Avamere Olympic Rehabilitation Of Sequim

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure peripherally inserted central catheters (PICC, a long, flexible tube inserted into a vein in the arm, used for prolonged intravenous access to deliver medications, fluids, and nutrition) were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 73 & 84) reviewed for IV therapy. This failure placed residents at risk for unidentified complications, loss of vascular access, infection, and other potential negative health outcomes.Findings included . Review of the facility's Vascular Access Devices and Infusion Therapy Procedures policy, dated August 2021, showed upon admission or insertion staff would measure the PICC external length and the residents arm circumference 10 centimeter (cm) above the insertion site, to establish a baseline. The PICC external length would then be measured weekly with PICC dressing changes and compared with the baseline measurement to rule out line…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 1 resident (Resident 73) reviewed for respiratory care and services. The failure to document when oxygen was administered, to check and replace empty portable oxygen cylinders, and ensure humidifier bottles contained fluid and were functional, placed residents at risk for respiratory compromise and/or unmet respiratory needs. Findings included . Resident 73 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident had diagnoses of heart failure and pulmonary hypertension (high blood pressure in the arteries connecting your heart to your lungs) and received oxygen therapy during the assessment period.Review of Resident 73's electronic medical record showed the following 11/04/2025 oxygen orders:-Oxygen 1-2 liters via nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reevaluate the necessity and safety of bed rails/mobility bars for 2 of 2 residents (Residents 12 & 8) reviewed for bed rails. This failure placed residents at risk of accidents and a diminished quality of life.Findings included.Review of the facility policy titled Assistive Devices and Equipment, revision date of 2/2021, showed the facility was to assess the appropriateness for resident condition, personal fit, device condition, and staff practices, to decrease the risk of avoidable accidents associated with the devices and equipment.Resident 12Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia (decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, reasoning issues, and personality changes). The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's falls care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monthly pharmacist recommendations were carried out accurately and timely, for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure placed residents at increase for accidents, unnecessary medication, complications, and a diminished quality of life.Findings included.Review of the facility policy titled Medication Monitoring Medication Regimen Review and Reporting, dated 01/2024, documented the nursing care center would follow up on the recommendations to verify that appropriate action had been taken, with recommendations acted upon within thirty calendar days or per facility specific protocols. For issues that required physician intervention, the provider was to either accept the recommendation or to document their rational of why the recommendation was rejected in the medical record.Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia. The Quarterly Minimum Data Set (MDS) assessment, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was properly stored and labeled in refrigerators, food temperatures were checked without preventing cross contamination, and the resident snack refrigerators were monitored in accordance with professional standards for safe food service. These failures placed the residents at potential risk for food borne illnesses, and a diminished quality of life.Findings included .Initial RoundsOn 12/01/2025 at 10:50 AM, an unidentified item in the dairy refrigerator without a date on it was observed. Staff BB, Registered Dietician, said it was a cake and she could not find a date on it and threw it away. Also observed was a stick of butter partially used with the excess paper crumbled around it. When asked if there was a date on it, Staff BB said no and it should have been placed in a container. Staff BB placed the butter in a container and dated it before she placed it back in the refrigerator.On 12/01/2025 at 10:51 AM, in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' records were accurate and complete for 10 of 24 sampled residents (Resident 9, 81, 6, 52, 10, 26, 31, 7, 1, & 37) reviewed for resident records. The failure to document resident information accurately and completely, and/or correctly identify residents' primary care physician, placed the resident at risk for incomplete and inaccurate medical records and unmet care needs.Findings included .Resident 9 Resident 9 was admitted to the facility on [DATE], with diagnoses of dementia with psychotic disturbance (involves symptoms of hallucinations (seeing things not there) and delusions (fixed false beliefs)). Review of the Modification of Quarterly Minimum Data Set (MDS, an assessment tool), dated 10/04/2025, documented Resident 9 was severely cognitively impaired. Record review of Resident 9's progress notes, from 07/04/2025 through 07/17/2025, showed the following behaviors were noted. A behavior progress note, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed standard precautions (common sense practices to prevent the spread of infection in healthcare) and enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug resistant organisms and precautions that are implemented when someone has chronic wounds or confirmed or suspected infections). Additionally, the facility failed to perform infection surveillance for 1 of 1 resident (Resident 52) reviewed for surveillance. This failure placed residents at risk of undetected infection, spread of infection, and a diminished quality of life. Findings included.STANDARD PRECAUTIONS During an observation on 12/02/2025 at 11:38 AM, Staff J, Resident Care Manager/Licensed Practical Nurse, gave Resident 74 insulin (medication injected via a needle, that regulates blood sugar) without wearing gloves. During an interview on 12/02/2025 at 11:51 AM, Staff J said they did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety devices were consented for 1 of 2 residents (Resident 12) reviewed for safety devices/bed rails. This failure placed residents at risk of uninformed consent, increased chance of accidents, and a diminished quality of life. Findings included.Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia (decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, reasoning issues, and personality changes). The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's safety device assessment and consent form for their wander guard device (device worn on person or mobility aid that alarms when exiting certain doors), dated 06/05/2025, showed the device was being used to remind the resident to not leave the facility without assistance. Under potential risks (a section on the risks of using…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services in accordance with professional standards of practice and their comprehensive care plans for 4 of 22 sampled residents (Residents 1, 3, 8 & 81). The failure to initiate bowel care, identify and monitor non-pressure skin conditions, complete and document respiratory assessments, and evaluate daily weights and report significant variances to the physician, placed resident at risk for unidentified and/or avoidable decline, delay in treatment, pain/discomfort, unmet care needs and other potential negative health outcomes. Findings included . The facility's bowel care protocol dated 10/2020 documented, If a resident has not had a bowel movement for three consecutive days (must be medium or large), observe the following protocol after a physician order had been obtained.a. evening shift is to run a look back reportb. Evening shift to give milk of magnesia. If no results, thenc. Day shift to give the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 4 of 5 residents (Residents 12, 73, 59 & 17) reviewed for accident hazards. This failure placed residents at an increase for falls, injury, and a diminished quality of life. Findings included. Resident 12 Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's falls care plan, revised 11/20/2025, showed they were a high risk for falls related to limited mobility, incontinence, cognitive problems gait/balance problems, history of falls, lack of impulse control, poor communication and comprehension, poor insight and judgement, psychoactive drug use, unaware of safety needs, and hearing problems. In this care plan, 14 total falls were listed: 05/24/2025, 05/25/2025, 06/09/2025, 06/13/2025, 06/17/2025, 06/18/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and monitoring for pre and post hospitalization, including following the hospital's discharge plan of care, to prevent or treat urinary tract infections (UTIs) for 2 of 4 residents (Resident 6 & 52) reviewed for urinary catheters and hospitalization. These failures placed residents at risk for hospitalization, urinary tract infections, urethral erosion and a decreased quality of life.Findings included.Resident 6 Resident 6 was admitted to the facility on [DATE], with a diagnosis of urinary retention (an inability to completely empty the bladder). The admission Minimum Data Set (MDS, an assessment tool), dated 10/16/2025, documented Resident 6 was cognitively intact, relied on staff for most cares, and had a urinary catheter. On 12/01/2025 at 12:44 PM, Resident 6 was observed seated in their wheelchair. Resident 6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with professional standards, by not providing urostomy (urinary diversion, which is a surgical procedure to create an opening (stoma) on the abdomen to allow urine to exit the body when the bladder is not functioning or has been removed. The urine is then collected in a pouch attached to the stoma) supplies for 1 of 1 sample resident (Resident 10) reviewed for urostomy care. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Resident 10 was admitted to the facility on [DATE] with a diagnosis of acute pancreatitis (inflammation of the pancreas). The admission Minimum Data Set (an assessment tool), dated 10/07/2025, documented the resident was cognitively intact and had a urostomy.Resident 10's care plan, dated 10/01/2025, said The resident has Urostomy r/t [related to] Traumatic Injury. Interventions included Resident has Urostomy per MD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 annual performance reviews as required for 5 of 5 Certified Nursing Assistants (CNA) (Staff EE, FF, GG, HH & II) who were reviewed. Failure to complete annual performance evaluations did not ensure staff were adequately trained, and placed residents at risk for unmet care needs.Findings included . 1) Staff GG, CNA, was hired on 01/30/1996. Review of Staff GG's employee records showed the most recent annual performance review was signed on 02/22/2024 for the period of 01/30/2023 - 01/30/2024. No annual performance review was completed in the previous 22 months. 2) Staff HH, CNA, was hired on 08/11/2015. Review of Staff HH's employee records showed the most recent annual performance review was for the period of 08/01/2023 - 08/01/2024. No performance review was completed in the previous 16 months. 3) Staff II, CNA, was hired on 11/22/2021. Review of Staff II's employee records showed the most recent annual performance review was signed on 01/06/2024. No annual performance review was completed in the previous 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.

Based on observation and interview, the facility failed to maintain locked medication carts for 1 of 5 medication storage carts (Pine Ave Nurses station) when reviewed for medication storage. This failure placed the residents at risk for missing medications, medication discrepancies and impaired quality of life.Findings included.On 12/09/2025 at 10:57 AM, observation of unlocked medication cart parked at the Pine Ave Nurses station. No staff were present or around mediation cart. On 12/09/2025 at 11:11 AM, Staff R, Infection Preventionist, walked past the medication cart with a visitor. After escorting the visitor to the exit, Staff R was stopped and asked to open the medication cart. Staff R opened the medication cart without having to use keys. When asked what the expectation was when staff walked away from a medication cart, Staff R said the cart should have been locked. Staff R said the medication cart should have been locked. On 12/09/2025 at 11:24 AM, Staff C, Assistant Director of Nursing Services, was provided with details of unlocked mediation cart observation. When asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program with monitoring, documentation, reevaluation and/or education for three of three months (August 2025, September 2025, and October 2025) reviewed, and for 1 of 1 resident reviewed (Resident 8) for prophylactic (usage to prevent disease) antibiotic usage. This failure placed residents at risk for unnecessary antibiotics, an increased risk of infections and a decreased quality of life.Findings included.According to the facility's Antibiotic Stewardship Policy, revised December 2016, the purpose of the Antibiotic Stewardship Program was to monitor the use of antibiotics for the facility's residents. The policy documented that orientation, training, and education of staff would emphasize the importance of antibiotic stewardship and would include how inappropriate use of antibiotics affects individual residents and the overall community.Review of the facility provided document Minimum Criteria for Initiating…

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

Based on interview and record review, the facility failed to develop, implement and maintain an in-service training program that ensured nursing assistants (NA) completed the required 12 hours of annual Inservice training for 1 of 5 NAs (Staff EE) reviewed for annual training hours. The failure to ensure NAs completed 12 hours of annual training as required, placed residents at risk of receiving inadequate care.Findings included . Review of Staff EE's, NA, employee file showed they were hired on 09/29/2022. Staff EE's in-service training records for the period of 09/29/2024 -09/29/2025 showed Staff EE completed 4.25 training hours, 7.75 hours short of the 12 hours required per year to ensure continuing competence. On 12/08/2025 at 12:37 PM, When asked if Staff EE met the requirement for 12 hours of training annually Staff R, Infection Preventionist, stated, No, he didn't complete the training. Reference WAC 388-97-1680(2)(a-c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to identify and prevent an allegation of neglect, failed to suspend staff members alleged to have neglected residents and failed to initiate the investigation and assess and monitor residents in a timely manner for three of three residents (Residents 1, 2 and 3) reviewed for neglect. These failures placed residents at risk for continued neglect and a diminished quality of life.Findings included .Review of the Washington State Department of Social & Health Services Nursing Home Guidelines -The Purple Book (guidelines to assist nursing homes with compliance of the State and Federal requirements for the prevention, identification, reporting, and investigating incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, exploitation, and misappropriation of nursing home residents), dated October 2015, showed the facility must begin an immediate investigation of alleged violations in order to collect accurate data and take immediate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review, the facility failed to ensure activities of daily living (ADLs) pertaining to bathing/showers were provided for dependent residents for 5 of 9 residents (4, 5, 6, 7, and 8) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life. Findings included . Review of the facility policy titled, Supporting Activities of Daily Living, revised March 2018, showed residents who were unable to carry out ADLs independently would receive services necessary to maintain good hygiene, this included bathing, grooming and oral care. Review of the facility grievance log for 01/01/2025 to 01/28/2025 showed three residents reported not receiving showers. Two were included in the sample below (Resident 4 and 5). <Resident 4> Resident 4 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS/an assessment tool), dated 12/25/2024 showed that 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 provide care and services consistent with professional standards for 2 of 9 Residents (Residents 1 and 2) reviewed for Quality of Care when the facility staff failed to monitor the residents for psychosocial harm following allegations against staff members. This failure placed all residents at risk for psychosocial harm, unmet care needs and decreased quality of life. Findings included . <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS/an assessment tool), dated 12/13/2024, documented Resident 1 had mild cognitive impairment and was medically complex. The facility investigation, dated 01/19/2025, showed Resident 1 alleged a staff member did not like her and purposely left her in bed. The facility investigation, dated 01/20/2025, showed that during the investigation of the 01/19/2025 allegation, Resident 1 made an additional allegation that another staff member refused to toilet them 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 maintain an effective infection control program by ensuring staff had appropriate personal protective equipment (PPE) available for 3 of 3 units and that staff donned (put on) appropriate PPE for residents on droplet precautions (infection control precaution of wearing mask and eye protection upon entering the room and gown and gloves for potential for exposure to secretions) for 2 of 5 residents (Resident 3 and 9) reviewed for infection control practices. Also, the facility failed to include the Infection Preventionist (IP) on the water management panel and ensure all control measures of the Legionella Water Management Program were implemented when routine chlorine testing and routine resident room faucet inspections and cleaning were not performed. These failures placed residents at risk for spread of infection, health complications, and a diminished quality of life. Findings included . The facility policy titled, Isolation-Categories…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there were sufficient qualified nursing staff to provide restorative nursing services for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed for restorative nursing. Additionally, review of Resident Council Minutes for June, July and August 2024, showed 3 of 3 months contained resident complaints related to staffing. The failure to have sufficient qualified nursing staff to respond timely to resident call lights and care needs, and that ensured the provision of restorative nursing programs (RNPs) residents had been assessed to require, placed residents at risk for a decline in strength, range of motion, contracture formation, increased dependence on staff for activities of daily living (ADLs), unmet care needs and decreased quality of life. Findings included . <Facility Assessment> Review of the facility's assessment, dated 07/10/2024, showed residents' ADLs were supported by restorative aides who helped residents with ROM, contractures, and splint application…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 6 sampled residents (Residents 25, 63, and 171) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 25> Resident 25 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 07/15/2024, documented Resident 25 was cognitively intact. Resident 25 was diagnosed with generalized anxiety (mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), major depressive disorder (mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure restorative nursing programs (RNPs) to increase, maintain and/or prevent decline in range of motion (ROM ), strength and mobility were provided for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed, who were assessed to require them in December 2023, when the facility stopped providing restorative services due to staffing issues. Additionally, after the facility reimplemented restorative nursing services, they failed to provide a restorative range of motion program at the frequency the resident was assessed to require for 1 of 1 resident (Resident 2) reviewed. These failures placed residents at risk for a decline in strength, range of motion, contracture formation, increased dependence on staff for activities of daily living (ADLs), and decreased quality of life. Findings included . On 09/26/2024 at 12:25 PM, Staff N, Assistant Director of Nursing (ADON)/ Restorative Nurse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 62> Resident 62 admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/13/2024, showed the resident was cognitively intact, had diagnoses of depressive (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorders (repeated episodes of intense anxiety, fear or terror) and received antidepressant and antianxiety medications during the assessment period. Review of Resident 62's electronic health record (EHR) showed the following psychotropic medication orders: a) 08/05/2024 order for mirtazapine (an antidepressant) daily at bedtime for major depression. b) 07/09/2024 order for Seroquel (an antipsychotic) daily at bedtime for unspecified dementia with other behavioral disturbances. Review of the EHR showed no documentation to show an Abnormal Involuntary Movement Scale (AIMS, a test to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to label and store drugs and biologicals used in the facility in accordance with current accepted professional principles for 2 of 3 medication carts ([NAME] & Dungeness) and 1 of 3 medication rooms (One) reviewed for medication storage and labeling, and 1 of 21 rooms for sampled residents (Resident 27). This failure placed residents at risk for decrease effectiveness of medication, worsening symptoms, unidentified complications, and a diminished quality of life. Findings included . <Medication Room> During an observation and interview of medication room one on [DATE] at 3:25 PM, a vial of Tuberculin Purified Protein (proteins used for the tuberculin skin test for diagnosis of tuberculosis) was observed to be opened without a date listed. Staff N, Assistant Director of Nursing (ADON), stated that the vial was opened, not dated, and should have been dated. Observation of a vial of Insulin Lispro (medication used to control blood sugars 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 interview and record review, the facility failed to ensure residents' medical records were complete accurate and readily accessible for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed for restorative services and for 1 of 1 Resident (Resident 11) reviewed for Hospice services. The facility failed to maintain documentation of the provision of restorative nursing services for residents who were assessed to require them. Additionally, the facility failed to maintain hospice documentation inlcuding details regarding coordination with hospice services, hospice recertification and details regarding visits by hospice staff. These failures resulted in residents' health records being incomplete and/or inaccurate and placed residents at risk for unmet care needs and potential negative health outcomes. Findings included . <Hospice Documentation> Resident 11 admitted to the facility on [DATE]. Review of the [DATE] Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were informed of the risks and benefits associated with proposed psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain the residents'/resident representatives' consent prior to administering the medication for 2 of 6 residents (Residents 62 and 63) reviewed for unnecessary medications. This failure prevented residents from making an informed decision about the use of the proposed medication and precluded the resident from exercising their right to decline such treatment therapy and from exercising their right to refuse/decline the proposed medication. Findings included . <Resident 62> Resident 62 admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/13/2024, showed the resident was cognitively intact, had diagnoses of depressive (a mood disorder that causes a persistent feeling of sadness and loss of interest) 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 provide adaptive equipment for cutting food that reflected the unique physical needs and preferences for 1 of 1 resident (Resident 63) reviewed for accommodation of needs. The facility failed to implement a plan for the resident's living environment that was conducive to their unique physical limitations and that took into consideration their needs and preferences which placed them at risk for a diminished quality of life and increased dependence on staff. Findings included . Review of the resident's comprehensive assessment showed Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, arthritis in left and right hands, malnutrition and hydrocephalus (fluid on the brain). The assessment showed Resident 63 required assistance to eat. The resident was alert, oriented and able to make their needs known. Review of Resident 63's Activities of Daily Living (ADL) care plan, revised on 09/16/2024, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to address required documentation for advance directives (AD) for 2 of 5 residents (Residents 2 and 40) reviewed for advanced directives. This failure placed the residents at risk of losing their right to have their preferences/decisions honored for end-of-life care. Findings included . <Resident 2> The resident was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/27/2024, showed the resident was severely cognitively impaired. A Care Conference Review progress note, dated 08/13/2024, said advanced directives are established. A review of Resident 2's electronic health record (EHR) showed no copy of the AD. On 09/26/2024 at 9:23 AM, Staff D, Social Services Director, said, I don't have a copy of the AD and I should have asked in August during the care conference to make sure we had it. <Resident 40> The resident was admitted to the facility on [DATE]. A review of the Quarterly MDS, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate and investigate grievances for resident concerns, maintain an accurate log of grievances and report grievances to the Administrator for review for 2 of 2 sampled resident (Residents 27 and 63) and 1 of 1 resident groups (Resident Council) reviewed for grievances. This failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievances investigated, delayed or incomplete resolution to grievances and a diminished quality of life. Findings included . The facility policy titled, Grievance, revised 01/05/2000, showed the grievance communication form would be forwarded to the administrator and the administrator would review the grievance and then forward a copy to the appropriate department manager. <Logging Grievances> The following grievances were made during Resident Council meetings on 06/24/2024, 07/22/2024, and 08/30/2024. Resident Council Meeting minutes, dated 06/24/2024, showed an unidentified resident talked about there not being enough sandwich options in the snack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of abuse and neglect were reported to the state agency for 1 of 4 sampled residents (Resident 46) reviewed for abuse/neglect. This failure placed residents at risk for experiencing potential abuse and neglect and a diminished quality of life. Findings included . A review of the facility's policy, dated April 2021, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program showed to investigate and report any allegations within timeframes required by federal requirements. Resident 46 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS, an assessment tool), dated 08/06/2024, showed the resident was cognitively intact. On 09/23/2024 at 2:14 PM, Resident 46 said a nurse at night, who's name the resident could not remember, would bring their pain medication late because the nurse was in control and because she was pissed at me. Resident 46 said the nurse would say that she didn't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly notify the Office of the State Long-Term Care Ombudsman of the discharge or transfer for 1 of 5 residents (Resident 40). This failure placed the residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and to ensure that the Offices of the State Long-Term-Care Ombudsman is aware of facility practices and activities related to transfers and discharges. Findings included . Resident 40 was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set, an assessment tool, dated 09/10/2024, showed the resident was severely cognitively impaired. A review of the Electronic Health Record showed no documentation of notification having been sent to the Ombudsman for Resident 40's transfer on 01/01/2024. On 09/26/2024 at 9:23 AM, Staff D, Social Services Director, said she did not have documentation the Ombudsman was notified 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 resident assessments accurately reflected their health status and/or care needs for 3 of 33 sample residents (Residents 11, 4 & 2) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to accurately assess whether residents had a terminal diagnosis, that residents were receiving restorative therapy or were on a physician ordered planned weight loss program, placed residents at risk for unidentified and/or unmet care needs. Findings included . 1) Resident 11 admitted to the facility on [DATE]. Review of the 09/05/2024 Annual MDS showed the resident received hospice services during the assessment period, but did not have a terminal diagnosis. Review of the electronic health record (EHR) showed the resident went on hospice on 10/08/2021 and had remained on uninterrupted services since. A 10/08/2021 Hospice Certification and Plan of Care showed two physicians signed that the resident was terminally ill with a life expectancy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 5 of 33 sampled residents (Residents 30, 10, 62, 42 & 54) reviewed for professional standards. The failure to follow and/or clarify incomplete physicians' orders, and to only sign for tasks that were completed, placed residents at risk for medication errors, complications of treatments, and other potential negative health outcomes. Findings included . 1) Resident 62 readmitted to the facility on [DATE], with orders for: a) Hydralazine (an antihypertensive) two times a day for high blood pressure, hold for a systolic blood pressure (SBP) below 110 b) Metoprolol (an antihypertensive) two times a day for high blood pressure, hold for a SBP below 110. Review of Resident 62's July and September 2024 Medication Administration Records (MARs) showed on the following occasions facility nurses administered the resident antihypertensive medications with a SBP less than 110, rather…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (ADLs) for 1 of 3 residents (Resident 58) reviewed for ADLs. Failure to provide assistance with oral care to residents who were dependent on staff for such care, placed the residents at risk for unmet needs, poor hygiene, diminished self-image, and decreased quality of life. Findings included . 1) Resident 58 admitted to the facility on [DATE]. Review of the 01/24/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had limited functional range of motion to both upper extremities, natural teeth, was dependent on staff for personal hygiene, and demonstrated no behaviors or rejection of care. An ADL self-care deficit care plan, revised 05/21/2024, showed the resident required one-to-two-person assistance with personal hygiene. On 09/24/2024 at 10:51 AM, Resident 58 stated, I don't have good care of my teeth. [Staff] don't brush them at all,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of 15 sample residents (Residents 30, 10, 62, and 63) received the necessary care and services in accordance with their comprehensive person-centered plan of care. The facility's failure to ensure residents received the care and services they were assessed to require related to edema management (Resident 30), treatment and monitoring of non-pressure skin issues (Resident 10 and 62), and positioning (Resident 63) placed residents at risk for wound decline and/or prolonged wound healing times, poorly controlled edema (swelling), delays in treatment, unmet care needs and decreased quality of life. Findings included . Review of the facility's Wound Management Guidelines policy, revised 08/25/2020, showed if a resident had a new skin alteration the licensed nurse would investigate the potential cause and develop and implement interventions. The licensed nurse would document in the resident's record the location, size, wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pressure ulcer care consistent with professional standards of practice to prevent and treat pressure ulcers for 1 of 3 sampled residents (Resident 4) reviewed for pressure ulcers. This failure placed residents at risk for developing pressure ulcers, worsening pressure ulcers, increased pain, and a diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE] with diagnoses including disorder of arteries and arterioles, unspecified (a disease that affects your arteries, the vessels that carry oxygen-rich blood away from your heart to your body's tissues) and osteoporosis (a condition in which bones become weak and brittle). The Significant Change Minimum Data Set, (MDS, an assessment tool), dated 08/13/2024, documented Resident 4 was severely cognitively impaired. Resident was documented to have two pressure ulcers, one of which was present upon admission. Resident 4 was documented as being at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to accurately document, monitor and assess resident fluid intake, to follow physician orders to obtain weights, implement nutritional interventions, and reevaluate the effectiveness of the interventions for 2 of 5 sampled residents (Resident 4 & 62) reviewed for nutrition/hydration. These failures placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unplanned significant weight loss, nutritional complications and a diminished quality of life. Findings included . <Resident 4> Resident 4 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 08/13/2024, documented Resident 4 was severely cognitively impaired. Resident 4 was placed on hospice on 08/01/2024. Resident 4's Nutritional Care Plan, dated 06/10/2024, documented Resident 4 was at nutritional risk related to diagnoses of Chronic Obstructive Pulmonary Disease (COPD, is an ongoing lung condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that cognitively impaired residents had social services to assist with obtaining a legal representative, for 1 of 21 sampled residents reviewed (Resident 171). This failure placed residents at risk for not being able to provide informed consent, confusion, unidentified and unmet care needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 171 was first admitted to the facility on [DATE]. Resident 171 had diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and generalized anxiety disorder (repeated episodes of intense anxiety, fear or terror). The Annual Minimum Data Set assessment, dated [DATE], showed Resident 171 was severely cognitively impaired, with no ability to recall. Review of document titled, Health Care Decision Declaration, dated [DATE], showed Resident 171 had a surrogate health care decision maker, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 resident (Resident 11) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care, to have documentation in residents' electronic health records that showed what hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) had visited, when they visited, and what care was provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the Hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included . Resident 11 admitted to the facility on [DATE]. Review of the [DATE] Annual Minimum Data Set (MDS, an assessment tool), showed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to maintain essential equipment in working condition for 1 of 5 refrigerators in the facility's kitchen and 2 of 4 resident nourishment refrigerators (A & B) at each nursing station. Additionally, the facility failed to maintain hot water temperatures at safe levels in 4 of 7 occupied resident rooms (102, 123, 214 & 203) and 1 of 2 dining rooms ([NAME]) reviewed for functional essential equipment. These failures placed residents at risk for food borne illness or for serious burns and decreased quality of life. Findings Included <Facility's Kitchen Refrigerator> During an interview with Staff W, Kitchen Manager, on 09/25/2024 at 11:40 AM, the digital thermometer of one refrigerator (A) read 47 degrees Fahrenheit (F) The potentially hazardous foods inside Refrigerator (A) were temped: - 3 of 10 Chef Salads for lunch this day, 55 degrees F. - 1 of 1 Ham Sandwich temped at 56 degrees F - Dessert, ambrosia, at 46 degrees F - Nutritious shakes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided met professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care when the facility failed to clarify a medication order that was entered incorrectly. This failure placed residents at risk for receiving medication at a higher dose than ordered, potential medical complications, and a decreased quality of life. Findings included . Review of the facility policy titled, Medication Orders, revised November 2014, showed the purpose was to establish uniform guidelines to receive and record medication orders. Medications ordered for PRN (as needed) would include dosage and frequency of administration. Physicians would provide timely, accurate, and complete orders. Resident 1 was admitted to the facility on [DATE]. The quarterly minimum data set (MDS), an assessment tool, dated 06/03/2024, showed Resident 1 was cognitively intact, and required staff assistance for activities of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a resident's representative were notified of significant changes related to abnormal lab values for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, delayed medical treatment, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnosis. The Annual Minimum Data Set (MDS), an assessment tool dated 10/31/2023, documented Resident 1 had moderate cognitive impairment and behaviors including refusal of care and treatment and was medically complex. A provider note, dated 10/30/2023, documented Resident 1 said she only wanted to take Tylenol and the provider was unsuccessful in educating Resident 1 regarding other treatment options. Review of Resident 1's Electronic Health Record (EHR) documented Resident 1 had blood values drawn on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure investigations were initiated for injury of unknown origin for 1 of 3 sampled residents (Resident 1) reviewed for completing thorough investigations. This failure placed residents at risk for injury, pain, and a diminished quality of life. Findings included . Facility policy entitled Care of Skin Tears, revised September 2013, documented upon discovery of an injury, staff were to initiate an Incident/Accident form and initiate investigation to determine cause and implement measures to prevent reoccurrence. Resident 1 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 07/21/2023, documented the resident was moderately cognitively impaired, did not display refusals of care, required extensive assistance from two staff members with bed repositioning and was dependent on two staff members with transfers and personal hygiene. A Nursing Care Note, dated 07/25/2023 at 6:38 PM and written by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure monitoring for anticoagulant (blood thinner) medication complications and side effects were completed for 6 of 6 sampled residents (16, 19, 44, 49, 63 & 233) reviewed for unnecessary medications related to anticoagulant medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life. Findings included . 1) Resident 49 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/07/2023, documented Resident 49 was cognitively intact. A Physician's order, dated 06/01/2023, documented Resident 49 was ordered Eliquis, an anticoagulant medication. Resident 49's Anticoagulant Medication Care Plan, dated 05/02/2023, documented, The resident is on Anticoagulant therapy: Eliquis r/t: [related to] Atrial fibrillation. An intervention documented to monitor/document/report to MD [physician] PRN [as needed] s/sx [signs or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure general infection control practices were implemented to prevent the spread of COVID-19 (a highly contagious infectious disease) for 2 of 3 halls (Greywolf hall and 300 hall) and failed to ensure staff completed hand hygiene when required during wound care for 1 of 1 sampled residents (Resident 9) reviewed for infection prevention and control. These failures placed residents at risk of infection from COVID-19, wound complications and a diminished quality of life. Findings included . Review of facility policy entitled COVID-19 Management Overview Policy for Infection Control, dated 04/28/2023, documented the facility should initiate the Outbreak Management Checklist for COVID-19 in Avamere Long Term Care Centers upon suspected or confirmed outbreak situations. Review of the facility document entitled Outbreak Management Checklist for COVID-19 in Avamere Long Term Care Centers, revised 09/28/2022, documented the facility should increase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 2 sampled residents (9) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . Resident 9 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/25/2023, documented Resident 9 was moderately cognitively impaired. Resident 9's Electronic Health Record (EHR) documented a transfer to the hospital on [DATE] with a readmission on [DATE]. The EHR did not show documentation of a bed-hold notice for the transfer. On 08/10/2023 at 12:05 PM, Staff F, Resident Care Manger and Registered Nurse (RN), said a bed-hold notice was sent with the resident at the time of transfer to the hospital. Staff F said if the bed-hold…

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

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 (PASARR), a screening tool used to identify mental health needs, was accurate for 1 of 5 sampled residents (44) reviewed for PASARR. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life. Findings included . Resident 44 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 07/30/2023, documented the resident was moderately cognitively impaired. Review of Resident 44's Electronic Health Record (EHR) documented a Level 1 PASARR was completed on 11/21/2022, indicating Resident 44 had no mental health diagnoses. The EHR showed on 02/09/2023 Resident 44 was diagnosed with Unspecified Psychosis not due to a substance or known physiological condition (people who experience psychotic disorder symptoms that do not match the criteria for a psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall prevention strategies were implemented before a fall with injuries and failed to monitor and follow the treatment plan after a fall with injury for 1 of 2 sampled residents (Resident 19) reviewed for accident hazards. This failure place residents at risk for injuries, unmet care needs, and a diminished quality of life. Findings included . Facility policy entitled Neurological Assessment, revised October 2010, documented staff should start neurological assessments after an unwitnessed fall and following a fall with head trauma. Staff should record the assessment in the resident's medical record. Facility policy entitled Alert Charting Guidelines, dated 02/2014, documented staff should place residents on alert after a fall. The assessment of the condition should be documented in the progress notes. The duration and frequency of alert charting would be determined by the interdisciplinary team or Resident Care Manager (RCM).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored in a manner allowing accurate accounting of pills for 2 of 3 medication carts ([NAME] and Pine) reviewed for medication storage. This failure placed residents at risk of financial exploitation from missing medication. Findings included . On 08/11/2023 at 10:58 AM, the [NAME] medication cart was observed to have a loose small white round pill in the drawer that held bubble packs. Staff J, Licensed Practical Nurse, disposed of the pill. At 11:15 AM, the Pine medication cart was observed to have four Spironolactone (blood pressure medication) pills in the top drawer without a resident name or label. Staff J said the medication was pulled out of the Pixis (medication dispensing system) under a specific resident's name. A loose oval white pill was observed in the drawer that held the bubble packs. Staff J disposed of the pill. In the controlled substance drawer, a dose of Lyrica (pain medication) was observed to be taped back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food items were stored [NAME] accordance with professional standards when items were labeled and dated when opened in 1 of 3 nourishment refrigerators (Unit 300) reviewed for food safety. This failure placed residents at risk for cross-contamination and food borne illness. Findings included . On 08/10/2023 at 2:52 PM, the Unit 300 nourishment refrigerator, directly behind the nurses' station, was observed with an undated, unlabeled, and partially filled plastic containers of mayonnaise, ranch dressing, and a 20 ounce bottle of 7-Up (a soft drink). In the same refrigerator unit, was an undated, and unlabeled plastic Tupperware container with unknown contents of food. The freezer compartment of the same Unit 300 refrigerator was observed with an an undated, unlabeled, and partially consumed McDonalds McFlurry ice cream, wrapped in a clear plastic bag. At 3:04 PM, Staff D, Dietary Services Manager, said it was standard practice to label and date…

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