Emerson Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide shaving and nail care for 2 of 2 sampled residents (Residents 19 and13) reviewed for activities of daily living (ADLS). This failure placed the residents at risk for poor personal hygiene, unmet care needs, and a diminished quality of life.Findings included . <Resident 19> The 06/18/2025 quarterly assessment documented Resident 19 needed assistance from nursing staff to complete ADLS for personal hygiene such as shaving. In addition, the assessment showed Resident 19 had severe cognitive impairment and unclear speech. On 07/21/2025 at 9:14 AM, Resident 19 was observed standing in the hallway by the ward entrance doors. The resident’s face was clean and there was facial stubble present on the cheeks, chin and upper lip. Additional observations of Resident 19 with facial stubble were made on the following: 07/22/2025 at 9:02 AM, 07/23/2025 at 8:59 AM, 9:36 AM, and 11:52 AM, and on 07/24/2025 at 7:10 AM. Review of the…

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

Based on observation, interview and record review, the facility failed to ensure care plan goals and interventions were developed and monitoring occurred for 2 of 2 sampled residents (Residents 11 and 22) reviewed for edema (swelling) management. This failure placed the residents at risk for worsening edema, unrecognized changes to their skin, and decreased quality of life. Findings included. <Resident 11> The 06/17/2025 Significant Change assessment documented Resident 11 had diagnoses that included lymphedema (swelling and fluid buildup caused by blockage in the lymphatic system, part of the immune and circulatory system) and osteomyelitis (infection of the bone). The resident was cognitively intact and made their needs known. The 03/11/2025 admission skin assessment documented Resident 11 had a surgical incision on their left heel and 4+ edema (a deep indentation of the skin that occurred when pressure was applied that required two to three minutes to fill back in once pressure was relieved) to both lower legs. The 03/11/2025 care plan documented Resident 11 had actual skin…

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

Based on observation, interview and record review, the facility failed to maintain oxygen saturations per provider orders and failed to ensure respiratory equipment was cleaned and maintained for 1 of 1 sampled residents (Resident 70), reviewed for respiratory care. This failure placed the resident at risk for illness and decreased quality of life. Findings included .The 05/12/2025 admission assessment documented Resident 70 had diagnoses that included respiratory and heart failure. The resident was cognitively intact and was dependent on supplemental oxygen.In an observation on 07/21/2025 at 11:09 AM, Resident 70 was lying in bed asleep and was wearing oxygen. The resident had a CPAP (continuous positive air pressure, a machine that delivered pressurized air through a mask worn during sleep) on a table near their bed. The CPAP had a few white spots inside of the mask. In an interview on 07/21/2025 at 1:09 PM, Resident 70 was lying in bed wearing oxygen. Resident 70 stated the facility had not cleaned their CPAP.No further observations were made of Resident 70 as they were…

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

Based on observation and interview, the facility failed to ensure the kitchen floor was maintained and torn linoleum was repaired when indicated. This failure placed staff at risk of potentially avoidable accidents, and infection control issues because the floor was not a cleanable surface.Findings included .In an observation of the kitchen on 07/21/2025 at 8:52 AM, the floor in the dishwashing area had a large area of the floor where the linoleum was torn off and missing, which created a possible tripping hazard for staff. The area was approximately 4 feet by 4 feet and had exposed wood which was not a cleanable surface. On 07/28/2025 at 1:23 PM, the floor in the dishwashing area was observed with Staff O, Dietary Manager. Staff O agreed the area was an infection control issue and a safety hazard and stated it was on their wish list to have it replaced. In an interview on 07/28/2025 at 1:51 PM, Staff B, Director of Nursing, stated they did not go past the yellow line in the kitchen (an area at the entrance of the kitchen where the staff entered to request items) so they were not…

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 2 sampled residents (Resident 51), reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life. Findings included . Review of the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, between the facility and the dialysis center dated 04/05/2021, documented the facility should provide the dialysis center with an interchange of information useful and/or necessary for the care of the dialysis resident. The agreement further documented there should be documentation of collaboration of care and communication between the long-term care facility and the dialysis center. According to the 12/19/2023 quarterly assessment, Resident 51 had a diagnosis of end…

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 transcribe provider orders and administer medications as intended by the provider for 1 of 6 sampled residents (Resident 34), reviewed for unnecessary medications. Specifically, Resident 34 was routinely administered pain medication when the provider intended to change the prescription to as needed. This failure placed residents at risk of adverse side effects, unnecessary medications, and diminished quality of life. Findings included . According to the 03/18/2024 quarterly assessment, Resident 34 had frequent mild pain that did not affect their activities of daily living. Resident 34 was cognitively intact and able to make their needs known. Review of the 12/16/2021 care plan instructed staff to offer nonpharmacological pain interventions such as repositioning, diversional activities, food, toileting, music, and a quiet environment. The care plan also instructed staff to monitor frequency of pain and medication effectiveness. Review of provider orders in the medical record showed an active 03/15/2023 Hydrocodone…

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 accommodate a resident's desire for a larger television that they could better visualize for 1 of 3 sampled residents (Resident 47) reviewed for environment. This failure placed the resident at risk of being unable to participate in their preferred activities and decreased quality of life. Findings included . A 01/15/2024 quarterly assessment documented Resident 47 had diagnoses including Parkinson's disease (nerve cell damage in the brain that causes stiffness, tremors, and difficult movement.) Resident 47 was cognitively intact, and it was very important for them to be able to listen to music and do their favorite activities. The 10/10/2023 Activities care plan documented Resident 47 enjoyed current events including the news on TV (television), music, assorted Westerns, talk shows, and comedy series with their personal room and recreational rooms as the preferred setting. The activity staff were to have 1 to 1 visits in the resident's room, help in selecting TV programs and music channels in the resident's…

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

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 2 sampled residents (Resident 48), reviewed for environment. This failure placed residents at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included . Resident 48 had diagnoses, including Vascular Dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain). A 02/28/2024 quarterly assessment documented Resident 48 was severely cognitively impaired and did not walk, making the wheelchair (w/c) their only method of mobility. Review of a 03/27/2024 cleaning assistive device task documented Resident 48 was to have their w/c cleaned once a week on Sundays but there was no documentation found within the last 30 days. During an observation on 03/24/2024 at 03:02 PM, Resident 48 was sitting in their w/c in the dining room requesting a cup of coffee. An observation was made of Resident 48's w/c; the black…

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

Based on interview, and record review, the facility failed to ensure incidents of potential abuse, such as misappropriation of personal property, were identified as such and reported to the State Survey Agency as required, for 1 of 6 sampled residents (Resident 30) reviewed for abuse. Failure to report allegations/incidents of abuse placed the resident at risk for additional abuse. Findings included . Review of the facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy, last revised 09/21/2022, documented the policy of the facility was their residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further showed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (hereafter referred to as abuse) would be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Per the 02/26/2024 quarterly assessment, Resident 30…

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 significant change assessment was completed timely when a resident had several areas of decline for 1 of 21 sampled residents (Resident 8) reviewed for declines in activities of daily living (ADLs). This failure placed residents at risk for unrecognized and unmet changes in care needs. Findings included . Per review of the record, Resident 8 was admitted from the hospital on [DATE] with diagnoses including dementia and adult failure to thrive. Review of the Minimum Data Set (MDS), a comprehensive assessment completed on 11/22/2023 documented Resident 8 was moderately impaired cognitively, required set up or clean up assistance for eating, substantial/maximum assistance for dressing their upper body, and completing personal hygiene, partial/moderate assistance when changing from a lying position to a sitting position and weighed 193 pounds (lbs.). In the Assessments area of the record, an interdisciplinary team (IDT) note completed…

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 for 1 of 5 sampled residents (Resident 48), 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 . According to the 02/28/2024 quarterly assessment, Resident 48 was admitted on [DATE] with diagnoses which included dementia and received psychotropic medication (medications that affect the mind, emotions, and behavior). Review of Resident 48s's Level I PASARR showed it was completed and signed by Staff E, Social Services, on 08/28/2023, 5 days after the resident's admission to the facility, and not prior to admission as required. In an interview on 03/29/2024 at 9:09 AM, Staff E stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 48) reviewed for activities of daily living, received assistance with eating and consuming fluids. These failures placed the resident at risk for weight loss, dehydration, and diminished quality of life. Findings included . According to Resident 48's quarterly assessment dated [DATE], Resident 48 had diagnoses including dementia and anxiety. Resident 48 was able to feed themselves after setup assistance. Resident 48's care plan dated 06/21/2023, documented Resident 48 required up to extensive assistance with eating. On 03/14/2024, an order was received to ensure Resident 48's cup was filled with ice water and placed at their side with and in between meals. During an observation on 03/25/2024 at 12:05 PM, Resident 48 took a large bite of cauliflower, was fidgety, held onto meal card holder for at least five minutes before taking another bite of food. At 12:09 PM, Resident 48 had food that had spilled…

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 consistently monitor and provide bowel care timely for 2 of 2 sampled residents (Resident 48 and 268), reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . Review of the facility's undated bowel management program instructed nursing staff to administer Milk of Magnesia or other laxative as ordered on the third day of a resident not having a bowel movement (BM), if not effective, a suppository would be given the following day, and if that was ineffective an enema would be given. Nursing staff was required to do an abdominal assessment on any resident that had received bowel medications. <Resident 48> Per the 02/28/2024 quarterly assessment, Resident 48 was unable to make decisions regarding cares, and needed assistance from staff for activities of daily living, such as toileting. Review of the care plan dated 06/21/2023 documented the resident was at risk for constipation and had interventions which instructed nursing staff to…

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

Based on observation, interview and record review, the facility failed to ensure a resident that had significant weight loss was reassessed by the Registered Dietician (RD) timely for 1 of 6 sampled residents (Resident 268) reviewed for nutrition. This failure placed residents at risk for further undesired weight loss, and a decline in their health. Findings included . According to an admission assessment completed on 03/06/2024, Resident 268 had diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident 268 was severely cognitively impaired and could feed self. A review of the weights showed the following for Resident 268: -03/09/2024 131.2 pounds (lbs.) -03/20/2024 126.8 lbs. The 03/11/2024 Nutritional Risk assessment documented resident's spouse stated Resident 268 weighed approximately 169 lbs. a year ago and had decreased to 140 lbs.…

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 dietary staff had the proper qualifications. Failure to ensure the dietary manager had the proper certification placed all residents at risk for receiving dietary services from staff without the required competencies. Findings included In an interview on 03/28/2024 at 12:28 PM, Staff D, Dietary Manager, stated they were in the process of getting certified as a dietary manager in Washington State. She stated they were currently enrolled in the course and needed to take the examination. On 03/29/2024 at 2:28 PM, Staff A, Administrator, confirmed the Dietary Manager for the facility was not certified as a dietary manager. Reference (WAC) 388-97-1160 (1)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dietary staff had the required training for 2 dietary staff (S,T). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed no Washington State Food Workers card for Staff S and Staff T. Staff S had a certificate dated 05/14/2021 that expired on 05/14/2024, Staff T had a certificate dated 06/01/2022 that expired on 06/01/2025 from Food Handler Solutions for completing the food handler's course. Review of Food Handler Solutions website, foodhandlersolutions.com/[NAME]-food-handler-card/ showed, the Food Handler Solutions Program is currently not approved in the state of [NAME]. This program is only intended to be used for personal development and preparation for the state provided training. During an interview on 03/29/2024 at 12:17 PM, Staff D, Dietary manager, stated they were unaware 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.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Failure to ensure expired foods were discarded for 1 of 3 refrigerators and 1 of 1 dry storage areas, and failure to cover food that was stored in 1 of 1 refrigerators. These failures placed residents served from the kitchen at risk for consuming expired food and food-borne illnesses. Findings included . During an initial tour of the kitchen on 03/24/2024 at 10:25 AM, the pantry revealed four boxes of corn starch that had expired on 03/23/2024 and eight boxes of apple juice that had expired on 03/14/2024. The refrigerator in the kitchen contained a container of soup that was uncovered without a date, and a pan of pork cutlets, partially covered without a date. In an interview on 03/24/2024 at 10:48 AM, Staff D, Dietary Manager, stated the dry storage area is checked twice weekly and expired food was discarded at that time. Staff D acknowledged the corn starch and apple juice was expired and should have been discarded. 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 observations, interview, and record review the facility failed to perform hand hygiene when indicated during meal service in 1 of 3 dining rooms (Meadowood) and 1 of 3 halls (Tuscan Trail), observed during meal service. These failures placed residents at risk for transmission of communicable diseases and/or healthcare associated diseases, and diminished quality of life. Findings included . Review of the facility's undated policy titled, Handwashing/Hand Hygiene, documented staff should follow handwashing/hand hygiene procedures to prevent the spread of infections to others. The policy instructed staff to perform hand hygiene before and after contact with residents, after contact with resident's intact skin, after contact with objects in the immediate vicinity of a resident, after removing gloves, before and after handling food, and before and after assisting a resident with meals. The policy further documented the use of gloves did not replace hand hygiene. The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff possessed appropriate competencies and skills to administer medications for 1 of 3 sample residents (Resident 1), reviewed for medication administration. This failure placed residents at risk for adverse medication outcomes and potential medication errors. Findings included . Per the Washington State Department of Health website: https://doh.wa.gov/licenses-permits-and-certificates/professions-new-renew-or-update/pharmacy-professions/who-can-prescribe-and-administer-prescriptions-[NAME]-state, a Certified Nursing Assistant (CNA) may administer medications in community-based care settings or in-home care settings under nurse delegation. The document showed a CNA may administer medications in a nursing home with a medication assistant endorsement. Review of a facility assessment dated [DATE] showed Resident 1 had diagnoses which included Diabetes and kidney disease. The resident was impaired with decision making. Review of the Medication…

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 qualified Registered Dietician (Staff E) completed nutritional assessments and failed to ensure the Registered Diet Technician (Staff G), received proper supervision in accordance with professional standards related to the care of 3 of 7 sample residents (19, 31, 57), reviewed for nutrition. This failure placed the residents at risk of receiving nutritional care and services from staff without the required competencies and skills, possible weight loss, and a deterioration in their nutritional status. Findings included . The Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietician Nutritionist. Journal of the Academy of Nutrition and Dietetics,118(1), p141-165 documented the registered dietitian nutritionist (RDN) develops and oversees the system for delivery of nutrition care activities, often with the input of others, including the nutrition and dietetic technicians, registered (NDTR). The RDN is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a vegetarian diet menu was in place, recipes were followed, and the high calorie high protein diet parameters were followed in accordance with established national guidelines. This deficient practice placed residents receiving food from the kitchen at risk of a diet lacking variety and adequate nutrient intake. Findings included . Review of the facility's policy titled Diet Orders (undated), showed, The regular diet is based on the Basic 4 Food Groups or Food Guide Pyramid to provide variety and assure adequate nutrient intake. All foods are allowed. Inclusion of the Dietary Guidelines for Americans for meal planning is encouraged to promote optimum health. Review of the policy High Cal Hi Protein (undated), showed, Interventions can include: -8 ounce whole milk at meals; -6 ounce fortified cereal at breakfast (add butter and 1 scoop beneprotein [commercial protein powder]); -4 ounces fortified mashed potatoes at lunch and/or dinner (add butter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop comprehensive person-centered care plans, to address a resident with a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine), and a resident receiving oxygen, for 2 of 20 sample residents (43, 220), whose care plans were reviewed. This failure placed the residents at risk for unmet needs. Findings included: Resident 43 According to Resident 43's admission assessment dated [DATE], the resident had a foley catheter (a flexible tubing inserted into the bladder to drain urine into a bag), and had diagnoses which included neurogenic bladder (a condition in which there is a lack of bladder control due to a brain, spinal cord or nerve problem). Review of the resident's medical record showed they had a suprapubic catheter (see above definition)placed on 02/13/2023. Review of Resident 43's care plan dated 12/02/2022, and last revised on 02/15/2023, showed they had a care plan for alteration in…

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

Based on observation, interview, and record review, the facility failed to ensure the food was palatable, attractive, and served at a safe and appetizing temperature for 6 of 6 sample residents (11,19, 31, 51, 522, 523), reviewed for food. This failure caused residents dissatisfaction with their meals and placed them at risk for reduced food intake and possible weight loss. Findings included . The undated Temperatures facility policy documented hot foods will be served at the appropriate hot temperature of 160 degrees Fahrenheit (F) or hotter. The policy also showed a designated food service worker will do quality management checks to identify if a temperature problem is occurring. The undated Preparation and Service of Food facility policy documented frequently observed food service violations included vegetables not being seasoned, foods not being tasted prior to being served, and when food was refused, appropriate substitutes of similar nutritive value will be offered. Review of the 12/28/2022 Resident Council meeting minutes showed residents reported the food was coming up cold…

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 monitor and report a low oxygen saturation reading to the provider for 1 of 4 sample residents (220), reviewed for oxygen use. This failure placed the resident at risk for potential deterioration in their medical condition and unmet care needs. Findings included . A quarterly Minimum Data Set assessment - a federally mandated clinical assessment of the resident - completed on 12/07/2022 showed Resident 220 had diagnoses including chronic obstructive pulmonary disease (COPD - a constriction of the airways causing difficulty breathing). The assessment also showed the resident was cognitively intact and required supplemental oxygen (extra oxygen administered from a tank or machine). Review of the 03/03/2022 provider orders for Resident 220 showed supplemental oxygen was to be given at 2 liters per minute (oxygen delivered into the nostrils through soft tubing, typically at a rate between one and 10 liters per minute), nursing staff were to monitor oxygen saturation (the amount of oxygen present in the blood), and to change…

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 care-planned restorative interventions for 1 of 3 sample residents (31), reviewed for restorative services (interventions developed to promote the resident's ability to achieve and maintain optimal physical, mental, and psychosocial functioning). This failure placed the resident at risk for a decline in mobility and a decreased quality of life. Findings included . The July 2022 Facility Assessment documented that services offered were based on resident needs. Services regarding mobility and fall prevention included transfers, ambulation, restorative nursing, contracture prevention, and supporting resident independence in doing as much of these activities by themselves. Resident 31 had diagnoses including Myoclonic Epilepsy with Ragged Red Fibers (MERRF syndrome, an incurable genetic mutation that causes symptoms of uncontrolled jerking movements, seizures, weakness, dementia, and progressive stiffness.) A Minimum Data Set (MDS)…

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 nutritional interventions as per the care plan, or provide the resident with a requested food in a timely manner, for 1 of 3 sample residents (19), reviewed for nutritional status. This failure resulted in the resident losing a significant amount of weight in a short period of time. Findings included . Review of the facility's undated policy titled Weight Assessment and Intervention showed care planning for weight loss or impaired nutrition would be a multidisciplinary effort and would include the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Resident 19 was admitted on [DATE] and had diagnoses including adult failure to thrive and diabetes. A 02/02/2023 Minimum Data Set (MDS) assessment - a federally mandated clinical assessment of the resident - showed the resident had moderately impaired cognition, required set-up help and supervision for eating, 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 1 of 5 sample residents (57), reviewed for unnecessary medication, was free from significant medication errors. Failure to follow the physician's orders for monitoring and administering insulin (a medication used to treat diabetes, a medical condition resulting in the body being unable to produce enough insulin), and contacting the provider when the blood sugar was over 450, placed the resident at risk for health complications. Findings included . Review of the Medication Administration Records (MAR's) and progress notes for 01/01/2023 through 02/23/2023 showed Resident 57 had an order dated 10/08/2023 to give 8 units of Lispro insulin (a short-acting form of the medication) for blood sugars greater than 400 (a level between and 90 and 140 would be considered normal) as needed, to treat diabetes. Per the January 2023 Medication Administration Record (MAR), the resident's blood sugar was documented above 400 on five occasions: 01/05/2023 (527), 01/20/2023 (412), 01/22/2023 (496, 468), and on 01/26/2023 (553). The 8…

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 discard undated, opened vials of long-acting and short-acting insulin, and expired vials of two other types of insulin. In addition, the following medications were expired: over-the-counter pain relieving patches, an over-the-counter acid reducer, vitamin B-12 and iron, for 1 of 4 medication carts reviewed (Tuscan hallway). This failure placed the residents at risk for receiving discharged resident's medications and compromised or ineffective medications. Findings included . On 02/24/2023 at 8:22 AM, an observation was made of medication cart #1 (Tuscan hallway) with Staff J, Licensed Practical Nurse (LPN). A partially used vial of long-acting insulin was observed in the top drawer of the medication cart. The insulin vial was labeled with Resident 27's name. The vial was undated, and had been opened and used. A partially used vial of a short-acting insulin was observed in the top drawer of the medication cart. The insulin vial was labeled with a discharged resident's name. Staff J stated that they were not sure when 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 observation, interview, and record review, the facility failed to provide food that accommodated food preferences for 1 of 6 sample residents (31), reviewed for preferences. This failure placed the resident at risk for decreased dietary intake and decreased quality of life. Findings included . A 01/30/2023 quarterly Minimum Data Set (MDS) assessment - a federally mandated clinical assessment of the resident - showed Resident 31 had diagnoses including Myoclonic Epilepsy with Ragged Red Fibers (MERRF Syndrome, a progressive illness that causes symptoms of uncontrolled jerking movements, seizures, dementia, heartbeat irregularities and others). The assessment also showed the resident was cognitively intact, weighed 160 pounds (lbs.), and required set-up help with their meals. The 04/25/2022 comprehensive care plan showed the resident was at nutritional risk related to their diagnosis of MERRF Syndrome, and staff were to provide a general diet of regular consistency and thin liquids, and were to monitor meals and weights per policy. An admission progress note dated 04/26/2022…

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.