Linden Grove Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 1, 40, 7 and 8) when reviewed for hospitalization and failed to provide written notice of transfer/discharge and recapitulation of their stay for 2 of 4 sampled residents (Residents 40 and 111) when reviewed for discharge. These failures placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (when the body doesn't process sugars) and respiratory failure. The resident was able to make needs known. Review of the progress notes showed Resident 1 was transferred to the hospital on [DATE]. No documentation was found that the resident was offered a bed hold. During an interview on 01/09/2026 at 12:18 PM, Staff B, Director 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 ensure the minimum data set assessment (MDS) accurately reflected the status for 3 of 27 sampled residents (Residents 10, 8 and 40) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life. Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental health condition with mood disorder symptoms), depression (mood disorder), and anxiety (emotion associated with worry, fear or panic). Resident 10 was able to make needs known. During an interview on 01/05/2026 at 11:36 AM, Resident 10 stated they were unable to hear anything in their left ear. Resident 10 stated they preferred for anyone speaking to them to come to their right side so they could hear clearly. Review of Resident 10's care plan dated 09/24/2022 showed the resident has impaired communication as evidenced by left…

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 ensure care plans were reviewed and revised for 5 of 22 residents (Residents 12, 8, 2, 37 and 51) reviewed for care plan review. This failure placed the residents at risk for injuries, unmet needs, care not provided as ordered and a diminished quality of life.Resident 12 Resident 12 admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), high blood pressure and muscle weakness. Resident 12 was able to make needs known. Observation and interview on 01/05/2026 at 10:57 AM, showed Resident 12 with a wander guard device on their left wrist. Resident 12 stated they did not know what the device was for. Observations on 01/06/2026 at 4:08 PM, 01/08/2026 at 11:46 AM, 01/09/2026 at 8:28 AM and 2:30 PM and 01/12/2026 at 3:13 PM showed Resident 12 asleep in bed with the wander guard in place. Review of the electronic health record (EHR) showed the most recent Elopement Risk assessment was completed on 06/06/2025. During 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 observation, interview and record review the facility failed to provide the necessary care and services to maintain personal hygiene for 3 of 5 residents (Residents 117, 99 and 17) when reviewed for activities of daily living. This failure placed the residents at risk for unmet needs, decreased sense of self-worth and a diminished quality of life. Findings included.Resident 117 Review of the electronic health record (EHR) showed Resident 117 admitted to the facility on [DATE] with diagnoses to include obesity (having unhealthy amount of extra body fat), history of falling, and presence of left artificial (manmade) knee joint. Resident 117 was able to make needs known. During an interview on 01/07/2026 at 9:49 AM, Resident 117 stated they had a shower a couple of days ago; however, when they asked for one, they did not always get one. Resident 117 stated they had asked a staff member how often they could have a shower and were told they just had to ask for one but that was not true, because they have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 40, 42 and 51) when reviewed for respiratory care. Failure to obtain and/or follow physician orders for oxygen (O2) therapy, ensure O2 saturation (Sats, the percentage of red blood cells carrying O2 in the blood) was ordered with parameters, care plan, and ensure O2 concentrators (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for unmet needs and potential negative outcomes.Findings included . Resident 40 Review of the electronic health record (EHR) showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, group of conditions that cause difficulty in breathing), respiratory failure, and high blood pressure. Resident 40 was able to make needs known.…

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 medications were administered only when necessary and in accordance with provider orders for 4 of 7 sampled residents (Residents 4, 115, 2, and 99) when reviewed for unnecessary medications/pain management. Failure to ensure non-medicated methods of pain relief were used before pain medications and ensuring blood pressure medications were provided per parameters placed residents at risk of using unnecessary medications, avoidable side effects, and a diminished quality of life. Findings included.Resident 4 Review of the electronic health record (EHR) showed Resident 4 re-admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 4 was able to make needs known. Review of Resident 4's current providers orders showed the resident received Roxicodone (a narcotic pain medication) every eight hours as needed (PRN) 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.

Based on observation, interview, and record review, the facility failed to ensure resident refrigerators were maintained to ensure food was safely stored for 2 of 2 sampled refrigerators (100 and 200 Hall Refrigerators) when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included.Review of the facility policy titled, Safe Handling of Foods from Visitor, revised 03/28/2024, showed, Label foods with resident's name, and the current date and 'use by date'. Items will be thrown out after 48 hours and Have temperature monitored daily for refrigeration < 41 F. Observation on 01/07/2026 at 11:54 PM showed the 100 Hall Resident Refrigerator contained the following items: 1) A bag teriyaki in Styrofoam packaging inside with a receipt showing the order was placed on 01/01/2026; 2) A cup of soup with no date label; 3) A plastic container teriyaki dated 12/08/2025; 4) A box of fried chicken with no date or resident name; 5) A bag with lettuce with brown spot spoilage with no date or name; 6) A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (October, November and December 2025) when reviewed for Infection Control. The facility also failed to implement transmission-based precautions (TBP) for 2 of 4 halls when reviewed for TBP. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life. Findings included. Review of the facility document titled Infection Prevention and Control Program dated 01/21/2025 showed they followed accepted infection prevention and control standards set by the Centers for Disease Control. <Tracking/Trending> Review of the facility provided infection control surveillance documentation 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 administer pneumococcal vaccines for 3 of 7 residents who consented to the vaccine (Residents 5,19 and 35) and failed to provide education on the risks and benefits of vaccines for 3 of 7 residents (Residents 42, 63 and 65) when reviewed for immunizations. These failures placed the residents at risk for communicable diseases and denied the residents the opportunity to make an informed decision regarding receiving immunizations. Findings included.Review of the facility policy titled Pneumococcal Vaccine dated August 2025 showed the facility would assess all residents on admission for the eligibility to receive the pneumococcal vaccine and when indicated provide the vaccine information sheet (VIS) and education on the risks and benefits and administer the vaccine within 30 days of admission if consented. Resident 5 Review of the electronic health record (EHR) on 01/11/2026 showed Resident 5 admitted to the facility on [DATE] with a diagnosis of dementia…

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 resident was provided risks/benefits and provided consent prior to being administered psychotropic (mind altering) medications for 1 of 5 sampled residents (Resident 114) when reviewed for unnecessary medications. This failure placed the resident at risk of unknown side effects, inability to advocate in their medication regimen, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 115 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a chronic autoimmune disease affecting brain, spinal cord, and optic nerves), diabetes (too much sugar in the blood), and anxiety. The resident was able to make needs known. Review of the provider's orders showed Resident 115 received the following psychotropic medications: citalopram hydrobromide (an antidepressant), alprazolam (an antianxiety), and methylphenidate (an antidepressant). Review of the EHR did not show…

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 reasonably accommodate a resident's expressed preference for grooming services by not assisting the resident with accessing a haircut after onsite salon services were discontinued for 1 of 22 sampled residents (Resident 4) when reviewed for resident rights. This failure placed the resident at risk for lack of dignity and diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 4 re-admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 4 was able to make needs known. During an interview on 01/09/2026 at 10:35 AM, Resident 4 stated they had been waiting for a haircut and had informed staff multiple times. Resident 4 stated upon admission the facility had a hairdresser who came regularly but had not been providing services for several months. During an…

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

Based on interview and record review, the facility failed to 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), was provided timely and/or completed as required for 2 of 3 sampled residents (Residents 93 and 23) when reviewed for Beneficiary Notification. This failure placed residents at risk of not upholding their right to make informed choices about further treatment or services as required by the Medicare Program.Findings included . Resident 93Review of a Notice of Medicare Non-Coverage (NOMNC), dated 07/30/2025, showed the facility informed Resident 93 that skilled nursing services would end on 08/01/2025 and the form was signed by the resident or representative on 07/30/2025. Resident 93's SNF ABN dated 08/04/2025 showed it was provided and signed by the resident or representative on 08/04/2025 (three days after the last covered date of skilled services ended…

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 homelike environment to include a mattress for a bed frame for 1 of 22 sampled Residents (Resident 8) reviewed for homelike environment. This failure placed the Resident at risk for decreased mood and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include hemorrhage in brain stem (bleeding in brain stem), depression, anxiety, and cognitive communication deficit. Resident 8 was not always able to communicate needs. Observation on 01/05/2026 at 9:55 AM showed Resident 8 in their room with a bed frame that had exposed metal frame. Observation on 01/07/2026 at 8:56 AM, showed Resident 8 in their bed with second bed near them with no mattress or covers. Observation on 01/08/2026 at 9:56 AM showed Resident 8 laying in their bed with bed frame nearby with no mattress and no covers. Observation on 01/09/2026,…

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 observation, interview, and record review, the facility failed to complete a follow up assessment for a Wander Guard (device that alarms and restricts movement in and out of doors) for 1 of 3 sampled residents (Resident 13) when reviewed for physical restraints. This failure placed the Resident at risk for unmet needs, decline in mood, and diminished quality of life. Findings included.Review of the facility's policy Use of Restraints, undated, showed under section 1 Physical Restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restrict normal access to one's body and under section 16, The assessment reviews are to be at least quarterly to determine reduction. Review of the electronic health record (EHR) showed Resident 13 was admitted to the facility on [DATE] with diagnoses to include dementia (term for decline in mental abilities…

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 psychotropic medications (medications affecting the mind) were prescribed to treat a specific condition for 2 of 5 sampled residents (Residents 13 and 115) when reviewed for unnecessary medications. This failure placed residents at risk for avoidable side effects, chemical restraint, and a diminished quality of life. Findings included.Resident 13 Review of the facility's policy Psychotropic Medication Use revision date 03/01/2025 showed under section 7, All medications used to treat behaviors must have clinical indication and be monitored for efficacy, risks, benefits and harm or adverse consequences, and under section10, If provider orders psychotropic medication in the absence of a diagnosis, the facility should ensure that the ordering prescriber reviews the medication plan and consider a gradual dose reduction (GDR). Review of the electronic health record (EHR) showed Resident 13 was admitted to the facility on [DATE] with diagnoses 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 interview and record review, the facility failed to implement their written abuse policies by failing to identify potential mental abuse for 1 of 3 sampled residents (Resident 46) when reviewed for abuse. Additionally, the facility failed to conduct and/or obtain reference checks/information from previous or current employers prior to hire for 5 out of 5 sampled staff (Staff D, Staff JJ, Staff C, Staff HH, and Staff H) and to complete timely criminal background checks for 2 out of 5 sampled staff (Staff D and C) when reviewed for abuse and neglect prevention. These failures placed the residents at risk for abuse, mental suffering, and a diminished quality of life. Findings included .Review of the facility's policy titled, Abuse Prohibition, revised on 10/25/2024 showed the center/facility would implement an abuse prohibition program that included;Screening of potential hires;Identification of possible incidents or allegations which need investigation;Investigation of incidents and allegations;Protection…

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 and report an allegation of abuse for 1 of 3 sampled residents (Resident 46) when reviewed for abuse. This failure placed the resident at risk of further abuse, psychological distress, and diminished quality of life. Findings included .According to the Nursing Home Guidelines also known as the Purple Book, sixth edition, dated October 2015, reporting requirements included that staff to resident abuse, neglect, mistreatment, sexual or physical abuse/assault were to be reported to the Department of Social and Health Services (DSHS) state hotline, the police, and logged on the DSHS reporting log within five days Review of the facility's policy titled, Abuse Prohibition, revised on 10/25/2024 showed the center/facility would implement an abuse prohibition program. Review showed, Mental Abuse includes, but not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal…

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 implement a comprehensive plan of care for 2 of 22 sampled residents (Residents 8 and 17) when reviewed for care plans. These failures placed the residents at risk for unmet care needs and a decreased quality of life. Findings included.Resident 8 Review of the Electronic Health Record (EHR) showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (Bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), major depression, anxiety, psychotic disorder with delusions ( fixed, false beliefs held with extraordinary conviction despite clear evidence of the contrary) and cognitive communication deficit. Resident 8 was not always able to communicate needs. Review of the provider's orders dated 12/31/2025 showed Resident 8 was to have nothing by mouth (NPO) status. Observation on 01/05/2026 at 9:55 AM, showed Resident 8 in their room with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a device to prevent pressure ulcers was applied per provider's order for 1 of 3 residents (Resident 114) when reviewed for pressure ulcers. This failure placed residents at risk for avoidable skin injury, pain, decrease in activities of daily living, and a diminished quality of life.Findings included. Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of stroke where part of the brain dies because its blood supply gets blocked), high blood pressure, and atherosclerosis (narrowing of blood vessels, restricting blood flow) of both legs. Resident 114 was able to make needs known. During an interview on 01/07/2026 at 9:15 AM, Resident 114 stated their left heel was sensitive and they were supposed to wear a boot on their left heel, but the staff forgot about it. Resident 114 stated that staff had told them a couple of times 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 observation, interview, and record review, the facility failed to provide quality of care related to monitoring of resident weights, bowel management/treatments, or edema management/treatment for 4 of 22 sampled resdients (Residents 5, 2, 13, and 99) when reviewed for quality of care. This failure placed residents at risk of unintended weight loss, untreated constipation, discomfort, unmitigated swelling, and a diminished quality of life. Findings included.Resident 5 Resident 5 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mental health condition with significant mood swings) and adult failure to thrive (significant decline in health and functional abilities). Resident 5 was able to make needs known. Review of Resident 5's electronic health record (EHR) showed Resident 5 weighed 147 pounds on 11/10/2025 and 123 pounds on 12/02/2025. Review of a progress note dated 12/05/2025 showed, Weight warning: MDS: five percent change over 30 days. Resident noted with variable…

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 the root cause of a fall, ensure new interventions were appropriately developed or timely initiated and analyzed in an effort to prevent future falls, failed to maintain safe food storage in a resident's personal refrigerator, and/or left unsecured chemicals in a resident's bathroom for 2 of 5 sampled residents (Residents 114 and 40) when reviewed for accidents. These failures placed residents at risk of injuries, foodborne illness, negative outcomes, and a diminished quality of life.Findings included. <Falls> Resident 114 Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of stroke where part of the brain dies because its blood supply gets blocked), high blood pressure, muscle weakness, and acquired absence of right leg above the knee. Resident 114 was able to make needs known. During an interview on 01/05/2026 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 interview, and record review, the facility failed to ensure residents with significant weight loss were identified, assessed and that interventions were implemented for 1 of 5 sampled residents (Resident 5) when reviewed for nutrition. This failure placed the resident at risk of malnourishment, poor healing, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mental health condition with significant mood swings) and adult failure to thrive (significant decline in health and functional abilities). Resident 5 was able to make needs known. Review of Resident 5's EHR showed Resident 5 weighed 147 pounds on 11/10/2025 and 123 pounds on 12/02/2025. Review of a progress note dated 12/05/2025 showed, Weight warning: MDS: five percent change over 30 days. Resident noted with variable meal intake, order placed to reweigh. Review of the EHR showed no documentation Resident 5…

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 enteral nutrition (the delivery of nutrients through a feeding tube directly into stomach or small intestines) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 8) when reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of formula (liquid food product) and water a resident receives was reconciled with the amount they were ordered to receive. This failure placed the Resident at risk for inadequate nutrition, dehydration, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), major depression, anxiety, and cognitive communication deficit.…

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 pain management that is consistent with professional standards for 2 of 3 residents (Residents 99 and 17) when reviewed for pain management. Failure to administer pain medications per providers ordered parameters placed the residents at risk for uncontrolled pain and decreased quality of life. Findings included.Resident 99 Review of the electronic heath record (EHR) showed Resident 99 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), and chronic venous hypertension of unknown cause (high pressure in leg veins due to faulty valves, causing swelling, pain, skin changes, cramps, and ulcers/open wound) with ulcer of bilateral lower extremity (both lower legs/ankles/feet), and fibromyalgia (a long-term condition causing the brain and spinal cord to become overly sensitive to pain signals, amplifying them). Resident 99 was able to make needs known. During an interview on 01/06/2026 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made in twenty-seven opportunities equaling a 7.4% medication error rate during medication administration for 2 of 3 sampled residents (Residents 7 and 52) when reviewed for medication administration. This failure placed the residents at risk of receiving medications that were not effective or less effective and a diminished quality of life. Finings included. Observation on 01/09/2026 at 8:14 AM, showed Staff Y, Licensed Practical Nurse (LPN), administering medications to include vitamin C 500mg to Resident 7. Review of the January 2026 medication administration record (MAR) showed Resident 7 did not have an order for Vitamin C 500mg and had received the wrong medication. Review of the January 2026 MAR showed Resident 7 had an order for cyanocobalamin (vitamin B12) 500mcg that was not administered. Observation on 01/09/2026 at 7:57 AM showed Staff K, LPN, administering medications to Resident 52 to include Folic acid 1000mcg…

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 secure (lock) 1 of 4 treatment Carts (Cart South 2) and 1 of 6 medication Carts (Cart South 3) when reviewed for medication storage. This failure placed residents at risk for medication diversion and misuse, lack of safety, poisoning, and a diminished quality of life. Findings included.Review of the Facility's policy titled, Storage of Medications, revised on November 2020, showed, Drugs and biological used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Observation on 01/07/2026 at 10:56 PM, showed the treatment Cart South 2 was unlocked without nurse supervision for 10 minutes. Staff X, Licensed Practical Nurse (LPN), was called to lock the cart. During an interview on 01/07/2026 at 11:00 PM, Staff X stated the nurse responsible for Cart South 2 was on break. Staff X stated the cart should have been locked. Observation on 01/09/2026 at 7:38 AM, 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 interview and record review, the facility failed to provide COVID-19 immunizations for 2 of 7 residents (Residents 26 and 19) reviewed for COVID-19 immunization. This failure placed the residents at an increased risk for complications related to COVID-19 infection that could result in severe illness or death. Findings included.Review of the facility policy titled Coronavirus Disease (Covid-19) - Vaccination of Residents undated, showed each resident would be offered the Covid-19 vaccine and if the resident or their representative consents to the vaccine the facility would provide the vaccine at the facility or arrange with an outside service. Resident 26Review of the electronic health record (EHR) showed Resident 26 admitted to the facility on [DATE] with a diagnosis of diabetes (when the body cannot process sugars) and had consented to receive the Covid-19 vaccine on 12/16/2025. No documentation was found in the EHR of the administration of the vaccine. Resident 19Review of the EHR showed Resident 19…

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 have psychotropic medication (medications that affect a person's mental state) consents completed, signed, and in place prior to residents receiving these medications for 3 of 5 sampled residents (Residents 92, 87, and 2) reviewed for unnecessary medication use. This failure placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life. Findings included . Resident 92 Review of the electronic health record (EHR) showed Resident 92 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 12/19/2024, showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness). Review of Resident 92's January 2025 medication administration records (MAR) from 01/01/2025 - 01/23/2025 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 observation, interview, and record review, the facility failed to obtain provider's order, assessment and consent for the use of low bed for 3 of 3 sampled residents (Residents 86, 74 and 89) reviewed for use of physical restraints. This failure placed the residents at risk for injury, unmet needs and a diminished quality of life. Findings included . Review of the facility's policy titled Use of Restraints, revised April 2017, showed, (1) Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body [ .] (9) Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Resident 86 Review of the electronic health record (EHR) showed Resident 86 was admitted to the facility on [DATE] with diagnoses to include intracranial…

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 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarterly MDS, dated [DATE], showed Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and osteoarthritis (a condition that causes pain, stiffness, and reduced movement in the joints). During an interview on 01/22/2025 at 11:50 AM, Resident 77 stated about five months ago a man creeped into their room, the man had a mental problem, and staff were aware. During a follow-up interview on 01/23/2024 at 10:04 AM, Resident 77 stated about six months ago they heard the door to their room shaking, a white man with white hair kicked the door open, they told the man to get out, and they told staff about it. Review of the facility's incident reporting log from August 2024 through January 24, 2025, showed no incident logged for a resident-to-resident altercation for Resident 77. Review of the facility'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 ensure an ordered intervention (Low Air Loss Mattress - LALM, a mattress used to redistribute pressure evenly and can help prevent pressure ulcers, also known as bedsores) was being monitored and used as directed in the prevention of pressure ulcers for 3 of 7 residents (Residents 73, 83, and 18) when reviewed for pressure wound related interventions. This failure prevented the facility implementing the plan of care that included the needed intervention (LALM) to promote wound healing and prevent decline. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) dated 02/20/18, described/defined that a suspected deep tissue injury as: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury can result from prolonged pressure and may either resolve or develop into further tissue loss. Findings included . Review 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.

Based on observation, interview, and record review, the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days when reviewed for staffing. This failure placed the residents at risk for delayed assessments/treatments and a diminished quality of care. Findings included . Review of the working nursing schedule for the month of July 2024 showed no RN scheduled for 23 of 31 days. Review of the working nursing schedule for the month of August 2024 showed no RN scheduled for 19 of 31 days. Review of the working nursing schedule for the month of September 2024 showed no RN scheduled for 18 of 30 days. During an interview on 01/29/2025 at 9:36 AM, Staff Q, Staffing Coordinator, stated they did their best with the RN nurses that were available and were scheduled, and the facility just did not have enough. During an interview on 01/30/2025 at 10:15 AM, via electronic communication, Staff B, Director of Nursing Services, stated the expectation was for the staffing coordinator to prioritize RN coverage. Staff B stated not having…

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 48 Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), quadriplegia (paralysis or loss of ability to move all four limbs), radiculopathy (a condition whereas one or more nerve roots in the spinal column becomes compressed and irritated), anxiety and depression. The electronic health record (EHR) showed Resident 48 was able to make needs known and was dependent on staff for all activities of daily living. Review of Resident 48's current care plan, multiple dates, showed the resident exhibited or was at risk for alterations in comfort related to chronic pain and musculoskeletal disorder. Interventions on the care plan documented licensed nurses (LN) were to monitor for pain and attempt NPI to alleviate pain and document effectiveness. Review of Resident 48's MAR for January 2025 showed 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 ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . <Self-Identify Areas of Concern> Refer to the following citations identified during the Long Term Care survey, dated 01/29/2025, which were not identified or were identified and not addressed. (D = Isolated, E = Pattern): REFER TO F609 (E) Reporting of Alleged Violations. The Long Term Care survey dated 01/29/2025: the facility failed to identify and investigate allegations of abuse/neglect for 6 of 7 sampled residents. REFER TO F686 (E) Treatment/Services to Prevent/Heal Pressure…

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 periodically review a resident's advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) and obtain and maintain court-appointed guardianship (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) documentation for 1 of 2 sampled residents (Resident 77) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decision maker, lack of ability to direct care, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 11/15/2024, showed Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations and interview, the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 sampled residents (Resident 62) reviewed for environment. Failure to ensure a wheelchair was in good repair placed the resident at risk for infections, injuries, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed that Resident 62 readmitted to the facility on [DATE] with diagnoses to include cancer and depression and was able to make needs known. Observation and interview on 01/23/2025 at 9:30 AM showed both armrests on Resident 62's wheelchair had multiple cracked areas in the vinyl with exposed beige material underneath which created an uncleanable surface. Resident 62 stated it was their personal wheelchair and eventually the material on the armrests just cracked. Follow-up observation and interview on 01/29/2025 at 10:54 AM showed Resident 62's wheelchair armrests continue to be in disrepair. Resident 62 stated both armrests on their…

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 a resident was free from neglect when it prevented transfer out of a power wheelchair for three nights, prevented wound care during that time and caused distress related to transfer assistance from staff for 1 of 7 sampled residents (Resident 78) reviewed for abuse/neglect. This failure placed facility residents at risk of not receiving required care and services and a decreased quality of life. Findings included . Review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management . All allegations are thoroughly investigated. The administrator initiates investigations. Resident 78…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written notification of the reason for hospital transfer to the resident or responsible party and/or Washington State Long-Term Care Ombudsman program (Ombuds) for 2 of 4 sampled residents (Resident 81 & 13) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged . Findings included . Review of the electronic health record (EHR) showed Resident 81 admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain) and diabetes (too much sugar in the blood). Resident 81 was able to make needs known. Review of Resident 81's EHR showed a hospitalization on 01/21/2025, and readmission to the facility on [DATE]. The EHR did not show documentation a notice of transfer was provided to Resident 81 or their representative. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 81 and 13) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 81 admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain) and diabetes (too much sugar in the blood). Resident 81 was able to make needs known. Review of Resident 81's EHR showed a hospitalization on 01/21/2025, and readmission to the facility on [DATE]. The EHR did not show documentation or progress notes related to a bed hold for the hospitalization. During an interview on 01/23/2025 at 12:46 PM, Staff D, Business Office Manager (BOM), stated it was their responsibility to follow up on bed holds;…

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 the status for 1 of 5 sampled residents (Resident 41) reviewed for Pre-admission Screening and Resident Review (PASARR, a mental health screening tool). This failure had the potential to place the resident at risk for not receiving the care and services required to meet their needs. Findings included . Review of electronic health record (EHR) showed Resident 41 was admitted to the facility on [DATE] with diagnoses to include anxiety, chronic obstructive pulmonary disease (disease that blocks airflow and make it difficult to breath), depression, and personality disorder (mental and behavioral disorder associated with significant distress or disability and have negative impact on the quality of life). Resident 41 was able to communicate needs. Review of the PASARR, dated 05/07/2020, showed Resident 41 had a level 2 evaluation and required special interventions and follow up by a provider. Review of the minimum data set assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a mental health screening tool) assessments were accurately or timely completed for 2 of 7 sampled residents (Residents 92 & 360) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs and a diminished quality of life. Findings included . Resident 92 Review of the electronic health record (EHR) showed that Resident 92 admitted to the facility on [DATE] and was able to make needs known. Review of the admission minimum data set assessment (MDS), an assessment tool, dated 09/26/2024, showed Resident 92 had diagnoses of depression and insomnia. It showed Resident 92 received antianxiety, antidepressant, and hypnotic (used to induce sleep) medications. The quarterly MDS dated [DATE] showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness). Review of Resident 92's level 1 PASARR,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 2 of 24 sampled residents (Residents 39 & 84) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to impaired vision and smoking status placed residents at risk of unmet care needs and potential negative outcomes. Findings included . Resident 39 Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (too much sugar in the blood), and anxiety disorder. Resident 39 was able to make needs known. Review of the annual minimum data set assessment (MDS), an assessment tool, dated 09/07/2024 showed in Section B that Resident 39 had impaired vision with no corrective lenses. It showed in Section V that Resident 39's care area assessment was triggered to have a care plan for visual function developed.…

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 conduct timely care planning meetings with residents or responsible party for 2 of 4 sampled residents (Residents 48 & 77) reviewed for care planning. These failures placed residents at risk for unmet needs, care not provided as directed, and a diminished quality of life. Findings included . Resident 48 Review of the electronic health record (EHR) showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), quadriplegia (paralysis or loss of ability to move all four limbs) and depression. Resident 48 was able to make needs known and was dependent on staff for activities of daily living. During an interview at 01/22/2025 at 1:21 PM, Resident 48 stated they did not recall having a recent care conference. During an interview on 01/23/2025 at 12:11 AM, Staff S, Social Service Director, stated Resident 48's last care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to meet professional standards of practice for diagnosing residents with mental health disorders 1 of 5 sampled residents (Resident 2) reviewed for use of unnecessary medications. This failure placed the resident at risk for unmet needs, complications, and diminished quality of life. Findings included . Review of electronic health record (EHR) showed Resident 2 was admitted to the facility on [DATE] with diagnoses to included diabetes (high sugar in the blood), heart failure, depression and suicidal ideation. Resident 2 was able to communicate needs. Review of the EHR showed Resident 2 received a level 2 Pre-admission Screening and Resident Review (PASARR, a mental health screening tool). Review of the PASARR level 2 showed, 2) why is [Resident 2] on quetiapine (psychoactive medication)? Admiting MD (physician) note states this is for 'schizophrenia' (mental disorder that affects a person's ability to think, feel and behave clearly), but…

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 a mobility device was available for 1 of 5 sampled residents (Resident 4) when reviewed for mobility. The facility failed to implement a bowel program for 2 of 5 sampled residents (Residents 24 and 108) reviewed for bowel management. These failures placed the residents at risk for unmet needs, worsening condition, and decreased quality of life. Findings included . <Mobility Device> Resident 4 Review of the electronic health record (EHR) showed Resident 4 was admitted to the facility on [DATE] with diagnoses to include malignant melanoma (skin cells that become cancerous), malnutrition, depression and diabetes (high sugar in blood). Resident 4 was able to make needs known. Observations on 01/22/2025 and 01/24/2025 showed Resident 4 lying in bed, naked. During an interview on 01/23/2025 at 9:40 AM, Resident 4 stated they did not get out of bed because the facility had not provided them a wheelchair which matched their height.…

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 risk factors were consistently monitored and addressed to minimize the risk for accident hazards for 2 of 7 residents (Residents 94 and 86) when reviewed for accident hazards. The failures to consistently monitor and ensure a wanderguard devices was functional for Resident 94 and to identify and minimize the risk factors for falls for Resident 86 placed them at risk for potential injury, negative outcomes and decreased quality of life. Findings included . Review of a facility's policy titled, Tab Alarms, Bed Alarms, Wanderguard System, dated 12/12/2024, showed the wanderguard (a wearable device used to monitor and alert caregivers when a resident with dementia or cognitive impairment attempts to leave a safe area) would be used for residents at risk for elopement (when a resident identified as wandering leaves the facility without staff knowledge or authorization). A plan of care must be formulated with the Interdisciplinary Team…

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 facility's Registered Dietician's (RD) recommendations were administered as ordered to prevent continued weight loss for 1 of 3 sample residents (Resident 73) reviewed for nutrition. This failure placed the residents at risk for unmet nutritional needs and continued weight loss. Findings included . Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 12/12/2024 showed that Resident 73 admitted on [DATE] with diagnoses to include heart and lung disease, hospice (end of life care), dementia (progressive decline in brain functions), and malnutrition. Review of the electronic health record (EHR) showed the resident was able to make needs known, received hospice care (care provided to sick or terminally ill residents), was dependent and required substantial/maximal assistance by staff to assist with meals. Review of a Registered Dietitian (RD) assessment dated [DATE] showed Resident 73 would benefit from increased…

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 respiratory care consistent with provider orders for 1 of 2 sampled residents (Resident 59) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed residents at risk for unmet needs and potential negative outcomes. Findings included . Review of the electronic health record (EHR) showed Resident 59 admitted to the facility on [DATE] with diagnoses that included dementia (a condition affecting memory, thinking and social abilities) and asthma. Resident 59 used oxygen therapy. Review of current provider orders, dated January 2025, showed Oxygen at 1-2 liters per minute by nasal canula every day and night shift. Observations throughout the day on 01/23/2025 and 01/24/2025 showed an unused O2 concentrator with no oxygen tubing in the corner of the room. Resident 59 was not observed wearing a nasal canula or using oxygen. During an interview on 01/24/2025 at 1:03 PM, Resident 59 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 pain medication per provider's order to ensure a resident was able to participate in physical therapy services for 1 of 5 sampled residents (Resident 24) reviewed for position and mobility. This failure placed residents at risk of decreased mobility, increased pain, unidentified and unmet care needs, and a diminished quality of life. Findings included . Review of the facility's document Pain Protocol, dated October 2022, showed the nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a chronic neurological disorder), pressure ulcer of right hip (a deep wound that may impact muscle, tendons, ligaments, and bone), chronic…

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 act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 92) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 92 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 12/19/2024 showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness). Review of Resident 92's provider orders showed an order dated 09/19/2024 for Clonazepam (antianxiety medication) 0.5 milligrams (mg) two times a day for anxiety and an order dated 11/15/2024 for Zolpidem Tartrate (a hypnotic medication used 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 interview and record review, the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontinue a medication) were free from excessive dosages and durations without adequate monitoring and indications for use, or in the presence of adverse consequences, related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents (Resident 94) and failed to monitor for psychoactive medication side effects for 2 of 5 sampled residents (Residents 87 and 92) when reviewed for unnecessary medication use. The facility's failure to monitor behaviors and side effects and conduct GDR related to use of psychoactive medications placed the residents at risk for adverse side effects, medical complications, and a diminished quality of life. Findings included . <Gradual Dose Reduction> Review of a policy titled, Tapering Medications and Gradual Drug Dose Reduction, dated July 2022, showed after medications were ordered for a resident, the staff and provider shall seek 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 observation, interview and record review the facility failed to ensure medications were properly labeled and stored prior to medication administration, in accordance with accepted professional standards, in 1 of 4 medication carts reviewed. This failure placed residents at risk of medication errors and potential adverse events. Findings included . According to Elsevier Clinical Nursing Skills & Techniques, 8th edition, p. 495 (Mosby 2014), when administering oral medications, nurses are to follow the five rights of medication administration (right patient, right drug (medication), right dose, right route, and right time), and to prepare medications for one patient at a time. Review of the facility's policy, Medication and Treatment Administration Guidelines, revised [DATE], documented medications are to be administered in a safe and timely manner and as prescribed. On [DATE] at 4:57 PM, Staff C, Registered Nurse (RN), was observed at a medication cart parked on 200 Hall. On top of the cart 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 interview and record review, the facility failed to ensure dressing changes were completed as ordered by the provider for 1 of 3 sample residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of unmet needs, decline in status, and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including high blood pressure, a stroke, and one-sided paralysis. The Minimum Data Assessment, an assessment tool, dated 04/04/2024, documented Resident 1 was alert and non-verbal, and required substantial assistance with activities of daily living. Review of Resident 1's record showed an order dated 12/20/2024 for wound care and dressing changes to one of Resident 1's feet to be done two times a day and as needed. The dressings were to be done at 7:00 AM and at 5:00 PM every day. Review of Resident 1's Treatment Administration Record for December 2024 showed blanks or spaces without documentation for the 5:00 PM…

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 consents were obtained for 2 of 5 residents (Residents 1 and 2) reviewed for consents for Wanderguard (a device worn on or close to the resident's body designed to alarm when the resident came within close proximity to an alarmed exit door), and failed to ensure physician orders and consents were obtained for 2 of 5 sampled residents (Residents 3 and 4) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . Record review of the facility's policy entitled, Use of Restraints, revised April 2017, documented, 1. Physical Restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 9. Restraints shall only be used upon the written order 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.

Based on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 29 of 29 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the daily nursing staff forms for May 2024 provided by Staff C, Staffing Coordinator, on 05/30/2024, showed no RN coverage for the following dates: 05/04/2024, 05/05/2024, 05/10/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 05/25/2024, and 05/26/2024. The daily nursing staff forms for the remainder days of May 2024 showed 8-hour RN coverage only. In an interview on 05/30/2024 at 2:15 PM, Staff B, Director of Nursing Services (DNS)/RN, said they were aware the facility did not provide 24-hour RN coverage. Staff B said there were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents. The facility had insufficient staff to ensure residents received assistance with Restorative services, Activities of Daily Living (ADL), and call light response in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident Council Review of the RC meeting minutes for November 2023 showed residents reported longer than expected wait times during the night shift for their call light to be answered. Restorative During an interview on 01/23/2024 at 11:24 AM, Resident 68 stated that it required two staff to get them out of bed but there's never enough help. During an interview on 01/23/2024 at 9:47 AM, Staff Q, Restorative Nursing Aid, stated that they conducted restorative Mondays,…

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 an infection prevention and control program to control and prevent the transmission of a communicable disease by ensuring the proper application of transmission-based precautions (TBP) for 2 of 2 hallways (North and South) and to ensure the proper use and fit of personal protective equipment (PPE) by staff during an outbreak of a respiratory virus. The facility also failed to provide laundry services in a safe and sanitary manner. These failures placed residents, visitors, and staff at risk for a communicable disease, infections, and a decreased quality of life. Findings included . North Hall Review of the facility's outbreak line list map dated 01/21/2024 showed seven residents (Residents 364 on the north hall and Residents 29, 361, 94, 38, 50 and 97 on the south hall) tested positive for Covid-19 (a highly contagious respiratory virus) on 01/19/2024. Review of a facility email dated 01/19/2024, which contained recommendations…

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 conduct timely care planning meetings with the resident or responsible party for 2 of 24 residents (Residents 38 and 49) reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and decreased quality of life. Findings included . Resident 38 During an interview on 01/22/2024 at 10:28 AM, Resident 38 stated that they did not have a recent care conference. Review of the electronic health record (EHR) showed the last care plan meeting was held on 03/02/2023. Resident 49 During an interview on 01/21/2024 at 11:13 AM, Resident 49 stated that they did not believe they had a care conference. Review of the EHR showed the last care plan meeting was on 06/05/2023. During an interview on 01/25/2024 at 11:54 AM, Staff A, Administrator (ADM), stated that the facility had been without Social Services staff and that was why care conferences were not completed. Staff A stated that it was their expectation that care conferences were held every three months or…

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 services to assist residents with activities of daily living (ADL) for 5 of 24 residents (Residents 88, 4, 12, 26, and 48) reviewed for activities of daily living. Failure to provide showers as scheduled (Residents 88, 4, 12, and 26) and assistance to get out of bed (Resident 48) placed the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of a document titled, Bath, Shower/Tub [Personal Care], dated February 2018, showed that the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The document showed that the facility staff were to date and time the shower/tub bath was performed, the name and titled of the individual(s) who assisted the resident with the shower/tub bath, conduct an assessment data of any reddened areas, sores, etc, on the residents skin, how the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide care which met professional standards for 5 of 24 residents (Residents 14, 38, 71, 59, and 48) when reviewed for quality of care. The facility's failure to consistently monitor and document bowel movements and implement the bowel program when needed (Residents 14, 38, 71, and 59), failure to monitor for adverse side effects (Resident 38), failure to identify and monitor a skin condition (Resident 48) placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Bowel Program Resident 14 Review of the annual minimum data set (MDS), a required assessment tool, dated 10/08/2023, showed resident was able to make needs known and was diagnosed with chronic pain and constipation. During an interview on 01/22/2024 at 9:18 AM, Resident 14 stated that they had constipation, it was a problem and sometimes would have three days without a bowel movement (BM). Review of a care plan dated 03/06/2023 showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 residents (Residents 71, 26, 2, 59, and 38) reviewed for unnecessary medications. Failure to provide nonpharmacological interventions prior to as needed pain medications (Residents 38, 26, 2, and 59) and to monitor for anticoagulation (blood thinning) side effects (Resident 71) placed the residents at risk for unintended side-effects related to the medications, medical complications, and a diminished quality of life. Findings Included . <Anticoagulation> Review of a document titled Anticoagulation - Clinical Protocol revised November 2018 showed, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situations with the physician before giving the next…

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 adequate monitoring and assessment of medications for mental health for 4 of 5 residents (Residents 81, 5, 12 and 26) when reviewed for unnecessary medications. Lack of meetings to discuss medications (Residents 81 and 5), lack of blood pressure monitoring (Resident 12) and prolonged use of as needed medications (Resident 26) placed residents at risk of receiving unnecessary medications, avoidable side effects, and a diminished quality of life. Findings included . Resident 81 During an interview and observation on 01/22/2024 at 11:05 AM, Resident 81 stated that they were concerned that people were looking into the bathroom window and invading their privacy. Observation showed a fogged window in the bathroom that could not be seen through. Resident 81 stated that they were concerned about the black things crawling in the corners of the room and pointed to a nearby corner. Observation showed that there was nothing in the indicated…

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 maintain a safe and sanitary food storage program in 1 of 1 facility kitchen reviewed for food safety. This failure placed residents at risk of foodborne illness and a diminished quality of life. Findings included . Observation on 01/21/2024 at 10:14 AM showed a small shelf next to the grease hood in the facility kitchen which held a personal cellular phone. Observation on 01/21/2024 at 11:35 AM showed a facility kitchen staff in the dishwashing area of the kitchen using their personal cellular phone. Observation of the North resident refrigerator on 01/21/2024 at 12:50 PM showed the following: 1) A half consumed frozen drink without name or date; 2) A box of taquitos opened without seal undated; 3) A bag of cauliflower wings without label; 4) A bag of frozen yellow substance without identifying label, name or date; 5) A bag of fried chicken with the dates 01/17/2024 and 01/20/2024; 6) A bag with a sandwich wrapped in a napkin with dates 01/04/2024 and 01/06/2024; and 7) A paper bag with the dates 01/08/2024…

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

Based on interview, the facility failed to maintain a qualified social worker on a fulltime basis. This placed residents at risk of a lack of medically related social services and a diminished quality of life. Findings included . During an interview on 01/23/2024 at 9:39 AM, Staff A, Administrator, stated that Staff D, Social Services, was the only social worker that worked in the facility as the facility was between social workers. Staff A stated that the facility had lacked a fulltime social worker for a month and Staff D would come to the facility a couple of days a week. During an interview on 01/25/2024 at 2:14 PM, Staff D stated that they had been the only social worker for the facility for around a month. Staff D further stated that they did not have enough time to provide all needed social services to the facility's residents. Reference WAC 388-97-0960 (2)(a)(b) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain an informed consent prior to psychotropic (affecting the brain) medication usage for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure had the potential for the resident or their legal representatives to have lack of knowledge to make an informed decision regarding use of these medications. Findings included . Review of the facility's policy titled, Psychotropic Medication Use Drugs, dated July 2022, showed that residents and/or the resident's representative(s) would be informed of risks and benefits prior to initiation of a psychotropic medication and had the right to decline treatment with the psychotropic medication. Review of the quarterly Minimum Data Set (MDS), a required assessment tool, dated 06/20/2023, showed Resident 12 admitted to the facility on [DATE] with multiple diagnoses to include psychosis (a mental disorder characterized by a disconnection from reality). Review of the physician's order,…

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

Based on interview and record review, the facility failed to address grievances/concerns raised by the Resident Council group for 3 of 3 months (October 2023, November 2023, and January 2024) when reviewed for Resident Council. Failure for administrative staff to act upon grievances voiced by the Resident Council and failure to report back to the council in writing for a response, rationale and action taken on grievances placed residents at risk for continued concerns, unmet needs, and a diminished quality of life. Findings included . During an interview on 01/24/2024 at 9:52 AM, Resident 45, Resident Council President, stated that there had been concerns brought up in the Resident Council (RC) meetings that had not been resolved nor had the RC attendees been updated on the status of the grievances. Resident 45 stated that, most recently, residents had complained about dirty bed linen, long call lights and noisy staff on night shift; however, they were unaware if management had investigated the concerns. Resident 45 stated that when a grievance was investigated it sometimes took…

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 obtain or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 2 of 24 residents (Residents 22 and 65) reviewed for AD. This failure placed the residents at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences. Findings included . Resident 22 Review of Resident 22's electronic health record (EHR) showed a Physician's Orders for Life Sustaining Treatment (POLST) titled as AD. The EHR did not show documentation of the resident requesting or declining the completion of an AD nor that the facility offered assistance in the development of an AD. Resident 65 Review of Resident 65's EHR showed a POLST titled AD. The EHR did not show documentation of the resident requesting or declining the completion of an AD nor that the facility offered assistance in the development of an AD. During an interview on 01/25/2024 at 10:42 AM, Staff D, Social Services, stated that staff thought 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.

Based on observation, interview and record review, the facility failed to provide clean sheets and/or reasonable care for personal property for 5 of 5 residents (Residents 12, 13, 35, 68 and 86) when reviewed for safe, clean, and comfortable environment. This failure placed the residents at risk for loss of personal property, a diminished sense of security, possible infections, and a diminished quality of life. Findings included . Clean Sheets Observation on 01/25/2024 at 9:52 AM showed Resident 86's flat sheets contained crumbs and several stains. Resident 86 stated that their bed sheets were changed approximately every other week, sometimes longer. Observation and interview on 01/25/2024 at 12:22 PM showed Resident 35 had stains on their flat sheet. Resident 35 stated that bed linen was changed when they got a shower and that when there was COVID on the hall showers were not given. Resident 35 further stated that they had gone two to three weeks without the bed linen changed and would prefer to have it changed once per week. During an interview on 01/26/2024 at 9:37 AM, 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 complete a thorough investigation on an allegation neglect for 1 of 5 residents (Resident 68) reviewed for accidents and/or incidents. This failure placed residents at risk for unidentified neglect and continued exposure to neglect. Findings included . Review of Resident 68's admission Minimum Data Set assessment (MDS) dated [DATE], showed that the resident admitted on [DATE] with multiple diagnoses to include left hip pain and osteoarthritis left hip (a joint disease, in which the tissues in the joint break down over time). During an interview on 01/21/2024 at 1:58 PM, Resident 68 stated that the night shift nurse on 01/19/2024 refused to give them their pain medication stating the medication could only be administered every six hours. Resident 68 stated that they believed the nurse was prejudiced against narcotic use. During an interview on 01/21/2024 at 3:56 PM, the above detailed allegation was reported to Staff A, Administrator (ADM), Staff B,…

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 properly notify the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) or the resident/resident representative of discharges for 2 of 5 residents (Residents 159 and 22) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and to ensure that the SLTCO and residnt/ resident representative was aware of facility practices and activities related to transfers and discharges. Findings included . Resident 159 Review of the discharge minimum data set assessment, dated 01/08/2024, showed Resident 159 admitted on [DATE] with multiple diagnoses to include heart, lung, kidney disease and diabetes. The MDS and electronic health record (EHR) showed that the resident was discharge on [DATE] to a local hospital with a return to the facility anticipated and was able to make their needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) accurately reflected the current status for 2 of 5 residents (Residents 80 and 88) reviewed for PASRRs. This failure had the potential to place residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Resident 80 Review of Resident 80's medical diagnosis list showed that the resident had a diagnosis of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) on admission dated 01/27/2023. Review of Resident 80's PASRR, dated 01/27/2023, completed by the facility on the date of admission, showed no mental disorders checked on the form. Review of the physician orders on 01/23/2024 showed that Resident 80 was prescribed a medication related to Schizophrenia to be administered daily. During an interview on 01/23/2024 at 11:04 AM, Staff D, Social Service Director…

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 a resident fall and plan new interventions to decrease the chance of a fall or reduce injury from a fall for 1 of 1 resident (Resident 81) reviewed for accidents. This failure placed residents at risk for repeated falls, avoidable injury, and a diminished quality of life. Findings included . Observation and interview on 01/22/2024 at 11:07 AM showed Resident 81 had a large lump with a scabbed wound on their forehead. Resident 81 stated that they had fallen and had been taken to the hospital. Review of a 01/06/2024 progress note showed that Resident 81 had fallen, sustained a head hematoma (a large bruise) and laceration (a deep cut) and was sent to the emergency department. Review of Resident 81's 05/15/2023 initiated care plan showed a focus area related to falling. This focus area showed that the most recently implemented intervention was dated 10/31/2023 with all other interventions dated 05/15/2023. Review 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 dialysis (a process to remove waste from blood) care consistent with professional standards for one of one resident (Resident 40) reviewed for dialysis. This failure placed the resident at risk for adverse health outcomes, inadequate quality of care and decreased quality of life. Findings included . <Communication> Review of the admission Minimum Data Set (MDS, a required assessment tool) on 01/24/2024 showed that Resident 40 was admitted on [DATE] with multiple diagnoses to include kidney disease. Review of Resident 40's electronic health record (EHR) showed that the resident received dialysis weekly on Monday, Wednesday, and Friday. Review form Hemodialysis Communication Record, dated 01/03/2024, showed missing and/or incomplete information which included missing vital sign information. Communication forms were unable to be located for dialysis dates 01/05/2024, 01/10/2024, 01/15/2024 and 01/17/2024. During an interview 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 observation, interview and record review, the facility failed to ensure expired medications were removed/disposed of in accordance with professional standards for 1 of 3 medication carts (North Hall medication cart #3) reviewed for Medication Storage. This failure placed residents at risk of receiving expired medications. Findings included . Review of the facility's documentation titled, Medication Labeling and Storage dated February 2023 showed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation of the North Hall medication cart #3 with Staff T, Licensed Practical Nurse (LPN), on 01/21/2024 at 2:01 PM showed that the top drawer had one bottle of vitamin C, 250 milligrams (dietary supplement) expired in December 2023 and a bottle of aspirin, 81 milligrams (used to help prevent heart attacks and strokes) expired in November 2023. During an interview on 01/21/2024 at 2:17 PM, Staff T, LPN, stated that the expired bottles 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.

Based on interview and record review, the facility failed to provide routine dental care for 1 of 3 residents (Resident 19) reviewed for dental. This failure placed residents at risk for difficulty eating, dental pain, unintended weight loss, and a diminished quality of life. Findings included . Review of a 10/27/2023 dental consultation showed that Resident 19 received a recommendation for full extraction of the lower teeth and new lower denture. Further review showed that Resident 19 was agreeable to this plan. Review of a 11/20/2023 progress note showed that Resident 19 had one to three broken or decayed teeth. During an interview on 01/23/2024 at 10:57 AM, Staff E, Resident Care Manager, stated that dental recommendations were given to the facility's appointment scheduler to have them scheduled. Staff E further stated that the facility's appointment scheduler position had transferred to several people in the previous months. Staff E stated that they were unsure whether Resident 19 had had any follow-up on the 10/27/2023 recommendations. During an interview on 01/23/2024 at 11:28…

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 and follow up on an appointment for dental care services for 1 of 3 resident (Residents 49) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and decreased the quality of life. Findings included . Review of the quarterly Minimum Data Set (a required assessment) dated 12/19/2023 showed Resident 49 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, hemiplegia (one side of body affected with paralysis), muscle weakness, depression, and anxiety. In addition, the MDS showed the resident was able to make needs known and received hospice services. During an interview on 01/22/2024 at 10:12 AM, Resident 49's family member stated that the resident had lost weight and dentures did not fit well and was supposed to receive new dentures but did not know the status. Review of a document titled, Smile Seattle Dentures, dated 11/03/2022, showed multiple missing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to timely refer a resident to hospice services for 1 of 2 residents (Resident 160) reviewed for hospice. This failure placed the resident at risk of not receiving palliative services, unnecessary pain and suffering, and a diminished quality of life. Findings included . Review of Resident 160's census showed that the resident admitted on [DATE] and discharged on 09/03/2023. Review of Resident 160's physician's orders showed a referral for hospice services on 08/28/2023. Review of a care conference note dated 08/28/2023 showed that family and facility staff agreed that Resident 160 would be referred for hospice services. During an interview on 01/25/2024 at 9:50 AM, Staff D, Social Services, stated that the social services department would make referrals for hospice services. Staff D further stated that they could not find documentation that Resident 160 was referred for hospice services and this did not meet expectation. Staff D stated that there 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 interview and record review, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 residents (Residents 93 and 98) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life. Findings included . Review on 01/24/2024 of Resident 93's electronic health record showed that the resident consented to receive the influenza vaccine on 11/30/2023. Further review showed no vaccine had been ordered or administered. Review on 01/24/2024 of Resident 98's electronic health record showed that the resident consented to receive the influenza and pneumococcal vaccines on 12/21/2024. Further review showed no influenza and pneumococcal vaccines had been ordered or administered. During an interview on 01/25/2024 at 12:14 PM, Staff H, Infection Preventionist, stated that if a resident consented to the influenza or pneumococcal vaccines an order should have been entered into the resident's medical record and the vaccines 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 provide the bed-hold notice at the time of transfer to the hospital for 4 of 4 residents (Residents 1, 2, 3 and 4) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their beds while admitted in the hospital. Findings included . Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed that all residents or resident representatives were to be provided written information regarding the facility and state bed-hold policies which addressed holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). According to the policy, residents regardless of payer source were to be provided written notice about these polices at least twice: well in advance of any transfer; and at the time of transfer (or if the transfer was an emergency, within 24 hours). Resident 1 Review of Resident 1's discharge Minimum Data Set…

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 the discharge plan and ensure a safe and orderly discharge for 1 of 3 residents (Resident 2) reviewed for discharge planning process. This failure placed the resident at risk for unmet needs, medical complications, readmission to the hospital or skilled nursing facility and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled, Discharge Summary and Plan, revised December 2016, showed that every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The discharge plan will include where the individual plans to reside; arrangements that have been made for follow-up care and services; the degree of caregiver/support person availability, capacity, and capability to perform required care; and how the interdisciplinary team will support the resident or representative in the transition to post-discharge care. Review of Resident 2's admission…

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 in the management of a surgical wound for 1 of 3 residents (Resident 3) reviewed for wound management. This failure placed the resident at risk for worsening of the wound, infection, medical complications, additional surgery, rehospitalization, and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled, Skin Integrity Management, dated 05/26/2021 showed that the facility was to identify the resident's skin integrity status and the need for prevention or treatment modalities through review of all appropriate assessment information. The facility was expected to perform skin inspection on admission and weekly and perform daily monitoring of wounds or dressings for presence of complications or decline and to document if indicated. The policy and procedure indicated that in the management of surgical wounds, specific orders from the surgeon were to be followed. Review 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.

Based on interview and record review, the facility failed to maintain 8 hours of Registered Nurse (RN) coverage to directly supervise resident care, 24 hours a day, seven days a week for 65 of 91 days (from April 2023 through June 2023) reviewed for RN coverage. This failure placed all residents at risk to not have immediate access to assessments, care and services provided by an RN, a delay in care and treatment, unmet care needs and medical complications. Findings included . Review of the facility's daily staffing posting report for April 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 16 of 30 days reviewed for RN coverage. Review of the facility's daily staffing posting report for May 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 28 of 31 days reviewed for RN coverage. Review of the facility's daily staffing posting report for June 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 21 of 30 days reviewed for RN coverage. In an interview on 10/02/2023 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.

Based on interview and record review, the facility failed to ensure the direct care data for registered nurse (RN) hours were accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Fiscal Year (FY) 2023 3rd quarter, April 2023 through June 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report dated FY Quarter 3 2023 (April 1 - June 30) showed that result of No RN hour was not triggered. According to the CASPER report, the definition of triggered was Four or More Days Within the Quarter with no RN Hours. Review of the facility's daily nursing staffing report from April 2023 through June 2023 showed 59 of 91 days had no RN hours. Review of the RN Punch Detail timesheets…

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 properly implement the compliance and ethics program, prevent the submission of data know to be inaccurate and unethical practices for 1of 1 quarter (Fiscal Year Quarter 3, April 2023 through June 2023) reviewed for Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) reporting. This failure had the potential to negatively impact the nursing staffing levels and the care and services being provided to all the residents in the facility. Findings included . Review of the facility's Compliance Plan revised 10/17/2022, showed that the purpose of the plan was to promote the integrity of the facility's operations, educate staff as to the standards by which they must conduct themselves and to serve as a mechanism for preventing, identifying, and correcting any violation of laws and regulations and/or policy. The guidelines contained in the compliance plan were designed to assist staff in following laws and regulations, to correct violations and to provide guidance in making ethical choices in the work…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that addressed the use of an indwelling urinary catheter for 1 of 3 residents (Resident 1) reviewed for indwelling catheter care. This failure placed the resident at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 08/15/2023, showed Resident 1 admitted on [DATE] with diagnosis of Benign Prostatic Hyperplasia (prostate gland enlargement causing difficulty of urination). The MDS further showed that Resident 1 was incontinent of urine. Review of the Care Area Assessment (CAA) dated 08/15/2023 showed that the care area of urinary incontinence required a comprehensive care plan. Review of Resident 1's physician order summary from 08/09/2023 through 08/29/2023, showed that on 08/16/2023 Resident 1 received an order for insertion of an indwelling urinary catheter due…

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 completed discharge summary that included discharge instructions regarding indwelling urinary catheter (a catheter inserted and kept in the bladder to drain urine) care and follow-up referrals for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed the resident at risk for complications by not receiving the necessary information to ensure continuity of care when discharged to the community. Findings included . Review of Resident 1's electronic health records showed Resident 1 admitted on [DATE] and discharged on 08/29/2023. Review of Resident 1's progress note dated 08/25/2023 at 11:52 AM, showed that a staff from the senior living facility the resident was discharging to, came in to assess Resident 1's discharge needs. According to the progress note, the senior living facility staff advised that if Resident 1's indwelling catheter removal was successful, the resident could go back to the same level 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 ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 5 sampled residents (Resident 1 & 2) reviewed for care plan revisions. This failure placed the residents at risk for unidentified, unmet care needs and a diminished quality of life. Findings included . <Resident 1> Resident 1 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set, (MDS-an assessment tool), dated 08/07/2023, documented Resident 1 was severely cognitively impaired. Review of a delivery ticket dated 08/01/2023 showed the facility received delivery of a scoop mattress for Resident 1. The identified delivery ticket was scanned into the Electronic Health Record (EHR) on 08/01/2023. Review of a Fall Investigation, dated 08/10/2023, showed Resident 1 was observed on the floor with their leg on the bed. Review of the Fall Care Plan, created on 07/17/2023, documented Resident 1 was at risk for falls related to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure fall prevention strategies were implemented before a non-injury fall for 1 of 5 sampled residents (Resident 1) reviewed for accident hazards. This failure place residents at risk for injuries, unmet care needs, and a diminished quality of life. Findings included . Facility policy entitled Fall Management with an effective date of 05/26/2021 states, Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified fall and seizures. The Significant Change Minimum Data Set, an assessment tool, dated 08/07/2023, documented Resident 1 was severely cognitively impaired. Review of the Fall Risk Assessment in the Nursing Documentation Evaluation, dated 07/17/2023, documented Resident 1 had fall risk indicators identified. A delivery ticket…

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.