Snohomish Health and Rehabilitation of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State PASRR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities [ID], or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in mental condition for 1 of 5 residents (Resident 37), reviewed for PASRR. This failure placed the resident at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and diminished quality of life.Finding included .Resident 37 admitted to the facility 01/04/2024 with diagnoses to include Parkinson's disease (progressive movement disorder of the nervous system), major depressive disorder, and anxiety.Review of Resident 37's PASRR dated 01/04/2024 documented they had indicators of serious mental illness but did not require a level two evaluation due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards were met for 2 of 5 residents (Resident 6 and Resident 52) reviewed for unnecessary medication review; 1 of 2 residents (Resident 29) for blood glucose monitoring; and 1 of 2 residents (Resident 6) for skin observation and treatment. The facility failed to ensure physician-ordered parameters were followed for blood pressure medication administration, failed to perform blood glucose (test to check sugar level in the blood) checks prior to meals, and failed to provide treatments for a wound. These failures placed the residents at risk for adverse outcomes, medication errors, infections, clinical complications, and unmet needs.Findings included .According to the facility policy titled Skin Integrity & Wound Prevention with revision date of 09/14/2025, new areas of concern identified are documented in the medical record, provider notified with treatment orders obtained and care plan updated. <WOUND> <RESIDENT 6>…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that 1 of 1 resident (Resident 34) who had been continent of bladder prior to admission to the facility, received appropriate treatment and services to restore continence to the extent possible. This failure placed residents at an increased risk of urinary tract infections, discomfort, loss of dignity, and decreased quality of life.Findings included . In a review of the facility policy titled Urinary Assessment & Toileting Program revised 09/15/2025 documented the facility would ensure residents were evaluated for bladder function and continence upon admission and as needed. Residents who were incontinent of bladder would receive appropriate care and services to prevent infection and restore bladder function as possible.Resident 34 admitted to the facility on [DATE] with diagnoses to include falls with concussion, Alzheimer's disease (progressive disease characterized by cognitive decline, memory loss and behavioral changes) and history 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 ensure 2 of 4 residents (Residents 37 and 42) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the oxygen concentrator (a medical device that filters air to deliver concentrated medical-grade oxygen) was set to the ordered rate and failed to ensure oxygen supplies were appropriately maintained, changed regularly and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and potential for complications of the respiratory system.Findings included .Review of a facility policy titled, Oxygen Administration, Safety, Storage and Maintenance with revised date 08/04/2023 documented:monitor oxygen parameters as needed and/or as ordered,change oxygen supplies weekly,equipment should be dated when set up or changed out,Humidifier (container of sterile water to add moisture to oxygen)…

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 for 3 of 5 residents reviewed for unnecessary medications (Residents 4,6 and 52) and 1 of 3 residents reviewed for pain management (Resident 20). Failure to follow providers orders for pain medication parameters and provide non-pharmacological interventions for pain placed residents at risk for adverse effects of unnecessary medication and decreased quality of life. Findings included . <RESIDENT 4> Resident 4 admitted [DATE] and had diagnoses to include dementia and chronic pain. Review of Resident 4's physician's orders with a print date 04/27/2026 documented an order for pain medications: Acetaminophen (non-narcotic pain medication) every four hours as needed for pain rating between 1-5, Oxycodone (narcotic pain medication) every four hours as needed for pain. Review of Resident 4's routine pain monitor from April 1-27, 2026, documented their pain rating as 0 on 24 days, 2 on one day, and 1 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 and interview, the facility failed to store medications securely for 2 of 2 residents (Resident 37 and 49) reviewed for medications stored in their room and failed to ensure 1 of 4 medication carts and 1 of 2 treatment carts were locked when left unsupervised by staff. These failures placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored.Findings included . On 04/26/2026 at 9:39 AM observed the treatment cart located outside of nursing station two, unlocked. The treatment cart contained scissors, zinc oxide ointment (medicated ointment), hydrocortisone cream (medicated cream), Vaseline, iodine antiseptic pads (medicated pads), silicone cream, and medicated wound dressings.In an interview on 04/26/2026 at 9:39 AM Staff B, Director of Nursing Services, stated treatment carts were expected to be locked when not in use and secured by staff.In an observation on 04/26/2026 at 12:15 PM observed the medication cart on the second hall unlocked outside of nursing station…

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 were compliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 4 residents (Resident's 11 and 79) reviewed for Enhanced Barrier Precaution (EBP- personal protective equipment (PPE) required for staff during high contact care activities), 1 of 1 observation of pericare (washing of the genitalia and buttocks), 1 random observation of medical equipment sanitation and 1 of 4 nurses (Staff U) reviewed for medication administration. The facility failed to ensure the staff to wear appropriate PPE in accordance with recommended national standards; failed to ensure staff were compliant with hand hygiene during pericare; failed to ensure appropriately disinfecting reusable medical equipment; and failed to ensure proper barriers were used for medication items. These failures placed all residents and staff at risk of potential infection. Findings included .According to the facility policy titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) reviewed for care planning. The failure to ensure the comprehensive care plan was person-centered to maintain and or attain the resident's highest practicable well-being placed the residents at risk of not receiving services and monitoring that would meet their needs, adverse health effects and a decreased quality of life. Findings included .Review of a facility policy titled, Comprehensive Care Plans and Conferences, revised date 09/03/2025, documented the facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes. The plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain physician orders and provide monitoring of fall related injuries and interventions for 3 of 4 sampled residents (Residents 1, 2, 3 and 4), document fall related injuries on the reporting log for 2 of 4 sampled residents (Residents 3 and 4), and documentation of fracture in the investigation summary for 1 of 4 sampled residents (Resident 2) reviewed for accidents. The facility failure to provide documentation and monitoring of injuries, non-weight bearing status, braces and slings placed residents at risk for further injury, unmet care needs, and a diminished quality of life. Findings included .Review of a facility policy titled Fall Response and Management, revised 08/21/2026, showed; The facility is committed to ensuring that residents are provided with an environment free from accident hazards and that residents receive appropriate supervision and assistive devices to minimize fall risk, while promoting resident autonomy 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 interviews and record reviews, the facility failed to ensure a safe discharge plan was in place for 1 of 2 residents (Resident 1) reviewed for discharges. The facility failed to provide discharge instructions, discuss medications, notify family and provider and provide community resources upon discharge. These failures placed residents at risk of an unsafe discharge and risk for medical complications.Findings included . According to the facility policy titled Transfer and Discharge revised on 10/15/2022, documented that in a situation where the resident signs out of the facility, or leaves Against Medical Advise (AMA), the medical record must have evidence of discussion with the resident to make it a safe discharge.Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. According to the admission Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], Resident 1 had moderate cognitive impairment, had impaired vision and used a front wheeled walker. 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 thoroughly investigate incidents for one of one resident (Resident 1) reviewed for medication errors. This failure prevented the facility from identifying the potential causes of the occurrence, placed residents at risk for repeated errors, substantial injury, left unanswered questions whether the incident was potentially related to neglect, and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable…

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 1 of 3 sampled residents (Resident 1) reviewed for intravenous (IV) hydration use was free from medication errors. Failure to follow physician orders to administer IV hydration placed the resident at risk for complications from dehydration, a decline in their condition, and decreased quality of life. Findings included .Review of a facility policy titled Medication Error revised 08/01/2023 showed;Medications are managed and safely administered to residents with a minimum of medication errors (not 5% or greater) and residents are free of any significant medication errors. Definitions:Medication ErrorMeans the observed or identified preparation or administration of medications or biologicals which is not in accordance with: The observed preparation or administration of drugs or biologicals that are not in accordance with:a. Prescriber's Ordersb. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct an investigation for 1 of 3 sampled Residents (Resident 1) reviewed for falls. Failure to conduct an investigation to identify the root cause(s) and all contributing factors related to Resident 1's incident, placed the resident at risk for unidentified abuse or neglect, risk for injury, and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. <RESIDENT 1> Resident 1 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 ensure 4 of 6 residents (Residents 25, 26, 59 and 60) had an accurate Pre-admission Screening and Resident Review (PASARR) on or before admission to the facility. This failure placed residents at risk for unmet care needs and at risk of not receiving appropriate mental health support/services needed. Findings included . Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. The intent of this process is to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual…

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 and/or their representatives were offered the opportunity to participate in care conferences (a collaborative care plan meeting where a resident's care is discussed and coordinated by a team of health care providers, family members and residents) for 3 of 6 sampled residents (Residents 3, 27, and 60) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included . <RESIDENT 27> Resident 27 admitted to the facility on [DATE] with diagnoses to include pneumonia and vascular dementia. According to the resident's Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], Resident 27 had moderate cognitive impairment. Review of Resident 27's medical record showed no documentation a quarterly care conference had been completed. <RESIDENT 60> Resident 60 admitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 1 of 6 residents (Resident 60) reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . An AD is A written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. <RESIDENT 60> Resident 60 admitted on [DATE]. According to the admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], Resident 60 had no cognitive impairment. Review of Resident 60's medical record document titled Advance Directive Review dated 11/05/2024 documented Resident 60 would like to pursue formulating an AD. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to review and revise care plans for 3 of 10 sampled residents (Residents 3, 34 and 31) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team placed residents at risk for unmet care needs, adverse health effects and diminished quality of life. Findings included . Review of the facility policy titled, Care Plans, revised date 10/15/2022, documented care plans are updated with any status change and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. <RESIDENT 3> Resident 3 readmitted to the facility on [DATE] with diagnoses to include shingles zoster without complications. Review of Resident 3's March 2025 Medication Administration Record (MAR) documented Resident 3 was taking antiviral medication for herpes (viral infection) daily since 02/01/2024. Review of Resident 3's care plan, print date 03/27/2025, under the focus of potential…

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 the resident's environment was free from accident hazards of 1 of 3 residents (Resident 59) reviewed for environmental hazards. These failures placed residents at risk for possible injury and diminished quality of life. Findings included . Resident 59 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease and on hospice care. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], the resident had severely impaired cognition. In an observation on 03/24/2025 at 10:34 AM, Resident 59 was in bed with a blanket over their head. The bed was in the lowest position with a scoop mattress (a special type of mattress with raised sides designed to prevent residents from rolling out of bed) on the left side of the bed on the floor and the bed was placed against the wall. Review of Resident 59's physician's orders on 03/28/2025 did not show any orders for the bed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 2 of 6 residents (Residents 26 and 59) reviewed for unnecessary medications were free from unnecessary psychotropic medications (drugs that affect a person's mind, emotions and behavior, used to treat mental health conditions like anxiety, depression, and psychosis). These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life. <RESIDENT 26> Resident 26 admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental health disorder that causes extreme mood swings that include emotional highs, called mania and lows known as depression). Review of Resident 26's physician's orders on 03/26/2025, showed the following order: Give Sertraline Hydrochloride (HCl) 25 milligrams (mg) by mouth one time a day for Depression, dated 09/25/2024. Review of Resident 26's Pharmacy Recommendation dated 03/07/2025, showed gradual dose reduction…

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 significant medication errors for 1 of 5 residents (Resident 26) selected for medication review. This failure placed Resident 26 at risk for adverse outcome related to receiving insulin when blood sugar was below the blood sugar parameter ordered. Findings included . Resident 26 admitted to the facility on [DATE] with admitting diagnoses to include Type 2 Diabetes Mellitus (DM - a chronic metabolic disorder characterized by persistent high blood sugar). According to the quarterly Minimum Date Set (MDS - an assessment tool) assessment dated [DATE] the resident had intact cognition. In a record review on 03/26/2025, Resident 26's physician's order documented: - Insulin Glargine (long-acting insulin), inject 25 units (U) subcutaneously (SQ - method of administering medication by injecting a drug into the fatty tissue layer beneath the skin) one time a day for DM. Hold for blood sugar (BS) less than (<) 90 and provide snack.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 27), reviewed for dental care, received timely assistance to coordinate appropriate denture services. This failure placed residents at risk for difficulty chewing, diminished quality of life and a loss of dignity. Findings included . <RESIDENT 27> Resident 27 admitted to the facility on [DATE] with diagnoses to include pneumonia and vascular dementia. According to Resident 27's Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had moderate cognitive impairment, and upper and lower dentures. The MDS documentation included: -Section L0200 A was documented No for broken or loose fitting full or partial denture (chipped, cracked, uncleanable, or loose) -Section L0200 F was documented No for mouth or facial pain, discomfort or difficulty chewing. In an interview on 03/25/2025 at 11:37 AM, Collateral Contact (CC) 1 stated Resident 27's dentures were old and broken…

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 facility staff used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for 2 of 3 sampled residents (Residents 42 and 10) with enhanced barrier precautions (EBP- infection control practices designed to reduce the spread of multidrug-resistant organisms in nursing homes by focusing on gown and glove use during high-contact resident care activities). These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications and a decreased quality of life. Findings included . <RESIDENT 42> Resident 42 admitted to the facility on [DATE] with diagnoses to include open wound. Review of Resident 43's Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], documented Resident 42 had stage 4 pressure ulcer and moisture associated skin damage. Review of a progress note on 03/27/2025 at 9:46 AM, documented a consulting…

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 conduct a thorough investigation for 1 of 1 resident (Resident 1) reviewed for falls. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to Resident 1's incident, placed residents at risk for unidentified abuse or neglect, risk for injury, and ineffective care planning. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, showed A thorough investigation is a systemic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences. Review of the facility policy titled, Accidents and Supervision to prevent accidents, revised on 10/15/2022, showed the facility provides an environment that is free from…

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 timely review and revise the care plan to accurately reflect the care needs for 1 of 1 resident (Resident 7), reviewed for timely care plan revision. This failure placed the residents at risk for unmet care needs and potential harm. Findings included . Resident 7 was admitted to the facility on [DATE] with diagnoses to include vascular dementia (a general term for problems with reasoning, planning, memory, and other thought processes cause by brain damage from impaired blood flow to the brain) with other behavioral disturbance, and major depressive disorder. On re-admission to the facility on [DATE], additional diagnoses to include left femur fracture. Review of Resident 7's care plan, dated 06/20/2022, showed a focus area of impaired mobility with risk for falls related to impaired mobility, and a history of falls. Interventions directed staff to keep the adjustable bed in position for safe transfers and lock bed brakes. An…

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

Based on interview, and record review, the facility failed to ensure the direct care data of both contract and agency staff was accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Quarter 3) for the Fiscal Year (FY) 2023(which included July 2023 through September 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility. Findings included . Review of the PBJ information submitted by the facility showed that for Quarter 3, 2023, the facility was 301 hours short the required hours. In an interview on 03/07/2024 at 9:30 AM, Staff B, Director of Nursing provided the PBJ information that was submitted for Quarter 3. Staff B stated they were unaware that behavioral health consultant hours could be submitted towards their 3.4 direct care hours per resident day (HPRD) staffing hours requirement. Staff B stated…

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 the required beneficiary notices for 3 of 3 sampled residents (Residents 227, 228 and 229) reviewed for liability notices. This failure placed the residents at risk of not being fully informed of their rights to appeal the decision to end skilled services and/or the potential costs of continued services if the residents wished to stay at the facility. Findings included . <RESIDENT 227> Review of Resident 227s medical record, showed the resident was discharged from a Medicare Covered Part A stay with benefit days remaining on 12/20/2023. The required Notice of Medicare Non-Coverage (NOMNC - a form that shows insurance will no longer cover services) was not provided to the resident. The resident discharged home without being fully informed of their appeal rights or costs of continued services. In an interview on 02/06/2024 at 8:48 AM, Staff B, interim Administrator, stated they could not find record the NOMNC form had been provided to Resident 227. <RESIDENT 228> Review of Resident 228's medical record, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Resident Assessment Instrument (RAI -instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information) Utilization Guidelines process was followed for 4 of 17 sampled residents (Residents 55, 57, 13 and 52) reviewed for comprehensive assessments. This failure placed residents at risk for inadequate care plan development and diminished quality of care. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - an assessment tool), the Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) process, 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 ensure Licensed Nurses (LN's) and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 5 of 6 sampled staff (Staff F, G, H, T, and W) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . The Facility Assessment, last reviewed 11/13/2023, showed staff competencies are completed based on required education/identified needs/changes in: i.e. Abuse/Neglect, Elder Justice Act (the first comprehensive federal law to address the abuse, neglect, and exploitation of older adults), Compliance, Health Insurance Portability and Accountability Act of 1996 (HIPAA, to protect residents from the unauthorized sharing of their private health information), Life Safety, Emergency Services,…

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 monitor the medication refrigerator temperatures and to ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (Hall 1 and Hall 2) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Findings included . <HALL 1> During an observation on 02/07/2024 10:39 AM, the Hall 1 medication refrigerator contained 21 Insulin (manages sugar in the body) pens, 1 Emergency Kit containing insulin, 6 intravenous antibiotics (medication to treat infection), 1 unopened multiple dose lorazepam (a medication used to treat anxiety) bottle, and 1 multi-dose Tubersol (a prescription solution to test for Tuberculosis which is a potentially serious infectious disease that mainly affect the lungs) vial. Review of Hall 1's medication room temperature log, dated January 2024, showed 15 missing readings for the AM shift and 20 missing readings for the PM shift. During 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 provide meals that accommodated residents' food preferences and choices regarding types of food to eat and portion size for 7 of 8 sampled residents (Residents 50, 16, 19, 59, 52, 176, and 60) reviewed for food preferences. This failure placed residents at risk for dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . Review of the facility policy titled, Dining Standards, dated 09/10/2020, showed: - Residents rights and wishes are respected, and reasonable accommodations are made for food preferences and amount of food to eat. - Tray cards are validated against items presented on meal trays for diet type, textures, fluids, likes and dislikes, prior to food delivery. In an interview and record review on 02/07/2024 at 8:43 AM, Staff K, Dietary Manager/Chef, stated activities staff hands out Select Menu's (a weekly menu with food choices and alternative food options). A review of Select Menu's 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.

Based on observation, interview, and record review, the facility failed to ensure 3 of 3 food workers (Staff I, J, and K) with beards had restrained their facial hair to prevent food contamination. The failure to ensure food workers restrained their facial hair placed residents at risk for food contamination and diminished quality of life. Findings included . Review of the facility policy titled, Personal Hygiene When Handling Food, dated 10/15/2022, showed hair restraints such as hats, hair coverings or nets, and beard restraints were to always be worn in the kitchen, and facial hair was to be neatly trimmed, and if longer than trimmed eyebrows, it was to be covered by a mask or beard guard. In an observation/interview on 02/06/2024 at 10:25 AM, Staff I, Cook, Staff J, Cook, and Staff K, Dietary Manager/Chef, were all observed working in the facility kitchen, all three had beards of several inches. Staff I and J were wearing no beard restraints, Staff K was wearing a surgical mask, but their beard protruded a few inches below the mask. Staff K was interviewed, and they stated 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 record review, and interview, the facility failed to ensure 3 of 4 sampled employees, (Staff F, Staff G, and Staff H) reviewed for training, had the required 12 hours per year of in-services and required annual dementia training. This failure placed residents at risk of less than competent care and services from staff. Findings included . Review of facility employee records showed: Staff F, Nursing Assistant Certified (NAC), had a hire date of 02/01/2022. For the year of January 2023 to December 2023, the facility was unable to provide documentation Staff F had completed the required 12 hours of annual in-services or dementia training. Staff G, NAC, had a hire date of 02/01/2022. For the year of January 2023 to December 2023, the facility was unable to provide documentation Staff G had completed the required 12 hours of annual in-services or dementia training. Staff H, NAC, had a hire date of 02/01/2022. For the year of January 2023 to December 2023, the facility was unable to provide documentation that Staff H had completed the required 12 hours of annual in-services or…

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

Based on observation, interview, and record review, the facility failed to ensure residents had a homelike environment for 2 of 4 sampled residents (Resident 55 and 17) reviewed for environment. This failure placed the residents at risk for decreased quality of life. Findings included . Review of the facility policy titled, Resident Environment, revision date 11/29/2019, showed that a homelike environment de-emphasizes institutional character 'as close to private home as possible' and stated residents with dementia or without family or friends and with few assets are assisted, to the extent possible, with making their bedroom homelike, if they so desire. <RESIDENT 55> Record review showed Resident 55 had been in their current room since 10/10/2023. The record showed the resident had cognitive impairment. In an interview and observation on 02/04/2023 at 1:15 PM, Resident 55's room had blank white walls with no pictures or any other personal or homelike items. The resident stated the only thing they did was stare at the second hand on their clock, watch TV, or watch traffic drive past…

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 identify a significant change in status for 1 of 3 sampled residents (Resident 55), reviewed for pressure ulcers (localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device). Failure to identify and complete a Significant Change in Status assessment, according to the Resident Assessment Instrument (RAI - instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information) Criteria, placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Record review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, Version 3.0, dated October 2019, showed that a Significant Change in Status assessment was appropriate when there was a determination that there had been a significant change in a resident's condition (a major decline in a resident's status that affected two or more…

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 record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, assessment of care needs) for 3 of 15 sampled residents (Residents 5, 61, and 55) reviewed for accuracy of the MDS. Failure to accurately assess the residents placed them at risk for unidentified and unmet care needs. Findings included . <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses including major depressive disorder, and Schizophrenia (a serious mental illness). Review of Resident 5's medical record, showed the Level II Preadmission Screening and Resident Review (PASRR- a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) was completed on 09/07/2022. Review of the PASRR Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation…

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 recommendations were acted upon for 1 of 5 sampled residents (Resident 52) reviewed for nutrition. Failure to review and initiate nutrition recommendations placed residents at risk for weight loss, a decline in nutritional status, and related complications. Resident 52 admitted to the facility on [DATE] with diagnoses to include iron deficiency anemia (blood lacks adequate healthy red blood cells) and Stage IV (wound exposing muscle and/or bone) pressure ulcer (bed sore). Review of Resident 52's nutrition comprehensive evaluation, dated 10/17/2023, showed the Registered Dietician (RD) recommended the resident receive ProSource (liquid protein supplement) 30 milliliters (ml) twice a day due to increased protein needs and wound healing. Review of Resident 52's nutrition review, dated 11/01/2023, showed the resident had 2.4% weight loss since admission to the facility. The RD had recommended ProSource 30ml twice a day on 10/19/2023 and was still…

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 1 of 2 sampled residents (Resident 61) reviewed for respiratory care were provided care consistent with professional standards of practice. Failure of the facility to ensure oxygen (O2) delivery and use of Continuous Positive Airway Pressure (CPAP, machine that uses air pressure to keep airways open) was provided according to physician orders, monitor respiratory status, and maintain oxygen equipment, placed residents at risk of discomfort and a potential negative outcome. Findings included . Review of a facility policy, titled, Oxygen Therapy, revised 08/04/2023, showed: - The facility staff were to monitor resident's tolerance to O2 for relief of physical symptoms, relief of difficulty breathing and/or improved O2 saturation. - Staff to provide ongoing documentation of routine and as needed (PRN) use. - Staff would change disposable O2 equipment per manufacturer directives. Review of a facility policy, titled, Respiratory…

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 1 of 5 sampled residents (Resident 13) reviewed for unnecessary medications were free of significant medication errors. Failure to accurately review and transcribe admission medication orders placed residents' health and safety in jeopardy. Resident 13 admitted to the facility from the hospital on [DATE]. Review of Resident 13's current physician orders, showed an order for quetiapine (medication used to treat hallucinations and disordered thoughts) 25 milligram (mg) every 12 hours for dementia (cognitive loss) with agitation with an initiation date of 12/20/2023. There was an order for trazodone (medication for depression that is often used to help sleep) 50 mg at bedtime for sleep with an initiation date of 12/21/2023. Review of the hospital Discharge summary, dated [DATE], showed Resident 13 was to have quetiapine 25 mg every 12 hours as needed for agitation and trazodone 50 mg tablet- give half tablet (25 mg) at bedtime. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident clinical records were complete and accurate for 2 of 24 sampled residents (Resident 60 and 65) reviewed for advance directives (AD, a resident wishes regarding medical treatment to ensure their wishes are carried out if they are unable to communicate them). The failure to ensure AD documentation was complete and accurate placed the residents at risk for not having their wishes honored. Findings included . <RESIDENT 60> The resident admitted to the facility on [DATE]. Review of Resident 60's Multidisciplinary Care Conference note, dated 01/16/2024, showed the facility documented: - The resident wanted help with getting a Medicare application approved. - The resident did not have an AD. The note documented no information was provided to the resident on their right to formulate an AD, and they documented the resident had not declined information on their right to formulate an AD. The note documented they reviewed a Living Will (an advance…

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, resident's representative(s) and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 5 of 5 resident's (2, 5, 6, 7, and 8) reviewed for hospitalizations. This failure did not afford resident and/or their representative to make informed decisions about transfers and prohibited access to an advocate who could inform resident/representative of their options and rights. This failure had the potential to affect all facility-initiated discharges. Findings included . Review of facility policy Transfer & Discharge, revision date 10/15/2022, stated if the facility determines a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility complies with the requirements: a. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed hold notice in writing at the time of a resident transfer to the hospital or within 24 hours of transfer to the hospital for 5 of 5 of sampled residents (Resident 2, 5, 6, 7, and 8) reviewed for hospitalizations. This failed practice placed the residents or their representative at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings included . Review of the facility's policy titled, Bed Hold Policy, undated, stated the facility upon transfer will offer residents and/or responsible party the option to hold the bed. The resident and responsible party will be informed of this policy in writing upon admission and discharge or transfer. If unable to provide at the time of transfer or discharge the policy will be provided within 24 hours. <RESIDENT 2> A review of Resident 2's nursing progress notes and admission/discharge history, showed the resident discharged from facility to the hospital…

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 conduct a thorough investigation for 1 of 3 resident (Resident 1) reviewed for falls. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to Resident 1's incident, placed residents at risk for unidentified abuse or neglect, risk for injury, and ineffective care planning. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. Review of facility policy titled,…

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 honor residents' rights to make choices for frequency of bathing for 4 of 6 residents (Resident 1, 2, 3 and 4) reviewed for choices. Failure to honor resident choices placed these residents at risk for a diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, dated 02/28/2019, showed activities of daily living include the resident's ability to bathe, dress and groom. The policy stated resident's preferences are respected, and reasonable accommodations are made. <RESIDENT 1> Resident 1 was a long-term care resident of the facility. The Quarterly Minimum Data Set (MDS- an assessment tool) assessment, dated 07/28/2023, showed Resident 1 was cognitively intact, and felt that it was very important for them to be able to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident 1's current care plan on 08/17/2023, showed a focus problem of Activities of Daily Living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an effective, resident-centered discharge plan was in place for 1 of 3 residents (Resident 3), reviewed for discharge planning. The failure to initiate a discharge plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-worth, and a diminished quality of life. Findings included . Review of the facility policy titled, Transfer & Discharge, dated 10/15/20222, showed the facility develops and implements an effective discharge planning process focusing on the resident's discharge goals, the preparation of the resident to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Resident 3 admitted to the facility on [DATE] with diagnoses that included a brain bleed (bleeding between the brain tissues and skull or within the brain tissue itself), diabetes,…

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.