Washington Care Center

Based on observation, interview, and record review the facility failed to appropriately use Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 2 supplemental residents (Residents 28 & 10) who required EBP reviewed for infection control. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment.Findings included . <Facility Policy>According to the facility's March 2025 Transmission-Based Precautions policy, EBP required the use of gowns and gloves by care providers during high-contact resident care activities. <Resident 28> Observation on 12/12/2025 at 10:47 AM showed Resident 28's room had an EBP sign posted outside their door. The signage showed staff must clean their hands before entering the room, and wear gloves and gowns for high-contact resident care activities including dressing and transferring residents, providing hygiene and care of a urinary catheter (tubing to assist 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 implement an Antibiotic (ABO) Stewardship program to promote appropriate use of ABO and reduce the risk of unnecessary ABO use for 2 of 3 residents (Resident 8 & 4) reviewed for unnecessary antibiotics. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and placed residents at a greater risk of developing ABO resistance.Findings included.<Policy>According to the facility policy titled, ABO Stewardship Program, dated March 2018, the facility would ensure residents met the McGeers criteria (a tool used for infection surveillance activities and management of ABO usage) for ABO usage. The policy showed the facility would use standard evaluations and communication tools for residents with suspected infections, utilize Antibiogram reports, and implement ABO time outs. <Resident 8>Review of Resident 8's health records showed they received an ABO from 01/23/2025 until 02/02/2025 for a urinary tract infection. Resident 8's records also showed they received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain infection control practices necessary to provide a safe and sanitary environment and prevent transmission of communicable diseases by having Personal Protective Equipment (PPE) available to staff for 12 of 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, &12) observed requiring Enhanced Barrier Precautions (EBP) with specific diagnoses including wounds and indwelling medical devices. The facility failed to ensure alcohol-based hand sanitizer dispensers were properly functioning for 25 of 46 rooms (Rooms 202, 203, 204, 209,211, 208, 215, 216, & 218; and outside rooms 219, 250, 251, 252, 255, 256, 257, 263, 264, 265, 266, 267, 268,270, 273, & 274) observed inside and along the hallway outside occupied resident rooms. These failures placed residents at risk for acquiring and developing communicable diseases, medical complications from infection, and a decreased quality of life. Findings included . <Facility Policy> According to the Enhanced Barrier Precautions-F880, facility…

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

Based on interview and record review, the facility failed to ensure residents were provided informed consent for treatments (ensuring an explanation of the risks and benefits was provided) for 3 of 5 (Residents 113, 21, & 17) residents whose medication regimen was reviewed. The failure to provide informed consent placed residents at risk for unwanted adverse side effects, unwanted treatment, and loss of autonomy. Findings included . <Resident 113> According to the 07/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 113 had diagnoses including depression and anxiety. The MDS showed Resident 113 received antidepressant and antianxiety medications. Review of the physician's orders showed a 04/26/2024 order for an antidepressant to be administered to Resident 113 at bedtime for insomnia. Record review showed no evidence the risks and benefits of the antidepressant medication were explained to Resident 113. There was no evidence Resident 113 consented to the medication prior to treatment. In an interview on 08/20/2024 at 4:50 PM Staff C (Regional 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 and interview, the facility failed to ensure the facility maintained a homelike environment for 2 of 4 units, and 1 of 1 entry way. The failure to ensure resident rooms were free of wall scrapes, stained doors and walls, damaged flooring, damaged closet doors, missing/damaged ceiling tiles, and dirty privacy curtains, and the failure to ensure the entry way was in good condition, placed residents at risk for a less than homelike environment, frustration, and a diminished sense of self-worth. Findings included . <100 Unit > Observations of the first-floor shower room door on 08/14/2024 at 1:27 PM showed multiple tan colored smears and marks on the outside visible from the hallway. In an interview on 08/21/2024 at 11:27 AM, Staff X (Maintenance Director) looked at the shower room door, stated it looked dirty and should be cleaned up and painted. Observations of the shared bathroom in room [ROOM NUMBER] on 08/15/2024 at 8:52 AM showed dried brown raised debris areas on the wall to the right 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 system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 5 (Residents 127, 34, 113, 55, & 96) of 7 residents reviewed for hospitalizations. Failure to provide written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Resident 127> Review of Resident 127's 06/18/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation staff provided written notification to Resident 127 and/or the resident's representative regarding their discharge as required. <Resident 34> Review of Resident 34'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 ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for 3 (Residents 134, 85, & 113) of 7 sampled residents reviewed for PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy> Review of the undated PASRR Completion facility policy showed the designated staff would make sure the PASRR was completed on all potential residents. This policy showed if the referral indicated the resident had a serious mental illness or intellectual disability, the PASRR would be completed prior to admission. <Resident 134> According to the 07/07/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 134 had no cognitive impairment and had diagnoses of anxiety disorder and a chronic mental illness that caused extreme mood swings. This MDS showed Resident 134 was not considered by the state level II PASRR…

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

<Resident 113> According to the 07/18/2024 Quarterly MDS, Resident 113 had medically complex conditions including anxiety, depression, and opioid dependence. The MDS showed Resident 113 took antipsychotic, and antidepressant medications. Review of the physician's orders showed Resident 113 currently took two antidepressant medications and an antipsychotic medication from 03/28/2024 until discontinued on 07/25/2024. The indication for the antipsychotic medication was for auditory hallucinations. Review of the comprehensive Care Plan (CP) showed Resident 113 had a Target Behavior due to Psychosis CP. This CP included a goal for staff to assist Resident 113 with daily episodes of psychosis. Review of the 03/13/2024 Level I PASRR indicated Resident 113 had a mood disorder and an anxiety disorder. This Level I PASRR did not show Resident 113 had a psychosis diagnosis, or otherwise address Resident 113's auditory hallucinations. The form showed Resident 113 exhibited serious functional limitations in the past six months prior to completion of the form related to a serious mental illness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY < Resident 55> According to the 06/21/2024 Quarterly MDS, Resident 55 had significant weight loss in the last six months and was not on prescribed weight loss regimen. The MDS showed Resident 55 required maximal assistance from staff with oral hygiene, eating, and toileting needs. Review of Resident 55's record showed Resident 55's weight on 01/04/2024 was 260 pounds and on 05/28/2024 was down to 221 pounds, representing a weight loss of 39 pounds in four months. Review of Resident 55's CP showed no documentation related to weight loss or any interventions for staff to follow. In an interview on 08/20/2024 at 2:17 PM, Staff H (Dietitian) stated they were aware of Resident 55's significant weight loss. Staff H stated Resident 55's CP should be updated accordingly. <Resident 99> According to the 07/01/2024 Quarterly MDS, Resident 99 readmitted to the facility on [DATE] and had no memory impairment. Review of Resident 99's August 2024 Medication Administration Record (MAR) showed Resident 99 received an antibiotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 7 (Residents 21,55, 99, 134, 10, 150, & 71) of 10 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with oral care, showers, getting out of bed, dressing, shaving, and nail care, placed the residents at risk for poor hygiene, greasy hair, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> According to the facility's revised March 2018 ADLs policy, residents would be provided with the care, treatment, and services needed to ensure they maintain or improve their ability to carry out their own ADLs. Residents unable to carry out their own ADLs, would be provided the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. <Resident 21> According to the 05/14/2024 Quarterly Minimum Data Set (MDS - an…

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

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 55) of 5 residents reviewed for Pressure Ulcers (PU's) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to consistently complete weekly skin assessments, assess skin integrity to identify PUs timely, ensure air mattress settings were appropriate according to resident's weight, repositioning in bed, update the Care Plan (CP) with Resident 55's refusals, and to follow the CP, placed Resident 55 at risk to develop a new PU, and diminished quality of life Findings included . <Facility Policy> According to the facility's revised April 2018 Pressure Ulcer/Skin Breakdown protocol, the facility would assess residents upon admission and thereafter, to identify if the residents had existing PU's or other skin conditions and would document the risk factors for developing PUs in resident's record. The protocol showed the provider would assess and order wound treatments,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility failed to maintain and environment that was free from accident hazards. The failure to: ensure appropriate supervision and storage of smoking materials for 1 of 2 sample residents (Resident 113) and 5 supplemental (Residents 135, 117, 54, 43, & 22) residents who smoked; failed to secure chemicals in 2 of 4 clean utility rooms; and failed to secure sharps in 1 of 4 clean utility rooms, placed residents at risk for smoking related injuries, accident hazards, and diminished safety. Findings included . <Smoking> <Facility Policy> Review of the facility's Smoking Policy revised June 2023 showed residents would be evaluated on admission to determine if they were a smoker or non-smoker. The evaluation would determine the resident's ability to smoke safely with or without supervision. This policy showed both independent smokers and residents assessed to require smoking supervision would not be permitted to keep cigarettes or other smoking materials in their possession. All smoking materials were to be locked with the activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: 1) perform Hand Hygiene (HH) during resident care and during dining service; 2) ensure staff used Personal Protective Equipment (PPE) for residents reviewed for Transmission Based Precautions (TBP); 3) identify and initiate Enhanced Barrier Precautions (EBP) for residents who required EBP precautions; 4) ensure staff disposed of contaminated gloves before entering the hallway. These failures placed residents at risk for the development and transmission of communicable diseases and related complications. Findings included . <Facility Policies> According to a facility's revised 06/08/2022 Infection Prevention and Control Program (IPCP) policy, the IPCP would utilize a system for prevention, identifying, reporting, investigating, and controlling infections, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 4 of 7 sample residents (Resident 127, 34, 55, & 96) reviewed for hospitalization. This failure placed the residents and/or their representatives at risk of not being informed of their right to, or the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Resident 127 > In an interview on 08/15/2024 at 1:57 PM, Resident 127 stated they were previously sent to the hospital for stomach issues and blood loss. Review of Resident 127's 06/18/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation or other indication the facility provided Resident 127 or their resident representative written…

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

<Signing For Tasks Not Completed> <Resident 10> Observations on 08/15/2024 at 8:58 AM showed Resident 10 with a pain medication patch on the top of their right ankle. This patch had a handwritten date of, 8/14. On 08/16/2024 at 8:42 AM, this same patch remained on Resident 10's right ankle. Review of August 2024 MAR showed orders for a pain medication patch to be applied to Resident 10 two times a day and gave an area for staff to document the patch was put on at 8:00 AM and removed each night at 8:00 PM. This MAR showed staff documented the patch was applied on 08/14/2024 and removed on 08/14/2024 but was still observed on Resident 10 two days later. In an interview and observation on 08/16/2024 at 9:01 AM, Staff Z (Licensed Practical Nurse) confirmed the pain medication patch was from two days prior, removed the patch, and stated, we should not have missed removing the patch. <Resident 85> According to the 07/04/2024 Quarterly MDS, Resident 85 had clear speech, intact memory, and had diagnoses including hypertension, history of pressure ulcers, chronic pain, and muscle weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were provided with a program of individualized activities for 2 of 5 (Residents 95 & 150) residents reviewed for activities. These failures left residents at risk for boredom and a diminished quality of life. Findings included . <Facility Policy> According to the facility's revised June 2018 Activity Programs policy, the purpose of the activity program was to support residents' wellbeing with independent and group activities. The policy showed activity programs were designed for maximum individual participation. <Resident 95> According to the 06/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 95 was assessed with a slightly impaired mood and diagnoses including anxiety and depression. The MDS showed all activity preferences were very important to Resident 95. The MDS showed Resident 95 was dependent on staff to get out of bed. Record review showed a 09/19/2023 Activities Care Plan (CP) developed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice to attain or maintain their highest practicable level of well-being for 2 of 5 residents (Resident 60 & 85) reviewed. The facility failed to ensure Resident 60 was provided pain management, services for loose stools, or follow the Care Plan (CP) for 1 of 1 residents for edema (swelling caused by too much fluid trapped in the body tissue). These failures placed the residents at increased risk of worsening conditions, discomfort, and a decreased quality of life. Findings included . <Pain Management> <Facility Policy> Review of the facility's undated Wound Care policy showed the policy included guidelines for preparation of wound care, reviewing the resident's CP to determine any special needs of the resident including administering pain medication prior to wound care. Review of the facility's Skin Breakdown-Clinical Protocol policy revised…

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

Based on observation, interview, and record review the facility failed to ensure 2 of 4 residents (Residents 21 & 71) reviewed for bowel and bladder incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the residents at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . <Resident 21> According to the 05/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 21 had impaired memory. The MDS showed Resident 21 required one person assistance with personal hygiene and had no rejection of care behavior during the assessment period. The MDS showed Resident 21 was occasionally incontinent of bowel and bladder. Observations on 08/15/2024 at 11:29 AM showed Resident 21 was lying in bed. Resident 21's room had a strong urine odor. Observation on 08/16/2024 at 10:24 AM showed Resident 21 out of their bed with their clothes wet with urine. Resident 21 went to the bathroom, changed their clothes and sat in a chair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored, labeled, and dated when opened and/or discarded when expired for 4 of 4 medication carts (100 Hall Cart 1, 200 Hall Cart 1, 200 Hall Cart 2, & 300 Hall Cart 1) and 2 of 2 medication rooms (Unit 200 East & Unit 200 West) observed. The failure to ensure unneeded medications and medical supplies were returned to the pharmacy or discarded when expired, medication refrigerators were monitored for appropriate temperatures, and medications were labeled for individual use placed residents at risk for ineffective treatment, expired medications, and contaminated medications Findings included . <Facility Policy> According to the facility's revised November 2020 Storage of Medications Policy, drugs and biologicals must be appropriately stored, including being locked and kept at the correct temperature. This policy showed nursing staff were responsible to ensure medication storage areas were clean. The policy showed discontinued, outdated, and deteriorated medications should be disposed of or returned to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to provide cares and services consistent with professional standards of practice to promote the healing of existing pressure ulcers. Failure to provide the dietary supplement, Impact Advanced Recovery Oral Liquid, that 1 (Resident 1) of 8 residents reviewed for dietary supplements as ordered, left Resident 1 at risk for a decline in wound healing and weight loss. Findings included . Resident 1 was admitted to the facility on [DATE] for skilled nursing care related to wound care and infection of the sacrum (lowest 5 bones of the spine). Physician Orders (PO) showed Impact Advanced Recovery Oral Liquid (IAROL- nutritional supplement for wound healing) was ordered on 08/22/2023 and to be given one time a day, for 62 days, to aid in wound healing. Review of the admission Minimum Data Set (MDS-an assessment tool) dated 08/28/2023, showed Resident 1 admitted with bone infections of the lower vertebra (back bones), the tailbone, and an unstageable…

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

Based on observation, interview, and record review the facility failed to maintain clean, sanitary surfaces and equipment in the kitchen and care floor utility rooms in accordance with standards for food service safety. The failure to 1) maintain a clean/sanitized kitchen, 2) maintain clean/sanitized ice machines, 3) maintain clean/sanitized microwaves, and 4) monitor/maintain resident refrigerator temperatures, placed residents at risk for cross-contamination, food-borne illnesses, and diminished quality of life. Findings included . <Kitchen Sanitation> Initial kitchen observation on 06/08/2023 at 8:50 AM showed four metal kitchen racks holding clean pots, pans, bowls, and warming pans. The racks had multiple areas of rust and were layered with dust and had dust webs hanging from the upper shelves over the clean cookware. The dust on the underside of the rack was removed with a swipe of a bare hand. The ledge on the wall behind the racks of clean cookware had a thick layer of dark dust that could be removed with a finger swipe. The corners of the floors had food debris and crumbs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conveyance (the act of legally transferring property from one entity to another) of a resident's trust funds, including a final accounting of those funds within 30 days of discharge for 2 of 2 discharged residents (Residents 602 & 603) reviewed for trust accounts. This failure prevented the residents from having access to their funds after leaving the facility. Findings included . Review of the 06/07/2023 facility trust fund balance sheet showed Resident 602 had a balance of $75.39. Resident 603 had a balance of $600.59. In an interview on 06/09/2023 at 2:28 PM, Staff BBB (Business Office Assistant) stated Resident 602 discharged [DATE] and Resident 603 discharged on 05/06/2022. In an interview on 06/09/2023 at 2:32 PM, Staff AAA (Business Office Manager) confirmed Resident 602 and Resident 603 discharged and both had money in their trust fund. Staff AAA stated it was important to refund money because it belongs to the resident to use for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided. Facility failure to: maintain a clean and homelike environment on 3 of 4 units (the 2 East Unit & the 100 Unit); ensure handrails were secure for 2 of 4 units (the 100 Unit & the 300 Unit); ensure residents were able to secure their property for 1 of 29 sample residents (Resident 113), left residents at risk for a less then homelike environment, and missing property. Findings included . <Resident Rooms> Observation on 06/08/2023 at 8:58 AM showed 2 boxes of incontinence supplies left on the floor on the bed 2 side of room [ROOM NUMBER]. The top dresser drawer on the bed 2 side was crooked and did not close fully. Observation on 06/08/2023 at 2:17 PM showed Resident 23's half of room [ROOM NUMBER] was cluttered and un-homelike. The wall behind Resident 23's bed was observed with 18 spots where the drywall was repaired but not repainted, including an 18-inch-high patch of wall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 9 (Residents 13, 91, 10, 68, 137, 58, 42, 76 & 98) of 29 residents' Minimum Data Sets (MDS- an assessment tool) were completed accurately to reflect the residents' condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 13> According to the 03/23/2023 quarterly MDS, Resident 13's primary language was Cantonese. The MDS showed Resident 13 completed a Brief Interview for Mental Status Assessment (BIMS - an assessment of memory and orientation to time) and was unable to answer any of the questions. In an interview on 06/13/2023 at 12:09 PM, Staff CC (Social Services) stated they were unable to determine from the assessment if Resident 13 answered the BIMS questions with the assistance of an interpreter or not. Staff CC stated it was noted in the record as of July 2022 that Resident 13 was unable to complete a BIMS assessment and that instead staff should assess Resident 13's memory/time orientation status. Staff CC stated they were unaware of any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: Care Plans (CPs) were implemented and revised as needed for 10 of 32 sample residents (Residents 10, 136, 137, 48, 84, 95, 58, 113, 74, & 132 ) and care planning conferences were conducted as required for 1 of 8 sample residents (Resident 23). These failures placed residents at risk for unmet care needs and negative health outcomes. Findings included . <Care Planning Conferences> <Resident 23> The 05/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 23's preferences for choice of clothing, taking care of their belongings, choosing between a bath and shower, bed time, private phone use, and having a place to secure their things were very important to them. The MDS showed Resident 23 had medically complex diagnoses including dementia, malnutrition, anxiety, and kidney issues requiring hemodialysis (a treatment to filter wastes and water from the blood). In an interview on 06/08/2023 at 2:16 PM, Resident 23 stated they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rotate injection sites for 1 (Resident 76) of 32 sampled residents, monitor for adverse side effects for 1 (Resident 98) of 32 sampled residents, follow Physician Orders (POs) for 2 (Residents 68 & 41) of 32 sampled Residents, clarifying POs for 3 (Residents 68, 48 & 42) of 32 sampled residents, signing for tasks not completed for 1 (Resident 68) of 32 sampled residents, and providing treatment without a PO for 1 (Resident 58) of 32 sampled residents. These failures placed residents at risk for unmet care needs, adverse side effects of medications going unnoticed by nursing staff, and other negative health outcomes. Findings included . <Injection Sites> <Resident 76> Review of a 05/08/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 76 had a diagnosis of diabetes (a blood sugar disorder). Review of Resident 76's June 2023 Medication Administration Record (MAR) showed Resident 76 received an injection 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 residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided necessary assistance for 7 (Residents 68, 84, 41, 42, 76, 11 & 132) of 12 sample residents reviewed. Failure to provide assistance to residents who were dependent on staff for bathing, oral care, nail care, assistance to get out of bed, and dressing placed residents at risk for unmet needs, poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Resident 68> According to a 05/18/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 68 had multiple medically complex diagnoses including a stroke and required physical assistance from staff for bed mobility, transfers, and personal hygiene, and was totally dependent on staff for bathing. This MDS showed staff assessed Resident 68 to be cognitively intact and had no rejection of care during the assessment period. According to 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 activity programs met the needs of each resident for 5 of 8 residents (Residents 23, 48, 74, 132 & 61) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 06/2018 Activity Evaluation policy, activities were assessed in order to promote the physical, mental, and psychosocial well-being of residents. Assessments were conducted at least quarterly and with any change that could affect resident participation. <Resident 23> The 05/15/2023 Activity Participation Review showed Resident 23's favorite activities, special accomplishments, and/or new interests included reading a lot of books, watching TV/Movies, Coloring, Crochet[ing], and utilizing [their electronic] tablet . According to the 05/23/2023 quarterly Minimum Data Set (MDS - an assessment tool) Resident 23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review the facility failed to ensure 4 of 5 (Residents 13, 48, 42, & 113) residents reviewed for positioning, Range of Motion (ROM), and mobility, and 1 supplemental resident (Resident 84) received the care and services they were assessed to require. These failures placed residents at risk for decline in ROM, increased dependence on staff, and a decreased quality of life. Findings included . <Resident 13> According to the 03/23/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 13 had diagnoses including stroke, left-sided immobility, loss of speech, and used a wheelchair. The MDS showed Resident 13 was totally dependent on staff assistance for bed mobility and transfers. The 07/31/2019 Requires assistance with ADLs [Activities of Daily Living] . Care Plan (CP) included a 07/31/2023 intervention for left arm trough (a scooped arm rest that provided additional support for a person whose arm was immobilized). The 11/06/2020 Limited Physical Mobility . CP…

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

Based on observation, interview, and record review the facility failed to ensure the facility was free of accident hazards for 4 of 9 residents (Residents 91, 95, 113 & 66) reviewed for accidents and 3 supplemental residents (553, 74 & 61). The failure to ensure mattresses were installed correctly (Residents 91, 113 & 66), wheelchair brakes were not used when not required by the resident (Residents 553, 95 & 61), and resident bedsides were free of hazards (Resident 74) left residents at risk for accidents, injuries, and other negative health outcomes. Findings included . <Resident Beds and Mattresses> <Resident 91> According to the 04/18/2023 quarterly Minimum Data Set (MDS - an assessment tool) Resident 91 had severe memory/time orientation impairment, required extensive assistance with bed mobility and transfers. The MDS showed Resident 91 had diagnoses including non-traumatic brain dysfunction, dementia, and left hip pain. The 05/01/2023 Falls Risk Assessment showed Resident 91 fell while a resident and took medications that increased their risk of falls. The assessment showed…

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

Based on observation, interview, and record review the facility failed to ensure proper consistency and nutritional value was maintained to meet the nutritional needs for 21 residents prescribed a ground (crushed/ minced) and/or pureed (pudding-like) textured diet. The failure to follow the written recipe did not ensure the proper consistency or flavor of food served and placed the residents at risk for a diminished dining experience, and inadequate nutritional intake potentially leading to malnutrition and weight loss. Additionally, the facility failed to provide food that was palatable, attractive, and an appetizing temperature for 2 of 10 resident (Residents 125 & 66) reviewed for food and nutrition services. This failure placed residents at risk for a diminished dining experience, less than adequate nutritional intake, and potential weight loss. Findings included . <Food Meets Nutritional Needs> Review of the 06/08/2023 Diet Type Report showed seven residents were prescribed a pureed texture diet. The report showed 14 residents were prescribed a ground texture diet. A total of…

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

Based on observation, interview, and record review, the facility failed to provide food that accommodated residents' food preferences and/or intolerances, provide options of similar nutrient value or provide opportunity to residents to request a different meal choice for 5 of 16 sampled residents (Residents 68, 137, 48, 11 & 23) and 1 supplemental resident (Resident 67) reviewed for food choices. The failure to 1) offer residents choices of foods served to them at meals, 2) provide food that followed the residents' personal likes/dislikes, 3) offer substitutions when residents were served foods they did not like and/or 4) offer replacements or supplements when meals were not eaten, placed residents at risk for malnutrition, weight loss and diminished quality of life. Findings included . <Facility Policies> The revised 7/2017 Resident Food Preference facility policy showed the food services department would 1) identify resident food preferences within 24 hours of admission, 2) interview the resident directly to determine current food preferences, 3) document food and eating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to consistently implement hand hygiene during care for 4 of 4 units (2 East, 2 West, and 3rd Floor), ensure staff used required Personal Protective Equipment (PPE - gowns, gloves, or masks) appropriately while providing care for a resident under isolation precautions for 1 of 1 resident(Resident 55) requiring isolation and ensure shared resident equipment was clean on 1 of 4 units (2 West). These failures placed the residents at risk for exposure to infectious diseases. Finding included . <Hand Hygiene> The facility's 08/2019 Hand Hygiene policy showed staff were expected to perform hand hygiene before and after direct contact with residents, after contact with objects in the immediate vicinity of the residents, before and after handling food, and before and after assisting a resident with meals. Observation on 06/08/2023 at 11:54 AM showed Staff FF (Certified Nursing Assistant - CNA) entered room [ROOM NUMBER] and moved the over-bed table in front 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 allow 4 (Residents 68, 48, 66, & 125) of 8 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing, ability to access the community at leisure, and have access to water pitchers. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . <Bathing> <Resident 68> According to a 05/18/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 68 was cognitively intact with clear speech, able to make self-understood, and understands others. This MDS showed it was very important for Resident 68 to choose between a tub bath, shower, bed bath, or sponge bath and was assessed to be totally dependent on staff for bathing. According to a 05/11/2023 Activities of Daily Living (ADL) Care Plan (CP) Resident 68 required assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were hospitalized emergently were offered a bed hold (the opportunity to pay for the bed the resident currently occupied while out of the facility in order to ensure their bed/room was available when ready to return) for 2 of 7 residents (Resident 121 & 58) reviewed for hospitalization. Failure to offer bed holds placed residents at risk for unwanted, avoidable room changes upon readmission, and frustration. Findings included . <Resident 121> According to the 05/10/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 121 readmitted to the facility on [DATE] from an acute hospital. The MDS showed Resident 121 had medically complex diagnoses including Diabetes Mellitus (difficulty controlling blood sugar), a bone infection, and a chronic ulcer (non-healing skin wound) of the left heel and midfoot. In an interview on 06/08/2023 at 10:18 AM Resident 121 stated they were hospitalized a couple of times since first…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 (Resident 137 & 58) 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 137> According to the 03/27/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 137 had multiple medically complex diagnoses including anxiety and required the use of an antianxiety and antidepressant medication. Review of March, April, and May 2023 Medication Administration Records showed Resident 137 was receiving a medication for depression. Review of a 05/26/2023 Level 1 PASRR showed staff identified Resident 137's only Serious Mental Illness (SMI) indicator was an anxiety disorder. Staff did not identify Resident 137 had depression and required the use of medications. In an interview on 06/14/2023 at 12:34 PM, Staff M (Social Service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop person-centered comprehensive Care Plans (CPs) for 4 (Residents 68, 58, 76, & 98) of 32 residents whose CPs were reviewed. Facility failure to develop individualized, comprehensive CPs left residents at risk for unmet care needs. Findings included . <Resident 68> According to a 05/18/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 68 had multiple complex medical diagnoses including heart failure. In an interview on 06/08/2023 at 12:17 PM, Resident 68 stated, I have plenty of trouble with my teeth and indicated they had some broken teeth. The resident stated they were not able to hear others very well. On 06/10/2023 at 9:28 AM Resident 68 stated they were unable to read their daily newsletter because their glasses were not too helpful. Review of a 05/16/2023 Care Conference assessment showed staff identified Resident 68 had poor dental status with chipped teeth, poor hearing status, with no hearing aids, and was hard of hearing, A 05/18/2023 Activities admission progress note showed…

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

Based on observation, interview, and record review, the facility failed to ensure communication needs were met for 3 of 11 residents (Residents 91, 13 & 74) reviewed for alternative communication. Failure to ensure care planned communication interventions were implemented left residents at risk for unmet needs, frustration, social isolation, and a diminished sense of well-being. Findings included . <Resident 13> According to the 03/23/2023 quarterly Minimum Data Set (MDS - an assessment tool) Resident 13 was assessed with no speech. Resident 13 was assessed to rarely/never understand or be understood in conversation. The MDS showed Resident 13's vision was highly impaired and they did not use corrective lenses. Resident 13's 11/02/2022 Care Area Assessment (CAA) worksheet showed Resident 13 was at risk for having unmet needs related to their language and speech difficulties. The CAA showed Resident 13 did not understand English. The 07/31/2019 Communication Deficit . Care Plan (CP) showed Resident 13 was able to nod and smile when spoken to. The CP included interventions to maximize…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 newly identified skin issues, were assessed, and treated as required for 3 of 10 residents reviewed for skin conditions (Resident 13, 58, & 132); provide treatment residents were assessed to require for 2 of 29 sample residents (Residents 91 & 121); reposition the resident according to the Care Plan (CP) for 1 of 10 residents (Resident 95). These failures placed residents at risk for avoidable or worsening skin issues, and other negative health outcomes. Findings included . <Skin Impairments> <Resident 13> According to the facility's 2018 Pressure Ulcers [PU]/Skin Breakdown - Clinical Protocol for a wound, nurses completed a full assessment of the wound including location, stage (assessment of severity), length, width and depth, presence of exudate (drainage) or necrotic (dead) tissue. The policy showed the physician should help identify the factors that contributed to the wound development, clarify any relevant medical issues, and order pertinent treatments such as pressure reducing approaches,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and recommendations were reviewed and incorporated for 3 of 5 (Resident 58, 76, & 98) residents reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes and at risk of receiving medications without required pharmacist oversight. <Facility Policy> According to a January 2023 MRR and Reporting facility policy, the MRR consisted of a review of residents' medical records in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. This policy indicated the facility's consultant pharmacist would review the medication regimen of each resident at least monthly. MRR recommendations and findings would be documented and acted upon by the nursing care center and/or physician. A record of the consultant pharmacist's observations and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents remained free of unnecessary psychotropic medications for 2 (Residents 48 & 58) of 5 sample residents whose medications were reviewed for unnecessary psychotropic medications. Failure to identify the adequate indications for use/extended use, identify triggers or specific behaviors, document behaviors, attempt Gradual Dose Reductions (GDR) or implement non-pharmaceutical interventions before administering medication, and failure to obtain informed consent prior to administration of Anti-Psychotic (AP) medications placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related adverse side effects (ASE), and diminished quality of life. Findings included . <Facility Policy> The revised [DATE] Antipsychotic Medication Use facility policy showed the need to continue PRN (as needed) orders for psychotropic medications beyond 14 days required the practitioner to document the rationale…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: (1) medications were labeled with pharmacy labels to include the resident's name, cautionary instructions, and expiration dates when applicable, (2) expired medications were disposed of timely for 2 of 4 (2 [NAME] Medication Cart A and B) medication carts and 1 of 2 (2 [NAME] Medication Room) medication rooms reviewed for medication labelling and storage, and (3) medications were secured for 1 of 1 (Resident 68) residents observed with medications at bedside. These failures placed residents at risk for medication errors, receiving compromised medications with decreased or no potency, and inadvertent self-administration of medications by residents. Findings included . <Facility Policy> The 2007 Medication Storage facility policy showed medications should be stored properly, and staff should follow manufacturer's or pharmacist's recommendations to support safe and effective drug administration. The policy instructed the pharmacist to dispense medications in containers that met state and federal labeling requirements.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt dental services were provided for 1 of 9 (Resident 113) residents reviewed for dental care. This failure placed Resident 113 and all other residents at risk for unmet dental needs, and a diminished quality of life. Findings included . <Facility Policy> The revised 12/2013 Dental Examination/Assessment facility policy showed each resident would undergo a dental assessment prior to or within 90 days of admission. The policy showed dental examinations were conducted either by the resident's personal dentist or by the facility consultant dentist. The policy outlined, upon completion of dental examination, residents in need of dental care services would be promptly referred to a dentist, and records of dental care provided were made part of the resident's medical records. <Resident 113> According to the 10/30/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 113 was admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of Antibiotics (ABO's) and reduce the risk of unnecessary ABO use for 2 of 3 (Residents 452 & 58) residents reviewed for unnecessary ABO's.This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate / unnecessary use of ABO's. Finding included . <Facility Policy> The facility's 12/2016 Antibiotic Stewardship policy showed the purpose for their ABO stewardship program was to monitor the use of ABOs in their residents. This policy showed the facility expected, when a Culture and Sensitivity (C&S) was ordered, that those results and current clinical situation would be communicated with the facility provider as soon as available to determine if ABO therapy should be continued, modified, or discontinued. <Resident 452> Review of Resident 452's physician orders showed that an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (Resident 48) of five residents reviewed for unnecessary medications reviewed for vaccinations, received information on the current recommendations from the Center for Disease and Control and Prevention (CDC) related to Influenza and Pneumococcal vaccinations, and failed to ensure residents were offered the recommended vaccinations. This failure placed residents at risk for contracting Influenza and pneumonia, with its associated complications of infection. Findings included . According to the revised October 2019 Pneumococcal Vaccine policy, prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. Assessments of pneumococcal vaccination status would be conducted within 5 working days 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.

Based on observation, interview, and record review the facility failed to: (1) assess the compatibility of the mattress used and/or purchased separately from the bed frame for unsafe gaps, and (2) conduct routine inspections of all bed frames and mattresses as part of a regular maintenance program for 2 of 2 (Resident 113 & 66) resident beds reviewed for accident hazards. These failures placed residents at risk for injury, entrapment, or death. Findings included . <Food and Drug Administration (FDA) Document> The 03/10/2006 FDA document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, identified seven potential zones of entrapment: Zone 1- Within the Rail, Zone 2- Under the Rail, Between the Rail Supports or Next to a Single Rail Support, Zone 3- Between the Rail and the Mattress, Zone 4- Under the Rail at the Ends of the Rail, Zone 5- Between Split Bed Rails, Zone 6- Between the End of the Rail and the Side Edge of the Head or Foot Board, and Zone 7- Between the Head or Foot Board and the End of the Mattress. The document showed facilities…

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