Olympia Transitional Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure diabetic nail care was provided for 1 of 2 residents (Resident 4) reviewed for foot care. The failure to refer residents to a qualified specialist when staff were unable to meet a resident's diabetic foot/nail care needs, placed the resident at risk for ingrown toenails, foot ulcers, infection, pain/discomfort, and other medical complications associated with inadequate of diabetic foot care.Findings included .Resident 4 was admitted to the facility on [DATE]. A provider order, dated 04/13/2026, directed licensed nurses to provide diabetic nail care every seven days and as needed. Resident 4's diabetes care plan, initiated 09/25/2025, also showed weekly nail care would be provided by the licensed nurse. Observations on 04/21/2026 at 9:17 AM and 04/23/2026 at 11:13 AM, showed Resident 4 had a right above knee amputation and the fifth digit (pinky toe) on the right foot had been amputated. Resident 4 indicated the amputations were due…

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, interviews and record review, the facility failed to provide adequate and ordered fluids, within reach of the resident and at mealtimes, to maintain hydration for 1 of 1 sampled resident (Resident 60) when reviewed for hydration. This failure placed residents at risk for dehydration, medical complications and a diminished quality of life.Findings included. Resident 60 was admitted to the facility on [DATE] with unspecified dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). The Significant Change Minimum Data Set (MDS, an assessment tool), dated 03/30/2026, documented Resident 60 was severely cognitive impaired and depended on staff for care. On 03/14/2026, Resident 60 was ordered to have a fortified diet (foods enhanced with additional vitamins, minerals, or other nutrients to improve overall nutritional intake and prevent deficiencies), with regular texture and thin liquids. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 residents (Residents 9, 96, & 3) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.Findings included .Review of the facility policy titled, Antibiotic Stewardship, last revision/review date of 4/2025, documented Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor the functioning of window alarms to prevent elopement for 1 of 20 residents (Resident 1) in a secure dementia unit. This failure placed residents at risk for elopement from the facility, injury and a diminished quality of life. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, function, and overall thinking to the point where it disrupts daily living) with behavior disturbance and sensorineural hearing loss (permanent hearing loss). The Minimum Data Set (MDS), an assessment tool, dated 02/15/2026 showed Resident 1 was cognitively impaired, had shown behavior symptoms, wandering behaviors and required staff supervision for ambulation and most activities of daily living.Review of Resident 1's elopement/wandering evaluation, dated 02/09/2026, documented the resident was disoriented, ambulated independently or with supervision and had a score of 21 (High risk…

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 laboratory tests were completed as ordered for 1 of 3 residents (Resident 4) reviewed for quality of care. This failure placed the resident at risk of medical complications from lack of monitoring of medical conditions.Findings included.Review of the facility policy, titled Laboratory Testing, undated showed It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, PA [Physicians Assistant], NP [Nurse Practitioner] or clinical nurse specialist and to promptly notify the ordering entity of test results.Lab results and pending or missing lab results will be part of a change of shift report.Pending or missing lab results will be followed-up during daily clinical meeting.Resident 4 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Hyperparathyroidism (occurs when 1 or more of the 4 parathyroid glands in the neck produce excessive parathyroid hormone [PTH], leading…

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 Ombudsman with transfer notification for 3 of 3 sampled residents (Resident 64, 71 & 16) reviewed for hospitalization. The failure to ensure required notifications were completed, prevented the Office of the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes) the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . Resident 64 was admitted to the facility on [DATE]. Resident 64 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 71 was admitted to the facility on [DATE]. Resident 71 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 16 was admitted to the facility on [DATE]. Resident 16 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On 03/31/2025 at 9:40 AM, documentation of the Ombudsman notification was requested from Staff D,…

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 routine assessment and monitoring of skin condition/injuries for 1 of 3 residents (Resident 331) reviewed for non-pressure skin, to provide bowel care in accordance with physicians' orders and facility protocol for 3 of 6 residents (Residents 67, 61 & 31) reviewed for bowel management, and to report dental pain for 1 of 2 residents (Resident 181) reviewed for dental care. These failures placed residents at risk for unidentified decline and/or delayed treatment of non-pressure skin conditions, abdominal pain, decreased appetite, other negative outcomes related to untreated constipation, and for untreated dental pain. Findings included . <Non-Pressure Skin> Review of the facility's Skin and Wound Monitoring and Management policy, revised 12/2023, showed a licensed nurses would assess non-pressure skin injuries that exist on a resident. These assessments would include measurements and a description of the nature, location and characteristics of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to fully operationalize an effective Infection Control and Prevention program when the facility failed to implement Infection Prevention and Surveillance Program (IPSP) to ensure line listings contained complete and accurate infection control data, with ongoing monitoring and analysis of infections and microorganisms for 2 of 2 months (January and February 2025) reviewed. Additionally, the facility failed to ensure staff performed hand hygiene, followed standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions used when someone has confirmed or suspected infections) for 3 of 4 residents (Residents 331, 16, & 31) reviewed for infection control. Additionally, the facility failed to have an adequate laundry sorting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement an antibiotic stewardship program that ensured complete and accurate information was collected (signs/symptoms, culture results etc.), evaluated to determine if McGeer's Criteria (tool for infection surveillance and antibiotic stewardship, criteria to show if antibiotics were indicated) was met, antibiotic use warranted, and providers were notified if criteria was not met or a microorganism was resistant to the current treatment for 3 of 3 residents (Residents 50, 31 & 335) reviewed for antibiotic use. These failures placed residents at risk for ineffective treatment of infections, development of multi-drug-resistant organisms, and other negative health outcomes. Findings included . During an interview on 03/26/2025 at 1:26 PM, Staff H, Infection Preventionist (IP), said the facility utilized revised McGeer's Criteria as their standardized tool for evaluating potential infections. Review of the facility's undated Statement of Leadership…

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 funds were transferred to the state office of financial recovery (OFR) within 30 days of death or discharge, for 1 of 1 discharged residents (Resident 332) reviewed for trust accounts. This failure resulted in delayed reconciliation of resident trusts. Findings included . Review of Resident 332's death in facility Minimum Data Set (an assessment tool), dated 12/23/2024, showed the resident was on Medicaid and discharged from the facility on 12/23/2024. Review of Resident 332's trust account ledger, showed a balance of $106.46 on 12/23/2024. On 04/01/2025 at 8:33 AM, a copy of the check for $106.46 sent to the OFR was requested. Staff L, Business Office Manager, reported that Resident 332's trust balance had not yet been conveyed (the act of legally transferring property from one entity to another) to the OFR. Reference WAC 388-97-0340(5) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised, and accurately reflected resident care needs for 4 of 18 sample residents (Residents 331, 26, 67 & 71) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . 1) Resident 331 admitted to the facility on [DATE], with a NPO (nothing by mouth) order secondary to dysphagia (difficulty swallowing). A nutrition care plan for Resident 331, initiated 03/14/2025, showed if the resident ate less than 50% of their meal, staff were to offer a meal replacement, and were to monitor and report to the physician any decrease in appetite. An at risk for falls care plan for Resident 331, initiated 03/14/2025, directed staff to keep needed items, water, etc., in reach. An antiplatelet therapy care plan for Resident 331, initiated 03/19/2025, directed staff to monitor for loss of appetite. An acute/chronic pain care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Documentation of Oral Care> Resident 331 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment and was dependent on staff for oral care. On 03/26/2025 at 2:31 PM, Resident 331 reported they were provided oral care the previous evening for the first time since admission. Physicians' orders, dated 03/14/2025, showed Resident 331 was NPO (nothing by mouth) secondary to dysphagia (difficulty swallowing), and directed licensed nurses to provide Resident 331's oral care twice daily, once on day shift and once on evening shift. On 03/28/2025 at 10:29 AM, Resident 331 said they had not received oral care since the evening of 03/25/2025, as previously reported. The resident said staff informed them they had to wait for an order of toothettes to be delivered. On 03/28/2025 at 11:26 AM, Resident 331's assigned care giver Staff O, Certified Nursing Assistant (CNA), said they had not provided oral care to the resident. On 03/28/2025 at 11:26 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents anticipated for discharge were provided with a discharge summary, discharge plan, or discharge medications for 1 of 1 residents (Resident 79) reviewed for discharge. This failure placed residents at risk for an unsafe discharge, for complications related to not receiving medications, delay in treatment, and a diminished quality of life. Findings included . Resident 79 was admitted to the facility on [DATE] for surgical aftercare, following surgery on the nervous system. The Quarterly Minimum Data Set Assessment, dated 12/13/2024, showed Resident 79 was cognitively intact. Review of Resident 79's discharge care plan, initiated on 09/12/2024, showed that at that time (admission) they wished to return to their one-story home with 2 stairs with rail at top step, had a 2-wheel walker, and had barriers of pain, surgical incision, and mobility. There was not a more up to date discharge care plan when reviewed. Review of Resident 79's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure the provision of bathing and oral care for 1 of 2 dependent residents (Resident 331) reviewed for activities of daily living (ADLs). These failures placed residents at risk for poor hygiene, body odor, dental caries (cavities or tooth decay), a decreased self-worth and diminished quality of life. Findings included . Review of the facility's undated Partial-Bath policy showed residents could be bathed via shower, bed-bath or tub bath. They could also receive a partial bath on the days when full baths/showers were not provided. A partial bath consisted of washing the face, hands, underarms and groin. The policy instructed partial-baths should be provided every day that a shower/bed-bath/tub-bath was not provided. Resident 331 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool), dated 03/20/2025, showed the resident had moderate cognitive impairment, was dependent on staff for bathing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed ensure timeliness of laboratory [NAME] to include the reporting of critical lab results to the provider immediately for 1 of 3 residents (Resident 71) reviewed for hospitalization. This failure placed residents at risk for medical complications, hospitalization, delayed treatment, and diminished quality of life. Findings included . The facility policy titled Policy/Procedure - Nursing Clinical, revised 09/2024, documented Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending physician, PA [physician assistant], NP [nurse practictioner] or clinical nurse specialist promptly or as specified in the order. Call MD [doctor of medicine] immediately with any critical levels. Resident 71 admitted to the facility 02/12/2025. According to the Medicare 5-day Minimum Data Set (an assessment tool), dated 03/12/2025, Resident 71 was severely cognitively impaired. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to complete wound care per physician's orders for 1 of 3 residents (Resident 2) reviewed for quality of care. This failure placed residents at risk for prolonged wound healing and infection. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes, orthopedic aftercare following surgical amputation and peripheral vascular disease (condition reduces blood flow to arms, legs, or other parts of the body). The 5-day Minimum Data Set, an assessment tool, dated 07/30/2024, showed Resident 2 had cognitive impairment and was dependent on staff for bathing, toilet use and transfers. Resident 2's admission assessment, dated 07/23/2024, showed Resident 2 had a 21.5 centimeter surgical incision with staples. Review of a physician's order, dated 08/12/2024, showed the resident had a surgical incision to left knee to be cleaned with wound cleanser, skin prep applied and cover with a dry dressing daily and ace wrap every…

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 timely laboratory (lab) services were provided for 2 of 3 residents (Resident 3 and 4) reviewed for lab services. This failure placed residents at risk for delayed identification and treatment of underlying health conditions, over or underdosing of medication and other potential negative outcomes. Findings included . Review of the undated facility policy, titled, Lab Test Results Protocol, showed incoming and outgoing nurses would review the lab book for any labs that were still pending and follow-up accordingly. <Resident 3> Resident 3 was admitted to the facility on [DATE] with diagnoses including aftercare following hip joint prosthesis, osteomyelitis (bone infection) of the left femur (thigh bone). The 5-day Minimum Data Set (MDS), an assessment tool, showed Resident 3 was cognitively intake, had no behaviors and was dependent on staff for personal hygiene, transfers and toileting. Resident 3's physician orders showed the following:…

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, interviews, and record review the facility failed to provide timely toileting assistance for 7 of 9 Residents (Residents 1, 2, 3, 6, 7, 8, & 9) and bathing services for 3 of 4 Residents (Residents 3, 4, & 11) reviewed for Activities of Daily Living (ADLs). These failures placed the residents at risk for skin breakdown, discomfort, urinary tract infections, undignified quality of care, and diminished quality of life. Findings included . POLICY Review of the facility's Policy/Procedure-Activities of Daily Living policy, revised 07/2015, showed the facility would develop care plans (CP) for ADL's that were personalized with resident preferences for care such as day/time/type of bathing, waking time, bedtime, and any other quality of life choice that was important to the resident. The interventions provided to staff would be in accordance with professional standards of quality, clinical practice, and be on the [NAME] (simplified care plan) and accessible in the Point of Care (POC) electronic…

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 residents who required colostomy (surgically created opening in the bowel) care received services and care consistent with professional standards of practice and per physician orders for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of having unrelieved pain, worsening skin conditions, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia and surgical repair of the digestive system after a perforation and abscess (opening and spilling of bowel and infection into the abdominal cavity). The quarterly Minimum Data Set (MDS) assessment, dated 01/11/2024, documented the resident was cognitively impaired and indicated the resident had an ostomy. Resident 1's physician's order, dated 01/04/2024, documented an order for acetaminophen (medication to treat pain) 325 milligrams (mg) two tablets every six…

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 services provided met professional standards of practice for 5 of 24 sampled residents (Residents 23, 177, 276, 128 and 129) reviewed. The failure to follow, obtain, and/or clarify incomplete or conflicting physicians' orders when indicated, placed residents at risk for medication errors and other potential negative outcomes. Findings included . <Resident 23> Resident 23 admitted to the facility on [DATE]. Review of their current physician's orders showed: a) 09/19/2023 order for clonidine (blood pressure medication) with instruction to hold all blood pressure medications for a systolic blood pressure (SBP) less than or equal to 100. b) 10/05/2023 order for lisinopril/hydrochlorothiazide (a combination blood pressure and diuretic medication) with instruction to hold all blood pressure medications if the resident's SBP was less than or equal to 110. Review of Resident 23's January 2024 Medication Administration Records (MARs),…

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 external catheter length of Peripherally Inserted Central Catheters (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) were measured upon admission and at least weekly thereafter, for 3 of 3 residents (Resident 128, 129 & 276) reviewed for intravenous (IV) therapy. These failures detracted from staffs' ability to determine if the PICC was in the same position or had migrated and placed residents at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Review of the facility's Central Venous Access Device (CVAD) Dressing Change policy, revised 06/01/2021, showed upon admission the external catheter length of a residents PICC must be measured as part of the initial assessment and then measured at least weekly. 1) Resident 128 admitted to the facility on [DATE]. Review of Resident 128's antibiotic therapy care…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 2 of 2 nurses (Staff H & Staff G) did not correctly administer 3 of 31 medications in accordance with physician orders and/or manufacturer's guidelines for 2 of 3 residents (Residents 23 & 17) observed during medication pass. This resulted in a medication error rate of 9.68% percent. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects. Findings included . <Resident 23> On 01/24/2024 at 8:03 AM, Staff G, Registered Nurse (RN), took Resident 23's blood pressure and pulse. The systolic blood pressure (SBP) was 110 and pulse was 62. Staff G then administered the resident's lisinopril/hydrochlorothiazide (a combination blood pressure and diuretic medication) and clonidine (a blood pressure medication.) Review of Resident 23's January 2024 Medication Administration Record (MAR) showed the 10/25/2023 lisinopril/hydrochlorothiazide order instructed nursing to hold all blood pressure…

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, interviews, and record review, the facility failed to maintain and document refrigerator temperatures for 2 of 3 facility refrigerators (Reach In & 500 Hall) reviewed for food service; failed to document dishwasher temperatures, and failed to discard expired beverages for 1 out of 1 beverage carts observed. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . <Refrigerator temperatures> On 01/24/2024 at 10:03 AM, review of the facility's refrigerator temperature logs, documented the Reach In and 500 Hallway refrigerators had multiple missing entries and documented temperatures outside the acceptable parameters for cold food holding: Dates over/missing temperatures for Reach In Refrig: degrees Fahrenheit (F) January 2024: 4th-42F; 19th-46F, 20th-45F. December 2023: 7th-46F, 8th-44F, 12th-46F, 13th-46, 15th-44F, 16th-44F, 26th-42F, 30th-46F. November 2023: 2nd-46F, 11th-44F, 23rd-42F, missing 30th. October 2023: 2nd-42F, 3rd-42F, 4th-43F, 5th-44F, 7th-48F, missing the 10th 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 interview and record review, the facility failed to ensure resident medical records were complete and accurate for 6 of 6 residents (Residents 177, 20, 51, 18, 54, & 277) reviewed for bowel management. The failure to accurately record resident bowel movements placed residents at risk for unidentified and/or unmet bowel care needs. Findings included . 1) Review of Resident 177's point of care charting (a charting software program) showed two separate areas were provided for staff to document resident bowel movements, one titled Bowel Movements (BM) and the other titled, Bowel Continence. Review of Resident 177's January 2024 BM flowsheet showed staff documented the resident had no BM on: 01/05/2024, 01/06/2024, 01/07/2024, 01/08/2024, 01/10/2024, 01/13/2024, 01/16/2024, 01/17/2024, 01/18/2024, 01/20/2024, 01/21/2024, 01/22/2024 and 01/24/2024. Review of Resident 177's January 2024 Bowel Continence flowsheet showed the resident had a BM daily with exception of 01/08/2024, 01/13/2024, 01/18/2024 and 01/242024. 2) Review of Resident 20's point of care charting showed two…

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 respect and value the residents' private space by not knocking and/or announcing themselves for 1 of 2 sampled residents (Resident 6) reviewed for resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . Review of policy entitled Dignity and Respect, dated April 2021, documented, Staff members shall knock before entering the Resident's room. Resident 6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (an assessment tool), dated 12/21/2023, showed Resident 6 was cognitively intact. On 01/22/2024 at 2:33 PM, Resident 6 said aides enter the room all the time without knocking. At 2:49 PM Staff F, Certified Nursing Assistant, entered Resident 6's room without knocking or announcing himself. When asked if entering without knocking was normal practice, Staff F stated, I'm sorry and existed the room. On 01/25/2024 at 11:38 AM, Staff C,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure visibly dirty/soiled bed linen was removed and clean linen provided for 1 of 4 sampled residents (Resident 18) reviewed for environment. This failure placed the resident at risk of feeling unclean, undignified, and for potential infections. Findings included . Resident 18 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (an assessment tool), dated 11/08/2023, showed Resident 18 was moderately cognitively impaired. On 01/22/2024 at 12:56 PM, Resident 18's hospital gown, bed linen sheet, and blanket was observed covered in multiple clustered yellow-orange stains, ranging from pea size to quarter size. Resident 18 said staff change the bed linens about once a week. On 01/24/2024 at 3:02 PM Resident 18's hospital gown, bed linen sheet, and blanket was observed covered in multiple clustered yellow-orange stains, ranging from pea size to quarter size. On 01/25/2024 at 11:38 AM, Staff C, Resident Care Manager, said residents bed…

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 written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to or a statement of the resident's appeal rights for 1 of 2 residents (Resident 41) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process. Findings included . Resident 41's 12/04/2023 discharge Minimum Data Set (MDS, an assessment tool) showed the resident had an unplanned transfer to an acute care hospital on [DATE], with return anticipated. Review of Resident 41's electronic health record (EHR) showed no documentation the facility provided the resident or resident representative written notice detailing the reasons for transfer. On 01/26/2024 at 1:51 PM, when asked if there was documentation to support Resident 41 or their representative were provided a written notice of transfer/discharge as required…

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/resident representative at the time of transfer or within 24 hours of transfer, a written notice that specified the bed hold policy for 1 of 2 residents (Resident 41) reviewed for hospitalization. This failure placed the resident at risk of being unaware of the right to hold their bed while in the hospital. Findings included . Review of the facility's Bed Hold policy, revised 11/2016, showed the facility would inform the resident or resident representative in writing of their right to exercise a bed hold. The written bed hold notice would be provided upon admission and at or before transfer to the hospital and a copy of the notification would become a part of the resident's health record. Resident 41's 12/04/2023 discharge Minimum Data Set (MDS, an assessment tool) showed the resident had an unplanned transfer to an acute care hospital on [DATE], with return anticipated. Review of Resident 41's electronic health record (EHR)…

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 resident dental assessment was correct and accurately reflected resident care needs for 1 of 3 sampled residents (Resident 55) reviewed for dental care. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . Resident 55 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, as assessment tool), dated 11/21/2023, showed Resident 55 was moderately cognitively impaired, required assistance for personal care, and had no obvious cavities or or broken natural teeth. On 01/22/2024 at 9:57 AM, Resident 55 stated, I have plenty of problems, not able to go to the dentist, unsure if there is a dentist that comes to the facility. Resident 55 pointed to his right upper teeth showing a dark and broken tooth, and stated, This has been here for long time. On 01/26/2024 at 2:42 PM, Staff B, Director of Nursing Services, said the expectation is 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 and interview, the facility failed to ensure an environment free of accident hazards for 1 of 2 sampled residents (Resident 29) reviewed for accidents. The facility's failure to identify and enclose free hanging electrical wires, placed residents at risk for avoidable falls, other injuries, and a diminished quality of life. Findings included . Resident 29 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool), dated 11/07/2023, showed Resident 29 was cognitively intact. On 01/22/2024 at 1:44 PM, Resident 29 said she was concerned about the two electrical cords hanging down from the back of TV to the electrical sockets. Resident 29 said she and her roommate have repeatedly hooked the arms of their wheelchair and or walker on the cords as they had passed by the electrical cords. Resident 29 said she had asked the facility twice to place the cords in an encasement to prevent equipment from getting hooked. The electrical cords were observed to 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.

Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled and/or dated when opened, in accordance with accepted professional standards of practice for 2 of 2 carts (400 & 500 Hall medication carts) and 2 of 2 medication rooms (300 & 500 Hall medication rooms) reviewed. These failures placed residents at risk to receive expired medications and negative health outcomes. Findings included . <300 Hall Medication Room> Observation of the 300 Hall medication room on 01/24/2024 at 7:27 AM, with Staff B, Director of Nursing (DON), revealed the following: 1) A multiuse vial of Tubersol (used for Tuberculosis testing) purified protein derivative (PPD), opened and undated. Per the Tubersol package insert, an opened vial should be discarded 30 days after opening. 2) A bottle of liquid lorazepam for Resident 8 was opened and undated. Review of the medication box showed instruction to discard the bottle of lorazepam 90 days after opening. 3) A bottle of liquid lorazepam for Resident 4 was opened and undated. Review of the medication box 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.