weights on 09/19/2024, 09/20/2024, and 09/21/2024. Comparison of this documentation with documented weights showed no documentation these weights had ever been done. In an interview on 11/13/2024 at 2:28 PM, Staff X, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), was unable to provide any information regarding the licensed nurse signing off they did daily weights on 09/19/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff had the skills and competencies to perform an ordered procedure on 1 of 1 sampled resident (Resident 1) reviewed for care of a chest tube (tubing that inserted into lining of lung to drain fluids). This failure placed the resident at risk of excess fluid collecting around the lung which could compromise breathing and respiratory function. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure, respiratory failure and malignant breast cancer. During a phone interview on 07/18/2024 at 8:24 AM, Collateral Contact 1 (CC1), Emergency Medical Staff (EMS), reported they had responded to a 911 call at the facility on 07/07/2024 at approximately 1:30 PM. CC1 stated Resident 1 had called 911 as they were having difficulty breathing. CC1 reported that Resident 1 was short of breath upon their arrival to the facility. CC1 stated the attending nurse had told them that Resident 1 had a tube that could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely reporting of an allegation of abuse for 1 of 2 allegations reviewed for abuse. The facility failed to report a resident-to-resident altercation (Resident 3 and 4) to the facility's abuse coordinator and the State Agency and failed to initiate a timely abuse investigation. This failure placed the resident at risk for further altercations and lack of protection, and exposed additional residents at risk for potential of abuse. Findings included . Review of a facility policy, titled Abuse, dated 10/20/2022, showed: If an allegation of abuse was made, the facility will immediately assess the resident and protect them and other residents from further harm or incident. Each mandated reporter (a person legally required to report suspected abuse or neglect) will report an allegation of abuse within two hours. All alleged violations of abuse are reported to the state survey agency within two hours. Review of a facility risk management system (incident report) document, titled Resident to Resident Altercation, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge summary was completed that included a recapitulation (overview) of the residents' stay, a final summary of the resident's status, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) and a post-discharge plan of care for 3 of 3 sampled residents (Residents 1, 3 and 4) reviewed for discharge planning. This failure put the residents at risk of complications and delayed treatment of medical conditions by not having the necessary information to ensure continuity of care when discharged to the community. Findings included . Review of the facility policy titled, Discharge Planning, dated 10/01/2021, showed when the facility anticipated discharge, the facility would prepare a discharge summary and a post-discharge plan that included, but was not limited to a recapitulation of the resident's diagnoses, course of illness/treatment or therapy, and pertinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct safe and orderly discharges for 2 of 3 sampled residents (Residents 3 and 4) reviewed for discharges. The failure: 1) to provide necessary post-discharge instructions regarding wound treatments, 2) to coordinate for and/or provide necessary post-discharge medications, 3) to provide discharge instructions to a resident's representative for a cognitively impaired resident, 4) to provide information regarding a resident's post-discharge follow-up physician appointment, 5) to document medications prescriptions provided to residents, 6) to follow the discharge plan for the time of day for a resident to be discharged , and 7) to document medications/quantities of medications sent with a resident on discharge placed residents at risk for unmet care needs and for Resident 3 it resulted in missed medications after discharge. Findings included . Review of the facility policy titled, Discharge Planning, dated 10/01/2021, showed: -When a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide sufficient qualified staff to provide care and services for 20 of 48 sampled residents (Residents 1, 7, 9, 10, 21, 30, 36, 37, 45, 48, 49, 59, 60, 61, 74, 77, 78, 120, 138, and 143), 3 of 4 family members (Residents 59, 138, and 141), and 2 of 2 anonymous complaints that had concerns related to staffing on 2 of 2 floors (Floor 1 and 2). Failure to timely respond to resident call lights and to provide adequate nursing supervision and oversight to the Nursing Assistants resulted in residents with diminished quality of life and unmet needs including having toileting accidents and soiling themselves when staff did not respond to their call lights timely and they were unable to hold it any longer. Findings included . <FACILITY ASSESSMENT> Review of the facility's assessment, dated 09/07/2023, showed the average daily census was 74 and the facility averaged two admits and two discharges daily. The assessment showed 75% of 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 interview and record review, the facility failed to ensure their facility assessment (a required document that comprehensively assessed levels and types of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff accurately reflected the risks and resources necessary for the facility's infection prevention and control program. This failure placed the facility at risk for lack of ability to manage day to day infection control and prevention and to respond appropriately in the event of an infectious disease outbreak in the facility. Findings included . Review of the facility assessment, revised 09/07/2023, showed the following: The facility was licensed for 113 beds. Review of the Facility Assessment section titled, Resident Population, showed the facility provided care to residents with infectious diseases and who were on contact, droplet, airborne and enhanced barrier precautions. The facility provided care to residents at risk for infection such as residents with wounds, urinary catheters, intravenous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective system to obtain and use information from staff, residents, and resident representatives to identify problem areas within the facility through a Quality Assurance and Performance Improvement (QAPI) program. This failed practice placed residents at risk of receiving lower quality services and for a diminished quality of life. Findings included . Review of the facility's undated policy titled Quality Assurance Performance Improvement Committee, showed their policy was the facility would maintain systems and processes to ensure that the quality assurance/performance improvement program identified and addressed issues and/or risks and they would implement corrective action plans as necessary. Review of the facility's QAPI program meeting minutes showed the facility only had documentation of four monthly meetings, 09/07/2023, 09/29/2023, 10/23/2023, and 11/30/2023. In an interview on 12/13/2023 at 8:47 AM, Staff A, Administrator, stated they could only provide four months of QAPI minutes as they couldn't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely and accurate Medicare notices to 3 of 4 sampled residents (Residents 290, 61 and 289) reviewed for required liability notices. This failure placed residents or their representatives at risk for not being informed of their appeal rights prior to the end of their health plan company (managed Medicare insurance) ended and not being fully informed of the cost of continued services after skilled services ended. Findings included . Review of a facility policy titled, Medicare Liability Notice, dated 10/01/2021, showed the facility will provide written notice when Medicare coverage was determined to be ending. The Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) must be provided to the resident no later than the last covered (Medicare) day. <RESIDENT 290> Resident 290 admitted to the facility on [DATE] under their private Medicare health plan. During an interview on 11/08/2023 at 12:02 PM, Collateral Contact 1 (CC1), Resident 290's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct thorough investigations for 4 of 5 residents (Residents 143, 3, 59, and 74) whose investigations were reviewed. The failure to conduct thorough investigations placed residents at risk for repeat incidents, unmet care needs, and for frustration with unresolved care issues. Findings included . Review of the facility's policy titled Abuse, dated 10/20/2022, showed: -The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. -Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. -Designated staff will immediately review and investigate all allegations or observations of abuse. If the alleged violation is verified appropriate corrective action must be taken. <RESIDENT 143> Resident 143 admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 7 sampled residents (40, 11, 19, 28 and 27) reviewed for unnecessary medications. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included . <RESIDENT 40> Resident 40 admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder. Resident 40 admitted to the facility on an anti-depressant medication. A Level 1 PASRR (a screening to determine if a resident may have 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 3 of 3 residents (Residents 143, 147, and 85) and/or their representatives with a written summary of their baseline care plans (minimum healthcare information necessary to properly care for a new resident). This failure resulted in residents not being informed of their initial plan for delivery of care and services. Findings included . <RESIDENT 143> The resident admitted to the facility on [DATE]. According to their admission Minimum Data Set (MDS - an assessment tool,) assessment, dated 12/05/2023, they had no cognitive impairment. In an interview on 12/06/2023 at 1:32 PM, Resident 143 stated they had not been provided with a written summary of their baseline care plan, and they did not know which medications they were receiving or what the medications were for. Review of Resident 143's clinical record on 12/11/2023 showed no documentation the resident or their representative had been provided with a written summary of their baseline 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 Based on observations, interviews, and record reviews, the facility failed to provide assistance with activities of daily living (ADLs) for 3 of 3 sampled residents (Residents 59, 28, and 49) reviewed for ADL's. The facility failed to provide the necessary assistance with grooming (oral care) and assist with hearing needs placed residents at risk for unmet care needs and diminished quality of life. Findings included . <RESIDENT 59> Resident 59 admitted to the facility on [DATE] with diagnoses to include history of a stroke with right sided weakness, difficulty with swallowing and cardiac disease. Review of Resident 59's admission Minimum Data Set (MD - an assessment tool used to identify a resident's care needs), dated 10/24/2023, showed the resident required substantial/maximum assistance with mobility and oral hygiene. Review of Resident 59's care plan showed the resident required substantial assistance with personal hygiene and oral care. During an interview on 12/07/2023 at 11:34 AM, Collateral Contact 4,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services according to professional standards of practice for 6 of 10 residents (Residents 138, 143, 1, 3, 40, and 61) reviewed. The failure to perform resident weights as ordered, to push fluids as ordered, and to hold medications when indicated per physician ordered parameters placed residents at risk for unidentified weight loss/gain, dehydration, and for medication-related complications, and for not reaching their highest practicable well-being. Findings included . Review of the facility provider standard orders revised 03/31/2023 directed staff to hold cardiac medications if the systolic blood pressure (top blood pressure value) was less than 100. <RESIDENT 138> Resident 138 admitted to the facility on [DATE]. On 12/08/2023, a review of Resident 138's weight documentation showed they had been weighed only one time, on 12/04/2023. Review of Resident 138's November 2023 Medication Administration Records/Treatment Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's order with a prescribed oxygen (O2) flow rate (the amount of supplemental oxygen flowing over a certain length of time), indication for use was completed, and failure to ensure O2 tubing was regularly changed and dated for 1 of 3 sampled residents (Resident 27). Additionally, the facility failed to provide routine cleaning for a C-Pap (continuous positive airway pressure device used for breathing issues during sleep) and Bi-Pap (Bi Level Positive Airway Pressure) machine for 3 of 3 sampled residents (Residents 5, 27, and 49) reviewed for respiratory care. This failure placed residents at risk for respiratory distress, respiratory infection, and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, undated, stated the faciltiy would verify that there was a physician's order for this procedure. Review of the facility policy titled, CPAP/BiPAP Guidance, 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 interview and record review, the facility failed to ensure Licensed Nurses and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 3 of 4 staff (Staff K, L and M) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1). Staff K Nurse's Aide Certified (NAC),was hired 10/04/2023. Staff K's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 2) Staff L, Licensed Practical Nurse (LPN) was hired 05/27/2020. Staff L's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 3). Staff M, Registered Nurse (RN) agency nurse's training records 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.

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for three of four employees (D, E, and GG) files reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents. Findings included . Staff D was hired on 10/09/2014. Review of Staff D's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff D. In an interview on 12/12/2023 at 2:20 PM, Staff D said they had not had a performance evaluation this year. Staff E was hired on 07/11/2005. Review of Staff E's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff E. Staff GG was hired on 03/04/1993. Review of Staff GG's employee file showed there was no current employee evaluation done. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (138, 40, 11, 36) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). The failure to monitor residents for adverse side effects and appropriate target behaviors (any behavior that has been chosen or targeted for change) and to provide/obtain informed consent for treatment with psychotropic drugs placed residents at risk for receiving unnecessary psychotropic drugs and for not being fully informed of the risks/benefits/alternatives of treatment with psychotropic drugs. Findings included . <RESIDENT 138> The resident admitted to the facility on [DATE] with diagnoses to include depression and insomnia. Review of Resident 138's December 2023 Medication Administration Records/Treatment Administration Records (MARS/TARS) showed: - the resident was being treated with bupropion (an antidepressant medication). Additional review of the MARS/TARS showed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (%). Failure to timely administer 19 of 28 medications for 3 of 5 residents (47, 69, and 78) observed during medication pass audit resulted in a medication error rate of 67.86%. The failure to administer medications on time placed residents at risk for side effects and/or altered medication effectiveness. Findings included . Review of the facility's policy and procedure titled, Medication Administration General Guidelines dated 2007, showed medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. <RESIDENT 47> During a medication administration observation on 12/11/2023 at 8:26 AM, Staff V, LPN (Licensed Practical Nurse), prepared and administered to Resident 47: - Novolog insulin (a 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 administer medications timely for 5 of 6 residents (3, 238, 144, 28, 151) reviewed for medication timeliness. The failure to administer medications timely resulted in these residents having multiple significant medication errors and placed them at risk for medication-related complications and for diminished quality of life. Findings included . Review of the facility's undated policy titled Medication Administration, showed medications were to be administered within 60 minutes of the scheduled time, except before or after meal orders, which are to be administered based on mealtimes. <RESIDENT 3> Review of Resident 3's Medication Administration audit records, dated 12/01/2023 through 12/13/2023, showed Piperacillin intravenous (IV) antibiotic was scheduled to be administered at 7:00 AM, 3:00 PM, and 11:00 PM. Piperacillin was administered late on: -The 12/01/2023 11:00 PM does, was administered on 12/02/2023 at 12:44 AM. -The 12/02/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (first floor and second floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Additionally, the facility failed to ensure medications were secured for two of two residents (19, 61) observed with medications at bedside. This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life. Findings included . <MEDICATION ROOMS> During an observation on 12/07/2023 at 2:28 PM, the second floor medication refrigerator contained 29 Insulin pens, 11 Insulin vials,16 multi-dose Fluzone Influenza Vaccines 5 ML (milliliters), 2 multi-dose Tubersol (a prescription solution to test 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines (IPC) and standards of practice for 1 of 2 units (2nd floor) reviewed for IPC procedures. The facility failed to follow processes to prevent cross contamination during meal delivery in resident halls and to follow standards of practice related to hand hygiene and disinfection of multi-use equipment. These failures placed residents at risk for food borne illness and/or other infectious diseases. Findings included . <Meal Delivery> In an interview on 12/06/2023 at 9:06 AM, Resident 9 stated the facility changed the way they were delivering the beverages during meals. Resident 9 stated the beverages used to be on the trays and now they come in and ask you what you want, then they go down the hall to get it and carry it back uncovered. I don't feel like that is a very hygienic practice, I don't know what gets in there. In an observation of the lunch meal delivery on…

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

Based on record review and interview, the facility failed to develop, implement and maintain an in-service training program for 3 of 4 Nursing Assistant's (D, E and GG) reviewed for the required 12 hours of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs. Findings included . Review of Staff D, E, and GG's employee file showed each NAC did not have documented evidence of 12 hours of in-servicing. Review of the in-service records showed the facility failed to document how long the in-service lasted or the time it started. In an interview on 12/13/2023 at 3:08 PM, Staff A, Administrator, stated they were aware the 12 hours were not completed for the NAC's and they planned to pull the NAC's from the floor to get their education completed. Refer to 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 residents were treated with respect and dignity for 3 of 5 residents (Residents 3, 1, and 61) reviewed for resident rights. The facility failed to ensure staff interacted with residents in a dignified manner which placed residents at potential risk to experience emotional distress, humiliation, embarrassment, and a diminished quality of life. Findings included . The Cambridge English Dictionary, dated April 28, 1995, defines Dignity as The quality of a person that makes him/her deserving of respect, sometimes shown in behavior or appearance. According to Washington State Long-Term Care Ombudsman Program website 12/15/2023, People who live in long-term care facilities are more vulnerable than people who live independently. In 1987, the U. S. Congress recognized this fact and passed The Nursing Home Reform Act that gave nursing home residents additional legal protections, including a set of Resident Rights. Resident rights include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 information and/or resources to residents to assist with the development of an Advanced Directive (AD) for 2 of 4 sampled residents (Residents 59 and 61) reviewed for AD. This failure denied residents the opportunity to appoint someone to make choices regarding finances and/or healthcare decisions if the residents became unable to make their own decisions. Findings included . Review of a facility policy, titled, Advanced Directives, revised date 10/13/2022, showed the resident would be provided written information concerning the right to formulate an AD. <RESIDENT 59> Resident 59 admitted to the facility on [DATE]. Review of Resident 59's electronic medical record (EMR) on 12/07/2023 at 11:15 AM, showed no record of an AD. <RESIDENT 61> Resident 61 initially admitted to the facility on [DATE]. Review of Resident 61's EMR on 12/08/2023 at 8:34 AM, showed no record of an AD. During an interview on 12/08/2023 at 8:39 AM, Staff A, Administrator,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain documentation regarding a grievance for 1 of 2 residents (Resident 49) reviewed for grievances. This failed practice placed the resident at risk for not having their grievance resolved and for diminished quality of life. Findings included . <RESIDENT 49> The resident admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment (an assessment tool), dated 12/05/2023, the resident had no cognitive impairment. In an interview on 12/12/2023 at 2:08 PM, Resident 49 stated they were missing a shirt, a pair of pajama bottoms, and their hearing aids. Review of the facility grievance log, dated October 2023, showed there was a grievance from Resident 49 regarding missing property. In an interview on 12/13/2023 at 2:06 PM, Staff A, Administrator, was unable to provide the investigation of the resident's grievance and stated they had lost the paperwork regarding Resident 49's grievance. Refer to WAC 388-97-0460 (2) .

Based on interview and record review, the facility failed to implement their Abuse policy by not ensuring reference checks were conducted prior to hire for 2 of 5 employees (Staff J and T) reviewed for reference checks. These failures placed residents at risk for abuse, neglect, or mistreatment by staff. Findings included . Review of a facility policy titled, Abuse, revised date 10/20/2022, showed the facility would screen potential employees for a history of abuse, neglect, or mistreating residents by obtaining employment references. <STAFF J> Staff J was hired on 03/01/2023 as a Nursing Assistant Registered. Review of Staff J's employee file showed there were no professional or personal reference checks completed. <STAFF T> Staff T was hired on 04/01/2023 as a housekeeping aide. Review of Staff T's employee file showed there were no professional or personal reference checks completed. During an interview on 12/12/2023 at 10:43 AM, Staff P, Human Resource Manager, stated they were unable to find any reference checks in Staff J or Staff T's employee files. This is a repeat citation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess 2 of 5 sampled residents (Residents 19 and 59) reviewed for Minimum Data Set (MDS - a required assessment used to identify resident's care needs) accuracy. Failure to ensure accurate assessments regarding dental/oral status and behavioral health indicators placed residents at risk for unidentified and/or unmet care needs, and inaccurate or incomplete care plans. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11 v6, dated October 2023, steps for assessment of Oral/Dental Status included: . Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining <RESIDENT 59> Resident 59 was admitted to the facility on [DATE] with diagnoses to include a history of stroke with right sided weakness. Review of Resident 59's admission MDS assessment, dated 10/24/2023, showed no dental concerns, No Obvious or likely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive care plan for 2 of 2 residents (Residents 1 and 61) in the areas of pacemaker and dialysis. This failure placed residents who had a pacemaker and were on dialysis at risk for unmet care needs. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart disease and an irregular heart rhythm with a cardiac pacemaker (a small device that helps the electrical events of the heart). Review of Resident 1's care plan, dated 10/27/2023, showed their pacemaker was not included on the care plan. In an interview on 12/13/2023 at 12:10 PM, Resident 1 said they have had their pacemaker for three years now and the battery was supposed to last ten years. Review of the resident's clinical record revealed there was no record of pacemaker information, or a pacemaker check being completed or scheduled. <RESIDENT 61> Resident 61 admitted [DATE] with a diagnosis to include end stage renal failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's request to change their code status (level of intervention a resident wishes to have started if their heart or breathing stops) for 1 of 1 resident (Resident 85) reviewed for Cardiopulmonary Resuscitation (CPR - staff performing chest compressions and providing breaths to mimic heartbeat and breathing). This failure placed residents at risk to have CPR initiated when they had requested to change their status to No CPR. Findings included . Review of the facility's undated policy, titled, Cardiopulmonary Resuscitation, showed a resident's code status would be reviewed periodically, with care plan review or any time the resident requests to change their decision. Resident 85 admitted to the facility on [DATE]. Review of the Portable Orders for Life-Sustaining Treatment (POLST) form, a form designated a resident's code status and other treatment options, showed Resident 85 requested to have Full Treatment including CPR initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative/rehabilitative treatment/services for 1 of 1 residents (Resident 11) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function. Findings included . Review of the facility policy (undated) titled: Range of Motion Exercises, stated that Range of Motion exercises would be provided by qualified nursing staff. The policy stated documentation should include the time spent on the exercise, how the resident tolerated the exercise, problems or compiaints and if the resident refused. <RESIDENT 11> Resident 11 admitted [DATE] with diagnoses which included Bipolar Disorder (a mood disorder), other psychotic disorder, dementia, and contracture (permanent shortening of a muscle) of the left hand. Review of the resident's care plan showed: RESTORATIVES: ROM:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two residents (47 and 61) reviewed for dialysis, received consistent ongoing communication and collaboration with the dialysis center. The facility further failed to document before and after-dialysis assessments of resident's condition, which placed the residents at risk for unmet care needs and dialysis related complications. Findings included . Review of the facility's policy titled, Hemodialysis Access Care, undated, showed that facility was committed to following current Centers for Medicare and Medicaid (CMS) guidelines, and clinical standards of practice providing care for residents with End Stage Renal Disease receiving hemodialysis at an outpatient dialysis facility. Nursing staff will care for, prevent infection and maintain patency (preventing clots) to the AVF (arteriovenous fistula), provide care immediately following dialysis treatment, and monitor and document the dialysis site type, patency, observing for signs of…

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

Based on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) license completed a Nursing Assistant Certified (NAC) class and passed the state license exam within four months of hire for 1 of 2 NAR's (Staff J) reviewed for staff licenses. This failure placed residents at risk to receive care from unlicensed staff. Findings included . Record review of the facility staff list showed Staff J was hired on 03/01/2023 as a Nurse Aide Trainee. Review of the daily staff assignment sheets from 12/01- 12/07/2023, showed that Staff E worked from 6 AM - 2 PM on 12/01/2023, 12/04/2023, 12/05/2023, and 12/06/2023. During an interview on 12/12/2023 at 10:43 AM, Staff P, Human Resource Manager, stated Staff J had a current NAR license, but had not yet taken the state test to become a NAC. Staff P confirmed Staff J's hire date of 03/01/2023 and that they had been working as a NAR until 12/07/2023. WAC Reference: (WAC) 388-97-1660 (2)(b), (3)(a)(i) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, and administering of all drugs) to meet the needs of each resident for two of two residents (40 and 147). Failure to ensure timely receipt and administration of ordered medications placed Residents 40 and 147 at risk for discomfort, pain and a decline in their physical health. Findings included . <RESIDENT 40> Resident 40 admitted [DATE] with diagnoses to include low back pain, left and right foot pain and chronic pain. Review of the physician's orders directed nursing staff to administer Suboxone film sublingually (under the tongue) every eight hours as needed for opioid dependance. Suboxone was a controlled drug (scheduled 3 substance that required facility to keep under double lock and account for each shift change). Review of a progress note dated 12/05/2023 at 5:17 PM, showed Resident 40 requested a dose of Suboxone in the morning and 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 2 of 5 residents (138, 27) remained free of unnecessary drugs. The failure to monitor for adverse side effects of medications and to provide non-pharmacological pain interventions placed the residents at risk for medication-related complications and for receiving unnecessary pain medication. Findings included . <RESIDENT 138> The resident admitted to the facility on [DATE] with diagnoses to include a stroke. Review of Resident 138's November and December 2023 Medication Administration Records/Treatment Administration Records (MARS/TARS) showed the resident was being treated with apixaban (an anticoagulant medication used to thin the blood to treat blood clots and to prevent/treat strokes). Review of the MARS/TARS showed no documentation the resident was being monitored for adverse side effects of the apixaban. In an interview on 12/08/2023 at 2:26 PM, Staff C, Registered Nurse/Resident Care Manager, stated they should have been monitoring 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 follow standards of practice for completing physician orders upon admission and medication administration for 1 of 1 residents (Resident1) reviewed for medication orders. Failure to transcribe orders accurately upon admission, failure to document when new orders were obtained and why, and failure to administer medications per orders placed residents at risk of exacerbation of acute medical problems. Findings included . Resident 1 admitted to the facility on [DATE] with diagnosis of diabetes (abnormal processing of sugar in the body), stroke, spinal stenosis (narrowing of spinal canal which causes pressure and pain on spinal cord), and low back pain. Review of the hospital Discharge summary, dated [DATE], showed Resident 1's medication orders were included: metformin (diabetic medication) 500 milligram (mg) once daily and to increase to 500mg twice a day on 10/07/2023, acetaminophen (pain medication) 650mg three times a day for pain, and levetiracetam…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate management of diabetes for 1 of 1 residents (Resident 1) reviewed for diabetes management. Failure to educate resident and/or resident representative on diabetes management such as diet, monitoring blood glucose (BG), use of glucometer (device to test blood glucose), and side effects of diabetes medications placed residents at risk of complications. Findings included . Review of a facility policy titled, Diabetes Management-Nursing Care of the Older Adult, dated 10/01/2021, showed the resident/resident representative be educated on diabetic management to include medications, dietary restrictions, and identification of hyperglycemia (elevated BG level)/hypoglycemia (low BG level). Resident 1 admitted to the facility on [DATE]. Review of the hospital Discharge summary, dated [DATE], showed resident had a new diagnosis of diabetes that was diagnosed during the hospital stay and was started on metformin (diabetic medication). During 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.