Avalon Health & Rehabilitation Center - Pasco

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor bowel movements and assess for and provide treatment for constipation (a condition where stool becomes hardened and difficult to pass) in accordance with professional standards of practice for 2 of 3 residents (Resident 1 and 2) reviewed for quality of care. This failure placed the residents at risk for discomfort and medical complications. Findings included. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including healing of a left thigh bone fracture, repeated falls, and heart failure. The 12/05/2025 comprehensive assessment showed Resident 1 required partial/moderate assistance for standing, toileting, and personal hygiene. The assessment also showed Resident 1 had an intact cognition. During an interview on 12/17/2025 at 5:04 PM, Resident 1's Representative (RR) stated Resident 1 had not had a bowel movement for more than 10 days. They stated Resident 1 had notified 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 provide adequate supervision, monitor, and develop care plans with effective fall prevention interventions, and ensure that planned interventions were consistently implemented to prevent avoidable falls for 2 of 5 residents (Residents 1 and 2) reviewed for accidents. In addition, the facility failed to conduct an investigation following a fall for 1 of 5 residents (Resident 1) reviewed for falls. This failed practice placed residents at risk for serious injury. Findings included .Review of the Facility's policy titled, Accident Hazards/Supervision/Device dated 07/2018 showed the facility will provide an environment that is free from controllable accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents. When a resident experiences a fall, the facility will evaluate factors to aid in the development and implementation of relevant, consistent and individualized interventions…

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 written notice of room changes that included the reason for the room change for 3 of 3 residents (Resident 1, 2, and 3) reviewed for notification of room changes. This failure prevented the residents from having the necessary information needed to make an informed decision regarding their living situation, placing them at risk for frustration, dissatisfaction, and psychosocial decline. Findings included. <Resident 1>Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including broken heart syndrome (temporary heart damage caused by severe emotional or physical stress), spina bifida (a birth defect where the spinal cord fails to develop properly) and weakness. The 07/23/2025 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living and set up assistance of one staff member for eating. The assessment also showed Resident 1 was cognitively intact. Record review of Resident 1's facility census showed they had room changes…

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

Based on interview and record review, the facility failed to inform residents of their rights and responsibilities and facility rules and regulations both orally and in writing upon admission and during their stay for 4 of 4 residents (Residents 2, 6, 7, and 13) reviewed for communication of resident's rights and responsibilities. This failure placed the residents at risk for the inability to execute their rights and make informed decisions about their care and services while living in the facility. Findings included . Review of a policy titled, Resident Rights - Right to Information and Communication, dated 07/2018, showed the facility would provide a notice of rights and services to the resident upon admission and during the resident's stay. The facility would inform the resident orally and in writing of their rights, rules, and regulations regarding resident conduct and resident responsibilities. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including heart failure, depression, and bacterial infections. The 03/28/2025…

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, interview, and record review, the facility failed to provide the required written notices and contact information for advocacy groups and how to file a complaint with the State Agency for 4 of 4 residents (Resident 2, 6, 7, and 13) reviewed for required notices and contact information. This failure placed the residents at risk for abuse, neglect, and not having rightful resources available to them. Findings included . Review of a policy titled, Resident Rights – Right to Required Notices and Contact Information, dated 07/2018, showed the facility would provide the resident with a list of names, addresses (mailing and email) and telephone numbers of all pertinent and regulatory agencies and resident advocacy groups such as the State Survey Agency and State Long Term Care Ombudsman [(ombudsman) an advocate for resident's rights in long term care) program. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including heart failure, depression, and bacterial infections. The 03/28/2025 comprehensive showed Resident…

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

Based on observation, interview, and record review, the facility failed to provide an environment that allowed for safe care and services, adequate lighting, and use of personal items for 2 of 2 residents (Resident 4 and 13) reviewed for environment. This failure placed the residents at risk for compromised dignity, low self-esteem, and dissatisfaction with their living environment. Findings included . Review of a policy titled, Resident Rights Safe, Clean, and Comfortable Environment, dated 07/2018, showed the facility would provide a safe, clean and comfortable environment, allowing the resident to use their personal belongings. The facility would provide adequate and comfortable lighting levels. The environment would support the resident in receiving care and services safely. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including heart disease, depression, and weakness. The 02/28/2025 comprehensive assessment showed Resident 4 was dependent on one to two staff members for activities of daily living (ADLs), set up…

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 address and provide feedback related to identified concerns brought forth by the Resident Council [(RC) a group of residents that meet regularly to improve the quality of life and care in the nursing home] group for 3 of 4 residents (Resident 6, 2, and 7) reviewed for grievances. Additionally, the facility failed to ensure residents were not in fear of retaliation for reporting identified concerns for 3 of 5 residents (Resident 3, 13, and 2) reviewed for the grievance process. This failure prevented the residents from reporting concerns that placed them at risk for abuse/neglect, frustration, and diminished self-worth. Findings included . Review of a policy titled, Resident Rights - Right to Organize and Participate in Resident Groups in the Facility, dated 07/2018, showed the facility would consider the views and act promptly upon the grievances and recommendations brought forth by the resident and/or family group concerning issues of resident care and life in the facility. The facility would demonstrate a response and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review [(PASARR) a federal requirement to ensure individuals were not inappropriately placed in nursing homes for long term care] evaluations were not completed prior to admission for 3 of 5 residents (Resident 3, 42, and 10) reviewed for PASARR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services. Findings included . Review of a policy titled, Resident Assessment - Preadmission Screening and Resident Review (PASRR), dated 11/2017, showed prior to admission, individuals identified with a mental disorder or intellectual disability were evaluated and received care and services appropriate to their needs. The PASARR screening would be completed prior to admission. The facility would not admit any new residents with a mental disorder/intellectual disability unless the State mental health authority has determined…

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 an ongoing program of meaningful activities for 6 of 6 residents (Resident 2, 6, 7, 13, 19, and 34) reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom. Findings included . Review of a policy titled, Quality Of Life Activities, dated 11/2017, showed the facility would provide an ongoing resident centered activities program to support the residents in their choice of activities. The programs would be based on the comprehensive assessment, care plan, and preferences of each resident to support their physical, mental, psychosocial well-being, and independence. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including diabetes (a group of diseases that results in too much sugar in the blood), depression, and anxiety. The 03/28/2025 comprehensive assessment showed Resident 2…

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

Based on observation, interview and record review, the facility failed to provide meals that were palatable and at an appetizing temperature for 7 of 11 residents (Resident 19, 10, 36, 2, 3, 33 and 27) reviewed for food. These failures resulted in residents experiencing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss. Findings included . Review of a policy titled, Food and Nutrition Services, Food and Drink, dated 07/2018, showed the facility will have food and drink prepared that would be palatable, appealing, and at a safe and appetizing temperature. The policy also showed food would be in a form that met individual needs, including intolerances and preferences. Review of the facility Food Committee Meetings showed: January 2025; the squash was very hard, and food was cold, including, soups, coffee and hot cocoa. April 2025; the hashbrowns were not cooked well, toast was soggy and white meat was hard. <Resident 19> Review of the medical record showed Resident 19 was admitted with diagnoses including diabetes (a group of…

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

Based on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to rescind (cancel) the agreement within 30 calendar days, in a manner and language that the resident understood for 4 of 4 residents (Resident 2, 6, 7, and 13) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing. Findings included . Review of a policy titled, Resident Arbitration Agreements - Entering into Binding Arbitration Agreements, dated 10/11/2022, showed the facility would not require any resident or their representative to sign an arbitration agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility. The agreement would grant the resident and/or their representative the right to rescind the agreement within 30 calendar days of signing it. The facility would…

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 care in a manner that maintained and promoted dignity and respect for 2 of 2 residents (Resident 19 and 33) when staff spoke Spanish to each other when providing cares. This failure placed residents at risk for diminished self-worth, frustration and embarrassment. Findings included . Review of a policy titled Resident Rights, Exercise of Rights, revised 08/2018, showed the facility would treat each resident with respect and dignity in a manner that promoted or enhanced their quality of life. <Resident 19> Review of the medical record showed Resident 19 was admitted to the facility with diagnoses including diabetes (a disease that results in too much sugar in the blood), neuropathy (damaged nerves causing numbness, weakness and a burning sensation in hands and feet), and pain. The 03/10/2025 comprehensive assessment showed Resident 19 required substantial/dependent assistance of one to two staff members for activities of daily living (ADLs) and had an intact cognition. During an interview on 05/19/2025 at 1:30 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.

AMENDED Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice [(ABN) a written notification upon a change in coverage that provides an estimated cost of services that may no longer be covered by Medicare Part A] upon a change in coverage for 1 of 3 residents (Resident 157) reviewed for liability notification requirements. This failure placed the residents at risk for the inability to make informed financial and healthcare decisions related to their stay in the facility. Findings included . Review of a policy titled, Resident Rights - Medicaid/Medicare Coverage/Liability Notice, revised 09/20/2022, showed the facility would inform residents before or at the time of admission and periodically during the resident's stay, of services available and the charges for those services, including any charges for services not covered under Medicare/Medicaid. <Resident 157> Review of the medical record showed Resident 157 was admitted to the facility with diagnoses including rib fractures, weakness, and arthritis. The 01/06/2025…

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 interview and record review, the facility failed to thoroughly investigate and take preventative action following an avoidable accident for 1 of 2 residents (Resident 3) reviewed for falls. This failure placed the resident at risk for additional falls, serious injury, and death. Findings included . Review of a policy titled, Quality of Care Accident Hazards/Supervision/Devices, dated 07/2018, showed when a fall occurred, the facility would determine what may have caused or contributed to the fall. Assistive devices and equipment would be used and maintained according to the manufacturer's recommendations. Staff would be trained on the use of assistive devices and transfer equipment. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including respiratory failure, depression, weakness, and need for assistance with personal care. The 02/20/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for activities of daily living, including transfers. The assessment also showed Resident 3 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 interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 2 of 2 residents (Resident 50 and 27) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility, Findings included . <Resident 50> Review of the medical record showed Resident 50 was admitted to the facility with diagnoses including Parkinsonism (a group of movement disorders such as slow movement, stiffness, and tremors), diabetes (a group of diseases that result in too much sugar in the blood), and heart failure. The 04/24/2025 comprehensive assessment showed Resident 50 was dependent on one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 50 had a severely impaired cognition. Record review of nursing progress notes (PN) dated 04/23/2025, showed Resident 50 was not responding verbally, more…

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

Based on record review and interview, the facility failed to ensure services provided met professional standards of practice for 1 of 5 residents (Resident 13) reviewed for physician orders. This failure placed the resident at risk for medication errors and adverse outcomes. Findings included . Review of a policy titled, Physician Services, dated 06/2018, showed the physician would communicate directly to a licensed nurse any changes to a resident's plan of care for timely implementation of new orders. <Resident 13> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including respiratory failure, depression, weakness, and need for assistance with personal care. The 02/20/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for activities of daily living, including transfers. The assessment also showed Resident 3 was cognitively intact. Record review of physician progress notes (PPN) dated 05/20/2025, showed Resident 13 reported persistent pain in their right hip. They stated their current dose 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 residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (Resident 4 and 46) reviewed for quality of care. 1.) Resident 4 was not assessed and evaluated for their mobility needs to ensure an appropriate wheelchair was provided for safety and comfort. 2.) Resident 46 was not provided their long-term use medications upon admission for chronic pain and depression. These failures placed the residents at risk for pain, isolation, and worsening of their medical conditions. Findings included . <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including heart disease, muscle weakness, and lack of coordination. The 02/28/2025 comprehensive assessment showed Resident 4 was dependent on one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 4 was cognitively intact. During a concurrent…

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

Based on interview and record review, the facility failed to implement safety interventions, including staff training, to prevent an avoidable fall for 1 of 2 residents (Resident 3) reviewed for accidents. This failure placed the residents at risk for additional falls and substantial injuries. Findings included . Review of a policy titled, Quality of Care Accident Hazards/Supervision/Devices, dated 07/2018, showed the facility would provide an environment that was free of accident hazards and provide supervision and assistance devices to residents to avoid preventable accidents. Staff would be trained on the use of assistive devices and transfer equipment. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including respiratory failure, diabetes (a group of diseases that result in too much sugar in the blood), anxiety, and depression. The 02/25/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for activities of daily living (ADLs) and required set up for eating/oral cares. The assessment…

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

The facility failed to develop and implement a scheduled toileting program (a process of taking a person to the bathroom at pre-determined intervals to facilitate bowel and bladder emptying) for 1 of 3 residents (Resident 4) reviewed for bowel and bladder incontinence. This failure placed the resident at risk for skin break down, feelings of frustration and embarrassment. Findings included . Review of a policy titled, Quality of Care - Incontinence, Fecal Incontinence, dated 11/2017, showed a resident that was admitted to the facility that was incontinent upon admission would receive care and services to restore as much normal bowel function as possible. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including heart disease, depression, and macular degeneration (an eye disease that causes blurriness in their central vision or trouble seeing in low lighting). The 02/28/2025 comprehensive assessment showed Resident 4 was dependent on one to two staff members for transfers and toileting hygiene. The assessment showed Resident 4…

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 vaccines were discarded when expired for 1 of 2 medication storage refrigerators (East/West Medication Storage room). The facility also failed to follow Centers for Disease Control (CDC) guidance for temperature monitor of vaccines in 1 of 1 medication storage refrigerator located in the medication storage room. This failures placed the residents at risk for receiving compromised or ineffective medications and vaccines and negative health outcomes. Findings inlcuded . Review of the policy titled Pharmacy Services, Labeling and Storage of Drugs and Biologicals, dated 11/2017, showed the facility would store drugs and biologicals under proper temperature controls. Review of the CDC guidance titled, Vaccine Storage and Handling, dated [DATE], showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device…

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 dental services were provided in a timely manner to 1 of 2 residents (Resident 13) reviewed for dental care. This failure placed the resident at risk for nutritional decline, embarrassment, and unmet dental needs. Findings included . Review of a policy titled, Dental Services, dated 11/2017, showed the facility would assist residents with routine dental care. The facility would assist the resident in making dental appointments and arranging transportation. The facility would assist with a referral for dental services, promptly within three business days of receiving the information, for residents with lost or damaged dentures. <Resident 13> Review of the medical record showed Resident 13 was admitted to the facility with diagnoses including heart failure, weakness, and depression. The 03/03/2025 comprehensive assessment showed Resident 13 required partial/maximal assistance of one staff member for activities of daily living. 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 consistent communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 2 residents (Resident 209) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services. Findings included . Review of the facility policy titled, Administration, Hospice, dated 07/2018, showed the facility would identify a designated staff member to work with hospice and coordinate care to the resident. The facility would establish a plan of care with hospice that identified specific services each provider was responsible for. <Resident 209> Review of the medical record showed Resident 209 was admitted to the facility on [DATE] with diagnoses including, emphysema (a progressive disease that caused damage to the airways and lungs, making it hard to breathe, shortness of breath) and chronic obstructive pulmonary disease with…

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

Based on interview and record review, the facility failed to implement written abuse policies and procedures for identification of and protection of further abuse for 1 of 1 resident (Resident 1) reviewed for abuse. This failure placed residents at risk for further abuse. Findings included . Review of a policy titled, Freedom From Abuse, Neglect, and Exploitation Preventing and Prohibiting Abuse, revised 09/13/2022, showed the facility would maintain and implement policies and procedures to prohibit and prevent abuse that would include screening, training, prevention, identification, investigation, protection, reporting, and coordination with Quality Assurance Performance Improvement (QAPI). Facility staff would be trained to identify the different types of abuse. Review of a policy titled, Freedom From Abuse, Neglect, and Exploitation, dated 09/13/2022, showed when the facility has identified abuse, they would take appropriated steps to protect residents from additional abuse immediately. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency as required for 1 of 1 resident (Resident 1) reviewed for abuse. The failure to report an allegation of abuse placed the residents at risk for additional abuse. Findings included . Review of the Nursing Home Guidelines titled, The Purple Book, dated October 2015, showed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse .are reported immediately to the administrator of the facility and to other officials in accordance with State law .including to the State survey and certification agency. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including chronic pulmonary respiratory disease [(COPD) a group of lung diseases that block airflow and make it difficult to breathe], chronic pain, and depression. The 11/13/2024 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living. The assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements while allowing them to serve as a nursing assistant for 1 of 5 staff (Staff F), reviewed for staff qualifications. This failure placed the residents at risk for abuse/neglect and unmet care needs. Findings included . Review of the Washington State Board of Nursing guidance titled, OBRA [(Omnibus Budget Reconciliation Act) a database that includes the names of individuals who met the federal requirements to provide caregiving to residents in skilled nursing facilities or nursing homes in Washington State] Registry, undated, showed a nursing assistant (NA) must be active on the OBRA Registry in order to work in skilled nursing facilities or nursing homes. The OBRA Registry also informs skilled nursing facilities of people that are ineligible to work in a skilled nursing facility or nursing home due to findings of abuse, neglect or misappropriation of property. <Staff F>…

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

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented for 3 of 3 staff (Staff C, D, and E) reviewed for hand hygiene [(HH) handwashing with soap and water or use of an alcohol-based foam or gel hand sanitizer]. This failure placed the residents at risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the Centers for Disease Control and Prevention guidance titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, showed HH protected both the healthcare personnel and resident. HH should be performed immediately before touching a resident, moving from work on a soiled body site to a clean body site, after touching a resident or their surroundings, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. Review of a policy titled, Infection Prevention and Control Program, revised 06/08/2022, showed staff would perform hand hygiene, even…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify administrative staff and law enforcement in a timely manner when 1 of 1 resident (Resident 1) did not return to the facility. This failed practice placed Resident 1 at risk for serious injury and/or exposure to the elements. Findings included . Review of the facility policy titled, Actions for a Suspected Resident Elopement, dated 06/2019, showed the charge nurse would initiate a search of the facility and facility grounds. If a thorough search does not locate the missing resident, the Charge Nurse would notify administrative staff (Administrator and Director of Nursing), resident representative and resident's physician. Administrative staff would notify the local law enforcement. On 12/19/2024 at 12:24 PM, Staff A, Administrator stated the facility elopement policy was being changed by the corporation to missing resident with no changes in the policy. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility 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 observation, interviews and record review, the facility failed to provide the necessary care and services to maintain the resident's highest practicable level of well-being for 1 of 1 resident (Resident 1) reviewed for seizure activity. The failure to initiate Vagus Nerve Stimulation (VNS) therapy (a treatment for epilepsy, a chronic brain disorder that causes seizures, that involved a stimulator which was connected inside the body to the left vagus nerve in the neck, it sends regular, mild electrical stimulations through the nerve to help calm down the irregular electrical brain activity that leads to seizures therapy. When there is a warning of a seizure a special magnet could be passed over the stimulator to give a stronger stimulator for a longer period of time) in accordance with physician's orders, placed the resident at risk for an increased number, length and severity of seizures. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility 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 interviews and record review, the facility failed to identify, assess for changes, report and implement interventions to prevent the development of pressure injuries (PI, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 residents (Resident 2) reviewed for PIs. This failed practice placed residents at risk for PIs, decreased mobility and a diminished quality of life. Findings included . <Resident 2> Review of the medical record showed Resident 2 was readmitted to the facility on [DATE] with diagnoses of dementia and Parkinson's disease (a chronic, progressive brain disorder that affects the nervous system). The resident was discharged to their home on [DATE]. Review of Resident 2's comprehensive assessment, dated 07/24/2024, showed they rarely/never understood. Review of the Initial Nursing Admission/readmission Evaluation, dated 07/18/2024, showed Resident 2 had a Stage II (partial thickness skin loss with exposed top inner layers of skin) PI to the right upper buttocks;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 3 of 3 residents (Resident 1, 2, 3) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital and the cost of holding the bed. Findings included . Review of a facility policy titled, Admission, Transfer and Discharge Notice of Bed Hold Policy Before/Upon Transfer, revised 11/2018, showed the facility would provide written information to the resident or resident representative the bed payment policy, length of bed hold, and information related to the resident's return to the facility. The information would be provided to the resident and the resident representative before a transfer and at the time of the transfer of a resident for hospitalization. The information would be provided to the 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 observation and interview, the facility failed to ensure resident rooms were repaired and maintained for 6 of 10 resident rooms (rooms 43, 44, 45, 47, 48, and 51) reviewed for a homelike environment. This failure placed the residents at risk for injury, compromised dignity, and dissatisfaction with their living environment. Findings included . Review of a policy titled, Safe, Clean and Comfortable Environment, dated 07/2018, showed the facility would provide a safe, clean, and comfortable environment. Additionally, the facility would provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. <room [ROOM NUMBER]> An observation on 04/15/2024 at 9:47 AM, showed the clothing closets in resident room [ROOM NUMBER] were made of wood with a stained finish. There were deep scrapes into the wood, and the 90-degree bottom corners were worn down to rounded ends. There was missing hardware from the closet doors. The resident bathroom for room [ROOM NUMBER]…

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 baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans for 6 of 6 newly admitted residents (Residents 59, 165, 167, 47, 2 and 56) reviewed for baseline care plans. This failure placed the residents at risk for lack of continuity of care and unmet care needs. Findings included . Record review of an undated facility policy titled Comprehensive Care Plan/Baseline Care Plan showed: The baseline care plan was developed within 48 hours of admission and should include a minimum health information to care for the resident, but not limited to; a. Initial goals based on admission orders b. Dietary Orders c. Therapy Services d. Social Services e. PASARR (a pre-screening requirement prior to admission into a nursing home). <Resident 59> Review of the residents medical record showed they were admitted to the facility on [DATE] with diagnoses including right lower leg skin infection and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure interdisciplinary team [(IDT) a group of healthcare providers from different fields who work together for the best outcome for residents] care conferences were completed for 5 of 5 residents (Residents 4, 6, 8, 15, and 22) reviewed for comprehensive care planning. Additionally, the facility failed to ensure the IDT care conference meetings included the required team members for 5 of 5 residents (Residents 4, 6, 8, 15, and 22) reviewed for comprehensive care planning. These failures disallowed the resident and/or their representative involvement in planning resident care and placed the residents at risk for unmet care needs. Findings included . <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including respiratory failure, venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), and depression. The 02/20/2024 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 observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets which included documented demonstration necessary to safely and efficiently perform care for residents' needs in the area of Central Vascular Access Devices (CVAD - a thin flexible tube that is inserted into a vein with the tip close to the heart) used to instill medications, fluids, flushes, draw blood, and complete sterile dressing changes) for 2 of 2 nursing staff (Staff Y and W) reviewed for staff competencies. This failure placed residents at risk for adverse outcomes related to CVAD's and unmet care needs. Findings included . Washington State Board of Nursing (an entity that regulates the competency and quality of nurses to protect the health and safety of the public) defines nurse competency in reference to WAC 246-840-210 section 5 titled, Continuing Competency .the ongoing ability of a nurse to maintain, update and demonstrate sufficient knowledge, skills,…

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 medication error rate of less than five percent. Three medication errors were identified for 2 of 8 residents (Residents 22 and 319) observed during 25 medication administration opportunities that resulted in an error rate of 12 percent. This failure placed the residents at risk of not receiving the full therapeutic effect of the medication and potential adverse side effects. Findings included . Review of a policy titled, General Dose Preparation and Medication Administration, revised 01/01/2013, showed facility staff should verify that the medication name and dose were correct. The facility should ensure that medication carts were locked when unattended. Review of the Instructions for use (IFU) by the U.S. Food and Drug Administration (USFDA) revised 07/2023, stated to prime the insulin pen with a new needle prior to each injection administration. Priming was meant to remove air from the needle and the cartridge. In addition,…

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 an effective Quality Assurance and Performance Improvement (QAPI) program that identified high-risk (refers to care and services associated with significant risk to the health and safety of residents), high-volume (refers to care and service areas preformed frequently or with a large population of residents, thus increasing the scope of the problem), problem-prone areas and/or implementation of corrective action for identified deficiencies related to nursing staff competencies, medication administration errors, infection prevention and control measures, resident immunizations, antibiotic stewardship program, or resident's homelike environment. Additionally, the facility failed to make a good faith attempt at correcting the identified quality deficiency with residents' baseline care plans. These failures placed all residents at risk for unidentified complications and prompt corrective action in resident care/services areas. Findings included . Refer to Code of Federal Regulations (CFR): • 483.21 (a)(1) F 655 Baseline…

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 components of an infection prevention control program to prevent the development and transmission of communicable (capable of being transmitted from person to person) infections by ensuring, A) the required procedure was followed for hand hygiene/glove change with resident (Resident 36 and 46) cares for 5 of 10 staff (Staff O, P, Q, H and V ) reviewed for hand hygiene, B) enhanced barrier precautions (EBP, indicated with high contact resident care activities with an infection, long term wound, indwelling medical device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) and staff use of Personal Protective Equipment (PPE) were implemented during resident wound cares for 1 of 3 residents (Resident 22) reviewed for PPE with EBP, C) facility's environment was cleaned and disinfected with an Environmental Protection Agency (EPA) registered disinfectant, and D)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received pneumococcal immunization (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) and influenza immunization (a vaccine that protects against a viral infection that attacks the lungs, nose, and throat) education regarding the potential risk versus benefits when offered the immunizations for 5 of 5 residents (Resident 56, 118, 41, 2 and 31) residents reviewed for immunizations and infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risks and/or benefits of the immunization in order to make an informed decision. Findings included . Review of the policy titled, Influenza and Pneumococcal Immunizations, dated 06/08/2022, showed the facility provided influenza and pneumococcal immunizations to minimize the risk of residents acquiring, transmitting, or experiencing complications 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 interview and record review, the facility failed to ensure that residents were offered and educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) vaccination for 5 of 5 sampled residents (Resident 56, 118, 41, 2 and 31) reviewed for immunization status. This failure placed the residents at risk of an uninformed decision and contracting the COVID-19 virus. Findings included . Review of the facility policy titled, COVID-19 Immunizations, dated 12/07/2023, showed the facility provided COVID-19 immunizations to protect facility residents and staff from the COVID-19 infection. The policy showed that resident and/or their representative would receive information/education related to the risks and benefits/potential side effects of the COVID-19 vaccination. 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 inform 2 of 2 residents (Resident 22 and 4) reviewed for resident rights, of their physician ordered daily fluid intake restriction. Additionally, the facility failed to provide Residents 22 and 4 with the risks/benefit education of fluid restrictions. These failures placed the residents at risk for the inability to make informed decisions regarding their health care, alternative treatments, and the right to refuse care. Findings included . Review of a policy titled, Resident Rights Planning and Implementing Care, dated 11/2017, showed that physicians or other practitioners would inform the resident and/or their representative in advance of treatment risks and benefits, options, and alternatives. <Resident 22> Review of the medical record showed Resident 22 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump blood efficiently, treated by limiting salt and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 268), reviewed for choices, was afforded the right to choose their preferred attending physician. This failure caused the resident to question staff about which practitioner ordered their care and potentially impeded their care choices. Findings included . Review of the facility's undated Consent to admission and Treatment agreement showed the resident has the right to designate who will act as the resident's attending physician. The resident is responsible for fees incurred by an idependent physician. However, the facility is responsible for coordination and communication with the resident's choice of attending physician. The independent attending physician would charge the resident's insurance or fee for services for care and treatment. <Resident 268> Review of the medical record showed the resident was re-admitted to the facility on [DATE] after an infection in their lower left leg which required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] as required for 2 of 3 residents (Residents 316 and 317) reviewed for beneficiary notification. Residents 316 and 317 were not issued the required ABN when they remained in the facility after their Medicare Part A skilled nursing and rehabilitation services (nursing services such as intravenous fluids or medications or therapy services) ended. This failure placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay. Findings included . Review of the facility policy titled, Medicaid/Medicare Coverage/Liability Notice, dated 09/20/2022, showed the facility would inform residents of services available in the facility and of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of hospital transfer for 1 of 2 residents (Resident 15) reviewed for hospital transfers. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of a policy titled, Notice of Bed Hold Policy Before/Upon Transfer, revised 11/2018, showed the facility would provide written information to the resident and/or their representative that included the bed payment policy, length of bed hold, and information related to the resident's ability to return to the facility. Further review showed the information would be provided to the resident and/or their representative before a transfer or therapeutic leave and at the time of the transfer of the resident for hospitalization or therapeutic leave. The facility would provide two notices; 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 make an admission comprehensive assessment of each resident's pressure injury for 1 of 3 residents (Resident 268) reviewed for comprehensive assessment and timing. This failure placed the facilty residents at risk of not having comprehensive care, not having appropriate services, and their needs/preferences not being identified or care planned. Findings included . According to the Resident Assessment Instrument (RAI - a manual that instructs staff on timing requirements for assessments), admission assessments were required to be completed by the 14th calendar day of the resident's admission, and annual assessments were required to be completed within 14 days of the Assessment Reference Date (ARD, +14 days). <Resident 268> Review of the medical record showed the resident re-admitted to the facility on [DATE] with diagnoses to include a sacrum (bottom or lower backside of the body) pressure injury (an injury caused by unrelieved pressure 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 ensure Pre-admission Screening and Resident Review (PASARR) Level II evaluation treatment recommendations were incorporated into a resident's care plan for 1 of 1 residents (Resident 55) who were reviewed for Level II PASARRs. This failure placed the resident at risk for unmet mental health and psychosocial needs. Findings included . <Resident 55> Review of the medical record showed the resident admitted to the facility on [DATE] with serious mental health diagnoses. A PASSAR Level 1 was done on 02/14/2024 with a recommendation for a Level II assessment which was requested from the hospital. Review of the medical record on 04/17/2024 showed the PASARR Level 1 with recommendation of a Level II. The Level II was not found in the resident medical record. Review of the resident's 02/20/2024 care plan showed there were no identified care interventions included from a documented request of a PASARR 1 Level II recommendation. During an interview on 04/17/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) was accurate for 1 of 5 sampled residents (Resident 56) reviewed for the coordination/assessment of the PASARR. This failure placed the resident at risk for not receiving specialized mental health services, and unmet mental health needs. Findings included . <Resident 56> Review of the medical record showed the resident was admitted on [DATE] with a diagnosis including right shoulder dislocation, depression, and anxiety. The 02/26/2024 comprehensive assessment showed the resident's cognition was moderately intact but was able to make their needs known. Record review of Resident 56's PASARR, dated 02/13/2024, showed that the section with serious mental illness indicators did not indicate the resident's depression and anxiety diagnosis. During an interview on 04/18/2024 at 3:53 PM, Staff I, Social Service Director (SSD), stated that the PASARR for Resident 56 was incorrect and did 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 observation, interview, and record review, the facility failed to develop and implement measures to prevent skin breakdown for 1 of 3 residents (Resident 268), reviewed for pressure injuries. The facility failed to implement care interventions for Resident 268, who was identified at increased risk for skin breakdown. This failure placed the resident at risk for worsening of their pressure injury and unmet care needs. Findings included . <Resident 268> Review of the resident's medical record showed they were re-admitted to the facility on [DATE]. Diagnoses include multiple health diagnoses and skin issues to include a sacrum (the bottom or lower back of the body) pressure injury (an injury caused by unrelieved pressure on skin over a bone). The 02/06/2024 comprehensive assessment showed the resident was alert and oriented and able to make needs known. The resident required assistance in bed mobility, transferring and used a wheelchair. During an interview on 04/15/2024 at 10:30 AM, the resident stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide necessary care and services for urinary retention catheters (a flexible tube inserted into the bladder to drain urine) for 1 of 1 resident (Resident 46) reviewed for urinary catheter care. This failure placed Resident 46 at risk for a urinary tract infection (UTI)and a decline in health status. According to Mosbys Text for Nursing Assistants (standard guideline for the instruction of basic nursing care), copyright 2022, eighth edition Caring for Persons with Indwelling Catheters page 393 stated .keep the drainage tube below the bladder this prevents urine from flowing backward into the bladder . <Resident 46> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a disease that causes the destruction of nerve cells) and dementia. Review of the most recent assessment dated [DATE] showed Resident 46 was cognitively impaired. Review of the [NAME] (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services related to tube feedings [(TF) the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, are unable to safely swallow, or need nutritional supplementation] for 1 of 1 resident (Resident 8) reviewed for TF. The failure check for tube placement and label the tube feeding administration set with the date and time the feeding was initiated, placed the resident at risk for receiving expired and/or inaccurate enteral nutrition, adverse consequences, and complications of tube feeding. Findings included . Review of a policy titled, Tube Feeding Management/Restore Eating Skills, dated 06/2018, showed monitoring for the feeding tube included verification of patency (the condition of the tube being unobstructed) and function of the feeding tube. This included checking for gastric residual volumes [(GSV)the amount of liquid drained…

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 dialysis services met professional standards of care for 1 of 1 resident (Resident 167) reviewed for dialysis care. The facility did not have a coordinated process for communication with the outside dialysis center and for monitoring the resident after dialysis treatments. This failure placed residents receiving dialysis at risk for complications and unmet care needs. Findings included . Review of a facility policy titled, Quality of Care/Dialysis, dated 01/2024, showed -The facility and the dialysis center would collaborate to assure that the resident's needs related to dialysis treatment were being met. - The facility would assess the resident's condition and monitor for complications before and after dialysis treatments. - Facility and dialysis dieticians would coordinate the nutritional care of the resident including weight fluctuations to fluid retention/depletion. - There would be ongoing communication between the facility and the dialysis…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 resident (Resident 4) reviewed for pharmacy services. Resident 4 expressed a need for an as needed (PRN) pain medication at bedtime and did not receive it. This failed practice placed the resident at risk for ongoing, uncontrolled pain, and emotional distress. Findings included . Review of a policy titled, Pain Management, dated 11/2017, showed residents were assessed and evaluated to identify and manage pain with appropriate interventions to assist the resident to attain or maintain their highest practicable level of well-being. The resident would be monitored for the presence of pain and be evaluated when there was a change in condition and whenever new pain or an exacerbation (an increase in the severity of a problem, illness, or bad situation) of pain was suspected.…

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

Based on observation and interview, the facility failed to ensure proper storage and labeling of medications for 1 of 2 medication carts (North Cart) reviewed for medication storage and labeling. Additionally, the facility failed to ensure 1 of 2 medication carts (North Cart) was locked when unattended. These failures placed the residents at risk for receiving compromised medications and access to potentially harmful medications resulting in negative health outcomes. Findings included . Review of a policy titled, General Dose Preparation and Medication Administration, dated 01/01/2013, showed facility staff should not administer a medication if the label was missing. Additionally, the medication carts should always be locked when out of sight or unattended. During a concurrent observation and interview on 04/17/2024 at 6:44 AM, Staff F, Registered Nurse, obtained medications from the North Cart. Staff F closed all the drawers on the cart and proceeded to take the medications to a resident room, without locking the cart. There was an outside wound care vendor and a resident 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, interview, and record review, the facility failed to maintain a clean and sanitary surface of the kitchen stove hood. This included maintenance on a non-operational fan in the hood that vented out and removed grease, smells of food cooking, and hot vapors from the stove during the cooking of foods. Grease accumulated around the hood's large stove pipe from the stove hood, up to the area where the stove pipe reached up towards the ceiling, was bolted through the roof of the building, for 1 of 1 facility kitchen. This failure placed residents at risk of recieving food prepared from a kitchen with less than sanitary conditions. Findings included . During an observation on 04/15/2024 at 9:51 AM, the stove hood had dark grease that showed through the metal filter on the right upper side of the stove hood. The large pipe over the stove hood had yellowish dried grease streaks on both sides of the stove pipe. The stove pipe from the stove hood to the ceiling, was bolted and had large amounts of dark grease around the bolt attachments of the stove pipe to the ceiling.…

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 effective coordination of care between the facility and hospice staff, for 1 of 2 residents (Resident 48) reviewed for hospice services. Additionally, the facility failed to communicate and update the resident's care plan, which identified which entity was responsible for resident care. These failures prevented a system by which consistent communication between the facility and hospice staff occurred and placed the residents at risk for not for receiving necessary care and services. Findings included . Review of the facility's policy titled, Hospice, dated 07/2018, showed the facility and hospice would establish a coordinated care plan which provided specific services and functions that each provider was responsible for performing. The facility retained primary responsibility for implementing those aspects of care that were not related to hospice. Additionally, the signed contract, dated 03/12/2015, titled, Nursing Facility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the infection prevention and control antibiotic stewardship program (ASP) implemented measures for a system-wide monitoring/tracking of antibiotic to ensure appropriate use of antibiotics for 2 of 3 sampled residents (Resident 47 and 2) reviewed for antibiotic stewardship. This failure increased all residents' risk for development of multidrug-resistant organisms (MDRO/a bacteria that are resistant to many antibiotics), and unidentified nursing care trends related to infection prevention. Findings included . Review of the facility's policy titled, ASP, dated May 2019, showed that the facility was to .implement a system for monitoring and reviewing antibiotic orders and antibiotic usage to aide in the responsible use of antibiotics . and that the Infection Preventionist (IP) would be responsible for oversight on the ASP. The policy stated that the IP would, verify that antibiotic orders were in compliance with the Loeb Criteria (a checklist that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a safe, clean, and comfortable homelike environment for residents and staff for 1 of 1 laundry rooms (LR 1), and 1 of 3 Hallways (North Hallway) reviewed for a homelike environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment. Findings included . <Laundry Room> Observations on 04/17/2024 at 2:57 PM, showed LR 1's corner wall behind the two washing machines had previous water damage (an accidental leakage or discharge of water that caused possible losses or value of materials) with two, three foot (ft, a unit of measure) by one ft sections of sheet rock that had been waterlogged (saturated or full of water) at one point, with the sheetrock or wall paper peeling off the wall. A three inch (a unit of measure) diameter black drainage pipe under the washing machines chemical dispenser was caked (a thick substance that has hardened and covered an area) in a thick white chemical…

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 professional standards of nursing practice were provided when nursing staff failed to accurately transcribe and follow physician orders for 3 of 4 residents (Residents 1, 2 and 3) reviewed for nursing care and services. This failure placed the residents at risk for worsened infections, delay of healing and adverse outcomes. Findings included . Review of Lippincott Manual of Nursing Practice 11th Edition, copywrite 2019 , Part 1, Chapter 2, showed The practice of professional nursing has standards of practice setting minimum level of acceptable performance for which its practitioners are accountable. Failures in professional nursing standards include . • Failure to implement a physicians or nurse practitioner order properly or in a timely fashion, • Failure to administer medications properly and in a timely fashion, • Failure to make prompt, accurate entries in a medical record, • Failure to perform nursing treatment or procedure properly, •…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the medical records were accurate for 1 of 10 residents (Resident 2) reviewed for complete medical records. This failure placed Resident 2 at risk for not having accurate information in the medical record and possible harm if inaccurate information was used to make medical decisions. Findings included . <Resident 2> Review of the medical record showed Resident 2 was readmitted to the facility on [DATE] from the hospital with diagnoses which included urianry tract infection and kidney disease. Review of Progress Notes (PNs), dated 03/04/2024 at 8:04 PM by Staff E, Licensed Practical Nurse (LPN), showed Resident 2's blood pressure, body temperature, pulse, respirations, and oxygen saturation level (level declined when the capacity of the lungs to transport oxygen into the blood was impaired) were documented as taken on 02/27/2024 at 2:06 PM (six days earlier). The resident's body temperature was elevated at 101.0 degrees Farenheit (normal body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure an incident of potential neglect was reported immediately, but not later than 24 hours, to the State Agency for 1 of 3 residents (Resident 1) reviewed for reporting of alleged violations. This failure placed residents at risk for additional incidents of neglect and a decreased quality of life. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart and lung issues and a bone infection. The resident required two staff to assist with transfers and activities of daily living. The resident was able to self direct their care when awake and alert. Review of a facility investigation report, dated 03/06/2024, showed on 03/03/2024 Staff H, Registered Nurse (RN), was alerted by a Nursing Assistant (NA) after lunch that some pills had been found in Resident 1's bed and on the floor. Two medication bottles were also found - one bottle labeled Gabapentin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to conduct a thorough investigation of a neglect incident and take appropriate correction action involving 1 of 3 residents (Resident 1) reviewed for neglect incidents. Failure of staff to recognize an incident as neglect prevented the facility from taking the necessary corrective action to prevent further incidents of neglect. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart and lung issues and a bone infection. The resident required two staff to assist with transfers and activities of daily living. The resident was able to self direct their care when awake and alert. Review of a written statement dated 03/03/2024 by Staff G, Registered Nurse (RN), who worked from 6:00 PM on 03/03/2024 to 6:00 AM on 03/04/2024, showed they had received shift report at 6:00 PM from Staff H, RN, that Resident 1 was found the morning of 03/03/2024 with pills in their…

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 complete a performance review at least once every 12 months as required, for 6 of 6 nursing assistants (NAs) (Staff D, E, F, G, H, and I) reviewed for performance reviews. The failure to complete annual performance reviews placed residents at risk for unmet care needs from potentially unqualified staff. Findings included . Review of the facility policy titled, Nurse Aide Performance Review, dated 07/2018, showed the facility would complete a performance review of each NA once every 12 months. On 07/14/2024 at 1:23 PM, a sample of NA personnel records that included the date of hire and annual performance reviews were requested from Staff A, Administrator. The records showed the following: • Staff D was hired on 03/01/2014; • Staff E was hired on 09/16/1994; • Staff F was hired on 08/18/1998; • Staff G was hired on 10/04/2022; • Staff H was hired on 10/04/2002; • Staff I was hired on 09/17/2021. There was no documentation provided for annual performance reviews. During an interview on 02/14/2024 at 2:22 PM, Staff A 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.

Based on interview and record review, the facility failed to implement their respiratory protection program for fit testing procedures (a medical evaluation, fit testing, training on the use and wearing of a respiratory mask) of the N95 respirator mask (N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. Sixty nine of the 108 staff had either not been fit tested annually or were initially assigned duties necessitating an N95 without first being fit tested. A COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) outbreak (two or more cases of probable or confirmed COVID-19 among residents in the same unit or having the potential to have been cared for by common healthcare providers within a seven day time period of each other) began on 02/13/2024, when a second…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop and implement a person-centered comprehensive care plan that addressed comfort care (includes physical, emotional, social and spiritual support for residents and their families, the goal for comfort care was to control pain and other symptoms so the resident could be as comfortable as possible) for 1 of 3 residents (Resident 1) reviewed for comfort care. This failure placed Resident 1 at risk for not receiving care and services to meet their individualized needs. Findings included . <Resident 1> Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included malnutrition, adult failure to thrive (condition with the associated symptoms of weight loss, decreased appetite, poor nutrition and inactivity) and anorexia (lack or loss of appetite). Review of a Progress Note, dated [DATE] at 11:30 AM, showed Resident 1 had increased lethargy (sluggishness, slowness, lack of energy) 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 interviews and record review the facility failed to notify the resident's representatives of changes in condition for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the representatives placed the resident at risk of not having their representatives involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (progressive disorder that affected the nervous system and the parts of the body controlled by the nerves such as tremors, stiffness or slowing of movement). Review of the 12/11/2023 comprehensive assessment showed Resident 1 had moderate impairment of cognition and required assistance with activities of daily living and walking. Review of Progress Notes, dated 01/06/2024 at 11:55 PM, showed Resident 1 was found on the floor with their head under the bed, holding onto…

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 notify the resident's representative for one of one resident (Resident 1), reviewed for notification of change. Failure to notify the representative of an acute change in the resident's condition and discharge to the hospital emergency room placed the resident at risk of not having a representative involved in the health care decision making for timely care and services. Findings included . <Resident 1> Per the medical record, the resident was admitted to the facility on [DATE] with diagnoses including a recent stroke with right sided weakness, multiple sclerosis, (a chronic disease of the central nervous system) rheumatoid arthritis, (a chronic disease causing inflammation in the joints), and diabetes. Resident 1's most recent comprehensive assessment, dated 09/14/2023, showed they required total assistance of two caregivers for bed mobility, transfers, dressing, and toileting and was moderately impaired cognitively regarding decision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to provide the necessary care and services for 1 of 3 residents (Resident 1) reviewed for pressure ulcers (PUs - a skin wound caused by pressure preventing blood flow to the skin). The failure to notify the physician of the open PU, thoroughly assess the PU to determine the effectiveness of the treatment, and perform wound treatments as ordered placed the resident at risk for delayed wound healing or worsening of wounds, development of new PUs, potential infection and a diminished quality of life. Findings included . Resident 1. Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included malnutrition, chronic respiratory disease and dementia (loss of cognitive functioning - thinking, remembering and reasoning). Review of Resident 1's comprehensive assessment, dated 08/03/2023, showed they had severe impairment of their cognition, required extensive assistance with two staff for turning,…

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 they followed proper drying of dishes, sanitization of several areas of the kitchen, stored foods safely by labeling and dating foods, and discard outdated foods for one of one kitchen. These failures placed all residents at risk for food-borne illness (an illness caused by the ingestion of contaminated food or beverages.) Findings included . Thawing/labeling of Foods An observation and concurrent interview, on 05/08/2023 at 10:46 AM, showed the reach in refrigerator, closest to the entrance door of the kitchen, had a gray basin with four, five-pound rolls of ground beef, and one roll of ground sausage, thawed, in the same bin. Next to this bin was another gray bin with a full bag of thawed chicken thighs and an opened partial bag of thawed chicken thighs, and a small plastic bag with more than five pieces of thawed sliced ham. On the top shelf, there was a clear container filled with thawed sliced ham, all the meat was unlabeled and undated. Staff V, Dietary Manager (DM) stated they would expect 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 implementation of infection prevention and control precautions for, 1) hand hygiene and the cleaning/disinfection of residents shared devices for 5 of 10 Staff (AA, CC, H, T, and E) and, 2) dressing changes for 2 of 2 Staff (E and F) observed during residents wound care dressing change and for one of one Staff (T) observed during a Peripherally Inserted Central Catheter (PICC, a tube that is threaded through the vein so that the tip of the line sits near the heart) sterile (free from bacteria ,totally clean) dressing change. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's policy titled, Infection Prevention and control program (IPCP), revised 06/08/2022 showed that facility staff were to implement standard precaution for all resident care activities, which included, hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, comfortable, and sanitary environment for 2 of 3 resident rooms (rooms [ROOM NUMBERS]) reviewed for comfortable temperature levels, 2 of 2 shower rooms (West and North Hall) and 1 of 2 soiled utility rooms (West Hall) all reviewed for safe and sanitary environment. These failures placed residents at risk for a diminished quality of life by not maintaining a clean, comfortable, and homelike environment. Findings included . Temperature levels Observations in room [ROOM NUMBER] on 05/08/2023 at 2:45 PM, showed the air conditioner was blowing warm air out towards the rooms entrance. Resident 44 was dressed in shorts and a t-shirt lying on top of the blankets of the bed. The resident commented that the air conditioner did not cool down the room enough, and that they could not feel the air blowing out so the door needed to be left open or it would get hotter in the room. Observation in room [ROOM NUMBER] on 05/09/2023 at 9:32 AM, showed that no…

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 evaluated and assessed for safe self-administration of medication for 3 of 3 (Residents 357, 49, and 43) reviewed for medication at the bedside. Additionally, the facility failed to obtain a physician's order for self-administration of medications for the residents. The failure to complete a self-administration assessment and obtain a physician's order placed the residents at risk for medication errors and adverse medication interactions. Findings included . Review of the facility policy titled, Self- Administration of Medications, dated 12/01/2007, showed that the facility, in conjunction with the interdisciplinary care team (a group of different health care professionals working together, commonly comprised of a physician and nursing staff), should assess, and determine if a resident's self-administration of medications was safe and appropriate. The policy further stated that the facility should ensure that each…

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 conveyance (transferring property from one person to another) of personal funds within 30 days of facility discharge for 1 of 1 resident (Resident 99) reviewed for transfer of resident funds. This failure placed the residents and/or their representatives at risk for a loss of funds. Findings included . Review of the facility's undated policy titled Patient Trust Policies and Procedures, showed that upon the discharge or death of a resident, the facility would convey the residents' personal funds held by the facility within the required state guidelines .these documents would be sent disbursed to the state recovery agency as determined by state guidelines. Review of the resident's medical record showed that they passed away on 11/06/2022. They had $10.00 in personal funds remaining in their facility held trust account. Review of the resident's trust fund account showed the balance of $10.00 had not been conveyed (transferred back) to the Office of Financial Recovery within 30 days of the resident's death as…

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 conduct a thorough investigation for 1 of 3 residents (Resident 38) reviewed for a resident-to-resident altercation and elopement (an instance where a resident leaves the facility without authorization and/or any necessary supervision to do so). This failure placed the resident at risk for unidentified abuse, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation, dated November 2017, showed that the facility staff were to be knowledgeable on how to react/respond to situations (like a resident-to-resident altercation or an event where a lack of supervision could lead to an unsafe environment) that could lead to abuse or neglect of a resident and a thorough investigation should be conducted to protect the resident from potential further abuse. Resident 38. Review of the resident's medical records showed that they were admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify a significant change of condition status for 1 of 3 residents (Resident 13), reviewed for a decline in activities of daily living (ADLs) and mobility. Failure to identify and complete a significant change of condition assessment put Resident 13 at risk for unmet care needs and a diminished quality of life. Findings included . Record review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, Version 3.0, dated October 2019, showed that a significant change in condition assessment was appropriate when: • there is a determination that there has been a significant change in a resident's condition (a major decline in a resident's status that has affected two or more areas of ADL's from his/her baseline . • the resident's condition is not expected to return to baseline within 2 weeks . Resident 13. Review of the resident's electronic health record (EHR) showed the resident had diagnoses which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 40 and, 12), reviewed for activities of daily living (ADLs), received adequate grooming, and oral care according to the residents' care plans. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 40. Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain), cerebral palsy (impaired muscle coordination) and muscle weakness. Review of Resident 40's most recent comprehensive assessment dated [DATE], showed the resident was cognitively intact, required extensive assistance of two persons for bed mobility and, transfers. The review further showed that the resident required set up assistance for personal/oral care. Review of Resident 40's care plan, dated 11/07/2022, showed the resident had an ADL self-care performance…

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 implement a system regarding their controlled medication (a group of medication, which includes opiates, used to reduce pain, that have the potential for abuse and could also lead to physical or psychological dependence) reconciliation records (recordkeeping that should show accurate inventory of controlled medications) which enabled the accurate accounting of these types of medications for 3 of 3 medication carts (East hall, North hall, and [NAME] hall) reviewed for medication storage. The failure to accurately count and verify the inventory of controlled substances during nursing shift change, placed residents at risk for potential financial loss, uncontrolled pain, and possible drug diversion (the abuse of prescription drugs use for purposes other than intended by the prescriber). Findings included . Review of the March through May 2023 controlled/narcotics (a drug class that includes pain medications) medications logbook (the facility's documentation of two nursing staff's verifications that narcotic…

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 that pharmacy Consultant Reports and recommendations were followed up on in a timely manner for 2 of 5 residents (Residents 13 and 37), reviewed for unnessesary medications. This failure placed residents at risk for adverse outcomes of medication use. Findings included . Record review of the facility's policy titled, Pharmacy Services Medication Regime Review, dated November 2017 showed, The pharmacist reports any irregularities in a separate written report to the attending physician, medical director and the director of nursing. The recommendations are reviewed, and a response is provided, in a timely manner . Resident 13. Review of the resident's electronic health record (EHR) showed the resident had diagnoses which included Alzheimer's disease (a mental disease that causes a progression of cognitive loss), anxiety and depression. Review of the most recent comprehensive assessment, dated 03/14/2023, showed the resident had cognitive impairment and had no indicators of a depressed mood. Record review of a pharmacy…

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 that; 1) residents on an as needed (PRN) psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication orders were not limited to 14 days for 1 of 1 resident (Resident 48), reviewed for psychotropic medication side effects. Additionally, the facility did not have a required rationale documented from the attending/prescribing medical provider for the expected duration, for the PRN medication. This failure placed residents at risk for unintended medication side effects, being overmedicated and a diminished quality of life. Findings included . Resident 48. Review of the resident's medical records showed that they were admitted [DATE] with a diagnosis of bone infection of the spine that was placed on hospice for end-of-life care on 04/25/2023. Review of Resident 48's physician's orders on 04/26/2023 showed: • Lorazepam (an antianxiety medication-psychotropic medication) oral tablet 0.5 milligram (mg/a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure influenza and pneumococcal vaccines were offered to 3 of 5 residents (Resident 37, 47, and 19) reviewed for immunization and infection control. This failure placed the residents at risk for illness, spread of a communicable disease, and a decreased quality of life. Findings included . Review of the 06/08/2022 facility policy Influenza and Pneumococcal Immunizations, showed that the facility provided influenza and pneumococcal immunization to minimize the risk of residents acquiring, transmitting, or experiencing complication from influenza and pneumococcal disease. The resident and/or their representative would receive information related to the risks and benefits of the immunizations. Further review showed that the resident record would reflect evidence that education had been provided and the administration or refusal of the immunization. Resident 37. Review of the medical record showed the resident 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.