The Terraces At Skyline

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 2), reviewed for significant change of condition. The failure to complete an SCSA within 14 days of a significant change of condition placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.Findings included .Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1 dated October 2024, showed that an SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual showed, A significant change is a major decline or improvement in a resident's status that:Will not normally resolve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 15 residents (Resident 28), reviewed for resident assessment. The failure to ensure resident assessment was completed accurately on the Minimum Data Set (MDS-an assessment tool) regarding discharge status placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included .According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the 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 important 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 interview and record review, the facility failed to develop and/or implement a discharge care plan for 1 of 12 residents (Resident 15), reviewed for comprehensive care plan. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .The facility's policy titled, Policy and Procedure - Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, showed the care plan is person centered and involves the interdisciplinary team. The policy further showed that the care plan will identify all the residents' needs according to the comprehensive assessment, care plan decisions will be documented, and it would be completed within seven days of completion of the comprehensive assessment.Review of a face sheet printed on 08/07/2025 showed Resident 15 was admitted to the facility on [DATE].Review of a comprehensive care plan printed on 08/04/2025, showed Resident 15 had no care plan for discharge planning.In an interview on 08/07/2025 at 12:26 PM, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 1 of 2 residents (Resident 2), reviewed for ADLs. The failure to provide a resident who was dependent on staff for assistance with personal hygiene and nourishment placed the resident at risk for aspiration (food and/or liquid enters the lungs instead of the stomach) and associated complications, poor hygiene, decreased self-esteem, and a diminished quality of life.Findings included .Review of the facility's policy titled, ADLs Policy, revised on 01/01/2025, showed that the purpose of the policy was to assist resident in achieving maximum function and to improve quality of life.PERSONAL HYGIENEReview of a face sheet printed on 08/05/2025, showed Resident 2 readmitted to the facility on [DATE] with diagnosis that included pneumonitis (lung infection) due to inhalation of food and vomit, dysphagia (difficulty swallowing) and rheumatoid arthritis (disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapeutic diet and to provide education to the resident's representative regarding the risks of not following the therapeutic diet for 1 of 1 resident (Resident 2), reviewed for nutrition. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life.Findings included .Review of a face sheet printed on 08/05/2025, showed Resident 2 readmitted to the facility on [DATE] with diagnosis that included pneumonitis (lung infection) due to aspiration (food or liquid enter the lungs instead of the stomach) of food and vomit, and dysphagia (difficulty swallowing).Record review of a physician order dated 07/25/2025 showed Resident 2 was prescribed a diet of minced and moist texture (a diet that consists of foods that are finely chopped and are moist enough to hold together easily) and mildly thick consistency (liquids that are slightly thicker than regular liquids).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 observation, interview, and record review, the facility failed to ensure disinfectants (cleaning products containing chemicals that kill germs) were stored properly for 1 of 1 room (room [ROOM NUMBER]), reviewed for accident hazards. This failure placed the residents at risk for potential ingestion and/or exposure to cleaning chemicals and potential negative outcomes.Findings included .Review of the facility's policy titled, Storage of Chemicals, revised on 01/01/2025, showed All chemicals, including cleaning supplies, disinfectants, and hazardous substances, must be stored in a secure, labeled, and well-ventilated area to prevent unauthorized access by residents, staff or visitors.The purpose of this policy is to ensure the safe and compliant storage of chemicals within the nursing facility to prevent accidental poisoning, exposure.Review of a face sheet showed Resident 3 readmitted to the facility to room [ROOM NUMBER] on 04/29/2025.An observation on 08/04/2025 at 10:46 AM showed a metal canister with…

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

Based on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 20), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life.Review of the facility's policy titled, Medication Regimen Review, revised on 07/01/2024, showed, Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of the facility provided MRR showed Resident 20 had recommendations dated on 04/11/2025 to change administration times for gabapentin (medication to treat restless leg syndrome [a condition that causes irresistible urge to move the legs]) and magnesium (supplement) to be spaced two hours apart due to the efficacy of gabapentin may be decreased resulting in…

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

Based on interview and record review, the facility failed to ensure staff was provided education about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in employee record for 1 of 1 staff (Staff O), reviewed for COVID-19 immunizations. This failure placed staff and residents at risk of and exposure to illness from COVID-19.Findings included .Review of the facility's policy titled, COVID-19 Prevention, Response and Reporting, reviewed on 02/07/2025, showed that the facility would offer resources and counseling to healthcare personnel, residents and visitors on the importance of receiving the COVID-19 vaccine and staying up to date with all recommended COVID-19 vaccine doses.Review of the staff list showed Staff O, Certified Nursing Assistant, was hired on 06/11/2010.In an interview on 08/06/2025 at 2:43 PM, Staff O stated they refused the COVID-19 vaccine booster and was informed of the risks and benefits last year and signed 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 observation, interview, and record review, the facility failed to ensure bed rails (bed enablers) were properly secured and maintained for safety for 2 of 2 residents (Residents 9 & 29), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.Findings included .Review of the facility's policy titled, Bed Rail, revised on 01/01/2025, showed that the facility would ensure the safe and appropriate use of bed rails in compliance with federal and state regulations, minimize risk of injury, and protect resident rights. It further showed that nursing staff would inspect rails each shift for secure attachment and defects, check resident's positioning and skin integrity, and monitor for signs of distress, agitation, or injury.RESIDENT 9Review of the activities of daily living care plan initiated on 11/30/2020, showed Resident 9 used bilateral (both) grab bars/enablers to maximize independence with turning and repositioning in bed dated 07/23/2024.Observations on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure incident of unexpected death was investigated timely for 1 of 2 residents (Resident 1), reviewed for abuse/neglect investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse/neglect, and a diminished quality of life. 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 . The facility must immediately begin the investigation in order to collect accurate data related to the incident. Any delay in…

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

Based on interview and record review, the facility failed to ensure that direct care staffing information was submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quarter (Quarter 4) for the fiscal year 2023 (which included October 2023 through December 2023), reviewed for Payroll Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services. Findings included . A review of the facility's policy titled, PBJ, revised on 07/01/2024, showed it is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. In an interview on 08/21/2024 at 1:32 PM, Staff J, Staffing/Central Supply Coordinator stated that they prepared the PBJ report…

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

Based on observation, interview, and record review, the facility failed to ensure a homelike dining environment was provided during 2 of 3 dining observations to 6 of 8 residents (Residents 3, 8, 235, 19, 14 & 13). The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for diminished quality of life. Findings included . A review of the facility's policy titled, Medication Administration, revised on 04/11/2024, showed that medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. EIGHTH FLOOR DINING ROOM RESIDENT 3 Observation on 08/19/2024 at 8:35 AM, Staff F, Licensed Practical Nurse (LPN), was observed assisting Resident 3 with their oral medications in the dining room during the breakfast meal. RESIDENT 8 Observation on 08/19/2024 at 8:42 AM, Staff F was observed giving Resident 8 their oral medications in the dining room. On 08/21/2024 at 11:26 AM, Staff F 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.

Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 6 of 92 days (10/07/2023, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023 & 11/04/2023), reviewed for sufficient and competent nurse staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life. Findings included . A review of the facility's policy titled, Staffing Requirement, revised on 04/01/2024, showed that the facility will ensure the staffing sufficient of accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable data in a uniform format according to specifications. The policy also showed that the standard minimum staffing will significantly reduce the risk of unsafe and low-quality care for residents. Total direct nursing care to residents of at least 0.55 hours per resident per day of care must be provided by RNs. A review of the facility's form titled, Daily Nursing Staff Posting,…

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

Based on observation, interview, and record review, the facility failed to appropriately label/store medications/biologicals (diverse group of medicines made from natural sources) and/or medical supplies for 2 of 2 medication rooms (Seventh Floor and Eighth Floor Medication Rooms), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications and medical supplies. Findings included . Review of the facility's policy titled, Medication Label, revised on 04/11/2024, showed that nursing would ensure resident's medication was appropriately labeled according to pharmacy recommendation. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 30 days unless the manufacturer specifies a shorter or longer date for the open vial. SEVENTH FLOOR MEDICATION ROOM A joint observation and interview on 08/20/2024 at 1:13 PM with Staff C, Resident Care Manager (RCM), showed the Seventh Floor Medication Room's refrigerator had one multidose vial of tuberculin (purified protein…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food items were discarded after the expiration date or use by date and failed to have a working thermometer in accordance with professional standards for food safety for 1 of 5 refrigerators (Kitchen Walk-In Refrigerator). These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages). Findings included . A review of the facility's policy titled, Food Safety Requirement, revised on 12/01/2023, showed that Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. The policy showed that expired food would be removed immediately. The policy further showed practices to maintain safe refrigerated storage included monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation and labeling, dating, and monitoring food, including, but not limited to leftovers, so it is used by its use-by date. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed during meal tray pass for 1 of 4 staff (Staff L), reviewed for infection control. In addition, the facility failed to follow infection control practices for 3 of 10 residents (Residents 6, 235 & 18), reviewed for medication administration. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . A review of the facility's policy titled, Handwashing Policy, revised on 04/11/2024, showed hand hygiene was indicated, immediately before touching a resident .after touching a resident .after touching the resident's environment. HAND HYGIENE DURING MEAL TRAY PASS Observation on 08/19/2024 at 8:53 AM, showed Staff L, Certified Nursing Assistant, set up the meal tray for the resident in room [ROOM NUMBER] and left the room without performing hand hygiene. Staff L then touched the meal cart, removed a meal tray, entered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consent for an antidepressant (medication used to treat depression) was completed before administration for 1 of 5 residents (Resident 4), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications before administration. Findings included . A review of the facility's policy titled, Psychotropic Drug Use, revised on 04/01/2024, showed that residents and/or their responsible parties will be asked to make an informed choice concerning the use of a psychoactive (mind altering) drug and for an informed choice to be made, potential negative outcomes (risks) and benefits for the drug use would be explained. A review of Resident 4's face sheet printed on 08/20/2024 showed that Resident 4 was readmitted to the facility on [DATE]. A review of a physician's order dated 03/19/2024 showed Resident 4 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 2 residents (Residents 235 & 20), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life. Findings included . A review of the facility's policy titled, Self-Administration of Medications, revised on 07/01/2024, showed that the facility would provide each resident with the opportunity to self-administer medications if the resident chooses. Self-administration of medications is listed as one of the rights, the resident is given the opportunity and may choose to do so if the interdisciplinary team determines the resident is safe to self-administer. An assessment of the resident's capabilities to self-administer is performed by the IDT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . A review of the facility's policy titled, Transfer/Return, revised on 04/14/2024, showed that before facility-initiated transfer, the resident would be notified in writing the reasons for transfer in a language and manner they can understand. The policy also showed that the notice would contain the reasons for transfers and be documented in the resident's record by the facility and the physician. A review of the discharge Minimum Data Set (MDS-an assessment tool) dated 05/28/2024 showed that Resident 12 was discharged to the hospital. A review of the admission MDS dated [DATE] showed that Resident 12 was readmitted back 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 ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . A review of the facility's policy titled, Bed Hold, revised on 01/22/2024, showed that It is the policy of this community to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. A review of the discharge Minimum Data Set (MDS-an assessment tool) dated 05/28/2024 showed Resident 12 discharged to the hospital. A review of the admission MDS dated [DATE] showed Resident 12 was readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 1 of 1 resident (Resident 9), reviewed for significant change in condition. The failure to complete a SCSA within 14 days placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed that a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting,' 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary [involving two or more different subjects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 9), reviewed for hospice services. This failure placed the resident at risk of not receiving necessary comfort care services, unmet care needs, and a diminished quality of life. Findings included . A review of the facility's policy titled, Nursing Services-Hospice, revised on 02/13/2024, showed that the facility will ensure all documentation of hospice visit[s] are complete according to the state and federal regulations. A review of the face sheet printed on 08/27/2024 showed Resident 9 admitted to the facility on [DATE]. A review of the Electronic Health Record (EHR) showed Resident 9 was admitted to hospice care on 09/22/2023. A review of Resident 9's clinical health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly assess and stage a pressure ulcer (localized damage to the skin and underlying tissue from prolonged pressure, friction, or shear, causing pain) at onset and weekly and maintain clear and accurate wound documentation for a pressure ulcer for 1 of 1 resident (Resident 9), reviewed for pressure ulcer. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life. Findings included . A review of the facility's policy titled, Pressure Ulcers and Skin Breakdown, revised on 04/11/2024, showed, The nurse shall describe and document/report the following: Full assessment of pressure sore [ulcer] including location, stage. A review of the face sheet printed on 08/27/2024 showed Resident 9 admitted to the facility on [DATE]. A review of the skin integrity care plan revised on 07/10/2024, showed Resident 9 had a left heel wound. A review of the mobility care plan revised on 08/20/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 2 of 2 residents (Residents 23 & 20), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . A review of the facility's policy titled, Oxygen Administration, revised on 02/07/2024, showed that the facility administers oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. The policy showed that the facility would assess the need for oxygen, obtain an order from a physician if needed longer than 24 hours, write the date on prepackaged humidifier bottles and discard the bottle after 7 days or when sterile water was gone, place nasal cannula(prongs) or mask in place with a date written on a label attached to tubing, and that oxygen tubing should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate and/or thoroughly investigate incidents for 3 of 3 residents (Residents 1, 2 & 3), reviewed for incident investigations. The failure to initiate and conduct thorough investigations placed the residents at risk for unidentified abuse/neglect, repeated incidents, and a decreased quality of life. Findings included . Review of the facility's policy titled, Policy and Procedure Abuse/Neglect, revised on 01/22/2024, showed that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly investigated, and reported according to State and Federal regulations . As soon as a report of alleged or suspected abuse/neglect is received, an investigation shall begin to rule out or identify abuse/neglect . The investigation will be completed within five days. RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of Resident 1's progress note dated 01/06/2024, showed Resident 1 was found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 posted and updated with actual hours worked for each shift for 30 out of 30 days reviewed for sufficient and competent staffing. This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels and census information. Findings included . Observations on 04/25/2023 at 2:22 PM, 04/26/2023 at 8:14 AM and 2:44 PM, 04/27/2023 at 2:21 PM and 4:30 PM, and 04/28/2023 at 2:36 PM, showed the facility's daily nursing staffing form located on the wall on the 7th floor by the nurse's station did not display the total actual nursing staff hours worked for previous shifts. Observations on 04/25/2023 at 2:30 PM, 04/26/2023 at 2:46 PM, 04/27/2023 at 2:26 PM, and 04/28/2023 at 9:29 AM, showed the facility's daily nursing staffing form located on the wall on the 8th floor by the nurse's station did not display the total actual nursing staff hours worked for previous shifts. Review of the daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 6 residents (Residents 18, 11, 12 and 22) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding hospice, antipsychotic medication, pressure ulcers, dental and injections placed the residents at risk for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). The Observation Period (also known as the Look-back period) is the time-period over which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 7 of 9 residents (Residents 12, 79, 378, 379, 128, 329 & 330) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Baseline Care Plan dated 10/25/2017, showed A baseline care plan will be developed for all newly admitted residents within 48 hours of admission. The policy also showed the facility will provide the resident and their representative a summary of the baseline care plan. RESIDENT 12 Resident 12 admitted to the facility on [DATE]. Review of the Electronic Health Record (EHR) showed no documentation that a summary of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 5 of 8 residents (Residents 11, 18, 3,12 and 22) reviewed for comprehensive CPs. The failure to develop CPs for residents' limited range of motion, medication, siderails, air mattresses, activities of daily Living (ADL) and pain, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . The facility's policy titled, Policy and Procedure - Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, showed the CP is person centered and involves the interdisciplinary team. The policy also showed that the CPs will identify all the residents' needs according to the comprehensive assessment, and it would be completed within 7 days of completion of the comprehensive assessment. RESIDENT 11 Resident 11 admitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (a stroke) and Hemiplegia (one-sided muscle paralysis or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerator and kitchen storage were labeled/dated when opened, and discard food products on or before the use by date in 1 of 3 refrigerators (main kitchen walk-in refrigerator) and 1 of 1 kitchen dry storage. These failures placed the residents at risk for developing food borne illness (caused by ingestion of contaminated food or beverages). Findings included . Review of the facility's policy and procedure titled, Food Storage, revised on 03/09/2020, showed all food products should be inspected for safety and quality, dated upon receipt, and when opened and/or prepared. The policy directs staff to discard any expired or outdated food products. MAIN KITCHEN WALK-IN REFRIGERATOR On 04/25/2023 at 8:48 AM, joint observation of the main kitchen walk-in refrigerator with Staff N, Dining Services Manager, showed the following: - A container of full paneer cheese, labeled with use by date of 04/01/2023. - A half full…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hand hygiene was performed between glove change for 1 of 1 resident (Resident 12) reviewed for wound care, and 1 of 6 residents (Resident 328) reviewed for medication pass. In addition, the facility failed to ensure components of an effective infection control program to include: Provide an on-going analysis of the infection surveillance data and review the surveillance data in their Quality Assurance Performance Improvement (QAPI), provide documentation to support that education was provided to staff about COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death), and ensure the soiled linen room, the sink in the soiled linen room to perform hand hygiene, and the red biohazard bin to place biohazard materials, were accessible to staff were implemented to provide a safe and sanitary environment to help prevent 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 develop and implement an antibiotic stewardship program (ASP) to promote appropriate use of antibiotics, failed to obtain/analyze and make antibiotic resistance patterns based on laboratory data and/or use of an antibiogram (antibiogram-a set of information usually in the form of a table reviewing the proportion of individual bacterial pathogens sensitive to different antimicrobial agents or medicine), failed to provide feedback to prescribing providers on their antibiotic use and compliance with the ASP, and failed to share ongoing analysis of surveillance data with the infection control committee. These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics, and an increased risk for multi-drug resistant organisms (MDRO-germs that are resistant to antibiotics). Findings included . The facility policy titled, Antibiotic Stewardship Program, dated 10/25/2017, showed that the facility was to maintain an ASP that promotes the appropriate use 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 a copy of the Advance Directive (AD) was obtained from the residents/representatives who have an AD in place and ensure a copy was readily available in the medical records for 2 of 6 residents (Residents 22 and 6) reviewed for advance directives. This failure placed the residents at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations. Findings included . An advance directive is a written instruction, such as a living will (LW) or durable power of attorney (DPOA), relating to the provision of health care when an individual is incapacitated. Review of the facility's policy titled, Policy and Procedure Advanced Directives, dated 10/25/2017, showed that a resident's AD will be documented in the clinical record and the care plan. RESIDENT 22 Resident 22 admitted to the facility on [DATE]. Resident 22's clinical records did not show a copy of AD document in their physical or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Notice of Medicare (national health program) Non-Coverage (NOMNC) was issued at least two calendar days before Medicare services ended and/or inform residents of their potential liability for payment for 1 of 6 sampled residents (Resident 178) reviewed for liability notice and coverage. This failure placed the resident and/or their representative at risk for not having adequate information to make financial decisions related to continued stay in the facility. Findings included . NOMNC, Form CMS-10123, is given by the facility to Medicare beneficiaries (residents) before the end of a Medicare covered Part A stay or when all of Part B therapies are ending to inform the beneficiary, they may have to pay for any services the Medicare provider (facility) as determined that Medicare probably will not pay for. Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055, is issued by the facility if the beneficiary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of abuse were reported to the State Agency (SA) within the required timeframe for 2 of 3 residents (Residents 11 & 78) reviewed for abuse. This failure placed the residents at risk for further abuse and lack of protection due to unrecognized abuse/neglect. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), For the purposes of reporting abuse .neglect .a nursing home employee (or other mandated reporter) is required to make a report if he or she had reasonable cause to believe the incident occurred. Examples of reasonable cause may include the individual observed the incident or heard the victim state it happened; or the individual heard about an incident from a permissive reporter who had direct knowledge of the incident; and Immediate telephone reporting was required when there was reasonable cause to believe abuse, neglect . had occurred . Federal law requires 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 identify allegations of abuse and ensure investigations were initiated and/or thoroughly investigated for 2 of 3 residents (Residents 11 and 78) reviewed for abuse investigation. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Finding included . The facility's policy titled, Policy and Procedure Abuse/neglect, dated 10/25/2017, showed, It is the policy of the facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated, and reported according to State and Federal regulations. RESIDENT 11 Resident 11 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 03/17/2023, showed Resident 11 had impaired cognition and required extensive assistance with activities of daily living. On 04/27/2023 at 3:32 PM, Resident 11's Representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely significant change in status Minimum Data Set (MDS) assessment for 1 out of 2 residents (Resident 18) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 1 of 3 residents (Resident 4) reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Manual, Discharge MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500B + 14 days) to the database as required. RESIDENT 45 Resident 45 admitted to the facility on [DATE]. Review of a progress note dated 01/17/2023 showed Resident 45 was discharged to home. Review of Resident 45's MDS assessments showed no discharge MDS was done. On 04/27/2023 at 10:53 AM, Staff B, Director 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 residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 3 residents (Residents 6 and 11) reviewed for ROM services. The failure to consistently assess, develop, implement, and/or revise individualized care plan interventions related to ROM placed the residents at risk for decline in functional ability and a diminished quality of life. Findings included . The facility's policy titled, Policy and Procedure - Restorative Nursing Program dated 2017, showed the purpose of Restorative Nursing Program (RNP) was to assess resident's needs for restorative care in mobility, Activities of Daily Living (ADL) and toileting. To create an environment which allows the residents to actively maintain or increase independence in mobility, ADLs, and toileting. RESIDENT 6 Resident 6 admitted to the facility on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice about the use and proper care of Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose and mouth that keeps the airway open) for 1 of 1 resident (Resident 329) reviewed for respiratory care. In addition, the facility failed to ensure a physician's order for use of O2 was accurate and/or followed according to resident's needs. These failures placed the resident at risk for respiratory infections and related complications. Findings included . Review of the facility document titled, CPAP Procedure revised in November 2022, showed that each part of the CPAP including any tubing will be labeled with the date it was opened, and changed per manufacturer's instruction. Resident 329 admitted to the facility on [DATE] with diagnosis to include dependence on supplemental oxygen. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess, obtain physician orders, provide risks/benefits of use, and develop care plans to meet the needs of 2 of 3 residents (Residents 18 and 3) for whom siderails devices were reviewed. This failed practice placed the residents at risk for injury. Findings included . A review of the facility provided policy titled, Policy and Procedure-Restraint and Device, dated 10/25/2017, showed the facility considered quarter siderails to be restraints/devices. It also showed, all residents have a Restraint/Device Assessment .completed prior to initiating any restraint/device .A physician's order is obtained for the use of any device that meets the definition of a restraint .The care plan identifies the type of restraint/device, when to be used .risks/benefits to use and interventions to decrease these specific risks. RESIDENT 18 Resident 18 admitted to the facility on [DATE] with diagnoses that included dementia (memory loss) and Parkinson's (a…

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

Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 3 staff (Staff M) reviewed for nursing aide registry. The facility's failure to receive registry verification that the individual had met competency evaluation requirements placed the residents at risk for abuse and unmet care needs. Findings included . Staff M was hired on 02/14/2022 as a Certified Nursing Assistant. Review of Staff M's employee record did not include documentation from the nurse aide registry. On 05/01/2023 at 2:15 PM, Staff A, Health Services Director (HR), stated that new staff completed on-boarding with Human Resources, which included background checks and the nurse aide registry. Staff A stated that Staff M did not have a nurse aid registry and that HR had been looking for it. Reference: (WAC) 388-97-1660(3)(c) .

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and dated for 1 of 2 medication storage rooms (7th floor medication room) reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications. Findings included . Review of the facility policy titled, Medication Storage, dated 04/12/2023, showed that the facility will follow the manufacturer's recommendations for proper medication storage. Review of the manufacturer package instructions for Lorazepam (an antianxiety medication) Oral Concentrate showed that an opened bottle should be discarded after 90 days. 7th FLOOR MEDICATION STORAGE ROOM On 04/26/2023 at 1:53 PM, during a joint observation and interview with Staff C, Resident Care Coordinator, showed two bottles of Lorazepam 2 milligrams/milliliters/30 ml bottle concentrate. Both bottles of the Lorazepam did not have an open date and/or no information on the bottle when they were first use or opened. Staff C stated the bottles of Lorazepam were opened and used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and resident representatives were provided education about COVID-19 vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in the medical record, and document as to why the vaccine was refused for 1 of 5 residents (Resident 330) reviewed for COVID-19 immunizations. This failure denied the resident and/or their representative of the right to make informed decisions. Findings included . COVID-19 is an infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Resident 330 admitted to the facility on [DATE]. Review of Resident 330's medical record showed no documentation to support that risks and benefits and/or education were provided 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 ensure Certified Nursing Assistants (CNAs) had the required abuse and neglect and/or dementia management training annually for 1 of 3 staff (Staff W). This failure placed residents at risk for potential negative outcomes and unmet care needs. Findings included . Staff W was hired on 12/29/2017 as a CNA. Review of the facility's employee record showed Staff W received abuse and neglect training dated 02/27/2018. Further review of the employee record showed Staff W did not have documentation to support Staff received the dementia management training. On 05/01/2023 at 11:43 AM, Staff B, Director of Nursing, stated staff had missing training documentation, and if the training record was not provided, then the education was not completed. Staff B also stated that staff attended Skills Day training at hire and annually, and that the dementia management training was not part of their Skills Day training, but it would be included moving forward. Reference: (WAC) 388-97-1680 (2)(b) .