Three Creeks Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement preventative measures to prevent avoidable pressure ulcer/pressure injuries (PU/PI) for 1 of 3 sampled residents (Resident 36) reviewed for PU/PI prevention. This failure caused Resident 36 to develop an avoidable deep tissue injury (DTPI, a pressure injury to deep layers of the skin that may resolve without opening or that may open to reveal a serious injury that involved muscle or even bone) on their left heel and created a risk for further skin compromise and decreased quality of life. Findings included.Findings included.The National Pressure Injury Advisory Panel Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Fourth Edition. [NAME] Haesler (Ed.). 2026. [cited: 03/09/2026], available from: https://internationalguideline.com, defined a DTPI as a non-blanchable deep red, maroon or purple discoloration of intact or non-intact skin that resulted from intense and/or prolonged pressure and shear forces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline and unintended health consequences.Findings included .According to the website www.mayoclinic.org, referenced on 3/10/2026, Post Traumatic Stress Disorder (PTSD) was a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event. Symptoms could include flashbacks (feelings that the traumatic event was occurring again), nightmares (repeated disturbing dreams), intrusive thoughts, severe anxiety, avoidance (not wanting to think or talk about a traumatic event), changes in mood or thinking and physical and emotional reactions. These symptoms last more than one month can cause major problems in social or work situations and affect how well a…

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

Based on observation, interview and record review, the facility failed to accurately reconcile all controlled medications in 2 of 2 medication carts (North and South Carts), reviewed for medication storage. In addition, the facility failed to discard expired medication in 1 of 1 medication rooms. This failure placed residents at risk for misappropriation of their controlled medications, placed the facility at increased risk for controlled substance drug diversion and residents receiving medications that may not be effective. Findings included.In an observation of the medication room on 03/01/2026 at 3:31 PM with Staff D, Infection Preventionist, there was a bottle of Lansoprazole (medication used to treat heartburn) in the refrigerator for Resident 49. The medication expired on 02/23/2026. A review of the medication administration records for February 2026 and March 2026 showed Resident 49 received their Lansoprazole. The medication room refrigerator only contained one bottle of Lansoprazole, and it was almost empty.In an interview on 03/01/2026 at 3:42 PM, Staff R, Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline, and unintended health consequences.Findings included .<Resident 22>The 10/28/2025 admission comprehensive assessment documented Resident 22 was admitted on [DATE] and had diagnoses that included obesity, diabetes with foot ulcers, and heart failure. The resident was cognitively intact, was dependent on staff for bed mobility and toileting, and had no pressure ulcers.A review of 10/10/2025 admission orders documented Resident 22 was to have a consistent carbohydrate diet with large protein portions. Staff were to follow the Registered Dietician (RD) recommendations for diet changes and supplements and to give the provider notice of the changes.Further review of the provider orders showed 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 4 sampled residents (Resident 1) received mental health services. This failure placed residents at risk for worsening mental health status, and diminished quality of life. Findings included: Record review of Resident 1's admission Minimum Data Set (MDS-a tool for implementing standardized assessment and for facilitating care management in nursing homes) showed the resident admitted to the facility on [DATE] with diagnoses of a fractured right hip and schizophrenia (a chronic, severe brain disorder characterized by a loss of contact with reality, involving persistent psychotic symptoms like hallucinations, delusions, and disorganized thinking. Diagnosed typically in late teens to early 30s, it involves significant functional impairment, including negative symptoms (reduced emotion/motivation) and cognitive issues). The same assessment showed the resident had a depression screening completed on [DATE], with a score indicating they experienced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Preadmission Screening and Resident Reviews (PASRR, a two-part screening assessment; Level I was determined by the presence of a Severe Mental Illness [SMI] or Developmental Disability. If present, a Level II evaluation by a specialized evaluator would then occur where it would be determined if nursing home placement was the appropriate level of care, and if behavioral health or other community services were recommended for the given resident. A Level I, and if indicated, a Level II PASRR was required to be completed prior to nursing home admission) were completed correctly and PASSR Level II were referred for evaluation prior to admission as required for 1of 6 sample residents (Resident 1). This failure placed residents at risk of behavioral health needs not being met and diminished quality of life.Findings included . A record review showed Resident 1 was admitted to the facility on [DATE] and had diagnoses that included major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 1) remained free from abuse. This failure placed residents at risk for abuse and diminished quality of life.Findings included.Review of Resident 1's medical record showed that they had been admitted to the facility on [DATE], with diagnoses of diabetes (a chronic condition characterized by persistently high levels of sugar in the blood, often treated with a medication, called insulin, used to help the body absorb excess sugar), enterocolitis due to Clostridium Difficile (swelling of the large intestine caused by a bacteria, with symptoms including fever, abdominal cramps, weakness and diarrhea), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and adult failure to thrive (gradual decline in health and functional abilities in older adults, characterized by weight loss, decreased appetite and fatigue). The resident's medical record further showed that they had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were given their medications as ordered for 2 of 3 sampled residents (Resident's 2 and 3) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted.Findings included . <Resident 2>The 09/11/2025 admission assessment documented Resident 2 had diagnoses which included osteomyelitis (a bone infection that spreads through the bloodstream) and sepsis (a life-threatening medical emergency that happens when your body's response to an infection triggers a chain reaction throughout your body, causing widespread inflammation and damage to organs). The resident was cognitively intact and able to make their needs known.The 09/06/2025 wound infection care plan documented Resident 2 would be free of an acute infection. Nursing staff were instructed to give medications as ordered.A 09/05/2025 hospital discharge order documented Resident 2 was supposed to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to complete testing for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) per federal guidelines for 8 of 10 staff (Staff A, B, C, D, F, G, I, J) during a COVID-19 outbreak. This failure increased the likelihood for delayed identification, diagnosis and treatment of COVID-19. In addition, the facility failed to implement their respiratory protection program in a timely manner for 4 of 10 staff (Staff A, B, D, H) every year within 12 months of the date of the last fit test. The respirator program consisted of fit testing procedures (a medical evaluation, fit testing and training on the use and wearing of a respiratory mask) of the N95 respirator mask (a respiratory protective device designed to achieve a…

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

Based on observation, interview, and record review the facility failed to store, discard and distribute food in accordance with professional standards for food safety for 1 of 1 facility kitchens reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised 01/18/2023, showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be consumed or discarded as directed by the food manufacturer's use-by-date. During a kitchen observation on 11/12/2024 at 10:31 AM, the produce refrigerator contained three extra-large bags of shredded iceberg lettuce that was brownish, wilted and soggy. The bags of lettuce were labeled with the used-by date of 10/24/2024. In an observation of the dry storage room on 11/12/2024 at 10:43 AM, a bag of opened crispy fried onions was undated and a 10-quart sealed container (less than 4 quarts full) of flour was labeled with an expiration date of 08/06/2024. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was a completed Physician's Order for Life-Sustaining Treatment [POLST] (a form which instructed medical staff what treatment the resident wished to have done in the event they are seriously ill, or their heart stopped beating for 1 of 2 sampled residents (Resident 6) reviewed for Advance Directives. This failure placed the resident at risk for not having their wishes and choices regarding end-of life care honored. Findings included . <Resident 6> The [DATE] admission assessment documented Resident 6 admitted to the facility on [DATE] and was cognitively intact to make decisions regarding their care. Review of the [DATE] care plan documented Resident 6 made their own health care decisions and a POLST was in their medical record. Review of Resident 6's medical record found no documentation of a completed POLST form or other documentation that showed education and/or conversation had occurred related to the resident's wishes 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 provide a Notification of Medicare Non-Coverage (NOMNC) two days prior to a planned discharge, as required, for 1 of 3 residents (Resident 136) reviewed for liability notices. This failure prevented the resident from exercising the right to appeal and dispute the termination of Medicare covered services. Findings included . According to their medical record, Resident 136 was admitted to the facility on [DATE] and discharged on 10/30/2024. Per the admission assessment, dated 10/28/2024, Resident 136 had diagnoses which included Myocardial Infarction (MI, a heart attack) and a recent Coronary Artery Bypass (open heart surgery.) Resident 136 was alert, oriented and able to make their needs known. A progress note, dated 10/28/2024 at 12:54 PM, documented the resident was going to be discharged on 10/30/2024. In a further review of Resident 136's record, no NOMNC form was found. During an interview at 11/15/2024 at 4:40 PM, Staff B, Director of Nursing,…

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

Based on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a hospital transfer and/or that the receiving hospital had received information of the resident's condition, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs. Findings included . <Resident 31> The 11/04/2024 discharge assessment documented Resident 31 had cognitive impairment and had diagnoses which included malnutrition and a fractured left leg. Review of Resident 31's record showed a transfer form dated 11/04/2024 which documented the resident needed a proxy to make decisions and was being transferred to the hospital to be evaluated for unresponsiveness. Aside from the resident's diagnoses, date of birth , full name, reason for the transfer, and name of the hospital the resident was being sent to, the form was blank and did not include any other additional information, such as the resident's care needs, treatments, or status prior to being sent. A…

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

Based on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included <Resident 31> The 11/04/2024 discharge assessment documented Resident 31 had cognitive impairment and had diagnoses which included malnutrition and a fractured left leg. Review of Resident 31's record showed a transfer form dated 11/04/2024 which documented the resident was being transferred to the hospital to be evaluated for unresponsiveness. Additional record review found no documentation that the resident and/or resident representative had been provided the required bed hold notice. In an interview on 11/17/2024 at 10:42 AM, Staff C,…

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

Based on observation, interview and record review, the facility failed to ensure that 1 of 2 sampled residents (Resident 5) had current and complete oxygen orders for respiratory care. This failure placed the resident at risk for respiratory complications and a diminished quality of life. Findings included . <Resident 5> Per the 08/08/2024 quarterly assessment, Resident 5 was moderately cognitively impaired, had chronic obstructive pulmonary disease (COPD: a progressive lung disease that blocks air flow and makes it difficult to breathe) and heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During an observation on 11/12/2024 at 3:03 PM, Resident 5 was sitting in their room with the oxygen concentrator (a device that converted room air to oxygen) placed next to their bed. The concentrator was on and administering oxygen at 3.5 litres (L) per minute, but the nasal cannula was draped over the top of the concentrator and was not being worn by the resident. During an observation on 11/14/2024 at 3:18 PM, Resident…

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

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate certifications necessary to carry out the functions of nutritional services for 30 residents. Specifically, the facility failed to ensure Staff E, Dietary Manager, had the required certification. This failure placed the residents at risk for unmet nutritional needs and a diminished quality of life. Findings included . A review of staff credentials showed that Staff E, Dietary Manager, did not have the required certification to serve as the dietary manager. In an interview on 11/14/2024 at 9:55 AM, Staff E confirmed that they had not finished completing the required training, and did not have the credentials for their role as a dietary manager. In an interview on 11/17/2024 at 12:20 PM, Staff A, Administrator, stated the facility did not have a full time Registered Dietician. When asked if Staff E had the certification required for a Dietary Manager, Staff A confirmed Staff E had not finished completing the training and did not have the certification. Reference (WAC):…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify the resident's representative of changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the representative placed the resident at risk of not having them involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. Review of Resident 1's comprehensive assessment, dated 04/24/2024, showed they were rarely/never understood and had short and long term memory issues. Review of Resident 1's plan of care, revised on 04/23/2024, showed they required extensive staff assistance with turning in bed, personal hygiene, dressing, transfers; and was totally dependent on staff for eating and toilet use. In addition, the plan of care showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure an incident of neglect was reported to the State Survey Agency, as required, for 1 of 1 resident (Resident 1) reviewed for neglect. Failure to report a worsening wound on Resident 1's left lower leg due to a lack of timely staff assessments and delay in receiving medical treatment placed all residents at risk for continued neglect and poor quality of care. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, showed neglect was the failure of the facility to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Staff were to report the incident immediately any allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property to applicable state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to conduct a thorough investigation in a timely manner for 1 of 3 residents (Resident 1) reviewed for falls. Failure to conduct a thorough investigation to identify the root cause and all contributing factors related to Resident 1's fall placed residents at risk for ineffective care planning interventions to prevent further falls with injury. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, showed staff was to review and investigate all allegations of abuse, neglect, exploitation, injuries of unknown source and misappropriation of resident property. Staff were to complete investigation summaries and final outcome summaries. Staff was to analyze the occurrences to determine what changes were needed to prevent further occurrences. <Resident 1> Review of the medical record 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, record review and interviews, the facility failed to ensure sufficient nursing staff were available to respond to call lights timely and to meet the care needs of 8 of 15 residents (Residents 3,1,4,5,6,2,7,8) reviewed for sufficient nursing staff. This failure resulted in feeling of frustration and vulnerability, diminished quality of life and unmet care needs of the residents. Findings included . <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses which included diabetes and cellulitis (bacterial skin infection that caused redness, swelling and pain in the affected area). Review of Resident 3's comprehensive assessment, dated 02/16/2024, showed they had no cognitive deficits. Review of Resident 3's plan of care, dated 11/15/2023, showed they required extensive assistance by staff for transfers, turning from side to side and bathing. Review of physician's orders, dated 04/19/2024, showed showers were to be given to Resident 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to serve meals that were at a safe temperature for 2 of 7 residents (Residents 1 and 2) reviewed for food temperatures. This failed practice placed residents at risk for decreased nutritional intake and food borne illness. Findings included . Review of the facility policy titled, Preventing Foodborne Illness - Food Handling, revised in July 2014, showed food temperatures would be monitored at designated intervals throughout the day and documented according to state-specific requirements. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included a serious illness that attacked the resident's nervous system, causing weakness and muscle paralysis. Review of the resident's comprehensive assessment, dated 03/09/2024, showed they had no cognitive deficits and required staff assistance with activities of daily living, including eating. On 04/26/2024 at 10:30 AM, Resident 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of potential abuse was reported immediately to the facility Administration as required for 1 of 3 residents (Resident 2), reviewed for abuse. Failure to report an incident of potential abuse placed Resident 2 and other residents in the facility at risk for additional abuse. Findings included . Per the quarterly assessment dated [DATE], Resident 2 had diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety and depression and was able to make their needs known. Review of the facility's policy for prevention and reporting allegations of abuse dated 08/2022, showed all alleged violations are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse. The center acknowledges the definition of abuse as a willful infliction of intimidation or punishment resulting in pain or mental…

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

Based on interview and record review, the facility failed to ensure a resident received consistent showers for 1 of 3 dependent sampled residents (Resident 1), reviewed for activities of daily living. This failure placed the resident at risk for poor hygiene. Findings included . Review of Resident 1's comprehensive assessment, dated 11/17/2023, they required assistance with activities of daily living, including transferring, dressing, personal hygiene, and bathing. Review of Resident 1's bathing documentation dated 11/11/2023 through 12/04/2023, showed the resident received showers on 11/11/2023, and 11/18/2023 (once weekly). Resident 1 did not receive a shower from 11/19/2023 through 11/28/2023 (ten days). During an interview on 12/05/2023 at 10:21 AM, Resident 1 stated they received a shower only twice in November 2023 and that was upsetting to them. The resident stated they would like at least two showers per week. During an interview on 12/05/2023 at 11:00 AM, Staff C, Nursing Assistant, stated showers were given twice weekly and refusals were charted in the electronic medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review the facility failed to implement their respiratory protection program for fit testing procedures which included a medical evaluation, fit testing (a 20 to 30 minute procedure to ensure a proper seal between the respirator face piece and the staff member's face) and training on the use and wearing of the respirator mask) of the N95 respirator mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. The facility had not implemented the respiratory protection program for 53 of 53 staff initially upon date of hire or transfer and then every year within 12 months of the date of the last fit test. A COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak began in the facility on 10/30/2023 with one staff testing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure sufficient preparation for a safe and orderly discharge home for 1 of 3 residents (Resident 1), reviewed for discharge to home. Resident 1 was discharged home without current referrals for in-home caregivers and home health for wound management and therapy services, supplies for diabetic testing, incontinent supplies, phone service, evaluation of the resident's home, and no assessment by staff to Resident 1 was able to perform blood sugar testing and administration of insulin. This placed Resident 1 at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included below knee amputation to the left lower leg, Stage IV pressure ulcer (full-thickness skin and tissue loss to the extent where bone was visible) to the tailbone, Stage II pressure ulcer (partial-thickness loss 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 wound management that met quality standards of care for 3 of 3 sampled residents, (Residents 5, 9 and 82) reviewed for wound care. The facility failed to follow provider orders for wound care, follow infection control standards during wound care, and fully document the wounds in the medical record. These failures placed the residents at risk of wound complications. Findings included . The facility's policy, Pressure Ulcer Prevention and Treatment dated 02/03/2023, showed skin should be assessed upon admission, weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk assessment (a scale used to determine the risk of skin breakdown). <Resident 82> According to an admission assessment, dated 05/13/2023, Resident 82 had a diagnosis of quadriplegia (paralysis affecting all four limbs) and used a wheelchair. The assessment further showed that the resident was alert, oriented and did not have any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 processes for proper holding temperatures were maintained for prepared foods, between when they were prepared in the kitchen, and when the residents received the food, opened foods were labeled and/or dated as required for 1 of 3 refrigerators, expired food in 1 of 1 dry storage area. This failure placed residents served from the kitchen at risk for onsuming expired food. Findings included . During an initial tour of the kitchen on 08/13/2023 at 9:45 AM, the pantry revealed a bag of tortilla shells that were opened and had expired, there were multiple packages of tortilla shells that expired on 08/09/2023, three loaves of bread, a bag of rolls and a cake mix that was undated and had no received or expiration date. The freezer contained a turkey, chicken breasts and hashbrowns that had been opened with no opened date or discard date. During an interview on 08/13/2023 at 10:20 AM, Staff D, Cook, stated that anyone who opened a package should write the date on it immediately. Staff D stated that the bread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 1 of 1 sampled resident (Resident 330), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 330, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . The 08/02/2023 admission assessment showed Resident 330 was cognitively intact to make decisions regarding cares, had medically complex conditions, and diagnoses which included kidney disease, and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells to use as energy). In addition, the assessment showed the resident received dialysis (a procedure that removes waste products…

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