Life Care Center Of Puyallup

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure their facility medication error rate was less than 5%. The facility's medication error rate was 12% for 2 of 5 residents (Resident 43 and 98) reviewed for medication error rate. These failures placed residents at risk for potentially significant medication errors, dehydration, inadequate pain management, and diminished quality of care/quality of life. Findings included. <RESIDENT 43>Review of the 02/18/2026 Significant Change minimum data set (MDS-assessment tool) showed Resident 43 admitted to the facility on [DATE] and had some problems with cognition. Resident 43 was hard of hearing and used hearing aids, vision impaired with the use of glasses, and was able understand others and was understood. Resident 43 was incontinent of bowel and bladder and required maximum assistance for toileting, bed mobility, and transfers.<Physician Order vs Medication Card Prescription label)During a medication administration observation on…

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

Based on observations, interviews, and record review the facility failed to ensure intravenous (IV-administered into the veins) medications were properly labeled during administration for 3 of 3 residents (Residents 14, 104, and 125) reviewed for medication labeling and storage. The failure to ensure the medication bag was labeled with the date, time, and nurse initials at the time of administration placed residents at risk for significant medication errors, adverse effects, and diminished quality of care/quality of life.Findings included. <RESIDENT 104>Review of Resident 104's April 2026 Medication Administration Record (MAR) showed: A physician order (PO) dated 03/19/2026 for Cefepime 2Gm Intravenously every eight hours for infection. The transcription schedule showed the medication was to be administered at 6:00 AM, 2:00 PM, and 10:00 PM.A PO dated 03/27/2026 for Daptomycin 825 mg intravenously every 24 hours for infection. The transcribed schedule time on the MAR showed 24h. Review of the nurse's documentation showed the antibiotic medication was administered between 10:00 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide needed dental services for 1 of 3 sampled residents (Resident 17) when reviewed for dental services. This failure placed residents at risk for unmet needs, poor nutritional intake, and a decreased quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 17 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, difficulty breathing) and diabetes (high blood sugar). The resident was able to make needs known. During an interview on 04/07/2026 at 10:06 AM, Resident 17 stated their dentures did not fit and they had seen a dentist three months ago for new dentures but had not heard anything further. Review of the EHR showed a form titled Dental Progress Note dated 02/05/2026 which recommended new upper and lower dentures and extractions for Resident 17. Review of a progress note dated 02/12/2026 showed Resident was seen by [outside dental provider]. Will need a referral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of neglect for 1 of 3 sample residents (Resident 6) reviewed for neglect. This failure placed residents at risk for lack of regulatory oversight and on-going abuse and neglect.Findings included .Review of a public complaint sent to the State Agency, dated 12/09/2025, showed allegations of neglect related to Resident 6. The complaint showed allegations that Resident 6 was left in soiled adult diapers for long periods of time, and had developed open sores in their groin area; that staff were using incorrect treatment to treat/prevent Resident 6's skin impairments; and that Resident 6 had complained of left arm numbness and tingling, as well as nausea and vomiting (email noted these were signs of stroke), and symptoms were ignored by facility staff. The complaint showed that the contents of the allegation were copied (cc'd), via email, to Staff A, Administrator. Review of the facility incident report logs dated December 1, 2025, through December 17, 2025, did not show an allegation of neglect 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 follow provider orders for laboratory blood work for 1 of 1 resident (Resident 1) reviewed for laboratory services. This failure placed the resident at risk for unidentified changes in condition and lack of, or delayed, medical intervention.Findings included . Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE] after surgical amputation of toes. The medical record showed that Resident 1 also had diagnoses to include diabetes and heart disease. Review of a document titled, After Visit Summary, dated 10/31/2025, showed Resident 1 had gone to an outpatient wound care center for follow up, and treatment of a dehiscence (opening/splitting apart) of their surgical foot wound. The After Visit Summary had orders for Resident 1 to have blood work drawn at the facility: c-reactive protein (CRP) and sed rate (ESR) - both laboratory tests are used to evaluate inflammation and infection in the body. Review of a facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate wound monitoring records for 1 of 1 resident (Resident 5) reviewed for medical records. This failure placed residents at risk for incomplete and inaccurate clinical information being presented to the interdisciplinary team, delays in care, prolonged stay, and a decreased quality of life.Findings included . Review of the admission Minimum Data Set assessment, dated 10/09/2025, showed Resident 5 admitted to the facility on [DATE] with a Stage 4 pressure ulcer (a full-thickness wound with extensive tissue loss, exposing muscle, tendons, ligaments or bone). Review of a facility document titled, NRSG: Admission/readmission Collection Tool - V 6, dated 10/07/2025, showed that Resident 5 had a Stage 4 pressure ulcer over their sacrum (a sheild-shaped bony structure located at the base of the spine, and between the two hip bones), with sacral bone exposed, measuring 3 centimeters (cm) by 2.2 cm by 1cm. Review of documents titled, Wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 create a comprehensive care plan for 2 of 3 residents (Residents 1 and 2) reviewed for urinary incontinence. This failure placed the residents at risk for unmet needs, skin impairments, feelings of discomfort and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS showed Resident 1 was always incontinent (had lack of voluntary control) of bowel and bladder.Review of the comprehensive care plan, last reviewed 07/09/2025, showed incontinence was not listed, nor were goals or interventions in the care plan to address Resident 1's incontinence. Resident 2Review of the admission MDS, dated [DATE], showed Resident 2 admitted on [DATE] with diagnoses to include dementia (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to routinely monitor and assess the status of skin impairments for 2 of 3 residents (Residents 1 and 2) reviewed for pressure injuries. This failure placed the residents at risk for worsening of pressure wounds, lack of appropriate treatment, medical complications and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed that Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS further showed that Resident 1 had a stage 1 pressure injury (the initial stage of a pressure ulcer, characterized by non-blanchable [does not fade or turn white when pressure is applied] redness of intact skin, usually over a bony prominence) over the sacrum (large triangular bone at the bottom of the spine).Review of the care plan, dated 06/16/2025, showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement treatment and/or monitoring orders for skin impairments (damaged skin) for 2 of 3 residents (Residents 2 and 3) reviewed for skin impairments. This failure placed the residents at risk for worsening wounds and other skin conditions, infection, and re-hospitalization. Findings included . Resident 2 Review of the admission minimum data set (MDS, a required assessment tool), dated 05/08/2025, showed that Resident 2 admitted on [DATE] with diagnoses to include falls, right lower leg laceration (a tear or cut in the skin), difficulty walking, generalized weakness and need for assistance with personal care. The Care Area Assessment (CAA) Summary, linked to the MDS, for pressure ulcer/injury showed, [Resident 2] has laceration on RLE. Wound was sutured in the hospital. [Resident 2] was then transferred here for ongoing care and rehab. Review of the hospital discharge/transfer orders, dated 05/06/2025, showed that the facility was to follow current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify an allegation of abuse and failed to report the allegation to the State Agency with the required timeframe for 1 of 3 sampled residents (Resident 1) reviewed for reporting alleged violations. These failures placed the resident at risk for ongoing abuse/neglect, unmet needs and a decreased quality of life. Findings included . Review of the electronic medical record (EMR) showed that Resident 1 admitted to the facility on [DATE] with diagnoses to include hemiplegia (a medical condition characterized by paralysis or severe weakness on one side of the body), muscle weakness, difficulty walking, and need for assistance with personal care. Review of a facility grievance form, dated 04/21/2025 at 8:00 AM, written by Staff C, Speech Language Pathologist (SLP, a health professional who evaluates, diagnoses, and treats communication and swallowing disorders), showed that Resident 1 reported that the previous night, a staff member refused to give them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to develop comprehensive care plans to include all provided nursing services for 2 of 19 sampled residents (Residents 10 and 80) when reviewed for care planning. This failure placed residents at risk for not receiving needed care, a decline in condition, and a diminished quality of life. Findings included . Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses of paraplegia (inability to move lower limbs), diabetes (too much sugar in the blood), and a pressure ulcer to the lower back. Resident 10 was able to make needs known. During an interview on 02/24/2025 at 10:07 AM, Resident 10 stated they had a pressure ulcer and facility staff were treating it with the help of an outside wound provider. Review of the care plan, initiated 04/07/2020, showed no focus area for Resident 10's pressure ulcer, no intervention for nursing staff to treat the pressure ulcer, and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 75 Review of the quarterly minimum data set (MDS, a required assessment tool), dated 01/16/2025, showed Resident 75 readmitted on [DATE] with multiple diagnoses to include stroke, muscle weakness, cancer, dementia, neurogenic bladder (a loss of bladder control due to damage in the brain, spinal cord, or nerves), anxiety and depression. The MDS showed the resident had a foley catheter (a thin flexible tube inserted into the bladder through the urethra to drain urine) and was dependent on staff for assistance with activities of daily living (ADLs). Review of Resident 75's provider's order summary, dated 07/02/2024, showed for licensed staff to place an indwelling (foley) catheter 16 French (FR, diameter size of the catheter) and to change for infection, obstruction or when closed system was compromised as needed related to the resident's neuromuscular dysfunction of the bladder. Review of Resident 75's care plan, revised on 11/14/2024, showed the resident had a catheter 16 FR for their neurogenic bladder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary grooming services to maintain hygiene for 2 of 4 sampled residents (Residents 49 and 61) when reviewed for activities of daily living. This failure placed the residents at risk of feelings of indignity, decreased social interaction, and diminished quality of life. Findings included . Resident 49 Review of the electronic health record (EHR) showed Resident 49 was admitted to the facility on [DATE] with diagnoses to include right humerus (upper arm bone) fracture, diabetes (high blood sugar) and depression. Resident 49 was able to communicate needs. During an interview on 02/24/2025 at 11:47 AM, Resident 49 stated they liked to shave, but the facility did not offer to help. Observation on 02/25/2025 at 11:22 AM, showed Resident 49 sat in the wheelchair in their room with facial hair about an inch long. Review of the care plan focus area on self-performance, revised on 12/31/2024, showed Resident 49 required one staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure the necessary interventions were in place for residents with a history of a fractured humerus (a bone in the upper arm) for 1 of 2 sampled residents (Resident 75) when reviewed for positioning and mobility. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 2 of 7 sampled residents (Residents 6 and 49) when reviewed for bowel protocol. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . <Position/Mobility> Resident 75 Review of the quarterly minimum data set (MDS), a required assessment tool, dated 01/16/2025, showed Resident 75 readmitted on [DATE] with multiple diagnoses to include stroke, muscle weakness, cancer, dementia, anxiety and depression. The electronic health record (EHR) showed the resident had a history of a left humerus fracture and was dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure fall mats were in place to minimize the risk for injury during a fall for 1 of 4 sampled residents (Residents 75) when reviewed for accident hazards. This failure placed residents at risk for potential injury, negative outcomes and decreased quality of life. Findings included . Review of a facility's policy titled, Fall Management, dated 09/25/2024, showed the facility would assess the resident upon admission/readmission, quarterly, with change in condition and with any fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls. In addition, the policy included for staff to implement interventions to include adequate supervision, and use assistive devices, consistent with resident needs, goals, care plan and current professional standards of practice. Review of the quarterly minimum data set (MDS), a required assessment tool, dated 01/16/2025, showed Resident 75…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain management to adequately control residents pain for 1 of 6 sampled residents (Resident 3) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 3 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), paraplegia (inability to move lower limbs), and anxiety. Resident 3 was able to make needs known. During an interview on 02/24/2025 at 11:09 AM, Resident 3 stated the facility staff would provide pain medication, but sometimes it did not control their pain. Resident 3 stated they would ask facility staff for additional pain medication but would be told by staff they could not have more yet. Review of Resident 3's January 2025 medication administration record (MAR) showed Resident 3 was prescribed two over the counter (OTC) pain medications 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 provide a safe, functional, sanitary, and comfortable environment in 1 of 4 hallways (300 hallway) reviewed for Environment. Failure to ensure Resident 21's and 72's wheelchair armrests were in good repair placed residents at risk for injury, medical complications, and decrease quality of life. Findings included . Resident 21 Review of the electronic health record (EHR) showed Resident 21 readmitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar levels), heart failure, and muscle weakness. It showed Resident 71 utilized a manual wheelchair for mobility and was able to make needs known. Observation and interview on 02/24/2025 at 12:25 PM, showed Resident 21's wheelchair left armrest had cracked/torn vinyl with exposed beige material underneath (not a cleanable surface). Resident 21 stated the left armrest was rough to the touch and they would not put their arm on the armrest if they did not have 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 and interview, the facility failed to cover resident catheter bags to maintain dignity for 2 of 2 residents (Residents 20 and 47) reviewed for dignity. This failure placed residents at risk of depressed mood, feelings of worthlessness, and a diminished quality of life. Findings included . Resident 20 Observation on 01/03/2024 at 9:24 AM showed Resident 20 laid in bed with a catheter bag hanging from the bottom of the frame. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Observation on 01/03/2024 at 11:55 AM showed Resident 20 sat in a wheelchair in the dining room during meal service with a catheter bag hanging from the bottom of the wheelchair. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Observations on 01/04/2024 at 10:47 AM and 01/05/2024 at 10:10 AM showed Resident 20 laid in bed with a catheter bag hanging from the bottom of the frame. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Resident 47 Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 3 of 5 residents (Residents 55, 11 and 25) and ensure that providers orders (heart rate parameters) were followed prior to the administration of medication for 1 of 5 residents (Resident 55) reviewed for unnecessary medication. These failures placed the residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Review of a document titled, Pain Assessment and Management, dated 09/12/2023 showed that the facility, will address/treat the underlying causes of the pain, to the extent possible. In addition, the document showed that the staff were to develop and implement both non-pharmacological and pharmacological interventions/approaches to pain management. Review of a document titled, Administration of Medication, dated 08/24/2023 showed that the facility will ensure medications are administered safely and appropriately per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable), and/or the Notice of Medicare Non-Coverage (NOMNC) was provided and completed as required for 2 of 3 residents (Residents 34 and 66) reviewed for Beneficiary Notification. These failures placed residents at risk of not upholding their right to make informed choices about further treatment or services as required by the Medicare Program and of not being informed of their appeal rights prior to the end of Medicare covered services. Findings included . Resident 34 Review of Resident 34's SNF ABN dated 10/03/2023 showed, Options: Check only one box. We can't choose a box for you, portion of the form was left blank regarding whether the resident wanted to get the care listed on the form.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe, sanitary, and homelike environment in 1 of 4 hallways (200 hallway) reviewed for Environment. Failure to ensure Resident 32's and 50's bathrooms and Resident 32's wheelchair break handles were sanitary and in good repair placed residents at risk for injury, medical complications, and decrease quality of life. Findings included . Resident 32 Observations on 01/03/2024 at 12:13 PM, 01/03/2024 at 3:50 PM, 01/05/2024 at 2:20 PM, and 01/08/2024 at 9:54 AM showed Resident 32's wheelchair had loose, frayed tape wrapped around both break handles (these were not cleanable surfaces), and a black rubber cover was missing from the top of the left break handle leaving metal exposed. Additionally, Resident 32's bathroom showed loose floor baseboards falling forward from the cracked and paint chipped lower walls around the toilet floor area. During an interview on 01/05/2024 at 2:20 PM, Resident 32 stated that the tape on the wheelchair…

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

Based on interview and record review, the facility failed to implement identified mental health interventions for 1 of 2 residents (Resident 47) when reviewed for PASRR. This failure placed residents at risk of not receiving needed mental health interventions, an increase in avoidable behaviors, and a diminished quality of life. Findings included . Review of Resident 47's electronic health record (EHR) showed a Pre-admission Screening and Resident Review Level 2 (PASRR, an assessment to determine appropriateness of placements and needed mental health interventions) was completed on 10/24/2023. Further review of Resident 47's EHR did not show that the interventions identified on the PASRR Level 2 were incorporated into Resident 47's plan of care. During an interview on 01/09/2024 at 9:48 AM, Staff G, Social Services Assistant, stated that the Social Services Department arranged PASRR Level 2 for residents that were assessed to require one and would then incorporate the identified interventions into the resident's plan of care. Staff G further stated that Resident 47's PASRR Level 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 25 During an interview on 01/03/2024 Resident 25 stated, I am on fluid restriction of 40 ounces [1182.941 milliliters (ml)] every day. During an interview and observation on 01/05/2024 at 11:39 AM, Resident 25 stated that staff filled their personal water bottle [NAME] with ice because they liked to chew on ice. Resident 25's water bottle [NAME] showed it held 24 ounces (710 ml), and there was a plastic water bottle of 16.9 fluid ounces that was two thirds filled with water on the overbed table. Additionally, Resident 25 stated that they received fluids from the kitchen with meals; however, they were not sure if staff kept track of how much they consumed during mealtime and on their own during the day. Review of the significant change in status MDS dated [DATE] showed that Resident 25 admitted on [DATE] with diagnoses that included heart failure and kidney failure. Additionally, it showed Resident 25 received dialysis (treatment to filter wastes and water from the blood) services. Review of the [NAME]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (Resident 25) reviewed for Dialysis. This failure had the potential to place the resident at risk for unmet care needs and medical complications. Findings included . Review of the facility's policy and procedure titled, Hemodialysis [procedure where a dialysis machine is used to clean the blood] Offsite Policy, revision dated 04/17/2023 showed that the facility should provide ongoing assessment of the resident's condition and monitoring for complications, before and after dialysis treatments received at a certified dialysis facility. It further showed that there should be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident, or the resident's responsible party, of new medications ordered to be administered for three of four residents (Residents 1, 3 and 4) reviewed for notification of changes. This failure prevented the resident and/or resident's representatives from being included in their plans of care and decision-making processes. Findings included . RESIDENT 1 Review of the electronic health record (EHR) showed that Resident 1 admitted to the facility on [DATE] and had another individual designated, as their responsible party, to make healthcare decisions. Review of a progress note, dated 11/06/2023, showed that an Advanced Registered Nurse Practitioner (ARNP) had seen Resident 1 that day, and ordered a new medication to be started to treat an infection. Review of the November 2023 medication administration record (MAR) showed that the medication was administered beginning the evening of 11/06/2023. Review of additional progress notes, and other…

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