Aurora Valley Care

Based on observation, interview and record review, the facility failed to ensure residents and/or visitors were informed of the location of the State Recertification Survey results documents/binder, and that the binder location was known for 4 of 5 sampled residents (Residents 21, 34, 38, and 46). This failure placed residents and visitors at the risk of not being able to access the Survey results. Findings included .During a Resident Council meeting on 09/05/2025 at 11:55 AM, attendees were asked if they had access to the State Recertification Survey binder that contained the results from inspections completed by the State Agency. Residents 21, 34, 38, and 46 all stated they had never seen the binder and did not know where it was located. On 09/09/2025 at 8:05 AM, a binder that contained the State Recertification Survey results was observed in a plastic holder on the wall just underneath framed documents of the facility license at the area that previously was the lobby and main entrance into the facility. During an interview on 09/09/2025 at 10:12 AM, when informed that residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide residents and/or their representatives a written notice that included the reason for transfer or discharge and failed to send a copy of the notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations), as required for 2 of 3 sampled residents (Residents 86 and 2) reviewed for discharges. This failure placed residents at risk of inappropriate transfers or discharges.Findings included.<Resident 2>The 09/05/2025 discharge assessment documented Resident 2 was discharged from the facility to the community on 09/01/2025 with a return not anticipated. Review of September 2025 nursing progress notes documented Resident 2 left the faciity on [DATE] against medical advice. There was no documentation the Ombudsman was notified of the discharge, as required. Ombudsman discharge notifications for the previous four months were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete interdisciplinary team (IDT, at a minimum consisting of the resident's attending physician, nurse and nurse aide responsible for the resident, a member of food and nutrition services, the resident and/or the resident representative) care planning conference meetings to enable resident and/or the resident representative participation in development, review, and revision of the plan of care for 9 of 9 sampled residents (Resident 5, 7, 9, 27, 41, 43, 44, 48 and 63), reviewed for care conferences. This failure placed residents at risk of unmet care needs, and diminished quality of life. Findings included. Review of the facility policy titled, Care Conferences revised May 2023, showed the social worker would encourage the resident and/or their legal representative to attend care plan conferences. Care conferences would be scheduled based on identified needs and regulatory standards. The policy further showed care conferences would be scheduled upon…

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 consistently provide assistance with bathing, nail care, and eating for 7 of 9 sampled residents (Residents 5, 7, 17, 19, 29, 43 and 48) reviewed for activities of daily living (ADLs) for dependent residents. Those failures placed the residents at risk for diminished quality of life and unmet care needs. Findings included… <Resident 29> The 09/03/2025 quarterly assessment documented Resident 29 was cognitively intact to make decisions regarding their care, and had diagnoses which included stroke and diabetes. In addition, the assessment documented the resident needed assistance from nursing staff to complete ADLs for personal hygiene tasks such as nail care. On 09/03/2025 at 3:49 PM, Resident 29 was observed lying in bed watching television and eating a chocolate snack cake with their left hand. The fingernails of both hands were observed to be long with black debris underneath them. On 09/05/2025 at 8:56 AM, 10:53 AM, and 1:55 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 implement and oversee a comprehensive restorative nursing program for 3 of 3 sampled residents (Resident 44, 43, and 19), reviewed for restorative services. This failure placed residents at risk for complications and diminished quality of life. Findings included. <Resident 44> According to the 07/22/2025 quarterly assessment, Resident 44 had diagnoses including stroke with weakness on one side of the body and a contracture of the left hand. The assessment further showed Resident 44 had functional limitations in range of motion to one arm and leg and received range of motion via a restorative nursing program. Review of the limited physical mobility care plan revised 01/31/2025 showed Resident 44 was to have gentle passive range of motion (PROM, joints moved by an outside source such as a staff, rather than independently) stretching performed to the joints in their left arm and leg, with participation documented. Review of the September 2024 through August 2025 PROM program documentation showed the following: -…

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 administer medication according to provider orders for 3 of 5 residents (Resident 9, 43, and 63) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and diminished quality of life. Findings included. <Resident 9> According to a comprehensive assessment, dated 07/17/2025, Resident 9 had diagnoses which included dementia (a disorder that caused impaired memory and reasoning), high blood pressure and heart failure (a condition where the heart muscle does not pump enough blood for the body's needs). They were alert and made their basic needs known. A review of the medical record documented a current order for Losartan (a medication to lower blood pressure) 100 milligrams (mg, a unit of measure) in the morning for high blood pressure. The order further showed the medication should not be given (held) if the systolic blood pressure (SBP, the top number of a blood pressure reading) was less than 110. A review of the Medication Administration Record (MAR) for August, 2025,…

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

Based on interview and record review, the facility failed to provide evidence that the Medical Director received and reviewed the content of Quality Assurance & Performance Improvement (QAPI) meetings when they were not present, communicated with and participated in the QAPI process, as required. This failure minimized the effectiveness of the interdisciplinary Quality Assessment & Assurance (QAA) team's ability to identify potential quality of care deficiencies and develop and implement corrective action. This failure placed residents at risk for complications, unmet needs, and diminished quality of life.Findings included.An undated facility policy titled Aurora Valley Care QAA Committee, showed the purpose was to coordinate and evaluate activities under the QAPI program. The policy further showed the following data would be reviewed at the meetings: 3 months of QAPI minutes/data, risk managements incident reports, grievance log, survey results, staff turnover, staff and resident satisfaction, infection control and facility quality measure triggers.Review of the facility 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 interview and record review the facility failed to ensure direct care staff received training on effective communication, as required. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included.Review of the staff list provided to the survey team on 09/03/2025 showed the facility employed 89 direct care staff. Effective communication training for all direct care staff was requested from Staff A, Administrator, on 09/15/2025 at 9:08 AM. Review of documentation provided showed only eight out of 89 direct care staff completed training on effective communication. In an interview on 09/15/2025 at 12:40 PM, Staff AA, Nursing Assistant, stated if they received training on effective communication, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:56 PM, Staff R, Licensed Practical Nurse, stated if they received training on effective communication, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:59 PM, Staff A, stated training on effective…

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 all staff received training on the Quality Assurance and Performance Improvement (QAPI, a systemic interdisciplinary comprehensive data-driven approach to maintaining and improving safety and quality in nursing homes) program, as required. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included.Review of the staff list provided to the survey team on 09/03/2025 showed the facility employed 109 staff. QAPI training for all staff was requested from Staff A, Administrator, on 09/15/2025 at 9:08 AM. No documentation was provided. In an interview on 09/15/2025 at 12:40 PM, Staff AA, Nursing Assistant, stated if they received training on the facility's QAPI program, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:41 PM, Staff BB, Receptionist, stated I don't know what QAPI is. Should I know what that is? In an interview on 09/15/2025 at 12:47 PM, Staff CC, Maintenance Assistant, explained QAPI was a way for quality improvement…

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 informed consents that explained the potential risks and benefits associated with the use of psychotropic medications (medications that affected mood or emotions) were obtained from the resident or their representative prior to their administration for 2 of 5 sampled residents (Residents 27 and 63) reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed of the potential risks and benefits of receiving the medications. Findings included. <Resident 27> The 07/06/2025 quarterly assessment documented Resident 27 had diagnoses that included depression and received psychotropic medication to treat the symptoms of the depression. Review of the Medication Administration Records (MARs) for August and September 2025 documented the psychotropic medication, Escitalopram, was prescribed by the physician on 04/12/2025, and Resident 27 received the medication daily as ordered. Review of Resident 27's record from 04/12/2025 through 09/08/2025 found an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review [PASARR, an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions] was completed after an exempted hospital stay (when the resident remained in the facility longer than thirty days) finished for 1 of 5 sampled residents (Resident 43), reviewed for PASARR services. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included .<Resident 43>The 08/21/2025 quarterly assessment documented Resident 43 was admitted on [DATE] with diagnoses post-traumatic stress disorder (PTSD, a disorder in which a person had difficulty recovering after experiencing or witnessing a terrifying event) and received psychotropic medication, (medications that affect the mind, emotions, and behavior).Review of Resident 43's Level I PASARR…

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 that residents received proper foot care in accordance with professional standards for 1 of 5 sampled residents (Resident 27) reviewed for skin care concerns. Specifically, Resident 27 had diagnoses and conditions that made them prone to the development of foot problems and had extremely dry, flaky skin on their feet. This failure put this high-risk resident at increased risk of complications and unmet care needs.Findings included .The 07/06/2025 comprehensive assessment documented Resident 27 had diagnoses that included diabetes and history of a stroke that affected their left side. Resident 27 was fully dependent on staff for bathing, dressing their lower body and transferring out of bed with a mechanical lift. They were alert, oriented and made their needs known.On 09/03/2025 at 2:57 PM, Resident 27 was observed lying in bed with their feet uncovered. Both of their feet were very dry and scaly on the bottom.Similar observations of Resident 27's dry, scaly feet were made on 09/05/2025 at 11:01 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to evaluate and assess a resident for safe smoking abilities for 1 of 5 sampled residents (Resident 54), reviewed for accident hazards and supervision. This failure placed residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Review of the facility policy titled, Smoking-[NAME] Center No Smoking revised June 2023, documented smoking tobacco or tobacco related products or substitutes were not permitted on the facility property. The policy further documented that all residents were screened for smoking when admitted to the facility and those residents who decided to continue smoking would have their decision included in their care plan.Findings included .The 07/17/2025 admission assessment documented Resident 54 was cognitively intact to make decisions regarding their care and had diagnoses which included nicotine dependence. Review of the 07/11/2025 admission evaluation form documented…

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

Based on observation, interview and record review, the facility failed to provide care and services necessary to improve bowel and bladder functions for 1 of 2 residents (Resident 63), reviewed for incontinence care. This failure placed the resident at risk for skin and medical complications.Findings included .The 08/08/2025 quarterly assessment documented Resident 63 admitted with diagnoses including back fractures and a stroke with hemiplegia (paralysis on one side of the body). The resident was able to make their needs known and required total staff assistance for toileting. The assessment further showed Resident 63 was always incontinent of bowel and bladder was not on a toileting program. The 05/01/2025 care plan documented Resident 63 was incontinent of bowel and bladder related to a stroke. Interventions instructed staff to provide care after each incontinent episode and for the resident to wear incontinence briefs. An 08/08/2025 quarterly bowel and bladder evaluation documented Resident 63 was not appropriate for a toileting program due to spasticity and inability to sit on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed maintain intravenous (IV) access consistent with professional standards of practice to include obtaining and implementing orders for saline flushes (a syringe of saline used to clear the IV and prevent it from clogging) and IV dressing changes (a transparent dressing over the insertion site) for 1 of 1 residents (Resident 35), reviewed for IV access maintenance. This failure placed resident at risk for medical complications, and diminished quality of life.Findings included.Review of comprehensive assessment dated [DATE], Resident 35 had diagnoses of diabetes and osteomyelitis (bone infection) of the spine. The resident was alert, oriented and made their needs known.During observation and interview on 09/05/2025 at 9:58 AM, Resident 35 stated that the facility nurse changed their IV dressing. An IV access was observed in the resident's right chest. The access had an intact, transparent dressing over the insertion site, which was labeled with 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 ensure respiratory equipment was implemented as ordered, functional and maintained in a clean manner for 2 of 2 residents (Resident 43 and 27), reviewed for respiratory care. Specifically, Resident 27's continuous positive airway pressure machine (CPAP, machine that helped people breathe by delivering pressurized air into their lungs through their nose, or nose and mouth) was not implemented as ordered by the physician or maintained in a functional manner. In addition, Resident 43's oxygen tubing and oxygen concentrator (a machine that delivers oxygen) were not maintained in a clean and sanitary manner. These failures placed residents at risk for impaired sleep, infections, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Mangement revised [DATE], showed the facility required a physician order for administration of oxygen. Oxygen tubing was to be changed weekly or when…

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 safety measures were in place and followed for 1 of 3 residents (Resident 35), reviewed for dialysis (a process of using a machine to filter the blood from excess fluid or waste when the kidneys were unable to do so). Staff often checked Resident 35's blood pressure on the same arm as their dialysis fistula (an access made by joining an artery and vein in the arm). This failure placed residents at risk for medical complications and diminished quality of life.Findings included.Review of the National Kidney Foundation (an organization dedicated to education about kidney disease and advocacy for patients) website Kidney.org documented to keep the fistula access working, a blood pressure cuff should never be used on the access arm.According to a 09/02/2025 comprehensive assessment, Resident 35 had diagnoses of diabetes, high blood pressure and dialysis dependent end stage kidney disease. The resident was alert, oriented and made their needs known.During observation and interview on 09/05/2025 at 9:58 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a psychological evaluation was completed and behavioral health services were offered as recommended to 1 of 2 sampled residents (Resident 1) reviewed for mood and behavior. This finding placed the resident of unmet care needs.Findings included .Review of admission Comprehensive assessment dated [DATE], Documented Resident 1 was admitted [DATE]. Resident 1 had diagnoses that included anxiety and depression. The resident had pain almost constantly, that interfered with day-to-day activities and affected sleep, and took scheduled and as needed pain medications, and antidepressant medications daily. Resident 1 was cognitively intact. An evaluation of the resident's mood documented a score of 12, moderate severity and frequency of depression symptoms.On 03/07/2025, a Level I Pre-admission Screening and Resident Review (PASRR, an evaluation that determined if a person met criteria for nursing home level care, had a serious mental illness,…

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 timely act upon the pharmacist's monthly medication regimen review recommendations for identified irregularities for 1 of 5 sampled residents (Resident 63), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, medication complications, and a diminished quality of life.Findings included .Review of the facility policy titled, Medication Regimen Review revised 11/28/2016, documented a pharmacist consultant reviewed the resident's medication regimen as described in their pharmacy consultant agreement and irregularities reported to the attending physician, medical director, and Director of Nursing (DNS). If an irregularity did not require urgent action, the recommendation needed to be completed by the next monthly review. The 08/08/2025 quarterly assessment documented Resident 63 had diagnoses which included a stroke, restlessness and agitation. The resident received an antipsychotic (a medication that affected the brain, mind, mood, and behaviors used to treat mental…

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 medications were discarded appropriately in 1 of 2 medication rooms (North) observed. In addition, the facility failed to ensure temperatures in the medication room and medication refrigerator were consistently monitored in 1 of 2 medication rooms (TCU) observed. This failure placed residents at risk of unmet care needs.Findings included.<North Medication Cart and Room> During observation of the North medication cart on 09/12/2025 at 10:23 AM, with Staff S, Licensed Practical Nurse (LPN), the following was noted:1) Lispro insulin pen for a current resident, labeled with an opened date of 08/05/2025, 38 days prior. There was a note taped to the bottom of the drawer where the pens were stored that showed discard insulin pens 30 days after opened.2) Lispro insulin pen for another resident that had been used and the date opened was blank.During a concurrent interview, Staff S stated insulin pens should be discarded one month after opening and since the open date was unknown on one pen, both insulin pens…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely follow-up dental appointments for 2 of 3 sampled residents (Residents 41, 29), reviewed for dental care. This failure placed residents at risk for diminished quality of life.Findings included.<Resident 41>The 06/27/2025 quarterly assessment documented Resident 41 was independent with eating and performing oral hygiene with set-up assistance from staff. The assessment further showed Resident 41 was moderately cognitively impaired, but able to make their needs known.On 09/03/2025 at 10:05 AM, Resident 41 was observed sitting upright in bed, using their iPad. When asked if they had any concerns regarding their care, Resident 41 stated they had a dental bridge that was broken, and nobody was doing anything to get it repaired. Resident 41 then took their left hand and moved their upper lip up to show the area where the bridge would be worn. Review of notes from the dental care provider who performed services in the facility…

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

Based on observation and interview, the facility failed to perform hand hygiene when indicated during the meal service. This failure placed residents at risk for foodborne illnesses.Findings included . In an observation on 09/10/2025 at 11:59 AM, Staff HH, Cook, touched the meat with their gloved hands, then touched the meal ticket, and continued to serve food without hand hygiene being performed. Prior to the meal service, the dietary aids sorted out the meal tickets. In an observation on 09/10/2025 at 12:00 PM, Staff KK, Dietary Aide, placed cold items on the meal trays, scratched their head with their bare hand, and continued putting plates of food on trays without hand hygiene being performed. In an observation on 09/10/2025 at 12:02 PM, Staff HH touched the meat and vegetables they placed on the resident's plate with gloved hands, then grabbed a meal ticket and served the next plate without hand hygiene being performed.In an observation on 09/10/2025 at 12:04 PM, Staff HH touched the meat with their gloved hands, grabbed a roll, opened the oven warmer, then grabbed a meal…

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

Based on observations, interviews and record reviews, the governing body failed to ensure the facility had resources to supply residents with an adequate supply of clean linens. Additionally, the governing body failed to respond to repeated staff concerns about insufficient quantity of linens, poor quality of current laundry service, requests for resources and/or a change in laundry vendors in a timely manner. This failure impacted all residents and placed them at risk for diminished quality of life. Findings included.During interviews on 09/03/2025, 09/04/2025, 09/08/2025, 09/09/2025, 09/10/2025, 09/12/2025 and 09/15/2025, as well as in the resident council meeting on 09/05/2025, multiple residents and staff members stated that not having enough bed linens and towels was a frequent issue at the facility.During an interview on 09/12/2025 at 3:12 PM, Staff A, Administrator stated that as part of their Quality Assurance and Performance Improvement (QAPI) program, each department head chose a problem to work on and developed a performance improvement plan (PIP). Staff A further stated…

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

Based on interview and record review, the facility failed to identify a designated interdisciplinary team member, to act as a liaison for coordinating care and communication with the hospice provider for 1 of 1 sampled residents (Resident 61), reviewed for hospice services. This failure placed the resident at risk for unmet care needs and diminished quality of life. Findings included Review of the 03/30/2022 agreement between the hospice provider and the facility documented services that were the responsibility of the facility and the services that were provided by the hospice agency. The agreement showed that the facility would designate an interdisciplinary team member that worked with the hospice staff to coordinate care of the hospice residents in the facility. The agreement did not identify who that staff member was, their title, nor the department where they worked.A review of the facility policy titled Hospice-Admission, Discharge, Care and Treatment dated December 2024 did not include documentation of who the designated facility liaison was that was responsible for…

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

Based on interview, and record review the facility failed to provide the necessary care and services to ensure that a dependent resident received assistance with toileting for 1 of 3 residents (Resident 1). This failure placed the resident at increased risk for skin breakdown and unmet care needs. Findings included . Review of Resident 1's care plan, dated 01/13/2025, showed that they were cognitively intact, required extensive assistance to use the bathroom and had episodes of incontinence with interventions to include provide pericare (hygiene of the private parts following toileting) after each incontinence episode. Record review of a facility investigation showed that on 02/28/2025 at 6:00 AM Staff C, Licensed Practical Nurse, had gone in to provide care to Resident 1 and had found them lying in .urine soaked bed and clothing with the transfer sheet from [emergency room] still under [resident]. Further record review found that Resident 1 had gone to the emergency room, for a wound evaluation, and had returned to the facility at 6:00 PM on 02/27/2025. At that time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to revise and implement a comprehensive plan of care to included resident specific information for 1 of 3 residents (Resident 1). The failure to establish and implement a care plan that was individualized, accurately reflected assessed care needs related to their ability and need for assistance to eat and provided direction to staff on this topic, placed the resident at risk to receive inappropriate and inadequate care to meet their individualized needs and preferences. Findings included . Review of Resident 1's electronic medical record showed that they admitted to the facility on [DATE] with diagnoses of right sided hemiplegia (almost complete paralysis of one side of body) and hemiparesis (weakness on one side of body) following a stroke, malnutrition and wounds on their left foot. Review of Resident 1's care plan dated 12/06/2024 showed they ate independently (did not need any assistance to eat). Review of progress notes showed that nurses who worked…

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 behavioral health needs were met for 1 of 3 residents (Resident 1) reviewed for behavioral-emotional health. Failure to seek mental health services after the resident was identified in a facility assessment as having symptoms of moderate depression, failure to seek mental health services in a timely manner after the medical provider ordered mental health services to occur, failure to identify behavioral health needs and utilize person-centered interventions developed by an interdisciplinary team (IDT). This failure placed at risk for potential skin injury and decreased quality of life. Findings included . Review of Resident 1's electronic medical record showed that they admitted to the facility on [DATE] with diagnoses of right sided hemiplegia (almost complete paralysis of one side of body) and hemiparesis (weakness on one side of body) following a stroke, mild dementia, anxiety, malnutrition and infected wounds in the bone (osteomyelitis) 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 follow-up on necessary dental services for 1 of 3 residents (Resident 1). Failure to follow-up on a referral to a denturist for ill-fitting dentures, that had caused an open sore, placed the resident at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE], with diagnoses including right sided weakness and paralysis after a stroke, severe malnutrition, dysphagia (difficulty swallowing) and chronic ulcers of their left foot and heel. Record review showed on 12/08/2024 at 6:16 PM, Staff K, Registered Nurse wrote in a progress note, c/o (complaint of) mouth pain, refuses to take upper denture out. Record review showed on 12/09/2024 10:49 AM Staff L, Transportation Assistant, wrote in a progress note that the first available dental appointment had been made for Resident 1 on 12/13/2024. Record review showed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 3 sampled residents (Resident 1 and 2), reviewed for accidents related to substance use disorder. This failure placed residents at risk of potentially avoidable accidents, and diminished quality of life. Findings included . Review of the facility policy titled, Substance Abuse-Residents dated 08/2022, defined substance abuse as recurrent use of alcohol and/or drugs that cause clinically and functionally significant impairment, such as health problems or disability. Signs and/or symptoms of substance abuse may include intoxication, decreased inhibition, combative behavior, belligerence, nausea/vomiting, involuntary eye movements, slurred speech, slow movements or poor coordination, tremors, falls, and dizziness. The policy instructed staff to assess residents upon admission and as needed for actual substance abuse and/or history of substance…

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 protect the residents' right to be free from neglect for 1 of 3 residents (Resident 1) reviewed for neglect. The failure of the facility to address identified concerns for incontinence and personal hygiene resulted in a diminished quality of life and led to Resident 1 being removed, by family, from the facility Against Medical Advice (AMA) (occurs when a person decides to leave a medical facility before the medical team recommends discharge). Findings included . Record review showed Resident 1 had admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy (a neurological disorder caused by thiamine deficiency with mental confusion and unsteady gait), and adult failure to thrive (an individual experiences a substantial decline in overall health and functional abilities). Further review showed Resident 1 was removed from the facility, by family members, AMA, on 11/10/2024. Review of Resident 1's care plan, dated 10/31/2024, and…

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

Based on interview and record review, the facility failed to ensure allegations of potential neglect were reported immediately to the State Agency as required, for 1 of 3 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk for possible neglect. Findings included . Record review showed that on 11/11/2024 at 12:26 PM Staff D, Social Services Director, reported to the required State Survey Agency that Resident 1 had left the facility Against Medical Advice (AMA) because their family claimed that [they were] always naked, not dressed and urine everywhere. In an interview at 12:28 PM on 12/16/2024, Staff D, stated that they had first been made aware of Resident 1's family concerns for neglect on 11/06/2024 during a care conference. They stated that they had not reported the concerns to their Administrator, nor made a report to the required State Agency. In an interview at 12:28 PM on 12/16/2204, Staff C, Resident Care Manager, stated that they had been made aware of concerns for neglect related to Resident 1 on several occasions, including during 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 quarantine and isolation precautions were followed for 4 of 5 Residents (Residents 1, 2, 3 and 4) and proper personal protection equipment (PPE's) was used by 1 of 5 staff (Staff H), during a COVID outbreak, in accordance with Centers for Disease Control (CDC) guidelines. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. Findings included . On 10/30/2024 record review showed that the facility had nine residents with a current COVID-19 infection in the facility. According to the June 2024 Center for Disease Control Infection Control Guidance: SARS-CoV-2 showed residents exposed to COVID-19 should be maintained in Transmission-Based Precautions for 7 to 10 days depending on the testing strategy of the facility. The publication further states that residents who test positive for COVID-19 should have their room door closed if it is safe to do so. On 10/30/2024 at 8:58 AM Resident 1 was observed to be lying in bed next to the door with their room door wide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess a change in condition, respond to the change of condition and notify the medical provider in a timely manner for 1 of 5 residents (Resident 5) reviewed for quality of care. This failure placed the resident at risk for medical complications, unmet care needs and diminished quality of life. Findings included . Record review showed Resident 1 admitted to the facility on [DATE] with diagnoses of end stage renal disease, diabetes and seizures. Further review found that the resident took a medication to prevent seizure activity every 12 hours and had tested positive for a COVID-19 infection on 10/24/2024. During an interview on 10/30/2024 at 9:30 AM, Staff E, Resident Care Manager, stated that during the morning of 10/28/2024 they had gone in to give Resident 5 their diabetes medication and could tell that they were not feeling well. A few minutes later a nursing assistant had come and gotten them and told them Resident 5 was vomiting and was having 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 repeatedly implement an effective discharge planning process, evaluate and document resident's discharge needs and discharge plan to avoid unnecessary delays in discharge, and document who determined why discharge to the community was not feasible for 3 of 3 sampled residents (Resident 4, 1, and 5), reviewed for discharge planning. This failure placed residents at risk of unsafe discharges, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Discharge Management revised 05/2023, showed residents were referred, transferred or discharged based on their assessed needs and by order of their attending physician. Discharges would be based on the resident's clinical condition and would occur as soon as reasonably possible following the physician's discharge order. The policy further showed the initial discharge plan and projected discharge date would be formulated based on diagnosis, level of function,…

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 repeatedly identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 3 of 3 sampled residents (Resident 1, 2, and 3), reviewed for substance use disorder. This failure placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life. Findings included . Review of the facility policy titled, Substance Abuse-Residents dated 08/2022, defined substance abuse as recurrent use of alcohol and/or drugs that cause clinically and functionally significant impairment, such as health problems or disability. Signs and/or symptoms of substance abuse may include intoxication, decreased inhibition, combative behavior, belligerence, nausea/vomiting, involuntary eye movements, slurred speech, slow movements or poor coordination, tremors, falls, and dizziness. In care of an overdose staff was to notify the physician immediately and provide increased…

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 accurately assess urinary status, follow provider orders, provide appropriate care and services to restore or improve normal bladder function, and provide indwelling urinary catheter (flexible tube inserted into the bladder to drain urine) care according to standards of practice for 1 of 3 sampled residents (Resident 4), reviewed for urinary catheter management. These failures placed residents at risk of medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Indwelling Catheters revised 07/2023, showed all residents with indwelling catheters required a medical justification for initiation and continued use. A comprehensive assessment that included underlying factors supporting medical justification, determination of which factors could be reversed and development of a plan for appropriate indications for continued use of an indwelling catheter would be completed. 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 physician visits were completed every 30 days, for the first three months after admission, then every 60 days, as required, for 8 of 14 sample residents (Resident 12, 15, 21, 24, 39, 42, 52, 60) reviewed for physician visits. This failure placed the residents at risk for delayed identification and treatment of medical needs. Findings included . <Resident 12> Resident 12 was admitted on [DATE] and had diagnoses including depression and stroke. There were no physician visits documented in Resident 12's Electronic Medical Record (EMR). <Resident 15> Resident 15 was admitted to the facility on [DATE] with diagnoses of dementia, malnutrition and failure to thrive (a syndrome of overall decline.) A review of Resident 15's EMR documented physician visits on 08/09/2023, 11/07/2023 (90 days later), 02/05/2024 (90 days later) and 06/04/2024 (120 days later). <Resident 21> Resident 21 was admitted to the facility on [DATE] with diagnoses including…

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

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 3 of 9 sampled residents (Residents 36, 42 and 80) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted. Findings included . <Resident 42> A06/09/2024 quarterly assessment documented Resident 42 had diagnoses including end-stage kidney disease, seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), and diabetes (a group of diseases that result in too much sugar in the blood). Resident 42 was cognitively intact and required dialysis (a way of ridding the body of waste when the kidneys do not function.) The 12/01/2023 care plan documented Resident 42 received dialysis every Monday, Wednesday and Friday at 2:00 PM. Staff were instructed to administer medications according to the dialysis center recommendations,…

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 hand hygiene was performed when indicated for 1 of 1 residents (Resident 78) during a medication pass observation, and enhanced barrier precautions (EBP) were implemented for 2 of 4 sampled residents (Residents 12 and 17) reviewed for infection control. Specifically, Resident 12 had a history of antibiotic resistance and had weeping leg wounds and was not on EBP, and staff did not implement EBP during wound care of a pressure ulcer for Resident 17. Also, the facility failed to develop, implement and review a water management plan. These failures placed residents at risk for transmission of disease, antibiotic resistance, water-borne infections, and unintended health consequences. Findings included . Per the CDC (Center for Disease Control), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve…

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 dignified dining experience for 4 of 6 sampled residents (Resident 1, 6, 9, 45) reviewed for dining. The failure to provide clothing protectors per the residents' preferences during meal service placed the residents at risk for embarrassment, humiliation, and an undignified dining experience. Findings included . Review of the facility policy titled, Resident Rights, dated 08/2022, showed each resident would be treated with respect and dignity, and care for each resident would be provided in a manner and in an environment that promoted maintenance or enhancement of their self-esteem and self-worth. <Resident 1> Review of the medical record documented Resident 1 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), fibromyalgia (a long-term condition that involves widespread body pain and fatigue), and depression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain consent for psychotropic medications prior to administration of the first dose, as required, for 3 of 5 sampled residents (Resident 19, 21, 333) reviewed for unnecessary medications. This failure placed the resident and representative at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care. Findings included . <Resident 21> According to a quarterly assessment dated [DATE], Resident 21 had moderate cognitive impairment and diagnoses which included diabetes, brain dysfunction and depression. A current physician order for daily Seroquel (an antidepressant) was written on 06/13/2024. A review of Resident 21's May 2024 Medication Administration Record (MAR) showed that the resident had been on Seroquel previously and it had been discontinued on 05/08/2024, and then was resumed on 06/13/2024. No consent was completed prior to the Seroquel being restarted on 06/13/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare Part A.) for 2 of 3 sampled residents (46, 62) reviewed for beneficiary notice requirements. This failure placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay. Findings included . <Resident 46> Review of the medical record showed Resident 46 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), peripheral vascular disease (PVD, reduced blood flow to the extremities) and heart failure. The 05/30/2024 comprehensive assessment showed Resident 46 was cognitively intact and required partial to moderate assistance of one staff member for most activities of daily living…

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

Based on interview and record review, the facility failed to ensure the right to receive unopened mail for 6 of 6 sampled residents (Resident 1,19,29, 42, 45, 47) reviewed for privacy. This failure resulted in a lack of privacy and potential diminished quality of life. Findings included . A review of the 03/14/2024 comprehensive assessment, Resident 1 was cognitively intact and able to direct their care. During an interview in Resident Council on 06/25/2024 at 2:00 PM, Resident 1 stated their mail was always opened before it was delivered to them. Residents 29, 42, 45, and 47 all verbally agreed with Resident 1's remark and stated their mail had also been opened when delivered to them. During an interview on 06/26/2024 at 3:00 PM, Resident 1 stated they were told by Staff N, Business Office Manager, all resident mail from the State was opened before being delivered to the residents. During an interview on 06/17/2024 at 1:56 PM, Resident 19 stated the facility opened their mail from Department of Social and Health Services (DSHS), mail from behavioral health and from welfare.…

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 exercise reasonable care for the protection of the resident's property from loss, and to reimburse the resident timely for the loss of a cell phone for 1 of 3 sampled residents (Resident19) investigated for personal property. This failure caused the resident to replace their cell phone from their own funds. Findings included . According to a quarterly assessment dated [DATE], Resident 19 had diagnoses that included diabetes and quadriplegia (paralysis that affects all four limbs) and was cognitively intact. During an interview on 06/17/2024 at 1:58 PM, Resident 19 stated that someone stole their cell phone in November 2023, and they had not received their reimbursement check yet and was told by Staff A, Executive Director, that it was in process. They further stated that since they needed a cell phone, they had bought another with their own funds. A review of the previous six months of missing property logs and grievance logs documented no entries for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were completed or implemented as required for 2 of 6 sampled residents (Resident 12, 21) reviewed. Resident 21 did not have a PASARR completed prior to admission to the facility, and Resident 12 had Level II behavioral health recommendations that were not implemented. This failure placed the residents at risk for a decline in their mental health and a decrease in their quality of life. Findings included . <Resident 12> Resident 12 was admitted on [DATE] and had diagnoses including depression. A review of the 03/31/2024 hospital discharge summary documented Resident 12 had been found at home wielding a knife and intended to harm themself. The resident was placed on a 72-hour psychiatric hold, and the hold was discontinued after the resident was assessed by the psychiatrist. A PASARR Level I screen completed on 03/27/2024, documented Resident 12 had mental illness indicators 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 care plan interventions were followed for 3 of 4 sampled residents (Resident 39, 54, 67) reviewed for care planning. Failure to follow the care planned interventions regarding positioning, mobility, and displays of affection placed residents at risk for unmet care needs and decreased quality of life and caused other residents to be uncomfortable. Findings included: <Resident 54> Per the 05/15/2024 comprehensive assessment, Resident 54 had diagnoses including stroke and paralysis on one side, was mildly cognitively impaired and participated in decisions regarding their care. Resident 54 required substantial assistance with most activities of daily living (ADLs). The 04/24/2024 care plan documented Resident 54 had a self-care deficit and was totally dependent on staff for bed mobility and transfers and required a mechanical lift device for transfers. Staff were instructed to get Resident 54 up in their wheelchair for breakfast until after lunch. A physical therapy (PT) progress note dated 04/23/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge for 1 of 2 residents (Resident 56) and failed to honor discharge preferences for 1 of 2 residents (79) reviewed for discharge planning processes. These failures placed the residents at risk for lack of necessary care and services, an unsafe living environment, and dissatisfaction with their living situation. Findings included . Review of a facility policy titled Against Medical Advice (AMA) Discharge, revised 05/11/2023, documented that if a resident wanted to be discharged to a setting that appeared unsafe, the facility must determine if a referral to Adult Protective Services (APS) or other state entity charged with investigating abuse and neglect, was necessary. The referral would be made at the time of discharge. <Resident 56> Review of the medical record showed Resident 56 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition that affects brain function), bipolar disorder (a mental…

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 residents with assistance completing their activities of daily living (ADLs) for 2 of 4 sampled residents (Resident 60, 75) reviewed. Specifically, Resident 60 was not provided showers and assistance, cueing, supplements and referrals necessary to promote their nutrition, and Resident 75 was not provided showers. This failure put residents at risk for skin breakdown, unintended weight loss and decreased quality of life. Findings included . <Resident 60> According to a 04/20/2024 quarterly assessment, Resident 60 had diagnoses including adult failure to thrive, osteoporosis (weak bones) and hypothyroidism (low levels of thyroid hormone.) Resident 60 was mildly cognitively impaired and did not reject care. The assessment further documented they required set-up/clean-up assistance for eating, maximum assistance with showering/bathing, and toileting hygiene. Resident 60 was incontinent of both bowel and bladder. The 01/22/2024…

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

Based on observation, interview and record review, the facility failed to ensure a resident received an ongoing program of activities that met their interests for 1 of 2 sampled residents (Resident 54) reviewed for activities. This failure placed the residents at risk for social isolation, mental decline, and diminished quality of life. Findings included . A 05/15/2024 comprehensive assessment documented Resident 54 had diagnoses including stroke and hemiplegia (paralysis or loss of strength on one side of the body). Resident 54 was severely cognitively impaired, used a manual wheelchair, and required maximum assistance from staff for mobility in their wheelchair. It was very important to Resident 54 to be involved in activities that included: reading, listening to music, being around animals, being outdoors, practicing religion, and doing their favorite activities. Review of the 06/03/2024 care plan documented Resident 54 would engage in independent leisure activities such as watching television (TV) and spending time with visitors and would accept 1 to 1 visits with activity…

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 a bowel management protocol when indicated for 2 of 3 residents (Resident 21, 75) reviewed for constipation. This failure placed residents at risk for worsening conditions, and unintended health consequences when unable to have bowel movements. Findings included . <Resident 21> A quarterly assessment dated [DATE] documented Resident 21 had diagnoses which included diabetes, brain dysfunction and a history of stroke. Resident 21 was cognitively impaired and required staff assistance with activities of daily living, including toileting. The June 2024 medication administration record (MAR) documented Resident 21 had the following orders: -Milk of Magnesia (MOM, a liquid laxative) as needed for constipation, if no bowel movement (BM) on the 3rd day. -Bisacodyl suppository (laxative) rectally every 24 hours, as needed for constipation, if no results from MOM after 12 hours -Fleet enema (liquid laxative) instilled rectally every 24 hours as needed…

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 schedule a vision appointment for 1 of 1 sample residents (Resident 59), reviewed for vision services. This failure placed the resident at risk for worsening vision and decreased quality of life. Findings included . According to the 3/20/2024 quarterly assessment, Resident 59 was cognitively intact and able to make their needs known. In an interview on 06/18/2024 at 2:15 PM, Resident 59 stated they had mentioned to Staff I, Resident Care Manager, and Staff T, Transportation about a month ago they needed a vision appointment set up. During an observation on 06/20/2024 at 9:41 AM, Resident 59 stated their eye caused them intermittent pain. In an interview on 06/25/2024 at 2:09 PM, Staff I, Resident Care Manager, stated Staff T was responsible for making all needed appointments for the residents. During an interview on 06/25/2024 at 2:20 PM, Staff T, Transportation, stated they were not aware that Resident 59 had vision pain, but was aware they had blurry vision. Staff T stated Resident 59 had an eye exam 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 observations, interviews and record review, the facility failed to remove a urinary catheter (a small flexible tube inserted into the bladder to drain urine) and provide bladder training as ordered for 1 of 1 sampled residents (Resident 2), reviewed for catheter use. This failure placed the resident at increased risk of acquiring potentially preventable catheter associated urinary tract infections and a diminished quality of life. Findings included . A 04/30/2024 admission assessment documented Resident 2 had diagnoses including obstructive uropathy (a condition in which the flow of urine is blocked, and the urine retained in the bladder) and had an indwelling urinary catheter. The assessment also documented Resident 2 was cognitively intact and able to make their needs known. A progress note dated 04/13/2024 at 10:30 AM documented Resident 2 had complained of abdominal pain and a bladder scan (a way of measuring urine in the bladder using ultrasound waves) was completed. The bladder scan revealed 1 liter of urine was retained in the bladder. A urinary catheter was placed,…

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 behavioral health care services for 1 of 1 sampled residents (Resident 80), reviewed for behavioral health. This failure placed the resident at risk for unmet care needs and diminished quality of life. Findings included . According to the 06/06/2024 admission assessment, Resident 80 had diagnoses including bipolar disorder (where moods range from depressive lows to manic highs) and substance abuse in remission. Resident 80 was cognitively intact and able to make decisions regarding their care. During an interview on 06/17/2024 at 10:43 AM, Resident 80 became tearful and began to cry. They stated they had been notified 15 minutes prior to their behavioral health appointment that the facility was unable to provide transportation. Resident 80 stated they were a recovering drug addict, had severe, and they had made the appointment so their medications could be reviewed. Resident 80 stated the appointment had been scheduled for a month and a half and they had no other means to get to there. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 5 sampled residents (Resident 9, 78) observed during 32 medication opportunities, that resulted in an error rate of 9.38 percent. The failure to administer medications correctly placed the residents at risk for receiving subtherapeutic effects of their medications and possible adverse side effects. Findings included . Review of a facility policy titled, Medication Administration, revised 12/2022, documented that the facility strived to provide safe administration of all medications, the licensed nurse would administer medications according to State specific regulation, and to document refused or omitted doses. Review of the instructions for use document titled, How to use your Lantus SoloStar pen, (a method of delivery for insulin injections,) dated 08/2022, included the following instructions: 1) Wipe the pen tip (rubber seal) 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 and interview, the facility failed to ensure controlled medications were properly stored in 1 of 2 medication storage rooms (North Medication Room), and expired medications were removed from 1 of 2 medication rooms (South Medication Room) and 1 of 2 medication carts (North Medication Cart), reviewed for medication storage. These failures placed the residents at risk for receiving medications with decreased efficacy and increased the risk for diversion of controlled substances. Findings included . Review of a facility policy titled, Controlled Medication Storage, dated 01/2023, showed that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. Controlled medication requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.…

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 Dietary Manager had the required credentials. This failure placed all resident at risk for receiving dietary services that did not provide the necesary nutritional requirements and foods prepared according to industry standards. Findings included . During an interview on 06/26/2024 at 3:42 PM, Staff H, Dietary Manager, stated that they did not have a Food Service Manager certification, and had planned to take the class. During an interview on 06/27/2024 at 10:00 AM, Staff K, Registered Dietician (RD), stated that they were at this facility only part-time. During an interview on 06 27/2024 at 3:19 PM, Staff A, Executive Director and Staff B, Director of Nursing acknowledged that since the RD was not full-time, Staff H did not have the required certification to meet the regulation. Reference: WAC 388-97-1160(1)

Based on observation, interview, and record review, the facility failed to provide palatable, attractive meals at a safe and appetizing temperature for 6 of 8 sampled residents (1, 9, 26, 42, 47, 338) reviewed for food. These failures placed the residents at risk for unplanned weight loss and dissatisfaction with their dining experiences. Findings included . Review of a policy titled, Food Preferences, dated 08/2023, showed upon admission, quarterly and as needed, the food and nutrition services manager, or designee, will interview the resident for the following information using a Food Preferences Interview form: • Likes/dislikes, intolerances, food allergies; • Cultural and/or religious preferences; • Preferred dining location; • Preferred mealtime; • Beverage preferences. The food preferences information would be kept on file in the food and nutrition department for six months and would be used to ensure each resident's needs and desires for food were met. <Resident 1> Review of the medical record showed Resident 1 had diagnoses including rheumatoid arthritis (inflammation…

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

Based on interview and record review, the facility failed to provide at least three meals daily for 1 of 1 sampled residents (42), reviewed for frequency of meals. Specifically, Resident 42 attended outside medical appointments every Monday, Wednesday and Friday and did not return to the facility for the regularly scheduled evening meal. This failure placed the resident at risk for unplanned weight loss, and nutritional deficits. Findings included . <Resident 42> Review of the medical record showed Resident 42 had diagnoses including end stage renal disease (loss of kidneys function), diabetes, and heart disease. The 06/09/2024 comprehensive assessment showed Resident 42 was cognitively intact and required no staff assistance for ADLs. During an interview on 06/25/2024 at 3:40 PM, Resident 42 stated they had repeatedly asked the facility to hold their evening meal on Mondays, Wednesdays and Fridays because they did not return from their dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) appointments until 6:45 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 communicate with the hospice provider about bathing services for 1 of 1 sampled residents (Resident 15), reviewed for Hospice services. Specifically, Resident 15 did not receive a shower or sponge bath from either the Hospice or facility staff for over 7 weeks, due to a scheduling error. This failed practice placed the resident at risk for skin breakdown and decreased quality of life. Findings included . According to a quarterly assessment dated [DATE], Resident 15 had diagnoses that included dementia, failure to thrive (a syndrome of overall decline) and had severe cognitive impairment. The resident required maximum assistance with repositioning and personal hygiene and was was totally dependent on staff for bathing and toileting. Brief observations of the resident in bed were made on 06/17/2024 at 3:17 PM, 06/18/2024 at 2:38 PM and 06/20/2024 at 8:44 AM and 3:36 PM. Resident 15 was resting quietly without distress and/or odor. According…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently implement interventions to reduce fall hazards, monitor for intervention effectiveness, and modify interventions when necessary for 1 of 3 sampled residents (Resident 4), reviewed for falls. This failure resulted in Resident 4 sustaining repeat falls and placed residents at risk for avoidable accidents, significant injury, and diminished quality of life. Findings included . Review of the facility policy titled, Fall and Injury Prevention and Management Care Plan revised 01/2023, showed the facility would revise a resident's care plan and/or center practices to attempt to determine casual factors that may have led to a fall, to prevent future occurrences and reduce the likelihood of another fall. The facility was to assess risk factors and hazards to identify potential interventions to implement. Review of the facility policy titled, Fall Injury Management- Post Fall or Injury revised 01/2023, showed proper action following a fall included:…

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 trauma informed care by ensuring trauma survivors were appropriately assessed, implement trauma care plans with potential triggers identified to prevent potential re-traumatization, and limit a resident's exposure to potential trauma triggers for 1 of 1 sampled residents (Resident 3), reviewed for trauma informed care. This failure placed residents at risk of becoming retraumatized, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Trauma-Informed Care and Screening revised 04/2023, showed a resident's experiences were accounted for in the development of a plan to eliminate or mitigate triggers that may cause re-traumatization. The policy listed examples of potential trauma which included experiencing or witnessing physical abuse or domestic violence. The policy showed all residents would be universally screened for trauma to determine if additional evaluations were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement person-centered care plans with individualized interventions to address behaviors for 1 of 2 sampled residents (Resident 2), reviewed for dementia care. This failure placed residents at risk of increased behaviors, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Dementia Care: Addressing Behaviors and Preventing Unnecessary Antipsychotic Use revised 06/2023, showed residents with dementia may exhibit behaviors as a way to communicate underlying and unresolved medical, physical, emotional, psychiatric, or environmental issues. The facility was to develop an individualized care plan focused on non-pharmacological approaches. The goal was to use person-centered approaches to reduce potentially distressing or harmful behaviors and promote quality of life. The policy instructed staff to assess new or worsening behaviors for possible underlying causes and gave a list of potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify verbally and physically aggressive resident to resident incidents as potential abuse, and report incidents to the State Survey Agency as required for 4 of 6 sampled residents (Resident 3, 4, 5, and 6), reviewed for abuse. In addition, the facility failed to identify a missing wallet with contents as potential misappropriation of resident property, and report the incident to the State Survey Agency as required for 1 of 6 sampled residents (Resident 2), reviewed for abuse. These failures placed residents at risk of potential abuse, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse . and Misappropriation of Resident Property dated 08/2022, showed when the facility received an allegation that met the definition of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property the facility would report 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 facility-initiated discharges had a valid basis for discharge, and the discharge documentation included the required components 2 of 3 sampled residents (Resident 1 and 2), reviewed for facility-initiated discharge. These failures placed residents at risk of discontinuation of medical services, untreated conditions, unsafe living conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Discharge Management revised 05/2023, showed discharges would be based on the resident's clinical condition and would occur as soon as reasonably possible following the physician's discharge order. The interdisciplinary team (IDT) would assist in planning and coordination of needed outside services and prepare written discharge instructions with pertinent information to provide a safe discharge. Review of the facility policy titled, Against Medical Advice Discharge dated 08/2022, showed a discharge against medical advice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently monitor tolerance to dialysis (procedure to remove fluid and waste from the body when the kidneys stop working properly) treatments and collaborate care with the dialysis center for 1 of 3 sampled residents (Resident 1), reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life. Findings included . According to the 03/09/2024 quarterly assessment, Resident 1 had a diagnosis of end stage renal disease (kidneys stop working and are not able to remove waste or extra water from the blood) and was dependent on dialysis to survive. Resident 1 was cognitively intact and able to make their needs known. Review of Resident 1's facility census information showed that they re-admitted on [DATE], were admitted to the hospital on [DATE] and were re-admitted to the facility on [DATE]. They were again admitted to the hospital on [DATE] and readmitted to the facility on…

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

Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 2 of 3 sampled residents (1 and 2) reviewed for abuse. This failure placed residents at risk for possible abuse. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility educated, completed substantial training, and began monitoring compliance for reporting of allegations of abuse, by 03/06/2024, of staff. The facility was notified of the past non-compliance on 03/07/2024. Findings included . <Resident 1> Record review showed that on 02/21/2024 Resident 1 alleged that Staff B had touched them inappropriately while helping them to prepare for bed. The facility investigation showed that Resident 1 had told Staff D, Nursing Assistant and Staff E, Licensed practical Nurse, of their concerns related to possible abuse on 02/22/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently assess fall risk, timely initiate fall care plans and implement new safety interventions for 2 of 4 sampled residents (Resident 1 and 2), reviewed for falls. Resident 1 sustained repeat falls when safety interventions were not initiated timely. This failure placed residents at risk for potentially avoidable accidents, injuries, and diminished quality of life. Findings included . Review of the facility policy titled, Fall and Injury Prevention and Management, revised 01/2023, showed residents would be assessed for fall risks on admission, quarterly, after a fall, and with a change of condition. The facility was to include the resident and/or their representative in determining a history of falls and their causative factors. A fall care plan was to be initiated at the time of admission with appropriate interventions implemented to address identified fall risk factors. The policy further showed the facility would revise the resident's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for a potential injury, for 4 of 6 residents (1, 2, 3 and 4), who experienced falls at the facility. Failure to monitor for the development of injuries after a fall, placed the residents at risk for a delay in treatment and possible decreased quality of life. Findings included . <Resident 1> According to a quarterly assessment dated [DATE], Resident 1 had diagnoses including heart disease, diabetes, and decreased function of one side of their body. The resident required extensive to total assistance to perform their activities of daily living. Additional record review showed the resident had a fall on 12/27/2023 while being transferred from their wheelchair to their bed in a mechanical lift. An initial fall evaluation was completed but no record of monitoring for injuries after this fall was found. <Resident 2> According to a quarterly assessment dated [DATE], Resident 2 had diagnoses including spinal cord dysfunction with impairment of both…

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 identified safety interventions and consistently provide adequate supervision to ensure resident safety for one of three sample residents (Resident 1) reviewed for accidents. This failure placed Resident 1, as well as other residents at risk for avoidable injury. Findings included: According to a quarterly assessment dated [DATE] Resident 1 had diagnoses including dementia with behaviors and experienced significant cognitive impairment. Record review of a facility investigation dated 10/01/2023 described a verbal and physical altercation between Resident 1 and Resident 4. Resident 4 was passing Resident 1 in their electric wheelchair when Resident 1 was first verbally aggressive and then stood up from their wheelchair and grabbed Resident 4's neck, scratching them. The facility decided to move the two residents to different areas of the facility and described further interventions to prevent reoccurrence of such events to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pain medication timely for one of three sampled residents (1), reviewed for pain. This failure placed the resident at risk for inadequate pain control and a diminished quality of life. Findings included . Resident 1's hospital wound nursing note dated 08/16/2023 described Resident 1 as having a procedure called incision and drainage (a surgical procedure to release pus or pressure that has built up under the skin) on 08/08/2023 related to a diagnosis of necrotizing soft tissue infection (a rare and severe type of life-threatening bacterial infection causing destruction of skin, muscle, and soft tissue). The note further describes the resident's wounds as 10 centimeters (cm) long, 4 cm wide and 1 cm deep on the back of their left arm and another wound 22 cm long, by 8 cm wide by 2 cm deep on the front of their left lower arm. Both wounds were requiring the use of a wound vacuum-assisted closure (VAC) device (a device that decreases air pressure…

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 annual abuse training for 6 of 7 staff (G, H, I, J, K and L), reviewed for abuse training. These failures placed residents at risk for potential abuse and neglect related to untrained staff. Findings included . Record review of the facility's policy titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injures of Unknown Source, and Misappropriation of Resident Property dated August 2022 showed employees would receive training on abuse upon hire and at least annually. The yearly training included instruction for mandatory reporting requirements. Review of Staff L's employee file showed they were a Nursing Assistant (NA) hired 03/12/2019, and their last yearly Abuse and Neglect Training was completed 05/05/2021. Review of Staff K's employee file showed they were a NA hired 10/22/2018, and their last yearly Abuse and Neglect Training was completed 04/12/2020. Review of Staff H's employee file showed they were a Licensed Practical Nurse hired 07/13/2006, and their last yearly Abuse and…

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

Based on interview and record review, the facility failed to ensure allegations of misappropriation for 2 of 5 sample residents (8, 6), and potential physical abuse for 2 of 5 sample residents (21, 15), were reported immediately to administration and the State Survey Agency as required, and that allegations of neglect were reported within 24 hours to the State Survey Agency for 1 of 5 sample residents (12). These failures placed the residents at risk for potential additional abuse, neglect, and misappropriation. Findings included . Resident 8 During an interview on 01/09/2023 at 3:43 PM, Resident 8 described the loss of their wedding ring in July of 2022. Resident 8 stated that they thought it had been stolen when they had been in a different room, quarantined with a COVID-19 infection (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). The resident stated they had reported it to Staff D, Social…

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.

Resident 15 Per the 11/18/2022 admission assessment, Resident 15 was able to make decisions regarding their care, and needed assistance from one to two staff to complete activities of daily living, such as toileting and turning in bed. Review of a grievance form dated 12/16/2022 at 1:23 PM showed Resident 15 had reported to Staff GG, Occupational Therapist, that a male staff (unnamed) that worked night shift was not respectful when assisting them with care. In addition, the form stated the staff member had been suspended pending an investigation, and education had been provided on how to treat residents. Review of the facility's mandatory reporting log showed that no entry related to Resident 15's allegation of abuse had been made, and no documentation was found or provided to show the facility had investigated the allegation of potential abuse. During an interview on 01/19/2023 at 10:11 AM Staff A, Administrator, stated the facility process was to fill out a grievance form for all allegations, the form was reviewed to determine the nature of the complaint, and if it was determined…

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 accuracy of a comprehensive assessment (an assessment tool used to identify a resident's specific care needs), for 1 of 1 sample residents (11), reviewed for hearing deficits. Failure to accurately assess the resident's hearing needs placed them at risk for unmet care needs. Findings included . Review of the admission record showed that Resident 11 was re-admitted to the facility on [DATE]. Review of the most recent assessment dated [DATE] showed Resident 11 with no diagnosis of hearing deficits. The assessment also showed that Resident 11 had highly impaired vision with no corrective lenses, and adequate hearing with no difficulty in normal conversation and no hearing aid. Per the same assessment, Resident 11 was cognitively intact and able to make their needs known. Review of the assessment dated [DATE] showed Resident 11 with minimal hearing impairment with no difficulty in normal conversation and no hearing aid. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet resident's medical, nursing, mental and psychosocial needs for 5 of 9 sample residents (21, 39, 9, 457, 11), reviewed for care plans. Failure to have resident specific interventions for mood, behavior, skin, and smoking placed the residents at risk for accidents, worsening wounds, unmet care needs, and a diminished quality of life. Findings included . Resident 39 admitted to the facility on [DATE] with diagnosis of depression (a common mental disorder characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), seizure disorder (a disorder characterized by sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and history of malignant neoplasm of the brain (a mass of abnormal cells…

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 residents and/or their representatives the opportunity to participate in the development of their care plan for 4 of 5 sample residents (16, 28, 6, 46), reviewed for care planning. In addition, the facility failed to ensure care plan interventions were implemented for 1 of 2 sample residents (17) reviewed for edema. These failures placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included CARE PLANNING Resident 16 Per the 10/04/2022 quarterly assessment, Resident 16 was cognitively intact to make decisions regarding care, and felt it was very important to have family, or a close friend, involved in discussions about their care. In an interview on 01/10/2023 at 10:46 AM, when asked if the facility included them in care planning meetings, the resident stated there had not been any discussions or care planning meetings recently that they were aware of, and they could not recall when the last care meeting had been. A review of the resident's record showed care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently provide showers for 5 of 5 sample residents (39, 21, 36, 37, 6), nail care for 3 of 5 sample residents (39, 21, 36), and shaving for 1 of 5 sample residents (37), reviewed for dependent residents requiring assistance with activities of daily living (ADL). These failures placed the residents at risk for poor hygiene and a diminished quality of life. Findings included . Resident 39 According to the most recent quarterly assessment dated [DATE], Resident 39 required limited assistance with personal hygiene, and required supervision with setup for bathing. In an interview on 01/09/2023 at 3:35 PM Resident 39 stated that they preferred two showers a week, but had not had a shower for a couple of weeks. According to Resident 39's care plan, the resident was to receive two showers per week, with a preference for showers in the morning. Review of the resident's shower record for the period of 12/14/2022 through 01/14/2023 showed 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 observation, interview, and record review, the facility failed to implement a system to maintain records for controlled drug reconciliation for 1 of 2 medication rooms. This system failure placed the facility at risk of untimely identification of drug diversion from the facility's emergency medication kit (E-kit). Findings included . Per observation of the south medication room on 01/19/2023 at 3:34 PM, the unlocked refrigerator contained two removable clear plastic containers labeled as E-kit box #304 and #305. Each contained two sealed vials of injectable Ativan (a class IV controlled medication used to treat anxiety, requiring refrigeration in injectable or liquid form), and two sealed 30 milliliter bottles of liquid Ativan. Review of the 11/2017 Controlled Medication Storage policy showed: 4) Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. 5) Accountability record necessity for scheduled III-V medications will depend on state regulations or a decision of the nursing care center 6) The nursing…

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 personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 6 staff (M, Y, JJ, KK, LL, MM), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus which is characterized mainly by a fever and cough, and is capable of progressing to severe symptoms and in some cases death). In addition, the facility failed to ensure fit testing (a test done to ensure an N-95 mask formed a tight seal) was completed for 4 of 6 staff (M, JJ, KK, NN), reviewed for fit testing, which also placed residents and staff at risk for contracting COVID-19. Findings included According to the 03/16/2022 CDC publication, How to use Your N95 Respirator, N95 respirators/masks (a special type of tight-fitting mask that filters particles) must form a seal to the face to work properly. The document showed the mask should be placed under the chin, with the nose piece bar at the top,…

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 comprehensive antibiotic stewardship program was developed and implemented, to prevent 1 of 3 sample residents (8), reviewed for antibiotic use, from receiving inappropriate antibiotics. This failure placed the resident at risk to receive unnecessary antibiotics with potential adverse side effects. Findings included . Review of the 11/16/2022 Antibiotic Stewardship policy showed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics and provide training and education of staff on how the inappropriate use of antibiotics affected residents. The policy described the process for reviewing antibiotic orders upon admission and discharge, and when prescribed, but was generic in nature and not specific to how the facility assessed and evaluated antibiotic use to ensure it was appropriate. Per the 12/11/2022 quarterly assessment, Resident 8 was cognitively intact to make decisions regarding care, and was able to make needs known to staff. A progress note made on 01/04/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was a completed Physician's Order for Life-Sustaining Treatment [POLST] (a form which instructed medical staff what treatment the resident wished to have done in the event they were seriously ill or their heart stopped beating), for two of three sample residents (32, 17), reviewed for advance directives. This failure placed the residents at risk for not having their wishes and choices regarding end-of life care honored. Findings included . Resident 32 Per the [DATE] quarterly assessment, Resident 32 admitted to the facility on [DATE], and was cognitively intact to make decisions regarding their care. Record review showed a POLST form was signed by the physician on [DATE], and showed the resident did not wish to have cardiopulmonary resuscitation (CPR) performed in the event their heart stopped beating. Further review of the form showed it was not signed by Resident 32 until [DATE], almost six months after they had been admitted to the…

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

Based on interview and record review, the facility failed to inform 2 of 3 sample residents (6, 18), reviewed for beneficiary notification, of their potential liability for payment related to Medicare services ending. This failure placed the residents at risk of not having adequate information to make financial decisions regarding their continued stay at the facility. Findings included . Review of Resident 6's records showed a Notice of Medicare Non-Coverage (NOMNC, a required form), dated 09/08/2022, informing the resident their skilled nursing services would end on a date given on the notice. The NOMNC was designed to inform the resident that their Medicare coverage would probably no longer cover skilled services and the resident may have to pay for any services received after the given date. It did not include any information about how much the resident would be responsible to pay. Review of Resident 18's records revealed a NOMNC was issued and signed by the resident's representative on 10/21/2022, informing the resident their skilled nursing services would end on 10/24/2022. Per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 sample residents (11), reviewed for communication. This failure had the potential to compromise Resident 11's ability to reach the highest practical well-being, meet their hearing needs, and dimish their quality of life. Findings included . Review of the admission record showed that Resident 11 was re-admitted to the facility on [DATE]. Review of the assessment dated [DATE] showed Resident 11 had no diagnosis of hearing deficits. The assessment also showed that Resident 11 had highly impaired vision with no corrective lenses and adequate hearing, with no difficulty in normal conversation and no hearing aids. The assessment showed the resident was cognitively intact and able to make their needs known. Review of care plan dated 11/28/2022 showed that Resident 11 was care planned for hearing loss and blindness. In addition, it also…

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 report a resident fall to other staff, monitor the resident for injury, complete a thorough and timely investigation, and implement interventions to prevent additional falls for 1 of 3 sample residents (17), investigated for accidents. This failure placed the resident at risk for continued falls. Findings included . Resident 17 According to a 12/07/2022 admission assessment, Resident 17 was cognitively intact and made their own decisions. The document further showed that the resident often needed an interpreter as they spoke little English. The resident had diagnoses which included congestive heart failure (a condition where the heart weakens and doesn't pump blood as well as it should. Symptoms included shortness of breath, fatigue and weakness). The assessment further showed that the resident required extensive, 2-person staff assistance with transfers and used a wheelchair. A 12/14/2022 progress note at 6:30 PM showed that the nurse noted bruising…

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 develop and implement policies and procedures with required timelines for monthly drug regimen reviews for 1 of 5 sample residents (9), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications, adverse side effects and a diminished quality of life. Findings included . Per the 12/08/2022 comprehensive assessment Resident 9 had diagnosis of anxiety and schizophrenia (a mental health condition in which people interpret reality abnormally). Resident 9 was cognitively intact and able to make their needs know. Review of the consultant pharmacist report for medication regimen review from 12/01/2022 through 12/31/2022 showed an as needed order for Clonazepam (a medication used to help reduce anxiety) without a stop date, and duplicate antidepressant therapy for Resident 9. In addition, medication regimen reports failed to address the need for monthly blood work for Clozaril (an antipsychotic) medication refills. Review of the January 2023 Order Summary Report showed an…

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

Based on observation, interview, and record review, the facility failed to store refrigerated medication under proper temperature controls for 3 of 3 refrigerators containing medications. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included . Per observation of the south medication room on 01/19/2023 at 3:34 PM, the thermometer in medication refrigerator read 53 degrees Fahrenheit (F) - that temperature was verified by Staff T, Registered Nurse. Review of the 01/2021 Storage of Medication policy stated: 11) Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. Review of the January 2023 medication refrigerator temperature logs showed: - The north medication room only showed 38 degrees F documented…

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

Based on observation and interview, the facility failed to ensure the daily menu and alternative menu were provided for 4 of 7 sample residents (16, 6, 28, 21), reviewed for meals. This failure denied the residents the right to choose their meal preference, and had the potential to negatively affect their nutritional needs and create a diminished quality of life. Findings included . Resident 16 Per the 10/04/2022 quarterly assessment, Resident 16 was cognitively intact to make decisions regarding care, and needed assistance from staff to utilize their wheelchair for mobility around the facility. On 01/10/2023 at 10:59 AM, Resident 16 was observed lying in bed watching television. When asked about the food, the resident stated the meat was like chewing a cable. When asked if the facility offered an alternative if they didn't want the main meal, the resident stated an alternative was offered, but they don't give out the menus. Review of the care plan showed an intervention that was implemented 01/31/2019 which instructed nursing staff to allow choice in mealtime, menu selection,…

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 each resident was offered an influenza and/or pneumococcal immunization as required for 3 of 5 sample residents (17, 18, 45), reviewed for immunizations. This failure prevented the residents from making decisions about their care, and placed the residents at risk for illness, and possible health complications. Findings included . The Center for Disease Control (CDC) has different guidelines for the schedule of pneumococcal vaccinations depending on age, medical conditions, and previous vaccination history. Per 02/17/2022 guidelines: Anyone ages 19-[AGE] years of age with certain underlying medical conditions, other risk factors, or those who have not previously received a pneumococcal conjugate vaccine, or who have an unknown vaccination history; 1 dose PCV15 or 1 dose of PCV20 should be given. If PCV15 was used, a dose of PPSV23 should be given at least one year later. For those who are 65 years or older who have not received a pneumococcal…

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.