Transitional Care Of Seattle

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reassess the resident after a significant change in function lasting more than 14 days occurred for 1 (Resident 60) of 19 sample residents. The failure to identify the need for a Significant Change in Status Assessment (SCSA - an assessment tool) after Resident 60 had a decline in their condition placed the resident at risk for unmet care needs and a diminished quality of life. Findings included .<Resident 60>In an interview on 09/16/2025 at 12:56 PM Resident 60 stated they went to the hospital emergently because of bleeding. Resident 60 stated they used to get up and go outside to smoke but since returning from the hospital they could no longer get out of bed. Resident 60 was observed to be in bed at this time.Record review showed Resident 60 was hospitalized from [DATE] and returned to facility on 05/24/2025.According to the 08/07/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 60 was scored at 00 out of a possible 27 points on 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 Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility or updated with changes with appropriate follow up with the State PASRR office for 3 of 6 (Residents 67, 60, & 68) reviewed for PASRRs. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.Findings included . <Facility Policy>According to the facility's 01/01/2025 PASRR Process Policy, if a Level 2 evaluation was indicated on a Level 1 PASSR screening, the social worker would validate within a timely period that an evaluation should occur. This policy showed if there was a significant change affecting a resident's mental health needs, staff would complete and submit a new Level 1 screening.<Resident 67> According to a 09/05/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 67 had diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facilitate quarterly care conferences for 2 of 3 residents (Resident 6 & 33) reviewed for care conferences. This failure placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes.<Resident 6>According to a 08/15/2025 re-entry Minimum Data Set (MDS-an assessment tool), Resident 6 had clear speech, understands, and was understood by others.In an interview on 09/16/2025 at 1:30 PM, Resident 6 stated no one at the facility talked to them about their care and stated they did not have a care conference recently.Review of Resident 6's records showed the last care conference was on 03/28/2025. A progress note dated 05/08/2025 showed the resident refused a care conference on that day. The progress notes did not show any further care conferences were scheduled.In an interview on 09/25/25 at 10:47 AM Staff GG (Social Services Director) stated care conferences were important to make sure everybody including staff and residents were on the same page. Staff GG stated during care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician orders were followed for 4 residents (Residents 64, 67, 2, & 3), failed to ensure physician orders were clarified for 2 residents (Resident 68 & 3), and failed to obtain physician orders prior to providing treatment for 1 resident (Resident 32) of 19 residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.Findings included .<Clarification of Orders> <Resident 68> Review of Resident 68’s September 2025 Medication Administration Records (MAR) showed two separate orders for a laxative suppository to be given as needed for constipation and two separate orders for a laxative enema (rectal administration of a medication) for constipation. There were no directions to staff to indicate which orders should be given over the other orders. In an interview on 09/23/2025 at 10:42 AM, Staff C (Resident Care Manager) stated duplicate orders should be clarified due 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 observation, activity, and record review the facility failed to ensure residents were provided a program of meaningful, life enriching activities for 2 (Residents 60 & 3) of 6 residents reviewed for activities. This failure placed residents at risk for boredom, frustration, a diminished quality of life, and social isolation. Findings included .<Facility Policy>According to the facility's July 2015 Activity Program policy, the facility would provide an ongoing program of activities designed to meet the interests of, as well as the physical, mental, and psychosocial needs of each resident. The policy showed the Activity Director was responsible for program implementation and showed the program should promote residents' physical, mental, and emotional wellbeing.<Resident 60> According to the 08/07/2025 A Minimum Data Set (MDS - an assessment tool) Resident 60 had moderate memory impairment and reported they felt down, depressed, or hopeless on 12-14 days of the assessment's 14-day lookback period. The MDS showed participating in their favorite activities was very 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.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 residents (Residents 9) reviewed for falls. This failure placed residents at risk for additional falls, discomfort, and substantial injuries.Findings included .<Resident 9> According to a 07/14/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 9 had clear speech, was understood, and was able to understand others. The MDS showed Resident 9 had multiple medically complex diagnoses including obesity and muscle weakness, required substantial assistance from staff to roll side to side in bed, and was dependent on staff for transfers from their chair to bed. Observation on 09/17/2025 at 9:04 AM showed Resident 9 lying in bed. In an interview at this time, Resident 9 stated they had previous falls but was unsure when the falls occurred. In an interview on 09/19/2025 at 8:00 AM, Resident 9 stated they had a fall the previous night when two staff members were transferring them to bed. Resident 9 stated staff were using a slide…

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

Based on observations, interviews, and record review the facility failed to assess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved or maintained for 1 of 1 residents (Resident 9) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and decreased quality of life.Findings included .<Facility Policy>Requested policy on 09/22/2025 and 09/25/2025 regarding bowel and bladder assessments. Facility was unable to provide a policy as requested.<Resident 9>According to a 07/14/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 9 had clear speech, understands, and was understood by others. This MDS showed Resident 9 required substantial assistance from staff to roll side to side in bed, was dependent on staff for bed to chair transfers and toileting hygiene, had no rejection of care, and was always incontinent with bowel and bladder.Review of a 10/18/2025 urinary incontinence Care Area Assessment (CAA) showed Resident 9's…

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

Based on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive Care Plan (CP) was implemented for 1 of 6 residents (Resident 1) whose CP was reviewed for assistance with Activities of Daily Living (ADLs). The failure to implement identified CP interventions for safety and adhere to individualized care of residents with identified behaviors affecting provision of ADL care placed residents at risk for potential abuse and/or neglect, inconsistent and/or inadequate care, worsening resident behaviors, and a decreased quality of life. Findings included . <Resident Assessment Instrument - RAI> The October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) showed clinical competence, observational, interviewing and critical thinking skills, and assessment expertise form all disciplines were required to develop individualized CP's. The manual showed the CP (together with the established goals and interventions) become each resident's unique path towards achieving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically-related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents; assist residents in obtaining resolution to their grievances regarding refusals of treatment and care; and advocate for residents in the assertion of their rights within the facility for 1 of 6 residents (Resident 1) reviewed for behavioral health. This failure placed residents at risk of unmet social service needs, unsafe care, psychosocial decline, and a diminished quality of life. <Facility Policy> The Comprehensive Resident Care Plan [CP] facility policy, revised July 2015, showed Social Services would review and update each resident CP quarterly, annually, and as mandated in the Resident Assessment Instrument process after MDS completion. The policy showed Social Services would review relevant resident information and determine appropriate care plan interventions. The Behavior Management facility policy, revised October 2022, showed residents exhibiting behavior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quarterly personal fund statements were provided to residents with personal fund accounts for 2 of 3 sampled residents (Residents 17 & 27) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . <Facility Policy> According to a revised facility December 2021 Resident Trust Fund policy, the facility would maintain resident trust fund accounts in accordance with state and federal regulations. This policy showed the facility would prepare and distribute, at a minimum, quarterly statements to each resident/resident's responsible party. Copies of the statements were to be kept with the trust reconciliation file. <Resident 27> According to a 05/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 27 admitted to the facility on [DATE] had no memory impairment. In an interview on 06/05/24 10:39 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 funds were reimbursed to the resident and/or state Office of Financial Recovery (OFR), within 30 days of resident discharge for 7 (Residents 229, 227, 228, 232, 231, 233, & 230) of 9 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required. Findings included . <Facility Policy> According to a revised facility [DATE] Resident Trust Fund policy, the facility would maintain resident trust fund accounts in accordance with state and federal regulations. This policy showed when a resident discharged or expired, the balance of the resident's personal funds would be returned to the resident, responsible party, or as directed by state regulation. <Resident 229> Record review showed Resident 229 was discharged from the facility on [DATE]. Review of trust records showed the resident had a balance of $0.60 that still remained in the facility trust's current account balance, 13 months after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 4 (Resident 41, 22, 49, & 2) of 21 sample residents whose CPs were reviewed, and failed to ensure residents participated in Care Conferences (CCs) for 4 (Residents 2, 226, 19, & 27) of 21 sample residents whose CPs were reviewed. This failure left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's undated Comprehensive Resident CP policy Social Services was responsible to update the CPs within seven days of the completion of the MDS assessment process. The policy showed Social Services would use CCs as an additional source of information for care planning, and CPs should be updated quarterly, annually, and as needed. <Updating and/or Revising CPs> <Resident 41> According to the 05/21/2024 admission Minimum Data Set (MDS - an…

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

Based on observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 2 (Resident 2 & 49) of 2 sample residents reviewed. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs. Findings included . <Facility Policy> Review of the facility's Dialysis policy, updated March 2021, the facility required the dialysis center to provide the resident's pre and post dialysis weights, labs, medications given at the appointment, and any follow up care required upon upon the resident's return to the facility. This policy showed if the facility nurse did not receive the required documentation, the facility was expected to call the dialysis center to request the information. <Resident 49> According to a 03/27/2204 Annual Minimum Data Set (MDS - an assessment tool), Resident 49 had multiple medically complex diagnoses including kidney failure and required dialysis services. 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.

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed up in a timely manner and/or included in the resident's records for 3 (Residents 43, 27, & 49) of 5 residents who were reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, lab work, incomplete medical records, and adverse side effects. Findings included . <Facility Policy> Review of the facility's Medication Regimen Review (MRR) policy dated March 2019, showed a pharmacist completed monthly MRR reviews for the residents. This policy showed the pharmacist emailed any irregularities or recommendations to the attending physician, medical director, and director of nursing. Once reviewed, the facility would respond to the pharmacist's recommendations for nursing tasks/interventions within two weeks. <Resident 27> According to a 05/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 27 had multiple medically complex diagnoses including heart failure, high blood pressure, and had frequent pain…

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

Based on observation and interview, the facility failed to ensure resident meals were prepared or stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 2 of 3 unit refrigerators. The failure to ensure dried foods were stored as required, that all refrigerated food was dated and labeled as required, to ensure Potentially Hazardous Food (PHF), drinks were served at the appropriate temperature, the kitchen was free from potential contaminants, and unit refrigerators were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings included . <Facility Policy> According to the facility's revised October 2017 Food Storage policy, cold foods should be maintained at a temperature of 41 degrees Fahrenheit or colder. The policy showed all opened food packages should have a use by date. The facility's revised August 2020 Resident Personal Refrigerators and Foods Brought Into Center by Family/Visitors policy showed perishable food brought in to residents from outside the facility must be covered,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consider and act promptly to address concerns raised by residents at the Resident Council (RC). Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken left residents at risk for unresolved concerns, frustration, and a less-than-homelike environment. Findings included . <Facility Policy> The facility's revised January 2017 Resident Council (RC) policy showed the purpose of the RC was to promote resident interest and involvement in the facility, as well as creating a space for residents to voice concerns. The policy showed the RC meetings were facilitated by the council president and minutes kept. The policy showed concerns generated at RC would be addressed via the facility's grievance process. Review of the facility's RC minutes showed the following: The 12/29/2023 RC minutes showed residents expressed a concern that room-bound residents did not receive snacks and treats when there was a party. The minutes did not address whether 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 complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 2 of 21 (Residents 17 & 38) sampled residents reviewed for resident assessments and timing. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2019 RAI Manual showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual onset of significant change(s) in their status. The RAI outlined a Quarterly MDS must be completed no later than 14 days after the established Assessment Reference Date (ARD) of the assessment. <Resident 17> Review of Resident 17's 02/14/2024 Quarterly MDS showed an ARD of 02/14/2024 and 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 4 (Residents 27, 38, 25, & 5) of 21 resident's Minimum Data Set (MDS - an assessment tool) reviewed were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet care needs. Findings included .<Resident 27> According to a 07/24/2023 Significant Change MDS, Resident 27 had multiple medically complex diagnoses including depression and a mood disorder, and required the use of antidepressant medications during the assessment period. This MDS showed staff indicated Resident 27 was not currently considered by the state Level 2 Preadmission Screen and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs that required further assessment/treatment) to have a Serious Mental Illness (SMI). Review of a 09/28/2021 Level 2 PASRR evaluation summary showed Resident 27 was considered by the state Level…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Orders (POs) were followed for 3 (Residents 27, 41, & 38) of 21 sample residents reviewed, POs were clarified for 3 (Residents 226, 27, & 49) of 21 sample residents reviewed, and nurses signed only for tasks completed for 2 (Residents 49 & 19) of 21 sample residents. These failures left residents at risk for unmet care needs, unnecessary treatment, inaccurate records, and other negative health outcomes. Findings included . <Follow Orders> <Resident 27> According to a 05/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 27 had multiple medically complex diagnoses including heart failure. Review of Resident 27's April, May, and June 2024 Medication Administration Records (MAR) showed the resident received a medication for heart failure with directions to staff to hold the dose if the heartrate was less than 60 beats per minute. The April 2024 MAR showed staff did not hold the medication when the heartrate was outside of the parameters on one of four occasions. In May 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a discharge planning process to effectively transition the residents to the community for 2 (Residents 26 & 22) of 2 residents reviewed for discharge planning. This failure placed the residents at risk for a delay in discharge, unnecessary nursing care, avoidable healthcare expenses, and diminished quality of life. Findings included . <Resident 26> According to a 04/19/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 26 admitted to the facility on [DATE], had no memory impairment, and had an active discharge plan occurring for the resident to return to the community. In an interview on 06/04/2024 at 2:41 PM, Resident 26 stated they waited a long time to be discharged to an adult family home and expressed frustration it was taking so long. Review of a 04/28/2023 admission MDS and the 01/30/2024 Annual MDS showed Resident 26 had an active discharge plan occurring for the resident to return to the community.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative program was provided for 2 of 4 (Resident 19 & 38) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life. Findings included . <Policy> According to a revised March 2019 facility, Restorative Program policy, the restorative program focused on achieving and maintaining each resident's highest practicable functioning. This policy showed each restorative service was recorded on a restorative flowsheet each time the program was implemented/completed. <Resident 19> According to a 04/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 19 had no memory impairment and was dependent on staff to roll from side to side and to sit up on the side of their bed. This MDS showed Resident 19 had no rejection of care and only received their Restorative Nursing Program (RNP) on one day during 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 provide residents the required medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1of 18 sampled residents (Resident 66). The failure to address the residents' refusals of care and follow up on essential care needs placed Resident 66 at risk for poor hygiene, skin issues, nd decreased quality of life. Findings included . According to the 04/03/2024 Quarterly Minimum Data Set Resident 66 admitted to the facility on [DATE] and had medically complex diagnoses including a history of stroke, an anxiety disorder, malnutrition, increased need for sleep, adult failure to thrive, Diabetes Mellitus (DM - difficulty controlling blood sugar) and hearing loss. The MDS showed Resident 66 refused an interview to assess their memory and was assessed by staff with intact memory. The MDS showed Resident 66 rejected care daily, and their rejection of care worsened since 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 observation, interview, and record review the facility failed to ensure food served from the facility kitchen met the dietary preferences or required texture for 6 of 21 sample residents (Residents 43, 56, 41, 18, 38, & 25). The failure to ensure residents were served meals that honored their preferences (Residents 38 & 25) and was prepared with the required texture (Residents 43, 56, 41, & 18) left residents at risk for weight loss, frustration, overly-processed food, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's updated March 2016 Food Preference Record Policy dietary orders and food allergy/intolerance information should be gathered from the medical record and resident preferences verified via interview with the resident by the Food and Nutrition Service (FANS) Manager. The interview would be a discussion of cultural/religious preferences and therapeutic or altered-texture diets. <06/11/2024 Lunch Service> Record review showed the main entree on the menu that day was lime tarragon chicken. The break out menu (a print…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 specialized rehabilitative services were provided as determined by the Physician's Order (PO) for 2 of 2 (Residents 22 & 17) residents reviewed for therapy services. This failure prevented residents from attaining, maintaining, or being restored to their highest practicable level of physical, mental, functional, and psycho-social well-being. Findings included . <Resident 22> According to a 05/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 22 had multiple medically complex diagnoses and had no memory impairment. This MDS showed Resident 22's most recent Physical Therapy (PT) or Occupational Therapy (OT) regimen was 10/06/2023. In an interview on 06/04/2024 at 10:40 AM, Resident 22 stated they were supposed to have therapy on their neck but reported, nothing was being done about that. Observations on 06/04/2024 at 11:23 AM, showed Resident 22 put on their call light, staff answered, and Resident 22 stated, when do I get therapy for my neck? At this time, the staff went 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 observation, interview, and record review the facility failed to ensure the menu was followed during meal service for 9 (Residents 1, 2, 3, 4, 5, 6, 7, 8 & 9) of 15 residents reviewed. Failure of the facility to serve what was listed on the menu and tray cards placed residents at risk of dissatisfaction with the food served, lack of dietary intake, and a diminished quality of life. Findings included . On 10/13/2023 at 10:57 AM, the Week 2 Menu was observed posted in the first-floor hallway. Listed for lunch was Baked Glazed Ham, Scalloped Potatoes, Sunny Carrots, Herb Biscuit and lemon mousse. The menu posted in the first-floor vending machine room showed lunch was Chicken, Steamed Rice, Capris vegetables or Spinach Mandarin Orange salad, muffin, and lemon cake. During an interview on 10/13/2023 at 1:28 PM, Staff C, Cook, stated the night shift dietary aids were responsible for changing the menus. During an interview on 10/13/2023 at 2:54 PM, Staff A, Administrator, stated the Food Service Manager was out on leave and so the weekly menu was not changed. <Resident 1> 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 interview and record review, the facility failed to provide written notification of the reason for transfer for 1 (Residents 52) of 1 sample residents reviewed for hospitalization, and 1 discharged resident (Resident 37). Facility failure to provide written notification to residents/their representatives, and the state Long Term Care Ombuds office (LTC Ombuds office - an advocacy group for residents in nursing homes) denied residents/their representatives knowledge of their rights regarding transfer, and prevented the LTC Ombuds office from knowing when residents were hospitalized . Findings included . Facility Policy According to the facility's October 2022 Transfer and Discharge policy, when a resident transferred from the facility to another institution (such as a hospital) the facility would provide written notification of the transfer including the date of the notice, the date of transfer, the reason for the transfer, where the resident moved to, contact information for the LTC Ombuds program and other advocacy agencies, and an explanation of the resident's transfer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess 4 (Residents 29, 69, 78 & 33) of 24 residents whose Minimum Data Sets (MDS - an assessment tool) were reviewed. Failure to ensure accurate assessments regarding vision (Resident 69), vaccinations (Resident 29), Pre-admission Screening and Resident Review (PASRR) (Resident 29 and 33), and guardianship status and ethnicity/race (Resident 78), placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 29 According to an 11/27/2022 Annual MDS, Resident 29 was not considered by the state Level 2 PASRR process to have a Serious Mental Illness (SMI). Review of Resident 29's records showed a 01/27/2021 Level 2 PASRR that identified the resident with SMI. In an interview on 03/02/2023 at 11:34 AM, Staff E (MDS Coordinator) stated the PASRR Level 2 indicator on the MDS was inaccurate and should have been marked yes for Resident 29 having a SMI as indicated by the Level 2 assessment. According to a 02/20/2023 Quarterly MDS, staff identified Resident 29 received 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 the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained, and/or implemented and incorporated into the Care Plan (CP) for 2 of 8 (Residents 52 and 68) residents reviewed for PASRR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . Resident 52 According to the 01/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 52 had multiple medically complex diagnoses including an anxiety disorder, depression, and psychotic disorder which required the use of antipsychotic and antidepressant medications. Review of a 02/08/2021 Level 1 PASRR completed by facility staff identified Resident 52 with a serious mental illness (SMI) indicator and required a Level 2 evaluation referral. No documentation was found in Resident 52's records of a Level 2 evaluation being obtained or implemented into the resident's CP. In an interview 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 interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 2 of 8 (Resident 52 & 69) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . Resident 52 According to the 01/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 52 had multiple medically complex diagnoses including an anxiety disorder, depression, and psychotic disorder which required the use of antipsychotic and antidepressant medications. Review of a 02/08/2021 Level 1 PASRR showed staff identified Resident 52's only Serious Mental Illness (SMI) indicator was a mood disorder. Staff did not identify Resident 52 had an anxiety or psychotic disorder and required the use of medications. In an interview on 03/02/2023 at 11:57 AM, Staff O (Social Service Director) stated the current Level 1 PASRR for Resident 52 did not accurately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Care Plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 (Resident 69, 35 & 52) of 21 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs. Findings included . Resident 69 Review of a revised 09/23/2022 anti-anxiety medications CP showed directions to staff to administer an anti-anxiety medication as ordered and to monitor for side effects and effectiveness every shift. Review of a February 2023 Medication Administration Record (MAR) showed Resident 69's anti-anxiety medication was discontinued on 10/12/2022, over four months earlier. In an interview on 03/02/2023 at 11:50 AM, Staff I (Registered Nurse/Resident Care Manager) confirmed Resident 69 did not currently receive anti-anxiety medications and stated the CP should have been updated and revised. Review of a revised 05/03/2023 skin integrity CP showed Resident 69 was at risk for skin impairment related to the use of crutches. Observations on 02/28/2023 at 1:05 PM 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 1 resident (Resident 33) of 2 residents reviewed for smoking was assessed for the safe use of an e-cigarette (an electronic device that delivers nicotine in a vapor when inhaled). Specifically, Resident 33 was observed using an e-cigarette in their room instead of the facility's designated smoking area. Ths failure placed the resident and others at potential risk for injury. Findings included . Review of a facility's March 2018 EmpRes Healthcare Notice of Center Smoking Policy, showed smoking in resident rooms was not allowed. The policy showed residents who wanted to smoke (including cigarettes, cigars, or pipes, including electronic e-cigarettes/vaping devices) must first complete the facility's Smoking Safety Evaluation. Review of the facility's April 2016 Center Smoking Regulations, showed smoking of e-cigarettes was not allowed inside the facility. According to the 11/30/2022 Quarterly Minimum Data Set (MDS - an assessment…

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