Marysville Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that services provided met professional standards for 2 of 3 (Resident 6 and 70) residents reviewed for professional standards. Resident 6 did not receive prescribed bowel medications when they experienced constipation and Resident 70 had a change in condition that required monitoring and new medication orders that were not documented timely. These failures placed residents at risk of not being appropriately monitored during a change in condition, effectiveness or side effects of new medications, constipation, pain, and a decreased quality of life. Findings included. Review of the facility policy titled Bowel Protocol, revised date 09/16/2024, documented the facility in coordination with the resident's attending practitioner would implement standing orders to address a lack of bowel movement. <RESIDENT 6> Resident 6 readmitted to the facility on [DATE]. Review of Resident 6's bowel elimination record from 09/09/2025 to 09/23/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 86), reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing), had consistent, completed and accurate assessments on the facility's dialysis communication form (a form containing vital information about the resident which is sent to the dialysis center for coordination of care and services). This failure placed the resident at risk for medical complications and unmet care needs.Review of facility policy Area of Focus: Dialysis, dated 11/19/2024 documented to initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident, obtain vital signs of the resident upon return from dialysis and complete the Pre/Post Dialysis Communication Form, and to maintain dialysis transfer form in the resident's medical record.Findings included.<RESIDENT 86>Resident 86 was admitted to the facility on [DATE] with diagnoses to 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 develop a dementia care plan that addressed the significant mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 2 residents (Resident 5) reviewed for dementia care. These failures placed residents at risk for unmet psychosocial needs, increased behaviors and decreased quality of life.Findings included .Review of the facility policy titled Care of the Cognitively Impaired (Dementia Care) reviewed 09/02/2025 documented the facility's procedure to provided dementia care services included the following:I . Identify, address, and/or obtain necessary services for the dementia care needs of residents;2. Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment;3. Develop individualized interventions related to the resident's symptomology and rate 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 and interviews, the facility failed to ensure 1 of 4 medication carts and treatment carts (Pilchuck unit) had secured medications. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse.Findings included.<PILCHUCK TREATMENT CART>On 09/25/2025 at 11:12 AM observed the Pilchuck unit treatment cart unlocked. The treatment cart was in front of the Pilchuck nurse's station. All drawers opened and contained creams and ointments in the top drawer. There were several staff, to include two housekeepers and Staff M, Nursing Aide Certified, who walked by the opened treatment cart. Staff N, Registered Nurse (RN), was assigned to Pilchuck unit, was not within sight of the cart and was located on the second hallway of Pilchuck. Staff N was located exiting a resident's room when asked to check the treatment cart. Staff N stated they had not used the treatment cart, but then stated they had, and it had not been open for more than 10-15 minutes. Staff N stated the cart does not always lock when pushed in. Staff N…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 1 of 4 residents (Resident 1) reviewed for care planning. The failure to ensure the comprehensive care plan was person-centered to maintain and or attain the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their needs, adverse health effects and a decreased quality of life. Findings included .<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses to include nontraumatic intracranial hemorrhage (bleeding within the [NAME]), atrial fibrillation (irregular heartbeat), and presence of prosthetic heart valve, and long term (current) use of anticoagulants (blood thinning medication).Review of Resident 1's medication orders on 07/16/2025, documented Resident 1 had a medication order for Warfarin (a blood thinning medication) for a diagnosis of prosthetic heart valve. Review of Resident 1's comprehensive 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 a resident record was provided for review in a timely manner to the legal representative for 1 of 1 sampled resident's (Resident 1) reviewed for requested medical records. This failure placed the legal representative at risk for not having full clinical information about the resident in order to best represent them and make informed decisions. Findings included . Review of facility policy titled, Disclosure of Protected Health Information (PHI)-Release of Information, revised 02/26/2025, documented: - Each resident has the right to access their PHI contained in the medical record. The policy stated requested copies of a resident's record should be provided within two working days (excluding weekends and/or holidays) if the resident currently resides at the facility unless state law mandates a shorter period. - In accordance with 42 CFR 483.10(b)(2), a request may be made orally by the resident/legal representative. - Review the copy fee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to review risks and benefits with the resident's legal representative for 1 of 3 residents (Resident 1) reviewed for psychotropic medication use. Failure to review the risk and benefits of a high-risk medication placed the resident at risk for unnecessary medication use and diminished quality of life and this failure placed the legal representative at risk for not having full clinical information about the resident to best represent the resident and make informed decisions. Findings include . <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include intercranial hemorrhage (bleeding within the [NAME]), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis (muscle weakness of partial paralysis) of left side, bipolar disorder, depression and anxiety. Resident 1 had a legal guardian as their responsible party and made decisions for the 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 conduct a thorough investigation for 2 of 5 sampled Residents (Residents 1 and 2) reviewed for incident investigations. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to incidents and investigations placed residents at risk for unidentified abuse or neglect, risk for injury, monitoring and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 thorough investigation for 1 of 2 sampled Residents (Resident 1) reviewed for abuse/neglect and skin concerns. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to Resident 1's incidents, placed the resident at risk for unidentified abuse or neglect, risk for injury, and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 17> Resident 17 admitted to the facility on [DATE] with diagnoses that included weakness, diabetes mellitus type two (condition in which the body had trouble controlling blood sugar), and arthropathic psoriasis (a type of arthritis that affects people with the skin condition psoriasis). Review of Resident 17's progress note dated 08/23/2024 showed the resident had been seen by a dentist and were started on an antibiotic medication for a dental infection. Review of Resident 17's electronic and paper medical record showed no consultation report regarding their visit to the dentist on 08/23/2024. In an interview on 10/10/2024 at 8:47 AM Staff N, Unit Coordinator, stated they send out a blank consultation report with residents when they leave the facility for an appointment, and they rarely get returned. Staff N stated they were not aware of a process to follow up with the outside provider to obtain records related to a resident's appointment. In an interview on 10/11/2024 at 9:04 AM Staff B, DNS, 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 interview and record review the facility failed to properly implement the compliance and ethics program, prevent the submission of data/documentation known to be inaccurate and unethical practice for eight of ten residents (Residents 14, 22,33,36, 42, 58, 60 and 67) reviewed for therapy missed visit documentation. This failure placed residents at risk of not receiving appropriate physician ordered therapy services and potential decline in condition. Findings included . Review of the facility's policy titled Compliance and Ethics Program dated 06/01/2024, showed the facility and associates are committed to providing quality care and services necessary to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. The facility is also firmly committed to preventing fraud and abuse, complying with all applicable Federal and state laws and regulations and ethical behavior. The policy also showed Falsification of Documentation - Documentation of care or service that…

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

Based on observation, interview, and record review, the facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved timely for 2 of 3 residents (Residents 1 and 2) reviewed for grievances. Facility failure to ensure missing personal items were found or replaced and resident representative comfort concerns were addressed placed residents at risk for missing property, discomfort and a decreased quality of life. Findings included . Review of the facility policy titled, Grievance Program (Comment and Concern reviewed date of 09/26/2024 showed: -Comment and concern program was utilized to address concerns of residents, family members, visitors and guests. -Any associate (staff) could assist in the completion of the comment and concern form and resolved the concern if possible and report all concerns to the supervisor on duty who will then contact the Administrator and Director of Nursing. <RESIDENT 1> Resident 1 admitted to the facility with diagnoses that included lung cancer, malnutrition, and spinal stenosis (spaces inside the bones 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission 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 receive the services they need in those settings), was followed for 1 of 6 sampled residents (Resident 17). Failure to accurately complete a level one PASRR for Resident 17 and refer for a level two (an in-depth evaluation to determine whether the resident required specialized rehabilitation services) as indicated placed residents at risk for not receiving care and services in the most integrated setting appropriate to their needs. Findings included . Review of the facility policy titled Pre-admission Screening and Resident Review (PASRR) review date of 09/26/2024 showed any resident with newly evident or possible serious mental disorder, intellectual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 3 of 6 sampled residents (Residents 48, 59 and 60) reviewed. 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 48> Resident 48 admitted to the facility on [DATE] with diagnoses to include dementia, anxiety and depression. According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/20/2024, the resident had moderate cognitive impairment. 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 develop a comprehensive person-centered care plan for 1 of 9 sampled residents (Resident 60) reviewed for care planning. The care plan for respiratory care did not show monitoring for signs of hypoxia (low oxygen (O2) level) and administering O2, the skin care plan did not include the type of wound, wound care, or interventions to prevent the wound from worsening, and the Diabetes (a disease in which blood sugar levels are too high) care plan did not include interventions for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life. Findings included . Resident 60 admitted to the facility on [DATE] with diagnoses to include a Stage 2 pressure ulcer (a partial thickness skin loss that appears as a shallow open wound with a red or pink wound bed), diabetes, and respiratory 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 observation, interview and record review, the facility failed to ensure care plans were reviewed and revised for 3 of 8 (Residents 13, 2 and 28) sampled residents reviewed for care plan revisions. Failure to revise care plans to accurately reflect resident conditions and needs placed residents at risk for unmet care needs. Findings included . <RESIDENT 13> Resident 13 initially admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. During an observation and interview on 10/07/2024 at 9:05 AM, Resident 13 was lying in bed. Resident 13 stated they had had a decline in their ADL (activities of daily living) abilities over the past six months. Review of a nurse practitioner note, dated 05/21/2024, showed that Resident 13 likely had kidney failure. The note showed the provider spoke with Resident 13 and they did not want to go to the hospital and wanted to remain in the facility on comfort care. The note showed that Resident 13 was no longer feeding themselves or performing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 dentures prior to meals for 1 of 5 sample residents (Resident 31) reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor nutrition, and diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, revised date of 09/10/2024, showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident 31 admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (conditions that cause weakness or paralysis on one side of the body) following stroke, diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or can't use insulin properly), dysphagia (difficulty swallowing), aphasia following cerebral infarction (a language disorder affects a person's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess and provide care and treatment to improve a resident's communication deficit for 1 of 2 sampled residents (Resident 12) reviewed for hearing. Failure to accurately assess, provide interventions to mitigate hearing loss, and/or offer a referral to improve a hearing deficit placed residents at risk of a decreased quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, (a guide to accurately complete the Minimum Data Set (MDS) assessment). The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. To help nursing facilities apply assessment data collected on the MDS, Care Area Assessments (CAAs) are triggered responses to items coded on the MDS specific to a resident's possible problems, needs or strengths. Care Area Assessment (CAA) is the further investigation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a dementia care plan that addressed the significant mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 3 residents (Resident 48) reviewed for dementia care. These failures placed residents at risk for unmet psychosocial needs, increased behaviors and decreased quality of life. Findings included . In an email interview on 10/11/2024 at 12:56 PM, Staff B, Director of Nursing, stated the only policy the facility had regarding dementia was a policy that specified education, for staff. Review of the facility policy titled Dementia Required Education, dated 09/22/2023, showed the facility had a policy that specified the facility would provide staff training and education. Resident 48 admitted to the facility on [DATE] with diagnoses to include dementia, anxiety and depression. According to the admission Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 (Residents 60 and 48) reviewed for unnecessary medications were free from unnecessary psychotropic drugs (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure there were valid and accurate diagnoses for use of psychotropic medications, appropriate indications for treatment with antipsychotic medications, to monitor adverse side effects and monitor and document appropriate behaviors. These failures placed the residents at risk for receiving unnecessary psychotropic medications, for adverse medication-related side effects, and for diminished quality of life. Findings included According to the facility policy titled Psychotropic Medication Informed Consent Policy, reviewed on 09/16/2024: Other medications not classified as anti-psychotic, anti-depressant, anti-anxiety, or hypnotic medications can also affect brain activity and should not be used as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 dental services were coordinated for 1 of 2 residents (Resident 17) reviewed for dental services. Failure to follow up on dental referrals and ensure the coordination of dental services for residents who had missing and broken teeth placed the residents at increased risk for difficulty chewing, associated health complications, and diminished quality of life. Findings included . Resident 17 admitted to the facility on [DATE] with diagnoses that included weakness, diabetes mellitus type two (condition in which the body had trouble controlling blood sugar), and arthropathic psoriasis (a type of arthritis that affects people with the skin condition psoriasis). In an interview on 10/07/2024 at 9:17 AM, Resident 17 stated they needed a dentist to have their teeth replaced and fixed. Review of the dental hygienist consultation report dated 12/06/2023 showed Resident 17 requested to see a dentist to address missing teeth, broken teeth, and a failing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 orderly discharge for 2 of 3 residents (Residents 5 and 2) reviewed for discharges. The failure to provide necessary information on discharge, and to document and/or assist residents with setting up follow-up physician appointments placed them at risk for unmet care needs. Findings included . RESIDENT 5 Resident 5 admitted to the facility on [DATE] and discharged [DATE]. The resident had diagnoses to include a cognitive communication deficit (difficulty thinking and how someone uses language). Review of Resident 5's Discharge Summary Information, dated 04/11/2024, showed there was no documentation regarding Follow-up Physician Care after their stay at the facility. The section of the form for their Primary Care Provider/Address/Phone #/whether an appointment had been made/to call to schedule an appointment was all left blank. <RESIDENT 2> The resident admitted to the facility on [DATE] with diagnoses to include a cognitive communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 nutritional supplements for 2 of 3 residents (Residents 1 and 4) reviewed for nutrition. The failure to provide nutritional supplements that had been recommended by the registered dietitian placed residents at risk for delayed wound healing. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include protein-calorie malnutrition (inadequate protein in the diet). The resident developed a Stage 3 pressure injury (full thickness tissue loss) while a resident in the facility. Review of Resident 1's Nutrition Assessment, dated 01/30/2024, showed the Registered Dietitian's (RD) plan was to supplement the resident with Prosource (protein supplement) 30 ml (milliliters) every day for wound healing. The assessment indicated the resident's oral intake was likely not meeting their nutrient needs for protein and for wound healing, and the resident would benefit from high protein supplements. Review of 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 ensure clinical records were complete and accurate for 2 of 3 residents (Resident 1 and 3) reviewed for wound care. The failure to ensure clinical records were complete and accurate placed residents at risk for unmet needs. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE]. The resident developed a Stage 3 pressure injury (full thickness tissue loss) on their right buttocks while a resident in the facility. Review of the wound healing consultant's progress note, dated 02/15/2024, showed Collateral Contact 1 (CC1), Physician Assistant recommended the dressing change to Resident 1's pressure injury wound be done every seven days, and as needed for accidental removal, saturation and/or soiling. Review of Resident 1's February 2024 Medication Administration Records/Treatment Administration Records (MARS/TARS), showed the facility did implement CC1's the wound care practitioner's recommendations to change the dressing, but 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 pharmacy services were provided to meet the residents need for 1 of 4 residents (Resident 1) reviewed. The failure to ensure medications were acquired and administered as ordered on the day of admission to the facility and follow facility process for medications not available placed residents at risk of diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include cancer, failure to thrive (FTT - when a resident has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), severe protein-calorie malnutrition (the body lacks enough protein and energy to function properly), depression, and anxiety. Review of the hospital Discharge summary dated [DATE], showed dronabinol / Marinol (a medication made from marijuana to control nausea and vomiting) was ordered to take two times daily before meals. Review of Resident 1's hospital 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 reported concerns were addressed and investigated timely for 1 of 1 resident (Resident 1), reviewed for grievances. This failure placed the resident at risk for unmet care needs, and a diminished quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses to include cancer in the lower lobe of left bronchus or lung, encounter for anticancer chemotherapy, unspecified protein-calorie malnutrition (the body lacks enough protein and energy to function properly), major depressive disorder, and anxiety disorder. Review of Resident 1's Care Conference/Progress Note dated 01/03/2024, showed the following care concerns were discussed: 1) lack of communication related to medication administration, 2) nutrition, 3) laundry, and 4) activity of daily living. The Resident Care Manager (RCM) was to implement an in-service following the care conference. Review of the January 2024 Grievance log showed no grievances for Resident 1. In 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 critical laboratory (lab) test results were reported and followed up timely for 1 of 2 resident (2) reviewed for laboratory services. This failure placed residents at risk of medical complications from lack of timely follow up for a chronic medical condition. Findings included . Resident 2 was admitted on [DATE] with diagnoses to include chronic anemia (a condition in which the body does not have enough healthy red blood cells), thrombocytopenia (a condition that occurs when the platelet count in the blood is too low. Platelets are tiny blood cells that are made in the bone marrow from larger cells) and myelomonocytic leukemia (cancer of the blood). Review of a Complete Blood Count (CBC-a type of lab test), lab report with Resident 3's name showed the lab specimen was collected on 01/03/2024. The specimen was received on 01/04/2024 and the results were faxed to the facility on [DATE] at 12:37 PM. The top of the report had a facsimile date 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 a person-centered discharge planning process/care plan comprehensively and effectively for 4 of 4 residents (Resident 26, 31, 57 and 59), when reviewed for discharge planning. Failure to initiate a discharge plan consistent with the resident's expressed desires, goals, and barriers to discharge, placed the resident at risk for unsafe discharge, and could negatively impact the resident's sense of self-worth and quality of life. Findings included . A review of facility policy titled, Transfers and Discharges, dated 08/09/2023, showed the comprehensive care plan should contain the resident's goals for admission and desired outcomes, which should be in alignment with the discharge if it is resident-initiated. <RESIDENT 26> Resident 26 admitted to the facility on [DATE], with diagnoses to included atrial fibrillation (rapid heart rate), acute kidney failure, dysphagia (difficulty swallowing), and repeated falls. Review of Resident 26's discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 16 (Resident 10) sampled residents reviewed for resident rights. The facility failed to ensure Resident 10's medication concern was reviewed with the Director of Nurses Services (Staff B) and follow up information regarding the medication concern was discussed with the resident, which caused embarrassment and low self-esteem for the resident. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment. Findings included . Review of the facilities policy titled, Dignity, dated 09/30/22, documented The Resident has the right to a be treated with respect and dignity . Resident 10 was admitted on [DATE] with diagnoses included anxiety, hypothyroidism, and depression. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/24/2023, showed Resident 10's cognition was intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents code status was accurately documented in all areas of the medical record for 1 of 3 residents (Resident 17). This failure placed the residents at risk for diminished quality of life, end-of-life care, or health care decisions which potentially did not reflect their wishes. Findings included . Review of Resident 17's Portable Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], located under the Documents tab of the hard chart, revealed the resident had selected to attempt resuscitation/cardiopulmonary resuscitation (CPR) in the event they had no pulse and was not breathing. Review of Resident 17's electronic medical record (EMR) revealed the header section of the chart read, Code Status: DO NOT RESUSCITATE Selective Treatment. Review of an order, dated [DATE], revealed Resident 17 had an order for DO NOT RESUSCITATE Selective Treatment. The order was created by Staff F, Licensed Practical Nurse (LPN)/Care Manager. 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, record review, the facility failed to ensure 1 of 5residents (Resident 60) reviewed for unnecessary medications did not receive unnecessary medications. Resident 60 was admitted to the facility with an as needed (prn) order for Zyprexa, an antipsychotic medication, and the order was changed to a scheduled dose without a physician documented rationale. Findings included . Review of the facility's policy titled, Psychotropic Medication Use, reviewed 10/24/2022, revealed Psychotropic drugs include but are not limited to antipsychotics . psychotropic medication is prescribed for a diagnosed condition . the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Review of the facility's policy titled, Unnecessary Medication, reviewed 08/09/2023, revealed, . the facility will ensure only medications required to treat 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 1 of 4 medication carts (Quilceda Unit, Cart 2) medication was secured and not left unattended. One nurse (Staff C, Registered Nurse) left medications ready for administration unattended on top of the medication cart. This failure placed medications at risk of being tampered with or diverted by a passerby. Findings included . Review of the facility's policy titled, Storage and Expiration of Dating medication, biologicals, revised 07/21/22, revealed . Facility should ensure that medications . are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . During an observation on 09/14/2023 at 4:19 PM, the medication cart 2 on the Quilceda Unit was parked in between Resident 25 and Resident 36's rooms. A medication cup containing what appeared to be yogurt with crushed medications was noted on top of the medication cart. No nursing staff were present at the medication cart. At 4:20 PM, Staff C exited Resident 25's room and was interviewed. Staff C…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain records in accordance with accepted professional standards and practices for 1 of 3 residents (Resident 31) reviewed for hospitalizations. The facility failed to ensure there was complete and accurate documentation in the clinical record related to Resident 31's hospitalization. Failure to ensure the medical record was complete and accurately documented placed residents at risk for inconsistent care and treatment. Findings included . Resident 31 was admitted to the facility on [DATE] with diagnoses to include multiple fractures related to a fall, and end stage kidney disease on dialysis. Review of a progress note, dated 09/07/2023 a late entry for 09/04/2023, showed Staff B, Director of Nursing Services (DNS), documented Resident 31 was sent to the hospital from the dialysis center on 08/30/2023. In an interview on 09/15/2023 at 10:52 AM, Staff N, Licensed Practical Nurse, stated if a resident was transferred to the hospital by an outside…

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