Rockwood South Hill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the requirements to protect resident rights in an arbitration agreement for 2 of 4 sample residents (Residents 13 and 14) reviewed for arbitration. This failure placed residents at risk of losing legal protection, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.Findings included.Review of the admission and Discharge report provided by the facility on 03/17/2026 included a handwritten statement across the top that documented all admissions signed arbitration agreements (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) upon campus move in. The report showed the skilled nursing facility had 147 admissions between 01/06/2025 and 03/16/2026.Review of campus residency agreement showed the facility operated as part of a continuing care community. As part of the community, residents 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 maintain a resident's call light system in a functional manner for 1 of 3 sampled residents (Resident 25) reviewed for environmental concerns. This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.Findings included.The 02/04/2026 quarterly assessment documented Resident 25 had diagnoses that included Parkinsons disease (a progressive disorder that affected movement), dementia, and weakness. Resident 25 required set up assistance to total assistance from staff to perform activities of daily living (ADLs). Resident 25 had severe cognitive impairment and was able to make their needs known. The 11/19/2020 care plan documented Resident 25 was at risk for falls related to Parkinsons, poor balance, dementia, vision impairments and a history of falls. Staff were instructed to keep Resident 25's call light in reach at all times and remind the resident to use their call light to request assistance.In an observation on 03/17/2026 at 2:19 PM, Resident 25…

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

Based on observation and interview, the facility failed to ensure wheelchairs were maintained in a clean manner for 2 of 3 sampled residents (Residents 25 and 29) reviewed for physical environment. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.Findings included .<Resident 25>The 02/24/2026 quarterly assessment documented Resident 25 had diagnoses that included Parkinsons disease (a progressive disorder that affected movement), dementia and weakness. The resident had severe cognitive impairments and required partial to total assistance with activities of daily living.The revised care plan dated 01/28/2026 documented Resident 25 was wheelchair bound and was dependent on staff for locomotion.In an observation on 03/16/2026 at 1:08 PM, Resident 25 was sitting in their wheelchair in their room. The wheelchair was unclean with food debris on the back of the wheelchair, sides and side bars, and the seat cushion. The right arm of the wheelchair was torn. Similar observations of the wheelchair being unclean with food…

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 staff performed the required hand hygiene and wore hair coverings during food preparation and meal service for 2 of 2 dining rooms observed. Additionally, the facility failed to ensure the staff discarded expired foods, labeled food items, monitored the temperatures of foods being served, and were competent on preparation of thickened liquids. This failure placed the residents at risk for foodborne illnesses and aspiration (accidental inhalation of liquid into the lungs). Findings included . <North Dining Room> An observation of meal services in the North Dining Room on 12/03/2024 at 11:14 AM showed, Staff G, Nursing Assistant (NA), serving meals from the steam table for other staff to deliver to the residents in the North Dining Room. Staff G wore no hair covering throughout the entire meal service period observation. An unidentified aide was observed to touch the table where Resident 27 was seated at.The aide brought 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 interview and record review, the facility failed to maintain complete and accurate records for 2 of 5 sampled residents (Resident 15 and 19) reviewed for unnecessary medications and 1 supplemental resident (Resident 17). Failure to ensure complete informed consents for psychotropics (drugs that affect a person's mental state), placed the residents at risk of not having their needs met. Findings included . <Resident 15> Review of Resident 15's November 2024 Medication Administration Record (MAR) showed the staff administered Nuplazid (an antipsychotic) daily, Trazodone (an antidepressant) at bedtime, and citalopram (an antidepressant) daily. Review of 05/02/2023 consents for Trazodone and Nuplazid showed the staff did not identify the drug class categories the psychotropics belonged to. Additionally, the consent for Nuplazid did not show the symptoms the medication was prescribed for and instead showed, of psychosis. <Resident 17> Review of Resident 17's November 2024 MAR showed the staff administered citalopram daily, Nuplazid daily, buspirone (an antianxiety agent) twice 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 follow an established Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics (ABX) and reduce the risk of unnecessary ABX use for 2 of 2 months of infection control records reviewed. This failure increased resident risk for development of multidrug organisms (germs that are resistant to many ABX) and adverse outcomes associated with the inappropriate/unnecessary use of ABX. Findings included . Review of a 09/01/2024 policy titled Antibiotic Stewardship Policy showed its purpose was to develop ABX use protocols and a system to monitor their use. The policy showed the facility would assess residents for infections using the McGeer Criteria (a nationally recognized standard for defining infections), Centers for Disease Control and Prevention guidelines, and their local health jurisdiction. The policy showed that when residents were placed on ABX empirically (the initial antibiotic selected in the absence of definitive…

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 notify the physician and the resident representative of a change in condition experienced by 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. This failure placed the resident at risk for delayed decisions for treatment by the legal representative and the physician/practitioner. Findings included . Review of an 08/08/2024 quarterly assessment showed Resident 15 admitted to the facility on [DATE] with medically complex conditions, to include high blood pressure (BP) and arrhythmia (an irregular heartbeat). This assessment showed Resident 15 had severe cognitive impairment. The medical record showed Resident 15 had an appointed power of attorney (POA) for healthcare. According to the National Heart, Lung and Blood Institute (NIH), a normal BP is less than 120 systolic (the top number in a BP reading) pressure and less than 80 diastolic (the lower number in a BP reading) pressure. The NIH defined a hypertensive crisis (a medical…

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

Based on interview and record review, the facility failed to provide the required beneficiary notices for 2 of 3 sampled residents (Resident 1 and 83) reviewed for required notices and associated choices related to Medicare services ending. This failure placed the residents at risk of not being fully informed of the potential cost of continued services. Findings included . Review of the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) form showed it provided information to Medicare beneficiaries so that they could decide if they wished to continue receiving the skilled services that might not be paid for by Medicare and assume financial responsibility. The form was required when a resident had skilled benefit days remaining, was being discharged from Medicare Part A services, and continued living in the facility. <Resident 83> Review of a Notice of Medicare Non-Coverage (NOMNC) form showed Resident 83's last day of Medicare Part A services ended on 08/22/2024. The resident discharged from the facility on 09/04/2024. Record review showed no documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting or investigating elopement episodes and the discovery of a skin injury for 1 of 2 sampled residents (Resident 30) reviewed for accident hazards. This failure placed the resident at risk for repeated elopement and precluded the state agency (SA) from being aware of and investigating the circumstances surrounding the resident's elopements and skin injury. Findings included . Review of a 2019 facility policy titled Abuse, Neglect and Exploitation showed, the facility provided protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. The policy showed the facility completed an immediate investigation when suspicion of or actual abuse, neglect or exploitation occurred. The policy showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a transfer to the hospital, or that the receiving hospital had received information of the resident's condition, for 2 of 2 sampled residents (Residents 24 and 22), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs. Findings included . Per the 10/31/2024 admission assessment, Resident 24 had diagnoses which included high blood pressure, heart failure and thrombocytopenia (abnormally low platelets in the blood). A 11/26/2024 progress note showed the resident was assessed, due to complaints of pain. Resident 24 was weak, lethargic and had a blood pressure of 76/52. The resident's family member was notified, and the resident was sent to the hospital. A review of Resident 24's record showed no order was obtained to send the resident to the hospital or that information had been communicated to the receiving hospital. A 12/04/2024…

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 interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer, for 2 of 2 sampled residents (Resident 24 and 22), reviewed for hospitalization/discharge. This failure placed the resident at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman. Findings included . The 11/26/2024 discharge assessment documented Resident 24 was cognitively intact to make decisions regarding their care and had diagnoses which included heart failure, pneumonia (an infection that inflames air sacs in one or both lungs) and thrombocytopenia (abnormally low platelets in the blood). Review of Resident 24's record showed an 11/26/2024 nursing progress note which documented the resident had experienced pain, was lethargic and had a low blood pressure. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital. A 12/04/2024 progress note showed the resident had…

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

Based on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 2 of 2 sampled residents (Resident 24 and 22), reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold, while they were hospitalized . Findings included Per the 10/31/2024 admission assessment, Resident 24 had diagnoses which included high blood pressure, heart failure, thrombocytopenia (abnormally low platelets in the blood), was cognitively intact and able to make decisions regarding their care. Review of Resident 24's record showed an 11/26/2024 nursing progress note which documented the resident had experienced pain, was lethargic and had a low blood pressure. The resident was assessed and was sent to the hospital for evaluation. Additional record review found no documentation…

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 comprehensive person-centered care plans to address all aspects of care for 4 of 16 sampled residents (Resident 15, 19, 24 and 8) whose care plans were reviewed. Failure to address the individualized needs of each resident placed them at risk for inadequate care and a diminished quality of life. Findings included . <Resident 15> Review of an 08/08/2024 quarterly assessment showed Resident 15 admitted to the facility on [DATE] with medically complex conditions, to include high blood pressure (BP) and arrhythmia (an irregular heartbeat). Review of the November 2024 Medication Administration Record (MAR) showed the staff administered the medications amlodipine for high BP since 05/15/2024, hydrochlorothiazide for both high BP and edema (fluid retention) since 10/23/2024, and an as needed order for Hydralazine every six hours since 02/28/2024, if the staff assessed Resident 15's systolic (the top number in a BP reading) BP was greater…

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 physician order for the treatment of elevated blood pressures for 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. This failure placed the resident at risk for a negative outcome from a high blood pressure. Findings included . Review of an 08/08/2024 quarterly assessment showed Resident 15 admitted to the facility on [DATE] with medically complex conditions, to include high blood pressure (BP) and arrhythmia (an irregular heartbeat). Review of the November 2024 Medication Administration Record (MAR) showed an as needed order for Hydralazine every 6 hours since 02/28/2024, if the staff assessed Resident 15's systolic (the top number in a BP reading) BP was greater than 160. Review of Resident 15's medical record showed the staff obtained multiple readings with a systolic BP above 160 (10/04/2024, 10/06/2024, 10/08/2024, 10/24/2024, 10/25/2024, 10/26/2024, 11/05/2024, 11/09/2024, 11/12/2024, 11/24/2024, 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 observation, interview, and record review, the facility failed to consistently provide grooming for 1 of 2 sampled residents (Resident 25), reviewed for activities of daily living (ADL's). This failure placed the resident at risk for not being groomed according to their preferences, and a diminished quality of life. Findings included . According to the 10/18/2024 quarterly assessment, Resident 25 was cognitively impaired and needed partial to moderate assistance from staff for ADL's, such as personal hygiene. Per the 04/11/2024 care plan, Resident 25 needed assistance with personal hygiene. Review of the personal hygiene task from 11/10/2024 through 12/13/2024 documented Resident 30 had their facial hair removed on 11/10/2024, 11/17/2024, 11/22/2024 and 12/08/2024 and had not refused cares. In an observation on 12/03/2024 at 9:11 AM, Resident 25 was sitting in their wheelchair and had hair on their chin that was approximately a centimeter long. Subsequent observations of Resident 25 with hair on their chin were made on 12/04/2024 at 07:38 AM, 10:25 AM, and 2:33 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on a resident's request to change their code status (level of intervention a resident chooses if their heart or breathing stops) for 1 of 1 sampled resident (Resident 17) reviewed for Cardiopulmonary Resuscitation (CPR, the act of performing chest compressions and providing breaths to mimic heartbeat and breathing). This failure placed Resident 17 at risk to have CPR initiated when their legal representative requested to change their code status to No CPR. Findings included . Review of a [DATE] quarterly assessment showed Resident 17 admitted to the facility on [DATE] with medically complex conditions. This assessment showed Resident 17 had severe cognitive impairment and the family participated in the completion of this assessment. Review of a [DATE] progress note showed the facility held a care conference for Resident 17. Present in the care conference were several members of the facility and the resident's family, to include their Power 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 interview and record review, the facility failed to ensure the staff implemented the bowel protocol for the management of constipation for 3 of 5 sampled residents (Resident 14, 28, and 30) reviewed for unnecessary medications and monitor non-pressure injury and a fall with injury for 1 of 2 sampled residents (Resident 30) reviewed for accidents. These failures placed the residents at risk for unmet needs and complications from constipation and injuries. Findings included . According to the Bowel Protocol policy, dated 04/22/2019 (reviewed on 12/06/2024, staff was to initiate the following procedures on a regular basis for the resident to ensure adequate function and/or need for intervention: 1. Give Lax Loaf (type of laxative given by mouth) daily as needed 2. Give Milk of Magnesia (MOM, type of laxative given by mouth) on the evening of the second day if no bowel movement (BM). 3. Administer Dulcolax (Bisacodyl, a suppository laxative inserted rectally) on the night shift of the third day if no BM. <Resident 14> Per the 08/27/2024 quarterly assessment, Resident 14 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the need for restorative services (a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments or enables them to function at their highest capacity), for 1 of 1 sampled residents (Resident 7), reviewed for range of motion. This failure placed the resident at risk for a further decline in range of motion, due to limitations in their lower extremities and unmet care needs. Findings included . A 10/20/2024 significant change assessment documented Resident 7 had diagnoses including dementia and abnormalities of gait and mobility (the way a person walks and moves around). Per the assessment, the resident had impaired range of motion to their lower extremities, needed substantial to total assistance to complete activities of daily living (ADL), and received physical and occupational therapy. A 10/15/2024 physical therapy evaluation showed Resident 7 was hospitalized from [DATE]…

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

Based on observation, interview, and record review, the facility failed to provide supervision during a coughing episode for 1 of 2 residents (Resident 183) reviewed for supervision. This failure placed Resident 183 at risk for choking and a diminished quality of life. Findings included . Per the 11/26/2024 admission assessment, Resident 183 had diagnoses including dementia and a stroke. The resident had severe cognitive impairments and needed total assistance with eating. The 11/20/2024 physician's order prescribed Resident 183 a mechanical soft diet (soft, easily chewable foods designed for people who have difficulty swallowing or chewing) with nectar thick liquids. The 12/03/2024 care plan documented Resident 183 had difficulties swallowing and received an altered textured diet and required one to one feeding assistance. The resident needed to sit upright to consume food and fluids and required small sips and to swallow between bites. The staff were instructed to remind the resident to tuck their chin to swallow. During an observation on 12/05/2024 at 11:20 AM, Staff U, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system to ensure the availability of a physician to timely coordinate the procurement of controlled substances during afterhours for 1 of 3 sampled residents (Resident 31) reviewed for closed records. This failure placed the resident at risk for unmet needs at end of life. Findings included . Review of a 01/21/2021 contract between a physician services group and the facility showed that if the designated physician was unable to provide services due to illness, disability, vacation or any other reason, then the group designated a replacement group physician to provide the services. This policy also showed the Medical Director aided in arranging for continuous physician coverage for medical emergencies, developed procedures for emergency treatment of residents, and became the primary physician in the absence of the resident's primary physician unless the resident or physician designated the responsibility to other physicians. 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 interview and record review, the facility failed to ensure sleep medications were consistently monitored for 1 of 5 sampled resident (Resident 183) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical conditions. Findings included . Per the 11/26/2024 admission assessment, Resident 183 had diagnoses which included dementia and weakness. Review of the Active Order Report documented the physician prescribed a medication for sleep (Melatonin) on 11/20/2024 to be given every day at bedtime. The November 2024 and December 2024 medication administration records documented the resident received the Melatonin every night at bedtime. In an interview on 12/09/2024 at 11:47 AM, Staff K, Licensed Practical Nurse, stated residents who received Melatonin needed a sleep monitor to ensure the medication was effective. During an interview on 12/09/2024 at 12:23 PM, Staff B, Director of Nursing, confirmed the resident should have had a sleep monitor in place to ensure the medication was effective. Reference (WAC):…

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 temperatures to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included . During an observation of the medication room on 12/06/2024 at 10:40 AM, with Staff D, Registered Nurse, the refrigerator in the medication room contained a vial of Tubersol (medication injected under the skin to determine exposure to Tuberculosis) and respiratory synticial virus vaccines (vaccine used to treat a severe respiratory infection). Review of the refrigerator temperature logs for September 2024, October 2024 and November 2024 showed the temperatures were not monitored consistently as required. The temperatures were monitored 14 days in September, 16 days in October and 16 days in November. The medication room did not have a thermometer to monitor the temperature the medications were stored at. In an interview on 12/06/2024 at 11:03 AM, Staff B, Director of Nursing, stated the temperature of the refrigerator should have been…

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 nursing staff had the required qualifications (current Washington State Food Worker Cards) for 3 nursing staff (Staff N, AA, BB). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . During an observation on 12/03/2024 at 11:14 AM, Staff G, Nursing Assistant, served meals from the steam table in the north dining room. Staff G wore no hair covering throughout the entire meal service observation. In an interview on 12/06/2024 at 10:54 AM, Staff Z, Cook, stated nursing assistants served food from the steam table when the dietary staff was unavailable. On 12/06/2024, a copy of dietary and nursing staff's current Washington State Food Worker cards were requested, and none were provided. Review of dietary cards on 12/09/2024 at 4:32 PM showed the following nursing assistants: Staff N (expired on 11/22/2024), Staff BB (expired on 10/09/2024), and Staff CC (no information). Reference WAC…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 183) reviewed for unnecessary medications, received information on and were offered the recommended vaccinations for pneumonia based on the current recommendations from the Centers for Disease and Control Prevention.This failure placed the resident at risk for contracting pneumonia with its associated complications of infection. Findings included . Review of a 10/19/2022 facility policy titled Immunizations showed the facility offered the pneumococcal (a bacteria) series vaccines unless medically contraindicated, to all residents upon admission. The pneumococcal vaccine protected against the bacteria which could cause many illnesses, including pneumonia, meningitis (a serious infection that causes inflammation of the membranes that protect the brain and spinal cord), sepsis (a life-threatening medical emergency that occurs when the body has an extreme response to an infection), and ear and sinus infections. 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 observations, interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency, as required, for residents residing on the South Hall (Resident 1, 2, 3, 4, 5). Failure to report an allegation of neglect placed all residents at risk for mistreatment and poor quality of life. Findings included . Per the facility policy titled Abuse, Neglect and Exploitation dated 2019, Section V11. Reporting/Response states the facility was to report all alleged violations to the Administrator, State Agency, Adult Protective Services and all other required agencies within specified timeframe: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received. A report from a collateral contact dated 10/02/2023 documented neglect had occurred for residents 1, 2, 3, 4, and 5 on 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 and interview, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 dining rooms (South dining room). Failure to securely close opened bags of food to protect from exposure to contaminants, label foods with dates they were opened or discard dates, and discard expired food, placed all residents at risk for food-borne illness. Findings included . On 07/25/2023 at 9:00 AM, during a tour of the kitchen with Staff N, Executive Chef, the following observations were made: Produce Refrigerator: An opened gallon of Asian Sesame Dressing was nearly empty. There was no date that showed when it was opened or should have been discarded. It was past the labeled manufacturer expiration date. Dairy Refrigerator: An opened bag of Pizza Blend shredded cheese. There was no date that showed when it was opened or should have been discarded. The top was unsecured and was gaping open. Dry Storage Room: 1. One opened large bulk bag of dry milk. The top was rolled down and not secured with a clamp. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychotropic medication (drug taken to exert an effect on the chemical makeup of the brain and nervous system) for 7 of 7 sampled residents (Residents 22, 31, 29, 15, 12, 18, and 1) reviewed for unnecessary medication use. The facility's failure to monitor side effects related to use of psychotropic medication placed the residents at risk for adverse side effects and medical complications. Findings included . <Resident 22> Review of 05/06/2023 admission assessment showed Resident 22 admitted to the facility in November of 2022, and had diagnoses which included anxiety and insomnia. Per review of the physician's orders, Resident 22 had orders for three different psychotropic medications used to treat anxiety, psychosis and insomnia Resident 22's care plan showed interventions were implemented on 11/15/2022 related to the use of psychotropic medications, and due to the risk for changes 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 provide a clean, comfortable, homelike environment for 1 of 2 sampled residents (Reisdent 23), reviewed for environment. This failure placed Resident 23 at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included . Resident 23 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A 07/13/2023 assessment showed Resident 23 was severely cognitively impaired, and required extensive to total assistance for activities of daily living. Review of a 05/04/2023 comprehensive care plan showed Resident 23 received finger foods to help maintain independence with eating, preferred to eat their meals in their room, and was at risk for falls. Care plan interventions were to use an air mattress with bolsters (a soft cushion that surrounded the edge of the bed to promote safety). On 07/27/2023 at 8:47 AM, Resident 23 was observed in their room lying on an air mattress. The air mattress was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment for a significant change in condition within 14 days as required for 1 of 2 sampled residents (Resident 1), reviewed for Hospice Services. This failure placed the resident at risk for decreased quality of care and implementing standard disease-related clinical interventions. Findings included . A review of the records showed Resident 1 was admitted on [DATE]. Further review showed comprehensive admission assessment was completed on 04/21/2023 with diagnoses including dementia and frequent pain. Resident 1 was placed on Hospice Services on 07/13/2023 which required the completion of a comprehensive assessment related to the significant change of Hospice Services placement. As of 08/02/2023 (day 20 after Hospice Services placement), the following three comprehensive assessments were noted in the record review: an entry assessment dated [DATE], an admission assessment dated [DATE], and an in progress comprehensive…

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 AMENDED Based on observations, interview, and record review, the facility failed to provide the necessary care and services for 1 of 2 Sampled residents (Resident 34) reviewed for urinary tract care. This failure placed the resident at risk for delayed identification and interventions for changes in the medical conditions. Findings included . Review of Minimum Data Set (MDS - an assessment tool) records showed Resident 34 admitted to the facility on [DATE]. Review of medical records showed Resident 34's diagnoses included Sepsis due to Enterococcus (the body's extreme response to an infection), Urinary tract infection, and retention of urine. Review of providers orders showed on 06/10/2023 an order by a urologist (medical doctor specializing in conditions that affect the urinary tract) to change the urine catheter every month. Review of the medication administration records and treatment administration records for July 2023 showed that the catheter was changed on 07/09/2023 and 07/10/2023. On 07/28/2023 at 10:48…

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 consistently received interventions to prevent further falls for 1 of 3 sample residents (Resident 22), reviewed for falls. These failures placed the residents at risk for injury from falling. Findings included . According to the 05/06/2023 admission assessment, Resident 22 had cognitive impairment and anxiety. The assessment also showed they required physical assistance for activities of daily living such as transferring, bed mobility, and toilet use. Per the assessment, the resident was not steady to move from a seated to standing position, transfer between surfaces, or move on and off of the toilet, and was only able to stabilize during those activities with assistance. According to Resident 22's care plan, interventions dated 11/04/2022 included: bed in lowest position, call light within reach, pharmacy consult to evaluate medications, provide one-on-one activity if bedbound, therapy consult for strength and mobility, and an alarm on bed and chair. Intervention dated 05/03/2023: encourage…

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 dialysis services consistent with professional standards related to not monitoring fluid restriction, bruit and thrill (bruit is a sound which indicates flow of blood through the vessels, thrill is felt on the overlying skin as a vibration and also indicates blood flow) and no direction to staff on which arm was needed to obtain a blood pressure for 1 of 1 sampled residents (Resident 5), reviewed for dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stopped working properly) services. This failure placed the residents for risk of medical condition complications and diminsihed quality of care. Findings included . The 06/26/2023 admission assessment showed Resident 5 had cognitive impairments, but was able to make their needs known, had medically complex conditions, and diagnoses which included kidney disease. In addition, the assessment showed the resident received dialysis. Review of the physician's orders showed Resident 5 went to dialysis on Tuesdays,…

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 physician personally approved, in writing, a recommendation that an individual be admitted to the facility, for 2 of 3 (Residents 34 and 22) sampled residents reviewed for physician services. This failure placed the resident at risk for unmet care needs. Findings included . <RESIDENT 34> Review of Minimum Data Set (MDS - an assessment tool) records showed Resident 34 admitted to the facility on [DATE]. Review of medical records and documents provided by the facility showed no indication that any physician approved, in writing, Resident 34's admission orders. In an interview on 08/02/2023 at 3:24 PM, Staff B, Director of Nursing, confirmed that there was no written physician approval for Resident 34. <Resident 22> Review of MDS records showed Resident 22 admitted to the facility on [DATE]. Review of medical records and documents provided by the facility showed no indication that any physician approved, in writing, Resident 22's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an initial comprehensive visit was done by physician after admission as required, for 1 of 3 sampled residents (Resident 34), reviewed for physician visits. This failure placed the resident at risk for delayed identification and treatment of medical needs. Findings included . Review of Minimum Data Set (MDS - an assessment tool) records revealed Resident 34 admitted to the facility on [DATE]. Review of provider visit showed that Resident 34 was seen on 04/24/2023 and 05/03/2023 by Staff G, Physician Assistant. Further review showed that the first visit by Staff H, Physician, was done on 06/01/2023. In an interview on 08/02/2023 at 11:00 AM, Staff G confirmed that there was no documentation that Staff H, Physician, visited Resident 34 before 06/01/2023 in the medical records. Reference: (WAC) 388-97-1260 (6)

Based on observation, the facility failed to ensure 1 of 1 medication rooms had the narcotic box affixed that was placed in the refrigerator, as required. This failure placed unintended access by others to drugs because they were not locked up and/or unmovable. Findings included . In an observation on 07/31/2023 at 8:12 AM, Staff F, Registered Nurse, provided access to the medication room to the surveyor. The refrigerator was locked, and there was no locked box that was permanently affixed inside the refrigerator as to prevent drug diversion. The refrigerator contained Ativan (medication used to treat anxiety), Haldol (medication used to treat agitation), Hydromorphone (medication used to treat pain), and Ativan/haloperidol suppositories (medication used to treat agitation). During an interview on 08/03/2023 at 1:28 PM Staff B, Director of Nursing, stated they were unaware they needed to have a locked narcotic box that was permanently affixed inside the refrigerator. Reference WAC: 388-97-1300(2), 2340

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hand hygiene and glove changes were performed when providing care, for 1 of 2 (Resident 15) sampled residents for infection prevention and control. These failures placed the residents at risk for infections and a diminished quality of life. Findings included Review of Minimum Data Set (MDS - an assessment tool) records showed Resident 15 admitted to the facility on [DATE]. Review of Resident 15's medical records showed that Resident 15 had four urinary tract infections (12/14/2022, 03/02/2023, 04/21/2023, and 07/21/2023). Further review showed that bacteria causing the urinary tract infection included Enterococcus Faecalis and Escherichia coli (most common tested fecal bacteria) During an observation on 07/28/2023 at 10:47 AM, staff L, Nursing Assistant (NA) and staff M, NA, provided peri care (cleaning the private areas of a patient) to Resident 15. Resident 15 was standing during the care. Staff M did not change gloves 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.