Regency Care Center At Monroe

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (Resident 54) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antifungal medication placed residents at risk for use of unnecessary medications and/or have adverse side effects. Findings include . Resident 54 was admitted to the facility on [DATE] with admitting diagnoses to include chronic abdominal wall abscess. In a record review on 05/05/2025 at 8:50 AM, Resident 5's orders showed Fluconazole 200 mg tablet one time a day every Thursday for infection. The order was dated 06/27/2024. Record review of the May 2025 Medication Administration Record (MAR) showed that Resident 54 received a dose of Fluconazole on 05/01/2025. Record review of monthly Medication Regimen Review Reports from Pharmacy since December 2024 did not show any notes regarding Fluconazole use of Resident 54. In an interview on 05/07/2025 at 8:53 AM, Staff F,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a system in which residents' records were complete, accurate, and accessible, for 1 of 1 resident (Resident 4) reviewed for hospice (end of life) services. The facility failed to ensure the residents' medical records contained hospice provider's notes which placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Finding included . <RESIDENT 4> Resident 4 was admitted to the facility on [DATE] and enrolled in hospice services starting on 12/13/2024. Review of Resident 4's electronic health record (EHR) showed no hospice visit nurse documentation since 12/26/2024. Review of a form titled, Interdisciplinary Team of Care SNF (Skilled Nurse Facility)/ALF (Assisted Living Facility) and Hospice Plan of care dated 12/13/2024, indicated the hospice skilled nurse to visit twice a week and the home health aide to visit twice a week. In an interview on 05/05/2025 at 9:07AM, Staff H, Registered Nurse (RN),…

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

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 2 emergency carts (carts that contain needed medical equipment during an emergency) when an unlocked sharps container (a specialized, puncture-resistant, and leak-proof container designed for the safe disposal of sharp medical instruments, like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste handling) was found to be soiled and contained five syringes. This failure placed residents and staff at risk for injury, potential exposure to diseases and lack of necessary medical equipment during an emergency. Findings Included . In an observation on 05/01/2025 at 8:53 AM observed an emergency cart located outside of the Cascade Residential Unit Nurses station, near the entrance of the shower room, with an unlocked sharps container on the lower shelf. In an observation of the sharp's container, the top cover to the sharp's container was soiled with unidentifiable brown matter and five syringes inside of the container. In…

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 the person designated to serve as the Director of Food and Nutrition Services (Staff P) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . On 02/20/2023 at 9:16 AM, Staff P, Dietary Manager (DM), stated they were not a certified DM. Staff P stated they had only experienced survey twice and were in the process of obtaining their certification. In an interview on 02/23/2024 at 1:08 PM, Staff P stated the facility had a contracted Registered Dietician that comes to the facility weekly. On 02/20/2024 at 9:16 AM, the posted food handler cards and certificates located on a corkboard in a hallway section of the kitchen were reviewed, showed no certifications for Staff P other than their food handler's card. In a review of the staff roster, undated, showed that Staff P had been employed at the facility since 09/19/2018. Refer to WAC 388-97-1160…

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 4 of 5 residents (Resident 3, 6, 21, and 7) reviewed for range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. This failure placed the residents already identified with decreased ROM risk for further decline in ROM. Findings included . Review of a facility policy titled, Restorative Program, dated April 2018, showed, The goal of the Restorative Program was to promote and maintain the highest practicable level of physical, mental and psychosocial functioning and thereby improve self-esteem and quality of life. The restorative program was a philosophy of care with a specific approach that was organized, planned, documented, monitored, must evaluated to improve or maintain function and/or prevent a slow decline. The restorative program much include the following: - An assessment completed by a licensed nurse, which demonstrated the need for the Restorative Program…

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

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 3 of 5 employee (NAC's Q, R and T) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NAC's and the quality of care provided to residents. Findings included . Review of the facility's policy, Training Requirements, revised 10/2022 showed facilities will conduct annual performance reviews to identify any areas of weakness that require further education. Staff Q, NAC, was hired on 03/09/2022. Review of Staff Q's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff Q. Staff R, NAC, was hired on 04/26/2022. Review of Staff R's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff R. Staff T, NAC, was hired on 08/30/2022.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, accessible, and systematically organized for 6 of 6 residents (Residents 6, 22, 35, 17, 50, and 61) reviewed for accurate and complete medical records. Failure to ensure that clinical records were complete and accurate placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Findings included . <RESIDENT 6> Review of the December 2023 documentation survey report (v2 - where the Nursing Assistant Certified documents when resident care was performed), showed no documentation of Activities of Daily Living (ADL - dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating) care was provided to Resident 6 once on the day shift (12/24/2023), twice on the evening shift (12/25/2023 and 12/26/2023), and six times on the NOC (night) shift (12/01/2023, 12/08/2023, 12/16/2023, 12/21/2023, 12/26/2023, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 6 nurses (Staff F, Staff G, and Staff H) during medication administration, for 1 of 3 residents (Resident 17) on Enhanced Barrier Precautions (EBP), for 1 of 2 residents (Resident 17) during enteral (nutrition provided through tube inserted directly into the intestine) feeding administration, and for appropriate hand hygiene practices in 2 of 3 dining rooms (Cascade and Sky River). The facility failed to ensure staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, staff followed appropriate infection control practices during medication administration, and administration of an enteral feeding. The facility's failure to ensure the staff were compliant with appropriate hand hygiene practices while serving meals and did not touch the resident's food with their bare…

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

Based on record review, and interview, the facility failed to develop, implement, and maintain an in-service training program for 4 of 5 Nursing Assistants Certified (NAC's Q, R, S and T) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure NAC's received 12 hour per year in-service training placed residents at risk for potential unmet care needs. Findings included Review of the facility's policy, Training Requirements, revised 10/2022, showed facilities will maintain an annual calendar of the required education. Facilities will provide annual required training that include: - Communication. - Resident Rights. - Abuse, Neglect, and Exploitation. - QAPI. - Infection Control. - Compliance and Ethics. - Required ln-service Training for Nurse Aides. - Required 12 hours including Dementia and Abuse Prevention. - Training for Feeding Assistants as applicable. - Dementia/Behavioral Health. - Trauma informed care. - Emergency/Disaster/Life Safety. - Blood borne Pathogen. Review of Staff Q, R, S and T's employee file, showed each NAC did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 1 of 3 residents (Resident 50) reviewed for activities. These failures placed the residents at risk for not receiving care and services to meet their individualized needs. Findings included . Resident 50 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), Alzheimer's Disease (a progressive brain disorder which affects memory, thinking and behavior), and glaucoma (a group of eye conditions that damage the optic nerve). On 02/21/2024 at 8:55 AM, Resident 50 was observed inside of the nurse's station, seated in their wheelchair (w/c), picking at the gold flecks in the countertop of the nurse's station. In a continuous observation on 02/21/2024 starting at 9:23 AM, Resident 50 was observed inside of the nurse's station, with a binder titled The Purple Book…

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 4 residents (Resident 55) were provided medications within physician prescribed medication parameters. These failures placed residents at risk for complications and adverse health outcomes. Findings included . Review of a facility policy titled, General Dose Preparation and Medication Administration, revised date 01/01/2022, showed prior to administration of a medication the staff were to check vital signs if necessary. Resident 55 admitted to the facility on [DATE] with diagnosis of high Blood Pressure (BP). Review of Resident 55's current physician orders, showed an order for lisinopril (medication for BP) 10 milligram daily, hold if systolic BP (top number of BP) was less than 100, dated 12/13/2023. Review of the January 2024 Medication Administration Record (MAR), showed no BP documented prior to the administration of lisinopril. There was an entry for weekly BP to be checked every Monday. Review of the February MAR dated 02/01/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview the facility failed to ensure proper storage of drugs and biologicals on 2 of 4 medication carts (Medication Carts Sky River and Cascade 2) and to ensure 1 of 4 medication carts (Sky River) was locked and not accessible to residents. This failure placed the residents, staff, and visitors at risk for medication related illness/injury due to unauthorized access to and use of medications. Findings included . The facility's policy titled, General Dose Preparation and Medication Administration, dated 01/01/2022, showed facility staff should not leave medications or chemicals unattended and should ensure medication carts are always locked when they are out of sight or unattended. Observation of the Sky River medication cart on 02/21/2024 at 8:47 AM, a medication box labeled Diclofenac (a mild pain reliever) 10% topical gel was on top of the medication cart to the left of room [ROOM NUMBER]. There were no staff present. At 8:50 AM, Staff F, Licensed Practical Nurse (LPN), returned 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.

Based on interview and record review the facility failed to provide the required refund for 1 of 4 sampled residents and/or their resident representative (Resident 1) within the required 30 days after the resident discharged . This failed practice placed the resident and/or resident representative at risk of financial hardship. Findings included . Review of the facility policy titled, Resident Refund Process, dated October 2021, showed resident refunds are issued to discharged residents who have credit balances resulting from advance payment of accommodation and ancillary charges. Refunds should be issued within 30 days of discharge. In a phone interview on 12/08/2023 at 1:10 PM, Collateral Contact 1 (CC1), Resident 1's representative, stated they had not received the resident's refund from the facility for their partial stay for the month of July 2023. CC1 stated they had spoken to the facility's Business Office Manager (BOM) twice, and each time the BOM had told them they would look into the matter and had never gotten back with them. CC 1 stated the resident had moved to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for 1 of 1 sampled resident (Resident 1) for death in the facility. Failure to provide CPR for a resident who was found with no pulse and no respirations, and who had a written advance directive that indicated the resident wanted to receive life-sustaining care and services placed the resident at risk for lack of needed emergency medical interventions and unexpected death. Findings included . Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR), dated 05/2019, showed the facility shall be able to and does provide emergency basic life support immediately when needed, including CPR, to a resident requiring such care prior to the arrival of emergency medical personnel in accordance with the related physicians' orders and the resident's advance directives. Review of Resident 1's medical record showed the resident was a full code according to their Physician Orders for Life-Sustaining…

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 a clean homelike environment in three of three hallways observed. The failure to maintain overhead light fixtures that were free of dead insects and debris placed residents at risk for a diminished quality of life. Findings included . In observations on 09/30/2022 at 1:20 PM, overhead light fixtures were observed to be soiled with dead insects and other debris, to include overhead light fixtures: -in many overhead lights in the front hallway of the facility; -in the hallway light fixture near room [ROOM NUMBER]; -outside rooms 303, 151, 154, 158, 161, 174, 176, 184, 403, 220, 223, 402, 218, 130; -in many overhead light fixtures at the Cascade and Sky River nursing stations; and -in many overhead light fixtures in the hallway outside the kitchen. In an interview on 09/30/2022 at 1:40 PM, Staff C, Maintenance Director, stated they had not had the time to get all of the light fixtures cleaned. Reference: (WAC) 388-97-0880 (1)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess five of 16 residents (21, 36, 37, 47, and 49) whose Minimum Data Sets (MDS) Assessment was reviewed. Failure to ensure accurate assessments regarding positioning (Resident 21), oxygen use (Resident 36), pressure ulcer (injury to skin from prolonged pressure) (Resident 37), blood thinner medication use (Resident 47) and hearing (Resident 49), placed residents at risk for unidentified and/or unmet care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, (a guide to accurately complete the Minimum Data Set (MDS) assessment). The RAI consists of three basic components: the MDS Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering…

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 staff were compliant with Infection Prevention and Control Guidelines and standards of practice for three of four halls. The facility failed to ensure oversight and management during an outbreak of the Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). The facility failed to ensure a positive staff member was not isolated from other staff, failed to ensure staff used personal protective equipment (PPE) in accordance with national standards, failed to ensure appropriate hand hygiene practices were followed, and failed to ensure the staff cleaned and disinfected eye protection according to national standards. These failures placed all…

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 infection prevention and control Antibiotic Stewardship Program (ASP, a system-wide implementation of measures for monitoring/tracking of antibiotics along with reducing the risk of unnecessary antibiotic use) was implemented for four of four residents (14, 17, 32, and 57). This failure increased the resident's risk for development of multidrug-resistant organisms (a bacteria that are resistant to many antibiotics) along with potential for unidentified nursing care trends that identify risk related to infection prevention. This failure had the potential for adverse outcomes associated with unnecessary or inappropriate antibiotic use and a decrease in quality of life for all facility residents. Findings included . Review of the facility policy titled, Antibiotic Stewardship, revised 10/2017, stated Regency Pacific affiliated skilled nursing facilities will monitor the appropriate use of antibiotics of the residents, reduce the threat 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 honor residents' rights to make choices for frequency of bathing for two of two residents (35 and 36) reviewed for choices. The failure to assess and honor resident choices placed residents at risk for impaired hygiene and a diminished quality of life. Findings included . Review of policy titled, Resident Rights, revised 11/2016, showed that the facility will honor resident rights as listed below: Resident has the right to reasonable accommodation of needs and preferences. RESIDENT 35 Resident 35 was admitted to the facility on [DATE] with diagnoses to include a degenerative disease of the nervous system. Review of the annual Minimum Data Set (MDS) assessment, a resident assessment tool, dated 08/04/2022, showed the resident was cognitively intact and that it was very important to the resident to make choices about showers. There were no preferences listed for the resident related to shower/bathing preferences of days, times of day or how many per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement care planned interventions for one of three residents (#32) reviewed. The facility failed to ensure safety interventions were implemented for a resident at risk for falls. This failure placed the resident at risk for unmet care needs and potential negative outcomes. Findings Included . Resident 32 was re-admitted to the facility on [DATE] with diagnoses that included delusions, hallucinations, muscle weakness, and dementia with behavioral disturbances. Review of current physician orders on 10/03/2022, showed order for Right bedside floor mat, ordered on 09/10/2022. Review of current comprehensive care plan showed Resident 32 was at risk for falls related to weakness, confusion, hallucinations, and delusions. Interventions included use of right bedside fall mat; ensure device is in place and in good repair, initiated on 09/15/2022. Multiple observations on 09/28/2022, 09/30/2022 and 10/03/2022 showed that the fall mat for 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 one of three sampled residents (26), reviewed for edema received care and services in accordance with professional standards of practice and the resident's person-centered care plan. This failure placed the resident at a risk for pain, discomfort, and unidentified decline. Findings included . Resident 26 admitted to the facility 07/22/2021 with diagnosis to include a history of a heart attack, atrial fibrillation (irregular heartbeat), and high blood pressure. Review of the Annual Minimum Data Set assessment dated [DATE] showed the resident had severe cognitive impairment and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. Review of the Discharge summary dated [DATE] showed the resident had a recommendation for a referral to cardiology (Heart specialist) related to their heart attack, and elevated blood pressure. The summary stated the resident had a medical history of heart failure. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of four residents (49 and 36) reviewed for respiratory care received appropriate oxygen (O2) services. Failure of the facility to ensure O2 delivery was provided according to physician ordered flow rates, monitor respiratory status, and maintain O2 equipment, placed residents at risk of discomfort and a potential negative outcome. Findings included . RESIDENT 49 Resident 49 most recently admitted on [DATE]. On 09/28/2022 at 11:39 AM, Staff J, Registered Nurse (RN), stated that Resident 49 was not on O2 all the time. Review of the physician orders on 09/29/2022, showed Resident 49 had a physician order dated 08/19/2019 that read, Oxygen 2L (liter). Increase as per resident needs and comfort. Every shift for Shortness of breath/comfort, decreased O2 sat (saturation) Review of nursing progress notes showed: - On 09/27/2022 at 1:12 AM resident was on 1.5 L of O2; - On 09/27/2022 at 9:42 PM resident was on 1.5 L of O2; - On…

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

Based on observation and interview, the facility failed to assure food was consumed or discarded within safe time limits for one of one residents (41) reviewed for in-room food service. Allowing residents to eat foods that had sat at room temperature for extended periods of time placed resident(s) at risk for food borne illness. Findings included . RESIDENT 41 On 09/28/2022 at 12:27 PM, the meal cart for the Reflections unit arrived from the Kitchen. At 3:25 PM, Resident 41 was noted to take two bites of ham from their meal tray that was still in front of them, almost three hours after it arrived on the unit. On 09/28/2022 at 3:59 PM, Staff A, Registered Nurse/Patient Care Coordinator, stated that the facility did not have a policy on how long food could remain at the bedside before it should be removed. On 09/29/2022 at 12:24 PM, the meal cart for the Reflections unit arrived from the Kitchen. At 3:02 PM, Resident 41 still had their meal tray in front of them and was picking at their food. 09/30/2022 at 3:02 PM, Staff F, Dietary Manager, stated that food should not sit out for more…

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.