Mountain View Rehabilitation And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure three (5, 20, and 50) of six residents reviewed for unnecessary medications, staff failed to followed provider orders in regard to weights and blood sugar (the amount of glucose in your blood) monitoring. These failures placed residents at potential risk of a decline in medical status and quality of life-related to unmet care needs. Findings included . <BOWEL MONITORING> <RESIDENT 20> Resident 20 admitted to the facility on [DATE]. Review of Resident 20's physician's orders showed the resident received Milk of Magnesia (laxative), twice daily and Docusate Sodium (stool softener) once a day for constipation. Review of Resident 20's bowel record showed the resident had no bowel movements (BM) from 12/29/2024 at 9:51 PM until 01/06/2025 at 9:59 PM. Review of Resident 20's progress notes from 12/29/2024 through 01/09/2025 showed no documentation about the constipation, abdominal assessment, or new order for Lactulose (laxative) twice daily ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate indications for use of an antipsychotic medication (medications that affect the mind or behavior) for 3 of 6 residents (Residents 5, 179 and 380), failed to ensure residents were monitored for adverse consequences of psychotic medication use for 2 of 6 residents (Residents 45 and 380), failed to ensure behaviors were monitored for 2 of 6 residents (Residents 45 and 380) and failed to obtain consents timely for 1 of 6 residents (Resident 179) reviewed for unnecessary medications. These failures put the residents at risk for experiencing adverse side-effects from unnecessary medication use. Findings included . As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a Significant Change in Status for 1 of 3 sampled residents (Resident 229) reviewed for hospice services. Failure to identify and complete a Significant Change in Status (SCSA) assessment placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, V1.19.1, dated October 2024, showed that a SCSA was required to be performed within 14 days when a resident enrolled in a hospice program. Review of the facility policy titled, Resident Assessment and Associated Process, revised August 2024, showed significant change in status assessments must be completed within 14 days of identification. Resident 229 admitted on [DATE] and were not receiving hospice services. Review of a Hospice Certification and Plan of Care showed Resident 229 elected their hospice benefit on 12/20/2024. Review of Resident 229's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with a hearing impairment had a base line care plan developed and implemented to provide effective and person-centered care for 1 of 1 resident (Resident 380) reviewed for base line care plans. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications. Findings included . Resident 380 admitted to the facility 12/26/2024, with diagnoses that included paranoid schizophrenia (chronic mental illness that affects a person's thoughts, feelings, and behaviors) and anxiety. The Minimum Data Set (MDS) Assessment (an assessment tool), dated 01/01/2025, showed the resident had mild cognition impairment and had moderate difficulty hearing with no devices. Review of Resident 380's nursing admission assessment dated [DATE], showed the resident had difficulty hearing with no devices to assist. Review of Resident 380's nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise care plans for 1 of 3 residents for falls (179), and 1 of 5 residents for nutrition (20). The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unmet care needs, feelings of boredom, agitation and a diminished quality of life. Findings included: Review of the facility policy titled, Fall Best Practice Guidelines dated 08/2024 showed a post fall assessment/evaluation including recommendations and care plan changes will be completed for all residents who have experienced a fall. The care plan will be completed/updated to include newly identified factors that may have contributed to the fall. The facility will develop an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. The facility is to update the resident care guide. <RESIDENT 179> Resident 179 admitted [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 observation, interview, and record review, the facility failed to provide assistance with 2 of 3 dependent residents including meal assistance for resident (4) and bathing for resident (179) reviewed for activities of daily living (ADL's). Facility failure to provide resident's, who were dependent on staff for assistance with hygiene including eating assistance and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Activities of Daily Living , revised July 2015, showed the policy was that nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex, which Is accessed in Point of Care (POC). <RESIDENT 179> Resident 179 admitted [DATE] with diagnoses to include stroke with hemiparesis (inability to move one side of body) and hemiplegia (paralysis on one side of the body) neurocognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care consistent with professional standards of practice for 1 of 1 residents (Resident 45) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration dated 05/2007, revised 04/2016; 07/2019 showed it was the policy of the facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order could be obtained. Resident 45 admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis (a lung disease that causes scaring in the lungs making it difficult to breathe) and congestive heart failure (CHF-a chronic condition in which the heart doesn't pump blood as quickly as the body needs). In an interview on 01/02/2025 at 2:12 PM Resident 45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with actual hours worked for each shift for 5 of 6 days (01/02/2025, 01/03/2025, 01/06/2025, 01/07/2025, and 01/08/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . In observations on 01/02/2025 at 9:46 AM, 11:06 AM, 1:55 PM, and 3:05 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/03/2025 at 9:11 AM, 12:06 PM, and 2:48 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/06/2025 at 9:48 AM, 12:33 PM, and 3:02 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/07/2025 at 10:50 AM, and 2:27 PM, showed that the facility's daily nursing staffing form posted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to address emotional and psychosocial well-being through assessment, care plan development and implementation for one of two residents (53), reviewed for individualized behavioral health needs. This failure placed residents at risk of unmet emotional and psychosocial health needs, unwanted behaviors, and a decreased quality of life. Findings included . Resident 53 admitted [DATE] with diagnoses which included a stroke and aphasia (effect of a stroke causing difficulty with verbal expression and/or comprehension) and dementia without behavioral disturbance. The resident's most recent entry following a hospitalization was 11/29/2024. According to the most recent Quarterly Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed Resident 53 did not participate in the cognitive interview documented as rarely or never understood, with short term and long-term memory problems, no verbal or physical behaviors directed toward others and no…

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

Based on observation, and interview the facility failed to ensure one of four medication carts had unsecured medications. In addition, the facility failed to ensure medications were secured and not accessible to residents for two of two (70 and 75) residents. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse. Findings included . Review of the facility policy titled, Storage if Medications dated May 2022 showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility policy titled, Bedside Medication Storage effective May 2022 showed bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 2 of 3 sampled residents (Residents 33 and 56) reviewed for dental services. This failure placed residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life. Findings included . <RESIDENT 33> Resident 33 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS - an assessment of care needs) assessment, dated 02/13/2024, showed Resident 33 had obvious or likely cavity or broken natural teeth. In an interview and observation on 01/02/2025 at 10:34 PM, Resident 33 stated they had missing teeth, and their teeth hurt when eating and they needed to see a dentist. Observation showed Resident 33 only had two upper teeth and three lower teeth with some yellow-brownish debris on them. Review of Resident 33's current care plan with a focus area initiated on 05/16/2024 showed Resident 33 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed infection control procedures and practices for 1 of 2 residents (Resident 229) on enhanced barrier precautions (EBP) that were observed for care. The facility also failed to disinfect resident care equipment between resident use. These failures placed residents at risk of cross contamination and/or the spread of disease. Findings included . <ENHANCED BARRIER PRECAUTIONS> During an observation on 01/06/2025 at 8:16 AM, a sign was posted outside Resident 229's room [ROOM NUMBER] that instructed staff they must wear gloves and gown for high contact resident care activities to include dressing, transferring, changing briefs or assisting with toileting. The sign had an 'M' written on it. room [ROOM NUMBER] had three occupants. Review of Resident 229's care plan showed an intervention that the resident required EBP during high contact resident care activities, dated 01/03/2025. During an observation on 01/06/2025 at 1:28…

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

Based on observations, interview and record review, the facility failed to ensure appropriate interventions were used to prevent the spread of germs for 3 of 4 residents (Residents 1, 2, and 3) reviewed for wound care. Failure to change gloves and complete hand hygiene when indicated during incontinent care and wound care placed residents at risk for the transmission of germs, including the potential for a wound infection. Findings included . Review of an undated facility procedure for Infection Control practices during wound dressing changes showed gloves should be discarded and hand hygiene performed after the old dressing was removed and prior to the cleansing of wound or application of a new dressing. Review of the Centers for Disease Control Website article, titled Hand Hygiene for Healthcare Workers, dated February 27, 2024, showed hand hygiene should be performed: - Before donning gloves - When moving from a soiled body site to a clean body site - Immediately after glove removal <RESIDENT 1> During an observation of wound care on 10/30/2024 at 7:34 AM, Staff C, Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow consultant recommendations for 1 of 2 residents (Resident 4) reviewed for wound clinic visits. Failure to follow up and/or implement consultant recommendations placed residents at risk of complications of health conditions. Findings included . Resident 4's most recent admission to the facility was on 05/30/2024. Review of a LN (licensed nurse) Skin evaluation, dated 09/25/2024, showed Resident 4 had wounds to the anterior (front) abdomen, right abdominal pannus (area of excess skin and fatty tissue), left buttock and right buttock. Review of Resident 4's wound clinic consult note, dated 10/09/2024, showed recommendations for treatment order changes to wounds as follows: 1. Anterior abdomen- apply skin prep daily for 1 week then discontinue. 2. Right abdominal pannus- cleanse wound with wound cleanser and gauze, treat around wound with skin prep, apply silicon barrier cream mix with antifungal powder to wound bed, cover with gauze and change every other day. 3. Right and Left buttock wounds-cleanse wound, treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 3 sampled residents (Residents 4, 2, and 5) reviewed for diabetes (disease where body does not use sugar effectively) remained free of significant medications errors related to the administration of insulin (high-risk medication for diabetes). Failure to administer insulin within the required time frame of one hour before/after the scheduled time parameter placed residents at risk of abnormal blood sugars (level of sugar in blood that is monitored for residents with diabetes). Findings included . Review of an undated facility policy titled, Medication Pass Times, showed medications ordered to be given before a meal should be administered 15 minutes to one hour before the scheduled mealtime. Review of the facility's mealtimes showed breakfast was to be served between 7:15 AM - 7:45 AM, lunch was to be served between 11:15 AM - 11:45 AM, and dinner was to be served between 4:15 PM - 5:00 PM. <RESIDENT 4> Resident 4 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 interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 of 5 sampled residents (Resident 1, 2, and 3) reviewed for admission orders. Failure to implement and follow physician prescribed orders on admission to the facility placed residents at risk of medical complications and a decline in health status. Findings included . <RESIDENT> 1 Resident 1 was admitted to the facility on [DATE] with diagnosis of acute (comes on suddenly) and chronic (long term problem) respiratory failure (the respiratory system fails in one or both of its gas exchange functions), sleep apnea (condition where breathing stops during sleep) and lung disease. Review of the Skilled Nursing Facility (SNF) transfer orders, dated 04/01/2024, showed Resident 1 was to have bipap (machine that provides air pressure to lungs to help someone breath better) during the night and when napping. Review of Resident 1's facility admission orders showed no order for 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 observation, interview and record review, the facility failed to ensure staff followed a physician's order with a prescribed oxygen (O2) flow rate (the amount of supplemental oxygen flowing over a certain length of time) and indication for use was completed for 2 of 8 sampled residents (Resident 275 and 222) and failure to ensure respiratory equipment and tubing was regularly cleaned and/or changed and dated for 6 of 8 sampled residents (Resident 275, 33, 42, 12, 225, and 222) reviewed for respiratory care. This failure placed the resident at potential risk for respiratory distress, respiratory infection, and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, revised 04/2016, stated oxygen therapy was administered as ordered by the physician or as an emergency measure until the order can be obtained and O2 tubing was to be replaced every seven days or when visible soiled. <RESIDENT 275> Resident 275 was admitted to the facility on [DATE] with…

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

Based on interview and record review, the facility failed to ensure staff were provided education about COVID-19 (an infectious respiratory disease caused by a virus) vaccination for 2 of 4 staff (Staff J and K) reviewed for employee COVID-19 immunizations. Failure to educate staff regarding the risks, benefits, and potential side effects of Covid-19 vaccination placed the staff at risk for having insufficient information to make informed decisions. Findings included . Review of the facility staff roster, showed that Staff J, Nursing Assistant Registered (NAR), was hired on 09/04/2023, and Staff K, NAR, was hired on 09/07/2023. On 11/20/2023, documentation was requested from the facility that showed Staff J and Staff K had been provided education regarding the risks and benefits of the Covid-19 vaccine. During an interview on 11/21/2023 at 8:15 AM, Staff A, Administrator, reported the facility did not have any documentation that Staff J or Staff K had been provided education on Covid-19 vaccine. Refer to WAC 388-97-1780(1)(2)(d) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a written notice to the resident, resident's representative(s) and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 4 of 4 sampled residents (Residents 25, 45, 46, and 53) reviewed for hospitalizations. This failure did not afford resident and/or their representative to make informed decisions about transfers and prohibited access to an advocate who could inform resident/representative of their options and rights. This failure had the potential to affect all facility-initiated discharges. Findings included . <RESIDENT 25> Resident 25 was transferred to the hospital on [DATE]. A review of the resident's clinical records showed no evidence of documentation regarding any notification to the Office of the State Long-Term Care Ombudsman for the facility-initiated discharge/hospitalization. <RESIDENT 45> Resident 45 was transferred to the hospital on [DATE]. A review of the resident's clinical records…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff contacted the Level II evaluator for a 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) Level II assessment (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) for 1 of 6 residents (Resident 21) reviewed for PASRR. Failure to update the PASRR with a change in mental health condition placed the resident at risk of health and/or emotional decline related to a lack of professional evaluation to determine if mental health interventions were required. Findings included . Resident 21 admitted to the facility on [DATE]. Review of Resident 21's PASRR, dated 11/29/2022, showed the resident had no indicators of mental illness within the previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge plan addressed the discharge needs for 1 of 3 sampled residents (Resident 71) reviewed for effective discharge planning. These failures placed the resident at risk of not having necessary medications available and for not having hospice care coordinated for after discharge. Findings included . Review of the facility policy titled, Discharge and Transfer, dated February 2016, showed it was the policy of this facility to provide the resident with a safe organized structured transfer and/or discharge from the facility to include but not limited to a discharge home would promote and maintain the resident's medical, physical, and psychosocial well-being. Resident 71 admitted to the facility on [DATE] with diagnoses to include chronic pain, methamphetamine (a stimulant drug) use, malnutrition, and failure to thrive (failure to thrive - happens when there is a loss of appetite, eating and drinking less than usual, 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 observation, and interview, the facility failed to provide the necessary assistance with grooming (nail care) for 2 of 6 sampled residents (Resident 51 and 3) dependent on staff to ensure their needs were met per their individual preferences. The failed practice placed residents at risk for medical complications, poor quality of life and psychosocial harm. Findings included . <RESIDENT 51> Resident 51 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - an assessment tool) assessment, dated 09/04/2023, showed Resident 51 required extensive assistance of one staff member for grooming/hygiene tasks. During an observation and interview on 11/15/2023 at 12:44 PM, Resident 51 was noted to have long fingernails with brown debris under their nails and the right fourth fingernail had a sharp jagged edge. Resident 51 stated they did not like their fingernails long and did not remember the last time the staff had cleaned or trimmed their nails. During an observation on 11/16/2023 at 10:03 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 53) reviewed for Mobility/Limited Range of Motion (ROM), received appropriate treatment and services to prevent further decrease in ROM. This failure placed the resident at risk for development of contractures (joint becomes fixed in place) and further decline in ROM. Findings included . Review of the facility policy titled, Splinting/Device Management Program, revised on 05/2007, indicated the facility was to screen residents for a splinting/device program. Under the staffing section, the Occupational Therapist (OT) and Physical Therapist (PT) were responsible for screening, evaluation and providing splints/devices for individual residents, establishing a splinting restorative program and training of Restorative staff in the implementation of the program, and modifying and adjusting the splint/devices if needed. Review of the procedure section of the policy showed: -Obtain physician order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) received appropriate treatment and services to prevent catheter-associated urinary tract infections (CAUTIs) for 2 of 3 sampled residents (Resident 45, and 48) reviewed for indwelling urinary catheter care/management. The facility failed to develop individualized plans for the prevention of CAUTIs including to develop individualized and specific clinical indications for changing the catheters and/or catheter bags. These failures placed residents with indwelling urinary catheters at an increased risk for UTI's and associated complications. Findings included . Review of the Centers for Disease Control (CDC), Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, 2009, showed the following: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended.…

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

Based on interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (Resident 48) reviewed for unnecessary medications. Failure to re-evaluate the need for continued use of antibiotic medications placed residents at potential risk for use of unnecessary medications and/or have adverse side effects. Findings included . Review of the Center for Disease Control, The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015, indicated studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harm from antibiotic overuse were significant for the frail and older adults receiving care in nursing homes. These harms included risk of serious diarrheal infections, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Resident 48 was re-admitted to the facility following a hospital stay on 05/16/2023 with diagnoses to include osteomyelitis (inflammation of the bone usually due 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.