Life Care Center Of Richland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents requiring assistance with showers, oral care, and nail care, were provided timely assistance according to their needs and preference for 6 of 10 sampled residents (Residents 11, 35, 13, 82, 9, and 26) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of infection, decreased dignity, and a decreased quality of life. Findings Included . <Resident 11> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include Alzheimer disease (a brain disorder that slowly destroys a person’s memory and thinking skills). The 06/26/2025 comprehensive assessment showed Resident 11’s cognition was severely impaired and was dependent upon staff for bathing and personal hygiene. During an interview on 07/16/2025 at 9:13 AM, the Resident Representative (RR) of Resident 11 stated they would arrive to the facility between 6:30 AM and 7:00 AM daily and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate staffing levels in order to provide care and services needed for 8 of 10 residents (Residents 11, 35, 13, 82, 9, 26, 8, and 18) reviewed for activities of daily living (ADLs), restorative therapy, and specialized therapy services (therapy that improves performing daily tasks, mobility and function). This failed practice placed residents at risk for an undignified existence and unmet care and service's needs. Findings included.<ADLs><Resident 11>Review of the resident's medical records showed they were admitted to the facility with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills). During an interview and concurrent observation on 07/16/2025 at 9:13 AM, showed Resident 11 had a build up of a white substance between their teeth and the Resident Representative (RR) stated they wanted the resident to receive showers more than twice a week. The RR stated they…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and discard medications when medications were not in use and when medications have expired on 2 of 2 medication carts (Team 1 and 2 medication carts) and 1 of 2 medication rooms (Team 2), reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medication. Findings included. Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals dated 12/01/2007, showed the facility should ensure medications and biologicals: (1) have an expired date on the label, (2) have been retained longer than recommended by manufacturer or supplier guidelines, and (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. <Team 1> An observation of the Team 1 medication cart on 07/22/2025 at 11:00 AM, with Staff D Licensed Practical Nurse (LPN),…

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 inform the Resident Representative (RR) of changes in the resident's pain medication regimen for 1 of 2 residents (Resident 57) reviewed for an order change for pain medication. This failure disallowed the RR to make an informed decision concerning the resident's care needs.Findings Included .<Resident 57> Review of the medical record showed the resident was admitted on [DATE] with diagnoses of a right hip fracture, muscle weakness, seizures and dementia (cognitive impairment). The 07/01/2025 nursing assessment/ care plan showed Resident 57 was totally dependent on staff for all activities of daily living to include bed mobility and transfers to a wheelchair. Resident 57's pain medication orders included a narcotic pain reliever which was discontinued on 07/10/2025. Tylenol (a non-narcotic pain reliever) was started on 07/10/2025 as needed. A 07/12/2025 order was initiated for Robaxin (a muscle relaxant) initiated three times a day on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication, leaving medications at bedside for 1 of 2 residents (Resident 82), reviewed for medication administration. This failure placed the residents at risk for medication errors and adverse medication interactions. Findings included .Review of the facility's policy titled, Administration of Medications, dated 09/16/2024, showed, the facility would ensure medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.<Resident 82> Review of the resident's medical record showed Resident 82 was admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (a disease in which the body does not control glucose [a type of sugar] in the blood), and dysphagia (difficulty swallowing). Review of Resident 82's comprehensive assessment dated [DATE], showed the resident's cognition 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 quarterly financial statements for resident trust accounts were provided in accordance with generally accepted standards of accounting practice for 1 of 3 residents (Resident 6), reviewed for trust accounts. Failure to provide resident /resident representative's quarterly financial statements for the months of January, March, November and October 2024, placed the resident at risk for loss of personal funds. Findings included . <Resident 6> Review of the resident's medical record showed Resident 6 was admitted on [DATE] with diagnoses to include bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function), dementia [the loss of thinking, remembering, and reasoning- to the extent that in interferes with Activities of Daily Living (ADLs)] and muscle weakness. The comprehensive assessment dated [DATE] showed the resident's cognition was severely impaired and required the assistance of two staff members…

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 resident received their mail for 1 of 1 resident (Resident 8) reviewed for resident rights. This failed practice put the resident at risk of not being able to make independent choices regarding their mail preferences. Findings included. <Resident 8> Review of the resident's medical records showed they admitted to the facility with diagnoses to include bipolar disorder (a mental health disorder that causes extreme mood swings) and diabetes (how the body regulates blood sugar levels). The 07/01/2025 comprehensive assessment showed the resident was cognitively intact and able to make their own decisions. During an interview on 07/16/2025 at 10:15 AM, Resident 8 stated they had not received packages they had ordered from Amazon (an online shopping retailer). Resident 8 stated they had several packages that showed as delivered but they had not received them yet. During an interview and concurrent observation on 07/17/2025 at 4:14 PM, Resident 8 stated they had still not received their packages and asked to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed during resident council meetings (a meeting of the facility's residents to communicate concerns, request improvements and keep up to date of the facility's activities/events) and individually, underwent prompt resolution through to their conclusion nor were residents appropriately updated on the voiced grievance progress/conclusion for 2 of 5 residents (Resident 77 and 69) reviewed for the grievances process. This failure placed residents at risk for unresolved concerns and unmet care needs.Findings included.Review of the facility policy titled, Grievances Program (concern and Comment), revised 01/07/2025, showed the facility would have a process in place for identification, investigation and follow-up of resident grievance/concern in a timely manner. Residents could convey grievances verbally or in writing. The policy showed that grievances…

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 on psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior) had non-pharmacological interventions (alternative treatment of a resident's symptoms that are directed toward understanding, preventing and relieving a resident's distress or loss of abilities and do not involve the use of medications) consistently attempted and were being monitored for individualized behaviors prior to psychotropic administration to reflect adequate need of the medication for 2 of 5 residents (Residents 11 and 71) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Finding included .<Resident 11> Review of the residents’ medical records showed they were admitted to the facility with diagnoses to include anxiety (an intense, excessive and persistent worry and fear about everyday…

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 patient-centered discharge plan by the interdisciplinary team and document required discharge information for 1 of 4 residents (Resident 45) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, worsening of wounds, psychological distress, and rehospitalization. Findings included. Review of the policy titled Transfers and Discharges, dated 04/22/2025, showed the facility would document in the resident's record the appropriate information was communicated to the receiving health care provider. The policy showed the documentation would show the reasons for discharge, infection status, functional status, and risks such as fall risk. <Resident 45> Review of the resident's medical records showed they were admitted to the facility with diagnoses of left superficial femoral artery endarterectomy with bovine patch angioplasty (when plaque builds up in the artery, then gets removed and a patch is used to restore…

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 up on written notices of bed holds (holding or reserving a resident's bed while the resident was absent from the facility) given at the time of hospital transfers, and/or failed to send a copy of the notice of transfers to the representative for 2 of 4 residents (Residents 26 and 1) reviewed for discharge process. This failure placed residents at risk of not being informed of their rights regarding a bed hold and the lack of advocacy. Findings Included . Review of the facility policy dated 04/22/2025, titled Bed-Hold policy, showed the facility would provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents returned to the facility to ensure that residents would be made aware of a facility’s bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. <Resident 26> Review of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS- a comprehensive assessment tool) accurately reflected the status for 2 of 10 sampled residents (Resident 10 and 35) reviewed for accuracy of assessments. This failure placed the resident at risk for unidentified care needs. Findings included . <Resident 10> Review of the resident medical record showed they were admitted to the facility on [DATE] with diagnoses including heart complications and stroke (blood flow to the brain is blocked or a blood vessel bursts). The 06/30/2025 comprehensive assessment showed the resident was taking an anticoagulant (a type of drug that prevents the blood from clotting as quickly or as effectively as normal) medication. Review of Resident 10's provider orders for June 2025 showed no medication that would meet the criteria for an anticoagulant. <Resident 35> Review of the resident medical record showed they were admitted to the facility on [DATE] with diagnoses including a…

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

Based on observation, interview, and record review, the facility failed to ensure restorative therapy services, including the use of an orthotic (a device designed to support, align, or correct function of movable parts of the body) were consistently implemented for 2 of 3 residents (Residents 8 and 35) reviewed for restorative therapy. This failure placed the residents at risk for loss of range of motion (ROM, the amount of movement that a joint can achieve in a specific direction), deconditioning (a decline in physical health from prolonged inactivity or illness), and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included. Review of the policy dated 11/19/2024, titled Restorative Nursing, showed the Restorative Nursing program was to promote a resident's ability to adjust and adapt to live as independent and safe as they possibly could. The policy showed .measurable objective and interventions must be documented in the care plan and medical record and the trained 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 97) reviewed for hydration were consistently monitored and received adequate hydration fluids as per physician orders. This failure placed residents at risk for dehydration, constipation, urinary tract infections (UTI), and other health complications including worsening cognitive impairment and behavioral changes. Findings included . Review of the facility's policy, titled Infusion Therapy-Hypodermoclysis (Subcutaneous Fluids), dated 09/16/2024, showed the facility assures that each resident receive care and services consistent with professional standards of practice. Provide safe administration of infusion fluids by qualified staff, including monitoring the resident status. Review of the Lippincott's journal of nursing titled, Hypodermoclysis (HDC) in Home and Long-term Care Settings dated January 2009, showed Lippincott's standards of practice in nursing were as follows: (1) monitoring the infusion site…

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 physician ordered Occupational (OT, specialized therapy that improves performing daily tasks) or Physical therapy (PT, specialized therapy that improves mobility and function) was received for 2 of 4 residents (Residents 13 and 18) reviewed for therapy services. This failure placed the residents at risk for decline in function, decreased independence, and the worsening or development of contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included. Based on observation, interview, and record review, the facility failed to ensure physician ordered Occupational (OT, specialized therapy that improves performing daily tasks) or Physical therapy (PT, specialized therapy that improves mobility and function) was received for 2 of 4 residents (Residents 13 and 18) reviewed for therapy services. This failure placed the residents at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement effective measures of their infection prevention and control antibiotic stewardship program (ASP) regarding monitoring of residents prescribed antibiotics to ensure appropriate antibiotic use for 1 of 2 residents (Resident 33) reviewed for antibiotic stewardship. This failure increased the risk for development of multidrug-resistant organisms (MDRO/a bacteria that are resistant to many antibiotics), and unmet care needs related to infections. Findings included .Review of the facility's policy titled, ASP, dated May 2019, showed that the facility was to .implement a system for monitoring and reviewing antibiotic orders and antibiotic usage to aide in the responsible use of antibiotics . and that the Infection Preventionist (IP) would be responsible for oversight on the ASP. The policy stated that the IP would, verify that antibiotic orders were in compliance with the Loeb Criteria (a checklist that evaluates the resident's signs and symptoms…

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 identify, accurately assess, and provide sufficient supervision to prevent elopement (a resident leaving the facility unsupervised and undetected) for 2 of 3 residents (Resident 1 and 2) reviewed for elopement. This failure placed the residents at risk for exposure to the elements, serious harm, and/or death. Findings included . Review of a policy titled, Unsafe Wandering and Elopement Prevention, dated 12/13/2018 and revised 03/04/2025, showed the facility would ensure residents were assessed to determine the risk of elopement and implement interventions to mitigate the identified risks. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including dementia (a group of conditions that cause a decline in memory, thinking, language, and problem solving that interferes with daily life), delirium (a serious, sudden change in mental abilities characterized by confused thinking, disorientation, and a decreased awareness of surroundings), attention-deficit…

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

Based on interviews and record review the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 4 of 4 NACs (Staff A, B, C, D) reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of those NACs and the quality of care provided to residents. Findings included . <Staff A> Review of Staff A's personnel file showed they were hired by the facility on 10/12/1993. The last performance review was on 10/30/2019 (over five years ago). <Staff B> Review of Staff B's personnel file showed they were hired by the facility on 06/14/2022. There had been no performance reviews completed on Staff B (over two years). <Staff C> Review of Staff C's personnel file showed they were hired by the facility on 12/27/2021. The last performance review was on 03/24/2023 (over one year). <Staff D> Review of Staff D's personnel file showed they were hired by the facility on 02/22/2023. There had been no performance reviews completed on Staff D (over one year). On 12/05/2024 at 11:30 AM, Staff E,…

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, interviews and record review, the facility failed to supervise to ensure the physician's diet order for 1 of 3 residents (Resident 1) was followed as ordered. This failed practice placed Resident 1 at risk for medical complications due to a choking incident. Findings included . <Resident 1> Review of the medical record showed Resident 1 had diagnoses which included difficulty swallowing following a stroke with left sided weakness. Review of Resident 1's comprehensive assessment, dated 09/25/2024, showed they had moderate impairment with cognition. Review of the resident's plan of care, dated 10/09/2024, showed they required assistance with one staff for toileting, turning in bed, dressing and eating to cut up the food items; and two staff for transfers utilizing a sit to stand mechanical device (designed to help those with limited mobility transfer from a seated position to an upright posture, and vice-versa). Review of Resident 1's prescribed diet order, dated 04/25/2023, showed regular…

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 interviews and record review, the facility failed to report an incident of neglect regarding a fall with significant injury to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency. Findings included . Review of the facility policy titled, Abuse - Reporting and Response - No Crime Suspected, reviewed on 06/17/2024, showed the facility would ensure that all alleged violations involving neglect were reported immediately to the State Survey Agency if the events that caused the allegation involved abuse or resulted in serious bodily injury. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart problems. Review of the resident's comprehensive assessment, dated 09/10/2024, showed they had moderately impaired cognition. Review of the resident's plan of care, dated 09/04/2024,…

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 interviews and record review, the facility failed to thoroughly investigate an incident of neglect, due to a fracture from a fall, for 1 of 4 residents (Resident 1), reviewed for investigations. Despite the significant changes in Resident 1's condition resulting in a hip fracture, and lack of staff assessments and timely medical care, the investigation did not include any statements by Staff C, G, and H. There was no investigation regarding the lack of timely assessments regarding significant changes in the resident's condition, pain medication and lack of obtaining the necessary medical evaluation and treatment. This failed practice placed residents at risk for unrecognized neglect, lack of monitoring, corrective action, and/or a diminished quality of life. Findings included . Review of the facility policy titled, Abuse - Conducting an Investigation, reviewed on 06/17/2024, showed that allegations of neglect were promptly and thoroughly investigated. The facility would prevent further neglect from…

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 address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) including incorporating ADs into the care planning process for 2 of 3 residents (Residents 22 and 35) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care. Findings included . <Resident 22> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include a stroke (a medical emergency that occurs when blood flow to the brain is blocked or reduced) with left sided deficits and acute respiratory failure. The 06/06/2024 comprehensive assessment, showed the resident's cognition was intact. Additionally, the medical record showed Resident 22 did…

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

Based on observation, interview, and record review, the facility failed to ensure the identification of physical and verbal abuse, and the protection of residents from their Alleged Perpetrator/Alleged Perpetrators (AP/APs), after allegations of abuse were reported to the facility for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse/neglect. This failure placed the residents at risk for further abuse, fear, and unmet care and services. Findings included . <Resident 22> Review of the resident's medical record showed the resident had diagnoses to include a stroke (a medical emergency that occurs when blood flow to the brain is blocked or reduced) affecting their left side, heart failure, and acute respiratory failure. The 06/06/2024 comprehensive assessment, showed the resident's cognition was intact and required one to two staff assistance for bed mobility, transfers, and toileting. During an interview on 07/08/2024 at 3:02 PM, Resident 22 stated a few weeks ago they had gotten tangled up in their call light cord and the cord had wrapped around their neck. 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 report allegations of abuse/neglect for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse and neglect. This failure placed the residents at risk for further and unrecognized abuse/neglect and unmet care needs. Findings included . Review of the policy titled Abuse-Reporting and Response dated 06/17/2024, showed the facility would report alleged violations of mistreatment .neglect, or abuse . The allegations were to be reported immediately, and no later than 2 hours if the allegation involved abuse and no later than 24 hours if the allegation did not involve abuse. The facility would report to the Administrator and the state agency. <Resident 22> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with a stroke (a medical emergency, when blood flow to the brain is blocked or reduced) that affected their left side. The 06/06/2024 showed the resident's cognition was intact and required…

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 complete and thorough investigation had been completed, nor did they ensure the residents were protected from their alleged perpetrator (AP) by not removing the AP from having any further contact with those residents during the investigation phase of the reported allegations of abuse/neglect for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse and neglect. The failure to conduct a thorough investigation to rule out root cause, contributing factors, and identifying preventative measures of the abuse/neglect allegations placed the residents at risk for further unmet care needs and psychosocial harm. Review of a policy titled Abuse-Protection of Residents dated 06/17/2024, showed the facility would Prevent further potential abuse, neglect ., or mistreatment while the investigation is in process. The policy further showed the resident should be examined for injury and the AP should be removed from the alleged victim and other residents for ongoing safety and protection. Review of a 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 complete the Minimum Data Set (MDS, a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) discharge assessment upon discharge, within the required 14-day time period, for 5 of 5 residents (Residents 1, 15, 33, 49, and 51). This failed practice placed residents at risk for not having their needs met upon discharge. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include diabetes (a disorder in which the body has high sugar levels for prolonged periods of time) and pneumonia (An infection of the air sacs in one or both the lungs). The record showed the resident discharged from the facility on 04/30/2024 and a comprehensive discharge assessment had not been completed. <Resident 15> Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include a stroke…

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 within 48 hours of admission that had the minimum requirements documented for dietary orders, physician orders, and treatment plans for 3 of 4 residents (Residents 19, 35, and 50) reviewed for recent admissions. The failed practice placed the resident at risk of not receiving continuity of care and resident centered care needs. Findings included . <Resident 19> Review of the medical record showed Resident 19 was readmitted to the facility on [DATE] with diagnoses including a right hip replacement, diabetes and cardiac disease. The resident's comprehensive assessment dated [DATE], showed Resident 19 required substantial assistance for bed mobility and transfers and was cognitively intact. During an interview with Resident 19 on 07/09/2024 at 11:23 AM, they stated they were discharged from the facility on 02/28/2024 and returned on 03/07/2024 following a scheduled hip replacement. Resident 19 stated they could not recall a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 5 of 5 residents (Residents 5, 6, 13, 14, and 22) reviewed for activities of daily living (ADLs), received adequate showers, grooming, and oral care according to the residents' care plans. This failure placed the residents at risk for unmet hygiene needs. Findings included . Review of the facility's policy titled Activities of Daily Living (ADLs) dated 02/12/2024 showed, the resident would receive assistance as needed to complete ADLs). Any change in the ability to perform ADLs would be reported to the nurse. <Resident #5> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, cardiac disease and depression. Resident 5's most recent comprehensive assessment dated [DATE] showed they required substantial assistance of one to two caregivers with bed mobility, transfers, dressing and personal hygiene and their cognition was intact. During…

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

Based on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections with, 1) hand hygiene and glove change for 6 of 6 staff (Staff F, T, U, V, LL, and OO) reviewed during resident cares, and isolation precautions requiring hand washing, 2) improper use of Personal Protective Equipment (PPE) in infection isolation rooms (rooms that require the use of PPE), when sorting facility residents laundry, and with self-testing of infectious diseases for 6 of 6 staff (Staff F, T, N, HH, KK, and PP) reviewed for standard precautions with PPE, 3) cleaning and disinfecting of the facility's isolation precaution room (a process used to reduce the transmission of infectious bacteria and organisms in the healthcare setting) without an Environmental Protection Agency (EPA) registered disinfectant for 1 of 2 staff (Staff QQ) reviewed for environmental cleaning and disinfecting. These failures placed residents at an increased risk for exposure to cross…

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 transfer of funds, from a resident trust account, were completed within 30 days following their discharge for 1 of 4 residents (Resident 316) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated. Findings included . <Resident 316> Review of the resident's medical records showed they were admitted on [DATE] with lung complications and lower back pain. Additionally, the resident was discharged [DATE]. Review of facility trust fund account reports, dated 06/21/2024, showed the remaining balances of monies ($165.01), in the form of a check, was sent to Resident 316 (37 days after the resident had discharged ) through the mail. During an interview on 07/09/2024 at 8:20 AM, Staff DD, Business Office Manager, stated that resident funds were to be transferred to the resident within 30 days of discharging from the facility. Staff DD stated, missed it in this…

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 quiet, comfortable and homelike environment for 1 of 1 resident (Resident 218) reviewed for homelike environment. This failure placed the residents at risk for fatigue, unwanted noise at night, and a non-homelike environment. Findings included . <Noise Level> An observation on 07/12/2024 at 3:49 AM, night shift, in the 100-hallway showed there were loud noises from TV's and music playing while the facility residents were trying to sleep. An observation on 07/12/2024 at 4:18 AM showed Resident 218 asked Staff Y, Nursing Assistant (NA)to please ask their neighbor in the next room to turn down their television. Resident 218 stated it has been on like that all night. Staff Y stated that they would try to have their neighbor turn down their TV. Staff Y went into the next room and asked the neighbor if they would turn down their TV. The neighbor did turn down their TV, but the TV continued to be loud enough to be heard from the hallway. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement 5 of 8 components (identify, protect, report, investigate, and coordinate with quality assurance performance improvement [QAPI] of their abuse/neglect policy/procedure for 4 of 7 residents (Residents 22, 53, 45, and 54) reviewed for allegations of abuse/neglect. Additionally, the facility failed to ensure the development of their abuse/neglect policy/procedure by not including Coordination with QAPI component. This failure placed the residents at risk for unrecognized abuse, and unmet care needs. Findings included . Review of the abuse policies dated 06/17/2024, showed no policy or procedures for communicating and coordinating allegations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. Review of a policy titled Abuse-Protection of Residents dated 06/17/2024, showed the facility would prevent further abuse, neglect, or mistreatment while the allegation was being investigated. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a written notice to the resident and/or their representative of the discharge for 2 of 2 residents (Residents 14 and 51) reviewed for hospitalization. In addition, the facility failed to properly notify the Office of the State Long-Term Care (LTC) Ombudsman (a person who advocates for residents in nursing homes). This failure placed the residents at risk for unmet discharge needs. Findings included . Review of the policy titled Transfers and Discharges dated 06/28/2024, showed the facility would provide a transfer and/or discharge notice to the resident or the resident's responsible party. The policy did not show the notice needed to be sent to the Office of the State LTC Ombudsman as well. <Resident 14> Review of the resident's medical record showed the resident was readmitted to the facility on [DATE] with diagnoses of a recent heart attack, diabetes and cardiac disease. Resident 14's most recent comprehensive assessment dated [DATE] showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of a hospital transfer for 3 of 3 residents (Residents 14, 19 and 51) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital. Findings included . Review of the policy titled Bed-Hold Policy dated 08/09/2023, showed the facility would provide the bed-hold policy to the resident upon admission, transfer to a hospital, or if the resident goes on therapeutic leave. <Resident 14> Review of the medical record showed Resident 14 was readmitted to the facility on [DATE] with diagnoses including cardiac disease, diabetes and depression. The Resident's comprehensive assessment dated [DATE] showed Resident 14 required substantial assistance of one to two staff members for all…

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 validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were correct on admission and corrected/updated as needed for 3 of 5 residents (Resident 19, 30 and 46) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility policy dated 09/25/2023, titled Pre-admission Screening and Resident Review (PASARR) showed the facilities procedure was to ensure PASARR Level I screening had been completed on potential admissions prior to admission. <Resident 19> Review of Residents 19's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include depression (a mood disorder that causes a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assist ensure an effective, resident-centered discharge plan was in place for 1 of 1 resident (Resident 46), reviewed for discharge planning. The failure to initiate a discharge plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-worth, and a diminished quality of life. Findings included . Review of the facility's policy titled Transfers and Discharges dated 06/28/2024 showed, the facility may initiate transfer or discharge of a resident, the documentation that must be included in the medical record, and who was responsible for making the documentation. Additionally, the facility would ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting was provided. <Resident 46> Review of Resident 46's medical record showed the resident was admitted 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 observation, interview, and record review the facility failed to ensure residents received medications or supplements that were physician prescribed and monitored as ordered for 1 of 1 resident (Resident 21) reviewed for insulin. This failed practice had the potential to cause the resident to experience adverse side effects and ineffective medication needs. Findings included . <Resident 21> Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include diabetes (a disorder in which the body has high sugar levels for prolonged periods of time) and morbid obesity. The 04/12/2024 comprehensive assessment showed the resident's cognition was intact and required one to two staff assistance for activities of daily living. A concurrent observation and interview on 07/08/2024 at 11:42 AM, Staff L, Licensed Practical Nurse (LPN) was checking Resident 21's blood sugar levels prior to lunch being served. Staff L stated to Resident 21 that their blood sugar had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide outside vision services for 1 of 1 resident (Resident 52), reviewed for experienced changes to their vision. This failed practice put the resident at risk for unmet vision needs and the ability to maintain their independence. Findings included . <Resident 52> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include diabetes (a disorder in which the body has high sugar levels for prolonged periods of time) and heart failure. The 05/06/2024 comprehensive assessment showed the resident's cognition was intact and required substantial to maximum staff assistance for bed mobility and was independent on staff for their transfers. The assessment further showed the resident wore glasses. During an interview on 07/09/2024 at 1:11 PM, Resident 52 stated they had experienced seeing double vision for the past month or longer and reported it to a nurse manager. The resident stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to complete skin assessments or obtain treatment orders to manage pressure ulcers to prevent the development and/or worsening of pressure ulcers for 1 of 1 (Resident 52) reviewed for pressure ulcers. This failure placed the resident at risk for developing and/or worsening of pressure ulcers and increased pain. Findings included . Review of the National Pressure Injury Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined pressure injury stages as follows: • Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). • Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). • Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic (medications capable of affecting the mind, emotions, and behavior) medications for 1 of 5 residents (Resident 30) reviewed for unnecessary medications. The facility failed to ensure psychotropic medications had a gradual dose reduction (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) to determine continued need and use of a medication, nor were person-centered behaviors being monitored to reflect adequate need of the medication. These failures placed the resident at an increased risk for receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication. Findings included . <Resident 30> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include bi-polar (serious…

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

Based on observation, interview and record review, the facility failed to ensure expired medications were destroyed in 1 of 1 medication room (Team 1 med room) and 1 of 2 medication carts (Team 2 med cart). These failures placed residents at risk for receiving expired medications and negative health outcomes. Findings included . <Team 1 Med Room> A concurrent observation and interview of the Team 1 medication room on 07/11/2024 at 11:00 AM with Staff C, Licensed Practical Nurse Unit/Coordinator showed the following expired medications and medical supplies: • A bottle of Megestrol Acetate (an oral medication used to stimulate the appetite) with an expiration date of 04/01/2024. • A Wixela inhaler (a medication used to control and prevent wheezing and shortness of breath caused by lung disease such as asthma and chronic obstructive lung disease (COPD) with an expiration date of 12/01/2024. • A Spiriva Respimat inhaler (a medication used for maintenance treatment of long-term lung disease such as asthma and COPD) with an expiration date of 01/23/2024. • A Fluticasone-Salmeterol inhaler…

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 labeled and dated, expired foods were removed, and proper temperatures were consistently monitored for 2 of 2 snack/nourishment refrigerators (Teams 1 and 2) reviewed for infection control. This failed practice placed residents at risk for food borne illness. Findings included . Review of the policy titled .Sanitation and Food safety dated 05/01/2024, showed a temperature monitoring log will be maintained, and a designated staff member will document refrigerator temperatures daily. The facility staff will check individual food items for expiration dates and discard outdated food. All food will be labeled and dated to monitor for food safety. All food items should be consumed or discarded after three days. All food items unmarked or unlabeled containers should be labeled with contents, and the date the food item was stored. Any food suspected to be contaminated or with visible signs of contamination should be discarded immediately. During an interview on 07/12/2024 at 9:14 AM, Staff JJ,…

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 interviews and record review, the facility failed to notify the resident's representative (RR) of significant changes in condition resulting in hospitalization for 1 of 3 residents (Resident 1) reviewed for notification. The failure to notify the RR placed the resident at risk of not having them involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart disease and diabetes. Review of Resident 1's comprehensive assessment, dated 06/03/2024, showed the resident had no cognitive impairments. Review of a Nursing Progress Note (NPN) documented by Staff A, Registered Nurse (RN), dated 05/29/2024 at 6:22 AM, showed Resident 1 was complaining of nausea and shortness of breath. The resident requested to be sent to the hospital. Emergency services was called at 5:45 AM on 05/29/2024 to transport the resident to the emergency room (ER).…

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 interviews and record review the facility failed to notify the resident's responsible party of significant changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the responsible party placed the resident at risk of not having them involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility from the hospital with diagnoses which included fractures of both arms and dementia. Review of Resident 1's comprehensive assessment, dated 03/22/2024, showed the resident had severe cognitive impairment. Review of Resident 1's plan of care, dated 03/12/2024, showed the resident required one to two staff for assistance with activities of daily living. Review of Progress Notes (PNs), dated 04/02/2024 at 11:53 PM, showed Resident 1 had a fall on the day shift and sustained a skin tear. Documentation showed there were no further concerns at that time. Seven days later on 04/09/2024 at…

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

Based on interview and record review the facility failed to provide a completed State Reporting Log (documentation used by facilities to report incidents of possible abuse, neglect, abandonment, mistreatment, injuries of unknown source, exploitation, major disasters/outbreaks, unexpected death/suicide, evacuation, or misappropriation of resident property in nursing homes) available to State Investigators upon their request. The failure to provide a completed State Reporting Log placed all residents at risk of unidentified abuse and neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, sixth edition, dated October 2015, showed the facility must maintain a state Reporting Log and always readily accessible to the state licensing and certification staff, and others according to their authority. The Reporting Log at a minimum must contain the information and codes provided from The Purple Book. During an interview on 04/16/2024 at 8:45 AM, Staff A, Administrator, stated the facility did not have a complete Reporting Log to provide to the State…

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 interviews and record review the facility failed to ensure a resident was adequately assessed/monitored after an unwitnessed fall which resulted in a lack of timely diagnosis for 1 of 3 residents (Resident 1), reviewed for significant changes in condition. Failure to assess/monitor Resident 1 following a fall placed them at risk for delay in treatment. Findings included . Review of the facility policy titled, Alert Charting Guidelines, undated, showed residents who have sustained falls were to be placed on alert charting by staff every shift for 72 hours. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility from the hospital with diagnoses which included fractures of both arms and dementia. Review of Resident 1's comprehensive assessment, dated 03/22/2024, showed the resident had severe cognitive impairment. Review of Resident 1's plan of care, dated 03/12/2024, showed the resident required one to two staff for assistance with activities of daily living. Review of the facility investigation report, dated 04/02/2024 at 3:30 PM, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure staff responsible for providing cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) had current CPR certification for 4 of 16 licensed nursing staff (Staff A, B, C, D) reviewed for CPR certification status. This failure had the potential risk of the facility having a lack of staff who were properly trained in CPR readily available to respond in an emergency. Findings included . Record review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Policy, reviewed on [DATE], showed the facility should ensure that properly trained personnel and certified in CPR for Healthcare Providers are available immediately 24 hours per day to provide basic life support (level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital), including CPR to residents requiring emergency care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used and resident testing for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) was performed in accordance with Centers for Disease Control and Prevention (CDC) guidelines by 2 of 5 staff (Staff A, G) observed for infection control practices. This failure placed residents and staff at risk for contracting COVID-19. Findings included . <PPE> Review of the Washington State Department of Health COVID-19 guidelines, dated June 2023, showed staff need to wear full PPE (gown, gloves, N-95 respirator mask and eye protection) upon entering COVID-19 resident rooms for one resident encounter, then PPE was to be discarded. Staff don (put on) new PPE…

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 pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) were offered to 3 of 5 residents (Resident 3, 4, 5) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease and a diminished quality of life. Findings included . Review of the facility policy titled, Area of Focus: Resident Vaccines, reviewed on 12/01/2022, showed for Influenza and Pneumococcal immunizations: 1) Before offering the vaccine, each resident or the resident's representative receives education regarding the benefits and potential side effects of the vaccine. 2) Each resident is offered an influenza/pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. Influenza immunizations are offered annually…

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 interviews and record review the facility failed to provide the necessary care and services for 1 of 2 residents (Resident 1) with diabetic ulcers (open wound that can occur in residents with diabetes) a) to obtain treatment orders and perform timely, accurate, and thorough assessments; and b) failed to evaluate and monitor regarding a change of condition for 1 of 3 residents (Resident 1) reviewed for assessments. These failures placed Resident 1 at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Treatment Orders, reviewed 03/31/2023, showed treatment orders were written per physician's orders. Following observation/evaluation of the affected skin area, the physician is notified. Review of the facility's policy titled, Documentation & Assessment of Wounds, reviewed on 03/31/2023, showed a wound assessment/documentation is required to occur at a minimum of weekly. If a resident refuses staff would obtain wound…

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

Based on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary and organized manner in accordance with professional standards for food service safety. The kitchen was in a state of disrepair; surfaces lacked deep cleaning, and bulk foods were not labeled. This failure placed all residents, staff, and visitors that ate food from the kitchen at risk for food borne illnesses and a diminished quality of life. Findings included . Review of the Sanitation and Maintenance policy, dated 04/26/2023, showed The Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state and local requirements . There is a facility process that includes reporting and follow up for all maintenance issues . Physical facilities are cleaned as often as necessary to keep them clean. Cleaning is done during periods when the least amount of food is exposed. Review of the 12/19/2022 facility policy titled, Work Request System 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, interview and record review, the facility failed to maintain a system of records for accurate accounting, reconciliation, and destruction of controlled substance medications (a group of medications that have the potential for abuse and/or physical or psychological dependence) for 2 of 3 medication carts (Halls 100 and 200) and 2 of 3 controlled substance logbooks (Halls 100 and 200), reviewed for medication storage. Failure to accurately verify the inventory of controlled medications through change of shift reconciliation and assure appropriate destruction procedures were maintained, placed residents at risk of financial loss, inadequate pain management, and the potential for drug diversion (the abuse of prescription drugs used for purposes other than intended by the prescriber). Review of the 04/10/2020 facility policy titled, Controlled Substance Destruction Process, showed that the facility would destroy Schedule II-V (categories of controlled substance medications based on the drugs abuse or dependency potential) in the presence of a Registered Nurse (RN),…

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 an environment that reflected the physical needs and preferences for 1 of 1 resident (Resident 17) reviewed for choices. The facility failed to ensure that the resident's living environment was conducive to their physical limitations, which placed the resident at risk for an increased dependence on staff and a diminished quality of life. Findings included . Resident 17. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including stroke (an interruption of blood flow to the brain), diabetes (a condition where the body does not use insulin properly), and kidney disease (kidneys cannot filter blood the way they should). The 04/17/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for activities of daily living (ADLs). The assessment showed Resident 17 used an electric wheelchair for locomotion and had an intact cognition. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure written transfers/discharge notices were provided to residents and/or their representatives, and to the Office of the State Long Term Care Ombudsman for 2 of 2 residents (Residents 18 and 3), reviewed for facility initiated hospital transfers. These failures disallowed the residents and/or their representatives and the Long Term Care Ombudsman the opportunity to have the knowledge of where and why the resident was transferred, and/or how to appeal the transfer if desired. Findings included . Review of the 08/16/2022 facility policy, Notices of Transfers and Discharges, showed, .the facility will provide notice to the resident and/or resident representative in situations where the facility initiates a transfer or discharge, including discharges that occur while the resident remains in the hospital after emergency transfer .Before a facility transfers or discharges a resident, the facility must - (i). Notify the resident and the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or their representative of the facility's bed hold policy at the time of hospital transfer for 3 of 3 residents (Residents 18, 3, and 23) reviewed for hospitalization. This failure disallowed the residents and/or their representative's access to the information needed to safeguard their return to the facility. Findings included . Review of the revised 11/17/2022 facility policy titled, Bed-Hold Policy, showed The facility will provide written information to the resident or resident representative, the nursing facility policy on bed-hold periods and the resident return to the facility to ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before an upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. Additionally, the policy showed that a second notice must be provided to the resident and/or their representative at the time of transfer, or in cases…

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 restorative nursing services to 1 of 3 residents (Resident 31) reviewed for restorative nursing and range of motion (ROM). Restorative nursing services were not provided for eight weeks starting in April 2023. This failure placed the residents at risk for pain, muscle contractures (shortening or hardening of muscles and tendons and stiffening of joints), and a diminished quality of life. Findings included . Review of the 09/19/2022 facility policy titled, Restorative Nursing, showed that the purpose was to promote the resident's highest level of functioning. The policy further showed that the restorative program could be initiated by nursing and/or therapy staff, based on the resident's comprehensive assessment. Nursing Assistants (NAs) must be trained in techniques that promoted resident involvement in the restorative activities. Additionally, the policy showed the facility must provide the necessary care and services to ensure that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 5 residents (Residents 3 and 8) reviewed for accident hazards, received adequate supervision and appropriate use of assistive devices to prevent accidents. Resident 3 rolled out of bed onto the floor while receiving peri-care (cleansing of a resident's private areas) from Staff Q, Nursing Assistant (NA). Resident 8 reportedly was transferred with a Hoyer (mechanical lift) lift by one staff member instead of the required two staff members as directed by the facility policy and the resident's care plan. These failures placed the residents at risk for preventable accidents and a diminished quality of life. Findings included . Review of the 09/29/2022 facility policy titled Fall Management Policy, showed that the facility would assess the resident upon admission/readmission, quarterly, with a change in condition, and with any fall event, for any fall risks and would identify appropriate interventions to minimize the risk of injury…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that an assessment was performed before and after receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services for 2 of 2 residents (Residents 20 and 18), reviewed for dialysis. These failures placed the residents at risk for unnoticed change in medical condition, delay in treatment, and a diminished quality of life. Findings included . Review of the 08/18/2022 facility policy titled Dialysis Policy and Procedures, showed that the resident receiving dialysis would receive consistent care before (pre) and after (post) dialysis. The vascular (blood vessels) access site would be checked daily with physician notification for any known or suspected problem. Additionally, the Pre/Post Dialysis Communication Form would be sent with the resident to the dialysis center. Post dialysis instructions included obtaining a set of vital signs (measurements of the body'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.