Corwin Center At Emerald Heights

Based on interview and record review, the facility failed to ensure a resident received education regarding the potential risks and benefits when offering influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) for 1 of 5 residents (Resident 10), reviewed for immunizations. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their influenza immunization. Findings included . Review of the facility's policy titled, IC [Infection Control]-Influenza Vaccine, revised in January 2023, showed that Prior to the vaccination [influenza vaccine], the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. It further showed, Provision of such education shall be documented in the resident's .medical record, as applicable. Review of a nursing progress note dated 11/04/2024, showed Resident [Resident 10] received her flu [Influenza] shot per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bed rails (bed positioning devices) were properly secured and maintained/checked for safety for 1 of 5 residents (Resident 3), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Proper Use of Positioning Devices, revised in January 2014, showed Positioning Devices can be considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) . Positioning Devices are only permissible if they are used to treat a resident's medical symptoms or to assist the resident with mobility and transfer . An assessment will be made to determine the resident will benefit from the use of a positioning device and that the resident can physically and safely use one. Resident 3 was admitted on [DATE] with multiple diagnoses that included Parkinsons disease (a progressive…

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 and/or develop comprehensive care plans for 5 of 6 residents (Residents 2, 1, 3, 4 & 5), reviewed for care planning. The failure to implement and develop care plans for risk of elopement placed residents at risk for elopement, unmet care needs, and potential negative outcomes. Findings included . Review of the facility's policy titled, Elopement and Wandering, Risk of, revised in February 2020, showed, It is the policy of the [Facility name] to ensure that residents who exhibit wandering behavior and/or are at risk of elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised in November 2011, showed, Each care plan is individualized to support the resident's medical concerns with interventions 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.

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 4 residents (Resident 1), reviewed for medication management. The failure to document narcotic (opioid/controlled drugs) medications in accordance with professional standards of practice placed the resident at risk for uncontrolled pain, medication errors, negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Administering Medications, revised in April 2013, showed, the individual administering the medication will record in the resident's medical record .the date and time the medication was administered, the dosage, the route of administration .and the signature and title of the person administering the drug. Review of Resident 1's January 2025 Medication Administration Record (MAR) showed an order for oxycodone (a narcotic medication for pain) five milligrams (mg-a unit of measurement) by mouth every four hours for pain, started on 01/28/2025. It further showed no documentation that oxycodone was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were protected from misappropriation of controlled (narcotic or opioid) medication for 1 of 3 residents (Resident 1), reviewed for misappropriation of controlled medications. This failure placed the resident at risk for pain, unmet care needs, ongoing misappropriation of medications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised in August 2024, showed Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the facility's policy titled, Controlled Substances, revised in November 2011, showed that nursing staff must count controlled drugs at the end of each shift and the nurse coming on duty and the nurse going off duty must make the count together 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 interview and record review, the facility failed to timely report allegations of misappropriation of controlled (narcotic or opioid) medication to the State Agency within the required timeframe for 1 of 3 residents (Resident 1), reviewed for allegations of misappropriation. This failure placed the resident at risk for potential unidentified abuse and lack of protection from misappropriation. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised in August 2024, showed The Facility shall report abuse allegations per Federal and State Law. Review of the facility's policy titled, Controlled Substances, revised in November 2011, showed that nursing staff must count controlled drugs at the end of each shift and the nurse coming on duty and the nurse going off duty must make the count together and sign off that the count was correct and they must document and report any discrepancies to the Director of Nursing…

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

Based on observation, interview and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen (Fireside Grill Skilled Kitchen). The failure to perform hand hygiene before and after glove change before and/or after serving food placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in November 2017, showed that all staff, residents, and visitors shall use proper hand hygiene/handwashing practices to prevent the spread of infection or contamination. It further showed that, Hand hygiene-a general term that applies to hand washing, antiseptic hand wash, and alcohol based hand rub. The use of gloves does not replace handwashing/hand hygiene. Review of the facility's undated training materials titled, Hand hygiene: Important Information for all Associates, showed that Good handwashing is…

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 discard expired medication for 1 of 3 medication carts (Cedar Medication Cart) and failed to label/date an open vial of Tubersol (testing solution to diagnose Tuberculosis [infectious bacterial disease that affects the lungs]) for 1 of 1 medication storage room (Cedar Medication Room), reviewed for medication administration and storage. This failure placed the residents at risk to receive expired or compromised medications. Findings included . Review of the facility's policy titled, Storage of Medication, reviewed in August 2012, showed the facility should store all drugs and biologicals in a safe, secure, and orderly manner. It further showed that the facility should not use discontinued, outdated, or deteriorated drugs or biologicals (medicines that are made from natural sources) and that such drugs should be returned to the dispensing pharmacy or destroyed. CEDAR MEDICATION CART During a joint observation and interview on 04/04/2024 at 8:22 AM with Staff M, Licensed Practical Nurse (LPN), showed the Cedar…

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 hand hygiene practices and/or proper use of gloves were followed during soiled linen collection by 1 of 1 staff (Staff Z) and failed to properly disinfect medical equipment for 3 of 5 staff (Staff AA, Staff J & Staff K). In addition, the facility failed to ensure the facility's water management program included a flow diagram that assessed the potential growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease) reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in November 2017, showed that all staff, residents, and visitors shall use proper hand hygiene/handwashing practices to prevent the spread of infection or contamination. Hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 1 of 6 residents (Resident 16), reviewed for dining observations. This failure placed the resident at risk for a diminished self-worth and over-all well-being. Findings included . Resident 16 admitted to the facility on [DATE] with diagnosis that included Alzheimer's (a brain disorder that slowly destroys memory and thinking skills, and eventually affects the ability to carry out the simplest tasks). Review of Resident 16's annual Minimum Data Set (an assessment tool) dated 02/22/2024, showed the resident had memory loss and was dependent on staff for eating. Observation on 04/01/2024 at 12:02 PM, showed Resident 16 was seated upright in their wheelchair with a food tray in front of them and was observed attempting to eat their lunch using a spoon without success. On 04/01/2024 at 12:05 PM, Staff R, Registered Nurse, was observed…

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 missing item was logged and investigated for 1 of 2 residents (Resident 23), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life. Findings included . Review of the facility's policy titled, Filing Grievances/Complaints, revised in November 2010, showed, Any resident, his or her representative (sponsor), family member, appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, missing items etc., without fear of threat or reprisal in any form. It further showed that the social services department representative will log the reported concern and the appropriate department manager will respond to the concerned party. Resident 23 admitted to the facility on [DATE]. On 04/01/2024 at 10:29 AM, Resident 23 stated they were missing an electric toothbrush and that their representative had informed…

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 free from physical abuse for 3 of 4 residents (Residents 37, 33 & 4), reviewed for abuse investigations. This failure placed the residents at risk for further physical abuse, injury, and diminished quality of life. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. The term 'willful' describes the deliberate or non-accidental action or inaction that resulted in the abuse of the resident. Review of the facility's policy titled, Freedom from Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised in September 2019, showed, It is the policy of the facility that each resident has the right to, and will be free from Abuse. The policy showed, the residents will be protected from abuse, neglect, 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 interview and record review, the facility failed to ensure allegations of abuse was reported to the State Agency as required for 1 of 3 residents (Resident 30), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised in September 2019, showed, if an incident is considered reportable, there shall be an initial (immediate or within 24 hours) report to the department. Resident 30 admitted to the facility on [DATE]. Review of the nursing progress note dated 03/18/2024, showed Staff P, Licensed Practical Nurse, documented that Resident 30 was placed on alert r/t [related to] increasing verbal abuse from roommate. It further showed that Resident 30 made numerous statements to the Nursing Assistant Certified (NAC) to stop roommate from yelling at them and that Resident also…

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 transmit resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 1 of 3 residents (Resident 5), reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, revised in October 2023, showed discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500+14 days) to the database as required. Resident 5 admitted to the facility on [DATE]. Review of the MDS look up assessment showed that a discharge MDS with an ARD of 12/29/2023 was not completed/submitted 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 interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 29), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate medication coding placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, coding instructions to code all high risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used. It further showed to check if the resident is taking any medication by pharmacological classification during the 7-day observation period. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 3 of 14 residents (Resident 11, 9 & 20), reviewed for care plan revision. The failure to revise care plans for oxygen use and refusal with care placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning- Interdisciplinary Team, revised in November 2011, showed that care plans would be individualized to support the resident's medical concerns with intervention and that each care plan would be updated at least quarterly and as needed. Review of the facility's undated policy titled, Oxygen Administration, showed the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident assessment and orders, such as, but not limited to the type of oxygen delivery system, when to administer, equipment setting for the prescribed flow rates, monitoring of oxygen saturation levels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow insulin (medication to lower blood sugar) orders and clarify medication orders to ensure parameters were in place in accordance with professional standards for 2 of 5 residents (Residents 11 & 1), reviewed for unnecessary medications. This failure placed the residents at risk for medication errors and negative outcomes. Findings included . Review of the facility's policy titled, Medication Administration, revised in April 2024, showed, Obtain and record vital signs [a measurement of the body's most basic functions (blood pressure [amount of force your blood uses to get through blood vessels], pulse rate and temperature)], when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters and to correct any discrepancies and report to the nurse manager. The policy showed that medications are administered by licensed nurses or other staff who are legally authorized to do so…

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 for signs and symptoms of bruises or bleeding on a resident receiving anticoagulant therapy (medication that decreases blood's ability to clot) for 1 of 2 residents (Resident 41) and failed to follow physician's order related to insulin (medication to lower blood sugar) sliding scale (a method where the insulin dosage is adjusted based on blood sugar level) for 1 of 1 resident (Resident 1), reviewed for quality of care. These failures placed the residents at risk for adverse consequences and other related complications. Findings included . Review of the facility's policy titled, Medication Administration, reviewed in April 2024, showed to refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. The policy further showed to report and document any adverse effects or refusals. Review of the facility's policy titled, Insulin Pen Policy, reviewed in April 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen nasal cannula/tubing (flexible tubing that sits inside the nose and delivers oxygen) for 2 of 2 residents (Residents 11 & 2), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's undated policy titled, Oxygen Administration, showed to change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. It further showed, Keep delivery services [oxygen mask/tubing and nasal cannula] covered in a plastic bag when not in use. RESIDENT 11 Resident 11 admitted to the facility on [DATE]. Review of the April 2024 Treatment Administration Record showed the following orders: - Continuous oxygen therapy during the night, one liter (a unit of measurement) via nasal cannula with a start date of 03/27/2023. - Change oxygen tubing weekly…

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 monthly pharmacy recommendations were followed up on by the physician for 1 of 5 residents (Resident 40), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Regimen Review, revised in August 2017, showed the facility will encourage physician/prescriber or other responsible parties receiving the Medication Regimen Review (MRR) and the Director of Nursing (DON) Services to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, facility should encourage to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. Resident 40 admitted…

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 an Antibiotic (medications to treat infection) Stewardship Program when the facility failed to implement antibiotic use protocols for 2 of 2 residents (Residents 43 & 38), and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs/symptoms used to determine whether to treat an infection with antibiotics] and/or SBAR [Situation, Background, Assessment, and Recommendation - a toolkit that helps staff/prescribing clinicians communicate about suspected UTIs [Urinary Tract Infections-bladder infection] and facilitates appropriate antibiotic prescribing) to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance. These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. 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 ensure resident screened for rehabilitation services received timely order and initiation of specialized rehabilitation services for 1 of 4 residents (Resident 1), reviewed for therapy services. The facility's delay in coordinating a Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment placed the resident at risk for decline in function, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Falls - Prevention and Management, dated June 2023, showed that it is the policy of the center that each resident shall be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy also showed that the facility utilizes a standard risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. For high-risk protocol…

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 appropriate use of Personal Protective Equipment (PPE - face mask/respirator, face shield, gown, and gloves) were followed when providing care for residents positive for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) in 2 of 6 rooms (Rooms 315 and room [ROOM NUMBER]), reviewed for infection control. This failure placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . According to Centers for Disease Control guidance, last updated on 05/08/2022, stated that health care personnel who enter the room of a patient [resident] with suspected or confirmed COVID-19 infection should adhere to Standard Precautions (are the minimum infection prevention practices that apply to all patient [resident] care, regardless of suspected or confirmed…

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 4 of 15 residents (Residents 16, 43, 19 & 5) reviewed for Minimum Data Set (MDS) assessments. The failure to ensure accurate assessments regarding wound dressing to the foot, Brief Interview for Mental Status (BIMS - cognitive patterns), mood interview (PHQ9), pressure ulcer wound/injury and wound care dressing placed the residents at risk for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e., comprehensive, quarterly, annual, significant…

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 baseline care plan and/or provide written summary of the baseline care plan to the residents or the resident representatives within 48 hours of admission for 4 of 15 residents (Residents 19, 35, 46, and 8) reviewed for baseline care plans. This failure placed newly admitted residents at risk of not receiving necessary care and services, not being informed of their initial plan for delivery of care and services, and a decreased quality of life. Findings included . RESIDENT 19 Resident 19 was admitted to the facility on [DATE] with multiple care needs. Review of the document provided by the facility titled, Plan of care meeting review and sign-in sheet dated 11/15/2021 (four days after admission date) for Resident 19 showed that the baseline care plan/summary was not offered within 48 hours of admission. On 01/04/2023 at 2:30 PM, Staff D, Social Services Director, acknowledged that the baseline care plan summary was not offered to 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.

Based on observation, interview, and record review, the facility failed to ensure foods stored in 2 of 3 refrigerators (kitchen & walk-in refrigerators) were properly labeled/dated when first opened and failed to ensure kitchen thermometer was properly sanitized in between use in 1 of 1 kitchen. In addition, the facility failed to ensure ready to eat food was handled appropriately in accordance with professional standards for food service safety in 1 of 1 dining room. These failures placed the residents at risk for food borne illnesses (an illness caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Services: Food Storage and Safe Handling, revised in October 2017 showed, The Facility shall monitor all refrigerators and freezers for safe food handling practices .All items will be labeled and dated. Review of the facility's policy titled, Food Temperatures, dated 2008, showed To take hot food temperatures . Wait for the thermometer to rise to the maximum…

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 infection control practices that provide a safe and sanitary environment to help prevent and contain the transmission of communicable diseases including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure contaminated/used N95 respirator/mask were discarded, and face shield/eye protection was changed or disinfected upon exiting residents' rooms on Transmission Based Precautions (TBPs) (Rooms 315 & 317) and failed to perform hand hygiene during wound care dressing change for 1 of 4 residents (Resident 9) reviewed for infection control. In addition, the facility failed to consistently ensure policies and procedures (P/Ps) related to Infection Prevention and Control (IPC) were reviewed annually as required. These failures placed the residents at risk for facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's physician and the resident's representatives when there was a severe weight loss for 1 of 1 resident (Resident 46) reviewed for nutrition. The failure to report significant weight loss to the resident's physician placed Resident 46 at risk for not receiving the needed care and services and for not having their representatives involved in any treatment plan and/or participation in care decisions regarding their weight loss. Findings included . Review of the facility's policy titled, Weight Loss/Gain, Unintentional Revised February 2016, defines significant weight loss as 5% weight loss in one month or 10% weight loss in 6 months. The policy also showed that the resident's attending provider, family/DPOA (Durable Power of Attorney) as well as any other appropriate clinicians will be notified with unanticipated significant weight changes. The policy also showed all notifications and referrals will be documented in 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 interview and record review, the facility failed to ensure comprehensive assessment was completed timely as required for 1 of 15 residents (Resident 43) reviewed for comprehensive Minimum Data Set (MDS - an assessment tool). This failure placed the resident at risk for delayed or unidentified care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, and dated October 2019, under Section 5.2 Timeliness Criteria, for the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). Resident 43 was admitted to the facility on [DATE] for multiple care needs. Review of the admission MDS with an Assessment Reference Date (ARD) of 09/19/2022 showed an entry date (A1600) of 09/12/2022, and the MDS completion date (Z0500B) was signed as completed on 10/03/2022, 21 days after the entry date. On 01/03/2023 at 3:22 PM, Staff E, MDS Coordinator, 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 interview and record review, the facility failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 3 of 15 residents (Residents 8, 12, and 16) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of 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 develop and implement a comprehensive care plan for 3 of 15 residents (Residents 35, 21 and 27) reviewed for comprehensive care plans. The failure to develop a pressure ulcer/injury (PU) care plan for Resident 35, a wandering/behavior care plan for Resident 21, and to implement the Activities of Daily Living (ADL) care plan for Resident 27 placed these residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning - Interdisciplinary Team revised November 2011, showed that each care plan is individualized to support the resident's medical concerns with interventions and reevaluating dates. RESIDENT 35 Resident 35 was admitted to the facility on [DATE] with multiple care needs. Review of the resident's quarterly Minimum Data Set (MDS - an assessment tool) dated 10/14/2022, showed that the resident had a moderately impaired cognition and needed extensive…

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 comprehensive care plan for 1 of 15 residents (Resident 46) reviewed for care planning. The failure to review and revise Resident 46's nutrition care plan after the resident had a significant weight loss placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Resident 46 was admitted to the facility on [DATE] with multiple care needs. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident 46 had impaired cognition. Review of Resident 46's weight record in the electronic medical record revealed Resident 46 had experienced a significant weight loss (8.85% weight loss in one month between 11/03/2022 and 12/08/2022 and 25.72% weight loss in less than two months). Review of Resident 46's nutrition care plan initiated on 11/03/2022 showed the resident was at risk for altered nutritional status and/or weight loss. Further review of the nutrition care plan…

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 provide restorative nursing programs to maintain range of motion (ROM) and mobility for 2 of 4 residents (Residents 1 and 9) and failed to apply an orthotic splint (brace to position the hand) in accordance with physician's order to prevent further decrease in ROM for 1 of 4 residents (Resident 27) reviewed for restorative services. These failures placed the residents at risk for decreased mobility, decreased ROM, pain, and a diminished quality of life. Findings included . Review of the provided facility policy titled, Restorative Services: Goals and Objectives with a revision date of August 2011, showed Resident specific program should be care planned, reviewed quarterly for revisions and include targeted activities or exercise, directions for physical or cognitive assistance, frequency and duration, plan for data collection. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with a diagnosis of Osteopetrosis (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.