Seattle Medical Post Acute Care

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 maintains and promotes dignity and respect for 2 of 4 residents (Residents 23 & 55), reviewed for dignity. The failure to knock on the door and introduce themselves before entering, ensure oxygen concentrator (a machine that generates oxygen) was correctly labeled, and provide adequate covering was provided to maintain privacy during transfer placed the residents at risk for lack of privacy, decreased self-worth, potential embarrassment, and diminished quality of life.Findings included.Review of the facility-provided document titled, Notice of Resident Rights under Federal Law, updated in July 2015, showed the center will protect and promote these rights to the best of their ability. The document further showed, The resident has the right to personal privacy. the resident has the right to a dignified existence and self-determination.RESIDENT 23Resident 23 was admitted to the facility on [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 provide written notices of transfer/discharge to the resident and/or their representative and failed to notify the Office of the State Long Term Care Ombudsman (an advocacy group for residents), describing the reason for transfers/discharge for 2 or 3 residents (Residents 101 & 8), reviewed for hospitalization and discharge. These failures placed the residents at risk for not having the opportunities to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Transfer and Discharge, updated in May 2025, showed, When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the following items: date of notice is given, effective date of the transfer/discharge, reason for the transfer/discharge, where the resident is to be moved, contact information for the state Long-Term Care Ombudsman . It further stated, The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 7 residents (Resident 77), reviewed for PASARR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs.Findings included.Review of the facility's policy titled, PASRR Process Policy and Procedure, revised on 01/01/2025, showed upon admission the admissions coordinator or designee validates the Level I PASRR and, if Level II was indicated, the Social Worker ensures timely referral to a Licensed Mental Health Professional.Resident 77 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic mental illness that affects a person's thoughts,…

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

Based on observation, interview, and record review, the facility failed to follow hospice (specialized care for people who are nearing the end of their life) physician orders and effectively communicate/coordinate hospice plan of care for 1 of 1 resident (Resident 8), reviewed for hospice services. This failure placed the resident at risk for delayed treatment, unidentified decline, and unmet care needs.Findings included . Review of the facility's policy titled, Hospice - Provision of Care by Outside Providers, updated September 2017, showed, The hospice and center communicate, establish, and agree upon a coordinated Plan of Care (POC) reflecting the hospice philosophy and based on an evaluation of the individual needs of the resident. The POC includes: directive for managing pain and other uncomfortable symptoms, and the care and services the Center and hospice provide in order to be responsive to the unique needs of the resident and his/her expressed desire for hospice care. It further showed, Medications, medical supplies and services are provided as indicated by the agreement…

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 followed safe transfer practices when using a mechanical lift (a medical device used to safely and efficiently move residents with limited mobility) for 1 of 4 residents (Resident 55), reviewed for accident prevention. This failure placed the resident at risk of falls, injury, and compromised safety.Findings included.Review of a face sheet printed on 09/11/2025 showed Resident 55 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS - an assessment tool) dated 07/09/2025 showed Resident 55 had severe cognitive impairment and was totally dependent on staff for activity of daily living.Observation on 09/05/2025 at 9:24 AM showed Staff W, Certified Nursing Assistant (CNA), transferred Resident 55 from a shower bed using a mechanical lift without a second person present. Staff DD, Respiratory Therapist Supervisor, was present holding the ventilator (a medical device that assists or takes over…

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 obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 5 nurse aides (Staff M), reviewed for nursing aide registry. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs.Findings included .Review of the facility's policy titled, Screening, updated October 2022, showed, The Center conducts registry checks for all employees before hire, annually, and more frequent as required by state law and regulation.Review of Staff M's personnel records showed they were hired by the facility on 08/01/2025 as a Certified Nursing Assistant. Further review showed Staff M's records did not include documentation from the nurse aide registry.In an interview on 09/10/2025 at 3:38 PM, Staff B, Director of Nursing, stated that Staff M's registry verification was not completed before the employee's start date. Staff B further stated that the facility should have had registry verification before Staff M started working at 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 record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 5 residents (Residents 9), reviewed for unnecessary medications. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication Administration General Guidelines, dated 01/24 [January 2024] showed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The individual who administers the medication dose, records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring was conducted before administering Blood Pressure (BP- the force of blood flowing through blood vessels) medication with parameters for 1 of 5 residents (Resident 77), reviewed for unnecessary medications. This failure placed the resident at risk for complications related to untreated or uncontrolled BP and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication Administration General Guidelines, dated January 2024, showed medications were to be administered in accordance with the prescriber's written order. The policy further directed staff to review and confirm each medication order on the Medication Administration Record (MAR) prior to administration, and to obtain and record any required vital signs before giving medications.Resident 77 was admitted to the facility on [DATE] with diagnoses that included hypotension (low BP). Review of the physician's orders printed on 09/11/2025,…

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 provided for 2 of 5 residents (Residents 9 & 77), reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease.Findings included.Review of the facility's policy titled, Pneumococcal Vaccination of Residents, dated March 2022, showed, PCV-20 [Pneumococcal Conjugate Vaccine-vaccine that protects against 20 types of bacteria that cause pneumonia] is recommended for all adults 65 or older. Adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors the Center follows the CDC [Centers for Disease Control and Prevention]. It further showed, Residents may refuse vaccination. Vaccination refusal and reasons why (e.g., [example] contraindicated, did not want vaccine, etc.) are documented.RESIDENT 9Review 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 the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered to 1 of 5 residents (Resident 3), reviewed for immunizations. The failure to educate and offer the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications. Findings included.Review of the facility's policy titled, SARS-CoV-2 [strain of the virus that causes COVID-19] (COVID-19) SNF [Skilled Nursing Facility], dated January 2025, showed that, residents are offered recommended COVID-19 vaccinations upon admission and as eligible per CDC [Centers for Disease Control and Prevention] recommendations.Review of the CDC online document titled, Staying Up to Date with COVID-19 Vaccines, dated 06/06/2025, recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. It further showed that getting the 2024-2025 COVID-19 vaccine is especially important if you.are…

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 a clean, comfortable, homelike, and safe environment for 1 of 2 rooms (room [ROOM NUMBER]), reviewed for safe and sanitary environment. The failure to ensure rooms were free from odors and maintained in safe and sanitary conditions placed the residents at risk of infection, poor living conditions, and a diminished quality of life.Findings included.Review of the facility's policy titled, Guidelines for Cleaning and Disinfecting Resident Rooms, dated May 2015, showed housekeeping surfaces were cleaned on a regular basis, when spills occur, and when these surfaces were visibly soiled. The policy showed resident room cleaning would include cleaning horizontal surfaces (such as bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution, and walls when they were visibly soiled.Observation on 09/03/2025 at 9:16 AM showed Resident 29 and Resident 30 shared room [ROOM NUMBER]. The room had a strong…

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 physician and resident representative were notified for 1 of 2 residents (Resident 1), reviewed for notification of changes. The failure to notify the physician and the resident's representative when Resident 1 had significant weight loss placed the resident at risk for a delay in medical/nutritional treatment, and not having their representative involved in the health care decision making process for timely care and services.Findings included .Review of the facility's policy titled, Weights, revised on 10/12/2023, showed, The Center uses weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention, or diuresis [excessive urination]. Significant weight loss/gain (five percent in 30 days, 7.5 % in 90 days, or 10 % in 180 days).The nurse records validated weights on the Weight Record in the resident's medical record.Licensed nurse will notify physician, resident/responsible party of significant…

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 1), reviewed for SCSA. This failure placed the residents 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 1.19.1, dated October 2024, 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 problems (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 interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 3 residents (Resident 1), reviewed for rehabilitation services. This failure placed the residents at risk for the decline in function, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Rights Under Washington State Law, updated in July 2015 showed, Pursuant to Washington State law, in addition to those rights enumerated under federal law, each resident of a long-term care facility located in [NAME] has the following additional rights. The Center [facility] will seek to ensure that these rights are not violated. The policy further showed that residents have rights to reside in and receive services from the Center with reasonable accommodation of individual needs and preferences . Review of a document titled, Policy: 8.14-Frequency/Duration/Intensity of Therapy Services, dated 2025 showed that therapists both employees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and/or develop discharge comprehensive care plans for 3 of 5 residents (Residents 1, 2 & 3), reviewed for care planning. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Resident Care Plan, dated in July 2015, showed, Social Services assures medically-related social services needs are incorporated into each resident's care plan, which is completed within seven days of completion of the RAP [Resident Assessment Protocol] summary. 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, After completing the MDS [Minimum Data Set - an assessment tool] and CAA [Care Area Assessment] portions of the comprehensive assessment, the next step is to evaluate the information gained…

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 act timely and ensure resident received the necessary care and services for examination and/or treatment after a sexual assault in accordance with professional standards of practice for 1 of 2 residents (Resident 1), reviewed for sexual abuse investigations. The failure to send resident to the emergency room (ER) after sexual assault placed the residents at risk for delay in care and services, unintended health consequences, and decreased quality of life. Findings included . According to the Center for Disease prevention and control's guideline titled, Sexual Assault and Abuse and STIs [sexually transmitted infections] - Adolescents and Adults, last reviewed on 07/22/2021, showed, Examinations of survivors of sexual assault should be conducted by an experienced clinician in a way that minimizes further trauma to the person. The decision to obtain genital or other specimens for STI diagnosis should be made on an individual basis. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received necessary assistance with toileting care for 2 of 3 residents (Resident 3 & 4), reviewed for bowel and bladder. This failure placed the residents at an increased risk of incontinence, loss of dignity, diminished quality of life, feelings of frustration and embarrassment. Findings included . Review of the facility's policy titled, Bladder and/or Bowel Incontinence, updated in October 2017, showed, Each resident is evaluated for bladder and bowel incontinence .Appropriate and individualized care plan interventions are implemented when evaluation is completed. RESIDENT 3 Resident 3 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 04/02/2025, showed Resident 3 had intact cognition and required substantial/maximal assistance with toileting. Review of the care plan area, Establish the Baseline Plan of Care, initiated on 04/10/2025 showed that Resident 3…

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 take timely action and ensure a urology (a surgical specialty that focuses on the urinary tract) referral, and urine analysis (UA- test for UTI [Urinary Tract Infection or bladder infection]) were conducted for 1 of 1 resident (Resident 1), reviewed for urinary care management. These failures placed the resident at risk for urinary associated infections, other health related complications, and diminished quality of life. Findings included . UROLOGY REFERRAL Review of the facility's policy titled, Clinical and Support Services, updated in July 2015, showed, The Social Services Department assists residents in obtaining needed clinical and support services. Resident 1 admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of the admission Minimum Data Set (an assessment tool) dated 07/15/2024, showed Resident 1 had 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 responsible parties were notified for 1 of 1 (Resident 1), reviewed for notification of changes. The failure to notify the resident's representative when Resident 1 went missing placed the resident at risk of not having their representative make decisions for timely care and services. Findings included . Review of Resident 1's face sheet printed on 12/12/2024 showed Resident 1 admitted to the facility on [DATE]. Further review of the face sheet showed that Resident 1's representative was listed as their Power of Attorney (a designated person to make decisions about another person's medical care) with their cell phone number listed on the face sheet. Review of the nursing progress note dated 12/11/2024 at 6:42 AM, showed Resident 1 left the faciity on [DATE] around noon and did not return to the facility and that law enforcement was notified. Further review of the nursing progress note did not show Resident 1's representative was notified. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF) directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 1 of 2 residents (Resident 2), reviewed for tube feeding management. The failure to clarify enteral nutrition orders to include route of administration and/or follow physician's orders on the amount of formula to administer placed the resident at risk for adverse health outcomes, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral Feeding, updated in April 2017, showed, Enteral feeding parameters are ordered by a physician. The nutritional value is calculated and documented in the medical record by the Registered Dietitian (RD). The licensed nurse administers the enteral feeding and medications per physician order using best practice. The policy further showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 1 of 7 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for pain, unmet care needs, on-going misappropriation of medication, and a diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, dated October 2022, showed, Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Examples of misappropriation of resident property included, missing prescription medications or diversion of a resident's medications, including, but not limited to, controlled substances for staff use or personal gain. Review of the admission 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.

Based on observation, interview and record review, the facility failed to ensure survey results were posted in a place readily accessible to residents and residents' legal representatives. In addition, the facility failed to ensure the survey result binder included the results for 8 of 9 (04/26/2021, 06/15/2021, 07/27/2021, 09/07/2021, 01/24/2022, 04/12/2022, 10/19/2023 & 12/06/2023) complaint surveys that resulted in citations. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction. Findings included . Review of the facility's document titled, Notice of Resident Rights Under Federal Law, updated in November 2016, showed, The resident has the right to examine the results of the three preceding years' survey, of the Center conducted by Federal or State surveyors, and any plan of correction in effect with respect to the Center. During a Resident Council meeting on 09/23/2024 at 11:59 AM, Resident 29 and Resident 19 stated they were not aware of their right to read 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 resident rooms were maintained for 4 of 6 rooms (Rooms 301, 303, 223 and 215) and 1 of 3 halls (Second floor hall), reviewed for environment. The failure to ensure resident rooms were free of wall scrapes, loose baseboards, holes in the walls, and the failure to ensure hall handrails were in good condition placed residents at risk for a less than homelike environment and diminished quality of life. Finding included . Review of the facility's policy titled, Preventative Maintenance published July 2008, showed that all areas of the Center and equipment therein, are inspected and maintained in accordance with the scheduled maintenance system (SMS). The maintenance department is responsible for the condition and function of the Center's physical plant including utilities, grounds, and equipment. room [ROOM NUMBER] Observations of room [ROOM NUMBER] on 09/20/2024 at 12:18 PM, on 09/23/2024 at 8:22 AM, and on 09/24/2024 at 8:26 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notices of transfer/discharge to the residents and/or their representatives and failed to notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents), describing the reason for transfers/discharge for 4 of 4 residents (Resident 9, 75, 52 & 15), reviewed for hospitalization and discharge. These failures placed the residents at risk for not having opportunities to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Transfer and Discharge, updated in October 2022, showed, When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the following items: date of notice is given, effective date of the transfer/discharge, reason for the transfer/discharge, where the resident is to be moved, contact information for the state Long-Term Care Ombudsman . It further…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 licensed staff (Staff GG) followed professional standards for proper medication administration via a gastrostomy tube (G-tube - a medical device used to provide nutrients through a tube directly into the stomach) and follow insulin (a hormone to lower blood sugar) order for 2 of 9 residents (Resident 54 & 36), reviewed for medication administration. In addition, the facility failed to ensure a urine specimen was properly labeled/stored in accordance with standard of practice for 1 of 1 specimen refrigerator (second floor specimen refrigerator), reviewed for environment. These failures placed the residents at risk for potential adverse effects and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral Feeding [or tube feeding, is the delivery of nutrients through a tube directly into the stomach], updated in April 2017, showed the licensed nurse administers the enteral feeding and medications per physician order using best practice. It further 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 services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 6 of 6 residents (Residents 14, 59, 37, 28, 35 & 10), 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 . Review of the facility's policy titled, Restorative Program, updated in March 2019, showed, Restorative services are provided by Restorative Nursing Assistants (RNA) .or other staff .trained in restorative techniques. The Restorative Program is under nursing supervision. It further stated, Each restorative service is recorded .each time the program is implemented/completed. RESIDENT 14 Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 06/30/2024, showed Resident 14 admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete or severe loss of strength,…

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

Based on observation and interview, the facility failed to ensure the daily nurse staffing form was posted 2 of 9 days and failed to post daily nurse staffing in prominent locations for 3 of 4 floors (First floor, Second floor & Third floor). This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels. Findings included . Observations on 09/19/2024 at 8:48 AM showed there was no nurse staffing posted that was visible on the Third floor. Observation on 09/19/2024 at 10:00 AM showed there was no nurse staffing posted that was visible on the Second floor. Observation and interview on 09/23/2024 at 8:16 AM, showed that the Daily Nurse Staffing Information Form for 09/20/2024 was posted in a glass case by the reception desk. Staff S, Staffing Coordinator, stated that they would have today's posting up in a minute. Observation on 09/24/2024 at 9:22 AM showed there was no Daily Nurse Staffing Information Form on the Third floor. Observation on 09/24/2024 at 9:24 AM showed there was no Daily Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately label and store drugs or biologicals (diverse group of medicines made from natural sources) and/or failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 2 of 3 medication carts (Second Floor Cart 2 & Third Floor Cart 1) and for 1 of 2 Medication Storage Room (Second Floor Medication Storage Room), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage, dated January 2023, showed, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. It further showed, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked,…

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 were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen and 2 of 2 resident personal refrigerators (Resident 6's two personal refrigerators), reviewed for food services. The failure to appropriately thaw food in a manner to provide food safety and failure to check temperature and maintain personal refrigerators, 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, Preparation and Service of Foods - Safety Precautions, updated November 2018, showed one of four acceptable methods for thawing food was to completely submerge under cold running potable water (temperature of 70 degrees Fahrenheit [F-unit of measurement] or below), with water that is running fast enough to agitate and float off loose ice particles.…

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 Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 2 of 5 staff (Staff MM & LL) and failed to implement Enhanced Barrier Precautions (EBP- precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) for 1 of 4 residents (Resident 6) 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 2 of 2 staff (Staff BB & GG) and failed to disinfect medical equipment for 1 of 2 staff (Staff R) reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings…

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 a call light (an alerting device for staff to assist residents in need) was within reach for 1 of 4 residents (Resident 35), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, SNF [skilled nursing facility] Clinic, Answering the Call Light, showed a guideline for staff to ensure that the call light is accessible to a resident in bed. Resident 35 readmitted to the facility on [DATE] with diagnoses that included hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (a type of stroke that occurs when blood flow to the brain is disrupted) affecting left non-dominant side. Review of Resident 35's activities of daily living care plan, revised on 03/23/2023, showed an intervention for soft touch call light is to be within [Resident 35'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 their abuse policy and procedure by not ensuring reference checks were conducted prior to hire for 1 of 5 staff (Staff W), reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated October 2022, showed, The Center screens prospective staff for a history of abuse, neglect, exploitation or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation, or misappropriation of resident property. (Refer to Screening Policy). Review of the facility's policy titled, Screening, updated October 2022, showed, The Center screens prospective employees by reviewing .information from employers (at least two reference checks), whether favorable or unfavorable. Review of employee records for Staff W, Certified…

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 admission Minimum Data Set (MDS-an assessment tool) was completed within 14 days of admission for 1 of 21 residents (Resident 26), reviewed for comprehensive assessment. 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 1.18.11, revised in October 2023, showed that, at a minimum, facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility (admission date + [plus] 13 days). Resident 26 admitted to the facility on [DATE]. Review of Resident 26's admission MDS dated [DATE], showed it was completed on 07/08/2024 (four days late). In an interview and joint record review on 09/26/2024 at 3:17 PM with Staff L, MDS Coordinator, stated they used…

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 timely for 1 of 3 residents (Resident 61), reviewed for significant change in condition. The failure to complete a SCSA within 14 days placed the resident at risk for 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 significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting,' 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary [involving two or more different subjects…

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 3 of 21 residents (Residents 84, 82 & 26), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding hospice care, pressure ulcer (injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time) care, and comatose status (deep sleep-like state where a person is unconscious, unresponsive, and unable to be awakened) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to revise comprehensive care plan for 1 of 21 residents (Resident 28), reviewed for care plan revision. The failure to revise the care plan to include current and specific restorative nursing program services placed the resident at risk for 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 1.18.11, revised in October 2023, showed that the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Resident 28…

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 necessary assistance with Activities of Daily Living (ADL) for 1 of 4 residents (Resident 14), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with getting out of bed placed the resident at risk for unmet needs, pressure related complications, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 06/30/2024, showed Resident 14 admitted to the facility on [DATE]. It further showed that Resident 14 was dependent for transferring to and from a bed to a chair or wheelchair. Review of Resident 14's Devices care plan printed on 09/19/2024, showed, patient [resident] to be up in wheelchair, initiated on 02/02/2023. It further showed, reclining/tilt-in-space [a wheelchair that can tilt and can be used to redistribute pressure] WC [wheelchair]. Used for positioning and to allow [Resident 14] to get out of bed safely. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (TF-the delivery of nutrients through a tube directly into the stomach) were followed for 2 of 3 residents (Residents 54 & 36), reviewed for TF management. The failure to check TF placement or check the gastric residual volumes (GRV - fluid/contents that remain undigested in the stomach) prior to TF and medication administration placed the residents at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral Feeding, updated in April 2017, showed the licensed nurse administers the enteral feeding and medications per physician order using best practice. It further showed additional procedure for enteral feeding which included residuals check. RESIDENT 54 Resident 54 admitted to the facility on [DATE] with a diagnosis of laryngeal cancer (cancer of the throat). Review of the quarterly Minimum…

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 complete required annual performance evaluation for 2 of 3 staff (Staff T & MM), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. The failure to complete a performance review of every nurse aid at least once every 12 months placed residents at risk for receiving care from underqualified care staff, unmet care needs and a diminished quality of life. Findings included . STAFF T, CNA Review of Staff T's personnel file showed they were hired on 01/22/2022. Their last performance review was completed on 02/23/2022. STAFF MM, CNA Review of Staff MM's personnel file showed they were hired on 02/23/2022. Their last performance review was completed on 12/08/2022. In an interview on 09/27/2024 at 1:09 PM, Staff A, Administrator, stated that they expected performance evaluations were completed annually. Reference: (WAC) 388-97-1680 (2)(b)(i) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (the delivery of nutrients through a tube directly into the stomach) were followed for 2 of 3 residents (Residents 54 & 36), reviewed for tube feeding management. The failure to check tube feeding placement for gastric residual volumes (GRV - fluid/contents that remain undigested in the stomach) prior to tube feeding and medication administration placed the residents at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral Feeding, updated in April 2017, showed the licensed nurse administers the enteral feeding and medications per physician order using best practice. It further showed additional procedure for enteral feeding which included residuals check. RESIDENT 54 Resident 54 admitted to the facility on [DATE] with a diagnosis of laryngeal cancer (cancer of the throat). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident meal preferences for meal services was provided for 1 of 2 residents (Resident 76). This failure placed the resident at risk for not having their food choices honored, dissatisfaction with food served, and a diminished quality of life. Findings included . A record review of Resident 76's face sheet, printed 09/23/2024, showed they admitted to the facility on [DATE] with multiple diagnoses including a fractured lumbar vertebra (broken back). A review of the facility's weekly menu showed the following: -09/22/2024: Oatmeal, fresh fruit, western omelet, and wheat toast -09/23/2024: Cereal cream of Wheat Fresh fruit, sausage patty, pancakes -09/24/2024: Cream of rice, fresh fruit, fried egg sandwich, hashbrown patty, bacon -09/25/2024: Oatmeal, fresh fruit, sausage patty, waffle -09/26/2024: Oatmeal, fresh fruit, fried egg, bacon, bagel -09/27/2024: Cream of rice, fresh fruit, biscuit, sausage gravy -09/28/2024: Oatmeal, fresh…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 1) reviewed for elopement. The resident was allowed to exit the facility unnoticed and was placed at risk for serious injury and a diminished quality of life. A past noncompliance was initiated on 08/28/2024 related to F689 Free of Accident Hazards/Supervision/Devices for failure to provide necessary supervision for a resident at risk for elopement. The facility implemented the following interventions that were initiated 08/28/2024 and corrected by 09/03/2024: - Assisted Resident 1 with returning to the facility from the kidney center [which was located across the street from the facility]. - Audits were completed for current residents for risk for wandering and elopement. - Elopement Risk evaluations were updated/completed. - Resident educated on signing in/out and informing staff of intent of leaving the facility. - Staff education on policies and procedures for wandering and…

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

Based on observation, interview and record review, the facility failed to ensure resident room doors with COVID-19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) were kept closed for 4 of 5 Residents (Residents 1, 2, 3, and 4) in accordance with the Centers for Disease Control (CDC) guidelines. In addition, the facility failed to ensure 3 of 3 staff members (Staff D, E, and F) used personal protective equipment (PPE - use of gowns, gloves, eye protection, and N95 or higher-level respirator) in accordance with the CDC guidelines when caring for residents with known COVID-19 infections. These failures placed the residents, staff, and visitors at risk for COVID-19 infection and related complications. Findings included . According to CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated as of 03/18/2024, showed when health care personnel enter the room of a patient with suspected 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 enteral nutrition/tube feeding (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach) was provided per physician's order at the prescribed rate for 1 of 3 residents (Resident 1), reviewed for tube feeding. This failure placed the resident at risk for inadequate nutrition/hydration, weight loss, and related complications. Findings included . Review of the facility's policy titled, Enteral Feeding, updated in April 2017, showed Enteral feeding parameters are ordered by a physician. The nutritional value is calculated and documented in the medical record by the Registered Dietician (RD). The licensed nurse administers the enteral feeding and medications per physician order using best practice. Resident 1 admitted to the facility on [DATE] with diagnoses that included diabetes (high blood sugar) and persistent vegetative state (a condition of profound non-responsiveness in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain resident windows in good condition for 2 of 6 resident rooms (Rooms 217 & 205), reviewed for comfortable homelike environment. This failure placed the residents at risk for injury and diminished quality of life. Findings included . Review of the facility's policy titled, Preventative Maintenance, dated July 2008, showed that the Maintenance Department was responsible for the condition and function of the Center's [facility's] physical plant, including utilities, grounds, and equipment. The Maintenance Department also showed they will complete the inspection, maintenance, and repair of equipment that deemed essential for the environmental support and care of the resident, resident families, and employees. room [ROOM NUMBER] On 11/28/2023 at 10:36 AM, room [ROOM NUMBER], bed 2's window showed the upper and left side of the window frame were covered by a black duck (brand, adhesive) tape. room [ROOM NUMBER] On 11/28/2023 at 10:38…

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) was completed for 1 of 1 resident (Resident 1), reviewed for significant change in condition. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) Manual, Version 1.16, revised in October 2023, showed that a Significant Change is defined as a decline or improvement in a resident's status such as an emergence of a new pressure ulcer/injury (bedsore) at Stage 2 (shallow open ulcer) or higher, a new unstageable pressure ulcer (the base of the wound is covered with slough [yellow, tan, brown dead tissue]), a new deep tissue injury (purple or discolored intact skin due to damage of tissue from pressure) or worsening in pressure ulcer status, and the emergence of a condition/disease in which a resident was judged to be unstable. Resident 1 admitted to the facility on [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 thoroughly investigate allegations of sexual aggression for 1 of 2 residents (Resident 1) reviewed for abuse investigations. This failure placed the resident at risk for unrecognized abuse, inappropriate corrective actions, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse Investigation, updated in October 2022, showed the center identifies, and interviews involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Through investigation, the center works to determine if the abuse neglect exploitation misappropriation of property and or mistreatment has occurred and to determine the extent and cause. Resident 1 admitted to the facility on [DATE]. Review of the comprehensive Minimum Data Set (an assessment tool) dated 09/08/2023, showed Resident 1 was cognitively intact (normal or sufficient mental processes such as thinking,…

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 written notification of room changes including the reason for the move and failed to ensure monitoring for acclimation to the new environment for 2 of 5 residents (Residents 1 & 2) reviewed for room changes. This failure placed the residents at risk for not being informed, feelings of powerlessness, and a diminished quality of life. Findings included . Review of the facility's policy titled, Room Changes/New Roommate, updated November 2016, showed the interdisciplinary team notifies the resident and/or representative of the new room change or roommate (prior to the change). Documents the decision and notification in the medical record and monitors the resident's acclimation to the new environment/roommate for 72 hours and documents in the medical record. RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of Resident 1's Electronic Health Record under the Census tab, showed Resident 1 transferred to a different room on 08/16/2023.…

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

Based on observation and interview, the facility failed to ensure tube feedings (inserted through the belly that brings nutrition directly to the stomach) and tube feeding pumps (used to deliver nutrition via feeding tubes) were clean and sanitary for 4 of 4 residents (Residents 36, 2, 1 and 14) reviewed for safe and clean environment. This failure placed the residents at risk for potential infection control issues and a diminished quality of life. Findings included . RESIDENT 36 Observations on 05/30/2023 at 9:20 AM and 2:58 PM, on 05/31/2023 at 5:02 PM, on 06/01/2023 at 8:34 AM and 10:23 AM, and on 06/02/2023 at 11:38 AM, showed Resident 36's tube feeding pump was observed to be soiled with dried tube feeding formula on the top and along the sides of the pump. RESIDENT 2 Observations on 05/30/2023 at 8:49 AM and 2:55 PM, on 05/31/2023 at 11:52 AM, 3:30 PM and 5:01 PM, on 06/01/2023 at 10:24 AM, and on 06/02/2023 at 11:38 AM, showed Resident 2's tube feeding pump was observed to be soiled with dried tube feeding formula on the top of the pump and on the bottom of the stand of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and/or the residents' responsible party of a transfer/discharge in writing for 6 of 6 residents (Residents 26, 42, 47, 36, 2 and 44) reviewed for hospitalization. The failure to provide the written notice disallowed the resident and/or their representative an opportunity to fully understand the reason for transfer/discharge and their rights associated with the resident discharge appeal process. Findings included . Review of the facility policy titled, Transfer and Discharge, dated October 2022, showed, Policy Statement: Residents are transferred or discharged from the Center under specific circumstances . 5. When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of transfer or Discharge which includes the following items: a. Date notice is given, b. Effective date of the transfer/discharge. c. Reason for the transfer/discharge. d. Where the resident is to move. e. Contact…

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 record review, interview, the facility failed ensure 6 of 6 residents (Residents 26, 42, 47, 36, 2 and 44) reviewed for hospital transfers were given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings included . Review of the facility policy titled, Bed Hold, dated October 2019, revealed, Policy Statement: The resident and/or resident representative is informed of the Bed Hold Policy in writing upon admission, transfer, or leave of absence (LOA). If unable to provide at the time of transfer or leave of absence, the policy is provided within 24 hours. Procedure: . 2. Upon transfer or discharge, the nursing department provides the resident and/or resident representative a copy of the Notice of Bed Hold Policy . 4. Whether or not the resident or responsible party chooses to secure a bed hold,…

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 store, prepare, and serve food in a sanitary manner and/or in accordance with professional standards of food safety. The failure to use the correct test strip to check the kitchen sanitizing solution, ensure food was dated when first opened/refrigerated, soiled sheet pans/manual can opener were cleaned after use, and food were stored with tight fitting covers or lids, placed the residents at risk for food contamination and food borne illness (caused by the ingestion of contaminated food or beverages). Findings included . CORRECT TEST STRIP TO CHECK SANITIZING SOLUTION On 05/30/2023 at 5:53 AM, Staff L, Cook, was observed in the kitchen. A container of sanitizing solution with a wiping cloth in it was observed sitting on the food preparation counter. Staff L stated the test strip for the sanitizer was mounted on the inside of the container and there was a different container of test strips in a box by the door to the kitchen. The test strip mounted to the inside of the container was a strip that was red 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.

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 for 3 of 3 residents (Residents 296, 41 & 246) reviewed during wound care and medication administration. In addition, the facility failed to ensure urinary drainage bag was off the floor for Resident 296 and failed to ensure enhanced barrier precautions (require gown and glove use) were followed for Resident 41. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility provided policy titled, Handwashing/Hand Hygiene, dated March 2018, showed to use alcohol based hand rub before and after direct contact with the residents, before preparing or handling medications, before handling clean dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after handling used dressings, after removing…

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 dignity for 2 of 2 residents (Residents 296 and 14) reviewed for resident rights. The failure to provide dignity bags to cover Resident 296's urinary drainage bag and the failure to cover Resident 14's disposable briefs while being transported to and from the shower room placed the residents at risk for lack of privacy, a decreased self-worth, and a diminished quality of life. Findings included . Review of the facility provided document titled, Notice of Resident Rights under Federal Law, updated in November 2016, showed the center will protect and promote these rights to the best of their ability .the resident has the right to personal privacy .the resident has the right to a dignified existence and self-determination. RESIDENT 296 Resident 296 admitted to the facility on [DATE] with a diagnosis that included neurogenic bladder (lacking bladder control due to a brain,…

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 supervise and implement measures to prevent a subsequent verbal and physical altercation for 1 of 2 residents (Resident 82) reviewed for abuse. The failure to monitor and provide additional interventions placed the resident at potential risk for harm, injury, and intimidation. Findings included Review of the facility policy titled, Resident's Rights, dated September 2010, showed the residents have the right To be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. RESIDENT 82 Review of the electronic medical record (EMR) showed Resident 82 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 03/30/2023, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident 82 was cognitively intact. Further review of the MDS showed Resident 82 required two person extensive assists with Activities of Daily Living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an allegation of financial exploitation/misappropriation of resident property (money) to the state agency within 24 hours for 1 of 1 (Resident 296) reviewed for reporting. This failure placed the residents at risk for abuse and neglect. Findings included . Review of the facility policy titled, Notice of Theft and Loss Control Policy, revised in October 2017, stated that any staff member who received a report of missing items from a resident completes a grievance form and forwards it to the social services department. Upon receipt of the grievance form, the social service department initiates an investigation and searches for the missing item. The Nursing Home Guidelines, The Purple Book, dated October 2015, stated facilities are required to report allegations of financial exportation and misappropriation of resident property to the State Agency within 24 hours and are required to investigate all allegations of financial exploitation and/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 accurately assess 2 of 26 residents (Residents 10 and 14) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding tube feeding (a device that delivers liquid nutrition via tube through the stomach) and injections placed the residents at risks 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, revised in October 2019 showed: Accuracy of 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 Observation Period (also known as the Look-back period) is 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, observation, and record review, the facility failed to ensure bathing/shower were consistently provided for 2 of 2 residents (Residents 296 and 2) reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decrease self-esteem, and a diminished quality of life. Findings included . RESIDENT 296 On 05/31/2023 at 9:40 AM, Resident 296 was interviewed and stated that they had not had a shower or bath since they were admitted to the facility on [DATE]. Resident 296 stated they was told they would get a bath yesterday. Resident 296 stated the nurse took them downstairs to smoke a cigarette and when they returned, they were informed they missed the allotted time for a bath so they would not be getting one on that date. Resident 296 stated if they had known they would have skipped smoking because they really wanted a shower. Review of the electronic medical record (EMR) revealed Resident was admitted to the facility on [DATE]. Review of Resident 296's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a properly fitted wheelchair for 1 of 19 residents (Resident 346) reviewed for care and services. The failure to allow the resident mobility without discomfort placed the resident at risks for increased leg pain and discomfort, and a diminished quality of life. Findings included . Review of the electronic medical record (EMR) showed Resident 346 was admitted on [DATE] with diagnoses that included broken left thigh bone, displaced/broken [NAME] (involving the ankle joint) and left foot. Review of the admission Minimum Data Set assessment dated [DATE], showed a Brief Interview for Mental Status score of 15 out of 15, indicating Resident 346 was cognitively intact. On 05/30/2023 at 8:21 AM, Resident 346 was observed to propel himself, in a manual wheelchair, to the elevator. No footrests were in place. Resident 346's left leg, in a cast, was directly on the floor. Resident 346 stated they were going downstairs to vape. Resident 346…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach) was administered in accordance with physician's orders and accurately provide the ordered amount of enteral formula administered for 1 of 2 residents (Resident 10) reviewed for enteral nutrition. This failure placed the resident at risk for inadequate nutrition/hydration, weight loss, and potential adverse health outcomes. Findings included . Review of the facility provided document titled, General Guidelines for Administering Medications Via Enteral Tube, dated January 2018, showed the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Resident 10 readmitted to the facility on [DATE] with a diagnosis that included dysphagia (difficulty swallowing food or liquid). Review of Resident 10's May 2023 Medication Administration Record (MAR),…

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 a medication error rate of less than five percent (%). Two medication errors were identified for 2 of 8 residents (Residents 10 and 296) observed during 26 medication opportunities resulted in an error rate of 7.69%. This failure placed the residents at risk for not receiving the full therapeutic effect of the medications and/or possible adverse side effects. Findings included . Review of the facility provided document titled, Medication Administration General Guidelines, revised [DATE], showed that ophthalmic (eye) drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. All other ophthalmic drops are expired after 60 days from the date opened. Additionally, the policy showed that the medications are administered in accordance with the written orders of the prescriber and obtain and record any vital signs as necessary prior to medication administration. Review of the undated 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 ensure eye drop medication was discarded within 60 days as required for 1 of 8 residents (Resident 10) reviewed for medication administration. This failure placed the resident at risk of receiving compromised/expired medications and potential for medication error and possibly experience adverse side effects. Findings included . Review of the facility provided document titled, Medication Administration General Guidelines, revised January 2023, showed that ophthalmic (eye) drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. All other ophthalmic drops are expired after 60 days from the date opened. Review of the undated facility provided pharmacy document titled, Abridged List of Medications with Shortened Expiration Dates, showed that all other eyedrop medications expire 60 days after opening. RESIDENT 10 Resident 10 admitted to the facility on [DATE] with a diagnosis 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 ensure the menu for the soft and bite sized diet and the minced and moist texture diet were followed for 3 of 3 residents (Residents 26, 65 and 86) reviewed for food and nutrition services. This failure placed the residents at risk for unmet nutritional needs, weight loss, and a diminished quality of life. Findings included . Review of the policy titled, Menus revised in October 2017 showed, it was the facility policy to follow the Menus. On 06/01/23, Staff M, Cook, was observed serving the lunch meal from 12:06 PM through 12:43 PM. Review of the menu showed the soft and bite sized diet, and the minced and moist textured diets were supposed to receive two (2) #8 scoops [four-ounce portion] of minced and moist/soft and bite sized cheese ravioli and ½ cup of frozen chopped vegetables. During the observation, Staff M was observed serving the food trays for the residents on the second floor. Staff M was observed serving Resident 26, 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.