Cascades Of St Anne

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide bed hold and/or transfer notices to the residents and/or their representatives in writing for 2 of 2 residents (Residents 25 & 32), reviewed for hospitalization. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.Findings included. Review of the facility's policy titled, Bed-Hold and Returns, revised in October 2022, showed, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). The policy further showed, Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement a care plan for 3 of 15 residents (Residents 2, 15 & 36), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for pressure ulcer (bed sore), anticoagulant (blood thinner), diuretics (water pills-medications that make kidneys produce more urine) and dementia (memory loss) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set – an assessment tool] assessment (Admission, Annual or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care conference or care plan meeting was conducted for 1 of 1 resident (Resident 3), reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care. The policy further stated, The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. Review of a face sheet printed on 01/14/2026 showed Resident 3 was admitted to the facility on [DATE]. In an interview on 01/13/2026 at 9:16 AM, Resident 3 stated that they did not remember participating in a care conference/care plan meeting. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary services to maintain personal hygiene for 1 of 1 resident (Resident 6), reviewed for Activities of Daily Living (ADL). The failure to provide bath/shower for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs and a diminished quality of life. Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Review the admission record printed on 01/20/2026 showed that Resident 6 was admitted to the facility on [DATE] with diagnosis that included generalized muscle weakness.Review of the quarterly Minimum Data Set (an assessment tool) dated 12/23/2025 showed Resident 6 had intact cognition and was dependent on staff for…

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

Based on observation and interview, the facility failed to ensure the Oxygen Storage Room door electronic keypad lock was functioning for 1 of 1 oxygen storage room, reviewed for accident hazards. This failure placed residents at risk of accidents, injuries and a diminished quality of life.Findings included .Observations on 01/13/2026 at 2:58 PM, on 01/14/2026 at 8:29 AM, on 01/16/2026 at 3:51 PM, and on 01/20/2026 at 8:43 AM, showed the door to the oxygen storage room to be unlocked and accessible without inputting the code into the electronic keypad lock.In an interview and joint observation on 01/20/2026 at 9:42 AM, Staff W, Certified Nursing Assistant, stated that the doors with the electronic keypad locks were locked so the residents did not have access to those rooms and to prevent them from getting hurt. A joint observation of the oxygen storage room showed the door was unlocked and accessible without inputting the code into the electronic keypad lock. Staff W stated the door should have been locked due to residents could get hurt from the oxygen tanks.In an interview 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 enteral nutrition (the delivery of nutrients through a tube feeding [TF - a method of delivering liquid nutrients, fluids, and medication directly into the stomach or small intestine through a flexible tube]) was administered in accordance with physician's orders and professional standards of practice for 1 of 1 resident (Resident 2), reviewed for TF. The failure to follow the physician's orders on the amount of formula to administer, document the amount of formula and water flush administered, and label, with date, and time TF formula bottle and water flush bag placed the resident at risk for unmet nutrition need, adverse health outcomes, and related complications.Findings included .Review of the facility policy titled, Enteral Nutrition, revised in November 2018, showed, Adequate nutritional support through enteral nutrition is provided to residents as ordered.Review of the admission record printed on 01/15/2026 showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use and have a proper physician order in place for 1 of 3 residents (Resident 19), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications.Findings included .Review of the facility policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure - breathing support device that delivers two pressure levels] Support, revised in March 2015, directed staff to document the CPAP settings in the resident's medical record.Review of the admission record printed on 01/20/2026 showed Resident 19 was admitted to the facility on [DATE] with diagnosis that included obstructive sleep apnea (a sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep and causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly store biologicals (diverse group of medicines made from natural sources) in accordance with Centers for Disease Control and Prevention (CDC) guidelines and accepted professional standards for 1 of 1 medication refrigerator (Medication Room Refrigerator), reviewed for medication storage. In addition, the facility failed to properly store drugs for 1 of 1 resident (Resident 23). These failures placed the residents at risk for receiving compromised and ineffective medications/biological and medication errors.Finding included. Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. MEDICATION ROOM REFRIGERATORAccording to the CDC's guideline titled, Vaccine Storage and Handling, dated 03/19/2024, showed, Keep your storage units and vaccines within the appropriate temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ sufficient staff that were adequately trained to properly perform kitchen sanitization practices (sanitizing buckets) and safely carry out functions of meal preparation (use of food thermometer) for 2 of 4 dietary staff (Staff L & Staff M), reviewed for food safety. These failures placed the residents at risk for food-borne illnesses (caused by ingestion of contaminated food or beverages) and a diminished quality of life.Findings included. Review of the Washington State Retail Food Code dated 03/01/2022, showed, Employees are properly sanitizing.multiuse equipment and utensils before they are reused, through routine monitoring.including the application of sanitizing chemicals by manual swabbing.Contact times must be consistent with those on EPA [Environmental Protection Agency-United States agency safeguarding human health and protecting the environment]-registered label use instructions. The policy further showed, Concentration of the sanitizing solution must be accurately determined by using a test…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pneumococcal vaccine (used to prevent pneumonia [a lung infection]) were up to date and offered to 2 of 5 residents (Residents 2 & 36), reviewed for pneumococcal immunizations. This failure placed the residents at risk for acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease.Findings included. Review of the facility's policy titled, Pneumococcal Vaccine, revised in March 2022, showed, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility.The policy further showed that Administration of the pneumococcal vaccines is made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. According to CDC'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 provide documentation about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination status for 1 of 1 staff (Staff H), reviewed for COVID-19 immunizations. This failure placed staff and residents at risk of exposure to illness from COVID-19.Findings included. Review of the facility's policy titled, Coronavirus Disease (COVID-19)-Vaccination of Staff, revised in May 2023, showed that staff would provide documentation of their vaccination and that the infection preventionist maintains a tracking worksheet of staff members and their vaccination status. The policy further showed that the facility would maintain documentation related to staff COVID-19 vaccination status. Review of the facility's staff list showed Staff H, Certified Nursing Assistant, was hired on 11/03/2025. In an interview on 01/16/2026 at 9:27 AM, Staff H stated that they received their COVID-19 vaccination in another state. Staff H further stated that they provided a copy of their vaccination status to the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the care plan for 1 of 1 resident (Resident 1), reviewed for accident hazards. The failure to follow two-person assistance when providing toileting care and repositioning placed the resident at risk for further falls, injury, and diminished quality of life. Findings included.Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised on March 2018, showed, appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Resident 1 was readmitted to the facility on [DATE] with diagnoses that included paraplegia (loss of muscle function in the lower half of the body) and Multiple Sclerosis (a disease of the brain and spine that can cause balance issues and muscle spasms).Review of the quarterly Minimum Data Set (an assessment tool) dated 11/03/2025, showed Resident 1 had intact cognition.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to the administration of pain medication for 1 of 2 residents (Resident 1), reviewed for pain management. In addition, the facility failed to adequately monitor adverse side effects of pain medication for Resident 1. These failures placed the resident at risk for unnecessary medications, incomplete pain control and unrecognized adverse side effects. Findings included . Review of the admission Minimum Data Set (a required assessment) dated 02/14/2025 showed Resident 1 was admitted to the facility on [DATE] with a diagnosis that included a fracture [break] in the lower back with lower back pain. Review of the February 2025 and March 2025 Medication Administration Record (MAR) showed Resident 1 had physician orders dated 02/08/2025 for Methocarbamol (medication used to relieve pain) 500 milligrams (mg-a unit of measurement) every six hours as needed and was administered the medication on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of antipsychotic (medication used to treat mental disorders) for 1 of 2 residents (Resident 1), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, unrecognized adverse side effects, and related complications. Review of the admission Minimum Data Set (a required assessment) dated 02/14/2025 showed Resident 1 was admitted to the facility on [DATE] with diagnosis that included a delirium (a sudden change in a person's mental state, often characterized by confusion, disorientation, and difficulty thinking clearly). Review of the February 2025 and March 2025 Medication Administration Record (MAR) showed a physician order dated 02/08/2025 for Quetiapine (an antipsychotic medication used to treat mental disorder) 25 milligrams (mg-a unit of measurement) one tablet at bedtime and another physician order dated 02/11/2025 for Quetiapine 25 mg one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 followed use of Personal Protection Equipment (PPE - use of gown, gloves, respirator/N95 mask and face shield/goggles) in accordance with the Centers for Disease Control guidelines when caring for residents with known COVID-19 (highly contagious respiratory disease) infection for 1 of 2 residents (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for COVID-19 infection and related complications. Findings included . Record review of a progress note dated 03/28/2025 showed Resident 2 tested positive for COVID-19 on 03/28/2025. Observation on 03/31/2025 at 1:01 PM, showed signage that Resident 2 was on aerosol precautions (a type of isolation used for infections spread through the air) and contact precautions (a set of safety measures used to prevent the spread of infectious diseases through direct or indirect contact with a resident or their environment). The sign showed that everyone must use a respirator/N95 mask, wear eye protection, gown…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary supervision for 1 of 1 resident (Resident 1), reviewed for elopement. The failure to provide the necessary supervision for Resident 1 resulted in an elopement and placed the resident at risk for injury. Findings included . Review of the admission Minimum Data Set assessment (MDS-a required assessment) dated 08/15/2024 showed the resident was admitted to the facility on [DATE] with diagnosis that included dementia (impaired memory). The MDS assessment also showed the resident required assistance for all care and used a wheelchair for mobility. Review of the facility's investigative report dated 11/11/2024 showed that on 11/11/2024 at approximately 5:15 PM, Resident 1 was unable to be found in the facility. The investigative report documented that the facility staff initiated a facility search inside and outside of the facility. A facility staff member walked around the neighborhood of the facility and staff did not find 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 survey results were posted in a place readily accessible to residents and residents' legal representatives. This failure prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction. Findings included . Observations on 10/28/2024 at 10:00 AM, on 10/29/2024 at 9:41 AM, and on 0/30/2024 at 9:56 AM, the facility lobby did not show a survey binder was readily available and accessible to all residents and their residents' legal representatives. In an interview on 10/31/2024 at 3:34 PM, Resident 11 stated that they would have to ask the business office to see the survey results. Resident 11 stated that they had not seen a survey binder book in the lobby. In an interview and joint observation on 11/04/2024 at 5:26 PM, Staff A, Administrator, stated that they kept the survey binder right by the opening of the business office window at the lobby. Staff A stated that the book was not out because they had the book 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 5 of 16 residents (Residents 9, 17, 3, 31 & 4), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding use of antibiotic (medication to inhibit growth of bacteria), use of insulin (medication/hormone that regulates blood sugar levels) injections, use of anticoagulant (medication to prevent blood clot), use of intrathecal pump (administration of medication through an injection into the spinal canal), use of diuretic (medication to increase urination), and tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 4 of 4 residents (Residents 9, 22, 32 & 28), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's policy titled, Oxygen Use, revised in October 2024, showed, It is the policy of this facility to promote resident safety in administering oxygen. The policy further showed that oxygen cannula or mask should be changed per orders or when visibly soiled, oxygen equipment should be cleaned regularly, and routine oxygen equipment inspection and maintenance should be performed based on manufacturer's recommendations. RESIDENT 9 Resident 9 admitted to the facility on [DATE] with diagnosis that included heart failure (affects the heart's ability to pump blood 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 and interview, the facility failed to ensure the daily nurse staffing form was placed in a prominent place accessible to residents, residents' representatives and visitors. This failure placed the residents, their representatives and visitors at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in November 2024, showed that within two (2) hours of the beginning of each shift, the number of licensed nurses (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nursing Assistants and Nursing Assistants) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Observations on 10/28/2024 at 11:18 AM and on 10/29/2024 at 10:52 AM, showed a daily nurse staffing form was posted along with other facility notices in the south area of the facility that was not visible, Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriately label and store drugs or biologicals (diverse group of medicines made from natural sources) for 1 of 1 Medication Storage Room and 1 of 2 medication carts (South Medication Cart), reviewed for medication storage and labeling. In addition, the facility failed to ensure the Medication Storage Room was free of expired medical supplies and tube feeding (TF-the delivery of nutrients through a tube directly into the stomach to provide nutrition) formulas. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Labeling and Storage, revised in [DATE], showed, multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility's policy titled, Administering Medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 periodically test the sanitizing solution/agent used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for food service safety for 1 of 1 kitchen and failed to consistently monitor and document refrigerator temperatures for 1 of 5 refrigerators (Snack Refrigerator), reviewed for food services. In addition, the facility failed to properly label, date, and/or discard nutritional supplements in the Food Refrigerator in the Medication Storage Room. These failures placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life. Findings included . Review of the facility's policy titled, Sanitization, revised in November 2024, showed that the food service area was maintained in a clean and sanitary manner. That kitchen areas and dining areas were kept clear, free from garbage and debris, protected from rodents and insects. The policy further showed that when cleaning fixed equipment-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a comprehensive water management program that assessed, measured, and/or monitored potential risk for exposure to Legionnaire's disease (or Legionella - a potentially dangerous bacteria that grows in water, which could cause a serious lung infection) or other waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease). In addition, the facility failed to ensure to follow Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - germs that are resistant to medications that treat infections] in nursing homes) during hygiene care and tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) manipulation for 1 of 1 resident (Resident 4), and failed to sanitize the transfer lift equipment for 2 of 2 staff (Staff J and K), reviewed for infection control. These failures placed 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 an effective pest control program was maintained to keep the facility free of houseflies for 3 of 3 residents (Residents 29, 93 & 5), for 1 of 1 dining room, and for 1 of 1 kitchen, reviewed for dining and kitchen. This failure placed the residents at risk for infection, maggot infestation (small, worm like bugs that hatch from fly eggs), and related complications. Findings included . Review of the facility's policy titled, Pest Control, revised in October 2024, showed that the facility would maintain an effective pest control program and that the facility would have a pest control contract that provided treatment of the environment for pests. RESIDENT ROOMS/RESIDENTS RESIDENT 29 Observation on 10/28/2024 at 9:47 AM, showed a fly on Resident 29's bedside table. Resident 29 shooed the fly away and the fly moved to Resident 29's bed. Resident 29 stated I don't know where the fly came from. RESIDENT 93 On 10/28/2024 at 9:49 AM, Resident 93 stated that they had seen flies around in their room, a big fly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike dining experience was provided for 1 of 8 residents (Resident 94), reviewed for dignity/privacy during dining. This failure placed the resident at risk for dignity issues and a diminished quality of life. Findings included . Review of the facility's policy titled, Administering Medications, revised in April 2019, showed that medications were administered in a safe and timely manner, and as prescribed. The policy further showed that medication administration times were determined by resident need and benefit, not staff convenience. Observation on 10/29/2024 at 8:52 AM, showed Staff N, Registered Nurse, giving Resident 94 their oral medications in the main dining room during the breakfast meal. Staff N was observed telling Resident 94 what medications they were taking and what they were for in front of seven other residents in the dining room. On 10/29/2024 at 4:08 PM, Staff N, stated that they gave Resident 94 their five oral medications in the dining room and that they should not have. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegation of abuse and/or neglect were thoroughly investigated for 2 of 4 residents (Resident 3 & 31), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse/Neglect Prevention Program Policy, dated April 2021, showed that residents had the right to be free from abuse/neglect, including freedom from physical abuse. The policy further showed that the facility would identify and investigate allegations of abuse, report any allegations within time frames required by the Federal Government, and protect residents from further harm during investigations. According to the Washington State Reporting Guidelines for Nursing Homes (The Purple Book), dated October 2015, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transfer/discharge notice to the resident and/or their representative for 1 of 2 residents (Resident 28), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Transfer or Discharge Notice, revised in October 2024, showed, Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon practicable. A review of the nursing progress notes showed Resident 28 discharged to the hospital on [DATE]. Another review of the nursing progress notes showed Resident 28 readmitted to the facility on [DATE]. A review of the electronic health record did not show documentation that Resident 28 was offered and/or provided 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 bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 2 residents (Resident 28), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed Holds and Returns, revised in November 2024, showed Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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) Level I was completed for 1 of 6 residents (Resident 17), reviewed for unnecessary medications. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled Clarification to the Pre-admission Screening and Resident Review (PASARR OR PASRR) Level I Screening Process, dated 07/06/2024 and amended on 08/23/2024, showed a positive Level I PASARR screen (that would then require a referral for a Level II PASARR) was if Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes. Review of the facility's 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 develop and implement care plans for 2 of 16 residents (Residents 31 & 17), reviewed for comprehensive care plan. The failure to develop care plans for diuretic (reduce swelling/fluid buildup in the body) medications placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in November 2024, showed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 2 of 3 residents (Residents 34 & 26), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with showers/bathing placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised in October 2024, showed that appropriate care and services were provided for residents who were unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming, and oral care. RESIDENT 34 On 10/28/2024 at 3:43 PM, Resident 34 stated they wanted to have more showers than once a week and that they have talked to facility staff numerous times that they have not gotten an answer. 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 diabetic [diabetes - a disease that occurs when blood sugar level is too high] nail care was provided for 1 of 6 residents (Resident 34), reviewed for quality of care. In addition, the facility failed to ensure residents on diuretic (that helps with edema [swelling] to reduce fluid buildup in the body) and/or anticoagulant medications (that stops blood from clotting too easily to help stop life-threatening conditions) were monitored for adverse side effects for 2 of 6 residents (Residents 31 & 32), reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Therapy, revised in November 2024, showed Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . Medication use shall be consistent with an individual'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 monitoring of antibiotic (medication to treat infection) side effects and use of antibiotic use had an appropriate diagnosis for 1 of 5 residents (Resident 22), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medication and a diminished quality of life. Findings included . Review of the facility's policy titled, Antibiotic Stewardship, revised in December 2016, showed that the purpose of the antibiotic stewardship program was to monitor the use of antibiotic in their residents. The policy showed that training and education would include how inappropriate use of antibiotics affects individual residents. The training would include emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, medication interactions, and the evolution of drug-resistant pathogens. The policy further showed that the prescriber would provide complete antibiotic orders including the following elements: drug name, dose, frequency of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently maintain an established Antibiotic (medications to treat infection) Stewardship Program to promote the appropriate use of antibiotics for 1 of 3 residents (Resident 26), and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs/ symptoms used to determine whether to treat an infection with antibiotic resistance). These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility's policy titled, Antibiotic Stewardship, revised in December 2016, showed the stewardship program's purpose was to monitor the use of antibiotics for residents. Review of the facility's policy titled, Staff and Clinician Training and Roles, revised in December 2016, showed that the Director of Nursing (DON) and Infection Preventionist (IP) will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 vaccine (used to prevent pneumonia [a lung infection]) and the COVID-19 vaccine (used to prevent an infectious disease caused by coronavirus) were provided for 1 of 5 residents (Resident 9), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and/or COVID-19. Findings included . Review of the facility's policy titled, Vaccination of Residents, revised in May 2023, showed all residents would be offered vaccines. The policy showed that prior to receiving vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination. It further showed that if the vaccines were refused, then than it shall be documented in the resident's medical record. Review of the face sheet showed Resident 9 admitted to the facility on [DATE]. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct routine maintenance to ensure side rails were safe to use for 3 of 4 Residents (Residents 32, 5 & 25), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Bed Safety and Bed Rails, revised in November 2024, showed that consideration is given to the resident's safety. The policy showed that the bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. The policy further stated that maintenance staff would routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department would then provide a copy of inspections to the administrator. RESIDENT 32 Joint observation and interview on 11/04/2024 at 8:47 AM with Staff M, Registered Nurse, showed Resident 32's left half bed rail was loose and moved side to side for six to eight inches. Staff M stated that Resident 32's left bed rail felt loose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency and failed to initiate timely investigation for 1 of 3 residents (Resident 1), reviewed for abuse reporting. These failures placed the residents at risk for abuse, unmet care needs, and a diminished quality of life. Findings Included . Review of the Abuse/Neglect Prevention Program Policy, dated April 2021, showed residents have the right to be free from abuse/neglect, this includes but is not limited to freedom from physical abuse. (8) Identify and investigate allegations of abuse. (9) Report any allegations within time frames required by the Federal Government. (10) Protect residents from further harm during investigations. Review of the quarterly Minimum Data Set assessment (MDS- an assessment tool) dated 09/02/2024, showed Resident 1 was admitted to the facility on [DATE], had impaired thinking and required assist with care and mobility. Review of a facility reported incident 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 observation, interview, and record review, the facility failed to ensure staff followed use of Personal Protection Equipment (PPE - use of gown, gloves, respirator/N95 and face shield/goggles) in accordance with the Centers for Disease Control guidelines when caring for residents with known COVID-19 (highly contagious respiratory disease) infection for 1 of 2 residents (Resident 1), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for COVID-19 infection and related complications. Findings included . Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised in May 2023, showed staff who enter the room of a resident with suspected or confirmed COVID-19 infection would adhere to standard precautions and use a respirator such as an N95 or higher, gown, gloves, and eye protection (goggles or a face shield). Review of a nursing progress notes dated 09/08/2024, showed Resident 1's presented with COVID-19 symptoms that day and was placed on isolation precaution.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely treatment of pressure injuries/pressure ulcers (wounds that occur due to prolonged pressure on the skin) for 1 of 3 residents (Resident 1), reviewed for pressure ulcers. The failure to provide timely treatments for pressure ulcers placed the resident at risk of further decrease in skin integrity, wound infection, and related complications. Findings Included . Review of the admission Minimum Data Set assessment (MDS - an assessment tool) dated 04/08/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (weakness or inability to move one side of the body) after a stroke. The MDS also showed Resident 1 required assistance with mobility and was at risk for pressure ulcers. Review of the admission screen form dated 04/02/2024, showed Resident 1 had redness to toes. On 05/23/2024 at 1:56 PM, Staff C, Registered Nurse (RN), stated they completed the admission screen for Resident 1 on 04/02/2024, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge process were implemented for 3 of 3 residents (Residents 1, 2 & 3), reviewed for discharge planning. The failure to ensure residents who discharged against medical advice (AMA) were provided risks and benefits prior to leaving the facility placed the residents at increased risk for hospital readmission, injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharging A Resident without a Physician's Approval, revised in October 2022, showed that should a resident, or their representative request an immediate discharge, the resident's attending physician is promptly notified. If the resident and/or their representative requests discharge without the approval of the attending physician, the resident and/or their representative will be asked to sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in 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 representative when there was a change in medications for 1 of 3 residents (Resident 1), reviewed for notification of change. This failure prevented the resident's representative of not having information to make informed decisions or be involved in the resident's health care decisions. Findings included . Resident 1 readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 10/09/2023, showed Resident 1 had severely impaired skills for decision making. The MDS also showed Resident 1 had an active diagnosis of a seizure disorder (epilepsy, uncontrolled electrical activity between brain cells that cause abnormalities in muscle tone [stiffness, twitching or limpness], behaviors or states of awareness). Review of a physician order dated 09/29/2023, showed the resident had an order for Valproate Sodium (or Depakote, medication used to treat seizures) 15 milliliters (ml, unit 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 inspect food items for quality upon receipt and ensure their proper storage. In addition, the facility failed to keep track of when to discard perishable foods, and failed to ensure foods stored in the freezers and refrigerators were covered, labeled, and dated. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life. Findings included . Review of the facility policy titled, Food Receiving and Storage, revised in July 2014 read in pertinent part, Foods shall be received and stored in a manner that complies with safe food handling practices. Dry food that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). FREEZER ONE On 07/25/2023 at 9:05 AM, during a joint observation of the kitchen with Staff D, Dietary…

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

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices were followed during medication administrations for 3 of 7 residents (Residents 4, 11, & 27) observed for infection control. Additionally, the facility failed to have a water management program that assessed, measured, and/or monitored the growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease). These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . HAND HYGIENE Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed the facility considers hand hygiene the primary means to prevent the spread of infection. It also stated that the facility was to use either alcohol-based hand rub or soap and water for the following situations: before and after direct contact with resident, and before preparing or handling medications. On 07/28/2023 at 7:47 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.

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals for 1 of 1 medication storage room, and 1 of 2 medication carts (Southwest Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and/or ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, revised in January 2018, showed that, outdated .medications .are immediately removed from inventory. Additionally, it showed that, when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .the nurse shall place a 'date opened' sticker on the medication and enter the date opened. Review of the facility's policy titled, Administering Medications, revised in April 2019, showed that, Insulin (medication for diabetes [a condition in which the body had high blood sugar levels for prolonged periods of time]) pens are clearly labeled with the resident's name or other identifying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective resident centered discharge plan was in place for 1 of 12 residents (Resident 24), 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 Resident 24's electronic medical record showed, diagnoses to include hemiplegia and hemiparesis (paralysis) affecting right dominant side, aphasia (speech difficulty), retention of urine, and vascular dementia (memory loss). Review of the admission Minimum Data Set (an assessment tool) dated 06/07/2023, showed Resident 24 required extensive assistance of one or two people to complete all activities of daily living such as transferring, bed mobility, dressing, eating and personal hygiene. Review of Resident 24's care plan, dated 06/06/2023, showed, there are no plans to discharge at this time. Review of the progress…

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