Renton Health & Rehabilitation

Based on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 of 6 residents (Resident 5) reviewed for Infection Control; and ensure visitors used gloves while pouring ice from a communal ice bucket to avoid cross contamination. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included . <Facility Policy>Review of the facility's Infection Prevention and Control Program policy, revised 04/23/2025, showed the facility established and maintained an infection control program to provide a safe, sanitary, and comfortable environment to all residents and staff to prevent the development and transmission of communicable diseases. The policy showed the facility would ensure healthcare personnel were educated and trained regarding the appropriate use of PPE prior to caring for a resident on isolation precautions…

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 notify 5 (Resident 1, 6, 25, 219, & 119) of 23 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. The facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 1 (Resident 219) of 3 discharged residents reviewed. This failure caused a delay in reconciling resident accounts within 30 days as required. Findings included . Review of a revised 08/2024 Resident Personal Funds policy, showed the facility must notify each resident who received Medicaid benefits: when the amount in the resident's account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person; and if the amount in the account reached the SSI resource limit, the resident may lose…

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 and interview, the facility failed to ensure walls in resident rooms were maintained in a homelike condition for 9 of 18 rooms sampled (Rooms 22, 26, 32, 34, 50, 42, 47, 48, & 49). The failure to ensure rooms were free from gouges (Rooms 22, 32, 50, 48), resident televisions were mounted (room [ROOM NUMBER]), fans in resident rooms were clean (room [ROOM NUMBER]), and sinks, toilets, and bathroom fixtures in resident rooms were free from rust and maintained in clean, sanitary conditions (Rooms 22, 32, 34, 42, 47, & 49). These failures left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . <room [ROOM NUMBER]> Observation of room [ROOM NUMBER] on 09/10/2024 at 10:46 AM showed wall behind the bed nearest the door was gouged where the bed rubbed against the wall, exposing drywall. The bathroom in room [ROOM NUMBER] had considerable dark yellow stains on the tile underneath and around the toilet. In an interview on 09/16/2024 at 9:18 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards for 1 of 1 laundry room and failed to ensure resident rooms were free of fall hazards for 1 of 3 (Resident 11) residents reviewed for falls. These failures placed residents at risk for elopement, ingestion of chemicals, and falls. Findings included . <Laundry Room Door> Observation on 09/10/2024 at 1:43 PM showed the door to the facility's laundry room was unlocked. The key code to unlock the door did not function. The door opened freely and allowed access to the laundry room. Observation on 09/11/2024 at 8:30 AM showed the laundry room door remained unlocked, entered the laundry room and a middle door was open. Inside the laundry room was a cart containing laundry detergent and other chemicals. The exterior door opening to the rear of the building was propped open and a large fan was placed in the doorway. There was nothing preventing a wandering resident from passing through the laundry…

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 medications were stored, labeled, dated when opened, and discarded when expired for 1 of 2 medication carts (Garden Wing Cart), 1 of 1 medication rooms (West Hall Medication Room Refrigerator), and for 1 of 19 residents (Resident 60) observed. The facility failed to ensure 2 of 4 medication carts were locked when left unsupervised by staff. The failure to ensure medication refrigerators were double locked, medications were discarded when expired, eye drop medications were dated upon opening, medication carts were locked, and medications were not left at bedside, placed residents at risk for ineffective treatment, expired medications, and contaminated medications. Findings included . <Facility Policy> According to a facility policy titled, Medication Storage, revised 08/2024, the facility would secure narcotics and controlled substances under double lock and key. The policy showed medication rooms and carts would be inspected routinely for discontinued and outdated medications. The policy showed the…

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

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens and for one unit refrigerator reviewed for food services. The failure to clean the facility's kitchen ice machine, cover food during transport, perform hand hygiene between glove use, and maintain sanitary unit refrigerators placed the residents at risk for food borne illness (illness caused by ingesting contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's revised August 2024 Food Safety Requirements policy, the facility would store, prepare, distribute and serve resident meals in accordance with professional standards of food service safety. The policy showed to prevent foodborne illness, dietary staff should clean and sanitize the internal components of the ice machines according to manufacturer's guidelines. The facility's revised July 2024 Ice Machines and Ice Storage Chest policy, ice machines and ice storage/distribution…

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 informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 2 of 5 (Residents 20 & 34) reviewed for unnecessary medications and for bed rails for 1 of 2 residents (Resident 60) reviewed for accident hazards. This placed residents at risk for unwanted treatment. <Findings included> <Facility Policy> According to the facility policy titled, Use of Psychotropic Medication, revised 08/2024, residents needing psychotropic medications would be educated on the risks and benefits. <Facility Policy> According to a facility policy titled, Proper Use of Bed Rails, revised 03/2024, showed the facility would obtain informed consent from the resident or resident representative prior to installation and use of the bed rails. The policy showed risks and benefits of bed rail use for the resident would be provided to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 2 of 4 residents (Resident 219 and 119) reviewed for beneficiary notification. This failure placed Residents 219, 119, and other residents at risk for not being fully informed and losing their right to an appeals process. Findings included . <Facility Policy> According to the facility policy titled, SNF Beneficiary Notices Under Medicare Part A, revised 06/2023, the facility would inform Medicare A beneficiaries when they no longer met the skilled coverage criteria. The policy showed a NOMNC was given by the facility to all Medicare beneficiaries at least two days before the end of their Medicare covered Part A stay because the notice contained information regarding the beneficiary's right to an expedited…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 3 (Resident 37, 51, & 61) of 19 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 37> Review of a 07/24/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 37 had clear speech, understands, and was understood by others. This MDS showed staff assessed Resident 37 with broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, (obvious or likely cavity or broken natural teeth, and mouth or facial pain, discomfort or difficulty with chewing. Observations on 09/10/2024 at 10:38 AM showed Resident 37 with multiple lower teeth and no upper denture in their mouth. In an interview at this time, Resident 37 stated they were waiting to have their dentures fixed. In an interview on 09/16/2024 at 1:35 PM, Staff BB (MDS Coordinator, Registered Nurse) reviewed Resident 37's…

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

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 1 of 5 (Resident 51) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> According to the facility policy titled, Admissions Criteria, revised July 2024, all new admission and readmissions must go through a PASRR screening prior to admission. The policy showed the facility's social worker was responsible for making referrals for Level II PASRR services. <Resident 51> According to a 06/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 51 had multiple medically complex diagnoses including dementia, anxiety, and schizophrenia (a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 58> According to the 07/30/2024 Quarterly MDS Resident 58 had diagnoses including a history of stroke and difficulty swallowing. The MDS showed Resident 58 received over half their daily calorie intake via a feeding tube (tubing that allows liquid nutrition to pass directly into the stomach for people with swallowing difficulties). According to the revised 05/13/2024 resident requires tube feeding . CP Resident 58 still received nutrition by feeding tube. Review of the physician's orders showed a 05/23/2024 order for a bolus (using gravity rather than a pump) feeding four times a day for Resident 34. This order was discontinued on 07/04/2024. In an interview on 09/16/2024 at 11:02 AM Staff AA (Dietician) stated Resident 20 successfully graduated from the tube feeding and was now able to meet their nutritional needs with oral intake. Staff AA stated the CP was no longer necessary. Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive 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.

Based on interview and record review the facility failed to provide nursing care within professional standards. The failure to follow physician's orders for 2 of 19 sample residents reviewed (Residents 34 & 20), clarify physician's orders when required, and sign for physician orders not completed for 2 of 19 sample residents (Residents 25 & 52) placed residents at risk for unmet care needs, medication errors, and ineffective treatment. Findings included . According to the facility's Medication Administration policy revised 08/2024, staff would correct any medication discrepancies and report to the nurse manager. <Following Orders> <Resident 34> According to the 07/24/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 34 had occasional pain that almost constantly affected their sleep and day-to-day activities. The MDS showed Resident 34 took opioid medications as needed. Review of the June 2024 Medication Administration Record (MAR) showed a 06/07/2024 physician's order for an as needed opioid pain medication 5-325 Milligram (MG), give one pill every 12 hours as…

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 Activities of Daily Living (ADL) assistance was provided for dependent residents for 3 (Residents 52, 60, & 1) of 6 residents reviewed for ADLs and one supplementary resident (Resident 58). Facility failure to provide ADL assistance as needed placed residents at risk for poor hygiene and feelings of diminished self-worth. Findings included . <Facility Policy> The facility's reviewed 08/2024 Activities of Daily Living (ADLs) policy showed, ADLs included bathing, dressing, grooming, oral care, transfers, toileting, and assistance with eating. The policy showed residents assessed to be unable to complete ADLs independently should receive the assistance they required. <Resident 58> According to the 07/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 58 had diagnoses including a history of stroke, heart failure, one-side partial paralysis, lack of coordination, and an abnormal posture. The MDS showed Resident 58…

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

Based on observation, interview, and record review the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 2 sampled residents (Resident 1 & 7) reviewed for hospice care. This failure placed residents at risk for not receiving necessary end- of- life care and services, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's Providing End of Life Care policy revised 08/2024, the facility would utilize a systematic approach for recognition, assessment, treatment, and monitoring of end-of-life care. The policy stated the facility and resident/family would coordinate the resident's Care Plan (CP) and implement interventions in accordance with the comprehensive assessment for the resident's needs, goals, and preferences. If the resident chose hospice services, the CP would specify the care and services to be provided by the facility and by hospice services. The facility would maintain communication with the resident, resident representative, and hospice services as it…

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 restorative program was provided for 1 of 2 (Resident 37) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> According to a revised July 2024 facility, Restorative Nursing Services policy, residents would receive restorative nursing care as needed to help promote optimal safety and independence. The policy showed restorative nursing services included splinting and bracing. The policy showed recommendations for restorative nursing services would be made at the time of discharge from therapy as needed and communicated to the aide responsible either by the discharging therapist or nurse overseeing the restorative program. <Resident 37> According to a 07/24/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 37 had multiple medically complex diagnoses…

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 weights were adequately monitored for 1 of 1 (Resident 58) residents reviewed for hydration/weights. The failure to monitor weights as ordered placed residents at risk for weight loss, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's August 2024 Weight Monitoring policy, a weight monitoring schedule should be developed for all residents at the time of admission. The policy showed resident weights would be collected monthly or more frequently, as needed. <Resident 58> According to the 07/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 58 needed supervision with eating and had diagnoses including a history of stroke, one-sided partial paralysis, and swallowing difficulties. The MDS showed Resident 58 received over half their calories via feeding tube (tubing allowing liquid nutrition to flow directly to the stomach avoiding the esophagus). Observation on 09/10/2024 at 12:38 PM showed two nursing aides assist Resident 58 to sit up…

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 prompt dental services were provided for 2 (Residents 52 & 37) of 5 residents reviewed for dental services. This failure placed residents at risk for oral discomfort and a diminished quality of life. Findings included . <Facility Policy> According to the facility's Dental Services policy, revised 08/2024, oral and denture care would be provided in accordance with identified needs and as specified in the resident's Care Plan (CP). The facility would assist residents with making dental appointments and arranging transportation when necessary. <Resident 52> According to the 07/17/2024 Minimum Data Set (MDS - an assessment tool), Resident 52 was understood and could understand others in conversation. The MDS showed Resident 52 had intact mental processing abilities. The MDS showed Resident 52 had mouth/facial pain and discomfort when chewing. Resident 52 was dependent on staff for cleaning and putting in their dentures. Review of…

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

Based on observation, interview, and record review the facility failed to establish and maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to 1) ensure staff used personal protective equipment for residents reviewed for Transmission Based Precautions (TBP); 2) perform hand hygiene during resident care and during dining service; and 3) provide catheter care with professional standards. These failures placed residents at risk for the development and transmission of communicable diseases and related complications. Findings included . <Facility Policy> According to the facility's Infection Control Policy and Practices policy dated March 2023, the facility would prevent, detect, investigate and control infections by maintaining a safe and sanitary environment, and to help prevent and manage transmission of diseases and infections. The policy stated the facility would manage transmission of diseases and infections by implementation of isolation precautions for standard 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 implement an effective Antibiotic (ABO) Stewardship Program, to promote appropriate use of ABO's, reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 3 of 5 sampled residents (Resident 223, 224, & 38) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's. Findings included . <Facility Policy> According to a facility policy titled, ABO Stewardship Program, dated 06/17/2024, ABOs would be prescribed and administered to the residents under the guidance of the facility's ABO Stewardship Program as part of the facility's overall infection prevention and control program. The policy showed appropriate indications for use of ABO's included meeting the Loeb minimum Criteria for clinical definition of active infection. This policy stated when a Culture and Sensitivity (C&S - a test to identify a specific type of bacteria and determine which ABO's will treat the infection best) was ordered, the results…

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 level of supervision necessary to prevent accidents for resident-to-resident altercations for 2 (Residents 1, 2) of 5 residents reviewed for supervision and accidents. The facility failed to provide supervision and placed residents at risk for potential verbal and physical abuse, serious injury, pain, and diminished quality of life. Findings included . Review of the facility policy titled, Safety and Supervision of Residents, revised 07/2017, showed the facility would strive to make the environment as free from accident hazards as possible and resident safety, supervision, and assistance to prevent accidents were facility wide priorities. The policy showed resident supervision was a core component of the systems approach to safety, the type and frequency of supervision was determined by the individual resident's assessed needs. The policy showed interventions would be developed to reduce the individuals risks related to hazards…

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, implement and maintain an in-service training program that ensured 3 of 3 Nursing Assistants (Staff's L, M, & N) reviewed for training and competency, had the required 12 hours per year of in-service training and education. This failure placed residents at risk of less than competent care and services from staff. Findings included . Review of the Facility Assessment, revised [DATE], showed required in-service training for nurse aides must be sufficient to ensure the continuing competence of nurse aids and must be no less than 12 hours per year, including dementia (a memory impairment) management training. Additional staff training identified included communication training, resident rights and facility responsibilities, cultural competency, identification of resident changes in condition, including how to determine if symptoms represent problems in need of intervention. On [DATE] at 2:27 PM, an Automated External Defibrillator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Physician Order for Life Sustaining Treatment (POLST - a form indicating the resident's wishes when found not breathing and without a pulse) to initiate Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air/Full Code) or not during medical emergency for 2 of 8 residents (Residents 3 & 4) reviewed for Advance Directives. The failure to ensure a copy of the POLST form was available in the medical records and accessible to staff (Resident 3) and to fully complete the POLST form (Resident 4) placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care, not receiving CPR when indicated, and potentially death. Findings included . <Resident 3> According to the [DATE] Discharge Minimum Data Set (MDS - an assessment tool), Resident 3 had medical conditions including unstable blood sugar…

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 4 (Residents 1, 3, 4 & 5 ) of 6 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to adequately monitor the effectiveness of medications ordered to treat insomnia (difficulty sleeping). Failure of the facility placed residents at risk to receive unnecessary medications and/or experience adverse side effects. Findings included . According to the facility Use of Psychotropic Medication Policy revised 12/22, residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. For new admissions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed conduct thorough investigations and implement preventative measures to ensure the safety of 2 (Resident 1 & 2) of 2 residents reviewed for accidents. Failure of the facility placed residents at risk of injury. Findings included . <Resident 1> Review of the 01/06/2024 admission Minimum Data Set (MDS - an assessment tool), showed Resident 1 was cognitively intact, was able to walk ten feet with partial-moderate assistance, walk 50 feet with substantial - maximal assistance, and the Resident's ability to get on and off a toilet or commode was noted as not applicable. According to this MDS the resident had a history of falls prior to admission, but no falls since admission on [DATE]. Review of the Care Area Assessments (CAA), showed the resident required moderate assistance with Activities of Daily Living (ADLs), was occasionally incontinent of urine and required moderate assisting with toileting and was a high risk for falls related to a history of falls,…

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 meals that accommodated resident food allergies and preferences for 2 (Resident 1 & 6) of 4 residents reviewed for food allergies/preferences. This failure placed the resident at risk for allergic reaction, dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . <Resident 1> Review of the Hospital History and Physical dated 12/15/2023 and printed 12/28/2023, showed Resident 1 was allergic to shellfish containing products and exhibited the allergic reaction of anaphylaxis ( a serious life-threatening allergic reaction which usually occurs within few seconds or minutes of exposure, involving hives, swelling and sudden drop in the blood pressure.) Resident 1 admitted to the facility on [DATE]. The diet order entered into the electronic medical record was a CCHO (consistent, constant, controlled carbohydrate), Diabetic, No Added Salt diet. It did not include additional directions. Review of the Dietary Profile…

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 schedule sufficient staff to provide care and services to ensure resident's needs were met on one of three shifts (night shift) reviewed for sufficient staffing. This failure placed resident's at risk for unmet care needs, accidents/injuries, and diminished quality of life. Findings included . Review of the Facility Assessment (FA) revised April 2023, showed 55 residents required 1-2 person assist with transfers, 13 residents were dependant on staff for transfers, 69 residents required 1-2 person assist with toileting, and three residents were dependent on staff to meet toileting needs. According to the FA the facility assessed the facility to require four nursing assistants on night shift for a census of 85. Review of lists provided by the facility on 09/01/2023 showed the facility had 23 residents that were assessed to require two-person assistance with mobility (16 in the back hall and seven in the front hall), and nine residents who were identified as Care in Pairs (six in the back hall and three in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the facility was administered in a manner that used its resources effectively and efficiently so residents could attain or maintain their highest practical physical, mental, and psychosocial well-being and to ensure the facility maintained substantial compliance with state and federal regulations. The Administration failed to provide administrative oversight and monitoring of facility personnel, systems, practices, and policies related to Abuse/Neglect; to provide sufficiently trained and supervised nursing staff to meet resident needs; and failed to ensure staff were trained on facility identified training and required mandatory training, including, but not limited to Abuse, Neglect, and Exploitation. These failures placed all 79 residents of the facility at risk for harm related to potential ongoing abuse and/or neglect. Findings included . On 08/31/2023 at 3:00 PM, the facility was notified of an Immediate Jeopardy (IJ) at CFR…

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 fall prevention strategies were implemented for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for falls with injury. Findings included . <Resident 1> Review of the Minimum Data Set (MDS - an assessment tool) dated 05/24/2023, Resident 1 was assessed to require two person extensive assistance with mobility. Review of the at risk for falls CP revised 05/08/2023 showed Resident 1 was at risk for falls. Interventions listed included, bed in lowest position, against the wall left side, fall mat on right side and bilateral quarter rails to assist with mobility. Review of a Written Notice of Room Change dated 05/24/2023 showed Resident 1 was moved on 05/23/2023 to a room in the front hall. The room move was deemed as medically necessary as the resident was needing one on one [1:1 care]. Review of a 07/17/2023 Provider Note showed Resident 1 was a high fall risk with frequent falls and poor safety awareness. According to the documentation the resident was asleep in bed with aid…

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 consider and act promptly to address concerns raised by residents at the Resident Council. Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided for why action could not be taken left residents at risk for frustration, and a less-than-homelike environment. Findings included . Review of the minutes from the facility's 02/28/2023 Resident Council meeting under the header Maintenance showed residents asked when the facility's patio would be cleaned up. The minutes indicated residents wanted to have the patio available as Spring approached. The 03/31/2023 Resident Council meeting minutes included no discussion of past concerns, including the availability and cleanliness of the patio area. Under the header Maintenance residents again asked when the patio would be cleaned up. The 04/25/2023 Resident Council Meeting minutes included no discussion of past concerns, including the prior patio concerns. Under the header of Maintenance the minutes showed Residents would REALLY…

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 and interview, the facility failed to maintain a safe, comfortable, and homelike environment on 2 of 4 units, 1 of 1 therapy gyms, 1 of 1 dining/activity rooms, and 1 of 1 patio areas. Facility failure to maintain a home with adequate space for residents to congregate freely and comfortably outside their rooms, and maintain resident rooms and halls in a safe and homelike environment, left residents at risk for an unsafe and less-than-homelike environment. Findings included . <Patio> Observation of the patio area accessed directly from the dining/activity room on 05/19/2023 at 2:08 PM showed the patio was used to store furniture and other equipment. Six dining room tables (some stacked on top of one another, others lying on their side with the table legs sticking out horizontally), seven dining chairs (positioned in a way that prevented anyone from sitting on them), two gas grills, an air conditioning unit, and an old whirlpool tub were observed in the covered area, minimizing the space…

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 67> According to the 02/23/2023 Quarterly MDS Resident 67 had medically complex diagnoses including metabolic encephalopathy (a brain disease that can cause delirium, lethargy, and dementia) and history of stroke. The MDS showed Resident 67 required extensive assistance with eating and a mechanically altered diet (the resident's food and/or drinks needed to be altered in order to allow the resident to safely swallow). According to an 04/12/2023 progress note, Resident 67 choked while eating green beans and their diet texture was downgraded to an easier to chew and swallow texture. A 04/20/2023 progress note showed Resident 67 had a new order for an antibiotic medication to treat aspiration pneumonia (a lung infection caused by inhaled food particles). Another 04/21/2023 progress note showed Resident 67 was transported to hospital on [DATE]. During an interview on 05/23/2023 at 10:42 AM, Staff D (RCM) acknowledged there was no documentation to support the resident or resident's representative 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.

Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and implemented for 10 of 18 sample residents (Residents 67, 4, 5, 20, 70, 63, 73, 25, 45 & 42). These failures left residents at risk for unmet care needs and negative health outcomes. Findings included . <Resident 67> According to the 02/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident had diagnoses including a history of stroke and difficulty swallowing. The MDS showed Resident 67 required extensive assistance with eating and had an altered-texture diet (to assist with swallowing/prevent choking). Review of the Physician's Orders (POs) showed Resident 67 had an order for pureed texture food and nectar-thick fluids. The POs did not include an order stating Nothing by mouth or any other orders restricting Resident 67's dietary intake. The 12/16/2022 resident has a nutritional problem . CP included a 05/04/2023 intervention stating NPO (nothing by mouth) was recommended related to Resident 67's swallowing difficulties. Resident 67's Kardex…

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 Activities of Daily Living (ADL) assistance to dependent residents for 8 of 9 residents (Residents 4, 5, 63, 73, 25, 45, 42, & 11) reviewed for ADLs. Facility failure to provide ADL assistance as needed placed residents at risk for poor hygiene, and feelings of diminished self-worth. Findings included . <Resident 4> According to the 03/16/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 4 was assessed with moderate difficulty with decision-making, and diagnoses including heart failure. The MDS showed Resident 4 required assistance to bathe, and showed the choice between a tub bath, shower, bed bath and sponge bath was very important for the resident. On 05/17/2023 at 9:08 AM Resident 4 was observed lying in bed with greasy hair. On 05/19/2023 at 8:27 AM, Resident 4's hair was again observed to be greasy. The 03/24/2023 ADL self-care performance deficit . Care Plan (CP) included interventions for facility staff 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 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. The facility failed to consistently perform hand hygiene before and after resident care/contact and staff failed to ensure equipment was cleaned and disinfected after each use and between resident use. These failures placed the residents and staff at risk for development of contagious, communicable infections and disease. Findings included . Hand Hygiene The 03/2023 facility policy titled Hand Hygiene directed staff to perform hand hygiene in the following situations: before and after direct resident contact, between resident contact, before and after handling foods and assisting residents with meals, before and after assisting residents with personal care, when taking a pulse or blood pressure, after removing gloves, and before/after handling clean or soiled…

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 honor preferences for bathing for 2 of 8 residents reviewed for choices for Activities of Daily Living (ADLs) (Residents 85 & 10). The facility's failure to accommodate resident choices regarding bathing preferences placed residents at risk for a frustration, embarrassment, and a diminished quality of life. Findings included . <Resident 85> According to the 05/07/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 85 admitted to the facility on [DATE]. The MDS showed Resident 85 was assessed with moderate cognitive impairment and totally dependent on staff for bathing. The MDS showed the choice between a tub bath, shower, bed bath, or sponge bath was very important for Resident 85. The 05/10/2023 resident has an ADL self-care performance deficit . Care Plan (CP) showed staff should provide a sponge bath when a full bath or shower could not be tolerated. The CP showed Resident 85 was scheduled for bathing on Tuesdays…

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 notify 7 (Resident 13, 51, 47, 28, 1, 42, & 55) of 25 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. The facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 1 (Resident 339) of 6 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Findings included . Review of a revised 12/01/2022 Resident Personal Funds policy, showed the facility must notify each resident who received Medicaid benefits: when the amount in the resident's account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person; and if the amount in the account reached the SSI resource limit, the resident…

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

Based on interview and record review, the facility failed to ensure 18 of 25 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . According to a revised 12/01/2022 facility Resident Personal Funds policy the facility would purchase a surety bond to assure the security of all personal funds of residents deposited with the facility. Record review of the facility's Trial Balance report showed 25 residents had funds in trust accounts. The trust account report showed a current balance of $33,112.29 as of 05/22/2023. Review of the facility's surety bond, dated 05/09/2018, showed the bond amount covered a trust account balance not to exceed $28,000. In an interview on 05/22/2023 at 10:30 AM, Staff S (Business Office Manager), stated the surety bond should be more than the total amount in the trust accounts. Staff S confirmed the facility's surety bond did not cover the current facility trust account balance.…

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 Advanced Directives (ADs - legal documents reflecting resident wishes for end-of-life care) were available in the resident record for 5 of 12 sample residents (Residents 5, 4, 3, 10 & 46) reviewed for ADs. These failures placed residents at risk for unnecessary care, and their end-of-life wishes not being honored. Findings included . <admission Packet> The facility's undated admission Packet showed residents had the legal right to make their own healthcare decisions including the right to determine in advance which life-sustaining treatments they wanted, such as cardiopulmonary resuscitation (CPR). These healthcare decisions could be provided in written form, as an AD. The packet instructed residents to provide the facility with their signed AD documentation if they had any. <Resident 5> According to the [DATE] admission Minimum Data Set (MDS - an assessment tool) Resident 6 admitted to the facility on [DATE]. The MDS showed Resident 5 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 who experienced a significant change in health status were comprehensively assessed using the Centers for Medicare and Medicaid (CMS) specified Resident Assessment Instrument (RAI) process. The facility failed to: (1) complete a Significant Change Minimum Data Set (MDS - an assessment tool) for 1 of 1 (Resident 338) residents, and (2) timely complete the Significant Change MDS for 1 of 1 (Resident 67) residents reviewed for hospice (supportive care focusing on comfort and quality of life) services. Failure to identify the need for a Significant Change MDS and timely complete the assessment placed residents at risk for unmet care needs, delayed care planning, and a decreased quality of life. Findings included . <RAI process> The October 2019 RAI Manual (a guide directing staff on how to accurately assess the status of residents) indicated a Significant Change MDS assessment was required when: (1) a resident experienced a decline 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 observations, interview, and record review the facility failed to ensure 6 (Residents 20, 55, 63, 45, 42, & 10) of 18 residents Minimum Data Set (MDS- an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 20> According to a 03/28/2023 Quarterly MDS, Resident 20 was cognitively intact with clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 20 with no broken or loosely fitting full or partial dentures. In an interview on 05/16/2023 at 11:53 AM, Resident 20 stated their dentures needed to be adjusted and stated staff were aware the dentures were too loose. Review of a 03/16/2023 progress note showed staff documented Resident 20 was on the dentist list for loose dentures. In an interview on 05/24/2023 at 10:18 AM, Staff K (MDS Coordinator) stated based on the 03/16/2023 progress note, loosely fitting dentures should have been, but was not captured on the 03/28/2023 Quarterly MDS. <Resident 55>…

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

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the Care Plan (CP) for 1 of 6 (Residents 55) residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Resident 55> According to a 04/17/2023 Quarterly Minimum Data Set (an assessment tool) Resident 55 had multiple medically complex diagnoses including depression and Schizophrenia (a mental disorder in which people interpret reality abnormally). Review of an undated Level 1 PASRR (Level 1 - the process to determine if mental health services are required) completed by facility staff identified Resident 55 with Serious Mental Illness (SMI) indictors and required a Level 2 evaluation referral. A review of a 12/14/2021 Notice of Determination form…

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

Based on observation, interview and record review, the facility failed to develop comprehensive Care Plans (CPs) for 3 of 18 residents (Residents 4, 20 & 70) whose CPs were reviewed. Facility failure to develop individualized, comprehensive CPs left residents at risk for unmet care needs. Findings included . <Resident 4> According to the 03/16/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 4 was assessed to have moderate difficulty with decicion making. The MDS showed Resident 4 required extensive assistance with toileting. Resident 4's Physician's Orders (POs) included a 03/27/2023 PO for a laxative powder 17 grams by mouth as needed for constipation. Review of Resident 4's comprehensive CP showed no CP developed to address Resident 4's constipation and related laxative use. In an interview on 05/23/2023 Staff D (Resident Care Manager - RCM) stated Resident 4 used a laxative powder. Staff D stated it was important for all care required by a resident to be care planned, and Resident 4's laxative use/constipation were not. <Resident 20> According to the…

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

Based on observation, interview, and record review, the facility failed to: follow Physician's Orders (POs) for 4 of 22 sample residents (Residents 73, 63, 44 & 41); clarify POs (Residents 67 & 70); sign only for tasks performed (Resident 20). These failures placed residents at risk for unmet care needs, medication and treatment errors, and negative health outcomes. Findings included . <Following POs> <Resident 73> According to a 02/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 73 had multiple complex diagnoses including chronic respiratory failure and required the use of oxygen therapy. Review of Resident 73's May 2023 Treatment Administration Record (TAR) showed the resident had a PO for oxygen to be given at 2 Liters Per Minute (lpm) when in use. Observations on 05/16/2023 at 8:33 AM, 05/17/2023 at 9:07 AM, and 05/24/2023 at 8:29 AM showed Resident 73's oxygen was set to 1.5 lpm. In an interview on 05/24/2023 at 8:33 AM, Staff U (Resident Care Manager - RCM), confirmed Resident 73's order for oxygen was to be at 2 lpm. Staff U read the PO and raised the…

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

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 4 of 6 residents (Residents 4, 73, 63, & 42) reviewed for Activities. The failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Resident 4> According to the 03/16/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 4 was assessed with moderate difficulty making decisions and required extensive assistance with transfers. The MDS showed it was very important for Resident 4 to participate in their favorite activities, and somewhat important for the resident to do things with groups of people. The 04/04/2023 resident is dependent on staff for meeting emotional, intellectual, physical, and social needs Care Plan (CP) included the following interventions: ensure Resident 4 attended activities that were compatible with their physical and mental capabilities; invite the resident to scheduled activities; provide bedside/in-room activities if Resident 4…

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

Based on interview and record review, the facility failed to provide assistive devices and/or proper treatment to maintain hearing for 1 of 1 resident (Resident 20) reviewed for hearing. This failure placed the resident at risk for frustration, decline in the ability to hear, and diminished quality of life. Findings included . Review of a revised 12/2022 facility Hearing and Vision Services policy showed the facility would ensure all residents have access to hearing and vision services and receive adaptive equipment as indicated. This policy stated once vision or hearing services were identified, the social worker/social service designee would assist the resident by making appointments and arranging for transportation. <Resident 20> According to a 04/26/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 20 did not have a memory impairment and was able to understand, and be understood by others. This MDS showed staff assessed Resident 20 with adequate hearing with no hearing aid. On a previous 03/28/2023 Quarterly MDS, staff assessed Resident 20 with minimal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to follow the Care Plans (CP) with interventions todevelop new skin issues and to promote wound healing for 1 (Resident 25) of 2 residents reviewed for Pressure Ulcers (PU). Failure to follow the CP such as positioning resident in bed, getting the resident out of bed, and provide pressure relieving devices placed residents at risk for deterioration in skin condition. Findings included . According to the 04/2023 revised Pressure Injury Prevention and Management facility policy, residents determined as at risk for developing pressure injuries would have interventions documented in the CP based on specific factors identified in the risk assessment. Evidence based interventions for wound prevention would be implemented for the residents at risk and with PUs would include repositioning, floating heels, providing pressure redistributing non-irritating surfaces, and maintaining nutrition and hydration status. According to this policy, interventions…

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 2 of 5 (Residents 59 & 2) residents reviewed for Restorative Nursing Services received the services as they were assessed to require. These failures placed residents at risk for decline in Range of Motion (ROM - move a joint in different directions), dependence on staff, and a decreased quality of life. Findings included . <Resident 59> According to the 02/26/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 59 was assessed as never understood in conversation, and had diagnoses including anoxic brain damage (brain injury caused by lack of oxygen to brain), right and left wrist contracture (tightening of the muscles and tissues that causes the joints become very stiff), right and left elbow contractures, and a left hip contracture. This assessment showed Resident 59 required extensive assistance from staff for bed mobility, dressing, personal hygiene, and was totally dependent on staff for transfers and toileting. This assessment showed the resident had both upper and lower extremity…

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

Based on observations, interview, and record review the facility failed to ensure 3 (Residents 77, 63, & 41) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to adequately monitor behaviors and adverse side effects of psychotropic medications, and failed to individualize target behaviors. These failures placed residents at risk to receive unnecessary medications and/or experience adverse side effects. <Resident 77> Review of a 04/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 77 had diagnoses of memory impairment and an anxiety disorder. This assessment showed Resident 77 received a psychotropic medication daily, during the assessment period. According to this MDS, Resident 77 did not have any physical or verbal behavioral symptoms. Resident 77 did not refuse care during the assessment period. In an observation on 05/17/2023 at 2:30 PM, Resident 77 was in in their wheelchair in the dining room, during a resident activity. Resident 77 was asleep. In an observation on 05/18/2023 at…

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

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were dated when opened, and expired medications and biologicals were disposed of timely for 2 of 4 medication carts reviewed. These failures placed residents at risk for receiving expired medications or experiencing medication errors. Findings included . Review of a 01/2023 facility Medication Storage policy showed medications and biologicals would be stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe, effective drug administration. This policy directed staff to note the date on the label for diabetic medication vials and pens when first used. Outdated or discontinued medications, and those in containers without secure closures would be immediately removed from stock, disposed of according to procedures for medication disposal. <Medication Storage and Labeling> <Wild [NAME] Medication Cart> Observation of the Wild [NAME] medication cart on 05/16/2023 at 12:26 PM, with Staff T (Licensed Practical 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.

Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 2 (Resident 20 & 70) of 6 sample residents and 1 supplemental resident (Resident 55) reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included . A revised 12/2022 facility Dental Services policy stated the facility would, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. All actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical records. <Resident 20> According to a 03/28/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 20 was able to make their own decisions, had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 20 with no broken or loosely fitting full or partial dentures. In an interview on 05/16/2023 at…

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

Based on observation, interview, and record review the facility failed to ensure 1 of 1 (Resident 38) residents reviewed for altered texture diet received food in the texture prescribed by a physician, and as assessed by the interdisciplinary team to support the resident's treatment and care. Failure to ensure Resident 38 received the correct diet texture as ordered placed residents at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), choking, and other serious medical complications. Findings included . <Facility Policy> The 12/2022 Therapeutic Diet Orders facility policy defined a mechanically altered diet as one in which the texture or consistency of food were altered to facilitate oral intake. The policy outlined the responsibility of both dietary and nursing staff to provide therapeutic diets in the prescribed form and/or nutritive content. <Resident 38> According to the 05/03/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 38 had multiple medical diagnoses including a condition…

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 food was prepared, stored, and served under sanitary conditions in accordance with professional standards for food service safety. Facility staff failed to: (1) conduct proper testing of sanitizing bucket solutions, (2) use hair covering in food preparation areas, (3) use disposable gloves for food handling during tray line service, (4) thoroughly clean and sanitize the food thermometer before use, and (5) prepare Resident 67's beverage according to the prescribed altered liquid consistency. These failures placed residents at risk for food contamination, bare-hand contact, foodborne illnesses, aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), and other serious medical complications. Findings included . <Facility Policy> The 12/2022 Maintaining a Sanitary Tray Line facility policy showed tray assembly was prioritized to ensure foods were handled safely and held at proper temperatures. The policy directed staff to wear gloves and hair…

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 specialized rehabilitative services were provided as determined by the physician's order for 2 of 3 (Residents 70 & 63) residents reviewed for therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. Findings included . <Resident 70> According to the 04/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 70 was able to understand, understood others, and had multiple diagnoses including a stroke (a brain injury), loss of function to the left side of their body, left hip contracture (tightening of the muscles and tissues that causes the joints become very stiff), and generalized muscle weakness. The MDS showed Resident 41 received skilled Physical Therapy (PT) services with a start date of 04/06/2023. In an interview on 05/16/2023 at 9:00 AM, Resident 70 stated they were not getting PT services they were supposed to. Resident 70 stated nobody had come 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.