Fircrest Nursing Facility

Based on observation, interview, and record review the facility failed to follow the plan of care and provide adequate supervision for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the residents at risk for further fall, injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Fall Protocol, revised on 01/23/2023, showed Falls require prompt response to determine cause, injury, and adherence to Care Plan (CP) or Individualized Habilitation Plan (IHP) expectations. The policy showed that if a client [resident] is unable to get up from a fall they will remain where they are until a nurse comes to assess them. The policy further showed that the Attendant Counselors (AC/Certified Nursing Assistant [CNA]) were responsible for following the resident's individualized plan of care as developed by the Interdisciplinary Team. Review of Resident 1's Activities of Daily Living (ADL) care plan initiated on 01/12/2023, showed, Always stay [sic] [in front] of client when giving her a shower. Review of Resident 1's fall…

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 inform the residents' representatives (RR) about the residents' positive Respiratory Syncytial Virus (RSV-a germ that could easily spread and cause lung infections) test and treatments for 2 of 3 residents (Resident 1 & 2), reviewed for change in condition. This failure placed the residents and/or their representatives at risk of not being provided adequate information to make informed decisions about their medical condition. Findings included . Review of the facility's undated policy titled, DSHS [Department of Social and Health Services]/DDA (Developmental Disabilities Administration) Policy 9.06 Health Services, Department of Health Surveillance and Reporting Guidelines for Disease Outbreaks ., showed that when the Primary Nurse is aware of any clients [residents] .with flu-like symptoms (or other contagious disease), the LN [licensed nurse] will report to the Resource Nurses or HCC [Health Care Coordinator] . The policy further stated that HCC 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 observation, interview, and record review, the facility failed to ensure the nurse staffing information postings were posted on daily basis at the beginning of each shift. In addition, the facility failed to ensure the nurse staffing information postings were in prominent locations readily accessible to residents and visitors for 5 of 5 units ([NAME], Hickory, Elm, Cherry, and Birch), reviewed for Nurse Staffing Information. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . [NAME] UNIT Observations on 10/30/2024 at 10:46 AM, on 10/31/2024 at 8:33 AM, on 11/01/2024 at 8:52 AM, on 11/04/2024 at 9:05 AM, and on 11/05/2024 at 11:52 AM, showed the [NAME] Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed on a clipboard and the clipboard was placed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 6 of 22 residents (Residents 348, 82, 45, 35, 97, & 12), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding capturing occurrences during the look-back period for anticoagulant (medication that helps to prevent blood clots from forming) use, tracheostomy (an opening into the trachea (windpipe) from outside the neck) care, timing of MDS sections completion, completion of a discharge assessment, 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 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include 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 develop and/or implement comprehensive care plans for 5 of 22 residents (Residents 44, 88, 45, 24, & 77), reviewed for care planning. The failure to develop/implement care plans for antidepressant medication use, pressure ulcer (bed sore) care, antibiotic (medication to treat infection) use, refusal of care and use of antipsychotic medication (to treat symptoms of certain mental health disorders) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled Roles and Responsibilities of Nursing Facility Interdisciplinary Team Members, dated 01/23/2023, indicated that a care plan is an individualized plan based on comprehensive assessment and professional recommendations. Further review of the policy showed that the care plan aims to promote the individual's highest level of functioning, with a focus on improvement where possible, maintenance of skills and abilities, 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 expired medication was disposed of timely and a controlled substance (a drug or chemical that is regulated by the government because it can be addictive or harmful if misused) medication was handled and accounted appropriately for 1 of 3 medication carts ([NAME] Building), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications and for potential diversion or misappropriation of controlled substance medication. Findings included . Review of the facility's policy titled, Preparation and Administration of Medications and Treatments, revised in 05/2024, showed that for medication in the original manufacturer's container (bottle), staff should check expiration dates of medication on manufacture's label .dispose of expired medications. Review of the facility's policy titled, Controlled Substance Medication Handling and Accountability, revised in 05/2023, 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.

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 3 refrigerators (Walk-in Produce/Milk Refrigerator and Walk-in Preparation Salad Refrigerator), 1 of 1 dry storage room (Commissary Dry Storage Room), and for 3 of 8 staff (Staff NN, OO & PP), reviewed for food services. The failure to date and discard food items past the use by/discard date, perform hand hygiene and handle kitchen equipment appropriately placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Facility Food Storage and Meal Preparation Policy, dated 04/08/2024, showed, Remove all expired food items and Any food that appears spoiled, contaminated, or past its use-by date must be discarded immediately. The policy showed, Note that the use of disposable gloves is not a substitute for proper hand washing. Hands must 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 observation, interview, and record review, the facility failed to ensure staff were fit tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) timely for N95 (a device/mask designed to protect the wearer against particles and help prevent the spread of germs) masks and used correctly for 2 of 6 staff (Staff EE & Staff FF), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care for 5 of 14 staff (Staff Z, L, JJ, Q & R), failed to disinfect medical equipment for 2 of 2 staff (Staff II & U), and failed to ensure that infection control practices were implemented with storage of sharp containers for 3 of 3 medication rooms (Cherry, Birch & Hickory). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . N95 MASK USE Review of the facility'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 observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with a meal for 1 of 18 residents (Resident 29), reviewed for dining observation. This failure placed the resident at risk for a diminished self-worth and over all wellbeing. Findings included . Review of Resident 29's quarterly minimum data set (an assessment tool) dated 10/03/2024, showed that the resident had moderately impaired cognition. Review of Resident 29's Activities of Daily Living (ADL) care plan, printed on 11/04/2024, directed staff to sit down at Resident 29's eye level when assisting with meals. Observation on 10/31/2024 at 12:04 PM, showed Resident 29 was seated upright in their wheelchair in the dining room with their lunch tray. Resident 29 was observed eating their lunch and dropped food. Further observation showed, Staff O, Attendant Counselor 1 assisted Resident 29 while standing over them. On 10/31/2024 at 12:33 PM, Staff O stated that Resident 29 was halfway through their lunch meal, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform residents and/or their representatives of risks and benefits before application of a restraint for 2 of 5 residents (Residents 41 & 12), reviewed for physical restraint. This failure placed the residents and/or their representatives at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care. Findings included . Review of the facility's policy titled, Informed Consent, revised on 10/15/2024, showed that informed consent means agreement to proceed with a particular treatment or service based upon certain components including the name, relationship to the client, and signature of the person giving informed consent signifying that they do or do not grant consent. The Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) shall obtain appropriate…

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 annual Minimum Data Set (MDS-an assessment tool) was completed within 14 days from the Assessment Reference Date (ARD) for 1 of 22 residents (Resident 24), reviewed for comprehensive assessments. This failure placed the resident at risk for delayed and/or unmet care needs, and a diminished quality of life. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.19.1, revised in October 2024, showed that annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) and should be completed no later than 14 days from the ARD (ARD + [plus] 14 days). Review of the facility's policy titled, Roles and Responsibilities of Nursing Facility Interdisciplinary Team Members, with effective date of 01/23/2023, showed that the Heath Care Coordinator serves as the person designated for finalizing the MDS, ensure it was completed by the due date…

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 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 35), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life. Findings included . Review of 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 that a SCSA is a comprehensive assessment for a resident that must be completed when determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual showed a significant change is a major decline or improvement in a resident's status that impacts more than one area of the resident's health status. The RAI manual further showed emergence of unplanned weight loss problem (5% change in 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 2 of 5 residents (Residents 12 & 81), reviewed for restorative services. This failure placed the residents at risk for a decline in ROM, unmet care needs, and a diminished quality of life. Findings included . RESIDENT 12 Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2024, showed Resident 12 had limited ROM to their upper and lower extremities on both sides. Review of the comprehensive care plan printed on 11/01/2024, showed an intervention that Resident 12 was on a right-hand soft splint/Therapy Aide program, which showed the application of right soft hand splints 5x[times]/week. Review of the facility's document titled, Therapy Aide Documentation for the month of October 2024, showed Resident 12 was on a therapy program to apply right hand soft splint .5x/week. It further showed the following…

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 medical supplies used for medication administration were stored properly for 2 of 3 medication rooms (Cherry and Hickory Buildings), reviewed for accident hazards. This failure placed the residents at risk for ingestion or exposure to cleaning chemicals and potential negative outcomes. Findings included . Review of the facility's policy titled, Globally Harmonized System for Hazard Communication Written Hazard Communication Program, revised on 10/01/2024, showed that The Chemical Hazard Communication compliance program establishes systems to mitigate the risks of and properly handle hazardous chemicals and drugs by ensuring that employees know the hazards and identifies the chemicals and drugs with which they work. CHERRY BUILDING MEDICATION ROOM Joint observation and interview on 11/04/2024 at 11:12 AM with Staff L, Registered Nurse (RN) 2, showed an open box of tongue depressors [popsicle sticks used for mixing medications], an open box of plastic pill cups [shallow cups used to hold medications in 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 appropriate treatment and services related to gastrostomy tube (G-tube - a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 3 residents (Resident 9), reviewed for tube feeding management. The failure to check for G-tube placement by visual inspection of aspirated stomach content prior to medication administration placed the resident at risk for medical complications and negative health outcomes. Findings included . Review of the facility's policy titled, Enteral Feeding [method of providing nutrition directly into the stomach when a person is unable to eat by mouth] Administration and Hang Time using Open/Close System via Gravity and Pump, revised in March 2024, showed that when staff accessed the feeding tube, they should check enteral tube for correct placement by aspiration [using a syringe to gently draw back on the G-tube to see if any gastric contents (fluid or air) can be aspirated]. Review of Resident 9's face sheet printed on 11/05/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing were labeled and/or appropriately stored for 2 of 4 residents (Residents 4 & 80), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs and potential negative outcomes. Findings included . Review of the facility's policy titled, Oxygen Administration and Safety Guidelines, revised in September 2023, showed, Change oxygen administration accessories (mask, tubing, humidifier [a device that adds moisture to the air], and concentrator filter) weekly and PRN [as needed]. The tubing's and the humidifier are dated. RESIDENT 4 Review of Resident 4's physician's order, dated 05/28/2024, showed an order for oxygen at two liters (a unit of measurement)/minute (flow rate of oxygen being delivered to a resident through a device like a nasal cannula [lightweight tube that splits into two prongs at one end and is inserted in the nostrils to deliver oxygen]) via nasal cannula with…

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

Based on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for 1 of 3 residents (Resident 18), reviewed for resident medical records. This failure placed the resident at risk for unmet care needs and medical complications. Findings included . Review of the facility's policy titled, Supporting End of Life Decisions in Residential Habilitation Centers, dated 06/15/2018, showed a definition for Physician Orders for Life-Sustaining Treatment (POLST) that meant a portable medical order form that allows a person with a serious illness or frailty to summarize their wishes regarding life-sustaining treatment. It further showed that all direct care staff who work with the client must be shown the POLST and trained to implement it. Review of Resident 18's hard chart showed a POLST form dated 05/14/2024 showed Resident 18's code status (instructions to their medical team about what to do if they have no pulse and was not breathing) was Do Not Attempt Resuscitation (DNAR). Review of Resident 18's Electronic Health Record (EHR)…

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]) was offered for 1 of 5 residents (Resident 80) reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and disease. Findings included . Review of the facility's policy titled, Immunizations for Clients, reviewed in May 2023, showed that clients will be provided immunizations per the standardized recommendations of the local health department, CDC [Centers for Disease Control and Prevention] and Advisory Committee on Immunization Practices (ACIP). Review of the CDC online document for Pneumococcal Vaccine for Adults Aged (greater than or equal to) 19 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2023, dated 09/08/2023, showed In 2021, two new pneumococcal conjugate vaccines, . (PCV15 [vaccine…

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 timely reporting of abuse allegation to the State Agency for 1 of 1 resident (Resident 1), reviewed for abuse/neglect reporting. This failure placed the resident at risk for potential unidentified and ongoing abuse and lack of protection from abuse. Findings included . Review of the facility's policy subject titled, Client Abuse Reporting Under Washington State Law, dated 01/01/2022 showed, the department must immediately report and process allegations of suspected abuse. Further review of the policy showed employees mandatory reporting responsibilities are not limited to the workplace, and always apply, including off-duty hours. Review of the facility's policy titled, Protection from Abuse: Mandatory Reporting, issued 07/2024, showed Immediately meant there should be no delay between reporter awareness of the incident/allegation and making the report. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's clinical note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure necessary care and services was provided per professional standards of practice for 1 of 1 resident (Resident 1), and failed to prevent an unnecessary replacement of gastrojejunostomy tube (GJ tube, is a feeding tube that is placed through the stomach into the jejunum [small intestine] and that has dual ports to access both the stomach and the small intestine for administration of food, fluids, and medications) for 1 of 1 resident (Resident 2), reviewed for GJ tube replacement. These failures placed the residents at risk of unmet care needs, unnecessary surgical procedure, medical complications, and a diminished quality of life. Finding included RESIDENT 1 Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident 1 was dependent on staff for all activities of daily living (ADL). Review of the progress notes dated 09/28/2023 showed that during medication administration, Staff G, Registered Nurse, found that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess 5 of 29 residents (Residents 49, 51, 48, 54, and 42) reviewed for Minimum Data Set (MDS- an assessment tool) assessment. The failure to ensure accurate assessments regarding eating, diagnosis for catheter (a flexible tube placed into the bladder to drain urine) use, falls, and dental condition placed the residents at risk for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed the accuracy of an assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, Quarterly, Annual, Significant Change in status). 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 foods stored in the kitchen were discarded on or before use by date. In addition, the facility failed to ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety in 1 of 6 dining rooms. These failures placed the residents at risk for food borne illnesses (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the undated policy titled, Food Storage, showed foods that are past the use by expiration date are to be disposed of unless stored Frozen. Review of the Fircrest Guideline for Keeping or Discarding Food Products, revised in 2021, showed foods prepared at Fircrest, potentially hazardous foods after cooking, leftovers if properly cooled and refrigerated, raw meat after thawing and pies should be discarded after 4 days. Review of the policy titled, Handwashing/Hand Hygiene, revised…

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 comprehensive care plans for 1 of 19 residents (Resident 94) reviewed for comprehensive care plans. Failure to develop and implement a comprehensive care plan placed residents at risk for unmet care needs and diminished quality of life. Findings included . Resident 94 admitted to the facility on [DATE] with diagnosis that included intellectual disabilities. Review of Resident 94's Quarterly Minimum Data Set assessment (an assessment tool), dated 05/27/2023, showed the resident was cognitively impaired and had received an antipsychotic (a type of drug that treats certain types of mental health problems) drug. Review of Resident 94's physician order, dated 07/27/2023, showed the resident had an order for Risperidone (an antipsychotic drug that is used to treat mental illness) 0.25 milligram two times a day for unspecified impulse disorder. A review of the May 2023, June 2023, and July 2023 Medication Administration Records, 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 ensure residents consistently received the appropriate treatment and services related to tube feeding (TF - a medical device used to provide nutrition through a tube directly to the stomach) for 1 of 3 residents (Resident 21) reviewed for tube feeding. Failure to change the TF administration set, formula, and water flush bag placed Resident 21 at risk for adverse consequences and/or complications of feeding via TF. Findings included . Review of the facility policy titled, Enteral [via the gastrointestinal] Feeding Administration and Hang Time using Open/Closed System via Gravity and Pump, last revised May 2023, directed the staff to change the formula and administration set every 24 to 48 hours for enteral formula administration using closed system by pump. The policy showed the administration set, and the top fill water bag should be changed every 24 hours. Resident 21 admitted to the facility on [DATE] with diagnoses that included…

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, clean and store respiratory (breathing) equipment properly for 1 of 3 residents (Resident 26) and 1 of 10 suction machines (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) (Elm's Suction Machine 2) reviewed for respiratory care. These failures placed residents at risk for infection and a decrease in health maintenance. Findings included . Review of the facility's policy titled, Oropharyngeal [mouth and throat] Suctioning, revised in April 2021, showed the requirement for facility staff was to detach the tonsil (suction) tip from the connecting tubing and place it in a clean towel or wrapper if it was to be reused within 24 hours; otherwise, discard it. The staff were directed to discard the tonsil tip after each use if secretions were thick or infected. <RESIDENT 26> Resident 26 admitted to the facility on [DATE] with risk of aspiration (inhaling food or liquid into the airway…

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 proper hand hygiene practices were followed during stoma (an opening surgically created in the wall of the stomach that allows waste to leave the body) care for 1 of 3 residents (Resident 32) reviewed for tube feeding (a device that delivers liquid nutrition via tube through the stomach). This failure placed the resident at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in December 2020, showed that hand hygiene was to be performed before applying gloves and after removing gloves. Resident 32 admitted to the facility on [DATE] with a diagnosis of gastrostomy (surgical procedure for inserting a tube through the abdomen wall into the stomach used for feeding) status. Review of Resident 32's August 2023 Medication Administration Record, showed an order to clean the gastrostomy tube stoma two times 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.