Shelton Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure potential restraints were assessed for safety, risks versus benefits associated with the device were discussed with the resident and/or representative and consent was obtained prior to device implementation for 1 of 2 residents (Resident 6) reviewed for physical restraints. This failure placed residents at risk for feelings of powerlessness, restrained or inhibited movement, physical injury, psychosocial harm and diminished quality of life. Findings included .Review of the facility's Physical Restraint and Enablers/Devices policy, updated January 2025, showed a restraint was defined as any manual method, physical or mechanical device, equipment or material attached or adjacent to the resident's body that meets all of the following: is attached to or adjacent to the resident's body; cannot be removed easily by the resident; restricts the resident's freedom of movement or normal access to his or her body. Prior to implementation of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medication related to excessive duration for 1 of 6 residents (Resident 19) reviewed for medications. This failure placed residents at risk of medication complications and a diminished quality of life.Findings included.Resident 19 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 03/05/2026, showed Resident 19 was cognitively moderately impaired.Resident 19 had a current order for a lidocaine patch (topical numbing medication), ordered on 03/05/2026. Starting on 03/08/2026, the order was to remove the patch at 8:59 AM and to apply at 9:00 AM. The lidocaine patch was applied from 03/08/2026 to 03/21/2026 (13 total administrations of 24 hours of duration) with the patch applied and removed the following day before a new application. During an interview on 03/23/2026 at 2:36 PM, Resident 19 said that staff put their lidocaine patch on for 24 hours at a time, and would take…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess food preferences and provide food that met preferences for 3 of 7 residents (Residents 75, 76, and 11) reviewed for food. These failures placed residents at risk for hunger, nutrient deficiency and diminished quality of life.Findings included.Resident 75 & 76 On 03/24/2026 at 8:36 AM, Resident 75 said they had recently been admitted to the facility, no one had talked to them about their food preferences yet (neither the Dietary Manager or the Registered Dietitian) and they had not been able to eat most of the food because they were supposed to be a on a diabetic diet. Observation of Resident 75's meal ticket documented CCHO [consistent carbohydrate diet], diet is eating the same amount of carbohydrates every day. This helps keep your blood sugar, or glucose, levels stable], NAS [no added salt] thin liquids. Observation of Residents 75's breakfast meal tray showed, Resident 75 was served pancakes with packaged syrup, sausage 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 designate a member of their inter-disciplinary team (IDT) who would be responsible for working with the hospice representatives to ensure effective coordination of care between the facility and hospice staff and to have documentation in residents' Electronic Health Records (EHR) that showed when hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) participated with care and what care was provided for 1 of 1 sampled resident (Resident 3) reviewed for hospice services. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included .Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 02/23/2026, documented Resident 3 was severely cognitively impaired and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure sufficient staffing levels were met to follow the plan of care and services for 5 of 10 residents (1, 2, 4, 5 & 6) reviewed for staffing. This failure placed residents at risk for unmet physical, mental and psychosocial needs, a decline in health status and a diminished quality of life.Findings included.Resident interviews, observations & record review1) Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, post-traumatic stress syndrome (a mental health condition that's caused by an extremely stressful or terrifying event), and diabetes mellitus. The quarterly minimum data set (MDS), an assessment tool, dated 06/30/2025, documented Resident 1 had moderate cognitive impairment and required supervision with bathing.Record review of the care plan, dated 02/26/2025, showed Resident 1 will have a shower on Sunday and Wednesday.On 08/18/2025 at 2:08 pm, Resident 1 said the facility had staffing problems. Resident 1 said…

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 treat residents with respect and honor privacy while having private conversations for 1 of 1 sampled resident (1) reviewed for privacy. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, post-traumatic stress syndrome (a mental health condition that's caused by an extremely stressful or terrifying event), and diabetes mellitus. The quarterly minimum data set, an assessment tool, dated 06/30/2025, documented Resident 1 had moderate cognitive impairment and required substantial assistance with activities of daily living.The care plan, dated 12/08/2024, documented Resident 1 was dependent on staff to meet emotional, intellectual, physical, and social needs. Staff will converse with the resident while providing care and will anticipate the residents' needs.On 08/18/2025 at 2:08 pm, Resident 1…

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 administer oxygen (O2) in accordance with physicians' orders, to monitor and replace humidifier bottles when empty, and to ensure O2 concentrator filters (used to protect the resident from inhaling dust and particulate matter) were routinely cleaned and maintained for 3 of 3 residents (Residents 51, 38 & 32) reviewed for respiratory care. These failures placed residents at risk for respiratory compromise, dry nares and other negative healthcare outcomes. Findings included . 1) Resident 51 admitted to the facility on [DATE]. Review of the electronic health record (EHR) showed a 01/14/2025 order for O2 at two liters per minute (2L/min) via nasal canula (NC) to keep oxygen saturation (SpO2) greater than 90%. On 03/10/2025 at 11:19 AM, Resident 51 was in bed receiving O2 at 2L/min via NC. Observation of the O2 concentrator showed the external filter was covered with light grey stringy debris, and the humidifier bottle was undated and empty.…

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) were reviewed in a manner that explicitly informed the resident or their representative of their right not to sign the binding arbitration agreement and/or to explain what a binding arbitration agreement was in a manner they could understand, for 3 of 3 sampled residents (Residents 32, 51, & 54) reviewed for binding arbitration agreements. This failure placed residents at risk for legal complications and a diminished quality of life. Findings included . 1) Resident 32 was admitted to the facility on [DATE]. During an interview on 03/12/2025 at 9:31 AM, Resident 32 when asked if they understood they were giving up their right to litigation in a court proceeding, said no. When asked if they were told the facility could not require them to enter into an arbitration agreement to be admitted or remain at the facility, said they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when the facility failed to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions used when someone has confirmed or suspected infections) for 3 of 5 (Residents 13, 14, & 12) reviewed for infection control. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications and a decreased quality of life. Findings include . <Resident 13> Resident 13 was admitted to the facility on [DATE]. Review of the Significant Change Minimum Data Set (MDS/an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the transfer of funds, from a resident trust account, was completed within 30 days following their discharge for 2 of 5 residents (Residents 165 and 166) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated. Findings included . A review of the electronic medical record showed Resident 165 discharged on [DATE] and a review of their account showed it contained a balance of $40.00. On [DATE] at 12:51 PM, Staff Q, Business Office Manager, said Resident 165's account was closed on [DATE]. A review of the electronic medical record showed Resident 166 died on [DATE] and a review of their account showed it contained a balance of $189.51. On [DATE] at 12:51 PM, Staff Q, Business Office Manager, said Resident 166's account was closed on [DATE]. On [DATE] at 2:00 PM, Staff A, Administrator, acknowledged the resident's accounts were not closed within 30 days 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 an allegation of abuse, neglect, or mistreatment that was identified by staff was reported to the Administrator and/or the state agency as required for 1 of 3 residents (Resident 18) reviewed for allegations related to abuse/neglect. This failure prevented the facility from conducting an immediate investigation, taking steps to protect residents from further abuse/neglect if necessary, conducting a thorough investigation and monitoring and treating residents as needed for potential harm. Findings included . Resident 18 admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 01/15/2025, documented Resident 18 was cognitively intact. Resident 18 had diagnoses of bipolar disorder (mood swings ranging from depressive lows to manic highs), borderline personality disorder (unstable moods, behaviors, and relationships), major depressive disorder (Depression) and unspecified dementia (thinking and social symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide the Ombudsman with transfer notification for 2 of 5 sampled residents (Residents 7 & 14) reviewed for hospitalization. The failure to ensure required notifications were completed, prevented the Office of the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes) the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . 1) Resident 7 was admitted to the facility on [DATE]. Resident 7 transferred to the hospital on [DATE] and returned to the facility on [DATE]. 2) Resident 14 was admitted to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On 03/18/2025 at 11:16 AM, Staff F, Social Services Director,…

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 49 admitted to the facility on [DATE]. Review of the 02/14/2024 admission MDS, dated [DATE], showed the resident did not use a wander/elopement alarm. Review of the electronic health record showed an order was obtained and consent provided for placement of a wander guard to Resident 49's left wrist. On 03/18/2025 at 8:02 AM, Staff B, DNS, confirmed Resident 49's wander guard should have been coded on the admission MDS. Based on interview and record review, the facility failed to accurately assess Minimum Data Sets (MDS, an assessment tool) for 4 of 18 sampled residents (Resident 29, 49, 13 & 14) reviewed. Failure to ensure accurate assessments regarding Wander guard (alarm), resident refusals, and signficant weight loss placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . 1) Resident 29 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 29 was severely cognitive impaired and had no physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 49> Resident 49 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident's diagnoses included non-Alzheimer's dementia, psychotic disorder (severe mental illness that causes abnormal thinking and perceptions) and depression, and the resident was treated with antipsychotic and antidepressant medication during the assessment period. Review of Resident 49's Level I PASRR, dated 02/04/2025, showed the resident had a diagnosis of major depressive disorder, but not a diagnosis of psychotic disorder. The assessment determined Level II PASRR evaluation for serious mental illness (SMI) was not indicated. On 03/18/2025 at 1:22 PM, Staff F, Social Services Director (SSD), said Resident 49's PASRR was inaccurate and should have included a diagnosis of psychotic disorder and acknowledged a referral for a Level II evaluation for SMI was required Based on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised and accurately reflected resident care needs for 5 of 18 sampled residents (Resident 51, 41, 49, 38 & 14) reviewed for care plans. This placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 51 admitted to the facility on [DATE]. Review of the admission Minimum Data Set Assessment (MDS), dated [DATE], showed the resident was cognitively intact, had diagnoses of schizophrenia and neurogenic bladder, received antipsychotic medication and required the use of an indwelling urinary catheter. A 01/15/2025 provider note documented Resident 51 had neurogenic bladder and required chronic urinary catheterization. An indwelling catheter care plan, initiated 01/14/2025, showed it did not identify why Resident 51 required the use of an indwelling catheter. It did not identify or address the resident's neurogenic bladder diagnosis. On 03/18/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Resident 51 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and required substantial to maximal assistance with bathing/showering. On 03/10/2025 at 3:19 PM, Resident 51 reported they were supposed to be bathed every Monday and Thursday, but staff don't show up. Review of Resident 51's bathing flowsheet showed the resident was scheduled to be bathed every Thursday and Sunday on evening shift. Review of the bathing record showed for the 30-day period from 02/13/2025 - 03/13/2025, showed the resident was offered/provided bathing 02/23/2025, 03/02/2025 and 03/09/2025. On 03/18/2025 at 11:02 AM, when asked if Resident 51 was consistently offered/provided bathing per their bathing schedule Staff D, Resident Care Manager (RCM), stated, No. 3) Resident 41 admitted to the facility on [DATE]. Review of the 01/25/2025 Quarterly MDS showed the resident was cognitively intact. On 03/11/2025 at 11:21 AM, Resident 41 said staff didn't always show up…

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 consistently document pre and post dialysis (a treatment to filter wastes and water from the blood) assessments and medications received, by making sure there was consistent ongoing follow-up with the dialysis center regarding the dialysis care and services for 1 of 1 sampled resident (Resident 163) reviewed for dialysis. This failure placed the resident at risk for unmet care needs and medical complications. Findings included . Resident 163 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (when the kidneys have deteriorated to the point where they can no longer perform their essential functions) and dependence on renal dialysis. The admission Minimum Data Set (a required assessment tool), dated 03/09/2025, showed Resident 163 was moderately cognitively impaired and received hemodialysis. A review of Resident 163's Electronic Medical Record (EMR) showed an order, dated 03/03/2025, that said dialysis days were on…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent, when 15 of 32 medication administration opportunities resulted in a 46.88% error rate due to late administration and omitting administration for 3 of 4 sampled residents (Residents 6, 12, and 57) reviewed for medication administration. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects, and other potential negative outcomes. Findings included . The facility policy, titled Medication Administration General Guidelines, dated 01/23, documented, medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. <Resident 6, late medications> On 03/11/2025 at 11:34 AM, Staff R, Registered Nurse (RN), was observed preparing and then performing a medication pass for Resident 6. Review of the physician's orders (which included medications scheduled times) for Resident 6 showed the following medications were…

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

Based on observation and interview, the facility failed to ensure medications were secured in a locked storage area and inaccessible to unauthorized staff and residents, for 1 of 2 medication carts (Team 3 Med Cart) observed for medication cart review and 1 of 4 residents (Resident 12) observed for medication administration. These failures placed residents at risk for unauthorized access to medications, medical complications, and a diminished quality of life. Findings included . <Medication Cart> On 03/11/2025 at 11:09 AM, an observation of a medication cart, Team 3 Med cart, near the nursing station showed that a bottle of MiraLAX (Constipation medication) and a white pill in an unlabled medication cup were left unattended on the medication cart. At 11:18 AM, Staff R, Registered Nurse (RN), regarding the MiraLAX bottle left on top of medication cart, said that because the cart was in their station they leave the MiraLAX bottle out while using it. Regarding the white pill in the medication cup, Staff R said they had pulled the pill out earlier because it was due for the next…

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 35 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 35 was severely cognitively impaired and needed set up assistance for being independent with ADLs. A review of the EHR showed a progress note, dated [DATE] at 7:35 PM, documented Resident 35 was taken to the hospital. There were no other progress notes that documented when Resident 35 returned to the facility from the hospital. On [DATE] at 1:47 PM, Staff C, RCM/RN, confirmed Resident 35 was sent to the hospital on [DATE] and he said they returned to the facility on [DATE]. Staff C said he did not see a progress note in the EHR and he had to look at the census to see when Resident 35 returned to the facility from the hospital. Staff C said his expectation was for staff to write a progress note when a resident came back from the hospital. At 2:30 PM, Staff B, DNS, said there was not a nursing note from when Resident 35 came back to the facility, and her expectation was that the nursing staff documented when a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to ensure timely physician visits were within the first 30 days after admission for 2 residents of 5 sample residents (Resident 11 and 14) reviewed for physician visits. This failure placed residents at risk of being denied face to face contact with a physician, during comprehensive review and for assessment of their health and well-being. The findings included . Review of the facility's policy, titled Physician Visits updated 2/2008 showed Residents were to be seen by a physician at least every 30 days for the first 90 days after admission. <Resident 11> Resident 11 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease (Stage 4) and Acquired Absence of the left lower leg. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/20/2024 showed the resident was alert and oriented and able to make needs known. Resident 11's medical record showed the resident was discharged from the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to update care plan and/or implement new interventions after resident had a fall for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for injury and diminished quality of life. Findings included . Review of the facility falls policy, titled, Fall Evaluation (Morse Scale) and Management, revised 03/2018, showed post fall actions included reviewing and updating the care plan with newly identified interventions as needed. Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia, psychosis and a fractured right femur (long leg bone). The admission Minimum Data Set (MDS), an assessment tool, dated 06/30/2024, showed the resident was cognitively impaired, required staff assistance for transfer and toileting needs and had a fall with a fracture within the last 6 months. Resident 1's care plan, dated 06/24/2024, showed the resident was at high risk for falls. Resident 1's nurse note, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure an abuse allegation was reported timely for 1 of 3 residents (Resident 2) reviewed for abuse. This failure placed residents at risk for abuse, neglect and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia and depression. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 01/31/2024, showed the resident was cognitively impaired, did not exhibit behaviors during the look back/review period and did not have impairment of upper or lower extremities. Review of the facility investigation, dated 03/14/2024 at 2:10 PM, showed during care it was alleged Staff C, Certified Nursing Assistant (CNA) grabbed Resident 2 by the front of the shirt, pulled him forward and told him that he needed to be nice to my girls and then Staff C allegedly slapped Resident 2 on the left upper arm. Review of the medical record and facility documentation showed 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 written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to or a statement of the resident's appeal rights for 3 of 5 sampled residents (Resident 8, 12 & 9) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process. Findings included . 1) Resident 8 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS, an assessment tool), dated 11/24/2023, documented Resident 8 was moderately cognitively impaired. Resident 8 had an unplanned transfer to an acute care hospital on [DATE], with return anticipated. Resident 8's electronic health record (EHR) showed no documentation the facility provided the resident or resident representative written notice detailing the reasons for transfer. On 02/12/2024 at 10:40 AM, when asked if there 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 Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was followed up with a Level II screening for 3 of 6 residents (Resident 3, 12 & 27) reviewed for PASRR. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life. Findings included . 1) Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool), dated 01/15/2024, documented Resident 3 was severely cognitively impaired. Resident 3's electronic health record (EHR) documented a PASRR Level I was completed on 07/20/2023, indicating Resident 3 had serious mental illness (SMI) indicators and a Level II evaluation referral was required. The EHR did not show a PASRR Level II had been completed. On 02/12/2024 at 10:40 AM, Staff B, Director on Nursing Services (DNS), said PASRR's were…

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 prepare food in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing. The facility's failure to follow written recipes for preparation of pureed food placed residents at risk for decreased satisfaction with meals. Findings included . On 02/09/2024 at 10:33 AM, Staff R, Cook, was observed preparing pureed Chinese buffet style green beans. Staff R poured an un-measured amount of green beans from a metal container into the blender and pulsed the blender three times. Staff R then poured the remaining green beans from the metal bin and blended for 10 seconds. An unmeasured amount of thickener was then added to the mixture from a plastic cup. Staff R blended the mixture for 10 seconds and poured the mixture into a metal steam table bin. The remaining thickener in the plastic cup was dumped into the trash can. A recipe for Chinese buffet style pureed green beans was requested but not provided. On 02/09/2024 at 10:42 AM, with staff Q, Registered Dietician (RD) present,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to respect and value the residents' private space by knocking and/or announcing themselves prior to entering a Resident's room and honoring residents' food preferences for 2 of 4 sampled residents (Resident 200 & 299) reviewed for resident rights and dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . 1) Resident 200 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 02/01/2024, showed Resident 200 was cognitively intact. On 02/05/2024 at 2:41 PM, during an interview with Resident 200, Staff H, Registered Nurse (RN), entered Resident 200's room without knocking or announcing herself. When asked if entering without knocking or announcing herself was normal practice, Staff H stated, I don't knock when the door is open. On 02/12/2024 at 10:38 AM, Staff G, Resident Care Manager, said staff are expected to knock and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 4 residents (Resident 199) reviewed for showers. This failure placed residents at risk for feeling unclean and decreased quality of life. Findings included . Resident 199 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 02/06/2024, showed Resident 199 was cognitively intact. On 02/05/2024 at 12:17 PM, Resident 199 said he had not had a shower or a sponge bath since being at the facility and was upset about it. Resident 199's Bathing Care Plan, documented Resident 199 was to receive a shower on Monday and Thursday evenings. Resident 199's electronic health record showed Resident 199 had not been showered on Thursday, 02/02/2024. On 02/12/2024 at 10:38 AM, Staff G, Resident Care Manager, said the facility provided showers on the Resident's preferred days. When asked if Resident 199 should have been offered a shower on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure resident rooms were maintained in good condition for 1 of 3 sampled rooms (room [ROOM NUMBER]) reviewed for homelike environment. This failure placed residents at risk of not having rooms maintained with a comfortable interior and a decreased quality of life. Findings included . On 02/05/2024 at 2:47 PM, room [ROOM NUMBER] was observed with 1) two deep scrapes, each over a foot long by three to four inches wide, through several layers of paint and drywall on the far side wall near the window, 2) a four by five inch deep scrape along the corner wall near the bathroom door and 3) a six foot tall wooden dresser provided to the resident, with multiple cuts, scrapes and gouges all over it. Resident 8 stated, I am private pay and this room needs a lot of work. On 02/12/2024 at 10:40 AM, Staff B, Director of Nursing Services, said their maintenance department surveyed weekly and Caring Partners went around monthly questioning residents about concerns…

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 residents/residents' representatives written bed hold notices at the time of transfer, or within 24 hours of an emergent transfer for 2 of 5 residents (Resident 12 and 9) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 12 admitted to the facility on [DATE]. Review of 01/17/2024 discharge Minimal Data Set showed Resident 12 was transferred to an acute care hospital on [DATE]. Review of Resident 12's electronic health record (EHR) showed there was no documentation a written bed hold notice was provided to the resident or their representative as required. On 02/09/2024 at 4:10 PM, when asked if there was documentation to show Resident 12 or their representative were provided a written bed hold notice as required, Staff B, Director of Nursing Services (DNS) stated, No. 2) Resident 9 admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days after the facility determined, or should have determined, that there was a significant change in a resident's physical or mental condition for 1 of 1 resident (Resident 9) reviewed for a decline in activities of daily living (ADLs). Failure to identify Resident 9's decline in ADL function and to complete a SCSA, placed the resident at risk for unidentified and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument Manual (RAI, a manual that directs staff on how to accurately assess the status of residents), showed a SCSA comprehensive assessment must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. According to the guidelines, a SCSA is appropriate if there is a consistent pattern of changes, with either two or more areas 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 accurately assess 4 of 22 residents (Residents 12, 27, 21 & 9), reviewed for accurate Minimum Data Set (MDS, an assessment tool). Failure to ensure residents' preferences, customary routine and activities were assessed, and dental status accurately coded, placed residents at risk for unidentified and/or unmet needs. Findings included . 1) Resident 12 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], and the significant change MDS, dated [DATE], showed the resident had no natural teeth and no loose-fitting dentures. Review of Resident 12's 04/19/2023 baseline care plan showed the resident had oral/dental health problems due to loose upper and lower dentures. A dental consult, dated 08/30/2023, showed the dentist recommended new upper and lower dentures for Resident 12 due to the current dentures being loose, ill-fitting, and worn. On 02/12/2024 at 12:27 PM, Staff N, MDS Coordinator, said that loose fitting…

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 as required for 1 of 6 residents (Residents 27) reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life. Findings included . Resident 27 admitted to the facility on [DATE]. Review of the 05/25/2023 admission Minimum Data Set (MDS, an assessment tool), showed the resident had severe cognitive impairment, diagnoses of Parkinson's disease and dementia, and required the use of antipsychotic medication during the assessment period. Review of the 05/22/2023 admission orders showed an order for quetiapine (an antipsychotic medication) once daily for a diagnosis of psychosis. Review of the electronic health record (EHR) showed no Level I PASRR was completed until 07/21/2023, two months after admission. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a comprehensive care plan with a specific measurable goal for 1 of 6 residents (Resident 31) reviewed for care plans. This failure placed residents at risk for unidentified and unmet care needs and diminished quality of life. Findings Included . Resident 31 was admitted to the facility on [DATE] with diagnosis of hypertension, depression, spinal stenosis (narrowing of spinal column and potential compression of the spinal cord) and muscle weakness. The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/17/2023, documented Resident 31 required extensive assistance with activities of daily living (ADL). Record review showed Resident 31 was at risk for ADL decline due to limited mobility, with a goal of baseline plan of care will be identified, a date of initiation 12/08/2023 and a target goal date of 06/01/2024. On 02/12/2024 at 9:04 AM, Staff B, Director of Nursing Services, said the goal was not specific. Reference WAC…

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 22 sample residents (Resident 12 & 21) reviewed. The failure to obtain and/or follow physician's orders, and to notify the physician when medications were held, placed residents at risk for medication errors, and adverse health outcomes. Findings included . Resident 12 admitted to the facility on [DATE]. Review of their current physician's orders showed an order for Levemir insulin (lowers blood sugar), with direction to hold and notify provider if the resident's chemical blood glucose (CBG) was less than 70 or call the physician if the CBG was over 400. Review of Resident 12's February 2024 Medication Administration Record (MAR) showed on 02/03/2024 at 7:30 AM the resident had a CBG of 68, the nurse administered Resident 12's Levemir rather than holding it and notifying the physician as ordered. On 02/08/2024 at 2:33 PM, Staff P, Resident Care Manager, said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 6 residents (Residents 12 & 21) reviewed for bowel management and 1 of 5 residents (Resident 27) reviewed for positioning. The failure to initiate bowel care in accordance with physician's orders and to implement positioning measures residents were assessed to require, placed residents at risk for pain/discomfort, wound development, and a diminished quality of life. Findings included . 1) Resident 12 admitted to the facility on [DATE]. On 02/05/2024 at 3:04 PM, Resident 12 stated, here lately I have been [struggling with constipation]. Review of Resident 12's physician's orders showed the following as needed bowel care orders, dated 01/24/2024: a) Milk of Magnesia (MOM), as needed for constipation, if resident does not have a bowel movement for three days, administer milk of magnesia on day four. b) Bisacodyl Suppository as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for 1 of 2 residents (Residents 100) reviewed for accidents. The failure to ensure portable liquid oxygen (O2) canisters were secured to residents' wheelchairs and in good repair, placed residents at risk for severe frostbite or cryogenic burns, pain and other potential negative outcomes. Findings included . Resident 100 admitted to the facility on [DATE]. Review of the February 2024 Treatment Administration Record (TAR) showed a 02/01/2024 order for O2 at two liters per minute (2 LPM) via nasal cannula (NC) to keep oxygen saturation greater than 92%. On 02/05/2024 at 10:14 AM, Resident 100 was observed sitting in a wheelchair (w/c) with a portable liquid oxygen canister hanging from the back of the chair. The straps from the portable O2 were secured around the right and left handles of the w/c. However, the right w/c hand grip was missing, resulting in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices were assessed and monitored in accordance with professional standards of practice for 1 of 1 resident (Residents 100) reviewed for IV therapy. The facility failed to provide Midline (a catheter is an 8 - 12 centimeter catheter inserted in the upper arm with the tip located just below the armpit) maintenance and monitoring to include changing needleless injection caps and monitoring the external length to verify the line had not migrated. This placed residents at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Review of the facility's Maintaining Patency of Peripheral and Central Vascular Access Devices policy, dated 08/2021, showed staff would perform dressing changes for midline and central venous access devices at least weekly. During the weekly dressing change, staff would assess the insertion site for redness, swelling and drainage; measure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice for 1 of 2 sampled residents (Residents 22) reviewed for respiratory care. The facility's failure to ensure physician's orders were in place before administrating oxygen treatment placed residents at risk for discomfort, a potential negative outcome and unmet needs. Findings included . Review of facility policy titled, Respiratory Care; Oxygen Administration, dated December 2017, stated, oxygen is administered per physician order. Resident 22 was admitted to the facility on [DATE], with a readmission on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 01/15/2024, documented Resident 22 was cognitively intact and Resident 22 was not receiving oxygen (O2) treatment. On 02/05/2024 at 4:10 PM, Resident 22's O2 concentrator was observed on the far side of room under the window and showed O2 was running at 2 liters per minute (LPM).…

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 psychotropic (affecting the mind) medications by failing to monitor for target behaviors for 1 of 5 sampled residents (Resident 199) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 199 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) and depression (persistent feeling of sadness and loss of interest). The 5-Day Minimum Data Set, an assessment tool, dated 02/06/2024, documented Resident 199 was cognitively intact. A Physician's order, dated 01/31/2024, documented Resident 199 was prescribed desvenlafaxine (an antidepressant). A Physician's order, dated 02/01/2024, documented…

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

Based on observations, interviews, and record review the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made out of 34 opportunities during medication administration for two of seven residents (Resident 38 & 32) who were sampled/observed for medication administration. The facility's medication error rate was 5.8%. This placed the residents at risk of receiving medications that were not effective or less effective. Findings included . On 2/08/2024 at 8:52 AM, Staff M, Registered Nurse, prepared and administered 11 medications including iron gluconate (iron supplement used to treat anemia) 27 miligrams (mg) to Resident 38. Record review showed a physician order for ferrous gluconate 324 mg. On 02/08/2024 at 8:56 AM, Staff M, Registered Nurse, prepared and administered six medications including citalopram (antidepressant) 40 mg at 8:56 AM to Resident 23. Record review showed a physician order for citalopram 40 mg with a specific time for 7:00 AM. On 02/08/2024 at 11:40 AM, Staff B, Director of Nursing Services was notified and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were kept secure and not left at the resident's bedside for 1 of 3 hallways reviewed for medication storage. This failure placed residents at risk for not receiving the full benefits of the medications or potential overuse of the medication. Findings included . Resident 33 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, morbid obesity and neuropathy. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 01/15/2024, showed the resident was cognitively intact. Resident 33's physician order, dated 10/29/2023, showed nystatin powder (topical powder to treat fungal/yeast) 100,000 unit/Grams (GM) to bilateral armpits x 14 days (discontinued on 11/12/2023). On 02/05/2024 at 10:20 AM, Resident 33 was observed resting in bed. A container of nystatin topical powder was observed on Resident 33's bedside table. Resident 33 said Staff I, Nursing Assistant in Training…

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 dental services were provided for 1 of 4 Medicaid residents (Residents 12) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to use ill-fitting dentures and/or go without dentures. These failures placed residents at risk for difficulty chewing, oral pain, decreased self-image and diminished quality of life. Findings included . Resident 12 admitted to the facility on [DATE]. Review of the 04/21/2023 admission Minimum Data Set (MDS, an assessment tool), showed the resident was severely cognitively impaired and had no natural teeth. A dental care plan, initiated 04/19/2023, showed the resident had oral/dental health problems related to loose upper and lower dentures. Staff were directed to coordinate arrangements for dental care and transportation as needed/as ordered. A 05/10/2023 progress note documented Resident 12 had a dental appointment on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure appropriate personal protective equipment (PPE) was donned (put on) timely for 1 of 3 sampled residents (Resident 18) observed on enhanced barrier precautions and failed to ensure staff maintained safe and sanitary food service for 1 of 3 hallways. This failure placed residents at risk for facility acquired or healthcare associated infections and related complications. Findings included . Review of the facility policy titled, Enhanced Barrier Precautions, dated 07/2022 showed, Enhanced Barrier Precautions are initiated to reduce transmission of multidrug resistant organisms (MDRO's). Enhanced Barrier Precautions requires use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hand and clothing of healthcare personnel <PPE> Resident 18 was admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus Aureus (an infection…

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 meet the requirements for implementing a facility-initiated discharge for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed residents at risk for homelessness, unmet care needs, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including a stroke. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 09/23/2023, documented Resident 1 did not have cognitive impairement. The MDS documented Resident 1 required set up assistance with their upper body and showering, moderate assistance with their lower body, and maximum assistance with footwear. The facility document, titled, Nursing Home Transfer or Discharge Notice, dated 09/20/2023, documented Resident 1 was given a notice for discharge due to refusal to pay their bill and the resident does not need [illegible] care. The effective date for discharge was noted as 10/20/2023. On 10/04/2023 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.