The Broadview Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods were served at proper temperature for 1 of 7 nursing units (Transitional Care Unit [TCU]), and 4 of 4 residents (Residents 3, 5, 6 & 16), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included .FOOD TEMPERATURES-TCUDuring a joint observation and interview on 09/10/2025 at 12:11 PM, Staff Q, Dietary Manager, used the facility's kitchen thermometer to check the temperatures of the meal that was delivered to the TCU. The plate that had food on it was removed from a plastic tray; the serving plate sat on a round plate warmer and was covered with a round plastic top that covered the entire plate. Staff Q stated, the meal being served was baked beans, hamburgers, corn on the cob and chicken noodle soup. The following food items' temperature were noted as follows:-Baked beans temperature showed 133…

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 employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 4 of 4 social workers (Staff L, M, N & O), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life.Findings included .Review of the Facility Assessment, updated on 07/10/2025, showed the facility was licensed to provide care for 211 residents.STAFF LReview of the facility staff list showed Staff L, Social Worker, was hired on 12/23/2024 and was employed per diem (works on an as-needed basis).STAFF MReview of the facility staff list showed Staff M, Social Worker, was hired on 08/04/2025 and was employed full time.On 09/16/2025 at 5:46 PM, Staff M stated that the facility was licensed to hold over 200 beds (or residents). When asked how many social workers were employed in the facility Staff M stated there were three full-time social workers, and that Staff L was per diem 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 interview and record review, the facility failed to ensure shower preferences were reasonably accommodated for 2 of 6 residents (Residents 2 & 3), reviewed for preferences. This failure placed the residents at risk of unmet care needs and a diminished quality of life.Findings included… Review of the facility's undated policy titled, “Dignity,” showed, “The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.” The policy further showed residents were supported in exercising their rights and allowed them to choose when to sleep, eat and conduct activities of daily living (ADL). RESIDENT 2Review of Resident 2's “Shower Preference Questionnaire,” dated 07/03/2023 and another one dated 05/30/2024, showed Resident 2 preferred a shower in the morning twice a week. Review of Resident 2's care plan printed on 09/09/2025, did not show Resident 2's shower preferences. Review of Resident 2's Electronic Health Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop care plans for 2 of 2 residents (Residents 8 & 4), reviewed for comprehensive care plans. The failure to develop care plans for assistive device use, independent community outings, and refusal of incontinent care (toileting assistance) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Care Planning - Comprehensive Person-Centered, showed, A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. It showed that Comprehensive Care Plan meant an interdisciplinary communication tool developed after completion of a comprehensive MDS [Minimum Data Set - an assessment tool] and review of the Care Area Assessments. It showed, The resident will receive the services and/or items included in the plan…

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 monitoring for latent (hidden or not active yet) signs of injury and prompt medical evaluation for treatment was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 8), reviewed for change of condition. These failures disallowed an opportunity to promptly evaluate the resident for a change in condition, which resulted in a delay of medical services, and placed the resident at risk for adverse consequences, related complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Change in a Resident's Condition, dated 10/01/2021, showed that the facility will promptly notify the resident's physician/practitioner of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been an accident or incident involving the resident.The nurse/designee…

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/replace a pressure relieving bed mattress (Dolphin Mattress-a type of mattress that alternated fluid through the mattress) as recommended by the wound consultant to prevent and protect skin/wounds from further breaking down for 1 or 3 residents (Resident 3), reviewed for pressure ulcers. This failure placed the resident at risk for related medical complications, a decrease in healing potential, and a diminished quality of life.Findings included.Review of the National Pressure Injury Advisory Panel (NPIAP - leading expert in pressure injuries/wounds), dated February 2025, defined pressure injury stages as follows: -Stage 4 Pressure Injury is a full-thickness loss of skin and tissue with exposed or directly palpable fascia (layer of tissue covering the muscle), muscle, tendon (a cord or band of dense, tough, inelastic, white, fibrous tissue, serving to connect a muscle with a bone or part), ligament (a tough fibrous band of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 2 residents (Residents 3 and 17) were free from significant medication errors. The failure to provide intravenous (IV- administered through a vein) antibiotic medications (to treat infection) placed the residents at risk for a decline in their medical condition, a life-threatening infection, and a diminished quality of life.Findings included .RESIDENT 3Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2025 showed Resident 3 was readmitted to the facility on [DATE] and had intact thinking.In an interview on 09/08/2025 at 2:32 PM, Resident 3 stated, a few weeks ago I missed the antibiotic [medication] I was supposed to take for the infection in my wounds and bone, it was an IV the nurses told me they did not have it and that they were trying to get it delivered from the pharmacy. After I missed a few doses, I started to feel like I had a fever and chills. When the aides took my temperature, it was normal, but I…

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 aerosol contact precautions (safety steps used to keep germs from spreading) that included keeping the door closed at all times and proper use of Personal Protective Equipment (PPE - gown, gloves, N95 [respirator -medical face mask that filters out at least 95% of tiny particles in the air] and face shield) were followed for 2 of 2 staff (Staff X & Z), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications.Findings included.Review of the facility's undated policy titled, Coronavirus Disease (COVID-19) [respiratory disease caused by a virus]-Infection Prevention and Control Measures, showed This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility, It further showed that IPC…

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 survey result binder included the recent recertification survey results and associated plan of correction for 2 of 3 years (November 2022 and February 2023), reviewed for availability of survey reports. This failure prevented residents, their 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 undated policy titled, Examination of Survey Results, showed, A copy of the most recent and three preceding years of standard surveys, including any subsequent extended surveys, follow-up revisit reports, complaint surveys, etc., along with state-approved plans of correction of noted deficiencies, are accessible in an area frequented by residents, resident representatives, and visitors. A review of a binder labelled, Annual Recertification Survey on 05/29/2025 at 10:18 AM, on 05/30/2025 at 2:17 PM, and on 06/02/2025 at 2:05 PM, showed the binder contained the 2024 annual recertification survey results 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 obtain and/or renew guardianship papers, and/or failed to offer assistance in formulating an Advance Directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA] for health care) for 3 of 4 residents (Residents 43, 77 & 102), reviewed for Advance Directives. These failures placed the residents and/or their representatives at risk of losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives, dated [DATE], showed, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive,…

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 RESIDENT 98 Review of a face sheet printed on 06/05/2025 showed Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's EHR showed a physician's order initiating an antidepressant (a drug used to treat mental health condition that causes a persistent feeling of sadness and loss of interest in activities, significantly impacting daily life) 7.5 milligrams (mg- unit of measurement) on 05/15/2025, and a dose increased to 15 mg on 05/20/2025. Review of Resident 98's May 2025 MAR, printed on 06/04/2025 did not show monitoring or documentation for target behaviors and potential adverse side effects. A joint record review and interview on 06/04/2025 at 10:52 AM with Staff D, showed Resident 98 had been taking an antidepressant since 05/15/2025. Staff D stated that adverse side effects and target behaviors were not monitored or documented and that they should have. In an interview on 06/06/2025 at 11:27 AM, Staff B stated it was their expectation that any resident taking antidepressants should have…

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 NAIL CARE RESIDENT 76 Review of a quarterly MDS dated [DATE], showed Resident 76 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. Observation on 06/02/2025 at 11:55 AM, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. The left great toenail had black discoloration, and the right great toenail had brown discoloration. Both great toenails were thick and had brown matter underneath them. Resident 76 stated they could not clip or clean their nails and had requested staff assistance and were told, We will get to it when we have [a] chance. A joint observation and interview on 06/06/2025 at 10:37 AM, Staff T, License Practical Nurse, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. The left great toenail had black discoloration, and the right great toenail had brown discoloration. Both great toenails were thick and had brown matter underneath them. Staff T stated that staff were…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for 7 of 7 days (05/29/2025, 05/30/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/05/2025 & 06/06/2025), reviewed for sufficient and competent staffing. This failure placed the residents and their representatives at risk of not being fully informed of current staffing levels, potentially affecting their understanding of staff availability and care delivery. Findings Included . Review of the facility's policy titled, Posting Nursing Staffing Policy, dated 10/06/2022, showed the facility was required to post the daily nurse staffing information in a prominent location accessible to residents and visitors. The policy further showed the posting must include the facility name, current date, resident census, total number and actual hours worked by staff, and reflect staff absences due to callouts and illness for each shift. Observation on 05/29/2025 at 2:42 PM, showed a posted staffing form…

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 RESIDENT 1 Review of a face sheet printed on 06/05/2025, showed Resident 1 readmitted to the facility on [DATE]. Review of Resident 1's facility provided document titled, Note to Attending Physician/Prescriber, dated 03/05/2025, showed a copy of the recommendation to Please consider ordering a new BMP [Basic Metabolic Panel- a blood test that measures the levels of different substances in your blood]. Most BUN [Blood Urea Nitrogen-a blood test to measure kidneys [organs responsible for filtering blood, regulating fluid balance and waste management through urine production function] lab [laboratory] shows it abnormally high . It further showed that the Physician/Prescriber Response was not completed. In an interview and joint record review on 06/06/2025 at 1:11 PM, Staff B stated that the Registered Nurse Unit Managers (RNUM) managed the medication regimen review recommendations provided by the pharmacist consultant. Staff B stated that when they received the recommendation from the pharmacist, they would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 300 UNIT MEDICATION STORAGE ROOM A joint observation and interview on 06/05/2025 at 9:09 AM with Staff D, RNUM, showed the following expired medical supplies: -Four unopened safety scalpels with an expiration date of 09/30/2023. -Two unopened disposable dermal (skin) curette (medical instrument used to scrape or remove unwanted tissue/skin) with an expiration date of 03/01/2023. -One unopened Bard-[NAME] (brand) scalpel with an expiration date of 07/31/2022. Staff D stated that they were expired and that they should have been discarded. Staff D stated that the Unit Managers checked the medication storage rooms and that the staff that used the medical supplies should have checked the five rights, which included to check for expiration date. In an interview on 06/06/2025 at 1:18 PM, Staff B stated that they expected expired medical supplies to be disposed of. Staff B further stated that they expected the medication room to be checked at least once a month and to dispose/discard expired medications/medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 dry storage room (Kitchen Dry Storage Room), 3 of 4 refrigerators (Kitchen Cooler A Refrigerator, Kitchen Cooler H Refrigerator and Kitchen Cooler D Refrigerator), 1 of 1 seasoning shelf (Kitchen Seasoning Shelf) and 5 of 6 dining room refrigerators (500 unit, 300 unit, 100 unit, 600 unit & 700 unit), reviewed for food services. The failure to date and discard expired food items and/or before use by date, 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, Receiving and Storage of Food, dated 10/01/2021, showed, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy showed, All foods stored in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required, failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) drainage bag appropriately for 1 of 2 residents (Resident 1), and failed to disinfect/sanitize medical equipment between resident use for 1 of 2 staff (Staff I), reviewed for infection control. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 2 of 8 residents (Residents 77 & 219). These failures placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Infection Control Program, dated 10/24/2022, showed, Infection control policies,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform a resident and/or their representative about risks and benefits of positioning a bed against the wall for 1 of 3 residents (Resident 93), reviewed for accidents. The failure to conduct an assessment, evaluation and/or providing information regarding bed positioning prevented the resident and/or their representative to exercise their right to make an informed decision. Findings included . Review of the undated facility's policy titled, Resident Rights, showed, The Resident has the right to be fully informed of, and participate in, his or her treatment including: the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. The policy further showed, The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident choices/preferences regarding shower/bathing were honored for 2 of 3 residents (Residents 41 & 10), reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk of being unable to exercise their rights, not having their choices/preferences honored, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Resident Rights, showed, The Resident has a right to a dignified existence, self-determination . The policy further showed that, The Resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice . Review of the facility's undated policy titled, Shower/Tub Bath, showed that residents would be offered at least two full baths or showers per week. The policy further showed that resident preference for type and frequency of baths would be taken into consideration and honored. RESIDENT 41 Review of…

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

Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality of medical information were maintained during a medical provider visit for 2 of 3 residents (Resident 42 & 51), reviewed for confidentiality of records. This failure placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Attending Physician Responsibilities, showed that, The Physician/NPP [Non-Physician Practitioner], will maintain a courteous and professional level of interaction with facility residents. RESIDENT 42 An observation on 06/04/2025 at 1:02 PM, showed several residents were gathered in the Memory Care Unit (MCU) Television (TV) room area and that Staff U, Advanced Registered Nurse Practitioner, was interacting with Resident 42. It further showed that Staff U asked about specific medical conditions and discussed medical laboratory results with Resident 42, while Resident 42 was in the company of other residents. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 2 residents (Resident 101), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences .All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect. Review of the facility's policy titled, Abuse, revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 3 residents (Resident 76), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and 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 the nursing home is required to complete an SCSA when the resident comes off hospice (a service that provides quality of life care for chronic conditions) benefit (revokes). The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election revocation. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess 3 of 20 residents (Residents 1, 97 & 90), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments for oral/dental status, medications, and hospice care (support for end-of-life care) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is…

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 RESIDENT 101 Review of a face sheet printed on 06/02/2025, showed Resident 101 admitted to the facility on [DATE]. Review of Resident 1's Level I PASARR dated 02/12/2025 showed that Section IV (Service Needs and Assessor Data) was marked No level II evaluation indicated at this time due to exempted hospital discharge. Level II must be completed if discharge does not occur. Review of the census tab in the EHR printed on 06/02/2025, showed Resident 101's status was active. In an interview and joint record review on 06/02/2025 at 2:21 PM, Staff F, Social Worker, stated that if a resident was marked for hospital exempted discharge on their Level I PASARR that was completed prior to their admission, they would have to complete a new Level I PASARR if the resident was in the facility for more than 30 days. A joint record review of Resident 101's Level I PASSAR dated 02/12/2025, showed it was marked for No level II evaluation indicated at this time due to exempted hospital discharge. Level II must be completed if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State PASARR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities [ID], or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in condition for 3 of 8 residents (Residents 76, 1 & 10), reviewed for PASARR. This failure placed the residents at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and diminished quality of life. Finding included . Review of an online document title, Preadmission Screening and Resident Review, dated 02/14/2020, showed that According to Medicaid, as part of the PASARR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD/SMI)…

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 care plans were revised timely and accurately to reflect changes in care related to discontinuation of hospice (a service that provides quality of life care for chronic conditions) services, initiation of comfort care or end-of-life care, and/or discontinuation of medication for 3 of 7 residents (Residents 76, 90 & 1), reviewed for care planning. These failures placed residents at risk for unidentified and unmet care needs, and a diminished quality of life. RESIDENT 76 Review of a face sheet printed on 06/02/2025 showed Resident 76 was readmitted to the facility on [DATE]. Review of a nursing progress note dated 06/12/2025 showed Resident 76 was admitted to hospice services on 06/12/2024. Review of Resident's 76's comprehensive care plan initiated on 06/12/2024 showed Resident 76 was on hospice for end-of-life/comfort care. Review of a hospice provider note dated 05/02/2025 showed Resident 76 was discharged from hospice services on 05/02/2025.…

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 observation, interview, and record review, the facility failed to ensure there was an ongoing activity program to meet the needs of 1 of 1 resident (Resident 95), reviewed for activities. This failure placed the residents at risk for unmet activity pursuit, social isolation, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities Programs, dated 10/01/2021, showed that the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. The policy showed that activities were available daily and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. The policy further showed that the resident's participation in activities was documented in the resident's medical record. Review of a face sheet printed on 06/04/2025 showed Resident 95 admitted to the facility on [DATE]. Review of the admission Minimum Date Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform skin evaluations, implement appropriate monitoring and treatment after sustaining a skin injury, and/or failed to monitor and obtain daily weights for a resident on diuretic (water pill) therapy in accordance with professional standard of practice for 2 of 7 residents (Residents 21 & 98), reviewed for quality of care. These failures placed the residents at risk for unmet care needs and diminished quality of life. Findings Included . SKIN INJURY RESIDENT 21 During an observation and interview on 06/02/2025 at 10:43 AM, Resident 21 had two scabs (a dry protective) on their left knee and another two scabs on their right shin. Resident 21 stated that their skin injuries occurred due to a fall and that they were not receiving treatment. Review of the weekly skin assessment dated [DATE] showed that Resident 21 skin was intact. A joint observation and interview on 06/05/2025 at 10:34 AM with Staff KK, Registered Nurse (RN), 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 follow a prescribed therapeutic diet of small, portioned meals for 1 of 3 residents (Resident 36), reviewed for nutrition/hydration. This failure placed the resident at risk for unintended weight loss, medical complications, and a diminished quality of life. Findings included . A review of the facility's policy titled, Therapeutic Diets, dated 10/01/2021, showed that, Therapeutic Diet, meant a diet ordered by a physician or delegated registered/licensed dietician as part of treatment for a clinical condition. It further showed that therapeutic diets were prescribed to support the resident's treatment and plan of care in accordance with his or her goals and preferences. Review of a face sheet printed on 06/05/2025, showed that Resident 36 admitted to the facility on [DATE] with diagnoses that included gastroparesis (a condition where the stomach muscles do not work properly to move food through the stomach, which can lead to vomiting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of respiratory equipment, and document oxygen (O2) saturation (the amount of O2 in the blood) for 1 of 3 residents (Resident 98), reviewed for respiratory care. These failures placed the resident at risk for respiratory infection, related complications, and a diminished quality of life. Findings Included . Review of the facility's undated policy titled, Oxygen Administration, showed that during O2 setup or adjustment, staff were instructed to check the mask, tank, humidifying (that increase humidity/moisture in the air) jar [container], to ensure they were in good working order and securely fastened. The policy further instructed staff to document the date and time the setup was performed. Review of a face sheet printed on 06/05/2025 showed Resident 98 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a progressive lung disease that makes 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.

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed and/or clarified in accordance with professional standards of practice for 3 of 9 residents (Residents 16, 321 & 219), reviewed for medication administration. This failure placed the residents at risk for receiving incorrect medication dosage and formulation, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, [Company name] Medication Administration Policy, showed, This policy establishes the guidelines for the safe and effective administration of medications . The policy further showed that the .right medication, right dose . must be confirmed . during medication administration. In addition, the policy showed, This policy ensures that medications are administered safely and effectively . maintaining compliance with regulatory standards and best practices. RESIDENT 16 Review of Resident 16's June 2025 physician orders showed, Calcium 600+D3 [cholecalciferol-type of Vitamin D-a supplement] Oral [by…

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 dental services were offered and/or provided for 1 of 1 resident (Resident 36), reviewed for dental services. This failure placed the resident at risk for unmet dental care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Dental Services, dated 10/01/2021, showed that Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. It further showed that routine dental services were provided through a referral to community dentists (tooth doctor), to the resident's personal dentist, referral to community dentists and/or referral to other health care organizations that provide dental services. Review of a face sheet printed on 06/05/2025, showed that Resident 36 admitted to the facility on [DATE]. In a phone interview on 05/29/2025 at 2:30 PM, Resident 36's representative stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure meal preferences were provided for 2 of 7 residents (Residents 35 & 10), reviewed for food preferences. This failure placed the residents at risk of not having their food choices honored, dissatisfaction with food served, and a diminished quality of life. Findings included . RESIDENT 35 Review of the annual Minimum Data Set (MDS-an assessment tool) dated 05/07/2025 showed Resident 35 had an intact cognition. In an interview on 05/29/2025 at 10:39 AM, Resident 35 stated that they were provided with a menu selection for their breakfast, lunch and dinner. Resident 35 stated that they would cross out the food items they did not want and circled or wrote down the ones they preferred to have. Resident 35 stated, I don't [do not] like the menu selection. Resident 35 further stated that the kitchen staff don't [do not] pay attention to what you like. Review of the lunch menu for 06/03/2025 at 10:32 AM, showed, Marinated [seasoned] chicken…

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 clinical or medical records were complete and accurate for 1 of 3 residents (Resident 118), reviewed for resident records. The failure to document resident health condition (assessment and evaluation) placed the resident at risk for incomplete and inaccurate medical records and unmet care needs. Findings included . Review of a face sheet printed on [DATE] showed Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Minimum Data Set (an assessment tool) look up page showed a completed Death in Facility assessment dated [DATE]. Review of the [DATE] nursing progress notes printed on [DATE] did not show documentation about Resident 118's clinical status or condition on [DATE]. Review of vital signs (measurable overall health status that included blood pressure (BP), heart rate (HR) and breathing rate) data for Resident 118, showed that their BP, HR and breathing rate were last documented on [DATE]. Review of the Electronic…

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]) and influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 1 of 5 residents (Resident 54), reviewed for immunizations and infection control. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and influenza disease. Findings included . Review of the facility's undated policy titled, Pneumococcal Vaccine, showed, Residents will be offered pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infection. It further showed, Re-vaccinations of the pneumococcal vaccine will be administered to those residents who are deemed appropriate by the physician. Review of the facility's policy titled, Influenza Vaccine, dated 08/10/2023, showed, All residents and employees who have no medical contraindications to the vaccine will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary supervision for 1 of 3 residents (Resident 1), reviewed for elopement. The failure to provide the necessary supervision for Resident 1 resulted in an elopement and placed the resident at risk for injury. Findings included . Review of the facility's elopement policy, revised in March 2021showed, elopement occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. The policy further showed all residents were assessed for exit seeking, wandering behavior on admission, quarterly and as needed using the Elopement/Wandering Risk Assessment. Review of the admission Minimum Data Set assessment (a required assessment) dated 05/01/2025 showed the resident was admitted to the facility on [DATE], had impaired memory and required assistance to walk safely. Review of a nursing progress note dated 04/27/2025, showed Resident 1 was wandering in the nursing unit 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 provide timely and necessary assistance with Activities of Daily Living (ADL) for 2 of 3 residents (Residents 1 & 2), reviewed for ADLs. The failure to provide the residents who were dependent on staff with assistance with toileting, changing soiled clothing, and bed linens placed the residents at risk for skin impairments, low self-esteem, and a diminished quality of life. Findings included . Review of the undated facility's policy titled, ADL, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. RESIDENT 1 Review of the admission Minimum Data Set assessment (MDS-a required assessment) dated 04/01/2025 showed Resident 1 admitted to the facility on [DATE], had impaired thinking/memory, and was dependent on staff for all care. Review of Resident 1's care plan dated 03/27/2025, showed Resident is dependent on staff for…

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

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 while entering a resident's room for 1 of 6 residents (Resident 34), use of urinary catheter (a flexible tube inserted into the bladder to drain urine) drainage bag for 2 of 3 residents (Residents 110 & 17), use of a mechanical lift sling for 1 of 1 resident (Resident 99), and meal assistance for 3 of 5 residents (Residents 99, 46 & 16) reviewed for dignity. These failures placed the residents at risk for a diminished self-worth and over-all well-being. Findings included . Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity, showed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform residents and/or their representatives of risks and benefits before placement of bed against the wall for 2 of 2 residents (Residents 73 & 74), use of tilt in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair for 1 of 1 resident (Resident 74), installation of a transfer pole for 1 of 2 residents (Resident 5), and prior to starting psychotropic (mind-altering) medications for 1 of 5 residents (Resident 99), reviewed for resident rights. These failures placed the residents at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care. Findings included . Review of the undated facility's policy titled, Safety Devices/Restraints, showed bed against the wall, tilt in space wheelchair, and transfer poles were safety devices. The policy showed the facility shall explain to the…

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

Based on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 16 of 16 residents (Residents 91, 6, 7, 10, 16, 20, 39, 42, 61, 63, 64, 78, 80, 100, 122 & 379) reviewed for resident rights. This failure placed the residents at risk of not understanding their rights and a reduced ability to self-advocate. Findings included . Review of the February 2023 to April 2024 Resident Council minutes did not show that the resident rights were being reviewed during Resident Council meetings. During an interview on 04/26/2024 at 10:15 AM with Residents 91, stated the facility staff did not review resident rights with them. Residents 6, 7, 10, 16, 20, 39, 42, 61, 63, 64, 78, 80, 100, 122 and 379 stated they agree with Resident 91. On 04/29/2024 at 10:16 AM, Staff DD, Social Worker, stated they did not review resident rights during resident council meetings. Staff DD stated they used to review it in the past but could not recall the last time they reviewed residents' rights during resident council meeting. On…

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

Based on observation, interview, and record review, the facility failed to provide the website address of the Washington State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) on the posted contact information in 7 of 7 facility areas (notice boards in units 100, 300, 400, 500, 600, 700, and inside of one elevator), reviewed for residents' rights. This failure placed the residents at risk for not being able to report their concerns online to the State Long-Term Care Ombudsman. Findings included . Observations on 04/26/2024 at 9:54 AM, at 11:59 AM, at 12:04 PM, at 12:10 PM, at 12:25 PM, and at 12:29 PM, showed that the posted State Long-Term Care Ombudsman information did not include the website address. During a joint observation and interview on 04/29/2024 at 9:03 AM with Staff A, Administrator, showed the posted State Long-Term Care Ombudsman information in the seven facility areas did not have a website address on it. Staff A stated they did not recall the last time they updated the contact information. Staff A further stated that the 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 observation, interview, and record review, the facility failed to ensure privacy and confidential information were maintained regarding residents' weights for 9 of 9 rooms (Rooms 306B, 308A, 312B, 305B, 203, 205, 302B, 303A & 307B), and failed to ensure residents' medical records and representatives' information were maintained for 4 of 5 residents (Residents 67, 17, 16 & 100), reviewed for privacy. These failures placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life. Findings included . Review of the facility's undated policy, Promoting/Maintaining Resident Dignity, showed that it was their policy to Maintain resident privacy. RESIDENT WEIGHTS Observation on 04/29/2024 at 8:21 AM, showed a piece of paper posted outside the shower room on the 300 unit dated 4/29 [04/29/2024]. The paper showed the following list of room numbers with residents' weights: - room [ROOM NUMBER]B 125 lbs. (pounds-a measurement of weight) - room…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 2 of 6 dining rooms (100 Unit Dining Room & 500 Unit Dining Room), reviewed for dining observations. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Serving a Meal, showed to place served meal items on dining table or the full tray on the overbed table if the resident eats in their room. 100 UNIT DINING ROOM-BREAKFAST Observation on 04/23/2024 at 8:20 AM in the 100 Unit Dining Room, showed Resident 14, Resident 53, Resident 26 and Resident 38 were eating their breakfast on the tray. 100 UNIT DINING ROOM-LUNCH Observation on 04/23/2024 at 11:56 AM in the 100 Unit Dining Room showed Staff J, Certified Nursing Assistant (CNA), delivered Resident 14's lunch tray. Staff J placed the tray on the table, removed the cups from the tray and placed it on the table. Resident 14's plate remained on the tray…

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 4 of 23 residents (Residents 86, 14, 90 & 99), reviewed for significant change in condition. This failure placed the residents at risk for delayed care planning, further Activities of Daily Living (ADL) decline, 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 5 of 23 residents (Residents 73, 74, 120, 95 & 39), reviewed for care plans. The failure to develop care plans for bed against the wall, tilt-in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair, bed enablers (bed rails)/halos (type of bed rail shaped like a ring), and vision placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Safety Devices/Restraints, showed that bed against the wall, tilt in space wheelchair, and bed enablers/halos were safety devices. The policy further showed that care plans should be updated accordingly to include the development and implementation of interventions to address any risks related to the use of the device. Review of the facility's undated document titled, Process for Halos, Bed Rails, showed to update…

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

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 3 walk-in kitchen refrigerators (Produce Walk-in Refrigerator & Dessert Walk-in Refrigerator), for 1 of 1 dry storage room, for 1 of 3 resident refrigerators (100 Unit Resident Refrigerator), for 1 of 1 kitchen, for 2 of 2 dining rooms (400 Unit Dining Room and 100 Unit Dining Room), and for 1 of 7 units (600 Unit) reviewed for food service. The failure to label, date, and discard food items, sanitize thermometers between use, and perform hand hygiene 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 undated policy titled, Food Safety and Storage Requirements, showed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. The policy showed that labeling, dating, and monitoring…

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 store clean linens appropriately for 1 of 7 units (200 Unit) and failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and with meals trays for 6 of 7 staff (Staff CCC, LLL, ZZ, S, TT & V), reviewed for infection control. In addition, 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) and/or Enhanced Barrier Precautions (EBP- precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 3 of 6 residents (Residents 27, 99 & 110), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.…

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 call light (an alerting device for staff to assist residents in need) was within reach for 1 of 2 residents (Resident 115), 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, Call Lights: Accessibility and Timely Response, showed that Staff will ensure the call light is within reach of resident and secured, as needed and The call system will be accessible to residents while in their bed. Resident 115 admitted to the facility on [DATE] with diagnoses that included hemiplegia (unable to move one side of the body) affecting their left side. Review of the falls care plan revised on 03/12/2024, showed the resident [Resident 115] needs a safe environment .a working and reachable call light. Observations on 04/22/2024 at 8:46 AM and on 04/22/2024 at 11:37 AM, showed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or durable power of attorney for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 1 of 3 residents (Resident 120), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's undated policy titled, Residents' Rights Regarding Treatment and Advance Directives, showed, On admission, the facility will determine if the resident has executed an advance directive and should the resident have an advance directive, copies will be made and placed on the chart. Resident 120 admitted to the facility on [DATE]. Review of Resident 120's clinical record did now show documentation that a copy of their advance directive was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 1 of 3 residents (Resident 71), reviewed for hospitalization. This failure placed the resident at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's undated policy titled, Bed Hold, showed that the facility will hold a bed for a discharged resident who expected to return to the facility. It showed that if the resident's absence from the facility exceeds the grace period [3 days] the designated personnel will contact the resident or the resident's responsible party to offer a Bed-Hold to guarantee the resident's bed at time of discharge. It further showed that a copy of the Bed Hold policy will be sent with the resident's paperwork at time of discharge. Resident 71 admitted to the facility on [DATE]. Review of the progress notes dated 04/01/2024, showed Resident 71 was transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 2 of 27 residents (Residents 14 & 99), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate hospice and medication coding placed the residents at risk for unidentified or 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, code residents identified as being in a hospice program for terminally ill person where an array of services is provided for the palliation and management of terminal illness and related conditions. It further showed coding instructions to code all high risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used. It showed to check if the resident is taking any…

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 and/or their representatives were invited to participate in care plan meetings/care conferences for 2 of 2 residents (Residents 89 & 42), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Care Planning-Care Conference-Resident Participation, showed it was the facility's policy to support the resident's right to be informed and participate in their care planning and treatment (implementation of care). The policy further showed that the facility will make an effort to schedule a care conference at the best time for the resident/representative and that if the resident/representative were determined not practicable for the development of the resident's care plan, an explanation would be documented in the resident's medical record. RESIDENT 89 Resident 89 admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 2 of 8 residents (Residents 89 & 81), reviewed for ADLs. This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Activities of Daily Living (ADL's), showed, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The policy further showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 01/26/2024, showed Resident 89 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident environment remained free from accident hazards for 2 of 2 offices (Transitional Care Unit [TCU]/Resident Care Manager] RCM] office and the office next to the TCU/RCM office), reviewed for accident hazard. This failure placed residents at risk for avoidable accident and/or injury and a diminished quality of life. Findings included . Observation on 04/24/2024 at 9:42 AM, showed the TCU-RCM office and another office next to it were opened, and unsupervised. The offices had both powered and non-powered tools that included two saws, two drillers, electrical wiring, and a brazing (joining process that uses a filler metal to join two base metals together at temperatures above 840 degrees Fahrenheit) solder (a process that involves heating a specialized [NAME] composed of lead and tin to form a bond between two metals) machine. On 04/24/2024 at 9:44 AM, Collateral Contact 1 (CC1), stated that when they go for break or bathroom, they leave 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 with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 3 residents (Residents 110 & 17), reviewed for urinary catheter. The failure to ensure urinary catheters were off the floor placed the residents at risk for infections and related complications. Findings included . Review of the facility's undated policy titled, Catheter Care/Bags, showed, It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. RESIDENT 110 Resident 110 admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked and causes the urine to flow backwards). Review of the admission Minimum Data Set (MDS- an assessment tool) dated 02/13/2024 showed Resident 110 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure tube feeding (a medical device used to provide nutrition into the stomach if resident is unable to swallow safely) supplies (tubing set) including the irrigation syringe were labeled/dated for 1 of 2 residents (Resident 4), reviewed for tube feeding management. This failure placed the residents at risk for infection and related complications. Finding included Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, showed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Resident 4 admitted to the facility on [DATE] with diagnoses that included stroke (restriction of blood flow or sudden burst of blood vessel in the brain), dysphagia (difficulty swallowing), and protein-calorie malnutrition (a condition that result from lack of sufficient nutrients in the body). 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 observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 1 resident (Resident 90), reviewed for respiratory care. The failure to have an oxygen administration order, maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) properly placed the resident at risk for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's undated policy titled, Oxygen Administration, showed oxygen is administered under orders of a physician, except in the case of an emergency. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. Staff shall change oxygen tubing and mask/cannula weekly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to comprehensively assess and evaluate the need for bed rails for 1 of 3 residents (Resident 95), reviewed for bed rail use. This failure placed the resident at risk for entrapment, injury, and a diminished quality of life. Findings included . Review of the facility's undated form titled, Process for halos [a type of bed rail shaped like a ring], bed rails, showed a nursing assessment was required regardless of prior function or use. Resident 95 admitted to the facility on [DATE]. Review of Resident 95's physician's order showed an order initiated on 02/23/2024 for Halos/Bed Enabler- Bilateral [both] for bed mobility. Review of a nursing progress notes dated 02/23/2024 at 12:40 PM, showed, halos requested by Resident 95's representative for bed mobility and support. Observations on 04/22/2024 at 12:44 PM and on 04/24/2024 at 9:15 AM, showed Resident 95's bed rails were loose, the left rail was looser than the right rail. Joint record review…

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

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the appropriate competencies, skills set and proficiencies to apply a condom catheter (external flexible tube that is used to collect urine from the body) for 1 of 5 nursing staff (Staff S), reviewed for competent nursing staffing. This failure placed the resident at risk for infection, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Competency Evaluation, showed, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. The policy further stated that checklists were to be used to document training and competency evaluations. Review of the facility's undated policy titled, Condom Catheter Care Policy, showed, It is the policy of this facility to ensure that condom catheters are applied appropriately, cared for and removed consistent with current standards of practice.…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed the total number of staff and actual number of hours worked for each shift for 1 of 7 days reviewed for posted nurse staffing information. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's undated policy titled, Nurse Staffing Post Information, showed the nurse staffing sheet would be posted daily, with the total number and the actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Aides. The policy further showed that the information posted would be in a prominent place readily accessible to residents and visitors. Observations on 04/30/2024 at 7:51 AM, showed the facility's Daily Nurse Staffing Form that day did not include the total number of staff and the total hours worked for evening and night shift. Joint observation and interview on 04/30/2024 at 9:07 AM with Staff Y,…

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 monthly pharmacy recommendations were followed up on for 2 of 5 residents (Resident 90 & 57), reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life. Findings included . RESIDENT 90 Resident 90 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 04/09/2024, showed Resident 90 was cognitively intact. Review of the physician's order summary report printed on 04/24/2024, showed Resident 90 was receiving insulin Glargine (a drug that lowers the level of glucose (a type of sugar) in the blood) 46 units two times a day with an order date of 04/03/2024. Review of the pharmacist Medication Regiment Review (MRR), dated 04/08/2024, showed there was a recommendation from the pharmacist to consider increasing insulin glargine to 50 units twice daily for better control of…

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

Based on observation, interview, and record review, the facility failed to discard expired medication for 1 of 4 medication carts (Unit 200 Medication Cart), reviewed for medication storage. This failure placed the resident at risk to receiving expired or compromised medication. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, reviewed on 12/24/2019, showed medication and biologicals are stored safely, secure, and properly, following manufacturer's recommendations or those of the supplier. It further showed that outdated or expired medications are immediately removed from stocks, disposed of according to procedure for medication disposal and reordered from the pharmacy if current order exists. During a joint observation and interview on 04/25/2024 at 3:56 PM with Staff W, Licensed Practical Nurse, showed the Unit 200 Medication Cart had one Lispro insulin pen (medication given to lower blood sugar) for Resident 120 that was opened on 03/22/2024 during resident's admission and had been used for 35 days. Staff W stated that the Insulin…

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 offer/serve food substitutes and/or serve food that accommodated preferences for 1 of 2 residents (Resident 35), reviewed for food preferences. This failure placed the resident at risk for dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Serving a Meal, showed the facility should serve meals that meet the nutritional needs of the residents. The policy further stated that staff should, check to be sure everything is served that is required by the menu ticket, and the resident's preference. Review of the facility's policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment Policy, dated January 2019, showed that it was the facility policy to identify and provide reasonable accommodation of the resident's needs and preferences. Review of Resident 35's nutrition care plan printed on 04/22/2024, showed an undated…

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 conduct routine maintenance to ensure bed rails and/or halos (type of bed rail shaped like a ring) were safe for 3 of 5 residents (Residents 35, 95 & 74), reviewed for bed rails safety. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's undated policy titled, Halo Ring Installation and Maintenance Policy, showed, Maintenance shall inspect all Halo Rings monthly to ensure proper installation and usage. This check shall be logged into the work order system. The policy further showed if any deficiency was found with the Halo Ring, maintenance staff would remove the affected hardware and replace it. RESIDENT 35 Resident 35 admitted to the facility on [DATE]. Review of Resident 35's transfers care plan showed an intervention, revised on 09/20/2022, showed, Assistive devices; Right and left Halo to assist in bed mobility [movement in bed]/ transfer; Staff to report to LN…

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 care and services consistent with professional standards of practice for 1 of 3 residents (Resident 1), reviewed for quality of care. The failure to monitor hypoglycemia (low blood glucose [a measurement of the amount of glucose (sugar) in the blood] and hyperglycemia (high blood glucose level) placed the resident at risk for unmet care needs and negative health outcomes. Findings included . Review of the facility's undated protocol titled, Diabetic [a person who has diabetes (a group of diseases that affect how the body uses blood sugar/glucose)] Hypo[hypoglycemia]/Hyperglycemia Protocol, showed that nursing will follow the direction of the provider's parameter and orders based on the individual who may respond to diabetes differently. The protocol further showed that nursing will monitor for signs and symptoms of hypoglycemia/hyperglycemia. Resident 1 admitted to the facility on [DATE] with diagnoses that included type 2 (adult onset)…

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 suction machines (a medical device to remove secretions [mucus/saliva/blood] obstructing a person's airway) were functioning properly, and medical crash cart (easily accessible supplies/equipment for life saving procedures) were stocked for 6 of 6 nursing units (Transitional Care, 100 Unit, 400 Unit, 500 Unit, 600 Unit & 700 Unit), reviewed for essential equipment. This failure placed Resident 1 and other residents at risk for choking, unmet care needs, and other medical complications. Findings included . NURSING 100 AND TRANSITIONAL CARE UNIT Review of the Daily Crash Cart [emergency cart] Supplies Checklist, dated October 2023, found at the Transitional Care and 100 nursing unit, showed a form on a clipboard that was blank. Further review of the form showed it included the suction machine and suction kits, and there was no place to check if the suction machine was functional and/or if the supplies were stocked. NURSING 400 UNIT AND NURSING 500…

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 remove outdated food from the residents' refrigerator on the 700 Unit and failed to ensure food stored in the dietary's walk-in coolers were labeled, dated when first opened and/or discarded after the expiration date. In addition, the facility failed to ensure food items were covered when non-food items were stored in the walk-in cooler. These failures placed the residents at risk for food borne illness (caused by ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the undated facility policy titled, Thawing directed Thaw food in a cooler .items should be covered, labeled and dated. An undated facility policy titled Storage Procedures indicated, Food should always be in a closed container . and Stock rotation is a good management practice. The facility lacked a policy for the placing of non-food items in the cooler with residents' food. 700 HALL/UNIT Observation of the 700-hall residents' foods refrigerator on 02/05/2023 at 8:30 AM revealed 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, record review, the facility failed to ensure a medication error rate was less than 5% for the 27 medication administrations for 4 of 9 residents (Residents 111, 72, 95 & 33) reviewed for medication administration. The facility's medication error rate was 14.18%. This failure placed the residents at risk of experiencing adverse side effects, ineffective medication, and potential negative outcomes. Finding included . RESIDENT 111 Observation on 02/07/2023 at 11:30 AM, Staff L, Licensed Practical Nurse (LPN), was preparing Resident 111's Insulin pen (medication to regulate the resident's blood sugar). Staff L attached the new needle set, then dialed the correct dosage of insulin and administered the insulin, without priming the needle set. An interview on 02/07/2023 at 11:32 AM, Staff L stated they knew to prime the insulin pen prior to Insulin administration but forgot. Review of the physician's orders in the EMR under the Orders tab revealed Resident 111 was to receive 17 units of…

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

Based on observation, interview, and record review, the facility failed to ensure expired liquid supplements, medical ointments, and wound treatment supplies were disposed of timely in accordance with current accepted professional standards of practice for 3 of 3 medication storage rooms (Medication Storage Rooms in Unit 700, 400 & Memory Care) reviewed for medication storage and labeling. In addition, the facility failed to ensure no food items was stored in the medication storage refrigerator in the Memory Care Medication Storage. These failures placed the residents at risk of receiving compromised medical supplements, treatment supplies, food snacks, and possibly experience adverse side effects. Findings included . Review of the facility provided policies and procedures titled, Medication: Labeling, Storage, Retention and Disposal, revised in July 2022 showed, multi-dose bottles, over the counter medications, and bulk supplies are labeled with the date of opening by the Licensed Nurse (LN) opening the bottle. It also showed, Expired medications are removed from medication cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 2 residents (Residents 33 & 45) had been assessed for the self-administration of medication. The facility's failure to assess the residents for self-administration of medications placed the residents at risk for the improper administration of the medications. Findings included . Review of the facility's policy titled Self-Administration of Medications with an effective date of 11/2017, revealed Policy: If a . resident requests to self-administer medications(s) the interdisciplinary team will assess the resident for determine if it clinically appropriate to home the resident's choice . The Procedure 3. Determination of the residents' ability self-administer medications by the IDT (Interdisciplinary Team) will be documented in the resident's medical record The procedure further directed 4. Education will be provided to the resident on identification of the medication, name. indication (reason for use), dose, route, times (s) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely reporting of potential abuse to appropriate entities as required for 1 of 2 residents (Resident 32) reviewed for abuse. This failure placed the resident at risk for abuse and neglect. Findings included . The facility's Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition Policy dated 04/2021 read, in pertinent part, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. (The facility) implements policies and procedures so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents, and Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were consistently receiving showers/grooming services for 2 of 3 residents (Residents 432 and 50) reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk for poor hygiene, medical complications, and a diminished quality of life. Findings included . The facility's Basic Care Standards Policy dated 10/2019 read, in pertinent part, Nursing services provided to residents will be implemented by licensed and certified personnel according to guidelines identified in the policy; and Bathing-Each resident will be bathed at least once a week. This may be a shower, or bed bath, as directed by the [NAME] and resident preferences; and Dressing and grooming- .female residents will be assisted with trimming of facial hair and makeup as desired. RESIDENT 432 Review of Resident 432's admission Record in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to consistently monitor nutrition and/or provide interventions as needed to prevent weight loss for 1 of 3 residents (Residents 54) reviewed for nutrition and weight loss. Resident 54 experienced a significant weight loss of 5.1 percent (%) in 1 month and 14.68% in 6 months. This failure placed the resident at risk for continued weight loss, worsened nutritional status and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Nutrition and Hydration Maintenance Policy date 01/2019 read, in pertinent part, (Facility) evaluates individual resident to assist with maintaining their nutrition and hydration, and Resident weights are reviewed weekly by the Resident Care Managers to identify any weight trend changes, and Residents with identified changes in weight will be referred to the Nutrition/Hydration Committee to evaluate and document cause of weight change, identify nutritional interventions,…

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 received adequate assessment and monitoring for the use of CPAP (Constant Positive Airway Pressure) machine for 1 of 1 resident (Resident 432) reviewed for respiratory care and services. In addition, there was no order for the use of the CPAP machine, and no monitoring and/or maintenance of the CPAP machine to ensure proper usage. These failures placed the resident at risk for respiratory infection, unmet care needs, and potential negative outcomes. Findings included . Review of the facility's undated Noninvasive Ventilation [CPAP, BiPAP (Bilevel Positive Airway Pressure), AVAPS [Average Volume Assure Pressure Support]) Policy read, in pertinent part, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice, and 2. The facility will obtain an order for the use of CPAP, BiPAP or AVAPS device and settings from the practitioner, and 3. A personal…

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

Based on interview and record review, the facility failed to provide risks and benefits of taking a psychotropic (psychoactive - mind altering) medication when there was a change in dosage for 1 of 1 resident (Resident 111) reviewed for unnecessary medications. This failure placed the resident at risk for unnecessary psychotropic medication, adverse side effects, and a diminished quality of life. Findings included . Review of Resident 11's Electronic Medical Record (EMR) under the Census tab revealed an admission date of 11/29/2022 with diagnoses that included insomnia (trouble falling asleep and/or staying asleep). Review of the admission Minimum Data Set (MDS) dated 02/05/2022 found in the EMR under the MDS tab revealed Resident 111's Brief Interview for Mental Status (BIMS) score was 13 out of 15, which revealed Resident 111 was cognitively intact. Review of Resident 111's Physician Orders in the EMR under the Orders tab, revealed an order dated 11/29/2022 for Ambien (a hypnotic psychoactive medication) ER (Extended Release) 6.5 mg (milligrams) orally each night. 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.