Fir Lane Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to accurately document and reconcile controlled substances for 2 of 3 (Resident 1 and 2) residents reviewed. This failure placed residents at risk for misappropriation of medications, missed medications and possible diversion of controlled substances.Findings included.<Policy>Review of the facility's undated policy titled, Med Administration, showed that staff were to prepare medication for administration and log out the drug on the controlled drug declining inventory page in the bound Controlled Substance Record Book and include the date, time, number/amount of drug and signature. The policy showed that staff were to document all controlled drugs had been counted at each change of shift.<Resident 1>Resident 1 was admitted to the facility on [DATE] with a diagnosis of malnutrition.Resident 1's physician orders, dated 08/06/2025, showed an order to administer dronabinol (controlled substance used to stimulate appetite) 5 milligrams two times a…

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

Based on interviews, observations and record review, facility staff failed to perform hand hygiene during medication administration for 2 of 3 (Staff C and D) staff reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life. Findings included.Review of the facility's undated policy, Handwashing/Hand Hygiene, showed hand hygiene was indicated: immediately before touching a patient, after touching a resident, after touching the resident's environment and immediately after glove removal.On 08/14/2025 at 3:32 PM, Collateral Contact 1 (CC1) said they visited their family member daily and when the nurses came in the room to give the resident their medications, they did not wash their hands coming and/or going. CC1 said they didn't wear gloves when administering eye drops and/or wash their hands when they finished.On 08/20/2025 at 10:43 AM, Staff C, Registered Nurse (RN), was observed entering Resident 4's room without performing hand hygiene. Staff C took Resident 4's blood pressure, and temperature using 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 3) Resident 75 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively moderately impaired. Review of Resident 75's EHR documented them as Responsible Party. A progress note by Staff F, SSD, dated 06/03/2025, documented he provided the family with paperwork and contact information so they could begin the process of becoming Resident 75's legal representative. On 06/06/2025 at 10:49 AM, Staff F said Resident 75 did not have an advanced directive. Staff F said he did not offer information to Resident 75 or their family about establishing a POA during the initial care conference, and said the information was not provided until recently in June 2025. On 06/09/2025 at 11:07 AM, Staff B, DNS, said her expectation was that advanced directives be addressed on admission, including offering information about formulating a POA. Reference WAC 388-97-0300 (1)(b), (3)(a-c) Based on interview and record review, the facility failed to ensure they informed and…

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

Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' complaints verbalized during Resident Council (RC) meeting for 4 of 6 months (December 2024, January, February and April 2025) The failure to initiate, log, investigate verbalized concerns, inform residents of their findings and actions taken, if any, prevented the facility from identifying care trends and determining if actions taken were effective in resolving the reported issues. These failures resulted in residents verbalizing the same complaints for multiple months without resolution, and placed residents at risk of feeling frustrated, unimportant and unheard, and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's Resident Council policy, revised 01/23/2023, showed the staff member who recorded the RC meeting minutes would report concerns/grievances to the Administrator and/or the department head responsible. A response would be provided in writing to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (resident advocates) occurred for residents transferred to the hospital, for 2 of 2 residents (Residents 19 & 25) reviewed for hospitalization. This failure placed residents at risk of a lack of advocacy and possible unidentified or unmet care needs. Findings included . Resident 19 was admitted to the facility on [DATE]. They were transferred to the hospital on [DATE] and again on 04/05/2025. Resident 25 was admitted to the facility on [DATE]. They were transferred to the hospital on [DATE]. On 06/04/2025 at 9:14 AM, a request was made with the social services department for documentation of ombudsman notifications for Resident 19's hospitalizations on 02/07/2025 and 04/05/2025, and Resident 25's hospitalization on 05/29/2025. During an interview on 06/04/2025 at 2:20 PM, Staff F, Social Services Director, said they had not provided the ombudsman with any notifications 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 Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed prior to admission and/or accurately reflected residents' mental health diagnoses for 7 of 8 residents (Residents 67, 53, 69, 78, 44, 54, & 19) reviewed for PASRR. These failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life. Findings included . 1) Resident 67 was admitted to the facility on [DATE]. Review of the 02/26/2025 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of anxiety disorder and received antianxiety medication on seven of seven days during assessment period. Review of the 02/19/2025 admission/transfer orders showed an order for lorazepam (an antianxiety medication) every six hours as needed (PRN), for anxiety for 14 days. Review of the electronic health record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure routine assessment and monitoring of skin conditions and implementation of interventions for 1 of 2 residents (Resident 67) reviewed for non-pressure skin, to provide bowel care in accordance with physicians' orders and facility protocol for 4 of 8 residents (Residents 67, 41, 45 & 283) reviewed for bowel management, and to effectively communicate, collaborate, and implement coordinated hospice plans of care for 2 of 2 (Residents 26 & 11) reviewed for Hospice services. These failures placed residents at risk for unidentified decline and/or delayed treatment and healing of non-pressure skin conditions, abdominal pain, decreased appetite, other negative outcomes related to untreated constipation, and unmet end of life care needs related to hospice services. Findings included . <Facility Policy> Review of the facility's Management of Constipation policy, revised November 2023, showed constipation was defined as three or more days without a bowel…

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 <Fluid Intake> Resident 41 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of end stage renal disease, and required dialysis during the assessment period. An end stage renal disease care plan, revised 05/01/2025, had a goal that the resident would not have any signs and symptoms (s/sx) of fluid volume overload or fluid volume deficit through the next review. Interventions included dialysis three times a week, monitoring for s/sx of hypervolemia (excessive fluid in the body) and hypovolemia (low levels of fluid in the body caused by various factors including dehydration.) A nutritional risk care plan, revised 05/01/2025, documented the resident was on a 1500 milliliter (ml)/day fluid restriction and directed staff to record food and fluid intake. Review of the resident's physician's orders, showed a 04/15/2025 order for a 1500 ml per day fluid restriction. Dietary was to provide 1080 ml per day, or 360 ml per meal 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 ensure sufficient qualified nursing staff were available to provide restorative nursing services for 2 of 2 residents (Residents 8 and 61) reviewed for limited range of motion. The failure to have sufficient qualified staff to provide restorative nursing services resulted in the therapy department not referring residents for restorative nursing programs, who they acknowledged were at risk for declines in range of motion (ROM), contracture formation/progression, and would have been referred for and benefited from restorative services, had sufficient staff been available to provide them. This failure placed residents at risk for decreased ROM, contractures, impaired skin integrity, increased dependence on staff for care needs and a diminished quality of life. Findings included . <Restorative Services> 1) Resident 61 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), showed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 39, 70, & 28) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . The facility's blank Arbitration Agreement, dated 07/2024, was reviewed on 06/06/2025, and documented: A. Resident and Resident's Representative ARE NOT required to sign the Agreement as a condition of admission to or as a requirement to continue to receive care at the Center. C. This agreement waives the right to a trail by judge or Jury. 1. Disputes to be Arbitrated. The Parties…

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 honor resident rights related to medical appointments for 1 of 1 resident (Resident 70) reviewed for resident rights. This failure placed residents at risk of delay in care, emotional upset, and a diminished quality of life. Findings included . Resident 70 was admitted to the facility on [DATE]. The admission Minimum Data Set Assessment, dated 04/29/2025, showed Resident 70 was understood and understands, and was cognitively intact. Review of an email dated 05/16/2025 at 11:25 AM, by Staff L, Transportation, showed Resident 70 had an appointment scheduled for 06/04/2025 with Neurology. During an interview on 06/06/2025 at 12:54 PM, Resident 70 said they were promised diagnostic testing when they came to the facility, as they were unsure of why they were no longer able to walk. Resident 70 reported they were supposed to have a nerve conduction test done on their lower spine, but transportation was not arranged and the appointment was canceled.…

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 2) Resident 52 was admitted to the facility on [DATE] and has a diagnosis of depression. Resident 52's Quarterly MDS, dated [DATE] documented the resident was cognitively intact and was dependent to moderate assist with activities of daily living. Resident 52's EHR documented Sertraline, an antidepressant, was ordered on 02/24/2025 and the consent was signed on 03/21/2025. On 06/09/2025 at 9:49 AM Staff C, RCM/RN said we should have had a consent done when the order was placed. I am not sure why this was missed. On 06/09/2025 at 11:07 AM Staff B, Director of Nursing Service said the expectation was for the resident provide consent before the medication was given. Reference WAC 388-97-0300 (3)(a) Based on interview and record review the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic (mind altering) medication for 2 of 6 sampled residents (Residents 52 and 283) reviewed for right to be informed about treatment decisions. This…

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 psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored, documented on and/or monthly pharmacist recommendations were acted upon timely, for 2 of 5 residents (Residents 54 &19) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage, increase in side effects without intervention, and a diminished quality of life. Findings included . 1) Resident 54 was admitted to the facility on [DATE] with diagnoses of depression, anxiety disorder, dementia with psychotic disturbance, and psychosis (disconnection from reality). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 54 was cognitively intact. Review of the electronic health record (EHR), showed Resident 54 was taking scheduled psychotropic medications including antipsychotic (a class of psychotropic medication primarily used to manage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours for 1 of 2 resident (Resident 3) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect. Findings included . Resident 3 admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 03/21/2025, documented Resident 3 was severely cognitively impaired. A social services progress note, dated 05/16/2025, documented that Resident 3 had stated, they hit me. Review of the facility investigation logs showed the allegation was not reported to the State Agency until 05/19/2025, 3 days after the allegation. On 06/04/2025 at 2:15 PM, Staff B, Director of Nursing Services, said an allegation of abuse should be reported to the State Agency within two 2 hours. Regarding Resident 3's allegation on 05/16/2025 not being reported to the State Agency until 05/19/2025, Staff B said it did not…

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 2) Resident 67 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had Stage 3 (Full-thickness skin loss in which fat is visible in the ulcer) and Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure injuries, required substantial to maximal assistance with bed mobility, and had an indwelling urinary catheter. A Urinary Incontinence and Indwelling Catheter care area assessment, completed 03/04/2025, documented Resident 67 required an indwelling catheter secondary to Stage 3 and Stage 4 pressure injuries to the sacrum and right buttock. Review of the urinary catheter care plan, revised 04/17/2025, showed there was no indication or justification for use documented. The goals were identified as: will remain free from urinary tract infections and other catheter related complications; and will have the catheter removed in the absence 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 3) On 06/05/2025 at 8:06 AM, during a medication administration observation and record review, it was noted that Resident 450 had a current order for Aspirin 81 mg tablet, in a chewable form. On 06/05/2025 at 8:15 AM, Staff Q, LPN, provided Resident 450 with a small plastic cup with multiple medications in it, including the chewable Aspirin. Resident 450 was observed taking all the medications with a drink of water, including the chewable medication. On 06/05/2025 at 8:36 AM, Staff Q, regarding the chewable medication being swallowed and not chewed, said Resident 450 requests to take them all together. Staff Q said she had to give them the chewable form of the medication, rather than the non-chewable form, because that was how it was ordered. On 06/09/2025 at 10:48 AM, Staff C, RCM/RN, when asked what the process was if a resident preferred a medication in a different form, said staff could get orders from the doctor to change it to the right form, such as with chewable aspirin, and staff could contact 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 pressure injuries (PIs) were consistently assessed, and ordered pressure redistribution measures and equipment were in place and functional for 1 of 4 residents (Resident 67) reviewed for PIs. The failure to ensure an ordered low air loss mattress was in place and functional and to routinely assess identified PIs, detracted from the ability to determine if current treatments and interventions were effective and appropriate. This failure placed residents at risk for prolonged wound healing, unidentified decline, and development of avoidable PIs. Findings included . The National Pressure Injury Advisory Panel (NPUIP) provided the following PI stage descriptions: - PI- localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device, because of intense and/or prolonged pressure or pressure in combination with shear. - Stage 1 Pressure Injury: Non-blanchable erythema…

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 admitted with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for catheter removal as soon as possible, and to ensure clinical condition/ justification existed for continued use for 1 of 1 resident (Resident 67) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, and a decreased quality of life. Findings included . Review of the facility's Indwelling Catheters policy, revised December 2024, showed all residents with indwelling catheters required a medical justification for their initiation and continued use. A Bladder Data Collection/Evaluation and/or the Catheter Justification Evaluation was required for all residents with an indwelling catheter. The assessment would determine the reason/ justification for use, if any factors were reversible, and a plan of care developed 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 3) Resident 283 admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 283 was severely cognitively impaired. Resident 283 was on hospice services (end of life care). Resident 283 had orders for morphine (pain reliever) oral solution, by mouth every 1 hours as needed for breakthrough pain; dyspnea (shortness of breath). Review of Resident 283's MAR, from 05/22/2025 through 06/05/2025, showed morphine was administered with documented pain on 05/24/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/30/2025, 06/01/2025, 06/02/2025 and 06/05/2025. Resident 283's May 2025 and June 2025 MARs also showed staff were ordered to provide NPI to reduce pain and document the effectiveness. Interventions included repositioning, relaxation, diversional activities and redirection. Staff were instructed to document the NPI intervention and effectiveness as needed. There was no documentation NPIs had been attempted. On 06/06/2025 at 11:19 AM, Staff C, RCM/RN, said NPIs should be implemented…

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 store and label medications appropriately and discard expired medications for 2 of 5 medication carts (Medication Carts A2 & A3) reviewed. These failures placed residents at risk of receiving expired or less effective medications, and inappropriate access to medication. Findings included . 1) Observation of Medication Cart A2 on 06/04/2025 at 11:57 AM, showed an unattended bottle of Tylenol on top of the cart. In addition, a bottle of Day Time Cold and Flu Relief was located within the cart with an expiration date of 12/2024. Located within the cart drawers, were a nystatin (antifungal) cream and clotrimazole (antifungal) cream, both without resident names and labels. Staff I, Licensed Practical Nurse, said the bottle of Tylenol on top of the cart came from central supply, and the employee that delivered it had left it unattended and it was a new staff member. Staff C, Resident Care Manager/Registered Nurse (RCM/RN), looked at the bottle of Day Time Cold and Flu medication and confirmed it was expired. 2) Observation 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 interview and record review the facility failed to store food for residents in accordance with professional standards for 5 of 5 refrigeration/freezer units (A1/A2, A3, B3, Walk in Cooler and Walk in Freezer) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . Review of the following refrigerator temperature logs located on A1/A2 hall, A3 hall, B3 hall, Walk in Cooler and Walk in Freezer in the kitchen, documented missing refrigerator/freezer temperatures: Snack Refrigerator since February 25th, 2025 (logs started on 02/25/2025): 02/25/2025 Hall A1 & A2- no temperatures recorded. 02/26/2025 Hall A1, A2, A3 & B3- no temperatures recorded. 02/27/2025 Hall A1 & A2- no temperatures recorded. 02/28/2025 Hall A1 & A2- no temperatures recorded. A3 Hall no temperatures recorded on: 03/06/2025, 03/23/2025, 03/29/2025, 04/03/2025, 04/10/2025, 04/11/2025,…

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 staff-maintained infection control practices during dressing changes for 1 of 3 wound cares observed, during meal tray delivery for 1 of 5 meal tray observations, and that regular temperature checks of the washing machines were complete for washing machines for for 1 of 1 laundry room reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life. Findings included . <Logs for Washer Temperatures> A Review of the Washer Temperature Logs showed no documentation on: -February 2025 blanks on the 1st, 2nd, 16th and 29th - 31st -May 2025 a blank on the 26th On 06/04/2025 at 1:03 PM Staff X, Housekeeping and Laundry Manager said the washer temperatures were checked to ensure proper standards for equipment, to make sure the laundry was sanitized, and it killed the germs. Staff X said she would in-service the staff and make sure the temperatures were done in the future.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews and record review, the facility failed to implement the plan of care for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, discomfort, lack of nutrition and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (a disease affecting your brain and spinal cord). The Minimum Data Set, an assessment tool, dated 04/11/2025, showed the resident had a pressure ulcer, required substantial/maximal assistance with bed mobility, was dependent on staff for transfers and had severe cognitive impairment. Resident 1's current care plan showed the following: -Focus Area-the resident has a stage III (pressure ulcer with full thickness loss of skin exposing subcutaneous tissue) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) present on the sacrum (tailbone), revised 04/29/2025.…

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.

Based on observation, interview and record review, the facility failed to ensure 3 of 6 staff members (Staff B, C and D) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19. Findings included . A 06/24/2024 CDC update titled, Infection Control Guidance: SARS-CoV-2 (the virus that causes COVID 19), showed residents should be placed on transmission based precautions and when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. A 04/12/2024 CDC guidance titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, showed staff were to remove and discard PPE, other…

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 bathing, dressing and personal hygiene for 2 of 4 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for poor hygiene, loss of dignity and a diminished quality of life. Findings included . <Resident 1> Resident 1 was admitted on [DATE]. The Minimum Data Set Assessment (MDS), an assessment tool, dated 03/07/2025, showed the resident was cognitively intact and required substantial assistance from staff for bathing, dressing and supervision/touching assistance for personal hygiene. On 03/27/2025 at 11:06 AM, Resident 1 was observed lying in bed. The resident said they had their first shower on 03/11/2025 (11 days after admission) after repeatedly asking for a shower. The resident said no one had offered to assist them with getting ready for the day. The resident said the staff did not routinely offer to get them out of bed, assist them to the bathroom, clean up for 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 of physical restraints for 3 of 3 residents (Resident 1, 2 and 3) when medical devices prevented the residents from freedom of movement. This failure placed the residents at risk for injury, frustration, and a decreased quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia and other progressive neurological conditions. The Minimum Data Set (MDS), an assessment tool, dated 02/18/2025, showed Resident 1 had severe cognitive impairment, had a fall since the last assessment and required substantial assistance for transfers. Resident 1's care plan, revised 12/29/2023, showed resident was at risk for falls and had poor safety awareness. On 03/10/2025 at 10:25 AM, Resident 1 was observed sitting in their wheelchair. The resident's right wrist was off the wheelchair armrest with the remainder of the forearm positioned on the armrest. 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 implement care plan interventions for 2 of 3 residents (Resident 2 and 3) reviewed for quality of care. This failure placed residents at risk for poor hygiene, clinical complications, and a diminished quality of life. Findings included . <Resident 2> Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia and depression. The Minimum Data Set (MDS), an assessment tool, dated 11/20/2024, showed Resident 2 was dependent on staff for transfers, bed mobility, dressing, hygiene and had cognitive impairment. Resident 2's self-care deficit care plan, revised on 07/20/2021, showed the resident had hearing aids. Staff were to ensure the resident had them on in the am and out at night. The care plan showed the resident was to set up at the sink and encouraged to assist with hygiene. Resident 2's ADL [activity of daily living] care plan, revised on 08/16/2024, showed the resident was to have TED hose (compression socks…

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 follow their policy to prevent resident elopement for 1 of 3 residents (Resident 4) reviewed for accidents. This failure placed residents at risk of elopement, accidents and a decreased quality of life. Findings included . Review of the facility policy, titled Elopement Prevention, dated 11/2022, showed elopement prevention included completing an admission assessments, elopement evaluations, identifying risk factors and hazards and could have included previous elopements, desire to leave the center and cognitive impairments. The policy included completing an elopement care plan and developing individualized interventions which may have included the electronic monitoring/alarm system to be used and to check through observation that the resident was wearing the device, if one was applied by indicating this on the Treatment Administration Record (TAR). Resident 4 was admitted to the facility on [DATE] with diagnoses including hepatic encephalopathy…

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 assess and treat pain for 1 of 3 residents (Resident 1) reviewed for pain. Failure to implement interventions to reduce pain, including administration of pain medication placed residents at risk of experiencing episodes of untreated pain and for a diminshed quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including a fractured left femur (thigh bone) with repair, neuropathy (nerve problem that causes pain, numbness, tingling, swelling and muscle weakness) and hypertension. The Minimum Data Set (MDS), an assessment tool, dated 07/31/2024, showed Resident 1 was cognitively intact and was on a scheduled pain medication regimen. Resident 1's Physicians' orders showed the following orders: - 07/24/2024 - oxycodone 5 milligrams (mg) (narcotic medication used to treat pain) by mouth every 4 hours as needed for pain. - 07/24/2024 - pregabalin (medication to treat nerve pain) 75 mg two times daily. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written notice to the resident, the resident representatives, and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 1 of 3 residents (1) reviewed for hospitalizations. This failure placed residents and/or their representatives at risk of not being able to make informed decisions about transfers and prohibited access to an advocate who could inform the resident/representative of their options and rights. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic inflammatory demyelinating polyneuritis (a condition resulting in loss of sensation in the arms and legs). The quarterly Minimum Data Set (MDS) assessment, dated 11/25/2023, documented Resident 1 had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living. The MDS documented Resident 1 had an active plan to return to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to consider re-admission of a resident after an unplanned hospitalization for 1 of 1 sample residents (1) reviewed for permitting residents to return to the facility. This failure placed residents at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic inflammatory demyelinating polyneuritis (a condition resulting in loss of sensation in the arms and legs). The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/25/2023, documented Resident 1 had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living. The MDS documented Resident 1 had an active plan to return to the community. No community referrals had been made for discharge planning. The care plan, dated 12/30/2022, documented Resident 1 wished to return home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 4 of 4 sampled residents (Residents 4, 5,19 and 24) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . 1) Resident 24 admitted to the facility on [DATE] with diagnoses including a neurological condition (a condition that affect the brain, spinal cord, and nerves) and was able to make needs known. During an interview on 05/05/2024 at 11:38 AM, Resident 24 said they had a personal funds account with the facility but never received statements of their balance. Review of the Trial Balance document, dated 05/08/2024, showed Resident 24 had a balance which was held in trust by the facility. Further review showed Residents 4, 5 and 19 also had balances. During an interview on 05/08/2024 at 1:20 PM, Staff H, Business Office…

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 2 of 32 sample residents (Residents 129 & 69) reviewed. Facility nurses failed to obtain, accurately transcribe, follow, and/or clarify physician's orders when indicated. The facility failed ensure nurses only signed for tasks that were completed. These failures placed residents at risk for medication errors, delays in treatment, unmet care needs and potential negative outcomes. Findings included . <Resident 129> Resident 129 admitted to the facility on [DATE] with care needs related to heart and lung disease. <pain medication> Review of the Resident 129's May 2024 Medication and Treatment Administration Records (MAR/TAR) showed 05/03/2024 orders for oxycodone (narcotic pain medication) 2.5 milligrams (mg) every four hours as needed for pain, and oxycodone 5 mg every four hours as needed for pain. The orders did not provide instruction or the assessment method a 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 . Based on interview and record review, the facility failed to provide services to maintain vision for 2 of 2 sampled residents (Residents 50 and 69) reviewed for vision/hearing. This failure placed residents at risk of inability to complete activities of daily living, a heightened risk of accidents and a diminished quality of life. Findings included . 1) Resident 50 admitted to the facility on [DATE] with diagnoses including diabetes and kidney failure. Review of Resident 50's admission Minimum Data Set (MDS, a required assessment tool) showed that the resident's vision was assessed to be moderately impaired. During an interview on 05/06/2024 at 9:27 AM, Resident 50 said they were having issues with their vision and they had been waiting for several months to be seen by the eye doctor. During an interview on 05/09/2024 at 11:39 AM, Staff F, Social Service Assistant, said the eye doctor conducts exams at the facility every three months. Staff F said they had recently found multiple appointments that were never…

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 sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 4 residents (Residents 24, 63, 128 & 67) interviewed, and 2 staff (Staff C & Staff D) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADLs) including showers, nail care and shaving. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Interviews/Observations> On 05/05/2024 at 11:25 AM, Resident 24 said sometimes aides didn't have time to give showers. On 05/05/2024 at 1:04 PM, Resident 63 said there was not enough staff and they were real busy. On 05/06/2024 at 11:36 AM, Resident 128 stated, I have had to wait four hours after requesting my pain pill, the excuse or what I was told was, 'I will tell the nurse again', or 'the nurse was on their rounds,' so I had to wait my turn. On 05/10/2024 at 11:41 AM,…

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

Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were recorded for 1 of 2 refrigerators in the locked medication rooms. This failure placed residents at risk for receiving medications that were not properly stored. Findings included . On 05/08/2024 10:03 AM, Staff E, Registered Nurse (RN) went into the medication room by the nurse station that was near the front entrance of the facility and they could not find a temperature log for the locked refrigerator. When asked if there was a temperature log, Staff E said, not that I see. When asked if there should have been a temperature log, Staff E said, yes and it is recorded by the staff on the night shift. On 05/08/2024 10:13 AM, Staff B, RN and Director of Nursing Services (DNS), went into the medication room at the nurse station near the entrance to the facility and she could not locate the log for the locked refrigerator temperatures. When asked if there should have been a temperature log, Staff B said, yes and it is usually placed on top of the refrigerator. On 05/10/2024 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.

Based on observation and interview, the facility failed to ensure food was stored and served under safe and sanitary conditions in one of one kitchen. These failures placed residents at potential risk for cross contamination, food borne illnesses and diminished quality of life. Findings included . <Brief Initial Tour> Observation of the industrial refrigerator on 05/05/2024 at 10:10 AM, showed several uncovered cups of juice on a rolling cart. Additional observation showed several bowls of uncovered pudding on a separate rolling cart in the path of a fan blowing with visible dust/debris blowing. Observation of the industrial freezer on 05/05/2024 at 10:14 AM, showed a package of hot dogs, chicken patties and manicotti unsealed and undated. The chicken patties and manicotti had a thick layer of frost on them. Observation on 05/05/2024 at 10:11 AM, showed three plastic containers of used spices without a date. <Follow-up kitchen observation> Observation of the industrial refrigerator during the lunch meal preparation on 05/07/2024 at 10:10 AM, showed uncovered desserts in the path 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 honor bathing and room preferences for 2 of 4 sampled residents (Residents 24 and 74) reviewed for choices. This failure placed residents at risk for poor hygiene, diminished quality of life and not being able to make choices considered important by the resident. Findings included . 1) Resident 24 admitted to the facility on [DATE] with a neurological condition (condition that affects the brain, spinal cord, and nerves). During an interview on 05/05/2024 at 11:25 AM, Resident 24 stated, sometimes the aides don't have time for showers so there have been weeks that I've only received one instead of two. Review of the annual Minimum Data Set (MDS, a required assessment tool), dated 03/15/2024, showed Resident 24 was able to make their needs known and their preferences showers were very important to the resident. Review of Resident 24's care plan (CP) showed the resident was to have a bath or shower twice a week on Wednesday and Saturday. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to notify 1 of 1 sampled resident (Resident 19), who was a Medicaid recipient, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed the resident at risk for personal financial liability for their care and diminished quality of life. Findings included . Resident 19 admitted to the facility on [DATE] with a diagnoses including diabetes and depression. Resident 19 was able to make needs known. Review of Resident 19's Medicaid award letter, dated 12/08/2023, showed that according to the rules, the resident could keep up to $2,000 in resources, and if resources were over $2,000, they would need to report it to the state agency. Review of the Trial Balance document, dated 05/08/2024, showed Resident 19 had a balance of $2,888.64. Review of the personal fund account transactions history showed the balance had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to initiate a resident grievance for 1 of 1 sampled resident (Resident 74) reviewed for grievances. This failure placed the resident at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life. Findings included . Review of a the Grievance Policy Revised/Reviewed Date: 01/2023, 2/2024 showed: Employee Responsibilities Initiate the resident grievance report for all concerns. a. A resident/resident representative may complete the Resident Grievance Report and return it to an employee. The employee should maintain the anonymity of the resident/resident representative to the extent desired. b. Alternatively, the employee who receives the Grievance form from the resident/resident representative should assist the resident/resident representative as needed to complete the form. The employee shall maintain the anonymity of the resident/resident representative to the extent desired. Resident 74 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR, an in-depth tool to evaluate psychosocial and psychiatric need) Level II, for 1 of 2 residents (Resident 30) reviewed for PASARR. This failure placed residents at risk of not receiving necessary services to meet their mental health and intellectual disability care needs and a diminished quality of life. Findings included . Resident 30's quarterly Minimum Data Set (MDS, an assessment tool), dated 03/27/2024, showed the resident admitted to the facility on [DATE] with multiple diagnoses including anxiety, unspecified lack of expected normal physiological development in childhood, and colon/liver and lung cancers. Resident 30 was moderately cognitively impaired. Resident 30 had a Level II PASARR determinations on 12/27/2023, conducted by the state contracted PASARR evaluator. The determinations stated, The Individual is determined to have RC (Related Condition). The box…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet residents' immediate care needs for 1 of 6 residents (Resident 129) reviewed, who recently admitted to the facility. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . Review of the facility's Baseline Care Plan Policy, dated 02/01/2023, showed the facility would develop and implement a baseline care plan on new residents within 48 hours of admission. The baseline care plan would include the minimum healthcare information necessary to properly care for a resident, such as: a. Initial goals based on admission orders b. Physician orders c. Dietary orders d. Therapy orders e. Social Services and PASRR recommendations if applicable. Resident 129 admitted to the facility on [DATE] after hospitalization for respiratory failure secondary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 1 of 1 resident (Resident 129) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the resident's total 24-hour fluid intake, precluded staff from determining if Resident 129 was adherent with or was exceeding the ordered fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications. Findings included . Resident 129 admitted to the facility on [DATE]. Review of the admission Evaluation, dated 05/03/2024, showed the resident admitted with a diagnosis of heart disease and an order for a 1500 milliliter (ml) per day fluid restriction. The kitchen would provide 360 ml with meals and nursing would provide 210 ml on day and evening shift, for a total of 1500 ml/day. A nutrition/hydration at risk care plan, initiated 05/07/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 2 residents (Resident 129) reviewed for respiratory care. Facility staffs' administration of oxygen without an order for oxygen, placed residents at risk for side effects related to oxygen therapy, respiratory compromise and/or unmet respiratory needs. Findings included . Resident 129 admitted to the facility on [DATE], after hospitalization for chronic lung disease, hypoxemia (low blood oxygen levels) and respiratory failure. Review of the admission Evaluation, dated 05/03/2024, showed the resident admitted to the facility on four liters of oxygen per minute (4L/min) via nasal cannula (NC). On 05/05/2024 at 1:28 PM, 05/06/2024 at 10:54 AM and 05/08/2024 at 11:18 AM, Resident 129 was observed in their room, receiving oxygen at 4L/min via NC. The oxygen tubing was undated and no humidifier bottle was in use. 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 provide medically related social services for 1 of 3 residents (Resident 30) reviewed for mood and behavior. The facility failed to monitor for mental health needs and coordinate necessary psychiatric consult/services. These failures placed residents at risk for unmet psychosocial needs, an increase in anxiety, and a diminished quality of life. Findings included . Resident 30 admitted to the facility on [DATE] with diagnoses including anxiety and Unspecified Lack of Expected Normal Physiological Development in Childhood. The admission Minimum Data Set (an assessment tool), dated 12/26/2023, showed Resident 30 was severely cognitively impaired. A Preadmission Screening and Resident Review (PASARR) Level II (an in-depth tool to evaluate psychosocial and psychiatric needs), dated 12/27/2023, showed, she could benefit from services during this tough time. The box under Specialized Services needed was filled in with yes. A provider 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 prepare and deliver food in a manner that conserved the nutritive value, palatability, an appetizing appearance, and that ensured meal temperatures were maintained for 6 of 6 residents (Residents 10, 54, 13, 23, 39 & 60) reviewed with pureed diets, and for 1 of 6 residents (Resident 46) reviewed for food quality. Dietary staffs' failure to follow written recipes when preparing pureed diets, to test and record holding temperatures including the time the food temperature was checked, and to ensure foods were not overcooked, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss and a diminished quality of life. Findings included . <Brief Initial Tour> Observation on 05/05/2024 at 10:22 AM during the initial kitchen tour showed incomplete temperature logs. The logs had missing temperatures and there was no documentation of when the temperatures were taken. <Lunch Service> Observation of the lunch meal…

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 that 2 of 2 sampled residents (Residents 24 and 50) received foods that accommodated the residents' preferences and allergies. This failure placed the resident at risk for meal dissatisfaction, allergic reaction and diminished quality of life. Findings included . 1) Resident 24 admitted to the facility on [DATE] with a neurological condition (condition that affects the brain, spinal cord, and nerves). Observation during the lunch meal on 05/06/2024 at 12:02 PM showed Resident 24 eating lunch in the dinning room with another resident. Resident 24 was observed scraping their broccoli onto a separate plate. Resident 24 said they continued to get items on their dislike list, especially broccoli, which they also received the night before in a stir fry. During an observation and interview on 05/06/2024 at 12:13 PM, Staff J, Dietary Manager (DM) observed Resident 24's plate and tray card and said, it must have been an oversight by the…

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

Based on observation, interview, and record review, the facility failed to appropriately provide specialized diets for 3 randomly observed residents (Resident 18, 69 and 428) during meal service. This failure placed the residents at risk for complications of their medical conditions, weight loss/gain and diminished quality of life. Findings included . Review of general diet lunch menu for 05/07/2024 showed the following: Beef tips, rice, seasoned carrots, dinner roll, chilled pears, juice and milk. Review of the diet spreadsheet provided showed the 05/07/2024 lunch meal for cardiac diet residents were to receive a wheat roll instead of a dinner roll. Observation on 05/07/2024 between 11:35 AM and 12:45 PM, showed Staff K, Cook, serving a general diet to include a dinner roll to all residents including Residents 18, 69 and 428 with tray cards that indicated a cardiac diet. Review of the diet spreadsheet showed cardiac diets and low cholesterol diets were to receive skim milk instead of 2% milk. Observation on 05/07/2024 between 11:35 AM and 12:45 PM, showed dietary staff providing…

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

Based on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 2 of 32 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 32 of 32 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessmnents, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the daily RN staffing hours report provided by Staff B, Director of Nursing Services (DNS), on 01/23/2024, showed between 12/22/2023 and 01/22/2024 the facility did not have any RN coverage on two days: 12/24/2023 and 12/28/2023. The report showed the following hours of consecutive RN coverage: seven days of eight-hour coverage, ten days of 12-hour coverage, 12-days of 16-hour coverage, and one day of 20-hour coverage. In an interview on 01/23/2024 at 1:45 pm, Staff B stated they were in the facility on 12/24/2023 and 12/28/2023 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the resident's designated legal representative were included in decisions to act on the resident's health needs for 1 of 4 sampled residents (1) reviewed for exercised rights of the representative related to transfer and discharge. This failure placed the resident at risk for violation of the resident's rights for health care decision-making by the designated legal representative and an unsafe/unplanned discharge. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (the heart no longer adequately pumps) and diabetes. The Minimum Data Assessment, an assessment tool, dated 06/17/2023, showed Resident 1 had no cognitive impairment and required extensive assistance with activities of daily living. Resident 1's medical record showed the durable power of attorney (POA) documents, dated 07/11/2023, immediately appointed Family Member (FM) 1 and FM 2 to manage Resident 1's health care…

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

Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 15 of 30 days reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care. Findings included . The facility's Staffing Pattern State Task Form, dated 05/05/2023 through 06/05/2023, documented there was no RN coverage for 15 of 30 days reviewed. On 06/09/2023 at 2:44 PM, Staff B, Director of Nursing Services and Registered Nurse, said the facility had difficulty getting RN's in the area. Staff B said the facility was advertising on [job search engines], offering sign on bonuses, and offering 12-hour shifts for interested nurses. Staff B said if the facility did not have an RN on shift for a required RN task, the resident would be sent to the hospital for RN tasks to be completed. Reference WAC 388-97-1080 (3) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure the call light was within reach for 3 of 6 sampled residents (Residents 11, 20 & 17) reviewed for accommodation of needs. This failure placed residents at risk of not being able to request needed assistance and a diminished quality of life. Findings included . Review of the Resident Call System policy, dated 09/2022, showed, The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which notifies a staff member or to a centralized staff work area from each resident's bedside and toilet/bathing areas . The call light communication system must be accessible to residents while in their bed or within reach while in the room . The call light communication system should be accessible to a resident if lying on the floor. 1) Resident 11 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/03/2023, documented Resident 11 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 obtain, provide, and/or assist with completing Advance Directives (ADs) for 4 of 6 sampled residents (Residents 6, 59, 3 & 70) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 04/13/2023, documented the resident was moderately cognitively impaired. Review of Resident 6's EHR (electronic health record) did not show documentation of an AD. 2) Resident 59 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired. Review of Resident 59's EHR did not show documentation of an AD. On 06/07/2023 at 1:27 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said she could not locate AD's for Residents 6 and Resident 59. At 2:05 PM, Staff C,…

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

Based on observation and interview, the facility failed to ensure resident medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic medical records for 3 of 8 sampled residents (Residents 43, 31 & 6) reviewed for privacy and confidentiality. This failure placed residents at risk of their medical information not being kept confidential and a diminished quality of life. Findings included . On 06/08/2023 at 11:09 AM Staff H, Licensed Practical Nurse (LPN), was observed leaving the medication (med) cart, on the B wing, to enter a resident's room. The computer screen on the med cart was observed open and logged into the electronic charting program with private resident healthcare information viewable. At 11:13 AM, Staff H was observed returning to the med cart. At 11:19 AM, Staff H was observed leaving the med cart to administer medications to a resident. The computer screen on the med cart was observed open and logged into the electronic charting program with private resident healthcare information viewable. At 11:22…

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 all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 4 of 7 medication storage areas (2 carts and 2 rooms) reviewed for medication storage. This failure placed residents at risk of receiving wrong or ineffective medications and treatments. Findings included . <Drug and Biological Labeling> On 06/05/2023 at 10:39 AM, the A1 medication cart was observed and showed four bottles of various creams, requiring a provider order, were not labeled with patient name nor was a pharmacy label attached to the bottles. On 06/08/2023 at 1:23 PM, the medication cart in the locked resident unit was observed with Staff O, Licensed Practical Nurse (LPN) and showed six bottles of powders and creams, requiring provider order, were not labeled with a patient name nor was a pharmacy label attached to the bottles. Staff O stated, The pharmacy label with the patient's name, medication name, provider, order date, etcetera, was required on all medications. Staff O said if the…

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

Based on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 1 of 2 sampled residents (25) reviewed for resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . On 06/05/2023 at 9:21 AM, Staff K, Certified Nursing Assistant (CNA), was observed entering Resident 25's room four times without knocking or announcing entry. At 9:22 AM, Resident 25 said she called her room the freeway. The resident said it was a parade of staff that came in and out of the room, and they do not knock prior to entering. At 10:22 AM, when asked how the staff ensure a resident was provided with dignity and privacy when enter a resident's room or providing care, Staff P, Nursing Assistant Registered, stated, It's a lot of little things but when I enter I always knock first, announce who I am, I sanitize my hands, let them know what I am doing in their room, always ask permission for what I want to do, and even if I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the resident and/or the resident's representative was informed and provided consent before administering a psychotropic (mind altering) medications for 1 of 6 sampled residents (Resident 65) reviewed right to be informed and make treatment decisions. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Resident 65 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease. The quarterly Minimum Data Set, an assessment tool, dated 03/07/2023, documented Resident 65 was severely cognitively impaired. A physician's order, dated 06/07/2023, documented Resident 65 was prescribed buspirone (an antianxiety medication) 10 milligrams (mg) three times a day for anxiety. A Progress Note date, 06/07/2023, documented, New order for buspirone 10 mg. VM (voicemail) left for husband POA (power 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 maintain and provide a safe, sanitary, and homelike environment for 1 of 3 sampled residents (Resident 42) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 42 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/01/2023, documented Resident 42 was severely cognitively impaired. Review of the Electronic Health Record (EHR) showed Resident 42 had no inventory list when he entered the facility. On 06/07/23 at 8:56 AM, Resident 42's room was observed to only contained one brown sofa chair, a small TV on a countertop across the room, a radio on the dresser next to the bed, one small picture of a sailboat on the wall and a pair of tennis shoes next to the bed. No other personal items were present in the room. On 06/09/23 at 10:03 AM, Staff I, Resident Care Manger and Licensed Practical Nurse, said Resident 42…

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 potential misappropriation of property was investigated for 1 of 3 sampled residents (Resident 75) reviewed for abuse. This failure placed residents at risk for abuse, misappropriation of property and a diminished quality of life. Findings included . Facility's policy, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, documented the facility must thoroughly investigate all alleged violation and retain documents showing that all alleged violations are thoroughly investigated. Resident 75 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 04/21/2023, documented the resident was cognitively intact. Resident 75's Electronic Health Record (EHR) and the facility's May 2023 incident reporting log showed no documentation of an initiation of an incident report or that the facility had investigated Resident 75'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 a Pre-admission Screening and Resident Review (PASARR) assessment was completed to reflect accurate mental health diagnoses for 1 of 6 sampled residents (Resident 17) reviewed for PASARR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life. Findings included . The facility's PASARR Requirements policy, dated 04/26/2023, documented, 1. Following admission of a resident, the nursing facility must: a. Review all level 1 screening for accuracy. If at any time the facility finds that the previous level 1 screening was incomplete, erroneous, or is no longer accurate, the facility must immediately complete a new screening using the department's standardized level 1 form, following the directions provided by the department's PASRR program. If the corrected level 1 screening identified a possible serious mental illness or intellectual disability or related condition, the facility must notify…

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 physician orders for an anticoagulant (medication that thins the blood) and an antibiotic were implemented and failed to ensure residents received timely interventions for constipation for 2 of 5 sampled residents (83 & 20) reviewed for quality of care related to unnecessary medications. These failures placed residents at risk for medical complications, worsening physical conditions and a decreased quality of life. Findings included . <Medication Administration> Resident 83 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 05/29/2023, documented the resident was cognitively intact. A physician order, dated 06/01/2023, documented, Hold warfarin (an anticoagulant) 05/31 [2023] and 06/01 [2023]. Recheck INR [laboratory blood test used to adjust warfarin dose based on how thin the blood is] 06/02/2023. Resident 83 had an physician order noting, check Coumadin [also known as warfarin] logbook…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure physician orders and standards of care were followed for 1 of 1 sampled residents (Resident 16) reviewed for tube feeding (food provided through tube directly to gut). This failure placed residents at risk for medical complications, including aspiration (inhaling food contents into lungs) and development of a lung infection. Findings included . Review of the facility's policy entitled Enteral Tubes (tube feeding), dated 12/22/2022, documented, Head of Bed [HOB] must remain at 30-45 degrees if resident is receiving continuous feeding. Resident 16 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 03/08/2023, showed Resident 16 was severely cognitively impaired. Resident 16's Nutrition Care Plan, dated 03/30/2023, documented, Keep HOB increased 35-45 degrees at all times while TF [tube feeding] is running. A physician order, dated 12/26/2018, directed staff to ensure Resident 16's HOB…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure physician's orders were followed related to supplemental oxygen for 2 of 3 sampled residents (Residents 57 & 3) reviewed for respiratory care. This failure placed residents at risk for respiratory distress and a diminished quality of life. Findings included . Review of the facility policy entitled, Oxygen Management, dated 07/2019 and revised on 12/2022, noted to adjust liter flow to amount that is prescribed by physician. The black ball on liter gauge should be positioned in the middle of the number line. 1) Resident 57 was admitted on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 04/30/2023, documented Resident 57 was cognitively intact. Resident 57's Physician orders documented an order for O2 [oxygen] 2l/nc (liters via nasal cannula), keep saturations above 92% every shift for SOB [shortness of breath]. Resident 57's care plan did not address the liters per minute (LPM) of oxygen. Resident 57's June 2023…

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 free from unnecessary medications by not monitoring anticoagulant complications for 1 of 5 sampled residents (55) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . Resident 6 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired. A physician order, dated 05/21/2023, documented Resident 6 was prescribed rivaroxaban [an anticoagulant medication] give 1 tablet by mouth at bedtime. Resident 6's Anticoagulant Care Plan, initiated 01/05/2023, documented the intervention to, Monitor/document signs and symptoms of anticoagulant complications. Resident 6's EHR did not show documentation of monitoring for complications of anticoagulants. On 06/08/2023 at 1:40 PM, Staff B, Director of Nursing Services and Registered Nurse, indicated Resident 6 was on an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by not monitoring target behaviors (the basis for medication use to either modify, remove, or add a resident specific behavior) and side effects (adverse reaction); and failed to ensure Gradual Dose Reductions (GDR) were attempted for psychotropic medications for 2 of 5 sampled residents (65 & 55) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . 1) Resident 65 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease (a progressive disease that affects memory and other mental functions). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/07/2023, documented Resident 65 was severely cognitively impaired. A physician order, dated 10/05/2021, documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure influenza and pneumococcal vaccines were offered to 1 of 5 sampled residents (Resident 20) reviewed for vaccinations. This failure placed residents at risk for developing influenza and/or pneumonia with potential negative outcomes and a diminished quality of life. Findings included . The facility's Influenza Vaccine Policy, version 2.3, undated, documented, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The facility's Pneumococcal Vaccine Policy, version 2.1, undated, documented, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .…

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.