Lynnwood Post Acute Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident assessments were completed accurately for 2 of 10 residents (Residents 23 & 46), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding medication use and dialysis (a process of removing excess water and toxins from the blood in people whose kidneys [organs that filter blood, remove waste and balance fluids in the body] can no longer perform these functions) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 1 of 6 residents (Resident 108), reviewed for PASARR screening. These failures placed the resident at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.Findings included .Review of the facility's policy titled, PASRR screening for Serious Mental Illness/Intellectual Disability, revised on 07/03/2025, showed that It is the policy of this facility to establish a PASRR process to.screen for possible serious mental disorders, intellectual disabilities, and…

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

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 1 of 6 residents (Residents 109), reviewed for respiratory care. The failure to obtain accurate oxygen orders placed the residents at risk of respiratory related complications and a diminished quality of life.Findings included .Review of the facility's policy titled, Oxygen Administration, revised in February 2023, showed that It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. It further showed that the first step for oxygen administration was obtain appropriate physician's order.Review of Resident 109's physician orders showed an order for Oxygen via mask at 3-4 [three to four] LPM [Liters per minute-a unit of measurement] continuously.Observations on 06/30/2025 at 9:01 AM, on 07/01/2025 at 1:55 PM, and on 07/02/2025 at 8:28 AM, showed Resident 109 was receiving six LPM of oxygen via nasal cannula (flexible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was less than five percent (%). The failure to properly administer 3 of 25 medications for 2 of 5 residents (Residents 40 & 6), observed during medication administration resulted in a medication error rate of 12%. This failure placed the residents at risk for not receiving the correct form, dose, and/or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.Findings included .Review of the facility's policy titled, Administration Procedures for all Medications, dated May 2022, showed the facility policy was, To administer medications in a safe and effective manner. The policy further showed staff should review the five rights three times; prior to removing the medication from the cart/drawer check the Medication Administration Record (MAR) for the order, and checking prior to removing the medication from the container, and after the dose has been prepared.RESIDENT 40 Review of Resident 40's physician orders printed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 4 residents (Resident 39) and failed to discard a laboratory sample for 1 of 1 discharged resident (Resident 164), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included .Review of the facility's policy titled, IPCP [Infection Prevention & Control Program] Standard and Transmission Based Precautions, revised in October 2022, showed EBP precautions indicated to use gown and gloves during high-contact resident care activities. The policy further showed that high-contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting. Additionally, 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 inform the resident and/or their representative about a high carbon dioxide (C02-a form of natural waste produced by the body and breathe out by the lungs) blood test level for 1 of 1 resident (Resident 1), reviewed for change in condition. This failure placed the resident and/or their representative at risk of not being provided adequate information to make informed decisions about their medical condition. Findings included . Review of the facility's policy titled, Best Practice in Change of Condition and Endorsement, revised in January 2025, showed, Physician, resident, and responsible party will be notified of any changes in resident status or condition. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/20/2025 showed Resident 1 had intact cognition with diagnosis that included chronic respiratory failure with hypoxia (a medical condition that occurs when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of a laboratory test results 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 1 of 1 resident (Resident 1) was free from a significant medication error. The failure to provide a medication (Apixaban - used to prevent blood clots) placed Resident 1 at risk for complications with heart disease, a decline in medical condition, and a diminished quality of life. Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility from a local hospital on [DATE] with a diagnosis list that included Atrial Fibrillation (or A-fib, a form of an abnormal heartbeat). The MDS also showed the resident had impaired thinking. In an interview on 08/05/2024 at 9:37 AM, Resident 1's Collateral Contact stated that Resident 1 did not receive their heart medication [Apixaban] for a few weeks after admitting to the facility and that they had a heart condition that required the medication to be given twice a day to prevent problems with their heart. 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.

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked, actual hours worked and included the census for 30 of 30 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members and visitors, at risk of not being fully informed of the current staffing levels. Findings included . Observation on 07/15/2024 at 9:32 AM, showed that the Daily Nursing Staffing Information posting did not include the census and the actual hours worked. The column under Actual Hours worked were the same numbers under the column # [number] Staff. Additional observations on 07/16/2024 at 8:37 AM, 07/17/2024 at 9:08 AM, 07/18/2024 at 8:33 and 07/19/2024 at 8:59 AM, showed that the Daily Nursing Staffing Information posting did not include the actual hours worked. The column under Actual Hours worked were the same numbers under the column # [number] Staff. Record review of the Daily Nursing Staffing Information 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 provide a written transfer/discharge notice to the residents and/or representatives for 3 of 4 residents (Residents 45, 47 & 46), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharges. Findings included . Review of the facility's policy titled, Discharge and Transfer, revised in February 2016, showed that transfer or discharge of a resident will be in writing, in language the resident understands and be given to the resident, resident's surrogate decision maker, if any, and the resident's family. RESIDENT 45 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 05/19/2024, showed Resident 45 was admitted to the facility on [DATE]. Review of the nursing progress note dated 07/12/2024 showed that Resident 45 was sent to the emergency room due to bleeding. Review of the Electronic Health Record (EHR) did not show documentation that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure bed hold (the opportunity to pay for the bed the resident currently occupied while out of the facility in order to ensure their bed/room was available when they are ready to return) notices were offered to residents and /or their representatives for 3 of 4 residents (Residents 45, 47 & 46), reviewed for hospitalization. This failure placed residents at risk for unwanted, avoidable room changes upon readmission, and frustration. Findings included . Review of the facility's policy titled, Bed-Hold, revised in December 2023, showed that the resident or their representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or at the start of a resident's therapeutic leave. The policy further showed that the notice shall include the duration of the State bed hold policy (if any) and /or of the facility's policy that the resident's bed will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for staff to assist residents in need) was within reach for 1 of 1 resident (Resident 102), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life. Findings included . Review of the facility's policy titled, Call Light/Bell, revised in May 2007, showed, Place the call device within resident's reach before leaving room. Review of the admission minimum data set (an assessment tool) dated 07/07/2024, showed Resident 102 admitted to the facility on [DATE]. Observations on 07/16/2024 at 8:33 AM and at 12:18 PM, showed Resident 102's call light was on the floor next to their bed. Observation on 07/16/2024 at 12:19 PM, showed Staff O, Certified Nursing Assistant (CNA), entered Resident 102's room and asked the resident if they needed help with their meal. The call light was still on the floor when Staff O exited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 37 & 102), reviewed for advance directives. Additionally, the facility failed to ensure the resident's right to refuse/discontinue medication for 1 of 1 resident (Resident 253). These failures 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 facility's policy titled, Advance Directives, revised December 2023, showed that Advance Directive is a written instruction that relates to the provision of health care when the individual is incapacitated, such as a living will, DPOA for health care. These documents allow 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 identify, initiate, thoroughly investigate, and promptly resolve a grievance for 1 of 1 resident (Resident 17), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Grievances, revised in March 2019, showed, Resident and/or Resident Representatives have the right to file grievances orally or in writing. It further showed that grievance forms are available and are to be initiated when concerns are made. Review of the facility's policy titled, Personal Inventory/Missing Items, revised in May 2017, showed a grievance form will be filled out and processed for all non-theft/non abuse allegations. Review of the annual minimum data set (an assessment tool) dated 05/05/2024, showed that Resident 17 admitted to the facility on [DATE]. It further showed that Resident 17 was dependent for transfers and used a manual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written summary of the baseline care plan was provided to the residents and/or their representatives for 2 of 2 residents (Residents 49 & 102), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in December 2023, showed, within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The policy further showed, the facility team would provide a written summary of the baseline care plan to the resident and their representative and would be provided by the time of the completion of the comprehensive care plan. The comprehensive care plan is developed within seven days of completion of the comprehensive Minimum Data Set (MDS-an assessment…

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

Based on observation, interview, and record review, the facility failed to meet professional standards of practice to ensure 2 of 2 licensed staff (Staff P & Staff F) observed for medication administration followed medication administration practices regarding unlabeled and undated medication at a resident's bed side and pain medication patch application. These failures placed the residents at risk for possible medication errors, potential negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, revised in January 2018, showed, when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated and the nurse shall place a 'date opened' sticker on the medication and enter the date opened. It further showed that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility's policy titled, Specific Medication 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 interview and record review, the facility failed to complete required annual performance evaluations for 1 of 3 staff (Staff J), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. Failure to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs. Findings included . Review of Staff J, CNA, personnel file on 07/17/2024 showed that they were hired on 07/23/2018 and transferred to the facility on [DATE]. The facility was not able to provide documentation that an annual performance evaluation was completed as required. On 07/18/2024 at 1:57 PM, Staff B, Director of Nursing, stated that staff performance evaluations were completed yearly. Staff B stated that they were new to the facility and that they thought it was unfair for them to evaluate staff when 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 observation, interview, and record review, the facility failed to ensure expired medication was disposed of timely in accordance with current accepted professional standards for 1 of 2 medication carts (Cascade Hall Cart) and the facility failed to appropriately label and store drugs or biologicals (diverse group of medicines made from natural sources) for 1 of 2 residents (Resident 20) reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage In The Facility, revised in January 2018 showed that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. It showed that certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require 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 observation, interview, and record review, the facility failed to ensure hand hygiene and infection control practices were followed during meal tray pass for 2 of 7 staff (Staff O and Staff G), failed to ensure Personal Protective Equipment (PPE-special equipment worn to protect from germs) protocols were followed for 1 of 3 staff (Staff G), and failed to ensure medical equipment was disinfected between resident use for 1 of 2 staff (Staff H) reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's undated policy titled, Hand Hygiene, showed, the facility considers hand hygiene the primary means to prevent the spread of infections. It further showed to sanitize hands with alcohol-based hand rub or soap and water before and after direct contact with residents and after contact with objects in the immediate vicinity of the resident. HAND HYGIENE/MEAL TRAY PASS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pneumococcal vaccine (used to prevent pneumonia [a lung infection]) and influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were provided for 1 of 5 residents (Resident 34) reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and/or influenza disease. Findings included . Review of the facility's policy titled, Immunizations-Residents, revised in July 2023, showed, It is the policy of this facility to offer and administer influenza, pneumococcal .immunization to eligible residents. It further showed, Residents admitted late in the influenza season [typically February or March] should be offered the influenza vaccine as late season outbreaks do occur. Review of the face sheet printed on 07/24/2024, showed Resident 34 admitted to the facility on [DATE]. Review of the…

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

Based on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE - gloves, N95 respirator/mask, gown and face shield/goggles), perform hand hygiene, and follow infection control precautions during COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) outbreak in accordance with the Centers for Disease Control (CDC) guidelines for 2 of 10 staff (Staff E & F), and failed to report COVID-19 outbreaks to the Department of Social and Health Services (DSHS) as required for 2 of 3 COVID-19 outbreaks (August 2023 and December 2023), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk of infection and related complications. Findings included . According to the CDC guidance, How to use Your N95 Respirator, updated on 03/16/2022, N95 masks must form a seal to the face to work properly. The document showed the mask should be placed with the top strap pulled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary assistance for bathing/showering for 1 of 5 residents (Residents 3), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, poor hygiene, skin impairment, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised on July 2015, showed that when developing plans of care for ADLs, ascertain individual's resident preferences to ensure the interventions are personalized to ensure such things as day/time/type of bathing and any other ADL/quality of life choice that is important to the resident. Additionally, it showed that nursing assistants will assist with ADL based on the resident's individualized plan of care. Resident 3 admitted to the facility on [DATE]. Review of Resident 3's ADL care plan dated 09/15/2023, showed Resident 3 required one-person maximum assistance with bathing. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written abuse policies and procedures related to allegations of abuse for 1of 3 residents (Resident 1) reviewed for abuse. This failure had the potential for Resident 1 to experience on-going abuse, harm, and a diminished quality of life. Findings included . A review of the facility's policy titled, Policy/Procedure-Abuse Prevention/Investigation, revised on 04/2019, showed as soon as a report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse. Further review of the policy showed the investigation will be completed in five days. Review of the admission Minimum Data Set assessment (a required assessment tool) dated 08/15/2023 showed Resident 1 was admitted to the facility on [DATE] and required assistance with all care and mobility. Review of Collateral Contact 2's (CC2) written report dated 11/03/2023 showed Resident 1 reported they were touched inappropriately, and it made them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of abuse was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 1), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy and procedure for Abuse Prevention and Investigation, revised on 04/2019, showed employees are mandated reporters and are required to report to the State agency. Resident 1 admitted to the facility on [DATE]. Review of Collateral Contact 2's (CC2) written report dated 11/03/2023, showed Resident 1 reported they were touched inappropriately, and it made them feel uncomfortable. Resident 1 also said an unknown staff member that worked at the facility threw them on the floor. Further review of CC2's written report showed CC2 notified the Director of Nursing Services (Staff A) of Resident 1's abuse allegations that day. Review of the November…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate allegations of abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse Prevention and Investigation, revised on 04/2019, showed that as soon as a report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse. Resident 1 admitted to the facility on [DATE]. Review of Collateral Contact 2's (CC2) written report dated 11/03/2023, showed Resident 1 stated that they were touched inappropriately and was thrown on the floor by an unknown staff member in the facility. Further review of CC2's written report showed that Staff A, Director of Nursing, was informed of what Resident 1 had stated to CC2. Review of the September 2023 to November 2023 Incident log, did not show that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were followed according to professional standards of practice for 4 of 5 residents (Residents 1, 3, 2 & 4) reviewed for respiratory care. The failure to transcribe and/or follow physician's orders for respiratory care, routinely change oxygen tubing, and initiate/review respiratory care plans placed the residents at risk of unmet care needs, respiratory infections, and related complications. Findings included . Review of the Oxygen Administration policy dated 07/2019, showed that oxygen therapy is administered as ordered by the physician and oxygen tubing is to be replaced every seven days or when visibly soiled. PHYSICIAN ORDER FOR USE OF OXYGEN RESIDENT 1 Review of the physician/transfer orders dated 07/20/2023, showed Resident 1 admitted to the facility that day with a diagnosis that included chronic respiratory failure with hypercapnia (a buildup of carbon dioxide in the blood). The transfer orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 5 of 9 residents (Residents 412, 112, 562, 312 & 313) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Baseline Care Plan revised in May 2021 showed that within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The policy also showed that facility team will provide a written summary of the baseline care plan to the resident or resident representative. RESIDENT 412 Resident admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label and store medications (no open date or not dating medications after opening it) and failed to ensure expired medical supplies were disposed of timely in accordance with current accepted professional standards for 2 of 2 medication carts (Sound & Cascade Medication Carts) and 1 of 1 medication storage room observed. These failures placed the residents at risks of receiving compromised medical supplies and experience adverse side effects. Findings included . Review of the policy titled, Medication Storage Policy/Procedure, revised in [DATE] showed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of the undated Advair manufacturer's instructions showed to Safely throw away ADVAIR DISKUS in the trash 1 month after you open the foil pouch on when the counter reads zero, which ever comes first. SOUND…

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

Based on observation and interview, the facility failed to ensure the kitchen thermometer was properly sanitized between use for 1 of 1 kitchen. This failure placed the residents at risk for cross contamination, food borne illnesses [an illness caused by the ingestion of contaminated food or beverages], and a diminished quality of life. Findings included . A joint observation with Staff E, Dietary Manager, on 04/10/2023 at 11:19 AM, showed, Staff P, Cook, took temperature of prepared foods for the lunch meal. Staff P cleaned/sanitized the kitchen thermometer with a new alcohol wipes before checking the temperature of the meat spaghetti sauce and then cleaned/sanitized the thermometer with the same alcohol wipes. Staff P then checked the temperature of the steamed vegetables, chopped spaghetti noodles mixed with meat sauce, chicken noodle soup, and white steamed rice using the same alcohol wipes when sanitizing the thermometer in-between these food items. Staff P then cleaned/sanitized the thermometer using a new alcohol wipe. On 04/10/2023 at 11:30 AM, Staff P stated that they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician's order and complete a self-medication administration assessment for 1 of 1 Resident (Resident 112) reviewed for medication at the bedside. The failure to complete a self-administration assessment and obtain a physician's order placed the resident at risk for medication errors and adverse medication interactions. Findings included . Review of the facility's policy titled, Self-Administration of Medications revised May 2016 showed that if a resident desires to participate in self-administration, the interdisciplinary team will assess the resident ability to self-administer medications. If the resident is a candidate for self-administration of medications, a physician's order will be obtained. Resident 112 admitted to the facility on [DATE] with diagnosis that included unspecified asthma (a chronic disease in which the airways in the lungs become narrowed and swollen, making it difficult to breathe). Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD) was obtained from the residents/representatives who have an AD in place and ensure a copy was readily available in the medical records for 1 of 1 resident (Resident 18) reviewed for advance directives. This failure placed the resident at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations. Findings included . An advance directive (AD) is a written instruction, such as a living will (LW) or durable power of attorney (DPOA), relating to the provision of health care when an individual is incapacitated. Review of the facility policy titled, Advance Directives, revised in November 2016, showed that Prior to, upon, or immediately after admission, the admission Nurse or Social Services will ask residents, and/or their family member, about the existence of any advance directives. Should the resident indicate that he or she/has issued advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a timely significant change in status Minimum Data Set (MDS) assessment for 1 of 9 residents (Residents 47) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, which has an impact on more than one area of the resident(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 1 of 15 residents (Resident 313) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments for pressure injury placed the resident at risks for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 PM on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents consistently received bathing/shower and personal hygiene per their plan of care for 2 of 3 residents (Residents 4 and 112) reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk for poor hygiene, decreased self-esteem, and diminished quality of life. Findings included . Review of the facility policy for ADLs, revised in July 2015 showed, Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care .ADL support and resident performance will be documented electronically using Point of Care (POC) .If a resident chooses to decline an intervention in the plan of care, the licensed nurse and social services will be notified. The IDT [Interdisciplinary Team] will review the plan of care with the resident in an effort to find alternative means to address the need. RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnosis that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to do skin evaluations, implement monitoring and interventions for skin care for 1 of 2 residents (Resident 25) reviewed for skin conditions. Additionally, the facility failed to assess and maintain weight-bearing restrictions for 1 of 4 residents (Resident 44) reviewed for limited mobility and positioning. These failures placed the residents at risk for unmet care needs and a diminished quality of care. Findings included . Review of the policy titled, Skin Care Policy/Procedure, revised in June 2016 stated that all residents will have a head-to-toe skin check performed weekly by a licensed nurse. The license nurse should document the findings. Any skin issues identified on the weekly skin check should be documented and responded to. Additionally, it stated that Licensed nurse should document skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper care of nebulizer tubing/mouthpiece (a type of equipment used to deliver a medicine into a fine mist that is breathed in) for 1 of 1 resident (Resident 4) reviewed for respiratory care. The failure to ensure nebulizer tubing/mouthpiece were replaced and/or stored properly when not in use placed the resident at risk for respiratory infections and related complications. Findings included . Resident 4 admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD - a lung disease where the small airways in the lungs are damaged causing shortness of breath [SOB]). Review of the annual Minimum Data Set (an assessment tool) dated 01/06/2023 showed Resident 4 had impaired cognition and required one-person extensive assistance for activities of daily living. Review of Resident 4's April 2023 Medication Administration Record showed the following: Albuterol Sulfate (a drug used to prevent…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with actual hours worked for each shift for 30 out of 30 days reviewed for sufficient and competent staffing. This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels and census information. Findings included . Observations on 04/05/2023 at 8:25 AM, 04/06/2023 at 8:01 AM and 04/07/2023 at 8:34 AM, showed the facility's daily nursing staffing form located on the wall to the right of the main entrance did not display the actual nursing staff hours worked for previous shifts. Observations on 04/10/2023 at 3:15 PM, 04/11/2023 at 3:00 PM and 04/12/2023 at 2:00 PM, the facility's daily nursing staffing form located on the wall to the right of the main entrance did not display the actual nursing staff hours worked for previous shifts. Review of the daily nursing staffing information form from 03/08/2023 to 04/09/2023 had no actual and/or total hours worked…

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