Washington Veteran Home-Retsil

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 1 of 3 residents (Residents 4) reviewed for limited range of motion. Facility nurses demonstrated a pattern of falsely documenting the application of bilateral wrist splints, that were not applied. This failure resulted in a resident losing trust in assigned nursing staff and placed residents at risk of contracture formation/progression, loss of independence and/or increased dependence on staff and a diminished quality of life. Findings included .Resident 4 Resident 4 was admitted to the facility on [DATE]. Record review showed a provider order, dated 09/17/2024, that directed staff to assist with the application of Resident 4's bilateral wrist splints every morning and to assist with the removal of the wrist splints at bedtime.On 05/04/2026 at 2:08 PM, 05/06/2026 at 10:48 AM and 05/07/2026 at 11:58 AM, Resident 4 was observed without wrist splints in place.On 05/07/2026…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely incontinent care for 1 of 2 residents (Resident 11) reviewed for activities of daily living (ADL) for dependent residents. This failure placed dependent residents at risk for skin breakdown, poor hygiene and diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 11 admitted to the facility on [DATE] with diagnoses that included overactive bladder, depression (mood disorder), chronic right heart failure and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 11 was dependent on staff for toileting hygiene.During an interview on 05/04/2026 at 12:02 PM, Resident 11 stated they were often left in a soiled (feces and urine) brief for long periods of time during mealtimes when they became a Hoyer transfer requiring two staff. Resident 11 stated they had developed sore areas that were painful. Resident 11 stated 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 provide bowel care in accordance with the facility's bowel protocol for 3 of 8 residents (Resident 3, 8 & 29) reviewed for bowel management. This failure placed residents at risk for nausea/vomiting, abdominal pain/discomfort, decreased appetite, and other negative health outcomes associated with untreated constipation.Findings included . Resident 3 Resident 3 was admitted to the facility on [DATE]. Review of the Quarterly minimum data set (MDS, an assessment tool), dated 02/11/2026, showed the resident was cognitively intact. On 05/05/2026 at 10:47 AM, Resident 3 said he had been struggling with constipation. Review of the April 2026 bowel record showed Resident 3 went from 04/15/2026 - 04/21/2026 (7 days), without a bowel movement (BM). Record review showed Resident 3 had the following as needed bowel care orders:a) Miralax as needed, for no BM for 48 hours, dated 02/25/2022.b) Milk of Magnesia once daily as needed for constipation, 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 1 of 3 residents (Residents 11) was consistently offered/received services to maintain or prevent declines in mobility when reviewed for range of motion (ROM). This failure placed the residents at risk of decreased motion, mobility and a diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 11 admitted to the facility on [DATE] with diagnoses that included overactive bladder, depression (mood disorder), chronic right heart failure and hemiplegia and hemiparesis affecting their right side (partial loss of strength and near complete loss of voluntary movement). Resident 11 was able to make their needs known.During an interview on 05/04/2026 at 12:14 PM, Resident 11 stated they recently requested to start participating in restorative or physical therapy due to declining mobility. Resident 11 stated in the past they had medical issues that interfered with their ability to participate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure non-pharmacological interventions (NPIs, non-medication interventions) were attempted prior to the administration of as needed (PRN) pain medications for 2 of 5 residents (Residents 2 & 121) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Resident 2 Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 05/01/2026, documented Resident 2 was severely cognitively impaired and was able to make needs known. A physician's order, dated 03/23/2021, documented, Pain Non-Pharmacological Codes: 1) Remove to calmer space 2) Ambulate resident 3) Refer to nurses note 4) Read material/coloring 5) Return to room [ROOM NUMBER]) Toileting 7) Provide food/snack 8) Give fluids 9) Change position 10) Adjust room temp 11) Back rub 12) 1 on 1 Conversation 13) Send to activities 14) Other were to be attempted prior 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 thoroughly assess resident risk for elopement and provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) for 1 of 4 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for inadequate supervision, elopement and potential of life-threatening situations. Findings included.Review of the facility policy titled, Missing Resident, dated 08/23/2024, showed the facility would identify residents at risk for elopement and they would be monitored to ensure their safety. Review of the facility policy titled, Wandering, Unsafe Resident, Revised August 2014, showed the facility would identify residents at risk for wandering/elopement, assess for correctable risk factors, and assess residents at risk for appropriateness of the use of a wander guard (specialized, wearable-based security solution to protect residents with cognitive deficits from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect/mistreatment for 1 of 6 residents (Resident 3) reviewed for allegations of abuse/neglect. Failure to thoroughly investigate the allegations of abuse/neglect placed the residents at risk for continued mistreatment, unmet needs, and diminished quality of life.Findings included .According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation is a systematic collection of review/evidence/information that describes and explains an event or a series of events to determine what occurred and make necessary changes to resident's plan of care and services to prevent reoccurrence. The investigation should include the who, what, when, where, why and how, of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) or attempting to exit the facility for 2 of 6 sampled residents (Resident 1 and 2) reviewed for accidents and failed to timely correct the wander guard system in place. These failures placed residents at risk of significant injury and a decreased quality of life.Review of the facility policy titled, Missing Resident/Elopement, dated 09/22/2023, showed that residents would be identified for risk of wandering and/or elopement and those at risk would be monitored and staff were to take necessary precautions to ensure resident safety. Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS) an assessment tool, dated 05/05/2025, showed Resident 1 had severe cognitive impairment, required the partial/ moderate assistance with the use of a manual wheelchair, and a wander/elopement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Sets (MDS, an assessment tool) for 5 of 35 sampled residents (Resident 41, 42, 108, 74 &75) reviewed. The failure to ensure complete and accurate assessments regarding appropriate diagnoses, communication, nutrition and mobility placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Review of the Resident Assessment Instrument Manual (RAI, a manual that directs staff on how to accurately assess and code the MDS), dated [DATE], showed staff should attempt to conduct a Brief Interview for Mental Status (BIMS, used to assess cognitive status in elderly patients) on all residents unless the resident was rarely/never understood; could not respond verbally, in writing, or by using another method; or an interpreter was needed but not available. Staff should not complete the Staff Assessment for Mental Status [SAMS] if the resident's interview should have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for 4 of 7 sampled residents (Resident 69, 129, 150 & 78) reviewed for PASRR. This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life. Findings included . 1) Resident 69 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry or fear that can interfere with daily life), and unspecified psychosis (a diagnosis used when someone experiences symptoms like hallucinations or delusions). The Annual Minimum Data Set (MDS), an assessment tool, dated 03/13/2025, documented Resident 69 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were administered Covid vaccinations in a timely manner, informed consent was obtained (review risk/benefits), and/or physicians orders were followed for 6 of 35 sampled residents (Residents 78, 75, 167, 204, 132 & 108). These failures placed residents at risk of contracting disease, not understanding services consented for, and medical complications. Findings included . 1) Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's vaccination consents showed consent was obtained on 08/19/2024 for the Covid vaccination. Review of Resident 78's immunization lists, showed the Covid vaccination was last administered on 01/18/2024. No immunization was found after consent on 08/19/2024. On 04/25/2025 at 8:25 AM, Staff Q, Infection Preventionist (IP), looked in the electronic health record (EHR) and said there was not documentation for Resident 78 that the risk/benefits for Covid vaccination was reviewed. Regarding 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 residents were screened on admission and/or during influenza season for influenza and/or pneumococcal vaccination and failed to obtain informed consent for vaccination for 5 of 5 residents (Residents 78, 75, 167, 204 & 132) reviewed for immunizations. This failure placed residents at risk of contracting disease, increased complications, not understanding services consented for, and a diminished quality of life. Findings included . 1) Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's vaccination consents showed consent was obtained on 08/19/2024 for the influenza vaccination. Review of Resident 78's immunization lists, showed the influenza vaccination was administered on 10/10/2024. On 04/25/2025 at 8:25 AM, Staff Q, Infection Preventionist (IP), looked in the electronic health record (EHR) and said there was not documentation the risk/benefits for influenza vaccination was reviewed. 2) Resident 75 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide care and services in a manner that promoted dignity for 1 of 1 sampled residents (Resident 184) reviewed for dining services and 1 of 3 sampled residents (Resident 74) reviewed for urinary catheter (thin tube to remove urine). The facility failed to honor resident rights related to privacy of personal mail and/or medical appointments for 2 of 4 residents (Resident 166 & 132) when reviewed for resident rights. These failures placed residents at risk for feelings of diminished self-worth, embarrassment and a diminished quality of life. Findings included . <Dignity During Dining Services> On 04/23/2025 at 12:38 PM, the E/G Unit Dining room started plating food for residents sitting in the dining area. At 1:04 PM, Resident 184 was brought to the dining room by a staff member and seated at their assigned table. Staff D, Certified Nursing Assistant (CNA), immediately told Staff E, Food Services Worker (FSW) and Staff F, FSW, Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 funds were transferred to the resident's representative or the resident's estate within 30 days of death or discharge, for 2 of 2 discharged residents (Resident 259 & 260) reviewed for trust accounts. This failure placed the residents and/or their representatives at risk for loss of funds and the interest accumulated. Findings included . 1) Review of Resident 259's Death in Facility Minimum Data Set (MDS, an assessment tool), dated 11/25/2024, showed the resident was discharged from the facility on 11/25/2024. Resident 259's trust account ledger, showed the resident had a trust balance of $83 on 11/25/2024. The check sent to the resident's representative/estate for $83, was dated 02/04/2025, 70 days after the resident discharged . On 04/28/2025 at 11:04 AM, Staff S, Fiscal Analyst 1, confirmed the facility failed to convey Resident 259's trust balance within 30 days as required. 2) Review of Resident 260's Death in Facility MDS, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 3 sampled residents (Residents 63) reviewed for grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included . Review of the electronic health record, showed Resident 63 admitted to the facility on [DATE] with a diagnosis that included insomnia (difficulty falling and or staying asleep). Resident 63 was able to make needs known. During an interview on 04/21/2025 at 10:21 AM, Resident 63 stated they were upset that staff said they were no longer able to use their essential oils due to the strong smell. Resident 63 stated a member of nursing staff made a complaint about the smell. Review of a progress note, dated 04/02/2025 at 12:22 PM, showed Staff N, Social Services, informed Resident 63 that they could no longer use their diffuser (a scent producing item) in the facility. Resident 63 expressed their discontent and was provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete care plans for 2 of 35 sampled residents (Resident 41 & 2) reviewed for care planning. The failure to ensure complete and accurate care plans regarding appropriate diagnoses, mobility and restorative programs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . 1) Resident 41 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/24/2025, documented Resident 41 was cognitively intact, was able to make their needs known and was diagnosed with a traumatic brain injury (a disruption in the normal function of the brain caused by an external force, such as a blow or jolt to the head), no diagnoses of Alzheimer's disease or dementia (a general term for the decline in mental abilities that affects memory, thinking, and reasoning, leading to difficulties with daily tasks). A physician's note, dated 01/31/2024, 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 provide assistance with activities of daily living (ADLs) for 1 of 3 residents (Resident 166) reviewed for ADLs. Failure to provide oral care for Resident 166, who was dependent on staff for oral care, placed the resident at risk for unmet needs, poor hygiene and diminished quality of life. Findings included . Review of the electronic health record showed Resident 166 was admitted to the facility on [DATE], with diagnoses of diabetes (too much sugar in the blood), obstructive and reflux uropathy (functional hindrance of urine flow) and depression. Resident 166 was dependent on staff for most activities of daily living. During an interview on 04/22/2025 at 10:32 AM, Resident 166 said staff were inconsistent with providing assistance with oral care. Review of Resident 166's care plan, dated 04/24/2024, showed they received oral care in the morning, after meals, and at bedtime, with substantial dependent assistance. During an interview on 04/24/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure quality of care for bowel management for 1 of 6 residents (Resident 60) reviewed for bowel management, and services for 1 of 1 resident (Resident 132) reviewed for edema. These failures placed residents at risk of medical complications, delay in care and services, and a diminished quality of life. Findings included . <Bowel Management> Review of the facility's document titled, Bowel Care Protocol, dated 02/01/2018, showed the night nurse would review bowel records and compile a list of residents who had not had a bowel movement for three days. The list would be passed on to the day shift nurse, who would initiate the bowel protocol as follows: a) Administer Polyethylene Glycol (laxative) at the beginning of day shift on day four. b) Administer Bisacodyl Suppository at the beginning of day shift on day five. c) Administer a Mineral oil enema at the beginning of day shift on day six. Note: If there were no results from the above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Resident 27 was admitted to the facility on [DATE] with diagnoses of Bipolar disorder (a mental health condition characterized by significant shifts in mood, energy, and activity levels, ranging from periods of intense happiness or irritability (mania or hypomania) to periods of deep sadness or hopelessness (depression)), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and anxiety (a normal human emotion characterized by feelings of unease, worry, or fear, often about something that is about to happen or could happen in the future). Resident 27 required substantial assistance with most activities of daily living. Resident 27's provider's orders showed an order dated 03/20/2025, for hydrocodone-acetaminophen 5-325 milligrams two every six hours as needed for severe pain. Review of the MAR dated April 2025 from 04/01/2025 - 04/24/2025 showed the ordered, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to ensure a Gradual Dose Reduction (GRD, progressively minimizes a patient's medication levels over time) was completed for 1 of 5 sampled residents (Resident 78) reviewed for unnecessary medications. The failure to complete a GDR placed residents at risk for overuse of psychotropic (mind altering) medication, health complications and a diminished quality of life. Findings included . Resident 78 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/04/2025, documented Resident 78 was moderately cognitively impaired. The Quarterly MDS documented a GDR had been completed on 06/13/2024 and documented as clinically contraindicated by the physician. The electronic health record (EHR) provided no supporting documentation a GDR had been completed on 06/13/2024 for any psychotropic medications. Resident 78 was prescribed Sertraline (an antidepressant) 10 milligrams (mg) twice a day for depression starting…

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

Based on observation and interview, the facility failed to maintain locked medication carts for 2 of 11 medication storage carts (Cart D and Cart G) when reviewed for medication storage. This failure placed the residents at risk for missing medications, medication discrepancies and impaired quality of life. Findings included . During an observation on 04/24/2025 at 9:08 AM, Medication Cart D was left unlocked, as Staff R, Licensed Practical Nurse (LPN) was on the other side of the cart working with a resident and after that was walking away to the nurse's station. During an interview on 04/24/2025 at 9:18 AM, Staff R, stated the medication cart should have been locked. On 04/21/2025 at 3:27 PM, Staff T, LPN, on G Hall (dementia unit) was standing at the medication cart speaking to a resident and then escorted the resident to his room. Observation of medication left unlocked. Three other residents were standing and or sitting within 10 feet of the medication cart. At 3:29 PM, Staff T returned to the medication cart. When asked to open the medication, Staff T opened the cart without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, prepare and serve food to residents in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The failure to maintain documented dishwasher temperatures, to throw out expired/moldy foods and maintain sanitary conditions 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 . <Dishwasher temperatures> Review of dishwasher temperature logs for January 2025 showed: Main dining room (MDR)- no temperatures were recorded. AC 1 Hall dining room (AC)- no temperatures were recorded. ABCD Hall dining room (ABCD)- some temperatures were recorded, but not consistently. EFGH Hall dining room (EFGH)- no temperatures were recorded. EG 1 Hall dining room (EG)- no temperatures were recorded. Review of dishwasher temperature logs for February 2025 showed: Main dining room (MDR)- no temperatures were recorded. AC 1 Hall dining room (AC)- no temperatures 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 staff-maintained infection control practices by donning and doffing their Personal Protective Equipment (PPE) for 1 of 1 COVID (G2 Hall) unit and to correctly carry out hand hygiene by staff when reviewed for infection control. The facility also failed to perform urinary catheter (thin tube to remove urine) care per standards of practice for 2 of 2 residents (Resident 26 & 135) reviewed for catheter care observation. This failure placed residents at risk for the spread of infection and a diminished quality of life. Findings included . <Donning and Doffing of PPE on G2 Unit with COVID Positive Residents> On 04/23/2025 at 2:22 PM, observed a cart with different types of N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) masks on a cart outside the closed double doors to the G2 Unit where COVID positive residents are located. A review of the sign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to the state agency and log allegations of abuse/mistreatment by staff on the reporting log within five working days for 8 of 14 residents (1, 2, 3, 7, 8, 10, 14, & 15) reviewed for abuse and neglect. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included . Facility policy, Abuse and Neglect, dated 12/01/2022, documented all alleged or suspected incidents of abuse, neglect, and misappropriation of property will be reported and investigated in accordance with State and Federal rules. <Resident 1 & 14> Resident 1's quarterly Minimum Data Set (MDS/an assessment tool) dated 01/09/2025, showed Resident 1 was admitted to the facility on [DATE] with intact cognition. Resident 14's quarterly MDS, dated [DATE], showed Resident 14 was admitted to the facility on [DATE] with severely impaired cognition. Progress notes, dated 11/22/2024, documented Resident 14 wandered into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation for 2 of 14 residents (3 & 7) reviewed for accidents. Facility failure to complete investigations placed residents at risk for ongoing neglect and abuse, unmet needs, and decreased quality of life. Findings included . Facility policy, Abuse and Neglect, dated 12/01/2022, documents all incidents of alleged or suspected abused, neglect, personal and/or misappropriation of property and reported and investigated in accordance with State and Federal rules. <Resident 7> Resident 7's quarterly Minimum Data Set (MDS/an assessment tool), dated 02/28/2025, showed Resident 7 was admitted to the facility on [DATE] with severely impaired cognition. Progress notes, dated 12/06/2024, documented an unknown resident shouted at and nearly hit Resident 7. The incident required staff intervention to separate the 2 residents. Progress notes, dated 02/18/2025, documented there was a resident to resident physical altercation between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions were consistently implemented and monitored for effectiveness for 1 of 3 residents (Resident 1) reviewed for accidents and hazards. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, post-traumatic stress disorder (a mental condition caused by experiencing a traumatic event), and blindness. The Minimum Data Set (MDS), dated [DATE], documented Resident 1 has severe cognitive impairment and is dependent on staff with activities of daily living. The care plan, revised on 11/20/2024, documented Resident 1 was at risk for falls due to impulsivity and poor safety judgement, fierce determination to be independent, and decreased mobility. Care plan documented staff would toilet the resident every waking hour, place items within reach, invite to activities, and keep the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to monitor the efficacy for use of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 1 of 3 sampled residents (1), reviewed for catheter use. This failure placed the residents at increased risk of a catheter associated urinary tract infections, pain, and urethral trauma. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder (a mental condition caused by experiencing a traumatic event), and blindness. The Minimum Data Set (MDS) dated , 10/14/2024, documented Resident 1 had severe cognitive impairment and was dependent on staff with activities of daily living. The care plan, dated 10/16/2024, documents Resident 1 had an indwelling foley catheter due to an enlarged prostate, bladder neck obstruction (a blockage of urine flow), and a neurogenic bladder (nerve damage to the muscles and nerves of the bladder). 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 activities of daily living (ADLs) were consistently provided for residents dependent on staff to perform oral care for 1 of 3 residents (1) reviewed for ADL care for dependent residents. This failure placed residents at risk of unmet care needs, poor oral hygiene, and a diminished quality of life. Findings included . Review of the facility policy/procedure titled Mouth Care, revised 02/2018, showed oral care was to be provided to clean and freshen the mouth and to prevent oral infection. The procedure spelled out the steps to perform oral care and directed staff to document the care provided and if the resident refused. If the resident refused, staff were to document interventions provided and report to their supervisor. Resident 1 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 03/21/2024, documented Resident 1 had severe cognitive impairment with non-traumatic brain…

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

Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 7 residents (Residents 84, 389, 14, 6, 41, 184 & 67) interviewed, and 9 staff (Staff Q, R, J, K, L, M, N, O & P) interviewed. The facility had insufficient staff to ensure residents received assistance with restorative services, meal tray delivery times, and Activities of Daily Living (ADLs) including showers and shaving. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNPs not being done for 3 of 3 residents (Residents 48, 97 & 102) reviewed for RNP. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Interviews/Observations> On 04/15/2024 at 10:55 AM, Resident 84 stated, I would prefer to be shaved daily. When asked if the aides or nurses have helped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and/or honor bathing choices for 3 of 5 residents (Residents 97, 102 & 125) reviewed for choices. The failure to promote and facilitate resident self-determination by offering and honoring residents' choices related to bathing frequency, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life. Findings included . 1) Resident 97 admitted to the facility on [DATE]. Review of the 04/09/2024 Significant Change Minimum Data Set (MDS, an assessment tool), showed the resident had moderate cognitive impairment, no behaviors or rejection of care, and choices about bathing were, very important. On 04/16/2024 at 11:32 AM, Resident 97 indicated he was not provided a choice about how frequently he would be bathed. He said the facility just tells you that you get one and they don't ask about what the resident wants and stated, I would prefer three a week. I think that's fair since I was used to bathing daily. My…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate 3 of 4 allegations of abuse, neglect and/or misappropriation for 2 of 2 residents (Residents 97 and 105) whose investigation were reviewed. The failure to establish a timeline of events, ensure all staff who were present, involved and/or had knowledge of alleged incidents were reviewed, and to implement identified interventions to prevent reoccurrence, placed residents at risk for unidentified and/or continued abuse, neglect, and/or misappropriation of their property. Findings included . Resident 97 admitted to the facility on [DATE]. On 04/16/2024 at 11:35 AM, the resident said a little over a month ago, there was an incident with a prior roommate. The roommate allegedly came over to Resident 97's side of the room and threatened to shoot him. Resident 97 said they notified staff, and the roommate was moved to a different room. The facility's incident/accident reporting log showed the following entries for 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 provide the necessary care and services to ensure a resident's ability to participate in activities of daily living did not diminish for 3 of 3 residents (Resident 97, 102 & 48) reviewed for rehabilitation and restorative services. The failure to provide restorative programs at the frequency residents were assessed to require, placed residents at risk for avoidable decline in activities of daily living (ADL), and increased dependence on facility staff to meet their ADL needs. Findings included . 1) Resident 102 admitted to the facility on [DATE]. Review of the 02/08/2024 quarterly MDS, showed the resident was cognitively intact, had limited range of motion to one lower extremity and to both upper extremities, but received no restorative services during the assessment period. A restorative nursing care plan, revised 02/09/2024, directed staff to provide Resident 102's restorative ambulation program six times a week. Review of Resident 102'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 provide the necessary care and services to maintain the highest practicable level of well-being for 5 of 7 residents (Residents 239, 91, 155, 175 & 82) reviewed for bowel management and 1 of 1 resident (Resident 125) reviewed for a fluid restriction. The failure to initiate bowel care in accordance with physicians' orders and to accurately document, total, and assess fluid intake, placed residents at risk for fluid and electrolyte imbalances, nausea/vomiting, pain/discomfort and other health complications related to untreated constipation. Findings included . Review of the facility's Bowel Regimen, dated 11/03/2023, showed the following direction to nursing staff: a) If a resident goes 72 hours without a bowel movement (BM), administer Miralax 17 grams; b) If no results within 12 hours of Miralax administration, administer Milk of Magnesia (MOM) 30 ml; c) If no results six hours after administration of MOM, administer a bisacodyl suppository…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe from falls for 1 of 6 sampled residents (Residents 171) reviewed for accidents and hazards. This failure placed residents at risk for fall related injury and a diminished quality of life. Findings included . Resident 171 admitted to the facility on [DATE] with a diagnosis of dementia. Review of Resident 171's fall care plan showed the resident had falls on: 11/22/2023 (6:20 AM) 11/22/2023 (2:10 PM) 11/23/2023 (8:30 AM) 03/29/2024 (5:16 AM) 04/09/2024 (12:45 PM) 04/15/2024 (11:45 AM). Review of the medical record showed a safe assessment for a recliner chair, dated 04/05/2023, and no additional assessments were located. Review of an unwitnessed incident report, dated 03/29/2024, showed Resident 171 was found on the floor between the bed and recliner chair after rolling out of bed. Review of the care plan intervention dated 04/01/2024 showed bilateral assist bed handles on bed for sense of security and to help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dated when opened when required and expired drugs and biologicals were discarded in accordance with currently accepted professional standards of practice for 2 of 4 medication carts (G2 & G1) and 2 of 3 medication rooms (G2/H2 & A2/B2) reviewed. Additionally, the facility failed to ensure medications were secured in locked storage for 2 of 2 residents (Resident 116 and 125) observed with medications at bedside. This placed residents at risk for accidentally taking another resident's medication and/or receiving expired/outdated medications and biologicals. Findings included . >Medication Rooms< <G2/H2> On 04/18/2024, at 5:57 AM, Staff Z, Registered Nurse (RN) 3, confirmed there was an opened and undated multiuse vial of tubersol (used to complete Tuberculosis testing) in the G2/H2 medication room refrigerator. Staff Z said the tubersol needed to be discarded because it was not dated when opened, and was only good for 28 days after opening. <A2/B2> On 04/18/2024 at 6:24 AM a bottle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide food at appetizing temperatures when reviewed for kitchen services. This failure placed residents at risk of lowered nutritional intake, potential weight loss, and a diminished quality of life. Findings included . <Dining Room Service> On 04/17/2024 at 11:57 AM the start of tray line service for the lunch meal was observed. None of the items on the steam table had the temperatures taken prior to being served. Further observation showed that a stack of plates was next to the plate warmer and were not being warmed within the plate holder. At 12:24 PM, Staff EE, Lead Food Service Worker was observed plating food for each hallway using only the top insulator. At 12:53 PM, Staff EE, said they usually took the temperature of all food prior to service however they were in a rush and thought a different staff member had taken the temperatures. Staff EE said the facility did not use the bottom plate insulator because the top keeps 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 develop and maintain a current hospice Plan of Care (POC) in collaboration with hospice, which identified what services were to be provided, and which delineated hospice versus facility responsibilities for 4 of 4 sampled residents (Resident 137, 118, 37 & 87) reviewed for hospice. This failure placed residents at risk for not receiving necessary care and services and a diminished quality of life. Findings included . The facility's hospice contract titled, Hospice Services Agreement, dated 2017, under article 4.2 stated, hospice shall deliver to facility the following information: (a) the most recent individualized Hospice Plan of Care for each Hospice Patient. 1) Resident 137 was admitted on [DATE] with a diagnoses including Parkinson's disease (a brain disorder that causes uncontrollable movements), Lewy Body Dementia (a disease with abnormal deposits of protein in the brain), and a UTI (urinary tract infection). The Quarterly Assessment MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for 1 of 2 residents (Resident 87) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity and respect and a diminished quality of life. Findings included . The facility's admissions packet, undated, documented, You have the right to be treated with respect and dignity. Resident 87 admitted to the facility on [DATE], with diagnoses including hemiplegia (stroke that caused left sided weakness) affecting resident's left nondominant side, depression (mood disorder that causes a persistent feeling of sadness), and polyneuropathy (malfunction of many peripheral nerves throughout the body). The significant change Minimum Data Sets (MDS), a comprehensive assessment tool, dated 03/29/2024, documented Resident 87 was referred to hospice (end of life care). Resident 87 required maximum assistance with most activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 2 sample residents (Resident 137) reviewed for change of condition. This failure placed residents at risk for not receiving adequate and/or appropriate care and services. Findings included . Resident 137 was admitted on [DATE] with a diagnosis of Parkinson's disease (a brain disorder that causes uncontrollable movements), Lewy Body Dementia (a disease with abnormal deposits of protein in the brain), and a UTI (urinary tract infection). The Quarterly Assessment MDS (Minimum Data Set), an assessment tool, dated 02/28/2024, indicated the resident was cognitively intact and was independent to needing supervision with ADLs (Activities of Daily Living). The medical record showed Resident 137 was admitted to hospice on 03/20/2024. A review of the Significant Change in Status Assessment MDS, dated [DATE], showed Resident 137 was not receiving hospice care. On 04/19/2024 at 8:32 AM Staff V, MDS Coordinator, said that hospice care 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 observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 4 of 52 sample residents (Residents 116, 97, 239 & 87) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 239 readmitted to the facility on [DATE]. Review of the 04/10/2024 readmission skin assessment showed Resident 239 had a double lumen Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) to the left upper arm. Review of Resident 239's comprehensive care plan, revised 04/11/2024, showed the type and location of the resident's venous access device and care instructions were not care planned. On 04/22/2024 at 8:23 AM, Staff B, Director of Nursing, said Resident 239's care plan should identify the type, location, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 30 sample residents (Residents 239, 97, 116, 125) reviewed. Facility nurses' failure to obtain, accurately transcribe, follow, and clarify physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, delays in treatment, unmet care needs and potential negative outcomes. Findings included . 1) Resident 239 admitted to the facility on [DATE]. Review of the resident's physician's orders showed a 11/16/2022 order directing nurses to hold the resident's dose of metoprolol, carvedilol, atenolol and propranolol (blood pressure medications) for a systolic blood pressure (SBP) less than a 100, a diastolic blood pressure (DBP) less than 60 or a pulse less than 60. Review of the February and March 2024 Medication Administration Record showed on the following dates the resident's 8:00 AM metoprolol 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 urinary catheter (a tube inserted into the bladder which drains urine into a collection bag outside the body) tubing and drainage bags were covered, appropriately positioned off the floor, below the level of the bladder, and in a manner to ensure unobstructed urine flow for 2 of 4 residents (Residents 164 & 116) reviewed for urinary catheter use. These failures placed residents at risk for catheter associated urinary tract infections, bladder pain and other medically related consequences. Findings included . 1) Resident 164 admitted to the facility on [DATE]. Review of the 02/08/2024 admission Minimum Data Set (MDS), an assessment tool, showed the resident had severe cognitive impairment, a diagnosis of obstructive uropathy and required the use of a indwelling urinary catheter. A catheter care plan, revised 02/20/2024, showed Resident 164 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from 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 intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 1 of 1 resident (Residents 239) reviewed for IV therapy. The facility failed to ensure Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) orders included direction to perform weekly PICC dressing changes, replace needleless injection caps, assess, and record external length upon admission/insertion and then weekly and as needed. Additionally, the facility failed to ensure nursing staff were trained and competent in the use of dial-a-flow infusion sets. These failures placed residents at risk for loss of vascular access, infection, IV medication errors and other potential negative outcomes. Findings included . Resident 239 readmitted to the facility on [DATE]. Review of their current physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide consistent behavior monitoring for the use of psychotropic medications (affecting the mind) for 2 of 5 residents (Resident 175 and 82) reviewed for unnecessary medications and psychotropic medication side effects. Failure to develop target behaviors, adequately monitor the behaviors and interventions for effectiveness, and monitor changes in orthostatic blood pressures, placed the residents at risk for incorrect dose and duration of psychotropic medications, unwanted side effects, medical complications, and decreased quality of life. Findings included . 1) Resident 175's quarterly minimum data set (MDS), a required assessment tool, dated 03/28/2024, showed Resident 175 was diagnoses including (a neurocognitive disorder). It further showed Resident 175 received an antipsychotic medication on a routine basis. A provider's order dated 03/27/2024 showed that Resident 175 was prescribed an antipsychotic medication to be provided once…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility staff failed to notify a provider when moderate and severe medication interactions were alerted on new medication orders for 1 of 5 residents (Resident 1) reviewed for medications. This failure placed residents at risk for adverse impact on physical health and well-being and a decreased quality of life. Findings included . Resident 1 admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 02/02/2024, documented Resident 1 was cognitively intact and required supervision to maximum assistance from staff for activities of daily living (ADLS). An order note, dated 02/21/2024 at 12:51 PM, documented a severe drug interaction between omeprazole (medication often give for acid reflux) and clopidogrel (medication used to help prevent blood clots) potentially causing an increased risk of a cardiovascular event. Review of Resident 1's medical record did not show documentation that a physician was notified of the severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 sampled residents (Resident 1) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 07/27/2023, documented Resident 1 had severe cognitive impairment, behaviors that interfered with care and was visually impaired. On 10/23/2023 at 2:27 PM, Collateral Contact (CC 1) said they had an ongoing concern regarding Resident 1's care. CC 1 said they frequently found the room smelled of urine and was messy with bagged, dirty laundry left on the floor. CC 1 said staff were to clean Resident 1's room when he was out for meals but they did not feel that was happening. On 11/07/2023 at 1:39 PM, Resident 1's room was observed with substantial debris on the floor which resembled food, pieces of papers and spilled liquid.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bathing and nail care was provided on a consistent basis for 1 of 5 residents sampled residents (Resident 1) dependent on staff assistance for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene, unmet care needs and a diminished quality of life. Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 07/27/2023, documented Resident 1 had severe cognitive impairment, behaviors that interfered with care, was visually impaired and required extensive assistance for staff to complete bathing and personal hygiene activities. Resident 1's care plan, initiated 11/22/2019, documented Resident 1 was to receive a weekly shower on Mondays and nail care was to be completed on shower days. The Point of Care (POC) response history for the task of bathing was reviewed for 09/28/2023 to 11/07/2023 and showed that Resident 1 received 2 showers. The POC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure residents who experienced dementia-related sleep disorders and Sundown syndrome (late day/evening increase in behaviors) received care and services to attain the highest practicable physical, mental and psychosocial well-being when it did not identify and implement individualized, person-centered interventions, document the results of those interventions and consistently implement the care plan over time and across shifts for 3 of 4 residents reviewed for dementia care. These failures placed residents at risk for risk for unmet needs for non-medication interventions when behaviors increased, unnecessary medication and a diminished quality of life. Findings included . RESIDENT 1 Resident 1 was admitted [DATE] with diagnoses including dementia, anxiety and insomnia. August 2023 Medication Administration Record (MAR) documented Resident 1 received anti-anxiety medication in the morning and afternoon for targeted symptoms 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.