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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide ordered pain-relieving interventions in a timely manner for 1 of 3 residents (Resident 1) reviewed for pain management. This failure placed residents at risk for unmet needs, anxiety, and a diminished quality of life.Finding included.Resident 1 admitted to the facility on [DATE] at 2PM from the hospital after having a left ureteral stint placement (a procedure where a thin, flexible tube is inserted into the ureter to ensure urine flows from the kidney to the bladder). The admission 5-day Minimum Data Set (an assessment tool), dated 11/12/2025, showed Resident 1 was cognitively intact and had pain that interfered with activities of daily living. During an interview and observation on 11/25/2025 at 2:35 PM, Resident 1 said they had severe pain to the left flank, 7 out of 10 on the pain scale. Resident 1 said they had not received the noon dose of Tylenol and had been waiting for over two hours for as needed (PRN) medication. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to involve the resident's representative in the development of the resident's plan of care, inform the representative of changes in the plan of care and review the plan of care for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of lack of advocacy for their healthcare needs, preferences and medical history. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's Clinical admission Assessment, dated 08/05/2025, showed Resident 1 was chronically confused and had moderate cognitive impairment.Resident 1's Durable Power of Attorney for Health Care (DPOA-HC) dated 10/02/2023 and uploaded to Resident 1's electronic medical record (EMR) on 08/05/2025, showed Collateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain and monitor laboratory tests timely per physician orders for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of clinical complications, unstable medical conditions and delayed recovery. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's medical provider notes, dated 08/07/2025, showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake. The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids (liquids administered through a catheter in the vein) for 48 hours for hydration. The note showed the plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents and staff related to shower rooms, utility rooms, and equipment storage rooms. This failure placed residents and staff at risk for injury, cross contamination (process by which bacteria or other microorganisms are transferred from one subject or object to another), and a decreased quality of life. Findings included.During an observation on 08/12/2025 at 1:15 PM, the shower room on the [NAME] wing was observed. The floor was littered with garbage (used gloves, paper towels, wipes). There were several personal hygiene items (body wash, shampoo, lotions) open and scattered around the room. The toilet had a brown ring inside of it with a piece of toilet paper hanging down. The drain for the shower was not covered. The exhaust fan in the ceiling was not covered and had wires hanging down.During an observation on 08/12/2025 at 1:30 PM, resident room [ROOM NUMBER] was observed. The door was open. There were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, the facility failed to ensure the resident or resident representatives' right to make healthcare choices was upheld. Specifically, the facility did not provide the resident's representative with adequate information or involvement in decision making related to care and treatment for 1 of 3 residents (Resident 1). This failure placed residents and their representatives at risk of not being able to make informed decision regarding care and services.Findings included.A Resident Rights Policy, undated, given to all residents and or resident's representatives on admit, stated, You have the right to be informed of, and participate in, your treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option you prefer.Resident 1 admitted to the facility on [DATE] and had a history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report and investigate an incident of potential neglect for 1 of 1 resident (Resident 1) reviewed for hospitalization related to a preventable complication of a suprapubic catheter. This failure limited the opportunity for the facility to identify and correct system failures that contributed to the residents' decline.Findings included.Resident 1 admitted to the facility on [DATE] with a diagnosis of Obstructive Uropathy (a urinary tract disorder that occurs when the urine flow is blocked) and had an indwelling urethral (the tube that carries urine from the bladder out of the body) catheter (a tube inserted into the bladder to drain urine). The quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact and needed minimal assistance with activities of daily living (ADL's). On 07/25/2024, the urethral catheter was replaced with a suprapubic (small hole in the lower abdomen leading to the bladder) catheter. Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to administering psychotropic medications, and/or ensure consent forms accurately identified the type of medication (drug class) and associated risks and benefits of use for 3 of 5 residents (Resident 62, 48, & 28) reviewed for unnecessary medications. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with end-of-life care and psychotropic medications and a diminished quality of life. Findings included . 1) Resident 62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/24/2025, showed the resident was severely cognitively impaired, had a diagnosis of depression, demonstrated signs and symptoms of delirium (a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were included in care conferences and discussions on their person-centered plans of care for 7 of 18 sampled residents (Resident 58, 56, 37, 15, 24, 45, & 28). This failure placed residents at risk of having services discontinued or started without being fully informed or involved, not having preferences honored at end of life, and unidentified/unmet care needs. Findings included . 1) Resident 58 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 58 was able to be understood and understands. Review of Resident 58's Portable Orders for Life-Sustaining Treatment (POLST), signed [DATE], showed Resident 58 had elected no Cardiopulmonary Resuscitation (CPR) in the event they were found with no pulse and/or were not breathing. For situations when the individual had a pulse and/or was breathing, there were three options to choose from: full treatment, selective treatment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free of chemical restraints for 5 of 6 residents (Residents 39, 62, 48, 28 and 56) reviewed for unnecessary medications or pain. The failure to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had adequate indications for use, resident specific target behaviors (TB) were identified and monitored, gradual dose reductions (GDRs) were performed, non-drug interventions were attempted prior to administration of as needed (PRN) psychotropic medications, and PRN psychotropic medication orders did not exceed 14 days unless a documented clinical rationale was provided, placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects such as sedation, decline in physical function, and other negative health outcomes. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 19 and 39) and ombudsman notification for 3 of 4 sample residents (Residents 19, 75 & 39) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident rights during transfers, and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/21/2025, documented Resident 19 was moderately cognitively impaired. A review of the Electronic Health Record (EHR) showed Resident 19 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 19's EHR showed documentation that Resident 19's bed hold notice was dated 04/15/2025 and signed on 05/05/2025 (greater than 24 hours after transfer). 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 provide residents with care plans that were comprehensive, individualized and person centered, updated, and/or accurate for 11 of 18 sampled residents (Residents 28, 56, 45, 63, 39, 127, 20, 16, 37, 15, & 24) reviewed. This failure placed residents at risk of unidentified and unmet care needs, and a diminished quality of life. Findings included . 1) Resident 28 was admitted to the facility on [DATE] with diagnoses of dementia and depression. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 28 was rarely understood or rarely understands. Review of Resident 28's past 30 days of meals monitor, showed three meals were refused. Review of Resident 28's nutritional risk care plan, showed standard interventions to monitor and record food/fluid intake, monitor weight, obtain and monitor labs, and serve diet as ordered. The care plan did not mention any refusals of meals or any alternatives/preferences if Resident 28 did not want…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 free from unnecessary medications by providing and documenting on non-pharmacological interventions (NPI) for pain management, having parameters for medications, and/or using non-opioid medications for 4 of 6 residents (Residents 56, 37, 40 & 48) reviewed for unnecessary medications or pain. This failure placed residents at risk of medication tolerance, increased pain, and a diminished quality of life. Findings included . 1) Resident 56 was admitted to the facility on [DATE] with diagnoses of chronic pain and muscle spasm. The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 56 was able to be understood and understands. Review of Resident 56's pain orders showed they had two as needed medications for pain: 1. Morphine, an opioid (strong pain medication), for every 3 hours as needed for end of life care (not listed for pain, no parameters/pain score listed on when to give). 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 store food for residents in accordance with professional standards for 2 of 2 nursing station refrigerators (East, West) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . Review of the following refrigerator temperature logs located at nurses stations included the following out of range temperatures (greater than 40 degrees Fahrenheit (F): February 2025 [NAME] refrigerator: 5th 43F AM shift/ 5th 43F PM shift 8th 43F AM shift 9th 42F AM shift 10th 43F AM shift 15th 43F AM shift 16th 44F AM shift there was no documentation of corrective action taken. February 2025 East refrigerator: 11th 43F AM shift 12th 45F AM shift 19th 43F AM shift there was no documentation of corrective action taken. March 2025 [NAME] refrigerator: 4th 45F AM shift 7th 43F AM shift 11th 49F AM/42F PM shifts 12th…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 binding arbitration agreements (legal document that required the use of a third party to resolve disputes) were reviewed in a manner that explicitly informed the resident or their representative of what they were consenting to, or were understood in their entirety, for 3 of 3 residents (Residents 39, 126, & 127) reviewed for binding arbitration. This failure placed residents at risk for legal complications and a diminished quality of life. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. Resident 39 signed their binding arbitration agreement on 11/25/2024. Review of the electronic health record showed Resident 39 was admitted after being in the hospital for sepsis (infection of the blood) and was re-hospitalized on [DATE] with altered mental status. During an interview on 05/07/2025 at 10:57 AM, Resident 39 was asked what their understanding of the arbitration process was, and said they did not really know. When…

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

Based on interview and record review, the facility failed to show evidence of an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to provide evidence of documentation that demonstrated the development, implementation, and evaluation of a performance improvement activity for 1 of 1 sampled Process Improvement Projects (PIP) reviewed. The facility failed to provide evidence of the medical director participating in the QAPI program. This failure placed residents at risk for ongoing unmet care needs and a diminished quality of life. Findings included . Record review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Process effective July 2015, stated, The center pursues the highest quality of care and services for their customers through a data-driven, proactive approach to improving the quality of life, care, and…

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

Based on interview and record review, the facility failed to have a system in place for maintaining documentation of staff screening, education, offering and current COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccination status for 12 of 12 months (May 2024 - May 2025) reviewed. These failures placed residents and staff at risk of contracting COVID-19, related complications and a diminished quality of life. Findings included . On 05/06/2025 at 1:06 PM, when asked to provide documentation of screening, education, offering and current COVID-19 vaccination status for staff, Staff A, Administrator and Infection Preventionist said they did not have any staff that agreed to take the COVID-19 vaccination. Staff A said they would talk about the importance of it, but they all had a choice. Staff A said they had last year's records, but did not have this year's records because all staff had refused the vaccination. On 05/10/2025 at 11:06 AM, Staff A was emailed a request for documentation of screening, education, offering and current COVID-19 vaccination status for 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately notify the physician and resident representative of significant changes in physical condition, for 2 of 5 residents (Resident 15 & 28) reviewed for nutrition. This failure placed residents at risk for a delay in medical/nutritional treatment and not having their representatives involved in the health care decision making process for timely care and services. Findings included . 1) Resident 15 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/09/2025, documented Resident 15 was severely cognitively impaired. The electronic health record (EHR) documented Resident 15's weight as 100.1 pounds (lbs) on 03/03/2024, the last documented weight in the weights/vitals tabs. On 05/07/2025, the resident weighed 85.8 lbs which was a -14.29 % loss in twelve months. A Nutritional Assessment, dated 03/07/2025, documented Resident 15 weighed 111.6 lbs on 09/21/2024. This weight was not documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to comprehensively assess for the use of bed rails/mobility bars, the use of a bed against the wall, and a wander guard for 4 of 4 sample residents (Residents 19, 20, 3 and 24) reviewed for physical restraints. This failure placed residents at risk of potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . <Wander Guard> 1) Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/21/2025, documented Resident 19 was moderately cognitively impaired and had a wander/elopement alarm used daily. A review of Resident 19's Electronic Health Record (EHR) showed an order dated 03/04/2025 for a wander guard placement due to elopement risk related to psychosis (a condition where a person experiences a significant loss of contact with reality, often marked by hallucinations, delusions, and disordered thinking). On 05/09/2025 at 9:29 AM, Staff C,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected residents' mental health diagnoses for 2 of 5 sampled residents (Residents 62 & 48) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental health needs. Findings included . 1) Resident 62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/24/2025, showed the resident had severe cognitive impairment, a diagnosis of depression, and demonstrated signs and symptoms of delirium (a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's surroundings) including inattention and altered levels of consciousness. Resident 62 received both antipsychotic and antidepressant medication during the assessment period. A level 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 32 residents (Residents 127 & 20). Facility staff's failure to administer medications in accordance with physician's orders, and to complete assessments and treatments as ordered placed residents at risk for ineffective treatment of disease processes, medication adverse side effects and other potential adverse health outcomes. Findings included . 1) Resident 127 admitted to the facility on [DATE] with orders for intravenous (IV) cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and midnight. Review of Resident 127's admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of pneumonia (infection in lungs) and sepsis (infection in blood), and received IV antibiotics via Peripherally Inserted Central Catheter (PICC - long, flexible, thin tube inserted into a vein in your arm, usually the upper arm, 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 bowel protocol was implemented, bowel movements were monitored and/or documented on, for 2 of 6 residents (Residents 56 & 48) reviewed for unnecessary medication and constipation. This failure placed residents at risk of bowel obstructions, pain, and a diminished quality of life. Findings included . Review of the facility's policy titled, Management of Constipation, revised 11/2023, showed the facility monitored bowel movements through point of care documentation (computer charting system used most frequently by nursing assitants) and clinical alerts. After 64 hours of no/small bowel movement, the nurse would assess and determine if the bowel protocol would be initiated and document findings, and interventions would be documented on the clinical alert. The standard bowel protocol would be as follows: 1. Milk of Magnesia (MOM) after 8 shifts of no bowel movement 2. Bisacodyl suppository if no results from the MOM 3. Fleets Enema if 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 interview and record review the facility failed to consistently provide weekly skin assessments and failed to implement supplements as recommended for wound healing for a pressure ulcer (PU, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. These failures placed residents at risk of developing avoidable pressure ulcers and/or delayed healing of pressure ulcers and a diminished quality of life. Findings included . Review of the facility policy, titled Documentation-Skin Conditions revised on 12/2024 documented weekly skin assessments were to be documented weekly using the Total Body Skin Evaluation. <Failed to do weekly skin assessments> Resident 24 admitted to the facility 03/06/2020. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 01/23/2025, documented Resident 24 had one Stage 3 (involves damage to the innermost layer of skin tissue, exposing the fatty tissue underneath), PU. On 05/08/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 1 resident (Resident 127) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC line, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, PICC dressing changes, measuring external length to verify the line had not migrated, and arm circumference to monitor for swelling. deep vein thrombosis. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Resident 127 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/29/2025, showed the resident was cognitively impaired, had a diagnosis of pneumonia and…

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

Based on interview and record review, the facility failed to have a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 1 of 1 medication carts (East B cart) reviewed for narcotic records. The failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion. Findings included . On 05/09/2025 at 7:52 AM, two controlled medication books/ ledger were observed on the East B medication cart. One ledger contained the count for schedule two medications (drugs that have a high potential for abuse and are regulated under the Controlled Substances Act) and the other for schedule three and four medications (drugs with low to moderate potential for abuse and/or addiction). On 05/09/2025 at 11:18 AM, Staff C, Resident Care Manager (RCM), said facility nurses were supposed to count all schedule two,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 127) reviewed for intravenous (IV) therapy, was free of significant medication errors. The failure to administer IV antibiotics at ordered times/intervals, placed residents at risk for ineffective treatment of infection, prolonged antibiotic therapy and associated adverse side effects. Findings included . Resident 127 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool), dated 04/29/2025, showed the resident was cognitively intact, had a diagnosis of bilateral lower lobe pneumonia (infection in both sides of lower lungs), and received IV antibiotics during the assessment period. Review of the electronic health record (EHR) showed the resident had a 04/23/2025 order for IV Cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and Midnight, with direction to infuse over one hour via Peripherally Inserted Central Catheter. Review of the April 2025 Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored at proper temperatures, dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 2 of 2 medication rooms (East and [NAME] Medication rooms) and 1 of 2 medication carts (West A cart) reviewed. This placed residents at risk of taking and/or receiving expired/outdated medications and biologicals. Findings included . <East Medication Room> On 05/13/2025 at 11:40 AM, observation of the medication refrigerator showed it contained 11 bags of intravenous cefazolin (to be stored at 37.5 - 41 degrees Fahrenheit (F)), multiple unopened insulin pens (to be stored at 36 - 46 degrees F), and an opened multi-use vial of Tuberculin purified protein derivative (PPD, to be stored at 35 - 45 degrees F). Review of the refrigerator temperature log showed staff had not checked the medication refrigerator temperature since October 2024 (greater than six months prior). On 05/09/2025 at 11:42 AM, Staff C, Resident Care Manager…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program that ensured accurate and complete information (signs/symptoms) was collected monitored and/or documented on for 2 of 3 monthly infection line listings (a document that tracks resident infections) reviewed (February 2025 & April 2025). The facility also failed to implement a process for documenting on McGeer's Criteria (tool that provided criteria to show if antibiotics were indicated), that included provider notification, intervention implemented (if provider wanted to continue or stop the antibiotic and the reason for it), and an accurate list for tracking residents that did and did not meet criteria, for 1 of 1 residents (Resident 26) reviewed for McGeer's Criteria. These failures placed residents at risk for unnecessary antibiotic use, development of [NAME]-drug-resistant organisms (MDROs), and other negative health outcomes. Findings included . Review of the facility's policy titled, Antibiotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate a resident grievance for 2 of 5 sampled resident (Resident 1 and 2) reviewed for grievances. This failure placed the residents at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life. Findings included . The Facility Policy titled, Grievances, revised 02/2024, documented that the grievance process was for both residents and resident representatives, included a process for receiving, tracking and concluding for any and all concerns. Grievances were to be logged on the Grievance Log, and the resident or resident representative should receive communication within 5 days for resolution. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission MDS (minimum data set), an assessment tool, date 03/25/2025, documented Resident 1 was cognitively intact, and required substantial to maximal assistance of staff for completion of activities of daily living (ADL's). The care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge planning included assessment of resident's ability to manage medications, prepare or have access to prepared meals, and to handicap accessible living quarters for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, re-hospitalization, and a decreased quality of life. Findings included . Review of the facility policy titled, Resident Discharge, revised 05/18/2023 showed that discharges must follow all state requirements to ensure safe and proper discharge for residents and it should include in the plan for the resident's continuity of care and reduction of potential transfer trauma. Resident 1 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), and assessment tool, dated 02/28/2025, showed Resident 1 was cognitively intact, required the use of a wheelchair, required daily medication via injections, and that discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) when reviewed for care plans. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life. Findings included . <Policy> Review of the facility policy titled, Baseline Care Plan Policy, revised 12/2024, showed the facility was to develop a baseline care plan within 48 hours of admission to direct the care team and should include the minimum healthcare necessary to properly care for the resident. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission minimum data set (MDS) and assessment tool, dated 02/09/2025, showed Resident 1 was cognitively intact, medically complex and had central line access (also known as a central venous catheter (CVC), 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 provide care and services adequate to prevent hospitalization for 2 of 3 residents (Residents 1 & 2) reviewed for hospitalization. The facility failed to provide central line maintenance for Resident 1 resulting in hospitalization for a potential central line (also known as a central venous catheter (CVC), is a long, thin tube (catheter) inserted into a large vein to provide long-term access for fluids, medications, blood draws, and monitoring) blood infection and failed to adequately monitor Resident 2 (who was receiving nutrition via a feeding tube), following an episode of emesis, resulting in hospitalization for acute respiratory failure with hypoxia. These failures placed residents at risk for infection, hospitalization, and a diminished quality of life. Findings included . Review of the CDC; Guidelines for prevention of intravascular Catheter-related Infections, dated 2011 showed that CVC (central venous catheters) site dressings should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations and interview, the facility failed to ensure the resident audible call system was functioning properly and repaired timely for 2 of 4 resident halls reviewed for call light systems. This failure placed residents at risk for delayed staff response to potential emergencies and resident needs, falls, injury and decreased quality of life. An intake reported on 03/04/2025 at 3:32 PM, documented the facility's audible call light system was not working for rooms 1-17 and manual bells were provided for the residents. On 03/07/2025 at 11:35 AM, the call light to room [ROOM NUMBER] was observed and it was noted there was no audible alarm. At 4:15 PM, Staff A, Administrator, said the repair company had been there, and they had to order a part, it had not arrived yet. They had passed out bells to the residents effected. On 03/19/2025 at 11:30 AM, Staff A said the part to repair the audible portion of the call light system had not arrived. At 11:50 AM, call light to room [ROOM NUMBER] was observed 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 thoroughly investigate an injury for 1 of 3 residents (Resident 1) reviewed for accidents. Facility failure to complete thorough investigations placed residents at risk for further falls and injuries, potential abuse, and other negative health outcomes. Findings included . Resident 1 was admitted to the facility on [DATE] with a right hip fracture. The admission Minimum Data Set (MDS), an assessment tool, dated 01/09/2025, showed Resident 1 was cognitively intact. The care plan, initiated 01/06/2025, showed Resident 1 required extensive assistance for bed mobility and transfers with the goal for improved function. The facility incident report, dated 01/26/2025 at 2:00 AM, showed Resident 1 was found on the floor next to her bed. Staff documented the resident was assessed and no injury was found, and the resident was assisted back to bed. It was documented the resident reported pain to her right hip but declined offer of acetaminophen. Documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 behavioral health care and services were provided for one of six sampled residents (Resident 2) reviewed for behavioral health services. This failure placed residents at risk for increased behaviors, not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 12/18/2024, showed the resident was cognitively intact, medically complex and had verbal behaviors directed toward others that significantly interfered with the resident's participation in activities and social interactions and intruded on the privacy and activity of others. The care plan focus for behavioral problems, initiated on 11/29/2023 and updated on 03/03/2025, identified the resident had the potential to make sexually inappropriate comments to female residents. Goals for the resident initiated on 11/29/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview the facility failed to maintain a safe, clean and comfortable environment through maintenance of the hallway carpets for 3 of 3 halls (East, Mid, and [NAME] B) observed. This failure has the potential to place residents at risk for not having a clean, homelike environment and a diminished quality of life. Findings included . On 12/17/2024 at 3:27 PM, it was reported a family member for a resident had removed resident from the facility because the facility was found to be dirty, filthy, and gross and the carpets were not cleaned or vacuumed, and there was a bad odor. On 12/31/2024 at 1:44 PM, Collateral Contact 1 said the building was a mess and was run down. On 01/09/2025 between 12:24 PM, and 12:30 PM, the following were observed in the East Hall: - Mostly brown and some pink stains in front of rooms 1 through 3 - Scattered debris of small white pieces of paper and plastic - Brown matter smeared into the carpet measuring approximately 1 by 2 inches outside of room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 4 sampled residents (Resident 1) reviewed for quality of care when facility staff 1. failed to assess, monitor and/or document resident responses to interventions on a daily basis for newly admitted residents receiving skilled services and 2. failed to obtain and document vital signs for residents at risk for sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection. It can lead to organ failure, shock, and death). These failures placed residents at risk for rehospitalization, health complications, and decreased quality of life. Findings included . The facility policy titled, Documentation, revised on 05/12/2023, showed frequency of documentation was dictated by the clinical needs of the resident, as well as state and federal requirements. Nursing documentation should be found in the medical record and 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 interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 2 of 5 residents (2, 3) reviewed for dignity and respect. This failure placed residents at risk for unmet needs, diminished self-worth, and continued episodes of disrespect. Findings included . Review of the facility policy, titled Resident Rights, dated 08/2022, showed the purpose was to treat each resident with dignity and respect, and in a manner that promotes maintenance or enhancement of self-esteem. Review of the Facility Grievance Log from 09/25/2024 to 10/25/2024 showed five entries from five different residents. All five entries were related to how staff treated or spoke to residents. The log showed: On 09/26/2024, a resident reported between the hours of 8pm and midnight, a staff member was unkind to him when he requested a blanket. The facility summary report showed the resident had dementia and could not identify a staff member or recall the incident. Staff reported there were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently provide care and services as ordered for non-pressure wounds for 1 of 5 residents (1) reviewed for quality of care. This failure placed residents at risk for worsening wounds, infection, and decreased quality of life. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/19/2024, documented the resident was cognitively intact, medically complex and had an infection and non-pressure wounds of the foot, requiring dressings. The care plan focus for right lower ulcer with gangrene (a serious condition that occurs when body tissue dies due to a lack of blood flow or a bacterial infection), initiated on 10/14/2024, included interventions to treat wound as per MD orders. A physician's order, dated 10/12/2024, instructed staff to paint all toes and gangrene [of right foot] with 10% provodine/iodine, let dry, cover with non-adherent gauze and secure with roll[ed] gauze…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent the development of pressure ulcers (PU - injury to skin and underlying tissue resulting from prolonged pressure), perform/document regular skin assessments, and to consistently complete provider ordered wound care for 4 of 4 sampled residents (Residents 1, 2, 3, & 4) reviewed for pressure ulcers. These failures placed residents at risk for continued deterioration or pressure ulcers/injuries, infection and pain. Findings included . According to the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Manual, dated October 2023, pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In addition, external factors, such as excess moisture and tissue exposure to urine or feces, can increase the risk. The Documentation-Skin Conditions facility policy, dated 02/24/2023, showed a weekly skin assessment would be documented using the total body skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure resident representatives were notified of changes in condition for 2 of 4 sampled residents (1 and 2) reviewed for notification of changes when resident family members were not notified of new pressure wounds. This failure prevented the residents' representative from participating in discussions about resident care decisions and placed the residents at risk for delayed medical treatment, diminished quality of life, and increased pain. Findings included . The facility policy titled, Notification of Change in Condition, revised 05/2024, showed the residents' representative should be made aware of any significant changes in the residents' physical, mental or psychosocial status. If the residents' condition was not crucial the representative would be notified at the earliest convenient time during business hours. Notification should be documented in the progress notes. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services consistent with professional standards for 1 of 4 residents (Resident 2) reviewed for quality of care when the facility staff failed to document assessment and monitoring of the resident for latent injuries, resolution of injuries, and potential adverse side effects of medications for multiple incidents involving the resident. This failure placed all residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The policy titled, Alert Charting, revised on 05/2023, documented that residents were to be placed on alert for a minimum of 72 hours for the following: resident care issues, changes in condition, medication changes, falls, and psychosocial harm. Documentation should include vital signs, physical assessment, resident's response, and symptoms. Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS/an assessment tool), dated 07/25/2024, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for quality of care, was provided care, in accordance with professional standards of practice. The facility failed to secure an order for administration and monitoring for the continuous positive airway pressure (CPAP: an external device that provides a fixed pressure to keep breathing airways open while you sleep) therapy. This failed practice placed residents at risk for ineffective assisted ventilation, worsening health conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Non-Invasive Ventilation, revised on 06/2023, showed residents receiving CPAP therapy would have the services provided as directed by the physician's order and the order would include the pressure and duration of use, amount of supplemental oxygen used, if applicable, and mask size and mode of delivery. The policy also indicated the resident would be monitored for potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consents for 2 of 5 sampled residents (Residents 33 and 53) reviewed for psychoactive medications. This failure placed residents and/or legal representatives at risk of not being fully informed to make decisions about their medications prior to administration. Findings Included . <Resident 33> Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5 day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living(ADLs). A review of Resident 33's Medication Administration Record (MAR) for January 2024 showed the resident started the medication, Escitalopram Oxalate, an antidepressant, in the morning for depression and anxiety on 01/17/2024. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to timely initiate and thoroughly investigate allegations of abuse, neglect, and/or misappropriation for 3 of 5 residents (Residents 23, 21 & 27) reviewed for abuse and neglect. The failure to immediately investigate an allegation of staff to resident abuse, identify the alleged perpetrator (AP), and implement interventions to ensure the alleged victims (AV) and other residents' safety, placed residents at risk for continued abuse/neglect, psychosocial harm, and decreased quality of life. Findings included . Review of the facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, dated 08/2022, showed when allegations are made that met the definition of abuse, neglect, exploitation, mistreatment or misappropriation the center would: a) Thoroughly investigate all alleged violations and retain documents showing that all alleged violations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the care plan for 2 of 5 residents (Resident 17 and 18) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Resident 17> Resident 17 was admitted to the facility on [DATE] with multiple diagnoses. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/17/2024, documented the resident was severely cognitively impaired. According to a Level 1 PASRR, dated 09/20/2023, Resident 17 had a Serious Mental Illness (SMI) of anxiety disorder (mental health condition), dementia (characterized symptoms affecting memory and social abilities) and mood disorders (characterized by…

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

Based on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 1 of 1 medication room (East Medication) and 1 of 2 medication carts (East medication carts) observed. These failures placed residents at risk to receive incorrect and/or expired medications. Findings included . <East Medication Room> Observation of the East Medication room on 07/26/2024 at 10:35 AM, with Staff C, Unit Manager (UM), revealed the following expired, opened and undated and/or improperly stored medication: 1) Resident 117 - a Novolin 70/30 insulin pen, was opened and undated. The manufacturer guidelines showed the insulin pen should be discarded 28 days after opening. On 07/26/2024 at 10:39 AM, Staff C, UM, said because Resident 117's Novolin 70/30 flex pen was opened and undated and it needed to be discarded. 2) A Refrigerator Temperature Log located on the counter next to the medication refrigerator, directed staff to record the medication refrigerators temperature twice daily to ensure it is maintained between 36…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve foods that were appetizing, palatable, and served at the proper temperature for 5 of 7 (Residents 23, 18, 39, 116 and 61) sampled residents reviewed for dining. The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life. Findings included . <Resident Council Meeting> On 07/25/2024 at 10:30 AM, during a Resident Council Meeting , residents expressed the following food quality concerns: 1) No hot items on the bistro menu 2) Hot food is cold and cold food is melted or warm. Example: ice cream is served melted 3) Failure to follow the menu, menu says one thing and that is not what is delivered on tray 4) Poor presentation - unable to determine what some foods are supposed to be, don't go the extra mile 5) Food is frequently unpalatable, the quiche was horrible last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refrigerator temperatures were maintained within acceptable ranges for 3 of 6 (East Nurse, [NAME] Nurse and Prep)refrigerators reviewed for food service. These failures placed residents at risk for food-borne illness and a diminished quality of life. Finding included . Review of the April 2024, May 2024, June 2024, and July 2024 temperature logs for the [NAME] Nurse refrigerator, East Nurse refrigerator and Prep refrigerator, showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: <West Nurse refrigerator> April 2024, AM, temperature readings: 1st 43F, 2nd 42F, 3rd 42F, 4th 42F, 6th 42F, 7th 42F, 8th 43F, 9th 42F, 10th 42F, 11th 42F, 13th 42F, 14th 43F, 15th 43F, 16th 42F, 17th 45F, 18th 42F, 19th 42F, 20th 45F, 21st 44F, 22nd 42F, 23rd 46F, 24th 49F, 25th 42F, 26th 43F, 28th 50F. April 2024, PM, temperature readings: 6th 42F, 7th 42F, 8th 42F, 9th 42F, 15th 42F, 17th 45F, 18th 45F, 19th 46F, 20th 46F, 24th 45F, 25th 45F, 27th 49F. May 2024, AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 1 of 5 residents (Resident 27) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property and for concerns related to sitting in soiled briefs. These failures placed the resident at risk for frustration, skin impairment, loss of dignity, and a diminished quality of life. Findings included . The facility's Grievance Policy, revised 01/27/2023, stated, If the grievance is an allegation of neglect, please take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The center strives to complete the review of grievances within 5 business days of receipt. <Lost property> Resident 27 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 06/18/2024, showed the resident was cognitively intact and needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report resident allegations of abuse to the state agency within 24 hours as required, for 2 of 5 residents (Residents 23 & 21) reviewed for abuse and neglect. These failures resulted in delayed investigations into alleged abuse, and placed residents at risk for abuse, psychosocial harm, and decreased quality of life. Findings included . Review of the facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, dated 08/2022, showed the facility would report all alleged incidents of abuse or incidents that resulted in serious bodily injury immediately, but not later than two hours after the allegation was made. Other allegations that did not include abuse or serious bodily injury, would be reported to the State Agency not later than 24 hours after an allegation is made. <Resident 23> Resident 23 admitted to the facility on [DATE]. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds. Findings included . Resident 32 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (MDS, an assessment tool) date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 was hospitalized from [DATE] until their return on 05/15/2024. The Electronic Health Record showed no documentation of a transfer notice or an Ombudsman notification. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said she did not have a copy of the transfer notice or Ombudsman notification. When asked if a transfer notice/Ombudsman notification should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide the resident and/or resident representative, a written notice of the facility's bed-hold policy at the time of transfer for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for emotional distress and a diminished quality of life. Findings included . Resident 32 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (an assessment tool), date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 was hospitalized from [DATE] until their return on 05/15/2024. The Electronic Health Record showed no documentation of a bed hold notice. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said she did not have a copy of the bed hold notice. When asked if a bed hold notice should have been completed, Staff B said yes. Reference WAC 388-97 -0120 (4) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 1 of 35 sampled residents (Residents 32) reviewed for MDS accuracy. The failure to accurately assess residents nutritional needs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 32 was admitted to the facility on [DATE]. The annual Minimal Data Set, (an assessment tool), dated 05/21/2024, documented Resident 32 was cognitively intact. The MDS, selection K, for Resident 32 read, Yes, on a prescribed weight loss regimen. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said Resident 32 was not on a prescribed weight-loss regimen. Staff B said she would have to check with the MDS Coordinator to know why Resident 32 was checked as being on a weight-loss regimen. At 2:26 PM, Staff E, Registered Dietitian, said Resident 32 was not 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 observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 1 of 1 sampled resident (Resident 32) reviewed for dialysis. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs. Findings included . The undated Dialysis Management (Hemodialysis) policy including the following directions: 1. Review the Dialysis Center Communication for pertinent information from the Dialysis Clinic and transcribe the information into section II.B of the Dialysis Center Communication Records UDA (User Defined Assessment) in the EMR (Electronic Medical Record) 2. If original is not returned with resident, contact Dialysis Center 3. Retain the original document in the hard chart behind the assessment tab 4. Check vital signs upon return post-dialysis and per physician's orders The Service Agreement for Northwest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to assess and maintain safety of quarter bed rails for 1 of 4 sampled residents (Resident 3) reviewed for accidents. This failure placed the resident at risk of injury and a diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 02/10/2024, documented the resident was cognitively intact and required supervision assistance with Activities of Daily Living (ADL's). On 07/22/2024 at 11:14 AM, Resident 3 had a quarter rail attached to the right side of the bed. The rail was leaning away from the bed, and when tested, moved forwards and backwards and side to side. Resident 3 stated, It's been like that for a long time. I just pulled the commode against it so it doesn't move when I get up. On 07/23/2024 at 3:12 PM, Staff H, Registered Nurse, said quarter rails should not move once attached so would not present a hazard. Staff H said if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to monitor behaviors for 1 of 5 sampled residents (Resident 33) reviewed for Unnecessary Medications. This failure placed residents at risk of experiencing behaviors without appropriate interventions to attain and/or maintain their highest practicable physical, mental and psychosocial well-being and a decreased quality of life. Findings Included . Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5-day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living (ADLs). A review of Resident 33's Medication Administration Record (MAR) for January 2024 showed the resident started the medication, Escitalopram Oxalate, in the morning for depression and anxiety on 01/17/2024.…

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 observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 3 sampled residents (Resident 6), reviewed for dental services. This failure placed the resident at risk for unmet dental needs, nutritional compromise, and a diminished quality of life. Findings included . Resident 6 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 05/29/2024, documented the resident was cognitively intact and needed extensive assist for Activities of Daily Living (ADL's). On 07/22/2024 at 11:46 AM, Resident 6 stated, I have been waiting for some bottom dentures. He said his lack of lower dentures affected his ability to eat and to enjoy his food. The facility Dental Policy, revised 12/30/2022, stated, the social services department will work to assist/and or coordinate services such as routine dental services. The procedure section stated, identify those residents who need routine services that include fitting dentures. Dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide proper infection prevention techniques for 1 of 3 sampled residents (Resident 35) reviewed for pressure ulcer/injury. This failure put residents at risk for infection and a diminished quality of life. Findings included . On 07/23/2024 at 12:39 PM, Staff C, Registered Nurse, Unit Manager, and Staff G, Certified Nursing Assistant, Medical Records, began wound care for Resident 35. Staff C retrieved scissors from her pocket and began to cut Alginate (a wound care product) with the scissors. At 1:02 PM, Staff C said that when she pulled her scissors out of her pocket, they were considered dirty, and the scissors should have been cleaned before proceeding to use them during wound care. On 07/24/2024 at 9:51 AM, Staff B, Director of Nursing Services, said it was not acceptable for equipment from staff pockets to be used for wound care. Reference WAC 388-97-1320 (2)(a) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 1 of 3 residents (1) reviewed for dignity and respect, when staff failed to provide toileting assistance when requested by the resident, prior to their physical therapy session. This failure placed residents at risk for embarrassment, anxiety, and diminished self-worth. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/18/2024, identified Resident 1 was admitted for orthopedic after care, was cognitively intact, and was dependent on staff for toileting transfers and toileting hygiene. Resident 1's Activity of Daily Living (ADL) self-care deficit care plan, initiated on 06/12/2024, included interventions directing staff to use a mechanical (Hoyer) lift for transfers. Resident 1's bowel elimination care plan, initiated on 06/21/2024, included interventions to assist the resident with toileting each time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely and thoroughly investigate an allegation of neglect for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for unidentified/continued abuse/neglect, not identifying corrective actions to prevent further neglect, and a diminished quality of life. Findings included . The facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Origin, and Misappropriation of Resident Property, dated 08/2022, showed staff were to thoroughly investigate all allegations and to retain documentation of a thorough investigation. The facility defined neglect as the indifference or disregard for resident care, comfort or safety that could result in physical harm, pain, mental anguish, or emotional distress. The investigation should include suspension of the alleged staff member(s), initiating an incident report in the identified resident's electronic health record, resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents 1,2,3,4) reviewed for quality of care when staff failed to assess, monitor and/or document resident responses to interventions on a daily basis, for newly admitted residents receiving skilled services. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The facility policy titled, Alert Charting, revised 05/2023, showed staff were to document according to Medicare charting guidelines while the resident was covered by Medicare or managed care. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 5/31/2024, documented Resident 1 was cognitively intact and admitted for orthopedic care. Review of Resident 1's Electronic Health Record (EHR) from 05/25/2024 to 06/10/2024 showed 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 interview and record review, the facility failed to ensure care plan conferences were held with the resident and/or resident representative for 1 of 4 sampled residents (Resident 4) reviewed for participation in care planning. This failure placed residents and/or resident representatives at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life. Findings included . The facility policy titled, Care Conferences, revised 05/2023, showed the facility would hold a care conference upon admission, quarterly, with significant changes, and as requested by the resident/family, or other team members. The facility would notify the resident and resident representative of the scheduled care conference and document under care conference progress notes. After completion, the care conference was to be summarized in a care conference progress note. Resident 4 was admitted to the facility on [DATE]. The admission minimum data set (MDS), an assessment tool,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 4 sampled residents (Resident 4) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life. Findings included . The facility policy titled, Notification of Change in Condition, revised 05/2024, showed that clinicians would immediately inform the resident representative when there was a significant change in the resident's physical, mental or psychosocial status. Staff were to notify the provider and resident representative and document in the progress note. Resident 4 was admitted to the facility on [DATE]. The admission minimum data set (MDS), an assessment tool, dated 5/30/2024, documented Resident 4 was cognitively intact and medically complex. A daily skilled note, dated 06/06/2024 at 10:35 AM, documented Resident 4 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents who required ileostomy (surgically created opening in the bowel for the discharge of body wastes into a collection bag) care received services consistent with professional standards for 1 of 4 residents (Resident 1) reviewed for quality of care. The failure to obtain orders for frequency of ostomy care, which supplies to use and lack of prompt attention to resident request for ostomy care placed residents at risk for skin breakdown and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 03/21/2024, documented Resident 1 was cognitively intact and had an ostomy. Review of the care plan, initiated 03/19/2024, documented Resident 1 had an ileostomy, and the goal was for the resident to verbalize any leaking or loosening of the device. Staff interventions included to notify the nurse if the appliance was leaking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) were provided with catheter care and management in a manner that minimized the risk for complications and catheter related urinary tract infections for 2 of 2 residents (Residents 4 and 5) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections, other potential health complications, and decreased quality of life. Findings included . The facility policy titled, Indwelling Catheters, revised 07/2023, documented a catheter care plan would be initiated for residents admitted with an indwelling catheter in place and residents would receive catheter care every shift. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 03/10/2024, documented Resident 4 was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident 3) reviewed for quality of care when staff failed to assess, monitor and/or document respiratory assessments and resident response to intervention. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The policy titled, Alert Charting, revised on 05/2023, showed residents were to be placed on alert for a minimum of 72 hours for the following: resident care issues, changes in condition, medication changes, falls, and psychosocial harm. The policy showed documentation should include vital signs, physical assessment, resident's response and symptoms. Resident 3 was admitted to the facility on [DATE] with diagnosis of a stroke, obstructive sleep apnea (when breathing is interrupted during sleep), anxiety and developmental delay. The Quarterly Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were not given as ordered for 1 of 4 sampled residents (Resident 2) reviewed for quality of care. The facility's failure had the potential to cause adverse side effects, declining mental and physical health, and decreased quality of life. Findings included . Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact, displayed verbal behaviors that significantly interfered with resident care and put others at risk for injury, was intrusive to others and significantly disrupted the living environment. Resident 2 was independent for all activities of daily living and used no assistive devices. The MDS also documented the resident was medically complex with diagnoses including alcohol dependence, major depressive disorder, anxiety, and auditory hallucinations and was receiving antipsychotic 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 provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident 2) reviewed for behavioral health services. The facility's failure to identify, communicate, and attempt to determine the reasons behind resident's nonadherence to recommendations precluded them from developing and implementing resident specific interventions to mitigate causative factors and increase acceptance of care. This failure placed residents at risk of having unmet social service needs and a diminished quality of life. Findings included . Review of facility policy titled, Management of Psychosocial Issues, revised 06/2023, documented the facility strived to assist residents in the management of psychosocial issues. A care plan would be developed, and effectiveness of interventions would be evaluated. The resident would be included in the development of the care plan, assessed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 3 sampled residents (1) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke. The Minimum Data Set (MDS), dated [DATE], documented Resident 1 had severe cognitive impairment and was dependent on staff for activities of daily living. The care plan for Resident 1, dated 10/16/2023, documented Resident 1's family would be informed of any new areas of skin breakdown. Progress notes for Resident 1, dated 10/10/2023, documented Resident 1 had an an episode of vomiting during therapy, the resident had appeared lethargic and a anti-nausea medication was ordered. The record did not contain documentation of notification of POA. The Wound Clinic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient staffing was available to provide necessary care, services, and supervision for 9 of 30 days review for sufficient staffing. This failure place resident at risk for unmet care needs and a diminished quality of life. Findings included . The PBJ (payroll-based journal) Staffing Data Report for fiscal year Quarter 2 2023 (January 1 - March 31) indicated the facility had excessively low weekend staffing. The facility's staff posting showed the following: On 07/22/2023, Noc shift (10:00 PM to 6:00 AM) had 2 LPN (Licensed Practical Nurse) and 2 NA (nursing assistant) for 71 residents. On 07/23/2023, Noc shift had 1 RN (registered nurse), 1 LPN and 2 NAs for 71 residents. On 08/08/2023, Evening shift (7:00 PM to 10:00 PM) had 1 RN, 1 LPN and 4 NAs for 79 residents. The Noc shift had 1 RN, 1 LPN and 2 NAs for 79 residents. On 08/09/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 79 residents. The Noc shift had 1 RN, 1 LPN and 3 NAs for 79 residents. On 08/15/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 80…

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

Based on interview and record review, the facility failed to ensure a comprehensive antibiotic stewardship program was in place for the facility. This failure placed all facility residents at risk for over-use and miss-use of antibiotic. Findings included . On 08/21/2023, during the entrance conference, the antibiotic stewardship program documentation was requested. On 08/22/2023, the antibiotic stewardship program documentation was requested. On 08/23/2023 at 11:15 AM, Staff A, Administrator and Registered Nurse, said she did not have a program, only pieces of one. Staff A said she would have one ready for next year. (Documentation of a antibiotic stewardship program was not provided the survey team.) No associated WAC reference .

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 transfer to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman describing the reason for transfer for 3 of 3 sampled residents (126, 9 & 20) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 126 was admitted to the facility on [DATE]. The discharge return anticipated Minimum Data Set, an assessment tool, dated 08/09/2023, documented the resident's short-term and long-term memory was OK. Resident 126's Electronic Medical Record (EMR) documented an emergent transfer to an acute-care hospital on [DATE]. Resident 126 returned to the facility on [DATE]. The EMR did not show documentation of a written notice of transfer for Resident 126. On 08/23/2023 at 10:23 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 3 of 3 sampled residents (9, 20 & 126) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/30/2023, documented Resident 9 was cognitively intact. Resident 9's Electronic Medical Record (EMR) documented a transfer to the hospital on [DATE] with a readmission on [DATE]. The EMR did not show documentation of a bed-hold notice for the transfer. 2) Resident 20 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 20 was cognitively intact. Resident 20's EMR documented Resident 20 transferred to an acute care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure staff with a medication endorsement were working within their scope of licensure for 4 of 4 Nurse Technicians (Staff L, Q, R & S) and 1 of 1 Certified Nursing Assistant (CNA) (Staff K), failed to ensure medications were passed according to professional standards for 1 of 1 Registered Nurse (Staff B), and failed to ensure provider medication orders were followed for 1 of 5 sampled residents (51) reviewed for services provided meet professional standards regarding medication administration. This failure placed residents at risk for inaccurate assessments, medication errors, and a diminished quality of care. Findings included . <CNA Medication Assistant Scope of Licensure> The Washington State Administrative Code (WAC), state law, chapter 246-841-589 for Certified Nursing Assistant Medication Assistant (C-MA), shows a medication assistant may not perform the following tasks: assessment of a resident need for, or response to medication;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform ongoing neurological assessments (neuro checks - assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) for residents after an unwitnessed fall for 4 of 4 sampled residents (19, 127, 37 & 1) reviewed for quality of care related to accident hazards. This failure placed residents at risk of having unidentified injuries, a delay in treatment, at risk for worsening conditions, health complications and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/17/2023, showed the resident was severely cognitively impaired. The Fall Scene Investigation Report, dated 05/20/2023, indicated CNA [certified nursing assistant] alerted this writer that resident was found lying face down on the floor beside her bed . The Neurological Assessment Flowsheet was initiated and showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure residents dependent on staff for eating assistance were offered dining assistance in a timely manner for 6 of 10 sampled residents (1, 8, 30, 33, 42 & 127) reviewed for resident rights related to dining services. This failure placed residents at risk for excessive wait times, cold food and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/05/2023, showed Resident 1 was totally dependent on staff for eating assistance. On 08/22/2023 at 5:19 PM, Resident 1 was observed sitting at a table waiting for assistance to eat his meal. The meal tray was on the table in front of Resident 1. At 5:27 PM, Resident 1 was still waiting for assistance with his meal tray in front of him. At 5:34 PM, Staff I, Certified Nursing Assistant (CNA)/Medical Records, was observed starting to assist Resident 1 with his meal. The observed wait time was 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 1 of 5 sampled residents (Resident 58) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. A physician's order, dated 05/18/2023, documented Resident 58 was prescribed Citalopram (an antidepressant). Resident 58's Electronic Health Record (EHR) did not show documentation of a consent from the resident or the resident's representative for the administration of citalopram. On 08/24/2023 at 11:09 AM, Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a newly admitted resident was informed of their rights and responsibilities as a resident in the facility for 1 of 1 sampled residents (126) reviewed for notice of rights and rules. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included . Resident 126 was admitted to the facility on [DATE]. The Discharge Return Anticipated Minimum Data Set, an assessment tool, dated 08/09/2023, documented the resident's short-term and long-term memory was OK. The complaint intake, dated 07/24/2023 at 4:58 PM, showed Resident 126 was concerned she did not receive an admission packet when she was admitted to the facility. Resident 126's Electronic Medical Record (EMR) did not show documentation of either a verbal or written discussion of resident rights and responsibilities. A signed acknowledgements of rights and responsibilities was not located in 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, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic health records (EHR) for 1 of 1 sampled residents (Resident 37) reviewed for privacy and confidentiality. This failure placed residents at risk of having their medical information not kept confidential and a diminished quality of life. Findings included . Resident 37 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 05/25/2023, showed Resident 51 was cognitively intact. On 08/24/2023 at 11:16 AM to 11:24 AM, a laptop on top of a medication cart was left open, unsupervised, unlocked, and the screen revealed private resident information to include Resident 37's name, date of birth , room number, diagnoses, and medications. At 1:06 PM, Staff O, Resident Care Manager and Licensed Practical Nurse, said resident privacy on a laptop should be maintained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and provide a safe, sanitary, and homelike environment for 1 of 3 sampled residents (Resident 4) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 07/01/2023, documented Resident 4 was cognitively intact. On 08/21/2023 at 3:31 PM, Resident 4's room was observed to have missing sections of paint and sheet rock, 8 inches long at the head of the bed, a one-inch section of tile missing next to the heating vent on the floor, and a 6-inch hole (missing paint and sheet rock) in the wall with 6 inches of mesh metal netting sticking out of the wall. Resident 4 said the room had been in this condition for a long time. On 08/24/2023 at 10:18 AM, Staff E, Maintenance Director, said he did not complete a daily check of residents' rooms, because he 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 ensure residents were free from physical restraints for 1 of 1 sampled residents (127) reviewed for physical restraints. This failure placed residents at risk for injury and a decrease quality of life. Findings included . The facility's policy entitled, Safety Device-Least Restrictive, dated 09/2022, documented, The center will us[sic} a safety device as indicated, to attain or maintain a resident's highest practicable well-being . 5) Complete a Safety Device Data Collection, Assessment, and Information evaluation: a. For each safety device when initiated or, b. For each safety device when State regulation requires a signature for consent. Resident 127 was admitted to the facility on [DATE]. Resident 127 was a new admission and a Minimum Data Set, an assessment tool, had not been completed, and his baseline cognitive status was described as confused. On 08/21/2023 at 2:36 PM, Resident 127's left side of the bed was observed to be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours and failed to log the incident in the facility's reporting log for 1 of 2 sampled residents (Resident 58) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. On 08/21/2023 at 11:27 AM, Resident 58 said about a month ago an employee of the facility, Staff F, Registered Nurse (RN), attempted to choke me. Resident 58 said he was sitting in his wheelchair while Staff F was providing care to his roommate. Resident 58 said Staff F walked over to him and put his hand around his neck. Resident 58 was observed demonstrating using his own hand to the front of his neck and stated, Went like this. Resident 58 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan addressed weight loss for 1 of 1 sampled residents (Resident 20) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 20 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/08/2023, documented Resident 20 was cognitively intact. Resident 20's Comprehensive Care Plan, dated 06/02/2023, documented prevent unplanned significant wt. (weight) changes, promote healing through review dates. Monitor weight as indicated. A Physician's order, dated 06/02/2023, ordered Resident 20 to be weighed every Friday on evening shift from 06/02/2023 until 06/30/2023. The Electronic Medical Record (EMR) documented Resident 20 weighed 348 pounds on 06/05/2023. The EMR documented Resident 20 weighed 286 pounds on 06/29/2023. No weights were obtained for the following days:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weekly weights per provider order and identify a weight loss for 1 of 1 sampled resident (Resident 20) reviewed for nutrition. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life. Findings included . Resident 20 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury. The admission Minimum Data Set (MDS), an assessment tool, dated 06/08/2023, documented Resident 20 was cognitively intact and received diuretics (medication used to reduce the amount of excess fluid in the body) for the seven days of the look back period. The 5-Day MDS, dated [DATE], showed the resident received diuretics six of the seven days of the look back period. A Physician's order, dated 06/02/2023, ordered Resident 20 be weighed ever Friday, evening shift, from 06/02/2023 until 06/30/2023. Resident 20's Care Plan, dated 06/05/2023, addressed therapeutic nutritional risk related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, obtain informed consent and care plan for the use of bed rails for 1 of 1 sampled residents (Resident 1) reviewed for restraints. This failure placed residents at risk of entrapment, injury, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance of 2 staff for bed mobility. On 08/21/2023 at 1:10 PM, on 08/22/2023 at 9:46 AM and 1:46 PM, and on 08/23/2023 at 9:22 AM; Resident 1 was observed in bed with the right side of his bed against the wall and the left side rail of the bed in the up position. Record review of Resident 1's Electronic Medical Record (EMR), reviewed 08/22/2023 at 08:41 PM, showed no care planned interventions, no risk assessment, and no consent for the use of the bed rails. The EMR 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 interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and target behaviors for 1 of 5 sampled residents (Resident 58) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. A Physician's order, dated 05/18/2023, documented Resident 58 was prescribed Citalopram (an antidepressant). Resident 58's Depression Care Plan, revised 05/30/2023, documented interventions on TARGET BEHAVIOR: Depression/Anxiety - Intervention 1: Engage in conversation, allow him time to talk. Intervention 2: Invite to participate in activities 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.