Woodard Creek Health & Rehabilitation

Based on observation, interview, and record review, the Administration failed to provide oversight and monitoring of facility personnel, systems and practices related to Abuse/Neglect and failed to ensure compliance for identifying, reporting, protecting and thoroughly investigating allegations of abuse/neglect. These failures resulted in residents experiencing verbal abuse and neglect and placed other residents at risk of unidentified abuse/neglect and resulted in an Immediate Jeopardy (IJ) situation related to CFR 483.12(2)-(4) F610, alleged violations-Investigate/Prevent/Correct.Findings included .The facility policy titled, Abuse, revised 10/20/2022, showed under the section titled Identification, staff were encouraged to identify, correct, and intervene in situations which abuse, neglect and/or misappropriation of resident property was more likely to occur. Immediately following ensuring the resident's safety, staff were to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. Under the section…

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 ask residents if they had an Advanced Directives (AD) and attempt to obtain a copy or failed to notify residents of their right to formulate one for 1 of 3 residents (Resident 11) reviewed for ADs. This failure detracted from the resident's ability to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their medical preferences and choices honored regarding emergent and end-of-life care. Findings included .Resident 11 was admitted to the facility on [DATE]. Review of the electronic health record showed no documentation that the resident was asked if they had an AD or that they were informed of their right to formulate one.On 05/18/2026 at 3:44 PM, documentation that Resident 11 was asked if they had an AD and/or were informed of their right to formulate one was requested from Staff A, Administrator, via email.On 05/18/2026 at 4:27 PM, Staff A, Administrator, responded in a email, I do not…

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 record review and interview, the facility failed to initiate grievances for 1 of 1 month, April 2026, that included sampled residents (Resident 139, 47, 25 & 80) reviewed for grievances. This failure placed the residents at risk of unmet needs, personal loss and a diminished quality of life. Findings included. Review of April 2026 Resident Council Meeting Minutes, on 05/18/2026, documented the following concerns: Resident 139 reported, that the CNAs are disrespectful, don't listen argue with the residents in regard to their care, they don't want to do their jobs, and the do it the way they want and not to the resident's needs. Resident 47 reported, CNAs keep taking her packages of wipes using them on her roommate. This brings up an infection control issue. Resident 25 reported, agency staff wearing ear buds, either listening to music or talking on their phone while on the floor and providing care for residents. Concerns with the morning shift coming in and being very loud first thing in the morning and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately assess 4 of 24 residents' Minimum Data Sets (MDS, an assessment tool) reviewed. Failure to ensure accurate assessments for Preadmission Screening and Resident Review (PASRR, a federally mandated program requiring all individuals to be screened for mental illness or intellectual disabilities before being admitted to a nursing facility) (Resident 4), weight loss (Resident 100), urinary incontinence (Resident 94), cognitive pattern assessments and formal pressure injury prediction tools (Resident 17) placed residents at risk for unidentified and or unmet care needs.Findings included. Resident 4 was admitted to the facility on [DATE] and had a diagnosis of Post Traumatic Stress Disorder (PTSD- A mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event.), Depression (A mood disorder that causes a persistent feeling of sadness and loss of interest.) , and anxiety disorder (a group of mental health…

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 4 of 24 sampled residents (Residents 17, 10, 11, & 119) reviewed. The failure to obtain, follow and/or clarify physicians' orders when indicated, only sign for those tasks completed, and to notify the physician/pharmacy of missed doses due to unavailable medications, resulted in medication errors and placed residents at risk for adverse side effects, ineffective treatment and adverse health outcomes.Findings included . Residents 17 Residents 17 was admitted to the facility on [DATE]. Record review showed the resident had 12/20/2025 orders for: Morphine sulfate 0.25 milliliters (ml) by mouth every four hours as needed for pain level of 1-4 out of 10, or air hunger Morphine sulfate 0.50 ml by mouth every four hours as needed for pain level of 5-10 out of 10, or air hunger. Review of the April 2026 Medication Administration Record (MAR) showed on the following occasions…

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 dependent resident's activities of daily living (ADLs) were followed related to nutrition and/or hygiene for 1 of 5 residents (Resident 100) reviewed for ADLs and 1 of 2 residents (Resident 30) reviewed for choices. These failures placed residents at risk for nutritional concerns, lack of dignity, poor hygiene, and a diminished quality of life.Findings included. Review of the facility's policy titled, Activities of Daily Living (ADLs), undated, showed the facility was to maintain good nutrition, grooming and personal and oral hygiene for residents that were unable to carry out activities of daily living independently. Resident 100 Resident 100 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie malnutrition (not getting enough protein and calories for body needs), neurocognitive disorder with Lewy bodies ((dementia, causes a decline in cognitive abilities which can interfere with daily life), 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 non-pressure skin conditions were assessed, monitored and treated, in accordance with physician orders, and as needed bowel care was provided for 3 of 8 residents (Residents 17, 78 & 10) reviewed for non-pressure skin and/or bowel management. The failure to initiate bowel care in accordance with physician's orders, and to assess, monitor and implement ordered treatments for non-pressure skin conditions, placed residents at risk for pain/discomfort, delayed wound healing, and a diminished quality of life. Findings included .Bowel Management Resident 78Resident 78 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 04/10/2026, showed the resident was cognitively intact. On 05/17/2026 at 2:35 PM, Resident 78 said they had a lot of trouble with constipation. Review of Resident 78's physician orders showed the following as needed bowel care orders, dated 01/02/2026: Miralax…

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 necessary foot care and treatment in accordance with professional standards, including provision of nail care and podiatry services for 3 of 7 (Resident 78, 11 & 10) residents reviewed for activities of daily living. Failure to provide timely toenail care placed the residents at risk for negative health outcomes. Findings included .Resident 78Resident 78 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 04/10/2026, indicated the resident was cognitively intact, had a diagnosis of diabetes (condition defined by persistently high levels of sugar in the blood) and was independent with most activities of daily living. On 05/17/2026 at 2:29 PM, Resident 78 said no one had assisted her with trimming her toenails since she admitted to the facility and they needed to be cut. She indicated at home she sometimes had to go to a foot doctor to get her toenails cut because 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 observation, interview, and record review, the facility failed to ensure falls were investigated and/or investigated thoroughly for 1 of 1 resident (Resident 2) reviewed for hospitalization related to falls, or to ensure residents with mobility bars (a form of a side rail, used to assist residents with mobility while in bed) had the required components necessary to determine if they were safe and also assess to determine they were not being used as a restraint for 3 of 3 residents (Resident 100, 37, & 50) reviewed for bed rails/restraints. These failures placed residents at risk of falls, medical complications, injury, restraint, and a diminished quality of life.Findings included . FALL INVESTIGATIONSReview of the facility's policy titled, Falls Protocols, undated, showed the facility was supposed to have an investigation by the interdisciplinary team (IDT) for each fall, to identify the reason, any contributing factors, and/or the root cause of the fall. The staff would conduct a comprehensive…

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 coordinate and manage dialysis (a procedure that filters the blood) care for 1 of 1 (Resident 2) reviewed for dialysis. The facility failed to maintain complete dialysis records, communicate essential dialysis information between the facility and dialysis center, update dialysis related care planning to reflect the resident's current treatment needs, monitor fluid restriction compliance, and assess and respond to abnormal blood pressure trends. As a result, Resident 2 experienced ongoing fluid management concerns, including presentation to dialysis treatments above prescribe dry weight and the need for additional dialysis treatments, placing the resident at risk for fluid overload, cardiovascular complications and a diminished quality of life. Findings included .Resident 2 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and end stage renal disease (kidney failure, requiring dialysis). The Medicare 5-Day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with a diagnosis of dementia received appropriate care and services for 1 of 1 resident (Resident 100) reviewed for dementia care. This failure placed residents at risk of unmet or unidentified care needs, and a diminished quality of life. Findings included.Resident 100 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie malnutrition (not getting enough protein and calories for body needs), neurocognitive disorder with Lewy bodies (dementia, causes a decline in cognitive abilities which can interfere with daily life), and weakness. The Medicare 5 Day Minimum Data Set Assessment, dated 03/17/2026, showed Resident 100 was severely cognitively impaired, and was dependent on staff for cares.Review of Resident 100's care plans on 05/18/2026, showed there was no dementia care plan, or other care plans that reviewed/assessed/planned interventions regarding the following:- Resident preferences with family…

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 resident safety for 1 of 1 resident (Resident 24) reviewed for medications at the bedside and expired influenza vaccinations were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This failure placed residents at risk of receiving compromised or ineffective medications, accidental ingestion of medication, and a diminished quality of life.Findings included .Medications at BedsideThe undated facility policy titled, Self-Administration of Medications and Treatments, documented Residents have the right to self-administer medications / treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Resident 24 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 02/13/2026, documented Resident 24 was cognitively intact.On 05/17/2026 at 3:21 PM, Resident 24 was observed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible and that residents personal identifiable information was protected for 1 of 1 resident (Resident 17) reviewed for Hospice services, 1 of 1 resident (Resident 2) reviewed for dialysis services, and 1 of 1 resident (Resident 142) reviewed for identifiable personal health information. These failures placed residents at risk for a loss of privacy, poor/impaired communication and coordination of care with Hospice and Dialysis center staff, and unidentified and/or unmet care needs. Findings included . Findings included . Resident 17Resident 17 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/14/2026, showed the resident had a terminal diagnosis and was on Hospice services during the assessment period. Review of Resident 17's electronic health record (EHR) showed there was no Hospice documentation present 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 interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 residents (Resident 17) reviewed for hospice services. The facility failed to designate a member of their inter-disciplinary team (IDT) to be the liaison with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/documentation of what hospice staff had visited (e,g,, registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care they provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the Hospice provider, and placed residents at risk for not receiving necessary care and services and/or unmet care needs.Findings included .Review of the facility's Hospice contract showed under Provision of Information, it documented…

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, record review, and interview, the facility failed to ensure a medication error rate of less than 5%, by having an error rate of 23.5%, with 8 errors of 34 medication administration opportunities observed. This failure placed residents at risk of medication complications and a diminished quality of life.Findings included.Medication Administration General Guidelines, dated 01/2023, documented medications administered will be explained to the resident. Medication is administered within 60 minutes of the scheduled time. Once staff administered the medication, they will immediately record the administration in the medical record. On 01/21/2026 7:38 AM, a medication pass performed by Staff G, licensed practical nurse, with the following observations:<Resident 15> Resident 15 was admitted to the facility on [DATE] with diagnoses including spina bifida (a condition where the spine does not fully close in utero) and diabetes mellitus. The admission minimum data set (MDS), an assessment tool, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible, and systematically organized for 3 of 4 sampled residents (1, 3, & 4), reviewed for quality of care. This failure placed residents at risk of having an incomplete medical record, unmet care needs, and diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis (scaring of the liver due to conditions such as long-term alcohol use), esophageal varices (enlarged veins in esophagus due to blocked blood flow in liver), and alcohol dependence. The quarterly minimum data set (MDS), an assessment tool, dated 11/11/2025, documented Resident 1 has no cognitive impairment and is partial to moderately dependent on staff for assistance activities of daily living (ADLs).On 01/02/2026 11:05 AM, Resident 1 said they felt like staff did not understand the importance of monitoring weights and vital signs. Resident 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (5) reviewed for care conferences. This failure placed residents at risk for weight loss, pain, and a diminished quality of life.Findings included .Resident 5 was admitted to the facility on [DATE] with diagnoses including failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease. The quarterly minimum data set (MDS), an assessment tool, dated 10/30/2025, documented Resident 5 had severe cognitive impairment and was dependent on staff for assistance with eating.Durable Power of Attorney for Health Care, dated 12/16/2023, designated Resident 5's family member, Collateral Contact (CC5), as their decision maker, if the resident can no longer make decisions. On 01/16/2026 at 11:40 AM, CC5 said he was shocked the last time he saw Resident 5 because of the amount of weight the resident had lost.…

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 a comprehensive, person-centered care plan that guided staff in providing care for 1 of 13 sampled residents (1) reviewed for care plans. The failure to establish care plans that were individualized placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis (scaring of the liver due to conditions such as long-term alcohol use), esophageal varices (enlarged veins in esophagus caused by blocked blood flow in liver), and alcohol dependence. The quarterly minimum data set (MDS), an assessment tool, dated 11/11/2025, documented Resident 1 had no cognitive impairment and was partial to moderately dependent on staff for assistance with activities of daily living.Review of care plan, dated 10/24/2025, documented Resident 1 had cirrhosis of the liver. The staff would monitor for yellowing 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 observation, interview and record review, the facility failed to monitor the efficacy for use of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 2 of 3 sampled residents (6 & 11), reviewed for catheter use. This failure placed the residents at increased risk of catheter associated urinary tract infections, pain, and urethral trauma.Findings included.<Resident 6>Resident 6 was admitted to the facility on [DATE] with diagnoses including a left hip fracture and diabetes mellitus. The admission minimum data set (MDS), an assessment tool, dated 10/13/2025, documented Resident 6 has moderate cognitive impairment and is partially/moderately dependent on staff for assistance with activities of daily living. The MDS documented the resident has an indwelling catheter.Review of a care plan, dated 10/07/2025, documented Resident 6 had an indwelling catheter related to benign prostatic hyperplasia (BPH - an enlargement of the prostate). Staff will change catheter…

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 medications were administered as ordered, resulting in repeated medication omissions that constituted significant medication error for 1 of 5 residents (Resident 1) reviewed for medication administration. This failure placed residents at risk for injury and adverse outcomes. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis (scaring of the liver due to conditions such as long-term alcohol use), esophageal varices (enlarged veins in esophagus due to blocked blood flow in liver), and attention deficit hyperactivity disorder (ADHD- patterns of inattention, hyperactivity, and impulsivity). The quarterly minimum data set (MDS), an assessment tool, dated 11/11/2025, documented Resident 1 had no cognitive impairment and was partial to moderately dependent on staff for assistance with activities of daily living.On 01/02/2026 11:05 AM, Resident 1 said staff did not pass all of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff donned (putting on) appropriate PPE (Personal Protective Equipment) when entering enhanced barrier precaution (EBP) rooms, failed to sanitize equipment used in the EBP rooms, failed to have PPE readily accessible to rooms that required additional PPE to enter, and failed to promptly dispose of dirty linen and trash for 2 of 3 halls (Hall A and Hall B) observed. The facility also failed to implement a respiratory protection program (a key component of infection control interventions intended to mitigate the risk of spreading infection) when the facility failed to provide fit testing of N95 respirator masks, as part of their respiratory protection program, in a timely manner for 21 of 21 newly hired employees reviewed for infection prevention and control. This failure placed residents, staff, and visitors at risk for exposure to cross contamination and transmission of infectious diseases. Findings included. 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 observation, interview and record review, the facility failed to ensure residents received assistance with meals for intake for 2 of 5 residents (1 & 7) reviewed for nutrition and hydration. The facility failed to promptly identify weight loss and implement interventions to prevent further weight loss for 2 of 4 residents (5 & 7) sampled for weight loss. This failure placed residents at risk for impaired nutrition, impaired hydration, and a decline in health status.Findings include:Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia and a stroke. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 haf moderate cognitive impairment and requires assistance with meals.The care plan, dated 10/22/2025, documented Resident 1 had swallowing difficulties and requires 1:1 assistance at meals and cueing to eat. The care plan documented staff would encourage the resident to go to the dining room for meals.Review of the 'Eating History,' dated 12/04/2025 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 ensure results of allegations/investigations were reported to the State Agency Hotline within 5 working days for 3 of 3 residents (2, 3, & 4) reviewed for abuse and neglect. This failure placed residents at risk for potential unmet needs and decreased quality of life. Findings include:Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses of sepsis and pneumonia. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 2 had severe cognitive impairment and was dependent on staff with activities of daily living (ADLs).The facility investigation, dated 09/23/2025, documented an allegation staff did not change the resident's tube feeding and the resident was without food for an extended period. The 5-day follow-up investigation submitted to the State Agency was missing interviews of sample residents.Interviews of staff were requested on 12/11/2025 and 12/18/2025 and none were provided.Resident 3Resident 3 was admitted 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 assess, monitor and intervene upon a change in the resident's respiratory status in accordance with standards of practice for 1 of 9 residents (2) reviewed for care and services. This failure placed residents at risk of unmet care needs and decreased quality of life.Findings include:Resident 2 was admitted to the facility on [DATE] with diagnoses of sepsis and pneumonia. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 2 had severe cognitive impairment and was dependent on staff with activities of daily living.The care plan, dated 10/30/2025, documented Resident 2 was at elevated risk for pneumonia due to use of a chronic nasogastric tube (a tube going into the stomach that provides artificial feedings). The care plan documented staff would administer nebulizers as ordered and observe for signs and symptoms of pneumonia.On 12/11/2025 at 12:58 pm, Resident 2 was observed laying in their bed. The residents' breathing…

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 allegations involving abuse were immediately reported, within two hours, to Law Enforcement for 1 of 1 sampled resident (4) reviewed for abuse. The facility failed to ensure residents leaving against medical advice (AMA) were logged and/or reported to the Adult Protective Services (APS) and/or the State Agency for 3 of 6 sampled residents (3, 5, & 6) reviewed for discharge. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life.Findings included .Review of the facility's policy, Abuse Investigation and Reporting, dated 10/01/2021, documented an alleged violation of abuse will be reported immediately, but not later than two hours if the alleged violation involves abuse. All alleged violations involving abuse will be reported, by the facility Administrator, to law enforcement officials (if applicable).Reporting of Allegations to State AgencyResident 4Resident 4 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate interventions to prevent elopements or act on an elopement for 2 of 3 residents (1, 5) reviewed for elopement. The facility failed to ensure discharges Against Medical Advice (AMA) were safe for 2 of 4 residents (3 & 6) reviewed for AMA discharges. This failure placed residents at risk of unmet needs, diminished quality of life, and other negative health outcomes.Findings included .ElopementResident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of blood clot in the lungs and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). The admission minimum data set (MDS), an assessment tool, dated 07/09/2025, documented Resident 1 had no cognitive impairment and was moderately dependent on staff for many activities of daily living (ADLs).The admission Nursing Collection Tool, dated 07/02/2025, documented Resident 1 wanted to leave AMA and just didn't want to be here. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure signs of psychosocial outcome related to allegations of abuse were monitored for 1 of 4 sampled residents (4) reviewed for abuse. This failure placed residents at risk of abuse, neglect and a decreased quality of life.Findings included .Resident 4 was admitted to the facility on [DATE] with diagnoses of Parkinsonism syndrome (tremors, stiffness, slowness of movement, and difficulty maintaining balance) and chronic pain. The 5-day Medicare MDS, dated [DATE], documented Resident 4 had moderate cognitive impairment and was dependent on staff for many ADLs.Review of Resident 4's care plan, dated 08/01/2025, documented Resident 4 suffered from Post Traumatic Stress Syndrome (mental health problem that can occur after a traumatic event) due to a history of physical and emotional abuse (a sexual assault) while in a nursing facility as a child.Review of facility incident report, dated 08/01/2025, documented Resident 4 made an allegation of sexual abuse…

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 assist residents with discharge needs to ensure a timely discharge for 1 of 3 residents (1) reviewed for discharge planning. The facility failed to ensure discharge planning reflected the resident's discharge status for 1 of 3 residents (3) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, risk for re-hospitalization, and a decreased quality of life.Findings included .Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of blood clot in the lungs and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). The admission minimum data set (MDS), an assessment tool, dated 07/09/2025, documented Resident 1 had no cognitive impairment and was moderately dependent on staff for many activities of daily living (ADLs).Review of Resident 1's care plan, dated 07/03/2025, documented Resident 1 would be at the facility short…

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 a discharge summary for 1 of 3 residents (2) reviewed for discharge planning. The facility failed to provide written bed hold notices at the time of a therapeutic leave for 1 of 1 sampled resident (3) reviewed for therapeutic leaves. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed, protection of resident rights during transfers, and a diminished quality of life.Findings included .Discharge SummaryThe facility policy, Transfer or Discharge, Preparing a Resident For, dated 10/01/2021, documented a post-discharge plan is developed for each resident prior to his or her transfer or discharge. Nursing services and/or social services is responsible for preparing a discharge summary and post-discharge plan and completing a discharge note in the medical record.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia and dysphasia. No minimum data set (MDS), 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 ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 13 sampled residents (2 & 4) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.Findings included .Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia and dysphasia. No minimum data set (MDS), an assessment tool, was completed.Review of the care plan, dated 06/25/2025, documented Resident 2 was at risk for dehydration, weight loss, or malnutrition related to advanced age. Interventions included checking weights as ordered.Review of physician orders, dated 06/24/2025, documented Resident 2 required moderately thick liquids with thin water between meals, small bites of food and sips of water, and use of a chin tuck, swallowing twice with every bite and/or sip.The Diet Nutritional Assessment, dated…

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

Based on interview and record review, the facility failed to ensure 5 of 5 sampled agency and facility (Staff I, J, K, L, M) reviewed for competency with mechanical lifts showed proficiency with the operation of mechanical lift transfers. This failure placed the residents at risk for falls and their associated injuries. Findings included . Staff L, facility staff, hired 04/01/2025, did not have documentation of training on the mechanical lifts in their personnel file. Staff J, facility staff, hired 04/01/2025, did not have documentation of training on the mechanical lift in their personnel files. Staff I, agency staff, hired 04/08/2025, did not have documentation of training on the mechanical lifts in their personnel file. Staff K, agency staff, hired 04/25/2025, did not have documentation of training on the mechanical lifts in their personnel file. Staff M, facility staff, hired 04/25/2025, did not have documentation of training on the mechanical lifts in their personnel file. On 06/30/2025 at 2:40 PM, Staff G, nursing assistant (NA), explained she used one staff with the standing…

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 4 of 5 sampled residents (6, 8, 9, 10) reviewed for infection control practices, received vaccinations for influenza and pneumonia. This failure placed the residents at risk of contracting pneumonia and influenza and potential complications associated with those illnesses. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's medical record, showed no documentation the facility assessed the resident's vaccination history. The record lacked documentation the influenza or pneumococcal vaccine was offered. <Resident 8> Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's medical record, showed no documentation of the resident's vaccine history. <Resident 9> Resident 9 was admitted to the facility on [DATE]. Resident 9 received a dose of the Pneumococcal polysaccharide vaccine (PPSV23) (used to prevent pneumococcal disease) on 06/24/2022. The clinical record did not show 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 the 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) vaccine was provided for 3 of 5 residents (6, 8, 10), reviewed for immunizations. The failure to provide the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's medical record, showed no documentation or indication the facility assessed the resident's vaccination history. The record lacked documentation the COVID vaccine was indicated. <Resident 8 Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's medical record, showed no documentation of the resident's vaccine history including the COVID vaccine. <Resident 10> Resident 10 was admitted to the facility on [DATE]. Review of 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 record review and interview, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored, documented on, had associated non-pharmacological interventions (non-medication interventions), that as needed psychotropic medications had end dates and limited to 14 days, and/or monthly pharmacist recommendations were acted upon timely, for 5 of 7 residents (Residents 9, 354, 91, 88 & 66) reviewed for unnecessary medication or hospice. This failure placed residents at risk of unnecessary medication usage, increase in side effects without intervention, and a diminished quality of life. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 05/04/2025, showed the resident was cognitively impaired, had diagnoses of bipolar and depressive disorders and received antipsychotic medication (drugs that work by…

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 transmit required Minimum Data Set (MDS, an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion as required for 8 of 9 residents (Residents 75, 36, 7, 31, 6, 62, 74 & 19) reviewed for resident assessment. The failure to ensure MDS assessment and tracking records were completed and transmitted timely as required, placed the resident at risk for unmet care needs and diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, revised October 2023, showed Admission, Significant Change, Quarterly, and Annual MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD), and must be submitted/transmitted to the CMS database, within 14 days of the MDS completion date. Review of the electronic health record (EHR) for the above identified residents, showed no MDS data was present for MDS assessents…

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, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 12 of 24 (Residents 9, 29, 33, 37, 90, 66, 57, 30, 79, 94, 91, & 88) residents reviewed. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 05/04/2025, showed the resident had severe cognitive impairment, diagnoses of heart failure, and malnutrition, and received diuretic medication (increases urine production and helps the body eliminate excess fluid and salt) during the assessment period. Resident 9 had a 05/07/2025 order to apply ace wraps to the lower extremities in the morning and remove at bedtime. Review of the comprehensive care plan showed no nutrition care plan addressing the resident'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 2) Resident 37 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively impaired and received greater than 51% of their calories via tube feeding. Review if the electronic health record (EHR) showed a 06/02/2025 order for nurses to change, date and initial Resident 37's tubefeeding syringe daily. Observation on 06/17/2025 at 9:34 AM, 06/23/2025 at 1:53 PM, and 06/24/2025 at 10:49 AM, showed Resident 37 had an undated /initialed 60 cubic centimeter (cc) syringe at bedside. Review of the June 2025 MAR showed the night shift nurse signed that the task was completed daily from 06/02/2025 - 06/23/2025. During an interview on 06/24/2025 at 10:57 AM, Staff B, DNS, observed Resident 37's 60 cc syrnge at bedside and confirmed it was undated/initialed. Staff B said it was the expectation that nurses only sign for tasks they completed. 3) Resident 9 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to maintain an environment free of accidents or hazards by creating a plan of care and implementing preventative measures and/or assessments for 3 of 4 residents (Residents 18, 91 & 94) reviewed for accident hazards. This failure placed residents at risk for falls, injuries, medical complications and a diminished quality of life. Findings included . 1) Resident 18 was admitted to the facility on [DATE], with diagnoses of stroke (when a portion of the brain is without blood flow for a period of time) and hemiplegia (paralysis of one side of the body). The resident was able to make needs known. Review of Resident 18's electronic health record (EHR), showed the resident had a fall on 06/16/2025 at 7:30 PM, during a shower and was assisted to the floor. An x-ray was completed on 06/17/2025 which showed a fracture on the right hip. Resident 18 was sent to the emergency room for evaluation on 06/17/2025 and returned to the facility on [DATE]…

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 sufficient nursing staff were available to provide care in a timely manner and complete activities of daily living (ADLs) as evidenced by information provided during resident interview for 16 of 38 residents (Residents 28, 55, 30, 79, 16, 87, 10, 66, 1, 39, 56, 254, 154, 33, 62, & 28) and 2 of 7 staff (Staff R & U) interviewed for sufficient staffing or resident council, for 3 of 3 resident council monthly meeting notes (March 2025, April 2025, & May 2025) reviewed, and review of 1 of 3 grievance logs (May 2025). These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life. Findings included . <Resident Interviews> 1) On 06/16/2025 at 2:26 PM, Resident 39 said they could wait an hour with their light on, it happened quite often, and they kept track on the clock. 2) On 06/16/2025 at 11:41 AM, Resident 28 said it took 20 to 30 minutes for staff to respond, and at night they were short staffed. 3) On 06/17/2025 at 11:15 AM, Resident 55 said it usually…

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, record review, and interview, the facility failed to ensure a medication error rate less than 5%, by having an error rate of 15.38%, with 4 errors of 26 medication administration opportunities observed. This failure placed residents at risk of medication complications and a diminished quality of life. Findings included . On 06/17/2025 at 9:22 AM, Resident 20 was observed to be given 3 insulin medications late: 1. Insulin Deglu[DATE] units one time a day, due at 8:00 AM 2. Insulin Lispro 13 units two times a day, with instructions to give with breakfast and dinner, due at 8:00 AM 3. Insulin Lispro, on a sliding scale (dependent on what the blood glucose level was), 2 units, with instructions to give with each meal, due at 8:00 AM On 06/17/2025 at 9:23 AM, Resident 20 reported they already had breakfast. Resident 20's breakfast tray had already been removed from the room. On 06/18/2025 at 1:25 PM, Resident 46 was observed to be given 1 oral medication late: 1. Baclofen for muscle spasms…

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 food was stored or covered to prevent cross-contamination, that outdated or unlabled food was discarded, and/or refridgerator temperature logs were filled out and monitored for 1 of 1 kitchen reviewed and from resident accessible refrigerators for 2 of 4 dining rooms (Country Kitchen & Bistro) reviewed. These failures placed residents at risk of eating expired/outdated food and/or food borne illnesses. Findings included . During an observation of the dietary service department on 06/16/2025 from 9:49 AM to 10:22 AM, the following was observed: <Kitchen's Walk-in Refrigerator> Observations of the walk-in refrigerator showed the following: 1. A large, uncovered metal bin of white rice. 2. A large, uncovered metal bin of brown gravy. On 06/16/2025 at 10:34 AM, Staff O, Food Service Supervisor, said the uncovered bins of rice and brown gravy had just been prepared and were in the refrigerator, unlidded, to cool down. <Kitchen's Refrigerator 3> Observation of Refrigerator 3 showed a container of peaches 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 provide care and services in a dignified manner for 2 of 3 residents (Residents 9 & 90) reviewed for dignity. Failure to ensure staff to residents interaction occured in a respectful and dignified manner, residents clothing was changed daily and residents were assisted out of their day clothes prior to bed, placed residents at risk for diminished self-worth and decreased quality of life. Findings included . 1) Resident 90 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 04/10/2025, showed the resident was cognitively intact and demonstrated verbal and physical behaviors directed toward others. On 06/23/2025 at 1:39 PM, Resident 90 was in the dining room and repeatedly called out Help me, please take me to my room. Staff Q, Certified Nursing Assistant (CNA), said, give me ten minutes. Resident 90 stated, That is too long. I am going to be on the floor; my body is killing…

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 they informed and provided written information to residents on their right to formulate an advance directive (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney (POA) for health care) for 2 of 3 residents (Residents 91 & 94) reviewed for advance directives. This failure placed residents at risk for not having their choice of who to care for them when incapacitated, not having their health care wishes honored, and a diminished quality of life. Findings included . 1) Resident 91 was admitted to the facility on [DATE]. The Medicare 5 Day Miminum Data Set (MDS, an assessment tool), dated [DATE], showed they were severely cognitively impaired. Review of Resident 91's electronic health record (EHR) showed no documentation of an advance directive or that the facility had offered the opportunity to formulate an advance directive. During a joint interview on…

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

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 1 of 3 sampled residents (Resident 22) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk for not having adequate information to make financial decisions related to the residents' stay in the facility. Findings included . The Notice of Medicare Non-Coverage, dated 03/28/2025, documented Resident 22 was not provided with a SNF ABN. On 06/20/2025 at 1:32 PM, Staff A, Administrator, said Resident 22 had not been provided with the SNF ABN and should have been. Reference (WAC) 388-97-0300 (4)(a-c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours for 1 of 2 sampled residents (Resident 39) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk of abuse and neglect. Findings included . Resident 39 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (an assessment tool), dated 04/28/2025, documented Resident 39 was cognitively intact and required substantial/maximal assistance with toileting hygiene. On 06/16/2025 at 2:26 PM, Resident 39 said on 05/04/2025 there was a bad episode, staff didn't change their brief and they didn't come back. Resident 39 said it had been reported to the state and that Staff V, had said he would report it. Resident 39 did not want to discuss this further at this time. Review of the Incident Log (an incident tracking system) from 01/02/2025 through 06/13/2025 showed no entries for Resident 39. Review of the Grievance log for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or neglect for 1 of 3 residents (Resident 91) reviewed for falls. Failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect, poor clinical outcomes and a decreased quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 91 admitted to the facility on [DATE] with diagnoses of diabetes and chronic obstructive pulmonary disease. The resident was able to make needs known. During an interview on 06/16/2025 at 12:55 PM, Resident 91 said they had a fall in their bathroom and had some small bruises on their arms. Review of the EHR showed a note from 06/01/2025 which stated the resident had a fall at 10:15 AM when the resident was found to have no footwear on and had attempted to transfer into the wheelchair from bed. Review of the facility provided incident log showed the resident had a fall on 05/21/2025, 05/22/2025…

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 were assisted with activities of daily living (ADLs) for 4 of 6 sampled residents (Residents 9, 33, 54 & 79) reviewed for ADLs and choices. Failure to provide assistance with nail care and/or bathing to residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, diminished self-image, and a decreased quality of life. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 05/04/2025, showed the resident was cognitively impaired, was dependent on staff for ADLs, and decisions related to bathing were Very Important. On 06/17/2025 at 9:58 AM, Resident 9's representative said facility staff were supposed to trim their fingernails every Monday, but they were not doing it. Resident 9's representative held up their left hand and stated, See, look they are too long.…

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 received care and services in accordance with professional standards of practice and their person-centered plan of care for 4 of 9 residents (Resident 90, 29, 33, and 88) reviewed for bowel management, and 1 of 2 residents (Resident 29) reviewed for fluid volume status. The failure to obtain and evaluate daily weights and ensure the provision of bowel care in accordance with physicians' orders and/or the facility bowel protocol, placed residents at risk for fluid volume overload, delays in treatment, unmet care needs and a decreased quality of life. Findings included . 1) Resident 90 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/10/2025, showed the resident was cognitively intact. On 06/17/2025 at 11:34 AM, Resident 90 said constipation was occasionally a problem. Review of Resident 90's bowel record showed they had no bowel movement (BM) from…

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 ongoing assessment, monitoring, and documentation of identified pressure injuries (PIs/ injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) for 1 of 2 residents (Resident 9) reviewed for pressure injuries. The failure to routinely assess and monitor PI wound characteristics with measurements, wound bed tissue type, details of drainage, wound edges, peri-wound (area of skin surrounding the wound) and response to treatment, impaired staffs' ability to determine if the wound was responding to treatment and determine if it was improving or declining. This failure placed residents at risk for unidentified wound decline, delays in treatment, prolonged wound healing, and diminished quality of life. Findings included . Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 10/01/2021, showed staff should promptly report any change in a resident's skin…

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 the necessary care and services to maintain range of motion for 2 of 4 residents (Resident 18 and 54) reviewed for positioning and mobility. These failures placed the residents at risk for decreased mobility, pain, discomfort and a decreased quality of life. <Resident 18> Review of the electronic health record (EHR) showed Resident 18 admitted to the facility on [DATE] with diagnoses of stroke (when a portion of the brain is without blood flow for a period), hemiplegia (paralysis of one side of the body) and contracture of the right hand. The resident was able to make needs known. During an observation on 06/16/2025 at 2:45 PM, Resident 18 was laying in bed, the resident was unable to move their right arm/hand and had a washcloth positioned in their right palm. Review of the EHR showed a nursing task for NURSING REHAB/RESTORATIVE: Hand/Splint Care. Assist/Instruct the resident to wash their hands thoroughly with soap and warm…

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 significant weight loss was identified, the physician was notified, and nutritional interventions were evaluated for effectiveness for 1 of 1 sampled resident (Residents 28) reviewed for nutrition. These failures placed the resident at risk for continued weight loss, malnutrition, and a decreased quality of life. Findings included . Resident 28 was admitted to the facility on [DATE], with diagnoses of diabetes and kidney disease. The Quarterly Minimum Data Set (an assessment tool), dated 04/28/2025, documented Resident 28 was moderately cognitively impaired and had a recent weight of 107 pounds in the last 30 days. It documented a weight loss of 5% or more in the previous month or a loss of 10% or more in the previous 6 months, and Resident 28 was not on a physician prescribed weight loss regimen. Resident 28 weighed 116.2 pounds (lbs) on 01/03/2025 and 100.2 lbs on 06/22/2025, which was a -13.77 %. This was a 16 lb loss in just over 5 months.…

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 respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 3 of 3 residents (Resident 29, 10, & 91) reviewed. The facility failed to ensure continuous positive airway (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) orders were complete and in place, to include the prescribed pressure settings, checking, refilling and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier. Additionally, staff failed to ensure oxygen (O2) was administered in accordance with physicians' orders, and portable oxygen tanks were refilled and periodically checked to ensure they were not empty. These failures placed residents at risk for ineffective assisted ventilation, shortness of breath, decreased oxygen saturation and other respiratory complications. Findings included . Review of the facility'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 interview and record review, the facility failed to ensure freedom from unnecessary medications for 2 of 5 sampled residents (Residents 62 & 91) when reviewed for unnecessary medications. The facility failed to ensure residents were provided non-pharmacological interventions (NPIs, treatments or strategies used to prevent, reduce, or manage symptoms without the use of medications) prior to the use of as needed pain medications. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . 1) Resident 62 was re-admitted to the facility on [DATE], with diagnoses including history of falling, humerus fracture (upper arm bone) and chronic pain. The resident was able to make needs known. During an interview on 06/16/2025 at 10:21 AM, Resident 62 said they had frequent pain and took as needed medication, which helped. Review of the electronic health record (EHR), showed a provider order, dated 05/01/2025,…

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, record review, and staff interviews, the facility failed to ensure medication carts were locked/secured in the absence of a nurse for 1 of 5 carts observed (A wing medication cart), and proper labeling and storing of medications and expired medications/equipment were discarded timely for 3 of 3 carts reviewed (carts #2, #3, #5). These failures placed residents at risk for receiving compromised or inaccurate medications, medication diversion and potential harm. Findings included . <Expired Medications/Equipment and Storage > On 06/18/2025 at 11:11 AM, an observation of Emerald Cart #3 with Staff G Registered Nurse (RN), showed: - an open resident medication cup containing white pills labeled with a marker APAP 500mg and no expiration date labeled on the cup - a bottle of Ibuprofen 200mg tablets that expired in May 2025 - 4 bottles of anti-itch lotion for Residents 41, 19, 31 and 13 that expired May 2025 And Staff G said we cannot give this medication, and I will get them out of the cart. On 06/18/2025 at 11:29 AM, an observation of C Wing Cart #5 with Staff H,…

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 prepare food in a manner that conserved nutritive value and palatability for 4 of 4 residents (Resident 9, 71, 156 and 157) with pureed diet textures, to honor residents' preferences for 3 of 5 residents (Residents 158, 356, and 46) observed with identified preferences, and to ensure meals/beverages were appetizing and served at appropriate temperatures as evidenced by 7 resident interviews and test tray results. These failures placed resident at risk of dissatisfaction with meals, decreased intake, weight loss, and decreased quality of life. Findings included . <Resident Interviews> On 06/17/2025 at 9:04 AM, Resident 44 said they wanted their meals hot, but by the time the meals reached the table they were cold. On 06/17/2025 at 8:44 AM, Resident 355 complained that facility food was often dried out or tasteless. On 06/16/2025 at 12:48 PM, Resident 15 said the food was horrible and it was not hot when received. On 06/16/2025 at 2:38 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents hearing needs were addressed and they had access to bariatric (treatment of obesity) equipment for 1 of 1 sampled resident (Resident 1) reviewed for accommodation of needs. These failures placed resident at risk of diminished independent functioning and a loss of comfort. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, heart failure, and kidney failure. The Minimum Data Set (MDS, an assessment tool), dated 10/08/2024, documented Resident 1 had no cognitive impairment, weighed 475 pounds, and was not on a physician-prescribed weight loss regimen. <Hearing> On 12/03/2024 at 3:31 PM, Resident 1 said several complaints had been made about their hearing and there had been no resolution. The resident said he was told the facility could not send him out to an appointment. On 02/05/2025 at 3:06 PM, Resident 1 said they continued to have ear and hearing issues and could not get…

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 a comprehensive plan of care for urinary care and urinary tract infection (UTI, an infection of the urine) for 1 of 4 sampled residents (Residents 1) reviewed for care plans. The failure to establish individualized care plans, that accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, heart failure, and kidney failure. The Minimum Data Set (MDS, an assessment tool), dated 10/08/2024, documented Resident 1 had no cognitive impairment and required maximal assistance from staff with toileting. The Care plan, dated 01/02/2024, documented Resident 1 needed assistance with activities of daily living (ADLs) due to deconditioning and poor activity intolerance. The Urine Analysis (a test to check for organisms in…

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

Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed for the facility residents who needed bariatric (treatment of residents' who experience morbid obesity) care. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . The Facility Assessment, dated March 2024, documented the facility assessed all resident needs, developing an action plan to train and support nursing staff to care for the resident. The analysis categories included bariatrics and how it impacted over all staffing, training, and services were noted as evaluated. The assessment lacked any detail on how the facility would support residents who were considered bariatric. The assessment was not revised when concerns arose related to residents who were bariatric. On 12/03/2024 at 3:31 PM, Resident 1 said staff told 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 possible allegations of abuse were thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigations. This failure placed residents at risk for unidentified abuse and a diminished quality of life. Findings included . The facility policy, Abuse Prohibition and Prevention, dated 01/2024, documented a thorough investigation would be completed in response to a suspected or allegation of abuse, neglect, exploitation and/or mistreatment. An investigation would include an assessment of the interactions and relationships between caregivers and the alleged victim (AV) and interviews with the AV, witnesses, and provider. A record review would be completed related to the alleged violation. Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke-like symptoms, bipolar disorder, and post-traumatic stress disorder (PTSD). The admission Minimum Data Set (MDS)/an assessment tool, documented 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 immediately report to the state agency potential financial exploitation for 1 of 1 resident (Resident 1) reviewed for allegations of misappropriation. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life. Findings included . The facility policy, Abuse Prohibition and Protection, dated 01/2024, documented staff will immediately report allegations to the Administrator and the State Agency. Allegations reportable to the Administrator and State Agency include misappropriation of resident property defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belonging or money without the resident's consent. Resident 1 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD), recurrent major depressive disorder, and general anxiety disorder. The quarterly Minimum Data Set (MDS),…

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 a personalized discharge plan based on each resident's identified needs, goals and preferences and implement it timely for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including post-accident traumatic injuries and fractures. The admission Minimum Data Set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required set-up assistance from staff for activities of daily living (ADLs). The care plan, dated 02/05/2024, documented the resident would improve in mobility prior to discharging home. On 08/02/2024 at 12:57 PM, Resident 2's family member (FM) said once admitted to the facility, staff did not explain what to expect while Resident 2 was admitted . The care conferences included staff who…

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 were trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 3 residents (Resident 1) reviewed for mood and behavior. This failed practice placed residents at risk for unidentified triggers, re-traumatization and unmet care needs. Findings included . The facility policy, Trauma Informed Care, dated 01/2022, documented staff would recognize the impact of trauma on recovery and establish standards for assessing the signs and symptoms of trauma. Staff would periodically assess and care plan resident-centered approaches to meet residents' emotional needs. Resident 1 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD) (mental health condition triggered by a terrifying event), recurrent major depressive disorder, and general anxiety disorder. The quarterly Minimum Data Set (MDS), dated [DATE],…

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 26 sampled residents (Residents 90, 88, 62, 34 and 427) of 20 reviewed for medication management. The failure to follow, obtain, and/or clarify incomplete physician's orders when indicated, to sign for medication(s) that were administered, to document the reason and notify the provider when medications were held, placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs. Findings included . 1) Resident 90 admitted to the facility on [DATE]. Review of Resident 90's electronic health record (EHR) showed orders for: a) Propranolol (a blood pressure medication) twice daily, with direction to hold the medication for a systolic blood pressure (SBP) less than 100 or Pulse (P) less than 55. b) Furosemide (a diuretic) daily, hold for a SBP less than 100 or P less than 55. c) Spironolactone (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Resident 161 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed Resident 161 was dependent on staff for bathing and decisions about bathing were Very important. On 05/21/2024 at 1:20 PM, Resident 161 said staff did not come on the days they were supposed to provide showers. The resident reported the previous Friday staff informed her they couldn't provide their shower because a nursing assistant called off. An ADL care plan (CP), dated 05/07/2024, showed Resident 161 was to be showered twice weekly. Review of Resident 161's March 2024 bathing record showed from 05/07/2024 - 05/29/2024 (23 days), no bathing was offered/provided. On 05/29/2024 at 12:11 PM, when asked how many baths/showers had been offered/provided to Resident 161 from 05/07/2024 - 05/29/2024, Staff B, stated, I don't see any. 3) Resident 93 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed Resident 93 was dependent on staff for bathing and decisions about bathing were Very…

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 the necessary care and services to maintain residents' highest practicable level of well-being for 9 of 11 residents (Residents 49, 62, 20, 76, 93, 90, 23, 34, and 50) reviewed for bowel management and 1 of 2 residents (Resident 88) reviewed for positioning. The failure to initiate bowel care in accordance with physician's orders, address changes in bowel habbits and to reposition residents at the frequency they were assessed to require, placed residents at risk for pain/discomfort, skin breakdown and unmet bowel care needs. Findings included . <Bowel Management> Review of the facility's Bowel Protocol policy, revised 08/2022, showed licensed staff would monitor residents' bowel movement (BM) report daily at the start of each shift. If a resident had no BM after nine shifts, nurses would administer: a) Miralax on the 10th shift. b) If no results from Miralax by the end of the 10th shift, Miralax would be administered again on 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 provide pharmaceutical services (including procedures that assure timely acquiring, receiving, and administering of all drugs) to meet the needs of each resident for 2 of 2 sampled residents (Residents 90 & 76) reviewed for pharmacy services. Failure to ensure timely receipt and administration of ordered medications, resulted in residents missing several doses of ordered medications and placed them at risk for inadequate and/or ineffective treatment of underlying medical conditions, and other negative health outcomes. Findings included . Review of the facility's undated pharmacy services agreement showed facility staff were to re-order medications three to five days before the supply runs out. For new orders and admissions if the medication(s) were ordered by noon the medications would be delivered in the 4:00 -5:00 PM delivery window except for Saturdays and Sundays. If ordered after noon, but before 8:00 PM, the medication(s) would be delivered 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 observation and interview, the facility failed to maintain a kitchen environment which allowed each resident to receive nourishing, palatable, and well-balanced meals without cross contamination when reviewed for kitchen. This failure placed residents at risk of lack of nutritional intake, avoidable weight loss, foodborne illness, and a diminished quality of life. Findings included . Tray line assembly started on 05/24/2024 at 11:55 AM. At 12:00 PM, Staff N, Cook, took the fish off the plate, and set it on the long 6 foot white cutting board on the steam table and cut it up into small pieces. Staff N then placed the fish back on plate. Staff N then changed her gloves. At 12:15 PM, Staff N opened door to small metal storage container (next to ice box, where fish was being held at temperature) with gloves on, shut the door and then grabbed a lemon with gloves on out of a container filled with more lemons and placed it on the plate. Staff N did not change gloves after touching environmental surfaces and before moving to next plate. At 12:16 PM, Staff N opened door to small…

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, interviews, and record review, the facility failed to obtain dishwasher temperatures logs and maintain the temperature in required range, failed to discard expired or no Use By Date (UBD) food and beverages items, and failed to maintain and document refrigerator temperature logs for 8 of 8 facility refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . <Refrigerator temperature logs> Review of the facility's refrigerator temperature logs, from 11/01/2023 through 05/27/2024, documented the Cooler/Freezer, Reach In refrigerator, Dairy refrigerator, Salad Bar, Montreal refrigerator, Bistro refrigerator, B wing refrigerator and C wing refrigerator had multiple missing entries and documented temperatures outside the acceptable parameters for cold food holding: Cooler/Freezer: Missing recorded temperatures on 12/23/2023, 01/11/2024 & 02/29/2024. Temperatures over cold…

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 maintain complete and accurate records for 7 of 7 sampled residents (Residents 93, 61, 161, 90, 22, 81 & 50) reviewed for activities of daily living and choices. The failure to identify and correct a system issue with the facility's Point of Care (a computer program) charting, caused staff to falsely document bathing and/or resident refusal of bathing that did not occur. These failures resulted resident medical records containing inaccurate documentation of bathing that was not provided and/or refusal of care that did not occur. This detracted from staffs' ability to investigate resident complaints about not receiving showers and placed residents at risk for unmet care needs. Findings included . Resident 93 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 04/04/2024, showed Resident 93 was cognitively intact and dependent on staff for the provision of bathing. An activity of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure staff compliance with current infection control guidelines and standards of practice for correctly donning/doffing (to put on/to take off) personal protective equipment (PPE) for 2 of 2 dining observations reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of illness), transmission of diseases and a diminished quality of life. Findings included . Facility policy titled PMJCC Isolation for Transmission Based Precautions revised 05/2024, documented In addition to Standard Precautions, use contact Precautions for patients/resident known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient/resident (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's/resident's dry skin) or indirect contact…

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 was provided in a manner that promoted the resident's dignity and quality of life when personal grooming was not provided for 2 of 6 sampled residents (Resident 61 & 88) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life. Findings included . 1) Resident 61 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, as assessment tool), dated 04/26/2024, documented Resident 61 was cognitively intact and needed supervision or touching assistance with activities of daily living (ADL's) including personal hygiene. On 05/21/2024 at 10:16 AM, Resident 61 said she had asked the facility staff multiple times for an emery board, to file her nails and for a razor, to address facial hair on her chin. Resident 61 was observed with multiple small hairs on her chin. 2) Resident 88 was admitted to the facility on [DATE]. The admission MDS,…

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 visual impaired/legally blind residents received reasonable accommodations for 1 of 1 sampled residents (Resident 61) reviewed for accommodation of needs. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included . Resident 61 was admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 04/26/2024, documented Resident 61 was cognitively intact and was not able to walk or transfer independently. Resident 61's Vision Plan of Care, dated 04/20/2024, documented, Visual impairments secondary to blindness as evident by patient states she is legally blind. Plan of care included: -Will move around room eat, and meet dressing and toileting needs with assistance recommended by therapy from staff. -Activities and social events that do not require visual acuity. -Ensure eyeglasses are worn, clean and in good repair. -Provide large print materials. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (ADs) for 1 of 4 sampled residents (Resident 42) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 42 admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 03/20/2024, documented the resident was severely cognitively impaired. Review of Resident 42's hard chart or Electronic Health Record did not show documentation of an AD or a declination to formulate an AD. On 05/29/2024 at 12:24 PM, Staff F, Social Services Director (SSD), said AD's were obtained upon admission. Staff F said if the family did not have an AD, the facility would provide them with documentation and encourage the family to completed it and return it to the facility. Staff F said it was the responsibility of Social Services to provide and obtain AD's. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure a visually impaired/legally blind resident's room was maintained in a safe and accommodating manor for 1 of 7 sampled residents (Resident 61) reviewed for environment. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included . Resident 61 was admitted to the facility on [DATE]. The admission Minimum Data Set (as assessment tool), dated 04/26/2024, documented Resident 61 was cognitively intact and was not able to walk or transfer independently. Resident 61's Vision Plan of Care, dated 04/20/2024 documented. Visual impairments secondary to blindness as evident by patient states she is legally blind. Plan of care includes: -Will move around room eat, and meet dressing and toileting needs with assistance recommended by therapy from staff. -Arrange furniture in resident's room as desired and maintain clutter free environment to increase ability to move around room without injury.…

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 system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns during resident council for 5 of 9 months (June 2023, August 2023, September 2023, October 2023 and November 2023) of resident council minutes reviewed. The failure to identify the initiate, log, investigate and timely resolve reported complaints/concerns, and inform residents of the findings and actions taken to correct the issues, placed residents at risk of feelings of frustration, unimportance, diminished self-worth, and quality of life. Findings included . Review of the facility's Resident Council policy, revised 05/2024, showed Activity and/or Social Service representatives will assist the resident council chairperson by recording minutes and following up on resident reported concerns/issues. The council minutes will be routed to the appropriate department leaders to be followed up on within one week. The grievances are shared with the Administrator 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 complete an assessment for 1 of 2 sampled residents (Resident 42) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . The facility's policy entitled Physical Restraint, reviewed 06/2021, documented 2. If the nursing or therapy assessment indicates that the device or restraint can help meet one of the goals above, potential risks and benefits of use of the device or restraint are discussed with the resident/responsible party. The resident/responsible party signs a form stating s/he has been informed of the results of the assessment, the risks and benefits of the restraint, and consent for its use. The assessment and consent form are filed in the restraint section of the resident record. Resident 42 admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 03/20/2024, documented the resident was severely…

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 Minimum Data Sets (MDS- an assessment tool) accurately reflected residents' health status and/or care needs for 3 of 29 sample residents (Residents 62, 76 and 88) reviewed for assessments. The failure to accurately assess whether residents' had a terminal diagnosis, were on a physician ordered planned weight loss program, and accuaretley code dental issues, placed residents at risk for unidentified and/or unmet care needs. Findings included . 1) Resident 62 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and had no obvious or likely cavities or broken natural teeth. On 05/22/2024 at 10:53 AM, Resident 62 complained she had teeth that were sensitive to hot and cold and stated, I have cracked upper and lower molars on the left side and my cap fell off my bottom right molar. Resident 62 said her dental issues were present prior to admission to the facility. On 05/24/2024 at…

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 (PASARR) [an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services] was completed accurately for 1 of 5 sampled residents (Resident 42), reviewed for unnecessary medication review. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . The facility's policy entitled Pre-admission Screening and Resident Review, revised 05/2024, documents, It is the policy of Providence Mother [NAME] Care Center to ensure the receipt of a complete and accurate Pre-admission Screening and Resident Review (PASRR) Level I from the referring hospital, physician or other referral source for all individuals who are seeking admission to the ministry. Resident 42 admitted 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 ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 5 sampled residents (Resident 20) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental health needs. Findings included . Resident 20 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/24/2023, showed the resident was cognitively intact, had a diagnoses of anxiety and depressive disorders, and received antidepressant and antianxiety medication during the assessment period. Resident 20's physician orders showed the following psychotropic medication ( medications that exert an effect on the chemical makeup of the brain and nervous system) orders: mirtazapine (an antidepressant medication) daily for depression;…

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, record review, and interview the facility failed to provide pressure ulcer treatment and services in accordance with professional standards for 1 of 6 sampled residents (Resident 45) reviewed for pressure ulcers. This failure placed residents at risk for untreated pressure ulcers, pain, and a decreased quality of life. Findings include . Resident 45 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 02/29/2024, indicated Resident 45 was moderately cognitively impaired. Review of the Medication Administration Record (MAR), dated 05/16/2024, showed an order to .apply Skin Prep [a protective substance applied to area surrounding wound to prepare and protect skin] to peri wound [area surrounding wound]. On 5/28/2024 at 11:44 AM, an observation of pressure ulcer treatment provided by Staff I, Licensed Practical Nurse (LPN) and Staff J, Charge Nurse, LPN, demonstrated that the step of applying Skin Prep to peri wound was not done. At 12:23…

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 Intravenous (IV) access devices were assessed, and maintained/monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 90 & 88) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care as ordered, to include changing needleless injection caps, weekly dressing changes and measuring of arm circumference and PICC external length. Additionally, the facility failed to ensure maintenance flushes and ongoing monitoring of a peripheral IV access sites. These failures placed residents at risk for loss of vascular access, infection, and other complications and negative outcomes. Findings included . Review of the facility's Peripherally inserted central catheter dressing change policy, revised 08/20/2023, showed PICC dressings, measurements…

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 have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 2 sampled residents (Resident 76) reviewed for hospice services. The facility failed to designate a member of their inter-disciplinary team (IDT) to be the liaison with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/ documentation of what hospice staff had visited (e,g,, registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care they provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the Hospice provider, and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included . Review of the facility's Hospice Coordination policy, revised 04/2023, 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 log allegations of abuse and neglect, mistreatment by staff, untimely incontinence care, and misappropriation of property on the reporting log within five working days for 5 of 5 investigations involving 9 residents (1, 2, 3, 4, 5, 6, 7, 8 & 9) reviewed for reporting of alleged violations. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included . <Neglect> Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS) and left below the knee amputation. The annual Minimum Data Set (MDS) assessment, dated 04/01/2024, documented Resident 1 had no cognitive impairment and was dependent on staff for assistance with activities of daily living (ADLs). Resident 2 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and chronic kidney disease. The significant change in status MDS, dated [DATE], documented 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 thoroughly investigate allegations of neglect and misappropriation of property for 4 of 6 sampled residents (1, 2, 3 & 4) reviewed for investigating alleged violations. This failure placed residents at risk for not identifying corrective actions to prevent further neglect, misappropriation, and a diminished quality of life. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (The Purple Book), dated [DATE], All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. <Neglect> Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS) and left below the knee amputation. The annual Minimum Data Set (MDS) assessment, dated [DATE], documented Resident 1 had no cognitive impairment and was dependent on staff for assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, 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 when a resident was not monitored and timely interventions were not implemented after experiencing end of life and death of a roommate for 3 of 4 sampled residents (1, 2 & 3)) reviewed for medically related social services. This failure placed residents at risk of having unmet social service needs, psychosocial decline and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS) and left below the knee amputation. The annual Minimum Data Set (MDS), an assessment tool, dated 04/01/2024 documented Resident 1 had no cognitive impairment and was dependent on staff for assistance with activities of daily living (ADLs). The Care Plan, dated 06/23/2023, documented Resident 1 could have difficulty adjusting to change…

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.