Puyallup Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a resident's bed fit them for 1 of 1 sampled resident (Resident 84) when reviewed for accommodation of need. This failure placed residents at risk of inability to sleep, decreased condition, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 84 admitted to the facility on [DATE] with diagnoses to include hemiplegia (difficulty moving one side of the body), repeated falls, and diabetes (too much sugar in the blood). Resident 84 was able to make needs known. Observation on 09/10/2025 at 9:53 AM showed Resident 84 laid in bed. Observation showed the footboard of the bed had been removed and Resident 84's feet hung off the bed with the back of the ankles resting on the bed. Observation on 09/15/2025 at 12:40 PM showed Resident 84's representative speaking with Staff M, Maintenance Director. Resident 84's representative stated Resident 84 had been waiting three weeks for a longer bed and Staff M…

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 and notify law enforcement for a physical abuse allegation with injuries for 1 of 3 sampled residents (Resident 45) reviewed for abuse and neglect. This failure placed residents at risk of physical and emotional harm, feelings of rejection and impaired quality of life. Findings included.Review of the Electronic Health Record (EHR) showed Resident 45 was readmitted to the facility on [DATE] with diagnoses to include acute respiratory failure, malnutrition (lack of sufficient nutrients in the body), depression, anxiety and seizure disorder (uncontrolled jerking, loss of consciousness, and other symptoms caused by abnormal electrical activities in the brain). Resident 45 was able to communicate needs. Observation and interview on 09/10/2025 at 9:45 AM showed Resident 45 in their room sitting on their wheelchair with worried facial expression and furrowed eyebrows. Resident 45 stated My knee hurts and they are not doing…

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 the following: medication parameters, non-pressure skin management, bowel management and anticoagulation management for 5 of 22 sampled residents (Residents 30,3, 9, 45 and 5) when reviewed for quality of care. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life. Findings included .Resident 5 Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnosis of stroke. The resident was unable to make their needs known. Review of the EHR showed an order for coumadin (a blood thinning medication) for blood clot prevention daily. Review of the plan of care on 09/10/2025 showed no active care plan for anticoagulant therapy. During an interview on 09/12/2025 at 9:20 AM, Staff E, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) stated Resident 5 should have had a care plan for anticoagulation therapy but did…

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 oxygen services per provider's orders for 1 of 3 sampled residents (Resident 48) when reviewed for respiratory services. This failure placed residents at risk of oxygen poisoning, decline in condition, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 48 admitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and diabetes (too much sugar in the blood). Resident 48 was able to make needs known. Review of the provider’s orders showed Resident 48 received oxygen at 2 liters per minute (L/m), dated 08/25/2025, and nursing staff was to verify the flow rate three times a day, dated 08/25/2025. Observation on 09/09/2025 at 12:43 PM, 09/11/2025 at 9:45 AM, and 09/15/2025 at 9:20 AM showed Resident 48 was receiving oxygen at 5 L/m.…

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 dental services to increase residents' ability to eat for 1 of 3 sampled residents (Resident 4) when reviewed for dental services. This failure placed the resident at risk of decreased nutritional intake, oral discomfort, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 4 admitted to the facility on [DATE] with diagnoses to include enterocolitis (inflammation of the intestines), malnutrition (insufficient nutritional intake), and adult failure to thrive. Resident 4 was able to make needs known. Observation and interview on 09/09/2025 at 10:24 AM showed Resident 4 had 2 teeth. Resident 4 stated the facility did not offer any dental services to them. Review of Resident 4's care plan, initiated 08/19/2025, showed no focus area related to dental. Review showed a focus area related to Resident 4 being at risk for nutritional problems, had a mechanically altered diet (a dietary…

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 laboratory services according to professional standards of practice for 6 of 18 Residents (Residents 3, 9, 10, 11, 12 & 13 ) reviewed for COVID-19 testing. The facility failure to obtain Physician Orders to conduct COVID-19 testing placed residents at risk of delayed identification/diagnosis of COVID-19. Findings included . COVID-19 is an infectious virus which causes respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. <Resident 3> Review of the June 2025 COVID-19 Reporting Line Listing showed Resident 3 tested positive for COVID-19 on 06/10/2025. Review of Progress Notes showed on 06/10/2025 at 4:54 AM, Resident was administered Tylenol for a fever of 101.9 degrees Fahrenheit (dF). A 06/10/2025 5:59 AM Nursing Note showed the resident had been coughing all night. Although the positive results were documented, 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and other infections for 18 of 32 Residents, (1, 2, 3, 4, 5, 6, 7, 8, 9. 10, 11, 12, 13, 14, 15, 16, 17 & 18) reviewed for infection control. COVID-19 is an infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to do contact tracing, to identify those who may have been exposed to COVID-19. For those residents (2, 4, 5, 6, 7, 8 & 11) identified as exposed, the facility failed to initiate exposure testing and place those exposed on Transmission Based Precautions (TBPs). The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 4 sample residents (Resident 1, 3 & 4) reviewed for two person assists with transfers. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Review of the facility Mechanical Lift Re-training dated 03/07/2025 showed Utilization of a Mechanical Lift to transfer dependent residents from one surface to another surface (Bed to wheelchair to bed, bed to shower chair, etc.) is a common occurrence in healthcare settings. It is never acceptable to use a lift with only one staff member. When using a lift, there must always be two staff members present to perform a mechanical lift transfer. This ensures safety during a resident transfer. <Resident 1> Review of the Annual Minimum Data Set (MDS), an assessment tool, dated 03/03/2025, showed Resident 1 was assessed as alert, oriented, and dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges for 3 of 3 sampled residents (Residents 54, 76 and 36) reviewed for hospitalization. This failure placed residents at risk for an inappropriate discharge and diminished quality of life. Findings included . Resident 54 Review of Resident 54's electronic health record (EHR) showed the resident was readmitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and was able to make needs known. Review of Resident 54's progress note dated 08/01/2024 showed that Resident 54 was transferred to the hospital via 911 and left the facility at around 3:50 PM. Review of Resident 54's minimum data set (MDS, a required assessment tool) showed that the resident readmitted to the facility on [DATE]. 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 or thoroughly complete a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 sampled residents (Residents 54 and 36) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital and diminished quality of life. Findings included . Resident 54 Review of Resident 54's electronic health record (EHR) showed the resident was readmitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and was able to make needs known. Review of Resident 54's progress note dated 08/01/2024 showed that Resident 54 was transferred to the hospital via 911. During an interview on 08/12/2024 at 11:08 AM, Resident 54 stated they had just returned from the hospital. Resident 54…

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 54 Review of Resident 54's electronic health record (EHR) showed the resident was transferred to the hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses to include heart failure, diabetes, and had a surgical wound located on the right lower leg. Resident 54 was able to make needs known. During an interview on 08/12/2024 at 11:08 AM, Resident 54 stated they had just returned from the hospital after having surgery on their right lower leg. Review of Resident 54's provider order dated 08/09/2024 showed a wound treatment for the right lower leg/shin to be provided every morning. Review of Resident 54's current care plan showed no actual skin impairment and/or surgical wound documented in the resident's care plan. During an interview on 08/15/2024 at 12:17 PM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated Resident 54's surgical wound was created/initiated in the resident's care plan on 08/15/2024 (six days after being readmitted ) and should have been 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 Resident 44 Review of Resident 44's electronic health record (EHR) showed Resident 44 readmitted to the facility on [DATE] with diagnoses to include anxiety disorder, depression, and psychotic disorder (a mental illness that can cause a person to lose touch with reality and have abnormal thinking and perceptions). The resident was able to make needs known. Review of Resident 44's care plan showed no diagnosis of anxiety disorder addressed. The focused care plan initiated on 06/16/2023 showed that Resident 44 took a psychotropic medication for the diagnosis of dementia with behaviors as evidenced by: and did not show documentation of what behaviors or adverse side effects to monitor for related to the antipsychotic medication use. During an interview on 08/14/2024 at 9:27 AM, Staff D, LPN/RCM, stated that Resident 44 had a diagnosis of an anxiety disorder; however, it was not addressed in the resident's care plan and should have been. Staff D stated Resident 44's psychotropic medication care plan initiated 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 observation, interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 2 of 5 sampled residents (Resident 44, and 36) reviewed for unnecessary medications and 1 of 1 sampled resident (Resident 379) reviewed for pain management. These failures placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life. Findings included . Review of a document titled, Pain Management, dated 07/26/2016 showed that the facility's pain management program was based on the facility's endeavors to provide care and services to effectively manage resident's pain. The facility was to develop and implement interventions, pharmacological and non-pharmacological (the use of medication to manage symptoms or management of symptoms without medications) to manage pain depending on factors such as whether the pain was episodic or continuous. In addition, specific strategies were needed to identify different levels and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychoactive medications for four of five residents (Resident's 9, 44, 36 and 26) reviewed for unnecessary medication use. The facility's failure to monitor behavioral monitoring and side effects related to use of an antipsychotic medications placed the residents at risk for adverse side effects, medical complications and a diminished quality of life. Findings included . Review of a policy titled, Psychotropic Medications, dated 01/01/2023 showed staff were to monitor the appropriateness, efficacy, and to prevent detrimental side effects from the usage of psychotropic medications in the residents at the community (facility). In addition, the facility would review residents on psychotropic medications for target behaviors and monitor for any adverse side effects (ASE) of the medications. Resident 9 Review of the quarterly minimum data set assessment (MDS) dated [DATE] 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 observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable disease and infections by ensuring the proper application of transmission-based precautions (TBP, precautions used with known or suspected infectious diseases/illnesses) for 1 of 2 sampled residents (Resident 23) reviewed for infections. The facility failed to follow recommendations for Enhanced Barrier Precautions (EBP, the use of gowns and gloves for high contact procedures) for 2 of 2 sampled residents (Residents 1 and 54) reviewed for infection control. The facility also failed to maintain sanitary conditions in 1 of 2 medication carts (East Long Hall medication cart) reviewed for medication storage. These failed practices placed residents, visitors, and staff at risk for infection, infection related complications, and a decreased quality of life. Findings included . <Transmission-based Precautions> Resident 23 Resident 23 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to have psychotropic medication (medications that affect a person's mental state) consents signed and in place prior to residents receiving medications for 2 of 5 sampled residents (Residents 9 and 44) reviewed for psychotropic medication use. This failure placed the residents at risk for adverse side effects and a diminished quality of life. Findings included . Review of a document titled, Nightingale Healthcare, Psychotropic Medications, dated 01/01/2023, showed the facility staff were to monitor the appropriateness, efficacy, and to prevent detrimental side effects from usage of psychotropic medications in the residents at the community. In addition, the facility's team would review all residents, who were started on psychotropic medications for the consent forms. Resident 9 Resident 9 admitted to the facility 01/19/2023 with multiple diagnoses to include dementia, anxiety, and depression. Review of the quarterly minimum data set (MDS, an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to provide written explanation of reason the facility initiated a room change or provide opportunity for the resident to see the new location and meet new roommates for 1 of 1 sampled resident (Resident 14) reviewed for resident rights. This failure placed the resident at risk for psychosocial distress and diminished quality of life. Findings included . Resident 14 was admitted to the facility on [DATE] with diagnosis that included Diabetes and Depression. The five-day admission Minimum Data Set (MDS, an assessment tool), dated 07/27/2024, showed the resident was cognitively intact and able to make needs known. During an interview on 08/15/2024 at 9:11 AM, Resident 14 stated they were unhappy with the room move and preferred to be back in their previous room where they were near the window and liked the staff. Resident 14 stated they did not receive advance notice about the move and did not get an opportunity to see the new room before…

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 a significant change of condition for 1 of 2 sampled residents (Resident 55) reviewed for Hospice (end of life care) services. Failure to identify the need for significant change in condition assessment Minimum Data Set (MDS, a required assessment tool) placed the resident at risk for unidentified/unmet care needs, and a diminished quality of life. Findings included . Resident 55 was admitted on [DATE], with diagnoses that included dementia (loss of memory and thinking abilities), malnutrition, and adult failure to thrive. The quarterly minimum data set (MDS), an assessment tool, dated 05/22/2024, showed the resident was not able to make their needs known. Review of the electronic health record (EHR) showed resident 55 was receiving Hospice services starting on 06/14/2024. Review of the MDS schedule showed a quarterly MDS dated [DATE], and a second quarterly MDS scheduled for 08/22/2024. There was no change of condition MDS completed after…

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 Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed for 1 of 5 residents (Residents 44) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Resident 44 readmitted to the facility 07/17/2023 with diagnoses to include anxiety disorder, depression, and psychotic disorder (a mental illness that can cause a person to lose touch with reality and have abnormal thinking and perceptions). Review of Resident 44's quarterly minimum data set assessment (MDS), an assessment tool, dated 06/26/2024, showed the resident was able to make needs known. Review of Resident 44's PASRR assessment, dated 07/23/2024, showed no psychotic disorder indicated as a serious mental illness indicator documented on the form. During an interview on 08/13/2024 at 1:51 PM, Staff H, Social Service Assistant, stated Resident 44's PASRR dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to review and revise the plan of care after a change of condition for 1 of 2 sampled residents (Resident 55) reviewed for Hospice (end of life care) services. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings included . Resident 55 was admitted on [DATE], with diagnoses that included dementia (loss of memory and thinking abilities), malnutrition, and adult failure to thrive. Review of the quarterly minimum data set assessment, an assessment tool, dated 05/22/2024, showed the resident was not able to make their needs known. Review of the electronic health record (EHR) showed resident 55 was receiving care from Hospice services initiated on 06/14/2024. Review of the care plan, initiated 03/23/2023, showed no new interventions or approaches for Hospice services. During an interview on 08/14/2024 at 10:21 AM, Staff D, Licensed Practical Nurse/ Resident Care Manger, stated Resident 55's care plan should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 21 sampled residents (Residents 19 and 26) when reviewed for quality of care. The facility failed to ensure the initiation of Resident 19's provider order for Physical and Occupational therapy (PT/OT) and failed to monitor pain/evaluate the effectiveness of pain management for Resident 26 per providers orders. These failures placed the residents at risk of medical complications, unmet needs, and a poor quality of life. Findings included . According to the Lippincott Manual of Nursing Practice, Tenth Edition ([NAME], [NAME] & [NAME], 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. According to [NAME], Duell & [NAME], Clinical Nursing Skills, 6th Edition, page 4, paragraph Nurse Practice Act identified skills and functions that professional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program when needed for 1 of 2 sampled residents (Resident 3 and 9) reviewed for bowel protocol. Additionally, the facility failed to initiate proper positioning, and re-start Physical and Occupational Therapy (PT/OT) for 1 of 3 sampled residents (Resident 19) when reviewed for limited range of motion. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . <Bowel Monitoring> Review of a document titled, House Bowel Program, dated 01/12/2019 showed the policy was developed to promote natural and predictable elimination of bowels. In addition, the policy showed that bowel movements or lack of were to be recorded by the Certified Nurse Aide (CNA), each shift. The Licensed Nurse (LN) will monitor results and start medication if necessary. The interventions included that the night shift nurse…

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 an accurate and current smoking assessment for 1 of 3 sampled residents (Resident 4) reviewed for accidents. This failure placed the resident at risk for avoidable accidents and diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE] with diagnoses that included stroke (damage to the brain from interruption of its blood supply), hemiparesis (paralysis) affecting right side of body and hemiparesis affecting left side of body. Review of the Quarterly Minimum Data Set (MDS, a required assessment tool), dated 05/18/2024, showed Resident 4 was able to make their needs known. Observation and interview on 08/12/2024 at 12:18 PM, showed Resident 4 sitting in an electric wheelchair in their room. Resident 4 was able to use their left hand, they gestured and wrote on a paper that that they smoked off of the facility property. There was cigarette odor present on their clothing. Review of the Electronic…

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 ostomy (a surgical procedure creating an opening in the body for the discharge of body wastes into a collection bag) care and treatment instructions were provided in the plan of care for 1 of 1 sampled resident (Resident 129) reviewed for ostomy care. This failure placed the resident at risk for unmet care needs, and diminished quality of life. Findings included . Review of Resident 129's electronic health record (EHR) showed Resident 129 admitted to the facility on [DATE] with a diagnosis to include diverticulitis (Inflammation of the large intestine). Resident 129 had an ostomy and was able to make their needs known. During an interview on 08/12/2024 at 1:08 PM, Resident 129 stated the area around their ostomy bag was hurting and they did not believe staff had the proper training to change or empty the bag. Review of Resident 129's provider orders did not show orders related to the ostomy. Review of the August 2024 Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to monitor and accurately document fluid restrictions (a diet which limits the amount of daily fluid intake) for 1 of 1 sampled residents (Resident 36) reviewed for hydration. This failure placed the resident at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Fluid Restriction, undated, showed, It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. It further showed, No water pitcher at bedside unless otherwise care planned. Review of the electronic health record showed Resident 36 admitted on [DATE] with diagnosis to include Chronic Obstructive Pulmonary Disease (a lung disease causing restricted airflow and breathing problems) Chronic Respiratory Failure (condition that makes it difficult to breathe on your own) and Diabetes. The resident was cognitively intact and able to make needs known. During…

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 ongoing collaboration and communication with a dialysis provider for 1 of 1 sampled resident (Resident 28) reviewed for dialysis (a procedure to remove waste from the blood). This failure placed the resident at risk of a decline in condition, lack of coordinated dialysis care, and a diminished quality of life. Findings included . Resident 28 admitted to the facility on [DATE] with diagnoses of end stage renal disease (kidney failure) and dependence on renal dialysis. Review of provider's orders, dated 07/25/2024, showed that Resident 28 underwent dialysis on Monday, Wednesday, and Friday. Review of Resident 28's care plan, initiated 07/25/2024, showed no focus area for dialysis. During an interview on 08/12/2024 at 9:57 AM, Resident 28 stated they were transported to dialysis by family and did not remember taking communication forms. Review of Resident 28's communication binder did not show communication forms for the dates of 07/26/2024,…

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 observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 2 of 6 sampled residents (Residents 1 and 8) reviewed for medication administration. During 25 medication administration observations, four medication errors were identified resulting in an error rate of 16 percent. This failure placed residents at risk of not receiving the full therapeutic effect of their medications, possible adverse side effects, and a diminished quality of life. Findings included . Review of the document titled Medication Administration General Guidelines, dated 01/2024, showed staff were to document on the resident's medication administration record (MAR) immediately following the administration of the medication. The residents should be watched after medication administration to ensure the doses were completely ingested, and if only a partial dose was ingested then this should be noted on the MAR and action should be taken if needed. Medications were to be administered within 60 minutes of the scheduled time. Resident 1 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 interview and record review the facility failed to ensure residents were provided a complete and accurate discharge summary that included a recapitulation (overview) of the residents' stay, a final summary of the resident's status (including skin condition), a reconciliation of all pre-discharge medications with the resident's post-discharge medications (prescriptions, over-the-counter medications, and treatments), scheduled appointments and contact information for Primary Care Provider (PCP), medical specialists, blood thinner clinic follow ups, and a post-discharge plan of care that included Physician Ordered (PO) Home Health (HH) services for 6 of 6 residents (Residents 3, 9, 8, 7, 10, & 11) reviewed for discharge summary. These failures placed residents at risk of post-discharge complications, delayed treatment, and decline in their overall condition by not having the necessary information and services established to ensure continuity of care for a successful discharged to the community. Findings…

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 necessary care and services to prevent the occurrence and/or worsening of avoidable pressure ulcer/pressure injury (PU/PIs) for 4 of 5 residents (Residents 3, 1, 4, & 6) reviewed for PU/PIs. The failure to develop a system to timely and accurately evaluate newly identified PU/PIs and perform weekly wound evaluations placed the residents at risk for worsening PU/PIs, unmet care needs, and diminished quality of care/quality of life. Findings included Review of the facility's Skin at Risk Program: skin integrity, wound care policy, undated, showed when a new wound was identified, an appropriate treatment order would be obtained, and a Weekly Skin Measurement Tool (WSMT) would be initiated for each PU/PI identified. PU/PIs would be evaluated weekly, documented on the WSMT, and would include the wound characteristics: length, width, depth, undermining, tunneling, pain, drainage, condition of the wound bed and edges. <Resident 3>…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party and/or to properly notify the Office of State Long-Term Care Ombudsmen (Ombuds, an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 7, 47, and 57) reviewed for Hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and ensure that the Offices of the State Long-Term Care Ombudsmen was aware of the facility practices and activities related to transfers and discharges. Findings included . Resident 7 Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed-hold notice in writing at the time of transfer/discharge to the hospital and/or within 24 hours of transfer/discharge to the hospital for 3 of 3 residents (Residents 7, 47 and 57) reviewed for Hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included . Resident 7 Review of the discharge/return anticipated Minimum Data Set assessment (MDS) dated [DATE] with return anticipated and the entry tracking record MDS dated [DATE] showed that Resident 7 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 7's electronic health record (EHR) on 07/17/2023 showed no documentation that a Resident 7 was offered a bed hold for the transfer/discharge on [DATE]. During an interview on 07/17/2023 at 10:07 AM, Staff S, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated…

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 services to prevent contractures (a shortening of tissues which leads to rigidity of the joints) for 2 of 4 residents (Residents 22 and 5) reviewed for Positioning/Mobility. This failure placed residents at risk of developing/worsening contractures, inability to complete activities of daily living, a diminished quality of life. Findings included . Resident 22 Observation and interview on 07/12/2023 at 1:48 PM showed Resident 22 had a right-sided contracture in the hand and elbow. Resident 22 stated that they did not receive services for this contracture. Further observation showed that Resident 22 did not have an appliance on the right arm. Review of Resident 22's care plan on 07/12/2023 at 2:03 PM showed that they were to wear an elbow brace, finger separator and palm guard in the morning. Observation on 07/13/2023 at 12:23 PM, 07/14/2023 at 11:55 AM, and 07/17/2023 at 10:13 AM showed Resident 22 in bed without appliances on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to identify significant weight loss in a timely manner and ensure interventions were in place to prevent continued weight loss for 2 of 6 residents (Residents 57 and 54) reviewed for nutrition. These failures placed the residents at risk for unmet nutritional needs and continued weight loss. Findings included . Resident 57 Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 06/30/2023 showed that Resident 57 re-admitted on [DATE] with diagnoses to include heart disease, pneumonia, septicemia (a condition caused by spread of bacteria and their toxins in the blood stream) and protein malnutrition. The MDS further showed that Resident 57 was able to make needs known and was able to feed after staff assisted by serving and setting up meals. Review of Resident 57's electronic health record (EHR) dated 07/01/2023 showed a Registered Dietitian (RD) assessment, documented the goal for the resident would be for no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pain medications were necessary prior to administration for 3 of 6 residents (Residents 22, 53, and 8) reviewed for Unnecessary Medications/Pain. Failure to ensure pain medications were necessary placed residents at risk of overmedication, unnecessary medication side effects, and a diminished quality of life. Findings included . Resident 22 Review of Resident 22's physician's orders on 07/17/2023 at 10:44 AM showed an order for acetaminophen (a pain medication) as needed (PRN) for mild pain and oxycodone (a narcotic pain medication) PRN for pain. Further review showed no order for nonpharmacological interventions (methods to reduce symptoms without medications, i.e., ice, heating pad, etc.) prior to the use of PRN pain medications. Review of Resident 22's July 2023 Medication Administration Record (MAR) on 07/17/2023 showed that the resident had received an oxycodone on 07/04/2023. Further review showed no nonpharmacological interventions 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 monitoring of potential side effects related to the use of psychoactive medications for 2 of 5 residents (Residents 12 and 9) reviewed for unnecessary medication use. The facility's failure to monitor orthostatic blood vital signs (blood pressure [BP] and heart rate taken while lying, sitting, and standing) related to use of an antipsychotic medication placed the residents at risk for adverse side effects and medical complications. Findings included . Nursing considerations when using antipsychotic medication requires baseline blood pressures measurements before starting therapy and monitor pressure regularly. Watch for orthostatic hypotension. Reference: [NAME] & [NAME], Nursing 2007 Drug Handbook (Page 1742). Resident 12 Review of Resident 12's quarterly Minimum Data Set (MDS, a required assessment tool) dated 04/18/2023, showed the resident admitted to the facility on [DATE] with diagnoses to heart disease, dementia, and depression. In…

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

Based on observation and interview, the facility failed to maintain sanitary food storage in 2 of 2 resident refrigerators (West and Activities) when reviewed for Kitchen. This failure placed residents at risk of ingesting contaminated food, foodborne illness, and a diminished quality of life. Findings included . During an interview on 07/14/2023 at 8:53 AM, Staff S, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that East Hall did not have a resident refrigerator and that staff stored resident food in the Activities refrigerator. Observation of the Activities refrigerator on 07/14/2023 at 8:55 AM showed an opened freezer meal in the freezer which did not have a resident name or date. Observation of the refrigerator section showed a fruit salad with no date and a label with a best used by date of 07/07/2023, a footlong sub sandwich with no date, and a half gallon of milk with a best by date of 04/21. Observation of the [NAME] refrigerator on 07/14/2023 at 9:38 AM showed a bag of cooked chicken with no name or date, a bag of cherries with no date, three containers…

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 a communicable disease by ensuring the proper application of transmission-based precautions (TBP) for 5 of 5 residents (Residents 48, 46, 269, 270, and 66) and to ensure the proper use and fit of personal protective equipment (PPE) by staff during an outbreak of a respiratory virus when reviewed for TBP. The facility also failed to notify the residents or representatives of a COVID-19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) outbreak when reviewed for infection control. Additionally, the facility failed to provide sanitary environment for 1 of 4 hallways (East Short Hall) reviewed for environment. These failures placed residents, visitors, and staff at risk for infections and a decreased quality of life. Findings included . Review of the facility policy titled…

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 (a highly infectious respiratory illness caused by a virus) vaccinations and education regarding the benefits and potential side effects of the COVID-19 vaccine for 2 of 5 residents (Residents 15, and 48) reviewed for COVID-19 vaccinations. These failures denied the resident/representative of the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease. Findings included . Review of the facility policy titled Influenza, Pneumococcal, Covid-19 disease Prevention Vaccination updated 08/12/2022 showed that on admission each resident would be screened for vaccination history. COVID-19 vaccination would be offered on an as needed basis and risks and benefits reviewed and a consent or declinations would be signed and placed in the residents Electronic Health Record (EHR). Also, an audit would be completed monthly by the infection preventionist or designee. Review on 07/14/2023 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 ased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessments were accurately completed for one of five residents (Resident 12) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . Review of Resident 12's quarterly Minimum Data Set (MDS, a required assessment tool) dated 04/18/2023, showed the resident admitted to the facility on [DATE] with diagnoses to include heart disease, dementia, and depression. In addition, review of Resident 12's electronic health record (EHR) showed that the provider prescribed medication for the treatment of anxiety and a psychotic disorder. The MDS further showed Resident 12 was able to make needs known. Review of Resident 12's medication administration record (MAR), dated July 2023, showed the provider had ordered a medication on 06/06/2023 (hydroxyzine) to be administered as needed…

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 a collaborative, comprehensive care plan involving Hospice services (care that focuses comfort and quality of life for persons with a serious illness who is approaching the end of life) for 1 of 1 Resident (Resident 47) reviewed for Hospice. This failure placed resident at potential risk for unmet needs and a diminished quality of life. Findings included . Review of the significant change in status Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 47 readmitted to the facility on [DATE] and was able to make needs known. This MDS further showed that Resident 47 received Hospice care. Review of Resident 47's physician order dated 06/07/2023 showed that the resident was to be admitted to Hospice. Review of Resident 47's care plan dated 06/07/2021 showed, The resident has a terminal prognosis [an irreversible condition that will result in death in the near future]. It further had an intervention that showed, Work cooperatively with…

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 showers as scheduled for 1 of 4 residents (Resident 165) reviewed for activities of daily living (ADLs). This failure placed the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of a document titled, Showers, undated, showed that the policy for the facility was to ensure sufficient personal hygiene essentials for residents and to meet state and federal regulations regarding showers needs. In addition, the document showed that if a shower was not physically tolerated by the resident, then a bed bath would be given. Any refusals of showers were to be documented and reported to the licensed nurse (LN). The Certified Nurse's Aide (CNA) was to document tasks that showers had be given. Review of the entry Minimum Data Set (MDS, a required assessment tool) dated 07/06/2023, showed that Resident 165 admitted on [DATE] with multiple diagnoses to include heart and lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and to document as needed dressing changes and skin assessments for 1 of 2 residents (Resident 266) reviewed for pressure injuries. These failures placed residents at risk for complications, impaired healing, and decreased quality of life. Findings included . Review on 07/12/2023 at 3:15 PM of Resident 266's Electronic Health Record (EHR) showed the resident was admitted on [DATE] with a pressure wound on the tailbone covered in white tissue. A physician order dated 07/12/2023 for Coccyx (tailbone) Treatment included directions to clean with wound cleanser, apply skin prep to skin around the wound and allow to dry, apply Iodasorb (a paste used to decrease bacteria and promote removal of the white tissue) to the base of the wound and secure with Bordered Foam 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 observation, interview and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 1 of 2 residents (Resident 166) reviewed for respiratory care. Failure to ensure oxygen delivery was provided according to the physician order, placed the resident at risk for discomfort, a potential negative outcome, and unmet needs. Findings included . Review of a document titled, Oxygen Administration, dated 07/20/2018, showed, Oxygen is administered to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulty. In addition, the document stated that oxygen was to be administered by licensed staff and was to be turned on to the prescribed liter flow. Review of the Resident 166's electronic health records (EHR) on 07/14/2023 showed that Resident 166 was admitted to the facility on [DATE] with multiple diagnoses of heart and lung disease to include congestive obstructive pulmonary disease (COPD, 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.