Alderwood Manor

Based on interview and record review, the facility failed to ensure the pharmacist's recommendation for a resident's inhaler (a medication that helped ease the effort of breathing) was addressed timely for 1 of 5 residents (Resident 11) reviewed for monthly medication regimen reviews. This failure placed the resident at risk for unintended side effects of the medication, and decreased quality of life. Findings included .The 12/08/2025 annual assessment documented Resident 11 had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that caused inflammation and difficulty breathing). Review of Resident 11's record showed a physician order dated 11/12/2025 for Arnuity Ellipta (an inhaled medication for asthma, a chronic disease of the lungs that caused episodes of wheezing, coughing, chest tightness, and shortness of breath) to be given once daily beginning on 11/13/2025.A pharmacy consultation report dated 12/17/2025 recommended the Arnuity Ellipta order be updated to include rinsing the mouth with water after use to prevent thrush (a painful…

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 a total medication error rate of five percent or less for 3 of 7 sampled residents (Residents 76, 42, and 8) observed during medication administration. Specifically, 3 of 25 medications were observed to be given incorrectly for an error rate of 12 percent. This failure placed residents at risk of medication errors, adverse side effects, and potential medical complications. Findings included.<Resident 42> The 02/04/2026 admission assessment documented Resident 42 had diagnoses that included cancer, heart failure and diabetes. The resident was cognitively intact and able to make their needs known. Review of the 01/22/2026 provider order instructed nursing staff to administer Preservision AREDS (medication used to slow the progression of vision loss) two tablets to Resident 42 daily. During an observation on 02/09/2026 at 8:12 AM, Staff Y, Registered Nurse (RN), administered a multivitamin with minerals instead of the Preservision AREDS to Resident 42. In an interview on 02/12/2026 at 10:46 AM, Staff B,…

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 a surgical wound for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure wounds. This failure placed residents with surgical incisions at risk of potential worsening skin conditions and complications. Findings included .A facility document titled Documentation and Assessment of Wounds, revised 06/12/2025, showed the facility Policy was to guide nurses in the assessment of wounds to include pressure ulcer/injuries (damage to the skin and underlying tissue caused by unrelieved pressure that restricts blood flow), venous (open sore on the lower leg from impaired circulation), arterial (painful wounds caused by poor circulation), diabetic (sores, ulcers, or chronic conditions that develop in people with diabetes, often on the feet, due to poor circulation, nerve damage), and dehisced surgical wounds (surgical wound that split open or separate), and other wounds not otherwise specified. A wound observation was to be made with each dressing change. The provider would be notified of changes 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 and interview, the facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service. This failure placed the residents at risk for foodborne illness. Findings included . A 04/30/2024 facility policy titled Associate Conduct and Dress Code showed hair and beard coverings were used when cooking, preparing or assembling food, but not required when distributing foods to the residents at the dining tables or when assisting the residents to dine. An observation on 10/22/2024 at 8:08 AM showed Staff Z, a Dietary Aide, participated in the breakfast tray line. Staff Z had visible facial hair and no beard covering. An observation on 10/25/2024 from 11:30 AM to 11:53 AM showed Staff Y, a Cook, standing in front of the food prep counter. The kitchen staff were getting ready to start lunch tray line. Staff Y wore a pink bandana. About three inches of hair was observed flowing down Staff Y's forehead. The bandana failed to contain Staff Y's hair, with visible hair observed coming out of the bandana around the sides and the back of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration (Residents 3, 13, 39) and failed to ensure a consent for treatment and admission were signed by someone able to make those decisions (Resident 27) for 4 of 5 sampled residents reviewed for unnecessary medications. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications and care being provided at the facility. Findings included . <Resident 3> Review of Resident 3's medical record showed the provider ordered the medication sertraline on 07/01/2024 for depression. Review of the October 2024 Medication Administration Record showed the staff administered the sertraline to Resident 3 at bedtime. Review of Resident 3's care plan showed the resident used sertraline related to depression. Review of a 07/02/2024 Medication Informed Consent showed Resident 3 and a…

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

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to cleanliness and grooming for 4 of 6 sampled residents (Residents 44, 37, 9, and 19) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 37), nail care (Resident 9), and bathing (Resident 44 and 19), placed the residents at risk for poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Resident 44> Review of a 10/17/2024 assessment showed Resident 44 admitted with medically complex conditions. This assessment showed the staff assessed the resident to be cognitively intact and dependent on the staff for bathing. In an interview on 10/22/2024 at 8:36 AM, Resident 44 stated, Bathing dwindled down to once a week. Resident 44 stated that they preferred a bed bath twice a week. Review of the electronic medical record under Tasks showed an instruction to the staff to provide bathing to Resident 44 twice a week on Mondays and Thursdays. 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 AMMENDED ON 11/18/2024. Based on observation, interview and record review, the facility failed to ensure residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for 4 of 5 sampled residents (Residents 7, 27, 25 and 254) reviewed for elopement. The facility failed to ensure 1 of 3 sampled residents (Resident 41) had adequate and prompt interventions and supervision to prevent falls. Also, the facility failed to ensure 2 of 2 sampled residents (Residents 24 and 41) reviewed for smoking were adequately supervised, to include safe keeping of smoking materials. These failures placed the residents at risk for injuries related to elopement, falls, and smoking. Findings included . <ELOPEMENT> <Resident 25> Review of a 09/25/2024 facility policy titled Unsafe Wandering and Elopement Prevention showed the facility would assess residents to determine their risk for elopement and implement interventions as appropriate to mitigate risks identified. 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.

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 2 of 2 medication carts, and needles and lab supplies were securely stored that were in a bistro. The facility failed to maintain temperatures to ensure medications were properly stored in 2 of 2 medication storage rooms. The facility further failed to ensure anti-anxiety medications were stored behind two locks as required and nursing staff were signing the narcotic logs verifying all medications were accounted for at shift change. This failure placed residents at risk for receiving compromised or ineffective medication, placed the facility at risk for potential diversion or misappropriation of psychotropic medications and potential for needlestick injuries. Findings included . On 10/22/2024 at 10:34 AM, an observation was made of a room called The Bistro. The room contained a kitchenette and had multiple cabinets and drawers. The lower unlocked cabinet contained two bottles of red liquid that…

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 accommodate preferences for bedtime routine for 1 of 2 sampled residents (Resident 44) reviewed for choices. This failure placed the resident at risk for a diminished quality of life. Findings included . Review of a 08/16/2022 facility policy titled Person Centered Planning, showed the facility would develop a person-centered care plan that addressed the goals, preferences, values, and practices of the resident. This policy showed it would include the resident's participation and reflect the resident's right to make informed choices. In an interview on 10/22/2024 at 8:36 AM, Resident 44 stated, I would prefer to be woken up at or before 6:00 AM to remove the bi pap [respiratory equipment] off as early as possible. Resident 44 stated their preferred bedtime hours was around 8:00 PM. Review of a 10/17/2024 quarterly assessment showed the staff identified it was very important for Resident 44 to choose their own bedtime. Review of a 04/15/2024 Activities Evaluation showed Resident 44's preferred wake up time in the morning…

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 a secure place for residents to store their valuables for 1 of 2 sampled residents (Resident 13) reviewed for personal property. This failure placed residents at risk for their property to be lost or stolen, and decreased quality of life. Findings included . The Life Care Centers of America Inventory of Personal Belongings policy revised 06/12/2024 documented on admission, a resident or their representative would bring in personal clothing and it was to be marked with the resident's name by the laundry department then returned to the resident after labeled or washed. This was done to ensure all of the resident's clothing was returned once it had been laundered. The policy did not describe how other belongings were to be secured or safeguarded. A review of the 08/20/2024 quarterly assessment documented Resident 13 had diagnoses including dementia and depression. Resident 13 was moderately impaired cognitively, and it was somewhat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 4 sampled residents (Resident 25) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse. Findings included . Review of an October 2022 facility policy titled Abuse - Prevention showed the facility prevented and prohibited all types of abuse, neglect, misappropriation of resident property, and exploitation. This policy showed the facility would identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, to include verbally or physically aggressive behavior. Review of a 06/27/2024 facility policy titled Abuse - Reporting and Response- Suspicion of a Crime showed it instructed the staff to report immediately…

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 Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization/discharge. This failure placed the resident at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman. Findings included . The 08/29/2024 discharge assessment documented Resident 51 was cognitively intact to make decisions regarding their care and had diagnoses which included anxiety and opioid dependence. Review of Resident 51's record showed a nursing progress note documented in the early morning hours of 08/29/2024, the resident was observed to be pulling their hair and experiencing severe jerking movements of their body. The resident was assessed, and per direction of the on-call provider, the resident was sent to the hospital for evaluation. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer 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.

Based on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they are hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold, while they were hospitalized . Findings included The 08/29/2024 discharge assessment documented Resident 51 was cognitively intact to make decisions regarding their care and had diagnoses which included anxiety and opioid dependence. Review of Resident 51's record showed a nursing progress note documented in the early morning hours of 08/29/2024, the resident was observed to be pulling their hair and experiencing severe jerking movements of their body. The resident was assessed, and per direction of the on-call provider, the resident was sent to the hospital for evaluation. Additional…

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 identify and incorporate specific recommendations made by the PASARR Level 2 evaluator for 1 of 3 sampled residents (Resident 25) reviewed for pre admission screening. A PASARR (Preadmission Screening and Resident Review) Level 2 Evaluation is a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition. This failure placed Resident 25 at risk for unmet mental health care needs. Findings included . Review of a 10/11/2024 assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions and assessed as cognitively intact. The assessment showed the diagnoses of depression and bipolar disorder. Bipolar disorder is a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior. These shifts can make it difficult to do daily tasks and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a PASARR Level 1 [preadmission screening for individuals with a mental disorder and/or intellectual disabilities] was completed as required for 2 of 5 residents (Residents 3 and 27) reviewed for pre admission screening. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Resident 3> Review of a 10/25/2024 comprehensive assessment showed Resident 3 re-admitted to the facility on [DATE] from the hospital with medically complex conditions, to include depression and anxiety disorder. Review of Resident 3's diagnoses list also included somatization disorder (when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning). Review of the medical record showed no presence of a PASARR Level 1. The above findings…

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 the provider was notified when a resident had possible seizure activity for 1 of 2 sampled residents (Resident 37) reviewed for quality of care. This failure placed residents at risk of not being assessed for possible decline by their provider, unintended health consequences, and decreased quality of life. Findings included . A review of the annual assessment dated [DATE] documented Resident 37 had diagnoses including dementia, and paralysis on one side of their body from a stroke. The resident was severely cognitively impaired and had not had a previous diagnosis of having seizures. A nursing progress note dated 10/19/2024 at 3:16 PM documented Resident 37 was in the dining room with their family when the resident had what looked like an absence seizure, (a short period of staring blankly in to space). The resident's hand and foot were having seizure like movements for about 10 minutes. The resident was aware and speaking during…

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 identify and monitor a pressure ulcer for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. This failure put the resident at risk for worsening breakdown of their skin, infection, and unintended health consequences. Findings included . A review of the 08/19/2024 admission assessment documented Resident 24 had diagnoses including paralysis of one upper extremity following a stroke and left fractured femur (thigh bone). Resident 24 was cognitively intact and was at risk for development of pressure ulcers but had none when admitted . On 09/16/2024, a significant change assessment was completed that documented Resident 24 rejected care and had one unstageable (the ulcer was covered by a layer of dead tissue that may have been green, brown, or black and made it unable to determine the extent of the wound underneath) pressure ulcer not present on admission. The 08/23/2024 care plan documented Resident 24 was at risk for break in skin integrity related to decreased mobility. Staff were to provide a…

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

Based on observation, interview, and record review, the facility failed to demonstrate orthotic devices (devices to help support muscles, tendons and ligaments in the wrist and hands) were implemented and monitored to prevent contractures for 1 of 3 sampled residents (Resident 10) reviewed for Position/Mobility. This failure placed the resident at risk for deterioration in Range of Motion (ROM) abilities and development of contractures. Findings included . On 10/22/2024 at 12:03 PM, Resident 10 stated that they participated in a Restorative Nursing Program for, arms and legs, hands and feet. On 10/23/2024 at 9:31 AM, Resident 10 was observed sitting in their wheelchair, with their legs propped on a pillow, and a rolled washcloth to each hand grip. On 10/24/2024 at 2:21 PM, Resident 10 was observed with a rolled washcloth to each hand grip and they stated, They gave me a splint for both hands. But it hurt my hands so now I have washcloths. The observation showed the washcloth to the right hand grip was out of Resident 10's hand. Resident 10 stated that they had the rolled washcloths…

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 2 residents (Resident 18)reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the resident at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . Review of a 10/15/2024 quarterly assessment showed Resident 18 re-admitted to the facility on [DATE]. This assessment showed the resident admitted to the facility with a stroke and assessed to have moderate cognitive impairment. The assessment showed the resident required substantial/maximal assistance to transfer to the toilet, was frequently incontinent of bowel and bladder, and no toileting program in place to manage the resident's incontinence. An observation on 10/22/2024 at 9:40 AM showed Resident 18 in bed. When asked if they required assistance to use the bathroom for bowel and bladder elimination,…

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 oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (Resident 19 and 38) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . <Resident 19> Per the 10/01/2024 admission assessment, Resident 19 had diagnoses which included heart failure and obstructive sleep apnea (OSA, when you can't breathe while asleep because of a blockage of your windpipe) and needed a CPAP (a machine that uses mild air pressure to keep breathing airways open) due to those conditions. The 09/27/2024 physician order instructed nursing staff to cleanse the CPAP mask with warm soapy water, rinse and air dry daily and as needed. The 02/28/2024 care plan documented Resident 19 used a CPAP for OSA. In an observation and interview on 10/22/2024 at 2:19 PM, Resident 19's CPAP was unclean with white splatter inside of the mask. Resident 19 stated staff had not cleaned their mask, and they cleaned it twice weekly by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dialysis care was provided consistently with professional standards for 2 of 2 sampled residents (Residents 13 and 19) reviewed. Specifically, Resident 13 was not consistently evaluated post-dialysis treatments, and Resident 19 was not given their morning medications on dialysis treatment days. This failure placed residents at risk for unintended health consequences, deterioration of their chronic diseases and decreased quality of life. Findings included . The Life Care Centers of America, Area of Focus: Dialysis policy revised 11/29/2023 documented on the day of dialysis, staff were to check medications the resident was taking and follow physician orders regarding medication administration and complete the Pre/Post Dialysis Communication form before and after treatment. Post-dialysis, staff were instructed to obtain vital signs, transcribe any orders received from the dialysis facility and maintain the communication form in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 2 of 2 sampled residents (Resident 3 and 25) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life. Findings included . <Resident 3> Review of a 09/06/2024 facility policy titled Trauma-Informed Care showed that residents who have a history of trauma and or post-traumatic stress disorder will receive appropriate treatment and services to correct the assessed problem. Trigger-specific interventions would identify ways to decrease the resident's exposure to triggers which re-traumatize the resident…

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

Based on interview and record review, the facility failed to ensure blood pressures and heart rates were monitored and medications were held when parameters required it for 2 of 5 sampled residents (Residents 10 & 22) reviewed for unnecessary medications. This failure placed the residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 10> Review of Resident 10's September and October 2024 Medication Administration Records (MAR) showed an order that instructed the staff to administer metoprolol (a medication used to treat high blood pressure and heart failure) by mouth at bedtime. The order also instructed the staff to hold the metoprolol if the resident's pulse was less than 60 beats per minute. Review of the September and October 2024 MAR showed the staff administered the metoprolol at bedtime even though they assessed Resident 10's pulse was below 60 on 09/01/2024, 09/05/2024, 09/07/2024, 09/13/2024, 10/01/2024, 10/02/2024, 10/03/2024, 10/08/2024, 10/10/2024, 10/15/2024 and 10/29/2024. The above findings were shared with…

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 develop a complete water management plan, to mitigate the facility's risk factors associated with Legionnaire's Disease (a serious condition, caused by exposure to water sources infected with the Legionella pathogen), failed to ensure soiled linens were transported properly, and failed to ensure oxygen was administered in a sanitary manner and equipment was clean and maintained for 1 of 3 sampled residents (Resident 38) reviewed for respiratory care. These failures placed all residents at risk for exposure to Legionella, infections, respiratory complications, and diminished quality of life. Findings included . <Water Management Program> Review of the facility's water management plan showed it was last reviewed on 03/11/2024. Review of the plan showed it had not been fully developed and, aside from identifying the facility's water source, the facility's contacts, and the facility's characteristics, the rest of the program was either not fully completed or blank. On 10/30/2024 at 12:51 PM, Staff A,…

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

Based on observation and interview the facility failed to ensure wheelchairs were maintained in a clean manner for 2 of 4 sampled residents (Residents 14 and 19) reviewed for physical environment. This failure placed residents at risk for lack of dignity and diminished quality of life. Findings included . <Resident 14> Per the 10/16/2024 quarterly assessment, Resident 14 had diagnoses which included a stroke and hemiplegia (paralysis on one side of the body), had moderate cognitive impairments and required substantial to total assist for all cares. Review of the 01/25/2023 comprehensive care plan documented Resident 14 was wheelchair bound. During an observation on 10/22/2024 at 10:22 AM, Resident 14 was sitting in their wheelchair in their room. The left armrest of their wheelchair was covered with sheepskin and a netting was placed over it. The sheepskin and netting were unclean and had a brown and red substance on it. In an observation on 10/23/2024 at 8:14 AM, Resident 14 was sitting in the dining room. The sheepskin and netting were unclean with a red and brown substance on it.…

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

Based on observation, interview, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 8 out of 9 residents (Resident 1, 2, 3, 4, 5, 6, 8, and 9) related to not honoring residents food choices and not following resident meal cards (cards that show likes, dislikes, allergies, and fluids to be served). Failure to promptly resolve grievances resulted in on-going dietary complaints from residents and a diminished quality of life. Findings included . <Resident interviews> On 05/29/2024 at 1:00 PM, Resident 1 stated they attended the food committee monthly and residents had been told they don't fill out menus correctly and that was why they didn't get the food they ordered. Resident 1 stated they were served food they hadn't circled on the menu and was often served their dislikes. The resident stated kitchen management told the committee changes would be made and it didn't happen. On 05/29/2024 at 1:14 PM, Resident 8 stated the food wasn't good. The resident stated it didn't matter what was filled out on the menu, the kitchen didn't serve it…

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

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 4 of 6 residents (Resident 4, 5, 6, and 7), reviewed for abuse and/or neglect. This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life. Findings included . <Resident 4> According to the facility assessment, dated 06/03/2024, Resident 4 had diagnoses to include heart disease. Resident 4 was able to make their needs known. On 06/12/2024 at 10:25 AM, Resident 4 was sitting in a wheel chair in their room. The resident was asked if they had any concerns with staff and replied not that they could recall. Resident 4 stated if they did, it was probably one of the agency people that worked weekends, because they didn't know the residents very well. Review of the facility grievance log showed Resident 4 had filed a nursing concern on 05/14/2024. Review of the grievance form, dated 05/14/2024, showed Resident 4 had a concern about Staff A, Licensed Practical Nurse (LPN), who was rough and rude to them. Under Facility…

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

Based on interview and record review, the facility failed to consistently monitor and documented condition changes for 1 of 3 residents (Resident 1), reviewed for change in condition. This failure placed residents at risk for worsening medical conditions and unmet care needs. Findings included . Review of a facility assessment, dated 11/29/2023, showed Resident 1 had diagnoses which included heart and lung disease, difficulty swallowing, and dementia. Resident 1 had difficulty making their needs known and required extensive assistance with Activities of Daily Living (ADL's). Review of a facility document titled Alert Charting Guidelines showed residents with a change in condition were to be charted on every shift until the condition resolved, the resident was sent out, or the resident returned to their baseline (their medical condition prior to having a change). Review of a progress note by Staff A, Physician Assistant (PA), dated 01/10/2024, showed staff had asked Staff A to assess Resident 1 for a decline in their condition. Review of nursing progress notes from 01/09/2024 through…

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 they staffed enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 7 sampled residents (Resident 1, 2, 3 ,4, and 5), reviewed for sufficient staffing. This failure placed residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, revised 08/2023 showed residents would receive assistance as needed to complete activities of daily living. The policy further showed the facility must ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident choices. Review of the facility assessment revised 10/17/2023 showed the facility had an average daily census of 47.9 residents and no…

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 sufficient preparation for a safe discharge for 1 of 3 residents (Resident 1), reviewed for discharges. Resident 1 was discharged without adequate knowledge on using a glucometer (a machine that measures blood sugar levels) or injecting insulin (a medication that controls blood sugar). This failure placed the resident at risk for medical complications. Findings included . Review of the facility assessment, dated 08/10/2023, showed Resident 1 was admitted with diagnoses which included Diabetes. Resident 1 was able to make their needs known. Per record review, the resident was admitted from the hospital on insulin. The resident was to continue to use insulin after discharge. Per interview on 09/18/2023 at 12:50 PM, Staff A, Resident Care Manager, stated if a resident was going home with new equipment or medication they should receive education/training prior to discharge. With Resident 1, the teaching wasn't done on the glucometer and insulin until the day of discharge. Teaching should have started weeks prior 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.

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet the care needs for 4 of 17 sample residents (38, 22, 11, 31), reviewed for activities of daily living (ADLS), timely administration of medications, a clean and homelike environment, and supervision to prevent accidents. These failures placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . <ADLS and Resident Interviews> In an interview on 06/22/2023 at 9:47 AM, Resident 22 stated there was not enough staff to ensure cares are provided. During an interview on 06/22/2023 at 10:12 AM, Resident 18 stated there were not enough staff to provide cares. Resident 18 added they would like more showers but there was not enough staff. In an interview on 06/22/23 10:25 AM, Resident 45 stated they did not get changed timely during the night shift because there was not enough staff at night. They said they usually needed to be changed twice during the night but sometimes it only happened once. On 06/23/23 at 9:48 AM, when asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Staff D, the Registered Dietician (RD) had proper qualifications. This failure placed residents at risk for nutritional mis-management and potential decline. Findings included . The 05/23/2023 Facility Assessment tool showed the facility residents required and were to be provided nutrition care that included individualized, liberal, or specialized diets, assistive devices, cultural or ethnic dietary needs, and fluid monitoring or restrictions. A dietician or other clinically qualified nutrition professional was to serve as the director of food and nutrition services. The 07/01/2016 Agreement for Dietary Consulting Services showed the Consultant certifies that the Consultant is licensed by and registered in the state in which the Facility is located and has all other approvals and certificates required by state and federal agencies in order to qualify for and participate in Medicaid and Medicare and other healthcare programs. The Consultant 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.

Based on observation and interview, the facility failed to label and date food products, and to discard of food products on or before the expiration date. This failure placed the residents at risk for food-borne illness. Findings included: <Food labeling and storage observation> Observation of facility kitchen dry food storage area on 6/22/2023 at 09:00AM showed expired food which included: 1 can of chili with an expiration date of 3/2023 6 cans of chili with an expiration date of 4/2023 15 packages of tortillas with and expiration date of 4/2023 2 cans of pork and beans with an expiration date of 3/2023 1 can of butterscotch pudding with and expiration date of 4/2023 3 cans of chow Mein noodles with and expiration date of 7/18/2022 5 bags of raisins with an expiration date of 1/2023 2 bags of marshmallows with an expiration date of 5/2023 Observation of facility kitchen pantry on 06/28/2023 at 5:33 AM, 4 expired food items, as well as 26 open food containers with no use by date and/or opened date were found. In an interview on 07/03/23 at 12:16 PM with Kitchen Staff Member Z, 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 maintain an infection prevention and control program that provided a safe and sanitary environment. Failure to ensure hand hygiene was completed and gloves were changed between clean and dirty tasks while medications were given for 1 of 6 sampled residents (Resident 4) reviewed for medication administration, and to ensure staff were informed and preventative measures were implemented to prevent the spread of bed bugs, prior to admitting a resident (Resident 153) placed the residents at risk for infectious diseases and a decreased quality of life. Findings included . <Safe and Sanitary Environment> Observations showed the following: - On 06/22/2023 at 8:32 AM, a mobile cart was sitting in the corner of the conference room that had been provided to the survey team. On the second shelf of the cart, a box without a lid was full and contained used COVID-19 tests. In addition, a quarter full drink cup containing green liquid was sitting on the cart. Staff B, Director of Nursing, was present and when the survey team…

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 one of five sampled residents (Resident 41), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included Per the 04/04/2023 admission assessment, Resident 41 was able to make decisions regarding care, and had diagnoses which included depression. In addition, the assessment showed the resident received psychotropic medication daily (defined above). A review of the Order Summary Report showed on 05/30/2023, the physician had prescribed a psychotropic medication (Venlafaxine) to treat depression. Review of the May and June 2023 Medication Administration Records (MARS) showed the medication was given daily as ordered. Review of Resident 41's record did not show documentation that the risks and benefits of the medication were discussed, either…

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 a clean, homelike environment for 3 of 9 sampled residents (Residents 6, 14, and 202), reviewed for durable medical equipment, on 1 of 2 nursing units (east), that had large sections of wallpaper peeling off the walls, and in 1 of 2 nourishment kitchenettes (east) that was unclean and had unpleasant odors. These failures placed the residents at risk for a decreased quality of life. Findings included . <Wheelchairs> The 06/09/2023 quarterly assessment showed Resident 6 had diagnoses including heart failure, required the assistance of one staff for mobility on the nursing unit, and used a wheelchair. The 05/15/2023 quarterly assessment showed Resident 14 had diagnoses including paralysis on one side of their body following a stroke, and required extensive assistance of one staff to transfer them from their bed to their wheelchair. The 06/16/2023 admission assessment showed Resident 202 had diagnoses including dementia and weakness, and was dependent on two staff to transfer them from their bed to their…

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 incidents of potential abuse, such as financial exploitation, were identified as such, and reported to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to report allegations/incidents of abuse placed the resident at risk for additional abuse. Findings included . Review of the facility Abuse Prevention policy, last revised 10/04/2022, showed it was the policy of the facility to prevent, prohibit, identify, and thoroughly investigate allegations of abuse, neglect, and exploitation of residents, along with misappropriation of resident property. The policy further showed, The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. The facility will ensure that all staff are aware of reporting requirements. Per the 05/10/2023 quarterly…

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 and thoroughly investigate an allegation of potential exploitation for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to identify and investigate an allegation of potential exploitation for the resident placed them at risk for further exploitation. Findings included . Review of the facility Abuse Prevention policy, last revised 10/04/2022, showed it was the policy of the facility to prevent, prohibit, identify, and thoroughly investigate allegations of abuse, neglect, exploitation of residents, and misappropriation of resident property. Per the 05/10/2023 quarterly assessment, Resident 3 was cognitively intact to make decisions regarding care and had medically complex diagnoses which included depression and post-traumatic stress disorder (a disorder in which people have intense, disturbing thoughts and feelings related to their experience that last long after a traumatic event occurred). A review of the progress notes from 02/01/2023 thorough 07/04/2023 showed the following entries: - On…

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

Based on observation, interview, and record review, the facility failed to provide care and services according to professional standards for 1 of 6 sampled residents (Resident 22) reviewed for medication administration, and for 3 of 3 sampled residents (Residents 27, 43, 202), reviewed for oxygen therapy. Failure to consistently change resident 22's dressing for the PICC (a thin catheter inserted into a large vein to enable the administration of intravenous medications), and failure to change resident 27, 43, and 202's oxygen tubing and clean the filters for the oxygen equipment, placed the residents at risk for infection, medical complications, and a diminished quality of life. Findings included . According to the article, Central Line Management, published by the National Library of Medicine on 05/26/2023, dressing changes for a central venous access line (such as a PICC) should occur every five to seven days with a transparent dressing or every two days if a gauze dressing was used, and the dressing needed to be changed sooner if it was no longer adherent, it's integrity 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.

Based on observation, interview, and record review, the facility failed to provide dependent residents services to maintain their nutrition and personal hygiene for 2 of 4 sampled residents (Residents 14 and 22), reviewed for activities of daily living ADLs for dependent residents. Resident 14 had difficulty manipulating their eating utensils and was not assisted or reassessed, and Resident 22 did not receive showers twice weekly as scheduled and requested. Findings included . <Resident 14> A review of the record showed Resident 14 had diagnoses included paralysis of one side of the body after a stroke, difficult swallowing, and a contracture (hardening of muscle and rigidity of a joint) of the right elbow and hand. A 05/15/2023 quarterly assessment showed the resident was severely cognitively impaired, required extensive assistance of one staff for most ADLs, needed supervision and set-up help for eating, and did not cough or lose food or fluids from their mouth when eating. The 07/2019 Comprehensive Care Plan included the following care areas: -ADL self-care performance deficit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 202> Resident 202 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, and a history of urogential implants (a device used to treat urinary incontinence). The 06/16/2023 admission assessment showed Resident 202 had a urinary catheter (a thin flexible tube placed in the bladder to drain urine). The assessment did not include a diagnosis that would medically justify the need for the urinary catheter. Per review of Resident 202's medical record, there was no documentation that showed the facility had attempted to remove the catheter and perform a voiding trial. The hospital record showed the urinary catheter had been placed during Resident 202's hospital stay. During an interview on 07/05/2023 at 11:16 AM Staff FF, Physician's Assistant, stated urogenital implants was not an appropriate diagnosis for a urinary catheter. Staff FF added when a resident admitted to the facility without a proper diagnosis, the catheter was discontinued and a voiding trial was started. Staff…

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 dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 2 of 3 sampled residents (Residents 11, 27), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 11, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . <Resident 11> The 05/30/2023 admission assessment showed Resident 11 was cognitively intact to make decisions regarding cares, had medically complex conditions, and diagnoses which included kidney disease, and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells to use as energy). In addition, the assessment showed the resident received dialysis (a procedure that removes…

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 acquire and administer medications timely for 2 of 6 sampled residents (Residents 8, 203), reviewed for pharmaceutical services. This failure resulted in a delay of medication administration, and potential for worsening medical conditions. Findings included . <Resident 8> Per the 04/17/2023 assessment, Resident 8 was admitted with diagnoses to include dementia and dysphagia (a swallowing disorder). Per a progress note on 04/03/2023 at 12:08, an outside provider phoned the facility with an order for Protonix (a medication that treats heartburn, ulcers, and acid reflux - a condition in which stomach acid goes into the esophagus), related to ulcers being found. Resident 8 was already receiving famotidine, a medication that treated the same conditions. A review of the physician orders and progress notes from 04/03/2023 through 05/04/2023 showed the medication was unavailable and not provided (due to a need for a prior authorization), the physician 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.

Based on interview and record review, the facility failed to ensure proper monitoring of medication which affected blood pressure was consistently done for 1 of 5 sampled resident (Resident 3), reviewed for unnecessary medications. This failure placed the resident at risk for potential adverse side effects and medical conditions. Findings included . Per the 05/10/2023 quarterly assessment, Resident 3 had diagnoses which included high blood pressure and atrial fibrillation (an irregular heart rhythm). Review of the Order Summary Report from 01/01/2023 through 06/30/2023 showed the physician ordered a blood pressure medication (Metoprolol) on 05/18/2023 to be given twice a day. The order instructed nursing staff to hold the medication if the heart rate was below 55 beats per minute or if the top number of the blood pressure (systolic) was under 110, to recheck the blood pressure in an hour, and to notify the doctor and document a nursing note in the resident's record. Review of the June 2023 Medication Administration Records (MARS) showed the AM dose of Metoprolol was held on…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 8 sampled residents (Resident 205) reviewed for medication administration, was free from significant medication errors. Failure to completely process a medical provider's order for a narcotic pain medication caused increased sedation for Resident 205, and placed the resident at risk for medical complications, and unmet care needs. Findings included . Per the 06/16/2023 admission assessment, Resident 205 had moderate cognitive impairment, was able to make needs known, and had medically complex conditions which included anxiety, depression, and chronic pain. In addition, the assessment showed the resident had frequent pain and received a narcotic pain medication daily. A progress note on 07/04/2023 at 10:53 PM documented that a visiting family member informed the nurse that something was wrong with the resident. The resident was observed to be sweating profusely, weak, shaky, and intermittently responsive. Vital signs were within normal values, but the resident's respirations had become slower 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, the facility failed to ensure one of two medication rooms (east), had the narcotic box affixed that was placed in the refrigerator, as required. This failure placed unintended access by others to drugs because they were not locked up and/or unmovable. Findings included . In an observation on 06/26/2023 at 3:08 PM, Staff B, Director of Nursing (DON), provided access to the medication room on the east unit to the surveyor. The refrigerator was locked, and the unlocked narcotic box, inside the refrigerator, which contained Marinol (a schedule III medication used to treat nausea and increase appetite), was not permanently affixed, as to prevent potential drug diversion. During an interview on 06/06/26 at 3:15 PM Staff B stated the narcotic box should have been locked, and was unaware it needed to be permanently affixed. Staff B added that the issue would be resolved. Reference WAC: 388-97-1300(2), 2340