Life Care Center Of Port Orchard

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 1 of 2 sampled residents (Residents 2) reviewed for respiratory care. Failure to have a provider's order for oxygen placed residents at risk for discomfort, unmet needs and a diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (gradual loss of kidney function), hyperlipidemia (high cholesterol or fats in the blood) and diabetes (too much sugar in the blood). Resident 2 was able to make needs known. Observations on 04/06/206 at 9:36 AM, 04/07/2026 at 10:48 AM and 04/08/2026 at 8:40 AM showed an oxygen concentrator on set to 2 liters per minute near Resident 2's bed. Resident 2 was not observed wearing a nasal cannula during the observations.Review of Resident 2's Care Plan initiated 03/19/2026, showed an…

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

Based on interview and record review, the facility failed to complete Certified Nursing Assistant's (CNA) annual performance reviews as required for 3 of 5 sampled nursing assistants (Staff H, I, & J) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life. Findings included .Staff H, CNA, was hired on 04/09/2025. Record reviewed on 04/09/2026, showed no annual performance review had been completed. Staff I, CNA, was hired on 04/25/2024. Record reviewed on 04/09/2026, showed an annual performance review was completed on 09/17/2025 (5 months past annual review date). Staff J, CNA was hired on 06/20/2024. Record reviewed on 04/09/2026, showed an annual performance review was completed on 09/17/2025 (3 months past annual review date). On 04/09/2026 at 12:38 PM, Staff B, Director of Nursing Services, said annual performance reviews needed to be completed and pointed to a binder (indicating CNA annual performance reviews that needed to be completed). When shown…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were dated when opened for 2 of 3 medication carts (A hall cart & North hall cart) reviewed for medication storage. Additionally, the facility failed to ensure medications were secured for 1 of 1 resident (Resident 28) observed with medications at bedside. These failures placed residents at risk for medication discrepancies and an impaired quality of life.Findings included. <North Hall Medication Cart>An audit of the North Hall medication cart on 04/10/2026 at 9:26 AM showed the following:a) Resident 104's latanoprost eye drops were opened and undated. Review of the package insert showed the medication should be discarded six weeks after opening.b) Resident 104's fluticasone propionate was opened and undated. Review of the package insert showed the medication should be discarded 90 days after opening.c) Resident 103's latanoprost eye drops were opened and undated. Review of the package insert showed the medication should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 dental services were provided for 1 of 3 Medicaid residents (Resident 1) reviewed for dental services. The facility's failure to follow up on dental referrals and to assist with appointment scheduling and transportation arrangements that resulted in Resident 1 not receiving the dental services they were assessed to require (tooth extraction(s) and new upper and lower dentures). These failures placed residents at risk for unmet dental needs including difficulty chewing, oral pain, decreased self-image and diminished quality of life.Findings included .Resident 1 was admitted to the facility on [DATE]. Review of the 10/06/2025 admission Minimum Data Set, an assessment tool, showed the resident was cognitively intact and had mouth or facial pain, discomfort or difficulty with chewing. On 04/06/2026 at 2:10 PM, Resident 1 reported they had chipped and cracked teeth on the bottom that needed work and stated, I pulled one out last week. Resident 1 went…

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

Based on observation, interview and record review the facility failed to ensure food preferences related to portion sizes were honored for 7 of 19 sampled residents (Residents 87, 77, 63, 61, 57, 37 and 4) reviewed for resident rights. This failure placed the residents at risk for dissatisfaction and diminished quality of life.Findings included.Review of the Diet spreadsheet showed the 04/10/2026 breakfast menu consisted of cheese scrambled eggs, bacon, buttered toast and choice of cereal. The entree was to be served with a #10 scoop for residents who received a regular diet.Observation on 04/10/2026 at 7:30 AM, showed Resident 61 preferred small portions and a small serving of starch. Staff T, Cook, used the size #12 scoop to plate a regular portion size and regular portion size of starch.Observation on 04/10/2026 at 7:32 AM, showed Resident 77 preferred small portions. Staff T used the size #12 scoop to plate a regular portion sizeObservation on 04/10/2026 at 7:41 AM, showed Resident 57 preferred small portions. Staff T used the size #12 scoop to plate a regular portion…

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

Based on interview and record review, the facility failed to implement a system to ensure Certified Nursing Assistants (CNAs) received the required training for continued competency of no less than 12 hours per year for 2 of 5 sampled staff (Staff I & K) reviewed for training. The failure to implement a system to provide mandatory training placed residents at risk for abuse, neglect, emotional distress, physical injury and a diminished quality of life. Findings included .Staff I, CNA, was hired on 04/25/2024. Record reviewed on 04/09/2026, documented Staff I had 3.75 hours of training annually (from 04/25/2024-04/25/2025). Staff K, CNA, was hired on 07/15/2024. Record reviewed on 04/09/2026, documented Staff K had 11.25 hours of training annually (from 07/15/2024-07/15/2025). On 04/09/2026 at 12:38 PM, when shown the staff that did not meet the required annual 12-hour training minimum, Staff B, Director of Nursing Services, said the training hours should have been completed. Reference WAC 388-97-1680 (2)(a-c)

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 and monitor for adequate hydration, recognize and intervene when decline occurred, and failed to notify physician and family of abnormal laboratory results. This failure placed residents at risk for dehydration, hospitalization, and a diminished quality of life. Findings included . Review of the facility policy, Hydration and Nutrition, revised 09/10/2024, showed that each resident would receive sufficient fluids to maintain acceptable parameters of nutritional and hydration status. Review of the facility policy, Laboratory Services, revised 09/23/2024, showed that laboratory services would meet the needs of residents and results would be promptly reported to the provider to address potential concerns, diagnose, and treat. <Resident 1> Resident 1 was admitted to the facility on [DATE] 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 accurately assess Minimum Data Set (MDS) assessments for 2 of 24 sampled residents (Residents 12 & 39) reviewed. Failure to ensure accurate assessments regarding Preadmission Screening and Resident Review (PASRR) and oxygen requirements, placed residents at risk for unidentified and/or unmet care needs. Findings included . 1) Resident 12 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE] and 03/10/2024, documented no that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. A review of the Level II PASRR Initial Psychiatric Evaluation Summary and Notice of Determination, dated 12/28/2023, said Resident 12 was determined to require a Level II for depressive disorder. On 02/26/2025 at 1:54 PM, Staff H, Registered Nurse (RN) and MDS Coordinator, said Resident 12 was assessed to need a Level II PASRR and received specialized services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 2 of 6 residents (Residents 131 and 331) reviewed for new admission. This failure placed residents at risk for unidentified and/or unmet care needs, and other negative health outcomes. Findings included . 1) Resident 131 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 02/22/2025, showed the resident's diagnoses included a venous stasis (open sore that occurs on the lower legs due to impaired blood flow caused by venous insufficiency), cellulitis (a bacterial infection affecting the deeper layers of the skin), and edema (swelling caused by too much fluid trapped in the body's tissue). Resident 131 also received diuretic and anticoagulant medication during the assessment period. Review of the 02/19/2025 hospital discharge summary 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 develop and implement individualized comprehensive care plans for 3 of 19 residents (Residents 1, 44, & 59) whose care plans were reviewed. This failure placed residents at risk for unmet care needs and other potential negative outcomes. Findings included . 1) Resident 1 admitted to the facility on [DATE]. Review of the 02/10/2025 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, and identified the following activities as Very Important: keeping up with the news, taking part in group activities, doing their favorite activity and going outside for fresh air when the weather was nice. They identified participation in religious activities as Somewhat Important. Review of the Activity Care Area Assessment (CAA), dated 02/20/2025, showed staff documented they would proceed to care plan the resident's activity preferences. An at risk for social isolation/activity care plan, initiated 02/20/2025, documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 19 sample residents (Residents 1, 21, 331 and 59) reviewed. The facility's failure to obtain, follow and clarify physicians' orders when indicated, and to only sign for tasks they completed or validated were complete, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes. Findings included . 1) Resident 21 had a 10/10/2024 order for Lisinopril (blood pressure medication) daily, hold for a systolic blood pressure (SBP) less than 100. Review of the January 2025 Medication Administration Record (MAR) showed on 01/26/2025 at 8:00 AM, Resident 21's SBP was 91 and the nurse administered the medication instead of holding it as ordered On 02/28/2025 at 9:53 AM, Staff C, Resident Care Manager (RCM), said the nurse administered Resident 21's lisinopril outside of the physician ordered parameters when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement or document on the bowel protocol (how the facility intervenes to a resident with no bowel movement over a certain amount of time) for 2 of 3 sampled residents (Residents 59 & 1) reviewed for constipation. This failure placed residents at risk for unidentified care needs, discomfort, lack of monitoring, and a diminished quality of life. Findings included . Review of the facility policy titled, LCC [Life Care Center] Port Orchard Bowel Protocol, undated, showed the following order of medications to be given: 1. Milk of Magnesia (helps stimulate a bowel movement) to be given after 72 hours/on day four of no bowel movement 2. Bisacodyl (helps stimulate a bowel movement) to be given after no bowel movement on day five 3. Fleet Enema (helps stimulate a bowel movement) to be given after no bowel movement on day six 1) Resident 59 was admitted to the facility on [DATE] with a diagnosis of constipation. The admission Minimum Data Set 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 observation, interview and record review, the facility failed to appropriately monitor pressure ulcers in a manner consistent with professional standards of practice for 2 of 5 sampled residents (Residents 59 and 44) reviewed for pressure ulcers. This failure placed residents at risk of worsening conditions, unnecessary treatment, pain, and a diminished quality of life. Findings included . Review of the facility's policy titled, Documentation & Assessment of Wounds, dated with a review date of 07/09/2024, showed the Overall Wound Impression is documented based on the clinical impression of the overall wound bed, peri wound, and wound healing outcome as expected wound decline/worsening may not be acknowledged by just and increase in wound measurement [ .]. 1) Resident 59 was admitted to the facility on [DATE] and had diagnoses of chronic venous insufficiency (a disease that damages leg veins, can cause blood to pool in legs), malnutrition, and unstageable pressure ulcer of the left heel. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 21) reviewed for insulin administration were free of significant medication errors. The failure to administer insulin in accordance with physician orders, and to hold insulin when blood glucose (BG) levels were below the ordered parameters for administration, placed residents at risk for hypoglycemia, seizures, coma and death. Findings included . Resident 21 admitted to the facility on [DATE]. Review of 11/21/2025 Annual Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of diabetes (a condition where the body cannot use insulin correctly and glucose builds up in the blood), and required insulin injections on seven of seven days during the assessment period. Review of the electronic health record showed Resident 21 had the following insulin orders: a) A 02/08/2025 order for Aspart insulin (fast acting), with meals. Hold for a BG less than 150. b) A 11/14/2024 order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 enforce Enhanced Barrier Precautions (EBP) for 1 of 8 sampled residents (Resident 331) reviewed for infection control practices, to prevent residents' urinary catheter/foley (tube that goes into the bladder to drain urine) tubing or bags from touching the ground for 2 of 2 residents (Resident 331 &39) reviewed for urinary catheters, to ensure contact precautions were understood and followed outside of resident rooms for 2 of 2 sampled residents (Resident 39 & 131) reviewed, and to ensure staff complied with current infection control guidelines and standards of practice regarding proper hand hygiene/gloving practices for 1 of 1 sampled resident (Resident 22) reviewed for wound care. This failure placed residents at risk of infection, the spread of multidrug resistant organisms (MDROs), worsening of wounds, and a diminished quality of life. Findings included . <Enhanced Barrier Precautions> Review of the facility policy, titled, Enhanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 a physician ordered x-ray, in a timely manner, for 1 of 3 residents (Resident 1) reviewed for radiology and other diagnostic services. This failure placed residents at risk for a delay in assessment and treatment of declining respiratory status. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnosis including emphysema (a lung disease that causes breathlessness), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had moderate cognitive impairment, experienced shortness of breath (SOB) with exertion and lying flat, and required oxygen. Review of the physician's order, dated 03/20/2024, showed Resident 1 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 safe transfers for 1 of 3 residents (Resident 1) reviewed for accidents when the facility did not use the mechanical lift's manufacturer's recommended sling when transferring a resident, resulting in the resident sliding from the sling. This failure placed residents at risk for unsafe transfers, potential injury, and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/31/2023, documented the resident was cognitively intact, medically complex, and was dependent on staff for dressing, toileting, and transfers. On 01/18/2024, Resident 1's recorded weight was 228 pounds. The care plan focus for impaired ADL (activities of daily living) function, initiated on 05/11/2022, documented Resident 1 required total assistance of two staff and a mechanical lift with an XL (extra-large) sling. A facility incident report, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents did not receive unnecessary medications for 3 of 5 sample Residents (25, 30, 62) reviewed for unnecessary medication use. The facility failure to attempt a Gradual Dose Reduction (GDR) of an antipsychotic medication or provide evidence a reduction had been attempted placed residents at risk for receiving an unneeded medication and potentially experiencing side effects related to the use of the medication. Findings included . 1) Resident 30 was admitted to the facility on [DATE] with diagnoses including dementia with agitation and major depressive disorder. The Minimum Data Set (MDS), an assessment tool, dated 09/17/2023, showed the resident required supervision from the staff for dressing and personal hygiene and was cognitively intact. A review of the December 2023 Medication Administration Record (MAR) showed Resident 30 received Seroquel (an anti-psychotic medication) 25 milligrams by mouth once per day at 8:00 PM for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 4 of 21 residents (Residents 12, 132, 25 and 13) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Review of Resident 12's annual Minimum Data Set (MDS, an assessment tool), dated 09/11/2023, showed the resident had a diagnosis of chronic lung disease, but did not require the use of supplemental oxygen. Review of Resident 12's electronic health record (EHR) showed the resident had a 10/19/2023 order for continuos oxygen (O2) at three to four liters per minute (3-4L/min) via nasal canula (NC). On 12/04/2023 at 2:51 PM, Resident 12 was observed lying in bed and receiving O2 at 4L/min via NC. Resident 12's oxygen therapy care plan (CP), revised 12/24/2021, showed staff were directed to provide O2 at 2L/min via NC as ordered, and when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 21 sampled residents (Residents 61, 64 and 132) reviewed. The failure to follow and/or clarify incomplete physician's orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) Resident 64 was admitted to the facility on [DATE] with diagnoses including fractures. Review of Resident 64's physician orders showed a 08/28/2023 order for oxycodone (pain medication) every four hours, as needed, for moderate to severe breakthrough pain. Hold the medication for sedation, a systolic blood pressure (SBP) less than 110 or a pulse (P) less than 60. Resident 64's September 2023 Medication Administration Record (MAR) showed facility nurses administered the resident their as needed oxycodone on multiple occasions. Review of Resident 64's electronic health record (EHR) 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 provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 8 residents (Residents 64 and 132) reviewed for bowel management and 1 of 4 residents (Resident 13) reviewed for non-pressure skin conditions. The failure to initiate bowel care in accordance with physician's orders and to implement ordered treatments for non-pressure skin conditions, placed residents at risk for pain/discomfort, delayed wound healing, and a diminished quality of life. Findings included . 1) Resident 65 admitted to the facility on [DATE]. On 12/05/2023 at 10:58 AM, Resident 64 said they had struggled with constipation their whole life and it continued to be an issue for them. Review of Resident 64's physician's orders showed the following as needed bowel care orders: a 08/25/2023 order for Milk of Magnesia (MOM), as needed, if resident goes 72 hours without a bowel movement (BM), administer MOM on day 4; a 08/25/2023 order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 13) reviewed for pressure ulcers received care and services in accordance with the physician's orders. The failure to implement a physician ordered treatment placed residents at risk for infection, unmet care needs and diminished quality of life. The findings included . Resident 13 was admitted to the facility on [DATE] with diagnoses including dementia. The significant change Minimum Data Set, an assessment tool, dated 11/06/2023, showed the resident was always incontinent of bowel and bladder, had a stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer) and moisture associated skin damage (MASD). Resident 13's skin assessments, dated 11/01/2023, showed Resident 13 had dry skin all over. Resident 13's hospice nurse visit note, dated 11/06/2023, showed the resident had a stage 2 pressure ulcer measuring 1 centimeter (cm) x (by) 1.5 cm x 0.1 cm. Resident 13's facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen services were provided in accordance with professional standards of practice for 1 of 1 resident (Residents 12) reviewed for respiratory care. The facility's failure to maintain oxygen concentrator filters (used to protect the resident from inhaling dust and particulate matter) in a clean functional condition, to ensure oxygen tubing was routinely changed, labeled/dated and ensure residents' humidifier bottles had enough fluid to maintain functionality, placed residents at risk for inhalation of contaminants, respiratory infections, bloody noses and other potential negative healthcare outcomes. Findings included . Review of the facility's Oxygen Administration/Safety/Storage/Maintenance policy, revised 08/02/2021, showed humidifier bottles were required for all residents who received oxygen (O2) at four liters per minute (4L/min.) or greater via a nasal cannula (NC). Humidifier bottles were to be replaced every seven days regardless of water level. Oxygen supplies (nasal cannula, mask tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible for 2 of 21 sampled residents (Residents 132 and 13) reviewed for medical records. The failure to ensure resident wound assessments were accurate, timely obtained from consulting wound care services, and filed and accessible in residents' medical records, prevented facility staff and providers from accessing complete and accurate health information on residents under their care. These failures placed residents at risk for delayed identification of changes in wound characteristics, medical decisions being made on incomplete or inaccurate information, unmet care needs and other adverse health outcomes. Findings included . 1) Resident 132 admitted to the facility on [DATE]. A hospital wound consult note, dated 11/18/2023, showed prior to hospitalization and subsequent admission to the facility, the resident was being followed by a wound clinic on an outpatient basis 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.