Providence Mount St Vincent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were clarified and followed, to have parameters for pain medications, and medications given within ordered parameters for 2 of 6 sample residents (Residents 7 & 17), Staff failed to sign for narcotics from the narcotic ledger when given, and count the narcotics effectively each shift for 1 of 5 medication carts reviewed (Four south unit). These failures placed residents at risk for medication errors, unmet care needs, narcotic diversion, and other negative health outcomes.Findings included .<Policy>According to the facility's 02/2026 Pain Management policy the facility would use adequate doses of as needed medications to achieve the residents desired level of pain relief.According to the facility's 02/2025 Bowel Care policy the facility would monitor resident bowel movements and if no bowel movement after 6 shifts staff were to follow the physician ordered bowel care protocol and administer stool softeners…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs), related to cleanliness and grooming for 3 of 7 sample residents (Residents 39, 189, & 156) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with nail care (Resident 39 and 189), and bathing (Resident 156) placed the residents at risk for poor hygiene, embarrassment and diminished quality of life.Findings included .<Facility Policy>According to the facility's Activities of Daily Living (ADLs) policy, revised 01/2025, the facility provided residents with care and services for ADLs, including bathing and grooming. <Resident 39> According to a 01/29/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 39 had no memory impairment, had clear speech, and was able to make independent daily decisions. This MDS showed Resident 39 required maximal assistance from staff for transfers, personal hygiene, and bathing, and had no…

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' skin was assessed, documented, monitored, and treated as required for 2 of 4 residents (Residents 188 & 214) reviewed for non-pressure skin. These failures placed all residents at risk for delay in treatment, worsening of condition, and decreased quality of life. Findings included .<Facility Policy>According to the facility policy titled, Skin Integrity Monitoring- Non-Pressure Related Conditions, dated 04/2024, the facility would ensure skin conditions would be assessed and issues would be documented in the resident's records to include location, description, and interventions. The policy showed follow up monitoring would occur to evaluate progression or resolution of the skin condition.<Resident 188> According to the 02/23/2026 5 Day Medicare Minimum Data Set (MDS - an assessment tool), Resident 188 did not have cognitive impairment, was understood, and able to understand others in conversation. This assessment 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 pain management was provided to residents consistent with professional standards of practice including the failure to assess pain medication effectiveness for as needed (PRN) pain medications and failure to assess residents pain utilizing pain assessments and pain scales for 2 of 6 residents (Resident 82 & 52 ) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain, possible side effects, and a decreased quality of life. Findings included <Facility Policy>According to the facility's Pain Management policy, revised 02/2026, the facility assessed residents who had pain using pain assessment tools, including a numeric pain rating scale (a pain severity scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable) or a Wong-Baker FACES Pain Rating Scale (a pain assessment tool using six faces ranging from smiling to crying), to ensure consistent and accurate evaluation 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 ensure a medication error rate of less than 5 percent (%). Failure of 1 of 5 nurses (Staff W - Long Term Care Registered Nurse) to properly administer 2 of 29 medications for 1 (Resident 56) of 6 residents observed during medication pass, resulted in a medication error rate of 6.9%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered.Findings included .<Facility Policy>Review of the facility's Medication Administration policy, revised 04/2025, showed the facility staff administering the medication should be sure to review elements of the medication order including verifying the resident name, name of medication, strength, dosage, time, and route.<Staff W>Observation on 04/08/2026 at 9:04 AM showed Staff W preparing to administer morning medications to Resident 56. Staff W measured 25 milliliters (ml) of a liquid supplement medication into a medication cup and prepared prescription eye drops for Resident 56. Staff W was ready to administer 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 specialized rehabilitative services were provided as assessed to be required for 3 of 5 sample residents (Residents 188, 189, & 156) reviewed for rehabilitation with skilled therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being.Findings included . <Resident 188> According to the 02/23/2026 5 Day Medicare Minimum Data Set (MDS - an assessment tool), Resident 188 did not have cognitive impairment, was understood, and able to understand others in conversation. The assessment showed Resident 188 had diagnoses of kidney stones and bladder infection and required assistance from staff with daily needs including personal hygiene. Review of the facility Census record showed Resident 188 was hospitalized on [DATE] for scheduled procedure to remove kidney stones and came back to the facility on [DATE]. Review of…

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

Based on interview and record review, the facility failed to ensure nurses aides completed required annual training for 2 of 5 nurses aides (Staff J, Certified Nursing Assistant - CNA, and Staff K, CNA) reviewed for annual training. The failure to ensure CNAs completed 12 hours of annual training placed residents at risk for care deficits and other negative health outcomes. Findings included . <Facility Policy>According the facility's 06/2025 Mandatory Education/Training Requirements policy, the facility would establish a system to ensure all caregivers completed mandatory education and training in accordance with certification and regulatory requirements. The policy showed CNAs must complete a minimum of 12 hours training annually. Review of Staff J's annual training documentation from their last full year of employment from 9/9/2024 through 09/09/2025 showed Staff J completed 4.3 hours of education/training. Staff J did not meet the 12 hour requirement. In an interview on 04/13/2026 at 11:47 AM, Staff B (Director of Nursing) stated the facility had difficulty encouraging CNAs to…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases. The facility failed to implement and/or follow Transmission Based Precaution (TBP) protocol for 4 of 16 residents (Residents 1, 2, 3, & 4) reviewed for infection control related to COVID-19 (Coronavirus Disease of 2019, an infectious respiratory disease caused by a virus). This failure placed residents at risk of infection and related complications.<Facility Policy>The facility's 08/2024 Transmission-Based Precautions (TBP) policy showed the facility would implement Aerosol Contact Precautions (ACP) for residents with confirmed or suspected infections from COVID-19, which spreads through airborne and droplet routes through coughing, sneezing, talking, and through the provision of care. The TBP policy showed the facility would place a sign on the resident's door to inform staff and visitors of the appropriate Personal Protective Equipment (PPE) to put on and actions to take before entering 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.

Based on interview and record review the facility failed to implement the facility's abuse policy for 1 of 2 residents (Resident 1) reviewed for injuries of unknown origin. The failure to identify resident injuries as potential abuse, placed residents at risk for further abuse, injuries, and diminished quality of life. Findings included Review of the facility's Abuse Prohibition and Prevention policy dated 01/2024 showed all residents had the right to be free from mistreatment including sexual, physical, mental, and verbal abuse. The facility would have processes and measures in place to prevent, investigate, and act on all allegations of abuse. The policy showed the prevention of further abuse would occur by taking measures to protect the alleged victim, as well as other residents during the investigation by placing the identified staff on suspension during the investigation. The alleged victims would be monitored and protected from psychological harm during and after the investigation. In a phone interview on 05/27/2025 at 10:25 AM, Staff A (Administrator) stated during an…

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

Based on interview and record review, the facility failed to identify potential abuse, initiate an investigation to rule out abuse, and implement interventions to prevent ongoing abuse for 1 of 3 residents (Resident 1) reviewed. The failure to investigate an injury of unknown origin, a sign of potential abuse, prevented the facility from protecting other residents from abuse, neglect, and diminished quality of life. Findings included . Per the Washington State Reporting Guidelines for Nursing Homes The Purple Book, dated October 2015, showed injuries of unknown source must be thoroughly investigated to determine what occurred and make necessary provisions to resident care to prevent reoccurrence. The first phase of the investigation must occur within the first 24 hours of the knowledge of the incident. If the reasonable cause of the injury is not determined, a second phase must follow to end with the identification of who was involved, and what, where, why and how the incident happened. Review of the facility's Abuse Prohibition and Prevention policy revised on 01/2024 showed staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an environment that was free from hazards for 2 of 4 residents (Resident 2 and 3) reviewed for accidents. The failure of staff to intervene when Resident 2 was using cannabis (an illegal drug that causes an altered mental status) through a vape pen (a device that heats the drug to a consistency to inhale through the lungs) and allowed secondary exposure of cannabis to the roommate, staff, and placed residents at risk of harm from fire, injury, exposure to an illegal drug, and diminished quality of life. Findings included . The 10/18/2024 Admissions Minimum Data Set (MDS, an assessment tool) showed Resident 2 was cognitively intact and rarely needed assistance with health literacy. The MDS showed Resident 2 had multiple medically complex conditions including pain and limited mobility. The MDS showed Resident 2 was assessed to require maximum assistance from staff for personal care and mobility. Review of the 10/11/2024 admission…

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 food and drinks served to residents were prepared and distributed under sanitary conditions for 1 of 1 facility kitchens, and 2 of 6 unit kitchenettes. The failure to maintain kitchen equipment in a sanitary manner, complete Hand Hygiene (HH - washing or sanitizing hands) as required, sanitize kitchen thermometers appropriately, and ensure Certified Nursing Assistant's (CNA's) hair was secured when preparing meals in unit kitchenettes placed residents at risk for contaminated/spoiled food, foodborne illness, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 04/2023 Neighborhood Food Service policy, staff must wash their hands prior to food preparation. The policy showed hair must be restrained. <Facility Main Kitchen - Equipment> Observation on 01/02/2025 of the facility's main kitchen from 8:45 AM through 8:50 AM showed: an uncovered meat slicer with nothing preventing dust 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 provide care and services in a manner that maintained and promoted resident rights and dignity for 10 (Residents 56, 170, 69, 18, 15, 92, 85, 22, 164, & 70) of 35 sample residents. The failure to provide dignity during dining services including administration of medications in the dining room (Residents 56, 170, 69, 18, 15, 92 & 300 South Dining Room), provide privacy (Residents 85 & 22), and provide care in a dignified manner (Resident 70 & 164) placed residents at risk for a diminished sense of self-worth and well-being. Findings included . <Facility Policy> Review of the 08/2017 Facility admission Agreement showed residents had the right to be treated with respect and dignity. According to the 11/2023 revised . Standards of Care facility policy, staff would close a resident's door or curtain for privacy when providing care. <Dining Services> <Resident 56> Observations of meal services in the dining room on 01/07/2025 at 8:36 AM 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 allow 3 (Resident 22, 142, & 170) of 4 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing, and 1 supplementary resident (Resident 100). The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . <Resident 22> According to a 12/12/2024 Quarterly MDS, Resident 22 had multiple medically complex diagnoses including stroke, had clear speech, was able to understand, and be understood by others. This MDS showed it was very important to Resident 22 to choose between a tub bath, shower, bed bath, or sponge bath, was dependent on staff for bathing, and had no rejection of care. In an interview on 01/06/2025 at 10:03 AM, Resident 22 indicated they could not remember the last time they had a shower and stated, bathing is not as often as it used to be. Resident 22 stated they preferred bathing more often.…

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 thoroughly investigate reportable incidents for 2 of 5 sample residents (Residents 110 & 95) reviewed for abuse, and one supplemental resident (Resident 124). The failure to thoroughly investigate allegation of abuse placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life. Findings included . <Facility Policy> The facility's Abuse Prohibition and Prevention policy dated 01/2024, defined sexual abuse as non-consensual sexual contact of any kind. The policy showed when a resident made an allegation of suspected or alleged abuse, a thorough investigation would be completed. The policy showed a thorough investigation would include interviews with any witnesses and document details of the alleged event. The policy showed the facility would document the details of the occurrence in the record of all affected residents, including immediate interventions. <Resident 110> According to the admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care conferences as required for 2 (Residents 427 & 28) of 35 sample residents whose Care Plans (CPs) were reviewed, and failed to ensure CPs were updated as needed to reflect changes in resident's care needs for 4 (Residents 22, 142, 170, & 7) of 35 sample residents whose CPs were reviewed. The failure to provide care conferences and to update CPs with changes in residents' health status placed residents at risk for unmet care needs, unnecessary care, and frustration. Findings included . <Facility Policy> According to a facility policy titled, Resident Care Plan Reviews and Care Conferences, revised 04/2023, showed the facility would hold care conferences in accordance with regulatory requirements and as needed. <Care Conference> <Resident 427> According to 01/01/2025 admission Minimum data Set (MDS - an assessment tool) Resident 427 admitted to the facility on [DATE] without memory impairment. In an interview on 01/02/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 8 of 35 residents (Resident 14, 22, 170, 93, 112, 120, 126, & 82) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with nail care, dentures, dressing, shaving, and bathing placed the residents at risk for poor hygiene, long facial hair, embarrassment, and a diminished quality of life. Findings included . <Nail Care> <Resident 14> According to the 12/19/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 14 readmitted to the facility on [DATE] with weakness on the left side of their body. The assessment showed Resident 14 was dependent on staff for personal hygiene, showers, and toileting needs. Observations on 01/03/2025 at 11:31 AM and on 01/06/2025 at 8:23 AM showed Resident 14 was in bed. Resident 14 had long fingernails with black debris under their fingernails.…

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 activity programs met the needs of each resident for 3 of 5 sampled residents (Resident 110, 170, & 171) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 07/2024 Activities policy, each resident should be provided the opportunity to participate in activities that reflected their interests and lifestyle. The policy showed the activities offered should help meet residents' physical, mental, and psychosocial wellbeing. <Resident 110> According to the 11/14/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 110 had intact memory, and sometimes experienced social isolation. The MDS showed it was extremely important to Resident 110 to get outside when the weather was suitable. The MDS showed all activity preferences were extremely important for Resident 110,…

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

Based on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards for 4 of 9 (2 North, 4 South, St Joseph's Residence (SJR), & 5 North) units reviewed. The failure to ensure sharps (syringe needles, razors etc.) and chemicals were stored safely placed residents at risk for injury, unsafe chemicals, and accident hazards. Findings included . <Facility Policy> According to the revised 01/2025 Cleaning and Disinfection of Environment Surfaces policy, all chemicals would remain out of reach of residents and stored behind locked doors to ensure safety. <2 North Unit> Observation on 01/02/2025 at 8:43 AM showed the clean utility room on the 2 North unit was unlocked. Eight blood collection kits with needles were observed uncontained on a shelf at waist height. A towel warmer device was present and in use in the utility room. The towel warmer was easily opened and not secured/locked. In an interview on 01/02/2025 at 9:44 AM, Staff V (Licensed Practical Nurse - LPN) confirmed the eight blood collection kits in the unlocked utility…

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 nursing staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to resident assessments and plans of care for 4 of 4 facility staff (Staff Q - Certified Nursing Assistant), Staff W Registered Nurse (RN), Staff X - (RN), and Staff Y - (RN)) randomly selected and reviewed for competency. Additionally, the facility failed to ensure proficiency of nursing staff. The failure of nursing and nurse aide staff, to demonstrate a measurable pattern of knowledge, skills, abilities, behaviors that nurses need to perform work roles successfully, resulted in deficiencies related to the competency of nursing staff. Findings included . The 2024 Facility Assessment review date 10/14/2024 showed training, education and competencies of nurses and nurse aides were necessary to provide support and care to the residents of the facility. 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 observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility failed to implement and/or follow isolation precautions for 3 of 7 residents (Resident 14, 85, and 15) reviewed for Enhanced Barrier Precautions (EBP) , and failed to follow Transmission Based Precaution (TBP) for 1 of 2 rooms (room [ROOM NUMBER]) reviewed for TBP. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy> The facility's 08/2024 Transmission-Based Precautions (TBP) policy showed the facility used different kinds of precautions to protect residents and staff from different kinds of communicable diseases. The policy showed the appropriate precautions would be implemented when residents were diagnosed with or suspected to have infections or communicable…

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 identify and resolve grievances for 1 (Resident 70) of 1 residents reviewed for grievances. This failure placed residents at risk for reoccurrence of issues and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 09/2024 revised Resident Grievance Policy, the facility would promote resident autonomy and self-directed care and services. The policy showed the facility would seek to respond to resident concerns with respect to care and treatment, the behavior of staff and other residents. Residents had the right to file grievances verbally or in writing and receive a written decision regarding their grievance. The policy showed facility staff would acknowledge grievances received verbally and in writing and provide assurance there would be follow up. <Resident 70> According to the 10/11/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 70 was understood and could understand others during conversation. This MDS showed Resident 70 did not have impaired memory 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 effectively implement policies addressing the prohibition and prevention of abuse for 2 of 5 residents (Residents 110 and 95) reviewed for abuse and one supplemental resident (Resident 124). The failure to implement abuse prohibition and prevention policies placed residents at risk for verbal and mental abuse, psychosocial harm, and diminished quality of life. Findings included . <Facility Policy> The facility's 01//2024 Abuse Prohibition and Prevention policy showed all residents receiving care and services at the facility had the right to be free from mistreatment including sexual, physical, mental, and verbal abuse. The policy defined sexual abuse as non-consensual sexual contact of any kind. The policy showed if the allegation was substantiated appropriate corrective action would be taken. The policy showed all suspected and alleged violations would immediately be reported to all required agencies. The policy showed when a resident made an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure local Law Enforcement (LE) was notified for reasonable suspicion of a crime for 1 of 5 residents (Resident 110) reviewed for abuse. The failure to notify LE after substantiating an allegation of inappropriate touch/abuse placed residents at risk for verbal and mental abuse, psychosocial harm, and diminished quality of life. Findings Included . According to Appendix D of Washington State's Department of Social & Health Services Purple Book (Nursing Home Guidelines on prevention and protection, incident identification, investigation, and reporting), incidents involving staff-to-resident concerns must be reported to LE. Appendix D showed that circumstances where findings were made against licensed, certified, or registered health care workers the State Department of Health (DOH) must be notified. <Facility Policy> According to the facility's 01/2024 Abuse Prohibition and Prevention policy, all suspected and alleged violations would immediately 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 a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 2 of 7 residents (Residents 14 and 120) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of a 02/2022 facility's Bed Hold and Return to Facility policy, showed for the planned transfers, the facility would provide the transfer/discharge information before or at the time of the transfer. The policy showed for emergency transfers, the facility would contact residents or representatives to offer information within 24 hours. <Resident 14> Review of Resident 14's 11/14/2024…

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 interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 2 of 7 sample residents (Resident 14 & 120) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> Review of a 02/2022 facility's Bed Hold and Return to Facility policy, showed facility would provide residents and their representatives bed hold and return information at admission and before a hospital transfer or therapeutic leave. For the planned transfers, the facility would provide the bed hold information before or at the time of the transfer. The policy showed for emergency transfers, the facility would contact residents or representatives to offer bed hold within 24…

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

Based on observations, interview, and record review the facility failed to ensure 1 (Resident 170) of 35 residents Minimum Data Set (MDS- an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 170> According to a 12/11/2024 admission MDS, Resident 170 had multiple medically complex diagnoses including cancer. This MDS indicated Resident 170 did not have a life expectancy of less than six months and was not on hospice. Review of Resident 170's physician orders showed the resident was receiving an antianxiety medication for anxiety as part of a hospice comfort kit. Observations on 01/07/2025 at 1:35 PM showed Resident 170's hard chart at the nurse's station had stickers on the front indicating the resident was on hospice services. According to a 12/06/2024 hospice election statement form, Resident 170 was started on hospice services on 12/06/2024. In an interview on 01/10/2025 at 2:31 PM, Staff SS (Care Manager - Registered Nurse) stated the completion…

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 comprehensive Care Plans (CPs) for 2 (Residents 428 & 93) of 35 sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, inappropriate care, and frustration. Findings included . <Resident 428> According to a 12/30/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 428 admitted to the facility on [DATE]. The MDS showed Resident 428 was frequently incontinent of bowels. Review of Resident 428's 12/30/2024 9:10 AM Infection Prevention & Control progress note Resident 428 admitted on [DATE] and was on enteric precautions (infection control measure designed to prevent transmission of pathogens through the fecal-oral route) at the hospital for diarrhea their entire hospital stay. The note showed the hospital ruled out any infectious origin, but Resident 428 was still experiencing diarrhea since admission to the facility. In an interview on 01/03/2025 at 8:55…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure: physician's orders were followed for 2 (Resident 22 & 85) and medications were administered for 1 (Resident 28) of 35 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Following Orders> <Resident 22> According to a 12/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 22 had multiple medically complex diagnoses including neurogenic bladder (a condition where the nerves that control the bladder are damaged) and required the use of an indwelling catheter (a tube inserted into the bladder to collect and drain urine). Observations on 01/06/2025 at 8:55 AM, and 01/07/2025 at 1:31 PM showed Resident 22 with a catheter bag hanging from the bottom of the bed frame. Review of Resident 22's physician orders showed a 12/21/2024 order to remove the indwelling catheter for a trial and to replace with a size 16 FR [French]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1 of 5 residents (Resident 15) reviewed for Pressure Ulcers (PU- injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to implement wound prevention interventions, report on worsening conditions and to use appropriate hand hygiene practices and personal protective equipment (gloves, masks and gowns) when providing wound care and provide proper infection control practices, placed residents at risk for deterioration in skin condition(s) pressure ulcers and a diminished quality of life. <Facility Policy> Review of the revised 01/2023 Pressure Ulcer Prevention and Treatment policy, showed the facility would evaluate the resident's clinical condition and pressure ulcer risk factors and implement interventions that were consistent with resident needs, goals 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 residents weights were accurately monitored for 1 of 7 residents (Resident 14) reviewed for nutrition. The failure to ensure resident weights were rechecked when appropriate and the physician notified as required placed residents at risk for weight loss, weight gain, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 10/2023 Weight and Nutrition Monitoring Policy, the facility would strive to prevent significant weight loss in residents. The policy showed changes in the residents' nutritional status and weight would be discussed routinely by clinical staff and the Registered Dietician (RD). <Resident 14> According to the 12/19/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 14 readmitted to the facility on [DATE] and had diagnoses including anemia and malnutrition. The MDS showed Resident 14 was dependent on staff for transfers, personal hygiene, showers,…

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 pain management was provided to residents consistent with professional standards of practice including the failure to complete a thorough pain assessment prior to as needed (PRN) pain medication administration and have pain medications readily available for 2 of 7 residents (Resident 120 & 28) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain and a decreased quality of life. Findings included . <Resident 120> According to a 09/25/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 120 had no cognitive impairment. The MDS showed Resident 120 had a diagnosis of chronic pain and received routine and PRN pain medications without any nonpharmacological pain interventions implemented. The MDS showed Resident 120 experienced pain more than five days during the assessment period and their pain occasionally affected their sleep and day to day activities. Review of a 09/27/2024 Altered Comfort related to Chronic Pain and Muscle Spasm Care Plan (CP)…

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

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were secured for 1 of 7 units (300 S/Resident 89), and expired medications and biologicals were disposed of for 1 of 6 medication carts (5 South Medication Cart 1), and 4 of 4 medication rooms (5 North, 5 South, 4 South, and 3 South) reviewed for medication storage and labeling. These failures to ensure medication rooms and carts were secured and free from expired medications and ensure medications were not left unattended in common areas placed residents at risk for receiving the wrong medications, expired medications, and other negative health outcomes. Findings included . <Facility Policy> According to the 06/2022 revised Medication Storage and Disposal facility policy, facility would provide proper disposal of medications. <300 South/Resident 89> According to the 11/05/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 89 was assessed with severely impaired memory. The MDS showed Resident 89 had a chronic respiratory disease. Observation on 01/02/2025 at…

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

Based on observation and interview the facility failed to keep all protected health information in the residents' records confidential and out of view from unauthorized individuals on 1 of 7 (5 North) units reviewed. This failure placed all former and current residents at risk for a violation of their right to privacy. Findings included . <Facility Policy> Review of the 08/2017 Facility admission Agreement showed residents had a right to secure and confidential personal and medical records. <5 North> Observation and interview on 01/06/2025 at 8:52 AM showed a paper copy of an interdisciplinary team progress note in the grievance file folder on the wall by the elevator on the fifth floor. Staff E (Resident Care Manager) stated the paper copy of the progress note should not be in the grievance wall folder as anyone had access to that file folder. Staff E stated it was important to maintain resident record confidentiality for resident rights. Observation and interview on 01/06/2025 at 10:41 AM showed a 5 North resident roster/report sheet lying on top of cart 1 in view for anyone to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff, for 1 of 2 residents (Resident 170) reviewed for hospice services. Additionally, the facility failed to update the resident's Care Plan (CP) to show which agency was responsible for the hospice care. These failures prevented implementation of a system by which consistent communication between the facility and hospice staff occurred, and placed residents at risk for not for receiving necessary care and services. Findings included . <Facility Policy> According to facility's revised 04/2023 Hospice Coordination policy, the facility and hospice would: establish a regular communication schedule and determine the appropriate method(s) for communication .; exchange all relevant resident information, including the resident's CP .; would ensure their staff were knowledgeable about the communication protocols and were trained to effectively communicate with each other.…

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 care and services were provided to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident 1, 2, 3, & 4) reviewed for falls and safety. The failure to implement a system for the use of air mattresses with a pump to include an assessment of the type of air mattress, size of air mattress and air pump settings, review of risk factors and obtain informed consent from the resident and/or the Resident Representative (RR), provision of staff training, develop and implement the Care Plan (CP), provide ongoing monitoring of air mattress safety, function and pump settings, and re-assessment of the risk for use of the air mattress after a resident fall, placed 16 other residents using air mattresses at risk for potential negative outcomes including falls, injury, and death. Findings included . <Facility Policy> The facility policy Safe Use of Devices and Medical Equipment 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 observation, interview, and record review the facility failed to implement their emergency preparedness plans and procedures for 1 of 1 resident (Resident 1) reviewed for elopement (A situation in which a resident leaves the premises without the facility's knowledge and/or supervision). The failure to identify, evaluate, implement, monitor, and modify interventions to prevent elopement for the safety of residents leaving the facility unsupervised, placed Resident 1 and other residents at risk for avoidable accidents, injuries, diminished quality of life, and death. Findings included . The 10/2019 facility procedure Missing Resident Handbook showed when a resident could not be located, the facility staff would attempt to locate the resident. A search of all facility areas indoors and outdoors would be completed and the family or responsible party would be contacted. When the resident was not located within 10 minutes, the staff would call 911 (emergency services) to report a missing resident and request…

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 Pre-admission Screening and Resident Review (PASRR) assessments were completed, accurate and/or updated for accuracy for 3 of 5 residents (Residents 45, 111, and 94) reviewed for PASRR, and 1 supplemental resident (Resident 103). The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> Review of the 02/2022 Mood and Behavior Program facility policy showed a resident's PASRR should be completed prior to admission to the facility. This policy showed the facility complete a resident's PASRR re-screen when their mental health diagnoses changed, or when there were increases in behavior. <Resident 45> According to the 08/09/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 45 was assessed with moderate memory/thinking impairment and had progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 of 5 residents (Residents 45, 56 & 30) reviewed for nutrition and 1 supplemental resident (Resident 144) maintained acceptable parameters of nutritional status. Failure to ensure resident weight changes were reported as required, weights were collected as ordered, and supplements were provided as ordered left residents at risk for avoidable weight loss, unwanted weight loss, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 10/2023 Nutrition policy, residents' nutritional status and weight would be regularly discussed by the Registered Dietician (RD) and clinical staff. The policy showed residents would be weighed weekly until their weight stabilized, and then monthly. The policy showed nurses should review weights daily, and the RD should monitor resident weights on a weekly basis. The policy showed the nurse manager or designee, and the RD would review long term care residents'…

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 completed hand hygiene, secured their hair, or covered ready to eat food during meal service on 5 of 7 kitchenettes (5 North, 5 South, 4 North, 3 South, & 4 South) reviewed for serving meals in a sanitary manner. This failure placed residents at risk of contracting an infectious disease, consuming food prepared in an unsanitary manner, and a decreased quality of life. Findings included . <5 North> Observation on 10/23/2023 at 11:46 AM showed Staff M (Kitchen Attendant) managing tray line. Staff M provided a plastic menu to the residents in the dining room. Staff M handed a menu to a resident, discussed the options, took the menu back, and placed it on the counter directly next to the tray line. The menu was not sanitized, and hand hygiene was not performed prior to preparing the next ready to eat meal. Additional observations of this process were made on this date at 12:18 PM, & 12:35 PM. Observation on 10/23/2023 at 11:46 AM showed Staff M preparing a resident's cup of tea. Staff M was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection prevention and control program designated to provide a safe and sanitary environment to help prevent the transmission of communicable diseases including Covid-19 (a highly transmissible respiratory disease) and other infections. The failure to ensure staff applied/removed Personal Protective Equipment (PPE) as required, clean shared resident equipment between uses, used a barrier between medications and potentially contaminated surfaces, and performed hand hygiene as required including before and after personal/incontinence care placed residents at risk for infection, disease, and other negative health outcomes. Findings included . <Facility Policy> The facility's 07/2022 Transmission-Based Precautions (TBP) policy showed the facility used different kinds of precautions to protect residents and staff from different kinds of communicable diseases. The policy showed the appropriate precautions would be implemented when residents…

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 inform residents in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 (Residents 41 & 69) residents and 1 supplemental (Resident 141) reviewed for unnecessary medications. Failure of facility staff to inform residents of the risks associated with medications when obtaining consent for psychotropic medications detracted from the residents' ability to exercise their right to make an informed decision about proposed treatments. Findings included . <Facility Policy> The facility's 12/2021 Psychotropic Medication policy showed before being treated with a psychotropic medication the Unit Manager would review the psychotropic medication assessment with the resident or their responsible party before asking the resident or their responsible party to sign a Psychotropic Medication Informed Consent form. <Resident 69> According to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident falls were thoroughly investigated with root cause for the fall and new safety interventions identified for 2 (Residents 144, & 111) of 7 residents reviewed for falls. These failures left residents at risk for injury, further falls, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 08/2022 Fall Prevention policy, residents should be assessed for fall risk on admission and periodically. The policy showed individualized Care Plans (CP) would be developed with resident-specific interventions. The policy directed staff report to the State when/as required and to initiate an investigation and complete an Incident/Event report. The policy did not direct staff to identify a root cause or identify and implement new interventions to prevent recurrence. <Resident 144> According to the 8/30/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 144 had moderate…

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 resident and/or the resident's representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 2 (Residents 30 & 74) of 6 residents reviewed for hospitalization. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> Review of the revised February 2022 SNF [Skilled Nursing Facility] Bed Hold and Return to Facility facility policy, showed residents and their representatives would be provided with bed hold information and information on returning to the facility before a hospital transfer. For emergency transfers, the resident and/or representative would be contacted within 24 hours. This policy showed residents who were transferred to the hospital would be provided written information about the state's bed hold duration and payment amount.…

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 Care Plans (CPs) were revised, updated, and maintained with measurable goals for 4 (Residents 41, 30, 94 & 109) of 32 residents whose CPs were reviewed. The facility staff failed to ensure the participation of the resident and the resident's representative(s) in the development of CPs for 3 (Residents 9, 24, & 103) of 32 residents reviewed. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 04/2023 Resident [CP] Review and Annual Care Conferences policy, CPs would be reviewed on a quarterly basis. The policy showed residents and/or their representatives would be invited to an annual care conference to discuss treatment and approaches. The policy showed care conferences should be initiated by the primary nurse or designee. <Care Conferences> <Resident 9> According to the 07/24/2023 Quarterly Minimum Data Set (MDS - an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were followed for 7 (Resident 94, 41, 45, 120, 24, 56, & 82 ) of 32 sample residents; POs were clarified for 1 (Resident 111) of 32 sample residents; medications were not given outside ordered parameters for 1 (Resident 69) of 32 sample residents. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes. Findings included . <Following Physician Orders> <Resident 94> According to an 08/23/2023 Quarterly minimum Data Set (MDS - an assessment tool) Resident 94 had multiple medically complex diagnoses including a brain injury and dementia. This MDS showed Resident 94 required extensive physical assistance from staff for bed mobility and toilet use. Review of Resident 94's POs showed three 09/25/2021 bowel medication orders for constipation: one order for an oral laxative medication with directions to staff to administer if the resident had no bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for 1 of 4 residents (Resident 402) reviewed for activities, and 1 supplemental resident (Resident 41). Failure to consistently implement meaningful individual activity plans left residents at risk for boredom, frustration, isolation, and a diminished quality of life. Findings included . <Policy> Review of the 10/2023 Recreation Therapy Program facility policy showed a recreation therapy assessment would be completed upon admission. Preferred activities would be included on the Kardex (a tool to communicate care needs). <Resident 402> According to the 10/12/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 402 admitted to the facility on [DATE]. The MDS showed Resident 402 made their own decisions, and had complex medical diagnoses including cancer, blood clots, pneumonia, and depression. The MDS 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' skin was assessed on admission and as ordered, documented, monitored, and treated as required for 3 (Residents 300, 62, & 402) of 32 residents reviewed for non-pressure skin. These failures placed residents at risk for new or worsening skin impairment, discomfort, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 10/2023 Skin Assessment and Interventions to Maintain and Restore Skin Integrity, policy staff were to assess all skin surfaces and wounds on residents admitted or readmitted to the facility on the day of admission. Once a week, staff were to perform a total body skin check and complete the weekly skin check assessment describing the resident's skin condition. <Resident 300> According to the 10/17/2023 admission assessment, Resident 300 was admitted to the facility on [DATE] with diagnoses of an irregular heart rhythm, high blood pressure and respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were assessed for and received necessary treatment, adaptive equipment, and services needed to maintain vision abilities for 2 of 4 (Residents 9 & 62) residents reviewed for vision. Failure to ensure residents received vision care they were assessed to require left residents at risk for worsening vision, unmet needs, and a diminished quality of life. Findings included . <Resident 9> According to the 07/24/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 9 was assessed to have impaired vision and did not use corrective lenses. The MDS showed Resident 9 was assessed to have a moderate memory/thinking impairment. The MDS showed Resident 9 used a wheelchair (WC) for mobility. The MDS showed Resident 9 had medically complex conditions including glaucoma. The MDS showed Resident 9 was totally dependent on the assistance of two or more staff to transfer from surface to surface (such as from bed to WC). The MDS showed it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were followed according to professional standards of practice for 3 of 8 residents (Residents 401, 94, & 109) reviewed for respiratory care, and 1 supplemental resident (Resident 14). The failure to follow Physicians Orders (POs) for respiratory care, routinely change oxygen tubing, and routinely cleaning the oxygen machine filter placed residents at risk for respiratory infections, unmet care needs, and related complications. Findings included . <Facility Policy> According to the facility's 10/2023 Oxygen (O2) Therapy policy, staff were to monitor residents receiving oxygen therapy for signs of respiratory distress or oxygen toxicity. Regular assessments were to be conducted to evaluate its necessity and effectiveness. The flow rate was to be adjusted based on assessment findings communicated to the provider. <Resident 401> According to the 10/10/2023 admission Minimum Data Set (MDS - an assessment…

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 2 (Residents 94, & 111) of 5 residents whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary psychotropic medications, adverse side effects, and other negative health outcomes. Findings included . <Resident 94> According to an 08/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 94 had multiple medically complex diagnoses including a brain injury, dementia, and a psychotic disorder and required the use of an antipsychotic medication during the assessment period. Review of a revised 05/24/2023 High-Risk Drug Use Care Plan (CP) showed staff identified a goal that Resident 94 would have effective symptom relief with daily drug administration and gave directions to staff to monitor target behaviors on the Medication Administration Record (MAR). Review of a 03/29/2022 behavior CP showed staff identified a goal that Resident 94 would be free…

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.