Mira Vista Care Center

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 10) received the necessary care and services to prevent significant and severe weight loss within the first 60 days of admission. This failed practice caused potential harm for Resident 10 in the form of severe weight loss and placed the resident and others at risk for adverse health, safety and diminished quality of life.Findings included . According to the State Operations Manual (SOM), with an implementation date of 11/22/2017, the Centers for Medicare and Medicaid Services defined the parameters for significance of unplanned and undesired weight loss for severe weight loss as greater than 5% in one month. Review of the facility's policy titled, Nutrition Status Management, revised on April 2025 showed any resident weight that varies from the previous reporting by more than 5 percent (%) in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team (IDT) to determine the cause of…

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

Based on interview and record review, the facility failed to ensure annual Certified Nursing Assistant (CNA) performance reviews were completed timely for 2 of 4 employees (Staff J and O) reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of the CNAs and the quality of care provided to residents. Findings included .Staff J, CNA was hired on 02/08/2024. Review of Staff J's employee file showed the employee evaluation was completed late on 09/15/2025. Staff O, CNA was hired on 04/11/2025. Review of Staff O's employee file showed the employee evaluation was completed late on 09/12/2025. In an interview on 03/11/2026 at 9:25 AM, Staff D, Assistant Director of Nursing, confirmed there were two of four performance evaluations that were late. Staff D said there was a process and a plan to ensure performance evaluations were completed timely. Reference WAC 388-97-1680 (2) (a-c)

Based on observation, interview and record review, the facility failed to ensure nurse staffing information postings were current, accurate, and included the census/number of residents in the facility. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . In an observation on 03/04/2026 at 8:21 AM, the daily nurse staffing posting did not contain the census. At 4:01 PM, there were no totals at end of the shift. In an observation on 03/09/2026 at 8:50 AM, the daily nurse staffing posting did not contain the census. The daily nurse staffing postings from the weekend showed no census or hours worked on Sunday 03/08/2026. In an interview on 03/09/2026 at 10:20 AM, Staff P, Nurse's Aide Certified and interim scheduling stated they were responsible for updating the daily staffing posting. Staff P stated they updated the hours worked after shifts and would add the census if they knew it. Staff P stated they were unaware the postings needed to be revised as changes occured.…

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 1 of 4 medication carts and 1 of 2 treatment carts on 2 of 3 halls had unsecured medications. 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 of Medications dated April 2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available. <MEDICATION CART> In an observation on 03/11/2026 from 9:44 AM to 9:51 AM the 200-hall medication cart was observed to be unlocked and unattended. Resident 2 was in a wheelchair across from the cart. Staff B, Director of Nursing (DNS) walked up at 9:51 AM and commented they could see the medication cart was unlocked. Staff B…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain and provide routine dental services for 1 of 2 sampled residents (Resident 39) reviewed for dental services. This failure placed residents at risk for continued dental problems, difficulty chewing, associated health complications, and a diminished quality of life. Findings included Resident 39 was admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing). In an interview on 03/04/2026, at 11:06 AM, Resident 39 stated their teeth were falling apart and needed to see a dentist. Resident 39 stated they had a hard time eating at times. In an observation during the interview Resident 39 had no upper teeth and their lower teeth were discolored and partially broken. In an interview on 03/06/2026, at 9:18 AM, Resident 39 stated they had not been offered to see a dentist while at the facility and would accept a referral. Review of Resident 39's admission MDS, dated [DATE], documented Resident 39 had no upper teeth and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the responsible party was immediately notified and failed to update the physician timely when there was a change in condition for 1 of 3 residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk of receiving less than optimum care.Findings included.Review of a facility policy titled, Change in Condition, revised date 04/2025, documented:There will be certain circumstances where immediate attention will be warrantedThe nurse will use clinical judgment and contact physician based on urgency of the situationThe resident representative will be notified of the change of condition.Resident 1 admitted to the facility on [DATE]. Review of the face sheet showed two emergency contacts.During an email interview on 02/04/2026 at 7:50 PM, Collateral Contact 1 (CC1), Resident 1's emergency contact, reported they had received a call from Resident 1's spouse reporting the resident had had a stroke (blood flow to brain impaired…

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 261> Resident 261 admitted to the facility on [DATE] with diagnoses which included recent norovirus (a contagious gastrointestinal virus spread by contact) infection and Clostridium Difficile infection (a contagious gastrointestinal toxin spread by contact). Both Norovirus and Clostridium difficile organisms required enteric precautions of soap and water hand hygiene; alcohol hand sanitizer does not kill those organisms. According to regulation based on Centers for Disease Control and Prevention standards, contact precautions require the staff to put on personal protective equipment (PPE) before entering the room, which included gowning and gloving, to perform hand hygiene that is appropriate to the organism, and require the facility to post signage to communicate the required level of precautions for staff and visitors. In an observation on 06/02/2025 at 2:11 PM, Resident 261's room was observed which showed a contact precautions sign on the door. The contact precautions sign showed instructions for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 2 of 6 residents (Residents 50, and 214) reviewed for unnecessary medications received medication specific monitoring. This failure placed residents at risk for unrecognized effects and/or side effects of high-risk medications. Findings included . <RESIDENT 50> Resident 50 admitted [DATE] with diagnoses which included depression and anxiety. Review of Resident 50's medical record on 06/05/2025 documented the resident admitted to the hospital after experiencing a side effect of their antidepressants which caused Syndrome of Inappropriate Antidiuretic Hormone (SIADH), (an issue with their body's production of antidiuretic hormone causing their body to retain more fluid) which caused their sodium levels to be too low. In an interview on 06/02/2025 at 1:00 PM, Resident 50 stated they had depression and a history of trauma. Resident 50 stated they were abruptly taken off the antidepressants they had been taking for 30 years. Resident 50 stated 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 <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include CHF and HTN. Review of Resident 31's MAR for June 2025 showed the following order: - Carvedilol tablet 6.25 mg, give one tablet by mouth two times daily for HTN. Hold for HR <55 or SBP <100. There was no documentation indicating that BP or HR had been monitored prior to administering eight of eleven doses per physician orders. Review of Resident 31's clinical record vital signs with a print date of 06/06/2025, showed no documented BP or HR for the eight of the eleven doses of the Carvedilol given in June 2025. The documentation for the vital signs included: - On 06/01/2025, BP and HR were documented once. - On 06/04/2025, BP and HR were documented once. - On 06/05/2025, BP and HR were documented once. In an interview on 06/06/2025 at 8:30 AM, Staff D, LPN stated that for medications that have BP and HR parameters, they check the BP and HR first to ensure they are within the parameters and document the BP and HR results 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 interviews, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and staff not wearing beard nets placed residents at risk for food contamination and foodborne illnesses. Findings included . According to the facility policy titled Dress policy dated 03/02/2015, kitchen staff, hair and beards must be effectively restrained upon entering the kitchen. Hair restraints include beard nets. In an observation on 06/03/2025 at 11:45 AM during tray line (a system used to assemble and distribute meal trays), Staff N, Dietary Supervisor and Staff O, Dietary Aid had beards and were not wearing beard nets. In an interview on 06/03/2025 at 11:45 AM, Staff N stated that as long as the beard was trimmed and short then staff did not need to wear a beard net. Both Staff N and Staff O had facial hair. In an observation on 06/03/2025 at 12:09 PM, Staff N put gloves on without washing their hands prior to preparing a salad plate with two slices of tomatoes and handed the plate 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 <RESIDENT 40> Resident 40 was initially admitted to the facility on [DATE], was hospitalized then re-admitted on [DATE] with diagnoses to include depression and anxiety. In a record review on 06/04/2025, Resident 40's electronic chart showed two PASSR's. The first PASSR was dated 05/05/2024, with an evaluation done on 07/20/2024 and did not identify any issues. The second PASSR was dated 08/19/2024, and was marked evaluation required for significant change. There were no evaluations for significant change documented in resident's electronic chart. Review of Resident 40's progress notes with a print date of 06/03/2025, documented there were no notes regarding the 08/19/2024 PASSR. In an interview on 06/04/2025 at 2:56 PM, Staff K stated that for existing residents, they would fill out a new PASSR if there were changes in a residents' psychotropic medications (drugs that affect a person's mind, emotions, and behaviors) or mentation and send it to the PASSR Coordinator for review. When asked about Resident 40's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a grievance was identified as an allegation of abuse or neglect for 1 of 3 residents (Resident 1) reviewed for care concern related grievances. The facility failed to ensure an allegation of abuse/neglect was identified when Resident 1 reported being left alone in their transport wheelchair for 6 hours and had become extremely sore, and 1 of 5 staff (Staff D) reviewed for annual abuse and neglect training had been completed within 12 months. These failures placed all residents at risk for abuse/neglect, psychosocial harm, physical harm, and a decreased quality of life. Findings included . Review of the facility provided policy, Abuse: Prevention of and Prohibition Against', revision date of 12/2023 documented the policy applied to all facility staff. Under the 'Definitions' part of the policy, documented: - Abuse- this includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain…

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 thorough investigation was completed for 1 of 3 residents (Resident 1) reviewed for care concern related grievances. The facility failed to ensure an allegation of abuse/neglect was investigated which placed all residents at risk for abuse/neglect, psychosocial harm, physical discomfort and a decreased quality of life. Findings included . Review of the facility provided policy, Abuse: Prevention of and Prohibition Against', revision date of 12/2023 documented the policy applied to all facility staff. Under the 'Investigation' phase of the policy, documented all allegations of abuse, neglect will be promptly and thoroughly investigated by facility administrator or their designee. Resident 1 admitted to the facility on [DATE] with diagnoses to include orthostatic hypotension (sudden drop in blood pressure when a person stands up), Cellulitis (bacterial infection of the skin and underlying tissues) of their left leg, need for assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bush, Kally L. Based on interview and record review, the facility failed to coordinate, and schedule ordered/recommended medical appointments and a procedure for 1 of 4 residents (Resident 1) reviewed for coordination of care. This failure to implement recommendations/orders placed residents at risk for discomfort, experiencing health complications and diminished qualify of life. Findings included . Resident 1 readmitted to the facility on [DATE] after hospitalization for diagnoses that included antibiotic resistance urinary tract infection and deep venous thrombosis (DVT- blood clot in a deep vein) in both legs. Review of Resident 1's Urology After Visit Summary, dated 01/13/2025 showed the physician recommended/ordered the resident to have a Cystoscopy (a procedure in which there is a surgical creation of an opening into the bladder) evaluation to investigate the underlying causes of their frequent urinary tract infections. A referral to infectious disease provider was initiated. Review of Resident 1's…

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

Based on interview and record review the facility failed to ensure their policy related to foods brought in from outside sources included how the facility would safely store those foods and the manner in which it would ensure they were stored in a way that was either separate or easily distinguishable from facility food. This failure placed residents at risk for decreased quality of life related to an inability to exercise their right and preference to have food items of their choice brought into the facility and safely stored. Findings included . Review of the facility policy titled, Resident/Personal Food Storage, dated 07/2024 stated the facility allowed residents the opportunity to choose to accept food from any friends, family, visitors, or other; however, the policy further stated that personal resident refrigeration units were not permitted in resident rooms due to electrical load capacity and that food or beverages brought in from outside sources may not be stored in facility pantries or refrigeration units. The policy stated any perishable food items not consumed the day 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 ensure the environment was clean, comfortable and homelike on 3 of 3 units observed. Stained carpets, broken blinds, damaged walls and dirty floors placed residents at risk of diminished quality of life. Findings included . In an observation on 07/18/2024 at 9:11 AM, the floor in room [ROOM NUMBER] floor was dirty and sticky. There were scattered wrappers and dirty paper towels on the floor around the room. In an observation on 07/18/2024 9:13 AM, the floor in room [ROOM NUMBER] was found soiled with dirt and debris Observations on 07/24/2024 at 2:30 PM showed: <CARPETS/HALLS> - The wall baseboard was missing at end of 100 hall. - The carpet seam was pulling apart down the length of the 100 hall. - Near rooms 111-113, the baseboard was pulling away from the wall, being supported by rolling table pushed up against it. - Near room [ROOM NUMBER], there were 3 irregular dark stains on the carpet, approximately 12 x 6 inches. - Near room [ROOM…

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 interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 1-unit refrigerators. The failure to ensure the kitchen was free from potential contaminants, the maintenance to ensure the kitchen refrigerator, freezer and unit refrigerators were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . <KITCHEN> REFRIGERATOR During an observation on 07/18/2024 at 9:15 AM, the walk-in refrigerator was observed with a broken door seal, and the temperature was 45 degrees Fahrenheit (F). The temperature log taped to the front of the door on the refrigerator showed the temperature was documented at 38 degrees F on 7/18/2024 with no time. A 5 gallon, opened and undated, bucket of pickles was observed inside the refrigerator sitting on a stool directly to the right of the refrigerator door with a rim lined 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to ensure resident preferences for food were obtained and honored for 2 of 2 residents (Resident 28 and 43) reviewed for choices. The facility's refusal to allow residents to store personal foods in the facility refrigerators resulted in Resident 43 having limited ability to enjoy food items of their choosing and failure for Resident 28 to obtain dietary preferences. These failures placed residents at risk for decreased quality of life. Findings included . Review of the facility policy titled, Resident/Personal Food Storage, dated 07/2024 stated the facility allowed residents the opportunity to choose to accept foods from any friends, family, visitors, or other; however, the policy further stated that personal resident refrigeration units were not permitted in resident rooms due to electrical load capacity and that food or beverages brought in from outside sources may not be stored in facility pantries or refrigeration units. The policy 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 obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 2 of 6 residents (Resident 26 and 28) reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . Review of the facility's undated policy titled, Advanced Directives and Associated Documentation, showed, 1. Prior to, upon, or immediately after admission, a facility staff member shall: a. provide the resident/family or responsible party written information, in a manner easily understood by the resident or resident representative, regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives b. document in the resident health record that, at the time of admission, the resident and/or resident representative have been provided with written information…

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 activities of daily living (ADL) to include meal assistance, personal hygiene and bathing for 3 of 6 dependent resident's (11, 28 and 33), reviewed for ADL's. Facility failure to provide the resident's, who were dependent on staff for assistance with eating, bed mobility, hygiene including oral care, and showers placed residents at risk for weight loss, pressure ulcers, embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's Policy/Procedure titled, Activities of Daily Living revised 07/2015, showed the policy documented interventions will be provided by staff in accordance with professional standards of quality and clinical practices. Nursing assistants will provide assistance with ADL's based on the residents individualized plan of care. These interventions will be on the Kardex (tool that directs nursing assistant's on how to provide 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 interviews and record reviews, the facility failed to identify the risk of sun exposure, adequately supervise and initiate interventions to avoid a sunburn for 1 of 1 resident (Resident 26) reviewed for accidents. Resident 1 sustained a first-degree sunburn to their forehead and arms when they left the faciity on an outing. This failure placed the resident at risk for a more severe sunburn, pain and decreased quality of life. Findings Included . Resident 26 admitted to the facility on [DATE] with diagnoses that include stroke, high blood pressure, and peripheral vascular disease (narrowing of blood vessels). Review of Resident 26's Quarterly Minimum Data Set (MDS- An assessment Tool) dated 06/03/2024 showed they were cognitively intact, required assistance with their upper and lower dressing, and had impaired range of motion (the capability of a joint to go through its complete movements) of their upper and lower extremities on their left side. Review of a progress note dated 07/15/2024 at 1:09 PM,…

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, facility staff failed to follow accepted infection control practices during the provision of catheter care and management for 2 of 4 residents (Residents 43 and 222) reviewed for urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <RESIDENT 222> Resident 222 admitted to the facility on [DATE], hospitalized on [DATE] and readmitted on [DATE] with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movements), urinary retention, and repeated falls. Review of Resident 222's hospital records dated 07/11/2024 showed the resident was hospitalized with a urinary tract infection associated with their urinary catheter In an observation and interview on 07/23/2024 at 10:58 AM, Staff M, Nursing Technician, was observed emptying Resident 222's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to resolve resident grievances for 1 of 1 sampled resident (Resident 1) reviewed for grievances. The failure to resolve resident grievances placed residents at risk for unresolved missing personal property. Findings included . Resident 1 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS- an assessment tool) assessment, dated 05/10/2024, Resident 1 was assessed to be cognitively intact. Review of Resident 1's undated Inventory of Personal Effects form included a list of the following items: - 1 belt, - $200.00 cash, - Burgundy felt hat, - 1 wooden bead necklace, - A floral suitcase, - 1 pair of black shoes and - 1 knee brace. Review of a progress note dated 05/24/2024 at 2:49 PM, showed Resident 1 had been admitted to the hospital. Review of the May 2024, June 2024 and 07/01/2024 through 07/09/2024 Grievance logs showed no issues had been logged regarding Resident 1. Review of a State Hot Line Report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written transfer discharge notice for 1 of 3 sampled residents (Resident 1) who discharged to a hospital and refused to allow the resident to return (re-admit) back to the facility. In addition, the facility failed to notify the Office of the State Long-Term Care Ombudsman of Resident 1's discharge. This failed practice placed residents at risk of not knowing their appeal rights, risk of not having advocacy and risk of a diminished quality of life when not permitted to return to a facility in the community where their support system resided. Findings included . Review of the facility's policy, Continuum of Care/ Discharge and Transfer/, revision date 02/2016, showed the facility would; 1) provide the required written notice of transfer or discharge to the resident, 2) attach a department designated hearing request form to the transfer or discharge notice, 3) inform the resident in writing, in a language and manner the resident could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a bed hold notice in writing at the time of a resident transfer to the hospital or within 24 hours of transfer to the hospital for 1 of 3 residents (Resident 1) reviewed for hospitalizations. This failed practice placed residents or their representative at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings included . Review of the facility's policy titled, Admission/Discharge/Transfer Bed Hold, dated 11/2016, stated the resident or resident's representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital. A review of Resident 1's medical record showed the resident was sent to a wound clinic appointment and was subsequently admitted to the hospital on [DATE]. Review of Resident 1's medical records, showed no documentation the resident or the resident's representative had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician orders to obtain a hospice referral for 1 of 1 resident (Resident 2) reviewed for change in condition. This failed practice placed the resident at risk of not receiving their hospice benefit for end-of-life support for both Resident 2 and their spouse. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity), chronic respiratory failure, thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), history of cancer, heart disease, depression, and anxiety. Review of a nursing note dated 05/28/2024 at 3:45 PM, showed a hospice referral was received from the Advanced Registered Nurse Practitioner (ARNP) and was placed into the Social Services box. In an interview on 07/11/2024 at 12:45 PM, Staff G, ARNP, stated Resident 2 had begun declining and they had discussed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide timely pain management for 1 of 3 sampled residents (Resident 1) reviewed for pain management. This failed practice resulted in increased pain to Resident 1 on 02/05/2024, when they were not provided pain medication per the physician orders and placed all residents at risk of the potential for poor pain management and a diminished quality of life. Findings included . Review of the facility policy titled, Recognition and Management of Pain, revised 04/2016, showed that resident pain was assessed and managed by an interdisciplinary team who worked together to achieve the highest practicable outcome. Resident 1 admitted to the facility on [DATE] with diagnoses to include chronic pain, osteoarthritis (degeneration of joints) of hips and knees, and anxiety disorder. Resident 1's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 12/25/2023 showed they were cognitively intact. Review of facility investigation, dated 02/05/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to promote resident preferences and choices for 1 of 4 residents (Resident 2) reviewed for showers. This failure placed the resident at risk for not having their choices met, unmet care needs, and impaired dignity. Findings included . Resident 2 admitted to the facility on [DATE] with diagnoses to include morbid obesity and chronic leg ulcers (wounds). Review of Resident 2's quarterly Minimum Data Set (an assessment tool) assessment, dated 06/12/2023, showed the resident was cognitively intact. Resident 2 was totally dependent on staff assistance for bathing and was frequently incontinent of bowel. Review of Resident 2's care plan for bathing/showering, dated 06/09/2021, showed they were totally dependent on one staff, to provide showers or a bed bath weekly per their preference, and as necessary. Review of Resident 2's clinical record for bathing from 05/18/2023 through 08/23/2023, showed Resident 2 had a shower on 06/21/2023, 06/30/2023,…

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