Royal Park Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, expired foods were not discarded for 1 of 2 refrigerators, 1 of 1 dry storage areas, and food items in the refrigerator and freezer were not dated when opened. The facility further failed to maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses. Findings included . <Expired/undated food> During an initial tour of the kitchen on 01/07/2025 at 8:47 AM, the dry storage area revealed a container of French salad dressing and two containers of Caesar salad dressing with no received or expiration date, six cartons of thickened cranberry cocktail that expired November 2024, a bag of coconut that expired November 21, 2024, and twelve containers of a vanilla nutritional drink that expired on 12/28/2024. The refrigerator in the main kitchen contained a bag of brown, wilted salad, two bags of brown wilted lettuce and a bag of spinach that was brown that had no received or expiration…

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 staff were offered the COVID-19 vaccine (COVID-19, a viral illness that caused fever, difficult breathing, and other viral symptoms that included possible hospitalization or even death), were provided education regarding the risks/benefits and potential side effects of the vaccine, and maintained documentation related to vaccine education, declination,or administration of the vaccine as required for 3 of 3 sampled staff (Staff G, H, and I) reviewed. This failure placed residents and staff at risk of illness or exposure to the COVID-19 virus and potential unintended health consequences. Findings included . The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages 19 years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age [AGE]-64 years or adults age [AGE] or older who were unvaccinated for COVID-19 were recommended to receive 1 or 2 doses…

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 residents could file grievances without reprisal or fear of reprisal, report grievances consistent with alleged abuse to the State Survey Agency as required, and repeatedly promptly resolve grievances for 4 of 5 sampled residents (Resident 40, 31, 10, 24), reviewed for grievances. This failure placed residents at risk of feelings of powerlessness, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy title, Grievance Procedure revised November 2016, documented residents and resident representatives were informed of their right to voice a grievance orally, in writing, and anonymously regarding the care and treatment/lack of treatment, behavior of staff and of other residents, and other concerns during their stay. The policy further documented residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Grievances were to be resolved immediately, when possible. If a grievance involved an allegation of abuse,…

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 its Abuse and Neglect Policy and Procedure to include the identification of potential allegations of abuse, responding to and reporting the allegation to the State Survey Agency (SA) as required, and thoroughly investigating allegations for 5 of 8 sampled residents (Resident 98, 10, 58, 40, and 31), reviewed for abuse. This failure placed residents at risk for abuse, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated [DATE], defined different forms of abuse. The policy defined mental abuse as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The policy further showed new and existing staff would be trained…

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 according to the person-centered care plans and provider orders for 4 of 8 sampled residents (Residents 27, 36, 54 and 89 ) reviewed for quality of care. Specifically, Resident 27 was on a fluid restriction and their intake was not monitored or maintained, Resident 36's blood sugar monitoring equipment was broken by staff and was not replced timely, Resident 54 did not have their bowel management medications administered to prevent constipation, and Resident 89 had difficulty swallowing and a Speech Therapy evaluation was not completed timely. These failures placed residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 36> A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a Central nervous system disease that caused stiffness, tremors and balance difficulty) and diabetes. The resident was cognitively…

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 interventions timely to prevent weight loss for 2 of 7 sampled residents (Resident 54 and 77) reviewed for nutrition. This failure placed the residents at risk for further weight loss and a decline in their health. Findings included . <Resident 77> According to the 11/09/2024 annual assessment, Resident 77 admitted to the facility on [DATE] with diagnoses including dysphagia and muscle weakness. The assessment further showed Resident 77 showed no signs and/or symptoms of a swallowing disorder. Resident 77's weight was 159 lbs within the last 30 days. Resident 77 was cognitively intact and able to clearly verbalize their needs. Review of the 01/05/2024 initial nutrition evaluation by the Registered Dietician showed Resident 77's weight was 181.6 lbs on 01/04/2024. The assessment further showed Resident 77 was on a regular texture diet with thin liquids and nourishment supplement ordered at bedtime. Resident 77 consumed 75-100% 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 complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 5 sampled staff (Staff F), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . Review of Staff F, Nursing Assistant, personnel file showed they were hired on 11/03/2022. The personnel file included a 01/10/2023 verbal warning for not completing training as required and a 07/29/2024 written warning for a verbal altercation with a peer which included use of profanity and threatening language at the nurse's station. No documentation of a performance evaluation was found. In an interview on 01/17/2025 at 12:28 PM, Staff G, Nursing Assistant, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:52 PM, Staff E, Registered Nurse, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:59 PM, Staff D,…

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 prepare palatable (acceptable/appetizing) meals for 7 of 10 residents (Residents 10, 28, 31, 35, 40, 50 and 77), reviewed for food palatability.This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served and a potential for less than adequate nutritional intake leading to weight loss. Findings included . <Resident 77> According to the 11/09/2024 annual assessment, Resident 77 was cognitively intact and able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 77 filed the following grievances: -09/03/2024 the clam chowder smelled and tasted bad with a 09/04/2024 resolution that the facility switched out soup for a replacement item. Review of a 09/24/2024 provider progress note showed Resident 77 was concerned about their weight loss. The note further showed Resident 77 had a 15-pound (lbs) weight loss in the last six months, moderate protein-calorie malnutrition with muscle wasting in their abdomen, thighs,…

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 perform hand hygiene when indicated and follow transmission-based precautions (TBP) when implemented for 1 of 3 sampled residents (Resident 61), reviewed for infection control. This failure placed residents at risk of acquiring communicable diseases and diminished quality of life Findings included . TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled, Transmission-Based Precautions (Isolation) revised March 2024, showed TBP were used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection. There were three types of TBP (airborne, contact, and droplet). Contact precautions were implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy listed infections, including Shingles…

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 urinary catheters (a tube inserted into the bladder that drains urine into a collection bag) in a dignified manner for 2 of 3 sampled residents (Residents 36 and 154) reviewed for urinary catheter care. This failure placed the residents at risk for public visualization of their urine and possible embarrassment. Findings included . The December 2000 Evaluation for Indwelling Catheters facility policy documented residents admitted to the facility with an indwelling catheter were evaluated at admission and quarterly for catheter usage. The policy did not address concerns regarding a resident's dignity when catheters were required. <Resident 36> A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that caused slow, stiff movement, tremors and loss of balance) and kidney disease. The resident had an indwelling urinary catheter and required substantial assistance of staff for toileting. A further…

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

Based on observation, interview, and record review the facility failed to implement the self-administration of medicaiton policy, ensure the interdisciplinary team (IDT) determined a residents could self-administer medications, ensure only provider approved medications were kept at the resident's bedside and/or safely and securely stored at the bedside for 1 of 3 sampled residents (Resident 24), reviewed for choices. This failure placed residents at risk of access to unsecured medications, potentially avoidable medication errors and/or accidents, and diminished quality of life. Findings included . Review of the facility policy titled, Self-Administration of Medication updated September 2017, showed if a resident desired to self-administer medications they would be evaluated using the self-medication evaluation assessment. If a resident was determined to self-administer medications provider orders that specified specific medications to self-administer would be obtained, a self-administration care plan would be implemented, a bedside self-administration record was to be implemented if…

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

Based on observation, interview and record review the facility failed to maintain a clean, comfortable, safe and homelike environment for 2 of 2 sampled residents (Resident 23 and 28), reviewed for environment. Specifically, Resident 23's personal refrigerator contained expired foods, and the facility failed to ensure an exit door was in good repair and Resident 28 had a large hole in the wall behind the door to their room. These failures placed Resident 23 at risk for a foodborne illness, and all residents at risk for injury and a diminished quality of life. Findings included . Review of the facility policy titled, Resident Personal Refrigerators And Foods Brought Into The Center By Family/Visitors dated August 2020, showed temperatures were to be monitored daily and perishable foods covered, labeled, dated and discarded following use by date guidelines on the Food Labeling Reference Guide. The policy further showed center staff may, at their discretion, discard food items that were not safe to eat nor labeled, after verbally notifying the resident and/or the responsible party.…

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 1 of 2 sampled residents (Resident 54), 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 12/23/2024 significant change in condition assessment, Resident 54 had diagnoses which included high blood pressure, diabetes, and dementia, and had severe cognitive impairments. Review of Resident 54's record showed a 12/12/2024 nursing progress note which documented the resident had a rapid heart rate and their oxygen level was 74 percent (the normal oxygen level is 90-100). The resident was assessed and was sent to the hospital for evaluation. Additional record review found no documentation that showed the resident had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 4 sampled residents (Resident 36) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . The Facility assessment dated [DATE] documented the facility offered cares to residents with various types of needs. Services for Mobility and Fall/Fall with injury Prevention included Restorative Nursing care among others in supporting the resident's independence in doing as many of these activities by him or herself. A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a central nervous system disorder that caused slow, stiff movements, tremors and balance difficulties) and muscle weakness. Resident 36 was cognitively intact, did not use assistive devices such as a walker or…

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

Based on observation, interview, and record review the facility failed to provide adequate assistance during mealtimes for 1 of 4 sampled residents (Resident 90), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, possible unintended weight loss and decreased quality of life. Findings included . Per the 12/17/2024 comprehensive assessment, Resident 90 had diagnoses which included traumatic brain injury (brain damage caused by a sudden forceful bump, blow, or jolt to the head), lack of coordination and muscle weakness. The assessment further documented Resident 90 had no range of motion impairment to their upper extremities, required set-up or clean-up assistance for eating and was cognitively intact for decision making. Review of the 12/09/2024 nutrition care plan showed Resident 90's assistance needs during meals varied from independent up to set -up assistance and instructed staff to refer to physical therapy (PT) and/or occupational therapy (OT) as appropriate. The 12/09/2024 limited physical ability care plan…

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 implement a resident's care plan and ensure appropriate treatment and services to restore as much normal bladder and bowel function as possible were received 1 of 3 sampled residents (Resident 81), reviewed accidents. These failures placed residents at risk for a decline in urinary and/or bowel function, embarrassment, and diminished quality of life. Findings included . Per the 11/14/2024 quarterly assessment, Resident 81 had diagnoses including stroke and hemiplegia (muscle weakness on one side of the body). The assessment further showed Resident 81 was dependent for transfers during toileting and was frequently incontinent of bowel and bladder. There was no bowel and bladder training program in place. Resident 81 had moderate cognitive impairment. Review of the 06/04/2024 self-care deficit care plan documented Resident 81 was dependent for toileting and instructed staff to only use a bedpan to use for toileting. The 08/27/2024 bowel incontinence care plan instructed staff to observe pattern 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 ensure bi-level positive airway pressure (BIPAP, a machine that helped people breathe by delivering pressurized air into their lungs through their nose, or nose and mouth) was implemented as ordered by the physician for 1 of 3 sampled residents (Resident 81) reviewed for respiratory care. This failure placed the resident at risk for impaired sleep, unmet care needs, and a diminished quality of life. Findings included . The 11/14/2024 quarterly assessment documented Resident 81 was moderately cognitively impaired, was able to make their needs known, and had diagnoses which included stroke and impaired ability to move the upper and lower extremity on one side of their body. In addition, the assessment documented the resident was dependent on nursing staff to complete activities of daily living (ADLS) for getting dressed. Review of Resident 81's care plan showed a respiratory care plan was developed on 12/10/2024 to provide interventions to treat the resident's sleep apnea, a condition that caused breathing 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 interview and record review the facility failed to timely act upon the pharmacist's monthly medication regimen review recommendations for identified irregularities for 1 of 5 sampled residents (Resident 24), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, medication complications, and diminished quality of life. Findings included . Review of the facility policy titled, Medication Regimen Review published March 2019, showed a pharmacist reviewed the resident's medication regimen monthly and report irregularities to the attending physician, medical director, and Director of Nursing (DNS). The pharmacist was to exit with the DNS or designee prior to leaving the facility and email their report of any irregularities, at the end of their visit. The attending physician was to respond to pharmacist recommendations within 2-4 weeks and provide documentation pharmacy recommendations were reviewed. If a change was made, the facility notified the pharmacy and completed the order. According to the 11/16/2024 quarterly…

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

Based on record review and interview, the facility failed to ensure significant medication errors were prevented when medications ordered by the provider were not supplied and as administered for 1 of 5 sampled residents (Resident 156) reviewed for unneccesary medications. This failure put the resident at risk for a possible decline in their physical and mental well-being and decreased quality of life. Findings included . A review of the 01/01/2025 admission assessment documented Resident 156 had diagnoses including bone infection of the hip, ankylosing spondylosis (causes swelling, joint pain and fatigue), and depression. Resident 156 was cognitively intact, and took antidepressant, antianxiety, and opioid pain medications daily. The resident had a depression screening score of 6 (on a scale of 0 to 27, six indicating mild depression) related to poor appetite, feeling tired, feeling down and depressed, and little interest in doing things. The 12/26/2024 care plan documented Resident 156 used antidepressant medication. Staff were instructed to administer medications as ordered,…

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 staff dated multi-dose vials of medications when first accessed or opened, monitored refrigerator temperatures to ensure vaccinations were adequately stored in 2 of 2 medication storage rooms, cleaned 1 of 2 medication carts reviewed for cleanliness, and ensured medications were secured in a resident's room. This failure placed residents at risk for receiving compromised or ineffective medication management. Findings included . <Expired Medications> An observation on 01/08/2025 at 2:08 PM with Staff PP, Licensed Practial Nurse (LPN), in the Oak Hall Medication Room identified an undated vial of Tuberculosis screening solution. The plastic cap on the vial's rubber stopper was removed and the vial had been accessed. The box where the vial was stored showed an instruction to the staff to discard the medication after 30 days from being opened.Staff PP stated the medication vial should have been dated when opend and needed to be discarded. This continued medication room observation on 01/08/2025…

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

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 4 of 17 sampled dietary staff (Staff M, N, O and P) reviewed for credentialing. 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 Staff P had no Washington State Food Workers card. Staff P had an expired certificate that was not provided. Staff M, N, and O had a certificate 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 was not currently an approved credentialing program in the State of [NAME]. This program was only intended to be used for personal development and preparation for the State provided training. During an interview on 01/14/2025 at 2:24 PM, Staff Q, Dietary Manager,…

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 resident records were complete, accurate, readily accessible and resident records were safeguarded against loss, destruction, or unauthorized use for 1 of 4 sampled residents (Resident 98), reviewed for accidents. This failure placed residents at risk of having an incomplete medical record, unauthorized access to confidential health information, and diminished quality of life. Findings included . Review of the facility employee handbook related to use of business equipment showed company telephones, computers, tablets, handheld computers, copiers, supplies, and other equipment were to be used for business use. Employees were not allowed to use cell phones or smart phones in resident care areas. Direct care staff were prohibited from using or having their cell phones turned on while on duty and were only to use these items during their meal or break times in non-resident care areas. The handbook further showed all employees were expected to follow…

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 arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a form, manner, and/or language understood by the resident and/or their legal representative for 2 of 3 sampled residents (Residents 13 and 88) reviewed for arbitration. Failure to ensure residents had the cognitive ability to understand and enter into an arbitration agreement with the facility, and failure to ensure staff responsible for explaining the arbitration process and offering the arbitration agreement had adequate training, placed the residents at risk of being uninformed of their rights, losing legal protection, the right to pursue legal action, and a diminishd quality of life. Findings included . The facility policy, [NAME] Arbitration Agreement, last updated September 2022, stated the parties understood that any legal dispute, controversy, demand or claim that arose out of or related to the Resident…

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

Based on interview and record review, the facility failed to prevent the development of a pressure ulcer for 1 of 3 sampled residents (Resident 3), reviewed for pressure ulcers. Resident 3 was at an increased risk for skin breakdown and developed an unstageable pressure ulcer that was not identified while at the facility. This failure placed the resident at risk for worsening pressure ulcer and a diminished quality of life. Findings included . Review of the facility admission assessment, dated 06/16/2024, showed Resident 3 was admitted with diagnoses which included Diabetes and paraplegia (paralysis of the legs and lower body). The resident was moderately impaired with decision making. Resident 3 required maximum assistance with bed mobility. The assessment showed the resident was at risk for pressure ulcers, did not currently have a pressure ulcer but had MASD (Moisture Associated Skin Damage which is inflammation of the skin caused by prolonged exposure of moisture which includes urine or stool). Review of the resident's care plan, dated 06/10/2024, showed Resident 3 was at risk…

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 care in a manner that promoted resident dignity for 1 of 2 sample residents (Resident 1), reviewed for dignity. The facility failed to dress Resident 1 in appropriate attire before going to an appointment in the community. This failure placed Resident 1 and other residents at risk for embarrassment and diminished self-worth. Findings included . According to the 03/10/2024 facility assessment, Resident 1 had diagnoses which included blindness, a fracture and dementia. The resident was moderately impaired with decision making. Resident 1 required moderate assistance for dressing their upper body, and dependent on staff to dress their lower body. On 04/30/2024 at 09:45 AM, a State Agency representative stated they had received information Resident 1 was not dressed appropriately when they went out for an appointment. The person they spoke to was very upset and stated Resident 1 was in a night gown and had a saturated brief. On 04/30/2024 at 10:15 AM, a Collateral Contact (CC) was interviewed. The CC stated they went…

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 notification to the resident's representative of a change in condition for 1 of 3 sample residents (Resident 2), reviewed for notification of change. This failure prevented the resident's representative from being informed of Resident 2's worsening condition until the resident was being sent to the hospital. Findings included . The 03/04/2024 assessment showed Resident 2 had a spinal cord dysfunction and inability to move their lower extremities. Resident 2 was able to make their needs known. During an interview on 04/08/2024 at 1:50 PM, a Collateral Contact (CC) stated the resident's representative attended a care conference 03/19/2024 and was told Resident 2 was doing well. The CC stated the representative would get several phone calls a day from Resident 2 and those calls stopped, which was a concern. The CC went in to visit the resident and described the resident as listless (lack of energy). The CC stated no one had called and told them the change in the resident. The CC asked staff to have Staff F, facility…

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

Based on interview and record review, the facility failed to consistently monitor and document a condition change for 1 of 3 residents (Resident 2), reviewed for change in condition. This failure placed residents at risk for worsening medical conditions and unmet care needs. Findings included . Review of a facility assessment, dated 03/04/2024, showed Resident 2 had a spinal cord dysfunction and was unable to move their lower legs. The resident was able to make their needs known and was dependent on staff for mobility in and out of bed. Review of nursing progress notes from 04/04/2024 through 04/08/2024 showed a note on 04/04/2024 related to the resident being nauseated and had not felt like eating the past few days. There was no further documentation of the resident's condition until 04/08/2024, when the resident was seen by Staff F, physician, and sent to the hospital. Review of a progress note by Staff F dated 04/08/2024, showed the resident was seen for follow-up related to nausea. When the provider went in to see the resident, the resident was lethargic (fatigue and low energy)…

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 notify a resident and their representative of a missed medication for 1 of 2 sampled residents (1) reviewed for medication errors. This failure placed the resident and representative at risk of not being fully informed to make decisions about Resident 1's clinical condition and necessary care. Findings included . Per the 02/25/2024 significant change in condition assessment, Resident 1 was cognitively impaired, and had a family member who was involved in their care. Review of a facility investigation, dated 02/13/2024, showed the resident had had not received their Apixaban (a medication used to reduce the risk of blood clots) as ordered. The investigation further showed the resident's family member was not notified of the incident. During an interview on 03/04/2024 at 1:40 PM, Resident 1 and their family member who was Power of Attorney, stated they were unaware that a medication error had occurred. Review of Resident 1's medical record showed no documentation that the resident or their representative was notified 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 medications were given as ordered for 1 of 2 sampled residents (1) reviewed for medication administration. This failure placed Resident 1 at risk for worsening of a deep vein thrombosis (DVT, a blood clot in a deep vein) and adverse health consequences when they missed doses of their medications. Findings included . Per the 01/28/2024 admission assessment, Resident 1 had diagnoses including a right ankle fracture. A review of the hospital admissions records documented Resident 1 was found to have a left lower extremity DVT on 01/31/2024 and had been started on Apixaban at that time. A review of Resident 1's hospital orders dated 02/07/2024, documented Resident 1 was to have Apixaban (a medication used to reduce the risk of blood clots) 10 milligrams (mg) twice daily for 7 doses, then Apixaban 5mg twice daily for 360 doses and the 5mg needed to start on 02/09/2024. A review of Resident 1's order summary documented Resident 1 was to receive Apixaban 10mg twice daily for 7 administrations, then give…

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

Based on interview and record review, the facility failed to consistently provide showers for 4 of 5 dependent sampled residents (Resident 2, 3, 4, 5), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 2> Review of a facility assessment, dated 01/11/2024, showed Resident 2 had diagnoses which included a stroke. The resident was alert and able to make their needs known. According to Resident 2's care plan, revised on 08/07/2023, Resident 2 required extensive assistance of one person with showers. The resident was to receive two showers a week. A review of the resident's shower records from 12/19/2024 through 01/25/2024 showed Resident 2 had a shower on 12/19/2023 and 12 days later on 01/01/2024. The resident received a shower on 01/05/2024 and bed bath 7 days later on 01/12/2024. On 01/15/2024 Resident 2 had a bed bath, refused a shower 01/18/2024 and didn't receive a shower until 01/25/2024, 10 days later. During an interview on 01/26/2024 at 12:32 PM, Resident 2 stated they didn't…

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 personal protection equipment (PPE's) was used in accordance with Centers for Disease Control (CDC) guidelines by 5 staff (A, B, C, D, E), when reviewing infection control practices. This failure placed the 103 residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. Findings included . At the beginning of the complaint investigation on 01/25/2024 at 1:00 PM, there were 15 residents that were in isolation for COVID-19. The residents were spread through out the facility on different units. According to the 05/16/2023 CDC publication, How to use your N95 Respirator, N95 masks (a special type of tight-fitting mask that filters particles) must form a seal to the face to work properly. The document showed the mask should be placed under the chin, with the nose piece bar at the top, with the top strap pulled over the head and placed near the crown, and the bottom strap at the back of the neck, below the ears. The straps should lay flat, be untwisted, and not crisscrossed. The document…

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 personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 15 staff (G, I, M, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG), when reviewing infection control practices. This failure placed the 96 residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. In addition, the facility's failure to nursing staff performed hand hygiene during wound care for 1 of 5 sample residents (Resident 83) reviewed. this failure placed the resident at further risk of infection and medical complications. Findings included At the time of the entrance to the facility on [DATE] at 8:37 AM, there were 8 residents isolated and positive for COVID-19. Two residents were removed from isolation that morning. Five remaining positive residents were housed on the transitional care unit (TCU), and one resident was housed on the Evergreen Unit. The Oak unit had no further…

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, interviewand record review, the facility failed to honor the shower preferences for 3 of 4 sampled residents (Residents 45, 48, and 84), reviewed for activities of daily living (ADLs). This failure placed the residents at risk for skin integrity concerns and decreased quality of life. Findings included . The Centers for Disease Control and Prevention (CDC) updated 05/08/2023, Interim Infection Prevention and Control for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. At the time of the entrance to the facility on [DATE], there were 8 residents isolated and positive for COVID-19 (a viral illness that caused difficult breathing, cough or other symptoms consistent with viral illnesses). Two residents were removed from isolation the same morning of 09/25/23. Five remaining positive residents were housed…

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 pharmacy services and medication administrations met professional standards when medications were not able to be re-ordered timely and residents missed multiple doses of their medications for 31 of 41 sampled residents (Residents 3, 5, 7, 9, 10, 18, 22, 34, 35, 37, 39, 41, 42, 45, 48, 50, 52, 53, 59, 65, 69, 71, 73, 77, 78, 80, 81, 83, 85, 86, and 212) reviewed for significant medication errors. This failure placed the 96 residents at risk for complications in their medical conditions, and decreased quality of life. Findings included . Record reviews completed on 09/27/2023 and 09/28/2023 showed that Residents 45, 48 and 71 had not received doses of medications to treat irritable bowel syndrome, blood pressure, viral illness, and mood disorders as the medications were documented as on order from pharmacy. A review of the 07/2023 Incident and Accident (A&I) logs showed that two residents (Residents 3 and 50) had also missed doses of their medications that treated depression. The medications were listed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents did not miss multiple doses of their ordered medications, investigate the causes of the missed doses timely, and educate the staff regarding the medication ordering process for 31 of 41 sampled residents (Residents 3, 5, 7, 9, 10, 18, 22, 34, 35, 37, 39, 41, 42, 45, 48, 50, 52, 53, 59, 65, 69, 71, 73, 77, 78, 80, 81, 83, 85, 86 and 212) reviewed for significant medication errors. The lack of ensuring the medication system was in place prior to change. This failure placed the residents at risk for complications in their medical conditions, and decreased quality of life. The facility had identified the issues and was in the process of correcting them. Findings included . The 06/2017 revised Medication Administration facility policy documented the nurse was to re-order medications prior to running out of the medication supply. If a medication was not available, the nurse was to document the medication was not available in the…

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

Based on interview and record review, the facility failed to identify an incident as potential neglect and initial an investigation as required for 1 of 2 sampled residents (Resident 289) reviewed for abuse. These failures placed the residents at risk of further neglect, and unmet care needs. Findings included . The facility's Grievance Procedure, last updated November 2016, instructed staff if the grievance involved abuse, neglect, exploitation, or misappropriation of resident property, the Executive Director was to be notified immediately, and an investigation started. Review of the facility's Abuse Identification and Investigation polices, last revised October 2022, stated activities that constituted abuse, neglect, exploitation, and misappropriation of resident property, were to be reported to the Executive Director and an investigation which included the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegation, was to be completed. The 06/19/2023 admission assessment showed Resident 289 was able to make their needs known, and needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Palm Guards (protective devices to prevent or assist with contractures and skin breakdown) were being used as directed in accordance with the comprehensive care plan for 2 of 2 sampled residents (Resident 21 and 29) reviewed for quality of care. This failure placed residents at risk of skin injuries, worsening contractures, the shortening or tightening of tissues that reduces movement, and a decreased quality of life. Findings included . <Resident 21> According to Resident 21's quarterly assessment dated [DATE], Resident 21 had severe cognitive impairments and diagnoses included contractures to the right and left hand. Review of Resident 21's care plan, dated 04/11/2022, showed the resident needed to wear bilateral palm guards at rest, and removed for discomfort or functional use of hands related to being at risk for skin tears. A physician's order, dated 09/09/2022, stated bilateral palm guards donned at rest and removed per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 2 residents (Resident 29 and 83), reviewed for respiratory care and treatment, received appropriate oxygen services. This failure placed the residents at risk to receive inappropriate care. Findings included . According to the facility's oxygen administration policy dated December 2017, Oxygen is administered by a physician order. Oxygen may be administered in the absence of a physician order in emergency situations . Oxygen liter flow is set by a licensed nurse in accordance with physician's orders . <Resident 83> According to an admission assessment, dated 05/19/2023, Resident 83 had diagnoses of COPD (lung disease that blocks airflow and make it difficult to breathe) and CHF (a chronic condition in which the heart does not pump blood as well as it should, which may cause difficulty breathing.) The resident was not using oxygen therapy at that time of their admission. On 09/27/2023 at 09:26 AM, 10/02/2023 at 10:34 AM, 10/03/2023 at 08:40…

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 implement a consistent process to ensure 1 of 2 observed potentially hazardous areas (housekeeping closet) was secured. This failure placed cognitively impaired residents at risk of injury. Findings included . Observation on 09/25/2023 at 10:04 AM showed a housekeeping closet at the end of Oak Hall was unlocked, and able to be opened. The room contained chemicals that were harmful if swallowed or contacted the skin or eyes. No residents were wandering by the room. Additional observations of the housekeeping closet with the door left unlocked, without facility staff nearby and directly supervising the area were made at the following dates and times: 09/27/2023 at 9:08 AM and 09/27/2023 at 11:07 AM. In an interview on 09/27/2023 at 11:03 AM, Staff L, Nursing Assistant, stated when they have seen a resident wandering, they redirect them by offering activities. In an interview on 09/27/2023 at 11:07 AM, Staff K, Housekeeper, stated the housekeeping closet must remained locked because the chemicals that are kept in there are…

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.