McKay Healthcare & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor the effectiveness of medications that affect blood pressure (BP [the force of blood against the walls of the arteries]) for 2 of 3 residents (Resident 1 and 3) reviewed for unnecessary medications. This deficient practice placed the resident at risk of developing abnormal vital signs (body temperature, heart rate, respiration rate, and BP), experiencing adverse side effects, and the potential of receiving medications unnecessarily. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysarthria (where you have difficulty speaking because the muscles you use for speech are weak), and high Blood Pressure (BP). Review of the comprehensive assessment, dated 05/17/2024, showed Resident 1 had moderate…

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 severely cognitively impaired resident was free from non-consensual sexual abuse for 1 of 4 residents (Resident 2) reviewed for sexual abuse. Resident 1 was observed interacting with Resident 2 in a nonconsensual sexually inappropriate manner.The failure to adequately supervise Resident 1 with their known pattern of inappropriate sexual behaviors toward female residents placed Resident 2 at risk for continued sexual abuse. Findings included . Review of the facility' policy titled Abuse, Neglect, and Exploitation Policy, dated 09/10/2023, showed the definition of sexual abuse was nonconsensual sexual contact of any type with a resident. Review of the State Operations Manual, dated 03/06/2019, defined Sexual abuse at Code of Federal Regulation (CFR) 483.5 as nonconsensual sexual contact of any type with a resident. Generally sexual contact is nonconsensual if the resident lacks the cognitive ability to consent. <Resident 2> 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.

Based on interview, and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency, as required, for one of three sampled residents (Resident 1), reviewed for abuse. Failure to report alleged neglect placed Resident 1 and additional residents in the facility at risk for continued neglect and poor quality of life. Findings included . Review of the facility's policy titled Abuse, Neglect and Misappropriation Policy, dated 09/10/2023, showed the facility was to report all alleged violations to the Administrator, State Agency, and all other required agencies in specified time frame. Review of the facility assessment, dated 12/15/2023, showed Resident 1 had diagnoses which included a neurological disorder. The resident was able to make their needs known. Per a facility investigation, initiated on 04/17/2024, Resident 1's representative reported to the facility they felt Resident 1 was being neglected and denied liquids. The allegation had not been reported to the State Agency, as required. During an interview on 04/25/2024 at 2:17 PM,…

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

Based on observation, interview, and record review, the facility failed to provide dietary information for staff to follow that recognized the resident's diet type, consistency, allergies, intolerances, and preferences for 34 of 34 residents living in the facility reviewed for dining. This failure placed the residents at risk of receiving food or drink that decreased their quality of life and had the potential to cause harm. Findings included . During an observation on 02/04/2024 between 12:20 PM and 1:15 PM, showed residents being served their lunch trays in the dining room from carts sent from the kitchen. It was noted there were only resident names on the meal trays and not any dietary cards that informed the staff of what kind of diet the residents were on or what kind of intolerances, preferences, or allergies the residents may have to the food and drinks being served. It was explained that currently there was a list of the resident's diets inside of a closet door in the dining room that they could refer to at any time to see the resident information about their type of diet.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) including incorporating ADs into the care planning process for 3 of 5 residents (Resident 3, 14, and 17) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care. Findings included . <Resident 3> Review of Resident 3's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include a chronic lung disease and depression. Review of the comprehensive assessment, dated 10/27/2023, showed the resident had moderately impaired cognition and required staff assistance with bed mobility and transfers. Further review of the records showed the resident did not have an AD nor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure allegations of abuse/neglect involving unwitnessed or unsupervised events with substantial injuries was reported to the state agency, as required for 2 of 2 residents (Residents 28 and 6), reviewed for accidents. The failure to report to the state agency resulted in the inability to recognize patterns of potential abuse and/or neglect. Findings included . Review of the policy titled Abuse, Neglect, and Exploitation dated 09/10/2023, showed the facility needed to report to the state agency no later than two hours after an incident for serious bodily injury. <Resident 28> Review of Resident 28's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of the comprehensive assessment, dated 11/24/2023, showed the resident's cognition was severely impaired. The assessment further 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 timely follow-up on a pharmacist recommendation for a gradual dose reduction (GDR- a stepwise tapering of a dose to determine if symptoms, conditions, or risks could be managed by a lower dose or if the dose or medication could be discontinued) of an anti-depressant medication and an anti-psychotic medication for 3 of 6 residents (Resident 3, 17 and 24) reviewed for unnecessary medication. The failure to act timely on the recommendation placed the resident at risk for health complications related to potential adverse consequences of the psychotropic medications. Findings included . <Resident 3> Review of Resident 3's medical records showed they admitted to the facility on [DATE] with diagnoses including anxiety (an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), depression (a persistent feeling of sadness and loss of interest), and a sleep disorder. The comprehensive assessment, dated 10/27/2023, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1) consistent monitoring of individualized targeted behaviors for 4 of 6 residents (Residents 3, 17, 24 and 25), 2) as needed (PRN) psychotropic medications (medications capable of affecting the mind, emotions, and/or behavior) were limited to 14-days or had a documented rationale for their extended use for 3 of 6 residents (Resident 4, 24, and 25), 3) the consistent attempt of non-pharmacological (non-medication) interventions prior to psychotropic medication administration for 1 of 6 residents (Resident 3), 4) completion of abnormal involuntary movement scale (AIMS, the assessment of the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia [abnormal and uncontrollable movements caused by anti-psychotic medications]) prior to starting a psychotropic medication and periodically thereafter for 3 of 6 residents (Resident 3, 24, and 25), and 5) an appropriate indication of use…

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 1) provide prompt routine dental services for 2 of 3 residents (Resident 3 and 7) and 2) Failed to replace lost dentures for 1 of 1 resident (Resident 17) reviewed for dental services. This failure placed residents at increased risk for dental impairment/nutritional needs, altered self-imagery and weight loss. Finding included . Record review of the facility policy titled Dental Services, dated 08/24/2023, showed that the facility was to assist residents in obtaining routine (to the extent covered under the state plan) dental care. <Resident 3> Review of Resident 3's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include an irregular and rapid heart rhythm, and anxiety (an unpleasant emotional state where the cause is either not readily identified or perceived as uncontrollable or unavoidable). Review of the comprehensive assessment, dated 10/27/2023, showed Resident 3 had moderately impaired…

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

Based on observation, interview and record review, the facility failed to maintain infection control practices for 4 of 4 residents (Residents 4, 6, 24, and 35), by not wearing the proper Personal Protection Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) during COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) testing, perform hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment and during wound care dressing changes), or ongoing surveillance of communicable diseases and infections within the facility for 3 of 12 months (October, November and December 2023). These failures placed residents at risk for development of communicable diseases and the spread of infections. Findings included . Review of the policy…

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 personal funds were reimbursed within 30 days of a residents death for 1 of 4 residents (Resident 191) reviewed for personal funds. This failed practice caused delay in the reconciliation of Resident 191's account within a 30-day period as required. Findings included . <Resident 191> Review of Resident 191's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include heart failure and a chronic lung disease. The record further showed the resident discharged from the facility on 07/20/2023. Review of Resident 191's personal funds account, dated 07/01/2023 through 09/30/2023, showed the resident had a balance of $3655.40 owed to them. Review of the facility's check dated 09/07/2023, showed $3655.40 was paid to the RR (49 days after the resident discharged ). During an interview on 02/09/2024 at 11:30 AM, Staff H, Business Office Manager, stated they were aware Resident 191's account reconciliation was late 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 assess a resident's need for the use of a postural support/safety harness (a device used to support impaired posture), that restricts a resident's freedom of movement for 1 of 1 resident (Resident 4) reviewed for physical restraints. Additionally, the documentation lacked least restrictive alternatives interventions were attempted, periodic removal of the device, and ongoing monitoring while in use. This failed practice placed the resident at risk for decline in physical function, restriction of movements, risk of injury, and loss of dignity. Findings included . <Resident 4> Review of Resident 4's medical records showed the resident admitted to the facility on [DATE], with diagnoses to include seizure (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) activity and traumatic brain injury (TBI, a head injury causing damage to the brain by external force or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate for allegations of abuse and/or neglect for 1 of 2 residents (Resident 28), reviewed for accidents. Resident 28 had an unwitnessed fall that resulted in a fractured nasal bone and a concussion (a traumatic brain injury caused by a blow to the head). This failed practice placed the resident at risk for unidentified abuse and neglect. Findings included . Review of the policy titled Abuse, Neglect, and Exploitation dated 09/10/2023, showed during an investigation the facility would identify and interview all persons involved with the investigation, determine if abuse or neglect occurred, and document thoroughly. <Resident 28> Review of Resident 28's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of the comprehensive assessment, dated 11/24/2023, showed the resident's cognition 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 observation, interview, and record review the facility failed to recognize a significant change in a resident's activities of daily living (ADLs) due to their disease progression for 1 of 1 resident (Resident 16) reviewed for ADL decline. This failed practice placed the resident at risk for unmet needs due to changes. Findings included . Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument manual, October 2023 (pages 2-24 thru 2-31), showed a significant change (a decline or improvement in a resident's status) should be identified while completing a resident's comprehensive assessment if the condition; 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting, 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary (involving two or more different subjects or areas of knowledge) review and/or revision 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 develop a baseline care plan within 48 hours of admission that documented resident specific initial goals, physician orders and treatment plans for 1 of 1 resident (Resident 241), reviewed for recent admissions. The failure to develop and provide a summary of the care plan to the resident and/or family representative placed the resident at risk of not receiving continuity of care and resident centered care needs. Findings included . <Resident 241> Review of Resident 241's medical record showed the resident admitted to the facility on [DATE] with diagnoses including diabetes and a recent above the knee amputation of the left leg. Review of Resident 241's most recent comprehensive assessment, dated 01/30/2024 showed the resident required extensive assistance with transfers, toileting, and dressing with one to two caregivers and was cognitively intact. Review of the medical record showed no 48-hour baseline care plan or documentation to show that 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 develop comprehensive care plans prepared by the required members of the interdisciplinary team (IDT a group of healthcare providers from different fields who work together for the best outcome for residents), including the residents and Resident Representatives (RRs) for 2 of 2 residents (Residents 18, and 3), reviewed for comprehensive care planning. This failure placed the residents at risk of unmet care needs. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023 §483.21(b)(2)(ii) The interdisciplinary team (IDT) must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative. <Resident 18> Review of the resident's electronic medical record showed they were admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice regarding ongoing skin assessments for 2 of 2 residents (Residents 14 and 16) reviewed for skin impairment. The facility's failure to provide the care and services required related to non-pressure skin issues placed residents at risk for unidentified and/or avoidable decline, delay in treatment, pain/discomfort, and unmet care needs. Findings included . Record review of the facility policy titled Skin assessment, Treatment and Prevention, dated 05/07/2019, showed . the facility will ensure all residents have a weekly skin assessment .skin integrity is quickly addressed, well documented .any identified skin issues must be measured and documented . <Resident 14> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of a stroke (when the blood flow to the brain stops or is interrupted). 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 restorative therapy services were implemented for 1 of 3 sampled residents (Resident 32), reviewed for restorative therapy. This failure placed the resident at risk for loss of range of motion, deconditioning, and contractures. Findings included . Record review of a facility policy titled Restorative Nursing Programs, dated 11/06/2023, showed . the facility will provide restorative nursing programs for patients who: • Will benefit from restorative programs. • In conjunction with specialized rehabilitation therapy, or upon discharge from therapy. • To help the patient obtain and maintain optimal physical, mental, and psychosocial well-being. <Resident 32> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (a heart condition that causes an irregular and fast heart rate) and congestive heart failure (a condition when your heart can not pump blood well enough 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 a resident who was continent of bowel and bladder on admission received services and assistance to maintain their continence status for one of one resident (Resident 241) assessed for bowel and bladder function. This failure left the resident with feelings of embarrassment and a loss of independence. Findings included . <Resident 241> Review of the resident's electronic medical record showed they were admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes and a recent above the knee amputation of the left leg. Resident 241's most recent comprehensive assessment dated [DATE] showed they required extensive assistance with a Hoyer lift (an assistive device that lifts patients for transfers from bed to wheelchair or toilet and back) and two caregivers and their cognition was intact. In an observation and interview with Resident 241 on 02/05/2024 at 10:47 AM, showed them sitting at a dining room table in…

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 (%). During observation of (4) medication passes, 2 of 3 Licensed Nurses (Staff K and V) administered 16 medications in error, out of 25 medications opportunities observed, resulting in an error rate of 64%. This failure placed the residents at risk for inaccurate and/or ineffective medication dosing and adverse side effects. Findings included . Review of the policy titled, Administering Medications, dated 02/27/2019, showed Medications shall be administered in a safe and timely manner, and as prescribed to decrease medication errors and adverse drug events . Medications must be administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meals orders) . Review of the Medication Administration Record (MAR), dated February 2024, showed Resident 35 had physician orders for pain, blood pressure, supplements , dementia, urinary health, depression, constipation, and gastric reflux…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 2 residents (Resident 18, and 35) reviewed for medication administration. This failed practice placed the residents at risk for medication adverse side effects. Findings included . Review of the facility's policy titled, Administering Medications, dated 02/27/2019, showed medications should be administered in a safe and timely manner, and as prescribed, to decrease medication errors and adverse drug events. Review of the Nursing 2023 Drug Handbook showed that the following medications were not to be crushed; memantine [(used for dementia (the loss of thinking, remembering, and reasoning- to the extent that in interferes with ADL's.)) do not allow the patient to divide, chew, or crush, this can release all of the medication at once, increasing the risk of trouble walking, headache, pain, increased confusion.], metoprolol [(used for blood pressure) never crushed 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 provide adequate supervision for 1 of 3 sampled residents (Resident 1), reviewed for elopements (when a resident leaves the facility without staff knowledge). The facility failed to identify Resident 1 had exited the building after a door alarm had been activated. This failure placed the resident at risk for potential injury. Findings included . According to the most recent assessment, dated 06/01/2023, Resident 1 had diagnoses which included Alzheimer's Dementia. Resident 1 had behaviors which included delusions (a false belief of things that are not true), and wandering. The resident had memory impairments and was impaired with decision making. According to the assessment, Resident 1 required supervision for ambulating. The resident's care plan, dated 03/01/2023, showed Resident 1 was at risk for elopement due to a history of wandering and elopement, had impaired safety awareness and was independent in ambulation. Interventions included to ensure the resident didn't follow visitors out of the facility 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 observation, interview, and record review, the facility failed to ensure expired foods were disposed of, and the concentration of the dish machine was of proper concentration and monitored in accordance with professional standards for food service safety for one of one kitchen. This failure placed the residents at risk of food-borne illness. Findings included . Review of the facility's policy titled Food Receiving and Storage, dated 01/24/2023, showed Foods found to exceed the expiration date on the package will be discarded immediately. Review of the facility's policy titled Manual Washing and Sanitizing Kitchen Ware, dated 01/24/2023, showed A three step process is used to manually wash, rinse and sanitize dishware correctly. The third step is sanitizing with chlorine or quaternary sanitizer at the correct concentration based on product, testing at least when initially filled and as needed such as with extended use. An observation in the kitchen on 01/24/2023 at 8:46 AM, the walk-in refrigerator had six containers of yogurt, dated 01/16/2023. There were four, five-pound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement an effective Infection Prevention and Control Program (IPCP) with 1. monitoring to demonstrate ongoing data analysis with tracking and trending of residents' infectious organisms for seven of twelve months reviewed; 2. establishing and maintaining a water program with policies and procedures that inhibit microbial growth of the Legionella bacterium; and 3. ensuring appropriate storage of the connection tip and tubing for one of one resident (2) reviewed for tube feeding. These failures increased the risk of infections to all residents residing at the facility. Findings included . Monitoring Review of the facility's policy titled, Infection Surveillance, with a review and revised date of 09/29/2020, revealed all infections should be captured, tracked, and reported monthly for trends and outbreaks. Review of the facility's Infection Control Surveillance Tracking Binder, for January 2022 through December 2022 showed tracking,…

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 resident's right to dignity and privacy was maintained during use of the public bathroom for four of four residents (24, 28, 2 and 1), reviewed for privacy and dignity during toileting. Additionally, the facility did not ensure resident privacy was maintained for one of one resident (7) reviewed for bathing activity. These failures had the potential to cause the residents embarrassment and a diminished quality of life. Findings included . Toileting Resident 24. Medical record review showed the resident had diagnoses including Alzheimer's Disease and chronic kidney disease (the kidneys no longer function normally). The most recent Minimum Data Set (MDS) assessment, dated 10/22/2022, showed the resident had impaired cognition and required extensive assistance from staff for transfers and toileting needs. During an observation on 01/23/2023 at 1:06 PM, Staff S Nursing Assistant (NA), wheeled Resident 24 to the large bathroom on Hall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure that a 1. Licensed nurse (LN) administered medications to one of one resident (28) reviewed for professional standards of medication administration . 2. Failured to ensure that medications were not left unsecured at a residents bedside for two of two residents (28 and 8) reviewed for safe/secure medications. 3) Failed to ensure that licensed staff monitored blood pressure (BP) and pulse prior to administration of BP medications when ordered by a physician for one of one resident (17) reviewed for blood pressure lowering agents. These failures placed the residents at risk for not receiving care that required assessment and supervision from a licensed nurse and placed residents at risk for negative health outcomes. Findings included . 1. Medication Administration Record review of the facility policy titled Administering medications dated 02/27/2019 showed .Only persons licensed permitted by Washington State to prepare, administer,…

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 safeguard the residents environment from accidents and hazards for three of four resident bathrooms (Bathrooms [ROOM NUMBER]) reviewed for security of cleaning chemicals. Additionally, one of one equipment rooms that had electric equipment near a sink of water reviewed for electrical safety. These failures put the residents at risk for accidents that could potentially result in the residents subsequent harm. Findings included . Record review of the undated Material Safety Data Sheet for Micro-kill disposable disinfectant wipes showed, .Emergency overview: Do not get into eyes .wash thoroughly with soap and water after handling and before eating or drinking . Record review of the 05/11/2020 Safety Data Sheet, (SDS), for Renown disinfectant deodorant II spary showed, ' Advice for safe handling: Avoid contact with skin and eyes .Always replace cap after use .may cause skin irritation to susceptible persons and severe eye irritant . 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 maintain a clean bedside commode for one of one resident (20) reviewed for providing a safe, clean, comfortable and home-like environment. This failed practice placed residents at risk for diminished quality of life and compromised dignity. Findings included . Resident 20. Record review showed that the resident was admitted to the facility on [DATE]. Record review showed the resident had diagnoses including dementia, muscle wasting and atrophy, difficulty in walking, lack of coordination, and muscle weakness. Record review of Resident 20's assessment dated [DATE], showed that the resident had severely impaired cognition and required limited assistance with one person for toileting. An observation on 01/22/2023 at 9:00 AM, showed Resident 20's bedside commode contained feces causing a strong odor. Resident 20 was observed in their bed. An observation on 01/22/2023 at 10:21 AM, showed Resident 20's bedside commode contained feces causing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nail care and shaving assistance for two of two residents (18 and 11) reviewed for Activities of Daily Living (ADL) assistance. This failed practice placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the undated facility policy titled [Facility Name] Routine Standards of Care - Nursing, showed .Check the resident's nails for cleanliness each shift and after bathing. Provide nail care weekly, after bathing and as need (PRN) .Provide equipment for residents to shave themselves and assist as necessary. Resident 18. Record review showed the resident was initially admitted to the facility on [DATE]. Record review showed the resident had diagnoses that included osteoarthritis (inflammation of one or more joints) of right and left wrist and secondary osteoarthritis of right elbow, abnormalities of gait and mobility, and chronic pain. Record review showed that Resident 18's…

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