North Bend Post Acute

Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 1 sample (Resident 8) and 1 supplemental (Resident 35) of 5 residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABOs. Findings included . <Facility Policy> According to the 2024 facility ABO Stewardship Program policy ABOs would be prescribed and administered to residents under the guidance of the facility's ABO Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. The purpose of this program was to optimize the treatment of infections while reducing the adverse events associated with ABOs. This policy stated nursing staff would monitor the initiation of antibiotics on residents and conduct an ABO timeout within 48-72 of antibiotic therapy, to monitor…

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

Based on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 3 of 13 residents (Resident 27, 112, & 57), reviewed for dining observations. This failure placed residents at risk for a diminished self-worth and over-all well-being. Findings included . <Resident 27> Observations during dining services on 02/28/2025 at 12:39 PM showed staff assisting Resident 27 to the dining room for lunch. The staff member stated to the resident, I'll get you a new bib. The staff member was referring to a clothing protector worn during meals. <Resident 112> Observations during dining services on 02/28/2025 at 12:48 PM showed Resident 112 sitting at a table in the dining room waiting for lunch with two other residents at the table. Staff placed Resident 112's lunch tray down in front of the resident and went back to the cart to continue passing trays. Resident 112 started reaching for the lid covering their food, so staff returned to the table and pulled the tray away from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 4 of 5 residents (Residents 9, 1, 41, & 37) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to an undated facility, Transfer and Discharge . policy, the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner in which they could understand. The form would include the specific reason and basis for the transfer or discharge, effective date, and would include information on how to obtain an appeal form.…

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 the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 5 sample residents (Resident 9, 1, & 37) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> According to an undated facility, Bed Hold Prior to Transfer policy, it was the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital. <Resident 9> Review of Resident 9's 11/07/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record…

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 Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 4 (Resident 25, 53, 1, & 41) of 17 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 25> According to an 11/27/2025 admission MDS, Resident 25 had no broken natural teeth. Review of a 11/20/2024 Admit Assessment form showed Resident 25 had their own teeth and included a question asking if the resident had broken teeth, this question was left blank by staff. In an interview on 02/26/2025 at 1:37 PM, Resident 25 stated they had some broken teeth and indicated staff never asked them about their teeth. In an observation at this time Resident 25 showed broken front upper and lower teeth and stated they were broken prior to admission to the facility. In an interview and observation on 02/28/2025 at 11:20 AM, Staff E (Licensed Practical Nurse)…

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 Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 6 (Resident 23, 1 & 27) residents and 1 supplemental resident (Resident 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> Review of a 2024 facility, Resident Assessment - Coordination with PASRR Program policy showed the social services director would be responsible for keeping track of each resident's PASRR screening status, and referring to the appropriate authority. <Resident 23> According to a 12/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 23 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 develop the care plans for 3 of 17 sampled residents (Resident 53, 58, & 25) reviewed for care planning. This failure placed the residents at risk for inadequate care, unmet care needs, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 2025 Comprehensive Care Plans policy, the facility would develop and implement a comprehensive, person-centered Care Plan (CP) for each resident that included measurable objectives and timeframes. <Resident 53> According to a 01/31/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 53 required set up assistance from staff for eating and was on a therapeutic diet. This MDS showed Resident 53 was at risk for developing pressure ulcers. Review of a revised 11/02/2024 nutrition CP showed Resident 53 had the potential for altered nutrition with an identified goal that the resident would maintain adequate nutritional status as evidenced by stable…

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 clarify diagnoses on physician's orders and to monitor and document resident's behaviors while on antipsychotic medications for 3 (Residents 8, 25, & 61) of 17 sample residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care interventions, and other negative health outcomes. Findings included . <Resident 8> According to the 12/25/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 8 admitted to the facility on [DATE] with medically complex conditions including non-Alzheimer's dementia (group of cognitive disorders that cause memory loss and confusion), depression, and anxiety. The MDS showed Resident 8 received antipsychotic and antidepressant medications every day during assessment period. The MDS showed Resident 8 had no behavior of rejecting care during the assessment period. Observations on 02/27/2025 at 11:29 AM, on 02/28/2025 at 9:24 AM, and on 03/03/2025 at 11:32 AM showed…

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 planning process to effectively transition residents to a community setting for 2 residents (Resident 23 & 60) of 17 residents reviewed for discharge planning. This failure placed the residents at risk for an unsafe discharge and diminished quality of life. Findings included <Facility Policy> According to an undated facility, Transfer and Discharge . policy, for anticipated transfers or discharges, a physician's order would be obtained for the transfer or discharge along with instructions or precautions for ongoing care. <Resident 23> According to a 12/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 23 admitted to the facility on [DATE], had clear speech, was understood, and could understood others. This MDS showed Resident 23 had a surgical wound and received surgical wound care during the assessment period. In an interview on 02/27/2025 at 11:23 AM, Resident 23 stated they were frustrated they…

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

Based on observation, interview, and record review the facility failed to monitor and identify changes in a resident's skin condition timely for 1 (Resident 25) of 7 sampled residents reviewed for skin conditions. These failures placed residents at risk for complications, worsening conditions, and a diminished quality of life. Findings included . <Resident 25> According to an 11/27/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 25 had clear speech, was understood, able to understand others, and had no memory impairment. This MDS showed staff assessed Resident 25 was at risk for developing pressure ulcers/injuries and had pressure ulcers on admission. During observations of wound care on 03/03/2025 at 11:25 AM with Staff K (Licensed Practical Nurse), Resident 25 reminded the nurse about the rash they had under their right-side abdominal fold and their right armpit. Staff K observed the areas which showed large areas of red, inflamed skin with some drainage noted to the areas. Staff K stated they would go get the powder they were using to the skin areas and…

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

Based on observation, interview, and record review the facility failed to ensure a restorative program was provided for 2 of 5 (Residents 41 & 23) sample residents reviewed for restorative nursing services. These failures placed residents at risk for a decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff, and decreased quality of life. Findings included . <Resident 41> According to the 01/29/2025 Annual Minimum Data Set (MDS - an assessment tool), Resident 41 had medical conditions including a stroke (brain injury) resulting in paralysis (loss of function) to one half of their body and required one-person extensive assistance with personal hygiene. The MDS showed Resident 41 was assessed as cognitively impaired and did not reject care during the assessment period. Review of a 02/29/2025 revised ADL (Activities of Daily Living) self-care deficit Care Plan (CP) showed Resident 41 had right sided weakness due to a stroke. Staff were instructed to apply a splint on the resident's right hand daily as tolerated and to report any skin issues related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services interventions for 1 of 5 residents (Resident 1) reviewed for unnecessary medications. The failure to initiate further assessment and appropriate interventions when the resident answered positively to a self-harm question, placed the resident at risk for unmet care needs and non addressed mental health concerns. Findings included . <Resident 1> According to the 11/27/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 1 admitted to the facility on [DATE], had no memory impairment, and had a diagnosis of depression. The MDS showed Resident 1 received antidepressant and antianxiety medications on seven of seven days during the assessment period. The 11/27/2024 MDS included a PHQ - 9 (an assessment for screening the severity of depression) of Resident 1's mood which identified the presence of multiple symptoms of depression. The section titled, Thoughts that you would be better off dead, or of hurting yourself 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 submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing health care programs and health insurance standards) for Quarter 1 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services. Findings included . <CMS- Electronic Staffing Data Submission PBJ> Review of the June 2022, CMS Long-Term Care Facility PBJ Policy Manual, showed long term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data. The data, when combined with census information can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact the quality of care delivered at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1) a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information, and 2) a system by which residents or their representative(s) were notified of the transfer or discharge for 6 (Residents 1, 4, 5, 8, 14, & 19) of 6 residents reviewed for hospitalization. Failure to ensure required notification was provided, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Facility policy> The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative. <Resident 5> According to a 10/10/2023 Discharge Minimum Data Set (MDS - an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 6 (Residents 1, 4, 5, 8, 14, & 19) of 9 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility policy> At the time of transfer for hospitalization, the facility will provide to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy and addressed information explaining the return of the resident to the next available bed. <Resident 5> Review of Resident 5's 08/10/2023 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Resident Record (RR) 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.

Based on interview and record review, the facility failed to 1) engage a full-time Registered Dietician (RD) and 2) provide a dietary manager with the appropriate competencies to manage and supervise the facilities kitchen. This failure placed residents at risk for unmet dietary and nutritional needs. Findings included . In an interview on 12/05/2023 at 11:30 AM Staff S (RD) stated they worked at the facility on a part time basis. Staff S stated they worked in the facility on Tuesdays. Review of timesheets for dietary staff showed monthly documentation of Staff S's hours at the facility. Staff S worked 41 hours for the June payroll cycle, 31.5 hours for the September cycle, and 32 hours for the November cycle. There were no documented hours for the July, August, or October payroll cycles. In an interview on 12/11/2023 at 1:50 PM Staff T (Dietary Manager) stated they did not complete the training required that would allow them to work as a Dietary Manager without a full-time RD at that time. Staff T stated they were in the process of enrolling. In an interview on 12/12/2023 at 12:41…

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

Based on observation, interview, and record review the facility failed to provide an adequate number of dietary staff. The failure to provide the kitchen with adequate dietary staff left residents at risk for less than palatable meals, improperly prepared meals, foodborne illness, late food service, and other negative health outcomes. Findings included . <Facility Assessment> According to the 11/10/2023 Facility Assessment (FA - a document developed and maintained by nursing homes that assessed the resident population and their care needs, the condition of the building, risks and threats to the building such as unique environmental risks etc., and the resources the facility would require to manage resident needs and safety including staff and equipment) the facility management assessed the nutritional needs of the resident population to require a Registered Dietician (RD), a Dietary Manager, three cooks, and three dietary aides. <Kitchen Staffing> Observation on 12/5/2023 at 8:55 AM showed three staff working in the kitchen. Staff U (Business Office Manager) stated they could be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure food was stored, prepared, and distributed in a sanitary manner. The failure to ensure food was stored correctly, surfaces were sanitized, food was prepared in an area free of potential contaminants, food waste was disposed in a fashion to prevent attracting pests, and food was transported in a fashion to prevent exposure to airborne pathogens left residents at risk for foodborne illness, food contamination, less than palatable food, and other negative outcomes. Findings included . <Food Storage> Observation of the kitchen's food storage on 12/05/2023 at 8:59 AM showed an opened box of cream of wheat on a shelf by the range. The box was not labeled to indicate when it was opened. Several boxes of cream of wheat were observed on a shelf in the dry storage area. Four of the boxes did not have a label indicating when they were delivered. Five cans of red salsa and six cans of marinara sauce were also observed to have no label indicating when they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a safe, comfortable and homelike environment on 2 of 2 units (north and south units), 1 of 1 dining rooms, 1 of 1 resident lounge/ Television (TV) area, and 1 of 1 kitchens. The failure to ensure resident rooms and halls were free of wall gouges and electrical repair, furniture and walls in the dining room and resident lounge were not peeling or gouged, and that essential equipment remained in good repair placed residents at risk for a less than homelike environment and other negative outcomes. Findings included . <Disposable Table Ware> Observation on 12/05/2023 at 1:02 PM during lunch service showed all residents in the dining room being served their meals in Styrofoam containers. Residents were served lunch with plastic utensils instead of silverware. In an interview on 12/05/2023 at 9:19 AM, Resident 44 stated, the food could use some help. The resident stated lately they were being served meals in Styrofoam containers 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 observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were reviewed and revised as needed, for 8 of 16 (Residents 1, 31, 46, 19, 17, 5, 8, & 21) sample residents whose CPs were reviewed. Failure to ensure CPs were revised to reflect residents needs for care left residents at risk for unmet care needs, the provision of unneeded care, and other negative health outcomes. Findings included <Facility Policy> The 2022 Care Plan Revision Upon Status Change facility policy showed resident's comprehensive CPs would be reviewed and revised as necessary. This policy showed the Minimum Data Set (MDS - an assessment tool) coordinator along with the interdisciplinary team would discuss the resident's condition and collaborate on intervention options. The CP would be modified by the MDS coordinator or other designated staff, and these modifications would be communicated to the direct care staff. <Resident 1> According to the 09/12/2023 Quarterly MDS, Resident 1 used a feeding tube for up to 50% of their nutritional intake. The MDS showed 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 3 of 3 nursing assistants (Staff Z, AA, & BB) with an active Nursing Assistant Registered (NAR) license met the training and competency evaluation requirements under the Nurse Aide Training or Competency Evaluation Program (NATCEP) within four months from their date of hire. This failure placed residents' safety at risk and predisposed residents to receive care from staff with incomplete nurse aide credentials. Findings included . <Staff Z> Record review of the facility's active staff list showed Staff Z (NAR) was hired on 08/01/2023 and should complete their training on 12/01/2023 per the updated 10/13/2023 Basic Training and Certification Deadline Changes for Long-Term Care (LTC) Workers related to Covid-19 (a respiratory infection categorized as a global outbreak) in order to continue working for the facility. Review of the daily staff assignment sheets from 11/07/2023 - 12/07/2023, showed Staff Z worked for the facility without meeting their training and competency requirements on 12/02/2023, 12/03/2023,…

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.

Based on interview and record review, the facility failed to ensure a system that provided annual nurse aide reviews for 2 of 2 Certified Nursing Assistants (CNAs - Staff CC & DD) whose personnel files were reviewed for CNA performance evaluations. Failure to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs. Findings included . <Staff CC> Review of Staff CC's personnel file on 12/12/2023 showed the staff was hired on 03/30/2022 and would need their annual performance evaluation reviewed and completed on 03/30/2023. The facility was not able to provide any documentation to support Staff CC received an annual performance review from the facility as required. <Staff DD> Review of Staff DD's personnel file on 12/12/2023 showed the staff was hired on 05/01/2021 and would need their annual performance evaluation reviewed and completed on 05/01/2022 and 05/01/2023. The facility was…

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.

<Resident 26> According to the 09/22/2023 Quarterly MDS Resident 26 had diagnoses including End Stage Renal Disease (ESRD - an irreversible kidney condition) and a nerve condition that made voiding urine more difficult. Record review showed Resident 26 had a 09/28/2023 Physician's Order (PO) restricting the resident to 1000 Milliliters (ML) of fluid a day. The PO showed the facility's dietary department was responsible for 600 ML daily and nursing would give 125 ML three times a day. Review of the November 2023 MAR showed there were two places for nurses to document how much fluid Resident 26 was provided on night shift. On the first night shift column on 28 of 30 days nurses documented Resident 26 received 950 ML. On the second night shift column on 28 of 30 days nurses documented Resident 26 received 125 ML of fluid. In an interview on 12/12/2023 at 10:11 AM Staff B stated it was important to accurately document how much fluid was provided to a resident on a fluid restriction. Staff B stated Resident 26 was provided fluids according to their fluid restriction. Staff B 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 observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. 1) The facility failed to ensure staff used Personal Protective Equipment (PPE) for 1 of 7 (Residents 43) residents reviewed for Transmission Based Precautions (TBP). 2) The facility failed to perform Hand Hygiene (HH) during resident care and during dining service for 5 (Resident 43, 8, 19, 28, 31) of 7 residents observed. 3) The facility failed to assess and monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. These failures placed residents at risk for the development and transmission of communicable diseases and infections. Finding included . <Facility Policy> The facility's 10/01/2023 TBP policy showed that the facility staff would apply TBPs to residents who were known or suspected to be infected 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.

Based on observations, interviews, and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of Antibiotics (ABOs) and reduce the risk of unnecessary ABO use for 2 of 3 (Residents 17 & 14) residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABO's. <Facility Policy> The facility's 10/01/2023 Antibiotic Stewardship Program policy showed the purpose for their ABO stewardship program was to optimize the treatment of infection's while reducing the adverse events associated with ABO use. This policy showed that when an ABO was ordered, the Infection Preventionist (IP) would review for appropriateness, monitor response to the ABO, and would determine if the ABO is still indicated or adjustments should have been made. This policy showed that nursing staff would monitor the initiation of ABOs for residents and conduct an ABO time-out within 48-72 hours of ABO…

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

Based on interview and record review, the facility failed to inform residents of the risks and benefits associated with psychotropic medication therapy (medications that affected the mind, emotions, and behavior), for 3 (Residents 31, 19, & 17) of 5 residents reviewed and gave 1 (Resident 19) a psychotropic medication despite Resident 19 declining to consent for the medication. These failures detracted from the residents' ability to exercise their right to make informed treatment decisions and prevented residents from exercising their right to decline treatment. Findings included . <Facility Policy> Review of a 09/04/2023 Use of Psychotropic Medication facility policy showed residents and/or their representatives would be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. <Resident 31> According to the 10/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 31 had memory impairment and complex medical diagnoses including depression. The MDS showed Resident 31 was administered an…

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

Based on observations, interviews, and record review the facility failed to initiate and complete a thorough grievance investigation for 2 of 4 residents (Residents 31, & 8) reviewed for missing property. The facility failed to ensure there was a summary statement coming from the resident themselves regarding their lost property and how the event would affect their quality of life if left unresolved. These failures placed residents at risk for frustration and a diminished quality of life. Findings included . <Facility Policy> The facility's undated Resident and Family Grievances policy showed the Grievance Official was responsible for overseeing the grievance process. The policy outlined responsibilities including receiving and tracking of grievances and issuing written grievance decisions to the resident. <Resident 31> According to the 10/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 31 had clear speech, usually understood conversations. Resident 31 made their own decisions. Resident 31 was able to hear adequately with the use of their hearing aid.…

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 a Significant Change in Status Assessment (SCSA), including Care Area Assessments, were completed within 14 days for 1 of 1 resident (Resident 8) reviewed for a decline in mental status, Activities of Daily Living (ADLs), and mobility. Failure to identify Resident 8's change in status and to complete a SCSA placed the resident at risk for unidentified and/or unmet care needs. Findings included . According to the October 2023 Resident Assessment Instrument Manual (a manual that directs staff on how to accurately assess the status of residents) a SCSA is a comprehensive assessment that must be completed when the interdisciplinary team has determined that a resident meets the significant change guidelines for either major improvement or decline. Review of the guidelines showed, a SCSA is appropriate if there is a determination a significant change in a resident's condition from their baseline had occurred and the resident's condition is not expected to return to baseline within two weeks. <Resident 8> According to an…

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

Based on interview and record review, the facility failed to ensure Minimum Data Sets (MDS - an assessment tool) were completed and accurate for 2 (Residents 19 & 46) of 16 sample residents. Facility failure to complete accurate MDS assessments prevented the facility from transmitting accurate and complete information to the Centers for Medicare and Medicaid Services for facility quality ratings, and left residents at risk for unidentified and/or unmet needs. <Resident 19> According to a 10/30/2023 Quarterly MDS, Resident 19 was assessed to have no memory impairment and had adequate hearing. This assessment showed Resident 19 had clear speech, was understood by others, and could understand others in conversation. According to this assessment, Resident 19 had no acute change to their mental status. Review of Section F (Preferences for Customary Routine and Activities) of the 10/30/2023 Quarterly MDS showed staff marked 0 indicating the interview for Resident 19's daily preferences should not be complete because the resident was rarely/never understood. The following assessment which…

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 a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was obtained and/or accurate to reflect the residents' mental health conditions for 2 of 5 (Resident 31 & 5) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> The facility's undated Resident Assessment - Coordination with PASRR Program showed the Social Services Director (SSD) was responsible for keeping track of each resident's PASRR screening status. The policy outlined any resident who exhibited a significant change and/or a newly evident or possible Serious Mental Illness (SMI) would be referred promptly to the state mental health for resident review. <Level 1 PASRR Guidance> According to the revised 09/2018 Level 1…

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 sign only for tasks completed for 1 (Residents 1), clarify Physician's Orders (POs) for 6 (Residents 51, 26, 5, 31, 43, & 14), and follow POs for 1 (Resident 14) of 16 sample residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care interventions, and other negative health outcomes. Findings included . <Signing Only for Tasks Completed> <Resident 1> According to the 09/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 1 had multiple medically complex diagnoses and received up to half their nutrition via a feeding tube. Resident 1's POs included a 03/07/2023 for the resident to be fed via a feeding tube. The order showed nurses should provide 1440 milliliters (MLs) of artificial nutrition. In an interview on 12/11/2023 at 10:36 AM Staff Q (Resident Care Manager) stated Resident 1 currently received their nutrition orally, not via a feeding tube. Staff Q stated since the resident's feeding tube malfunctioned for the second time on 09/23/2023,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensures residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 6 of 11 residents (Residents 26, 51, 31, 4, 14, & 41) reviewed for ADLs. The failure to provide necessary assistance with bathing (Residents 26, 51, 14, & 41), grooming (Residents 31), and nail care (Resident 4) left residents at risk unmet care needs, odors, and a diminished sense of self-worth. Findings included . <Facility Policy> According to the facility's 2022 ADL policy, the facility would assess each resident's need for ADL assistance including bathing and grooming. The policy showed the facility would develop and implement individualized Care Plans (CP) to address residents' ADL needs. <Resident 26> According to the 9/22/2023 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 26 had medically complex conditions including respiratory failure, irreversible…

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 residents received proper treatment and care that maintained their ability to hear adequately and effectively for 1 of 1 residents (Resident 31) reviewed for treatment and services to maintain hearing. Failure to ensure residents' hearing deficits were addressed accordingly placed residents at risk for frustrations, decline in communication, and a diminished quality of life. Findings included . <Facility Policy> The facility's undated Hearing and Vision Services policy showed the facility would utilize the comprehensive assessment process to identify and assess a resident's hearing ability to provide person-centered care including ongoing monitoring of the resident's sensory problems. The policy outlined employees would assist the resident with the use of their devices/adaptive equipment needed to maintain hearing and should refer any identified need for hearing services/appliances to social services. <Resident 31> According to the 10/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool),…

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 assess and implement wound treatment orders and care interventions for 1 of 2 residents (Resident 14) with pressure ulcers. This failure placed residents at risk for development and/or worsening of wounds, infection, and medical complications. Findings included . <Facility Policy> Review of the October 2022 Pressure Injury Prevention and Management facility policy showed licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. <Resident 14> According to the 11/15/2023 Quarterly Minimum Data Set (an assessment tool), Resident 14 readmitted to the facility on [DATE] after receiving a surgical toe amputation. Resident 14 was assessed to make their own decisions. Resident 14 admitted to the facility with medically complex diagnoses including a right lower leg skin infection, heart failure, and end stage kidney disease. Review of the 08/09/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to identify and initiate an intervention to prevent recurrence for 1 of 3 residents (Resident 41) reviewed for accidents. This failure placed residents at risk for avoidable incidents, injury, and diminished quality of life. Findings included . <Facility Policy> Review of the October 2022 facility policy titled Fall Risk Assessment showed the facility would provide an environment that is free from accident hazards and provides supervision and assistive devices to each resident to prevent avoidable accidents. <Resident 41> According to the 11/02/2023 Quarterly Minimum Data Set (an assessment tool) Resident 41 admitted to the facility on [DATE]. Resident 41 made their own decisions. Resident 41 had medically complex conditions to include anemia, anxiety, depression, and low thyroid function. Review of the 05/02/2023 Activities of Daily Living (ADL) Care Plan (CP) showed Resident 41 required assistance of one staff member for toileting and transfers 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.

Based on observations, interview, and record review, the facility failed to ensure residents with Foley Catheters (FC - a tube placed in the bladder to drain urine) received appropriate care and services for 1 of 3 (Resident 43) residents reviewed for indwelling FCs. This failure to obtain and follow Physician Orders (PO) for FCs and FC care, placed residents at risk for infection and diminished quality of life. Findings included . <Facility Policy> The facility's 2022 Indwelling Catheter Use and Removal policy showed the facility would provide appropriate care for the catheter in accordance with professional standards of practice. <Resident 43> According to the 10/22/2023 admission Minimum Data Set (an assessment tool) Resident 43 showed no memory/cognitive impairment and was assessed to require extensive physical assistance from staff for bed mobility, transfers, dressing, and personal hygiene. This MDS indicated Resident 43 did not exhibit rejection of care during the assessment period. This assessment showed Resident 43 had an indwelling FC. The 10/20/2023 Urinary Care Plan (CP)…

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 monitor resident's weights for 2 of 4 residents (Residents 1 & 23) reviewed for nutrition and failed to follow dietary orders for 1 of 4 (Resident 41) residents reviewed. The failure to collect weights as ordered and per the facility policy and to serve residents diets outside of Physician Orders (PO) left residents at risk for unplanned weight changes, risk for aspiration, fluid overload, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2022 Weight Monitoring policy, the facility would ensure all residents maintained acceptable parameters of nutritional status. The policy identified weight as a useful indicator of nutritional status. The policy identified a significant weight gain as five percent (%) change in one month, 7.5 % change in three months, or 10 % change in six months. This policy showed the physician would be notified of any significant weight change. <Resident 1>…

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 ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 1 of 1 (Resident 26) residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> According to the facility's 2023 Hemodialysis (a type of dialysis treatment done in a clinic) policy the facility would coordinate with the dialysis center to ensure the resident's treatments needs were met. The policy directed nurses to ensure there was ongoing communication between the nursing home and dialysis staff. <Dialysis Contract> Review of the Dialysis contract provided on 12/05/2023 showed the contract was between a sister facility and a dialysis center located in another county. A second contract was provided via email between Resident 26'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 observation, interview, and record review the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained their highest practicable physical, mental and psychosocial well-being as identified by resident assessments and according to individual plans of care, in consideration of the number, acuity and diagnoses of the facility's resident population, and in accordance with the facility assessment. The facility failed to provide education and training that pertained to the current resident population for 2 of 2 Licensed Practical Nurses (LPNs - Staff EE & FF) whose annual in-service training and education records were reviewed for competency. Failure of nursing staff to demonstrate knowledge, skills, abilities, behaviors, or other characteristics necessary perform job-related functions safely and successfully resulted in deficiencies demonstrating a lack of competent resident care by the facility's nursing staff. Findings included . According to the…

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

Based on interview and record review, the facility failed to maintain eight hours of Registered Nurse (RN) coverage to directly supervise resident care for 2 of 30 days (11/23/2023 and 11/26/2023) reviewed for staffing. This failure placed residents at risk for a delay in identification, response to changes in medical conditions, and provision of care and services by an RN, inadequate assessments, and unmet needs. Findings included . The Staffing Pattern form provided by Staff A (Administrator) on 12/05/2023 showed staffing review dates from 11/04/2023 through 12/04/2023 and identified the facility's actual number of direct-care nursing staff working each shift (Days, Evenings, and Nights). The document showed the facility did not have at least eight consecutive hours of RN coverage a day, seven days a week during: The week of 11/19/2023 - 11/25/2023 on 11/23/2023; and the week of 11/26/203 - 12/02/2023 on 11/26/2023 as required In an interview on 12/11/2023 at 8:02 AM, Staff B (Director of Nursing) stated they were aware that there were RN staffing issues identified during 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 PRN (as needed) orders for psychotropic medications were only used when the medication was necessary and the PRN use was limited according the prescribing guidelines for 1 of 5 residents (Resident 31) and failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 (Resident 41) residents reviewed for unnecessary medication use. This failure placed the residents at risk for receiving unnecessary medications with potentially harmful and unwarranted adverse side effects. Findings included . <PRN Use> <Facility Policy> According to the facility's revised 09/04/2023 Use of Psychotropic Medication policy, PRN orders for all psychotropic drugs were used for a limited duration (i.e. 14 days). The policy instructed the attending physician that if they believed it was appropriate for the PRN order to be extended beyond 14 days, they would document their rationale in the resident's medical record and indicate 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.

<Resident 43> In an observation and interview on 12/08/2023 at 8:46 AM, Staff O (LPN) prepared 30 milliliters (ml) of a liquid laxative for Resident 43. The order directed staff to administer 17 grams of the laxative daily. Staff O was unable to explain how they measured 17 grams to be 30 ml. Staff O stated the order was inaccurate. Staff O stated the normal dose for the prescribed laxative was 30 ml and that is why they prepared 30 ml for Resident 43. In an observation and interview on 12/08/2023 at 8:50 AM Staff B (Director of Nursing) assessed the physician orders and the bottle of the laxative. Staff B then directed Staff O to give 30 ml of the laxative, stating you give 30 ml of this laxative. The surveyor stopped Staff B prior to the medication being administered, and asked how 30 ml was equivalent to 17 grams, Staff B stated 30 ml was not equivalent to 17 grams and stated they would hold the medication. Staff B stated the physician order was inaccurate and needed to be corrected. REFERENCE: WAC 388-97-1060(3)(k)(ii). Based on observation, interview, and record review 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 serve foods that were palatable and served at the proper temperature. Observation of meal preparation and interviews with 4 sample residents (Residents 41, 5, 27, & 21) identified concerns with the temperature, and overall palatability of food served by the facility. Failure by the facility to ensure meals were at the proper temperature and palatable when served, placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals. Findings included . <Meal Tickets> Observation on 12/08/2023 at 10:13 AM showed Staff T (Dietary Manager) writing dietary orders on tray tickets. Staff T stated the facility recently switched computer systems and now dietary orders no longer transferred to the tray tickets. Staff T stated they knew all the residents' dietary orders, so they were able to add the necessary information. In an interview on 12/11/2023 at 1:50 PM Staff T stated they depended on nursing to communicate when…

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

Based on observation, interview, and record review the facility failed to ensure 1 of 1 sample residents (Resident 4) reviewed for choices received food that accommodated the resident's choices, preferences, and intolerances. Failure of the facility placed residents at risk of dissatisfaction with food, unnecessary weight loss, and a decreased quality of life. Findings included . <Resident 4> According to the 10/07/2023 Annual Minimum Data Set (MDS - an assessment tool), Resident 4 had clear speech and was cognitively intact. Resident 4 had multiple complex medical diagnoses including uncontrolled blood sugar (BS) levels in the body and was administered an injectable medication during the assessment period to manage their condition. In an interview on 12/05/2023 at 9:59 AM, Resident 4 stated they watched what they ate because their BS levels were unpredictable, sometimes too high, and sometimes very low. Resident 4 stated they did not like certain foods including most breads and high sugar desserts because of their sugar content. Resident 4 stated staff received their food choices…

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 specialized rehabilitative services were provided as determined by the Physician's Order (PO) for 2 of 3 residents (Residents 5 & 8) reviewed for rehabilitation with skilled therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. Findings included . <Resident 5> According to a 10/10/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex diagnoses including a traumatic spinal cord injury that resulted to the loss of muscle function in both their legs. The MDS showed Resident 5 had intact memory and was able to understand and be understood by others. In an interview on 12/06/2023 at 10:43 AM, Resident 5 stated they used to work with the staff in doing exercises and indicated the last time they were provided assistance with this was a week before. Review of Resident 5's POs showed a 10/20/2023 order for PT [Physical therapy]/OT…

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 abuse policies and procedures were implemented by failing to identify and investigate allegations of abuse and neglect, and protect residents from potential abuse for 8 of 15 residents (Resident 4, 5, 6, 7, 8, 9, 13, & 15) reviewed for incidents, and failed to conduct background screening for 2 of 3 agency staff (Agency Staff O, & E) reviewed for screening. These failures placed residents at risk for unidentified abuse and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 07/01/2023, showed the facility would designate an Abuse Prevention Coordinator in the facility who was responsible for reporting alleged or suspected abuse and neglect to the state survey agency. The facility would provide ongoing oversight and supervision of staff to ensure abuse policies were implemented. Additionally, potential employees would be screened for a history of abuse and…

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

Based on observation, interview, and record review the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 4 residents (Resident 5, 21, 17, & 16) interviewed, 1 family interview, 4 staff interviews, and observations. The facility had insufficient number of administrative and nursing staff to provide care and services for residents in the areas of supervision, behavior management, wound management, staffing coordination, central supply, infection control and antibiotic stewardship. Findings included . <Resident Interviews> <Resident 5> In an interview on 08/30/2023 at 2:17 PM Resident 5 stated call light response depended on who was working, at times it could take one to two hours for staff to respond to the call light, and it happened usually once a week. Resident 5 stated during meal service you can't get anyone to respond but eventually they will come or change of shift, can't get anyone to answer the light, and would request to be put into bed at 4:30 PM because if not, they would end up stuck in their chair until staff…

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 post the daily nurse staffing information including the total number of and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and the number of current residents residing in the facility. The failure to post required nurse staffing information daily and failure to retain the daily posted documents for a minimum of 18 months placed residents at risk for inadequate staffing and deterred the facility from ensuring adequate staff each shift. Findings included . Observation on 09/26/2023 at 11:06 AM showed the daily nurse staffing hours posted at the nurse's station at a standing person's eye level. The posted document was dated 08/08/2023. In an observation and interview on 09/26/2023 at 11:14 AM, Staff C (Operations Manager) observed the posted hours and confirmed the date on the sheet showed 08/08/2023. Staff C stated they were not aware of the requirement and did not know who was supposed to post the nursing hours. REFERENCE: WAC 388-97-1620(2)(b)(i).

Based on interview and record review the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal regulatory requirements. The Administration failed 1) to ensure residents were free from abuse and neglect, 2) to investigate incidents of abuse and neglect, 3) to maintain a safe and supervised environment for vulnerable residents, 4) to provide prevention, scare and services for pressure ulcers, 5) to identify and treat resident pain, 6) to identify and provide culturally competent trauma informed care to trauma survivors, 7) to ensure residents were free from unnecessary antipsychotic medications, 8) to provide sufficient staff to meet resident care needs, 9) to ensure staff was competent to perform resident care and nursing tasks, 10) to review, update, and implement a Facility Assessment (FA) that met the needs of the resident population, 11) to implement a transfer agreement with a local hospital, 12) to develop, implement, and monitor a Quality Assurance and Process Improvement…

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 Governing Body failed to establish, implement, policies and practices for the nursing home's operations and management. The failure to monitor and support the continuity of management responsibilities during turnover of required positions placed the facility in non-compliance in seventeen areas of resident care and placed residents at risk for incompetent care, unmet needs, injury, and diminished quality of life. Findings included . <Adequate and Qualified Workforce> The Governing Body failed to employ or designate qualified individuals into required positions including Infection Control Preventionist, Social Services, Administrator Designee, and Staff Development Nurse. This failure resulted in widespread failure to meet identified resident care needs. <Administration> The Governing Body appointed one of its members to be the Interim Administrator and failed to oversee the requirement for Administrators to be onsite, full-time, to oversee and direct daily operations 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 review and update the Facility Assessment (FA) as necessary, at least annually. The failure to complete an annual review deterred the facility from identifying and implementing programs requiring revision and delegation of tasks of critical staff open positions placing residents at risk for unmet needs and inadequate care. Findings included . In an interview on 09/26/2023 at 3:56 PM, Staff B provided documents including a draft of the FA worksheet. Staff B stated they did not have a copy of the current FA and would need to ask for it. Staff B returned with a 08/08/2022 FA and stated the corporate resource person emailed it to them. In an interview on 09/29/2023 at 11:05 AM, Staff A (Interim Administrator) stated they became the Interim Administrator in June 2023 and Staff B started as the Operations Manager in June 2023. Staff A stated Staff B did not have a copy of the current FA and was asked to create a new FA. Staff A stated the last FA was reviewed 08/08/2023 and was past the required annual review. REFERENCE: WAC…

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 have a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed transfer and potential lack of access to care, services, and the hospital in the event of an emergency. Findings included . In an interview on 09/26/2023 at 11:14 AM, Staff C (Operations Manager) was asked to provide the facility transfer agreement. Staff C was unable to provide a transfer agreement with a local hospital or another facility. In an interview on 09/27/2023 at 11:21 AM, Staff A (Administrator) confirmed the facility did not have a transfer agreement with a local hospital. REFERENCE: WAC 388-97-1620(6)(a).

Based on interview and record review the facility failed to maintain an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice. The facility failed to demonstrate evidence of an ongoing QAPI program that was completed on at least a quarterly basis, was documented, included systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. Findings included . A review of the facility 2022-2023 QAPI binder showed one QAPI meeting was held on 04/13/2023 and one meeting held on 10/28/2022. There were no QAPI meetings held in Quarter 1 or Quarter 3 of 2023. On 09/26/2023 at 3:56 PM Staff B provided an 08/22/2023 QAPI agenda and meeting notes. There were no identified participants in the notes.…

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 designate a qualified Infection Preventionist (IP) to oversee the facility's infection prevention and control program. The failure to designate a qualified staff to facilitate an effective infection control program including monitoring for, assessing, implementing transmission-based precautions, and acting on resident infections upon occurrence and failure to ensure antibiotics were used appropriately, placed all residents at risk for infections, inappropriate treatment, and diminished quality of life. Findings included . In an interview on 09/26/2023 at 1:50 PM, Staff C (Operations Manager) stated the facility does not have an infection control preventionist and the position was posted for hire. In an interview on 09/27/2023 at 4:15 PM, Staff C was asked which staff was monitoring resident infections and antibiotic use. Staff C stated there was no staff designated to provide oversight of new infections or new orders for antibiotics. Staff C stated there were no monthly reports to provide showing infection surveillance 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.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff consistent with their expected roles and based on the Facility Assessment. The failure to provide mandated annual training for 2 of 2 staff (Staff K Licensed Practical Nurse and Staff J Certified Nursing Assistant) employed over one year at the facility placed residents at risk of receiving care from untrained staff. Findings included . Review of the 09/26/2023 staff list with date of hire showed Staff J was a Certified Nursing Assistant (CNA) hired on 05/04/2022. The staff list showed Staff K was a Licensed Practical Nurse hired on 05/06/2022. Review of the daily staff schedule for 09/01/2023 thru 09/25/2023 showed Staff J worked 13/26 days and Staff K worked 20/26 days. In an interview on 09/26/2023 at 4:42 PM, Staff C (Operations Manager) reviewed the staff files for Staff J and Staff K and confirmed there were no annual training documents in the files. Staff C stated the staff development nurse left and no annual training…

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 alleged abuse or neglect the facility was aware of or witnessed, was thoroughly investigated for 4 of 15 residents (Residents 1, 2, 9, & 18 ) reviewed for abuse and neglect, and failed to log, report, and thoroughly investigate two falls for 1 of 3 residents (Resident 3) reviewed for falls. These failures placed all residents at risk for unidentified abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect & Exploitation, dated 04/27/2023, showed all alleged violations (a situation or occurrence that is observed or reported by staff, resident, visitor, or others) of abuse or neglect would be reported to the administrator, state agency, and all required agencies within the required timeframe's. An immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occurred. The facility would make…

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 3 of 3 (Residents 16, 3, 17 ) residents reviewed for pressure ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, and implement preventative skin measures placed all resident's at risk for deterioration in skin condition, pain, and diminished quality of life. Findings included . Review of the undated facility, Pressure Injury Prevention and Management policy, showed the facility would utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove the underlying risk factors; monitoring the impact of the interventions; and modifying interventions as needed. Licensed Nurses would perform a pressure injury risk assessment, after…

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 nursing staff was competent and had the skill sets to care for residents' needs as identified through assessment and described in the care plan. The facility failed to ensure nursing staff competency for 5 of 5 Staff (Staff F RN-Registered Nurse, Staff G NA-Nurse Aide, Staff H LPN- Licensed Practical Nurse, Staff J NA, Staff K LPN) Nurse Aides (NA) demonstrated competency in skills and techniques necessary to care for resident needs as described in the residents' care plan. The failure to evaluate nurse competency for 3 of 3 nurses and 2 of 2 NAs placed residents at risk for unmet needs, unsafe care, and diminished quality of life. Findings included . The 2022 Facility Assessment FA with a review date of 08/08/2022 showed the facility identified Staff Competencies required in basic ADL [Activities of Daily Living] care, safety and other emergencies, care for residents with contracture, communication, resident rights and facility responsibilities, abuse prevention, infection control, culture change, identification 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 verify nursing assistants met competency evaluation requirements before allowing an individual to serve as a nurse aide. The failure to verify 2 of 2 staff (Staff G and J) for nursing aide competency on the State Agency registry placed residents at risk for incompetent care, unmet needs, and possible injury during care. Findings included . Review of the 09/26/2023 staff list with date of hire showed Staff G was a Certified Nursing Assistant (CNA) hired on 08/08/2023. The staff list showed Staff J was a CNA hired on 05/04/2023. Review of the 09/26/2023 daily nurse schedule showed Staff G and Staff J were both scheduled to work on 09/26/2023. Review of the daily staff schedule for 09/01/2023 thru 09/25/2023 showed Staff G worked 11 days and Staff J worked 13 days. In an interview on 09/26/2023 at 3:47 PM, Staff C (Operations Manager) stated the staff development nurse left employment and no State Registry verification documents could be located at the facility or at the corporate office. In an interview 09/27/2023 at 4:42 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.

Based on observation, interview, and record review the facility failed to adequately monitor target behaviors, implement non-pharmacological interventions and assess the interventions effectiveness before increasing psychotropic medications for 3 of 3 residents (Resident 1, 15, & 9) reviewed for accidents and supervision. These failures placed residents at risk for unnecessary psychotropic medications, injuries from falls, unmet needs, and a decreased quality of life. Findings included . According to the undated facility, Use of Psychotropic Medication, policy showed residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the residents medical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documenting the resident's response to the medication. For psychotropic medications that were initiated after admission to the facility, documentation would include the specific condition as diagnosed by the physician, and would only be initiated after medical,…

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 implement a system to ensure 1 of 2 (Staff J) Nursing Aides (NA) received required training for continued competency that is no less than 12 hours per year. The failure to have a system in place to provide mandatory training in dementia management, abuse prevention, and other areas of resident special needs placed residents at risk for abuse, neglect, emotional distress, and physical injury. Findings included . In an interview and record review on 09/26/2023 at 4:42 PM, Staff C (Operations Manager) reviewed the personnel file for Staff J and found no training documents of any training received after Staff J's hire date on 05/04/2022. Staff C stated there are change of shift meetings with all staff scheduled to work where abuse prevention is discussed, but there is no staff sign sheet or tracking methods to ensure staff received training. Staff C stated since there was not a staff development nurse, there is no one tracking NA continuing education or providing annual training on the mandatory topics or the topics related 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Facility failure to ensure cold foods were stored appropriately; ensure adequate separation of clean and dirty processes; ensure sanitizing solution was tested and replaced as required; and ensure kitchen fans were clean left residents at risk for less than palatable food and foodborne illness. Findings included . Facility Policies According to the facility's revised April 2019 Food Preparation and Service Policy the area for cleaning dishes should be separate from the food service line in order to ensure a sanitary food service; work surfaces should be cleaned and sanitized according to food code guidelines. According to the facility's 2001 Sanitization Policy, revised 2008, Quaternary Ammonium Compound (quat) sanitizer must be used at a concentration of 150-200 ppm (parts per million), and that the solution must be replaced at least once per shift and when the solution is visibly soiled or cloudy.…

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 develop a Quality Assurance and Performance Improvement plan to ensure repeated and/or systemic deficiencies were analyzed and corrected. The facility failed to conduct a thorough analysis of quality assurance data, develop interventions, analyze interventions, and determine if the desired improvement was achieved/sustained. These failures placed all residents at risk for deficiencies in quality of care, quality of life, and resident safety. Findings include . Facility policy According to the facility's February 2020 Quality Assurance and Performance Improvement (QAPI) Program policy, the objective of the QAPI program was to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. The policy showed the QAPI plan should describe the process for identifying and correcting quality deficiencies. The policy showed the QAPI committee should meet monthly to review reports, evaluate data, monitor QAPI-related activities, and adjust the plan. The QAPI…

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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including Covid-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) and other infections during a global pandemic. The facility failed to report a Covid 19 outbreak (1 Resident with Covid 19 acquired at the facility) to the required entity and respond to the Covid 19 outbreak in accordance with the Local Health Jurisdiction (LHJ) recommendations; to discontinue Transmission Based Precautions (TBP) in accordance of the LHJ or Centers for Disease Control (CDC) recommendations for 1 of 1 (Resident 111); to implement and adhere to Aerosol Generating Procedures (AGP) for 4 of 4 Residents (27, 4, 53 & 3); to ensure staff used Personal Protective Equipment (PPE) and performed hand hygiene (HH) as required to prevent the spread…

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 develop and implement policies and procedures to ensure residents' and staff who refused to take the COVID-19 vaccine were informed of the risks and benefits of not receiving the vaccine, had the ability to ask and have questions answered. and failed to implement a system to document that information. This failure prevented residents and staff from making an informed decision with all needed information about receiving or declining the COVID-19 vaccine, including the risks and benefits. Findings included . Review of an undated facility Covid-19 Vaccine Mandate Policy and Procedure showed all staff must be fully vaccinated against Covid-19 by October 18, 2021, and any staff member not vaccinated must submit an exemption form for official review. Unvaccinated and exempted staff must wear an N-95 respirator while in the facility, test more frequently (3 times per week) and would receive more regular infection control training regarding social distancing and handwashing. The Covid-19 policy did not address the procedure 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 observation, interview and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 4 (Residents 37, 50, 111 & 43) of 18 sample residents. Facility failure to provide a dignified dining experience, ensure personal privacy was maintained, safeguard personal belongings, or determine a resident's capacity to make decisions placed residents at risk for undesired medical care, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth. Findings included . Resident 37 According to the 07/04/2022 Quarterly MDS (Minimum Data Set - an assessment tool) Resident 37 admitted to the facility on [DATE] and was assessed to be severely cognitively impaired. The MDS showed Resident 37 had diagnoses including Dementia and Stroke. A 09/28/2021 nursing Medicare meeting note showed Resident 37 had encephalopathy (a disease of brain function causing confusion and an altered…

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 thoroughly investigate injuries and accidents for 4 (Residents 55, 43, 50, & 37) of 10 sample residents and 2 supplemental residents (Residents 56 & 30). Failure to thoroughly investigate incidents, detracted from the facility's ability to prevent repeated incidents, injuries, and potential abuse/neglect. Findings included . Facility Policy According to the facility's Abuse Investigating and Reporting policy revised July 2017, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Resident 55 According to the 07/31/2022 Quarterly MDS Resident 55 admitted to the facility on [DATE] and had diagnoses including a history of falls, obesity, tremor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately assess 5 (Residents 43, 52, 27, 57 & 9) of 18 sample residents and 1 (Resident 24) supplemental resident reviewed for accurate Minimum Data Set (MDS- an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 43 Review of the 07/14/2022 Quarterly Minimum Data Set (MDS an assessment tool) showed Resident 43 admitted to the facility on [DATE], was cognitively intact, and had diagnoses including bipolar disorder, fractures, multiple traumas, and required aftercare following an orthopedic (bone) surgery. The MDS assessed the resident to have no verbal behaviors (threatening, cursing, screaming) directed towards others but did reject care four to six days of the lookback period. The MDS identified Resident 43's behavior worsened since the previous assessment. Review of the previous MDS, a 04/13/2022 Medicare 5-Day assessment, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected resident's condition for 4 of 5 residents (Residents 37, 30, 43 & 52) reviewed for unnecessary medications. The failure to ensure PASRR assessments were accurate placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . Resident 30 According to the 06/24/2022 admission Minimum Data Set (MDS an assessment tool), Resident 30 had severe cognitive impairment with multiple medically complex diagnoses including Traumatic Brain Injury, Alzheimer's Disease, anxiety disorder, and depression. This MDS showed Resident 30 received antipsychotic (AP) and antidepressant (AD) medications daily. Review of a 06/22/2022 Level 1 PASRR for Resident 30 showed staff identified the resident with serious mental illness indicators that included a mood disorder, anxiety, 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 nursing services were provided within professional standards of nursing for 7 (Residents 45, 43, 37, 50, 30, 27 & 9) of 18 sample residents reviewed. Failure to assess and acquire an order for adaptive eqiuipment (Resident 45), clarify physician's orders (POs - Residents 45 & 43), provide bowel care according to the facility's bowel protocol (Residents 37 & 50), administer medications as ordered (Residents 30, 27 &9), clarify intravenous (IV) orders (Resident 43) left residents at risk for unmet care needs and diminished qaulity of life. Findings included . Scoop Mattress Resident 45 According to the 07/15/2022 Significant Change MDS (Minimum Data Set - an assessment tool) Resident 45 had diagnoses including Alzheimer's Disease, Stroke, vertigo, a history of falling and Non-Alzheimer's Dementia. The MDS showed Resident 45 did not have Shortness of Breath (SOB). The MDS showed Resident 45 showed signs of pain daily including…

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 develop and implement an effective discharge (DC) planning process for 1 of 1 resident (Residents 158) reviewed for discharges from a complaint investigation and 4 supplemental residents (Residents 160, 159, 20 & 4). The failure to identify discharge needs, establish wound care services, and document referrals to local contact agencies when DC to the community for Residents 158 & 160 placed these residents at risk for unmet needs and rehospitalization. The failure to ensure a DC care plan (CP) was developed in collaboration with the resident and/or the resident representative and perform/document regular re-evaluation of resident's DC plan for Residents 20, 4, & 159 placed them at risk for emotional distress and unnecessary institutionalization. Findings included . Resident 158 The 05/25/2022 admission Minimum Data Set (MDS, an assessment tool) showed no DC plan was developed for Resident 158 to return to the community. The 05/25/2022 Care Area Assessment (CAA, a care planning tool) showed no planning for Resident 158 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 2 (Residents 111 & 13) of 4 residents reviewed for pressure ulcers (PUs) received the necessary treatment and services consistent with professional standards of practice and/or had appropriate and timely interventions in place based on individual risks, to promote healing of existing pressure injuries and prevent new pressure injuries from developing. These failures left residents at risk for avoidable PUs, extended healing duration and discomfort. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shifting, dragging). The tolerance…

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 observations, interview, and record review the facility failed to ensure 3 (Resident 11, 111 & 38) of 7 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent, timely weights, identify significant weight changes, and notify interested parties placed the residents at risk for delayed identification of interventions for continued weight loss. Findings included . Review of a 12/27/2021 facility Weight Assessment and Intervention policy, showed nursing staff would obtain weights on admission, daily for the first three days after admission, and at least bi-monthly thereafter. This policy indicated any weight change of five pounds (lbs) for residents that weigh 100 lbs or greater and 3 lbs for residents who weigh less than 100 lbs since the last weight assessment would be reweighed the next day for confirmation. If the weight loss was verified, nursing would contact the Registered Dietician (RD) and provider. The policy stated weights would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have sufficient and competent nursing staff to provide and supervise care as evidenced by 7 resident interviews and 4 staff interviews. The facility had insufficient staff to provide supervision to ensure residents received assistance with Activities of Daily Living (ADL) including showers and restorative services, received supervision to prevent accidents/hazards, received timely call light response in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and negative outcomes. Findings included . The Facility Assessment (FA), undated, showed required nursing staff was based on patient census and level of care needs using the nationally established standards on the CMS (Center for Medicare and Medicaid Services) Five-Star Rating. The FA showed the facility established a staffing plan to meet the regulation (of Washington State) of 3.4 nursing hours 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 ensure nursing staff (nurses and nurse aides) had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans (CP) and considering the number, acuity and diagnoses of the facility's resident population, and in accordance with the facility assessment. The failure to assess staffs' competency on hire, failure to provide orientation to agency staff and failure to verify nursing staff licensure and certification placed residents at risk for unsafe, substandard quality of care and unmet needs. Findings included . Abuse & Neglect Training In an interview on 08/11/2022 at 9:55 AM, Staff II (Receptionist/Nurse Aide in Training) stated they worked at the facility since 2018. Staff II stated they did not know what a mandated…

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 medication regimens were free of unnecessary medications for 7 (Residents 24, 43, 52, 37, 45, 57 & 30) of 8 residents reviewed. Failure to ensure residents were free from unnecessary medications, had behavior monitoring, provided informed consent, and completed Gradual Dose Reductions (GDR) left residents at risk for unnecessary medications and negative health outcomes. Findings included . Facility Policy According to the facility's undated Antipsychotic Medication Use Policy residents should only receive antipsychotic (AP) medications when necessary to treat specific conditions for which they are indicated and effective. The policy stated informed consent must be obtained and the physician notified if a resident or their representative did not consent to a medication. The policy stated diagnosis of a specific condition/diagnosis for which an AP medication was required in order to provide AP medications. The policy stated diagnoses…

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 establish an infection prevention and control program that included developing an antibiotic (ABO) stewardship program to promote appropriate use of antibiotics, failed to analyze and complete monthly surveillance effectively for 6 of 6 months (February 2022-July 2022) reviewed, and reduce the risk of unnecessary antibiotic use for 3 of 3 residents (Residents 43, 99 & 20) reviewed for unnecessary antibiotics, and failed to have an effective Infection Control Committee to meet regularly and analyze/review Antibiotic usage in the facility. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug resistant organisms (MDRO: microscopic organisms that are resistant to many antibiotics). Findings included . Review of a 12/2016 facility Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes policy showed ABO usage and outcome data would be collected and documented using a facility- approved ABO…

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 notification of COVID-19 infections for 2 (Residents 50 & 45) of 3 residents and/or representatives reviewed for notification. COVID-19 is an infectious disease caused by a novel virus with respiratory illness symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. This failure placed the Residents and their Representatives at risk of not being fully informed of COVID-19 activity in the facility. This deficiency occurred during the COVID-19 pandemic. Findings included . Review of the 05/2020 Coronavirus Disease (Covid-19) Reporting Facility Data to Residents and Families policy showed residents and families would be notified for a single confirmed case of Covid-19 no later than 5:00 PM the next day after the positive Covid case was confirmed. Review of resident records showed an 08/02/2022 progress note that residents and/or 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.

Based on observation, interview, and record review the facility failed to ensure employees, including contracted staff, were tested for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing that could result in impairment or death) according to the frequency recommended by the Local Health Jurisdiction (LHJ) and required based on the county positivity rate during a COVID-19 outbreak for staff COVID-19 testing. The facility failed to ensure COVID-19 testing was documented as completed and/or the results of that testing was documented in the residents' records for 4 of 4 residents (Residents 30, 43, 38 & 111) reviewed for documentation of COVID-19 testing. Additionally, the facility failed to conduct COVID-19 testing while maintaining proper infection control measures to reduce the potential for the spread of COVID-19, during a facility COVID-19 outbreak. This failure placed residents, staff, and visitors at risk for transmission of COVID-19 in the facility. Findings included . Review of an undated…

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 to assist to formulate Advanced Directives (AD) and/or Power of Attorney (POA) documentation for 4 (Residents 9, 37, 11 & 20) of 18 residents reviewed. This failure left residents at risk for losing the right to have their preferences and choices honored with regard to emergent and end-of-life care. Findings included . According to facility's December 2016 Advance Directives policy an AD is a written instruction, such as a living will or Durable Power of Attorney (DPOA) for health care, recognized by State law, relating to the provisions of health care when an individual is incapacitated. The policy stated information about whether or not the resident had executed an AD should be displayed prominently in the medical record and the plan of care for each resident, and would be consistent with their documented treatment preferences and/or AD. The facility's undated admission Agreement included an AD Acknowledgment form that had five…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were implemented and updated for 4 (Residents 45, 30, 57 & 55) of 18 sample residents reviewed. Failure to implement and individualize CPs, and failure to include residents in their care planning process left residents at risk for unmet care needs and diminished quality of life. Findings included . Resident 45 According to the 07/15/2022 Significant Change MDS (Minimum Data Set - an assessment tool) Resident 45 admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease and Non-Alzheimer's Dementia. The MDS showed Resident 45 was severely cognitively impaired and required extensive assistance with most care. According to the 01/28/2022 Admissions MDS Resident 45 was assessed to have Alzheimer's Disease and Non-Alzheimer's Dementia at the time of admission. Review of Resident 45's Comprehensive Care Plan (CP) showed an 08/08/2022 Resident has impaired cognitive function/impaired thought…

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 residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided necessary assistance for 3 (Residents 45, 24 & 52) 18 sample residents reviewed. Failure to provide assistance to residents who were dependent on staff for nail care (Resident 45 & 24), dressing (Resident 24), bathing (Resident 52), and oral hygiene (Residents 52) placed residents at risk for unmet needs, poor hygiene, embarrassment, and diminished quality of life. Findings included . According to an undated facility ADL, Supporting policy, the residents who are unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This policy stated interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Resident 24 According to the 06/11/2022 Annual MDS (Minimum Data Set - an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide restorative nursing services to 3 (Residents 20, 43 & 55) of 18 sample residents. Facility failure to . left residents at risk for . and . Findings included . According to the 07/2017 facility's Restorative Nursing Services policy, Restorative goals and objectives should be individualized and resident-centered, and outlined in the resident's plan of care. Resident 20 According to the 05/17/2022 Quarterly Minimum Data Set (MDS an assessment tool) Resident admitted to the facility on [DATE] and had diagnoses including Stroke, Dementia, and Ileus (a blockage of the intestines). The MDS showed Resident 20 did not walk in their room or in the hallway during the lookback period, had a functional limitation to their Range of Motion (ROM) in one leg and used a wheelchair for mobility. The MDS showed Resident 20 received Occupational Therapy (OT) from 03/22/2022 through 04/26/2022 and did not receive Restorative Services. The 04/26/2022 OT…

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 resident environment was free from hazards for 2 (Residents 50 & 52) of 18 sample residents and failed to ensure 1 of 2 shower rooms remained secure when not in use. These failures left residents at risk for accidents and injury. Findings included . Resident 50 The 07/22/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 50 had a diagnosis of dementia. Resident 50 was assessed to required extensive assistance from one staff person with transfers and mobility using a wheelchair. The MDS showed Resident 50 had wandering behaviors that affected other residents and had two prior falls. A 03/09/2022 Care Plan (CP) showed Resident 50 was a wanderer, aimlessly wandering, goes into other resident rooms, gets into beds not assigned to them related to lack of safety awareness and impaired memory. Staff interventions included distracting the resident from wandering by providing diversion, activities, food,…

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 medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident 20 & 43) of 18 residents reviewed; determine why residents demonstrated a pattern of refusals for care and services for 2 (Residents 43 & 30) of 18 sample residents reviewed; and failed to document and resolve for residents who had grievances about missing items for 2 (Residents 111 & 43) of 18 sample residents reviewed. These failures placed the residents at risk for frustration, diminished quality of life, and unmet or unidentified care needs. Findings Included . Facility Policy According to the facility's revised October 2010 Social Services policy, the Director of Social Services was responsible for assisting in meeting the social and emotional needs of the residents and maintaining a record system for social service data. The policy showed the Director of Social Services was responsible 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%). During observations of 25 opportunities for error, 2 of 2 licensed nurses made 2 errors and 1 Medication Tech (MT) made 1 error which amounted to a total error rate of 12%. This placed residents at risk for side effects and/or reduced medication effectiveness due to improper administration. Findings included . The April 2021 facility policy for Administering Medications, showed staff should check the label three times to verify the right medication and the right dosage. This policy directed staff to check the expiration/beyond use date on the medication label prior to administering. Resident 27 On 08/10/2022 at 8:20 AM, Staff S (Licensed Practical Nurse), was observed to dispense 20 mg (milligrams) of an Over The Counter (OTC) antacid and administer to Resident 27. Review of Resident 27's Physician Orders (PO) read Omeprazole-Soduim Bicarbonate Packet 40-160 mg, a prescription antacid medication. On 08/11/2022 at 10:19 AM, when asked if the correct…

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 drugs and biologicals were secured and dated when opened, and expired medications and biologicals were disposed of timely in accordance with professional standards for 1 of 3 medication carts, and 1 of 1 medication rooms reviewed, and leaving medication in residents' rooms. These failures placed residents at risk for receiving expired medications, medication errors, and non-assessed, self-administration of medications by residents. Findings included . According to the facility's revised April 2019 Storage of Medications policy, nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. This policy stated drugs and biologicals used in the facility were stored in locked compartments and any discontinued or outdated drugs or biologicals were returned to the dispensing pharmacy or destroyed. Medications at Bedside Resident 43 Observation on 08/08/2022 at 10:35 AM showed Resident 43 with a small medicine cup full of pills (their morning…

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 (Resident 39 & 24) of 4 sample residents and 1 supplemental resident (Resident 43) reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included . Review of an undated facility Dental Services policy showed routine, and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Resident 39 According to the 07/08/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 39 had diagnoses including Stroke, a Seizure Disorder and a pervasive developmental disorder, and required extensive assistance with personal hygiene. The MDS showed Resident 39 had an obvious or likely cavity or broken natural teeth. Observation on 08/08/2022 at 5:26 AM showed several of Resident 39's teeth were blackened, rotten and broken.…

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 resident's records were complete, accurate, and readily accessible for 10 (Residents 11, 24, 30, 8, 52, 37, 50, 30, 43 & 56) of 18 residents whose records were reviewed. The failure to monitor, identify and correct missed documentation by nurse aides in areas of Activities of Daily Living (ADL), nutritional intake, and the failure to obtain records from outside providers detracted the nurses from monitoring resident care and identifying/implementing interventions for resident needs, which left residents at risk for inaccurate assessments, poor coordination of care and unmet needs. Findings included . Nutritional Intake Resident 11 Review of Resident 11's June 2022 nutritional intake documentation showed, staff failed to document the resident's meal intake for 22 of the 90 meals provided. July 2022 records showed 32 of the 93 meals were not documented and August 2022 nutritional intake records showed 22 of the 33 meals had no documentation of Resident 11's meal intake. Resident 24 Review of Resident 24's June 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.