Spokane Falls Care

Based on observation, interview and record review, the facility failed to ensure residents received an ongoing program of activities that met their interests for 1 of 2 sampled residents (Resident 6), reviewed for activities. This failure placed the resident at risk for sadness, feeling alone and diminished quality of life. Findings included The 02/04/2026 quarterly assessment documented Resident 6 had diagnoses that included anxiety and depression. Resident 6 was cognitively intact and able to make their needs known. The 06/06/2024 activities care plan documented Resident 6 structured their leisure time independently and was highly involved in group activities and/or independent activities. The care plan did not address spending 1:1 time with the resident as they desired. In an observation and interview on 04/02/2026 at 3:49 PM, Resident 6 was lying in bed in a dark room watching television. Resident 6 stated they had a counselor they used to talk to and it was helpful and they enjoyed it. Resident 6 stated they liked visiting and talking to people.Observations made on 04/03/2026…

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 foot care and seek podiatry services (a physician that specialized in care and treatment of the feet) for 1 of 3 sampled residents (Resident 74) reviewed for skin conditions. This failure placed the resident at risk for skin breakdown and unintended health consequences.Findings included.The 12/04/2025 quarterly assessment documented Resident 74 had diagnoses that included diabetes (high blood sugar) and high blood pressure. Resident 74 was cognitively intact and required partial to moderate assistance with personal hygiene. The 08/08/2025 activities of daily living care plan documented Resident 74 required total assistance with personal hygiene. The 10/14/2025 diabetic care plan instructed nursing staff to inspect Resident 74's feet daily for open areas, sores, pressure areas, blisters, swelling or redness and report it to the physician. The 02/10/2026 chronic ulcer to left foot care plan instructed nursing staff to avoid dry…

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 oxygen equipment in a clean and sanitary manner for 2 of 3 sampled residents (Residents 62 and 74) and failed to administer oxygen per provider orders for 1 of 3 sampled residents (Resident 74), reviewed for respiratory care. This failure placed residents at risk of potential medical complications, potential respiratory infections, and diminished quality of life.Findings included. <Resident 74> The 12/04/2025 quarterly assessment documented Resident 74 had diagnoses that included chronic obstructive pulmonary disease (COPD, a progressive lung disease that blocked airflow and made it difficult to breathe), and respiratory failure. Resident 74 was cognitively intact and dependent on oxygen. The 08/28/2025 oxygen care plan instructed nursing staff to administer medications as ordered by the physician. An 08/28/2025 provider order instructed nursing staff to wash the concentrator filter weekly. A 03/21/2026 provider order instructed nursing staff to administer oxygen at 2L continuously for COPD. The March 2026…

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 routinely complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff AA and BB), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.Findings included.<Staff AA>Review of Staff AA's, Nursing Assistant (NA), personnel file showed they were hired on 10/30/2023. No documentation of a yearly performance evaluation was on file.<Staff BB>Review of Staff BB's, NA, personnel file showed they were hired on 07/23/2019. No documentation of a yearly performance evaluation was found on file.In an interview on 04/07/2026 at 1:53 PM, Staff O, Regional Director, stated they did not have performance evaluations for Staff AA and Staff BB.In an interview on 04/10/2026 at 1:53 PM, Staff B, Director of Nursing, stated performance evaluations were to be completed yearly and conducted by Staff B or the Resident Care…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Specifically, two medication errors were identified during 26 medication administration opportunities. This resulted in an error rate of 7.69 %. This failure placed residents at risk of receiving subtherapeutic (a dosage or concentration that is too low to produce the intended medical effect or treat a disease) effects of their medications, possible adverse side effects, and diminished quality of life.Findings included.During observation on 04/10/2026 at 9:20 AM, Staff Q, Registered Nurse, prepared and administered ten medications for Resident 76.Included in the medications given were the following:Calcium (a supplement) 500 milligrams (mg, a unit of measurement) with Vitamin D 10 micrograms (mcg, a unit of measurement), one tablet by mouth.Colestipol (a cholesterol medication) 1 Gram (Gm, a unit of measurement), one tablet by mouth.A review of Resident 76's orders and April 2026 Medication Administration Record (MAR) showed the following morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure refrigerator temperatures were maintained in an acceptable range and expired medications were removed from inventory in 1 of 2 medication rooms (Medication room [ROOM NUMBER] - South Unit) observed. This failure placed residents at risk of receiving potentially compromised or expired medications. Findings included.<Glucometer Quality Control Testing Solutions>On 04/10/2026 at 9:15 AM the Southeast Medication Cart was observed with Staff E, Licensed Practical Nurse. The cart had two small bottles of control testing solutions in the box of Assure Dose Quality Controls (solutions placed on a test strip that verified the accuracy of glucometer blood sugar test results). The solutions had a manufacturer expiration date of 08/17/2025. Staff E stated the glucometer checks were completed on the nightshift. Staff E stated they did not work nights, so they were unaware of the process. The solutions were removed from the cart's inventory.…

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 follow the ordered diet for 1 of 10 residents (Resident 23), reviewed for food preferences. This failure placed residents at risk for inadequate nutrition, possible weight loss and diminished quality of life.Findings included.According to the 03/05/2026 admission assessment, Resident 23 admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening medical emergency caused by the body's extreme, overactive response to an infection, which damages its own tissues and organs) and a wound infection. Resident 23 was cognitively intact. The assessment further showed Resident 23 did not receive a therapeutic diet while at the facility. Review of the 03/05/2026 nutrition care plan showed Resident 23 was at risk for significant weight changes related to alteration to skin integrity and food allergies. Staff was instructed to serve diet as ordered, allow choices at mealtime and menu selection, monitor and record food 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, record review and interview, the facility failed to provide food in the correct consistency for 1 of 6 sampled residents (Resident 11), reviewed for nutrition. This failure placed the resident at risk for choking, aspiration pneumonia (an infection caused by inhaling foreign material-such as food, liquid, or vomit into the lungs) and a diminished quality of life.Findings included.The 02/06/2026 significant change assessment documented Resident 11 had diagnoses that included dysphagia (difficulty swallowing). Resident 11 had severe cognitive impairments and was on a mechanically altered texture diet. The 01/20/2026 nutritional care plan showed Resident 11 was at risk for malnutrition from decreased food intake secondary to chewing/swallowing difficulties. The goal was for Resident 11 not to have any choking episodes. The care plan instructed nursing assistants to report signs of coughing and choking to the nurses. The 01/20/2026 dysphagia care plan documented Resident 11 would not have complications related to aspiration and choking. The care plan instructed…

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) agreements were explained in a form and manner understood by the resident and/or their representative for 2 of 3 residents (Resident 11 and 28) 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.<Resident 11>According to the 12/09/2025 admission assessment, Resident 11 admitted to the facility on [DATE] with diagnoses that included borderline personality disorder and severe cognitive impairment. According to the admission agreement dated 12/08/2025, Resident 11 did not have a Power of Attorney (a legal document enabling a person to designate another to manage their financial, legal, or health affairs).Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to assess, monitor, and document non-pressure skin conditions for 1 of 3 sampled residents (Resident 1), reviewed for skin conditions. The inconsistent skin assessments and monitoring of identified skin issues placed the residents at risk of unmet needs and potential worsening skin conditions. Findings included .The revised 02/03/2026 facility policy titled Wound Prevention and Treatment documented wounds included diabetic ulcers, significant skin tears, and other skin conditions. These types of wounds were to be monitored weekly and documented in the electronic medical record with size, color, odor, healing progression, notifications, and other pertinent information related to the skin conditions. The facility's Skin Grid form was completed on admission on [DATE]. It showed Resident 1 had cellulitis on both lower legs, which wrapped around the calf, and was 1.5 feet long. No further Skin Grid forms were found in the residents record to be completed for…

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

Based on interview and record review, the facility failed to administer medications as intended by the provider for 2 of 3 sampled residents (Resident 1 and 2), reviewed for medication administration. This failure placed the residents at risk of adverse side effects, worsening infection, and diminished quality of life. Findings included .<Resident 1>The admission assessment, dated 12/26/2025, documented Resident 1 was admitted with a diagnosis of diabetes. The assessment showed the resident took insulin (an injection to help regulate blood sugar) daily to manage their diabetes. Resident 1 was able to make their needs known. The 12/12/2025 admission orders documented Resident 1 was to be given long-acting insulin (a slow-release, injectable diabetes medication that controls blood sugar levels for 16 to 42 hours), 26 units, twice a day. A short acting insulin (an insulin that starts to work 30-60 minutes after administered and is used to control blood sugar, particularly after meals), and 20 units three times a day with meals plus a sliding scale short acting insulin that was given…

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 adequate supervision for 1 of 3 sampled residents (Resident 1), reviewed for elopement (leaving the premises or safe area without authorization). The resident left the facility, unattended, after being identified with poor memory and safety awareness. This failure placed the resident at risk for possible injury and being in an unsafe situation. Findings included . Review of a facility assessment dated [DATE] showed Resident 1 was admitted with diagnoses to include a stroke and heart disease. The resident was independent and/or required supervision with Activities of Daily Living (ADL's) to include mobility. Review of the facility admission assessment, dated 05/23/2025, showed the resident was not identified as an elopement risk at the time of admission. Review of an admission assessment by Staff A, Nurse Practitioner, dated 05/27/2025, showed the resident had significant encephalopathy (brain not functioning properly) and cognitive…

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 N-95 mask (a type of mask used to protect the wearer from particles or from liquid contaminating the face) fit testing (a test conducted to verify that a N-95 mask provides the user with the expected protection) was performed in accordance with applicable federal regulations for 103 of 103 employees. This failure placed employees and residents at risk of exposure to COVID-19 (a highly contagious respiratory virus). Findings included .In an interview on 08/21/2025 at 2:58 PM, Staff A, Administrator, stated the facility was out of compliance with N-95 fit-testing. They stated the last time N-95 fit-testing was done, building wide, was in the Spring of 2024, and although they had a plan in place, they had not yet started the process of getting all employees N-95 fit-tested. On 8/21/2025 at 3:55 PM, when asked for a list of employees who had been N-95 fit-tested Staff B, Infection Preventionist stated they were unable to provide the information because it did not exist. Staff B stated they had received certification 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 identify and report potential allegations of abuse and/or negect to the State Survey Agency as required for 3 of 5 sampled residents (Resident 1, 2, and 4), reviewed for abuse and/or negelct. This failure placed the residents at risk for further abuse and/or neglect and a diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 04/16/2025, showed Resident 1 was admitted with diagnoses to include an amputation of their lower leg. The resident was able to make their needs known. Review of the facility grievance log from January 2025 through April 2025 showed on 04/24/2025, Resident 1 filed a grievance which was noted as a nursing concern. Review of the facility's Grievance Summary Report, dated 04/24/2025, showed Resident 1 reported staff had not changed their roommate (Resident 2) from 7:00 PM to 6:30 AM. The resident wrote Resident 2 had to sit in their own feces all night, take care of people like they are your family! Review of the facility reporting incident log showed Resident…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). Failure for the facility to obtain informed consent for treatment with psychotropic drugs and to ensure Resident 4 was monitored for adverse side effects, placed residents at risk of not being fully informed of the risks and benefits of treatment with psychotropic drugs and to receive unnecessary psychotropic drugs. Findings included . Review of a facility assessment, dated 03/14/2025, showed Resident 4 had diagnoses which included Cellulitis (an infection of the skin and tissues beneath) of their lower legs, anxiety, and depression. The resident was able to make their needs known. Review of Staff C, Nurse Practitioner, progress notes, dated 04/21/2025, showed the provider spoke to Resident 4 about their behaviors. Staff C documented the resident had acute psychosis (when a person experiences a sudden onset of psychotic symptoms, often…

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 5 of 6 dependent residents (Residents 1, 3, 4, 5, 6), reviewed for Activities of Daily Living (ADL's), received the appropriate number of baths per week. In addition, the facility failed to provide grooming for 4 of 6 dependent residents (Residents 1, 2, 4, and 5), reviewed for nail care. This placed residents at risk for poor hygiene and diminished quality of life. Findings included . SHOWERS <Resident 1> Review of a facility assessment, dated 03/07/2025, showed Resident 1 was admitted with diagnoses which included cancer of the blood and multiple fractures. The resident was able to make their needs known and required substantial to maximum assistance for showers and partial to moderate assistance for hygiene. During an interview on 3/14/2025 at 1:10 PM, Resident 1 was observed laying in bed. The resident stated they had gotten a bed bath, not a shower, because the pain they had when being moved. Review of the resident's shower record from 02/28/2025 to 04/03/2025 showed the resident had a partial…

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 investigate an allegation of potential verbal abuse for 1 of 1 sampled residents (Resident 8), reviewed for abuse and/or neglect. This failure placed all resident at risk for abuse and a diminished quality of life. Findings included . A facility assessment, dated 01/24/2025, showed Resident 8 had diagnoses which included a history of a stroke which affected their left side. The resident was able to make their needs known. During an interview on 03/14/2025 at 2:30 PM, Resident 8 was laying in bed with a hospital gown on. The resident stated Staff I came into their room and hollered and screamed at them. Staff I was telling Resident 8 what to do and argued with everything the resident said and then told Staff I to leave the room. Resident 8 stated there was another staff member in the room during the incident and the higher ups came into their room and asked why they told Staff I to get out of their room. In a follow up interview on 03/20/2025 at 1:35 PM, Resident 8 stated they weren't fearful of Staff I but it made them…

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, monitor, and/or measure non-pressure related skin conditions for 2 of 3 sampled residents (Resident 1 and 5), reviewed for skin conditions. This failure placed residents at risk for worsening skin conditions and a decreased quality of life. Findings included . Review of a facility policy titled Wound Prevention and Treatment, dated 02/03/2023, showed the policy included the following wounds; surgical wounds, pressure injuries, stasis ulcers (open sores that occur due to poor blood flow in the veins, leading to fluid buildup and skin breakdown, typically in the lower legs and ankles), venous/arterial ulcers (chronic, open wounds that develop on the lower legs due to poor blood circulation), and Diabetic ulcers (open sores or wounds on the feet of people with diabetes, often caused by nerve damage and poor circulation). These wound types were to be monitored weekly and documentation of size, color, odor, healing progression, and…

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

Based on observation, interview, and record review, the facility failed to ensure staff obtained timely weights, re-weighed residents to ensure accuracy, and had measures implemented to prevent significant weight loss for 1 of 3 residents (Resident 4), reviewed for nutrition. In addition, the facility failed to obtain weekly weights for a resident on enteral nutrition (nutrition through a tube into the stomach), to monitor for adequate nutrition, for 1 of 1 resident (Resident 1), reviewed for tube feedings. This failure placed residents at risk for weight loss and unmet nutritional needs. Findings included . Review of a facility policy titled Weight Monitoring, revised 11/2022, showed the facility required measured and recorded weights to assure accuracy and to provide information for the assessment of clinical status unless clinically contraindicated. The residents would be weighed by the Nursing Assistants (CNA) or designee, and the Licensed Nurses (LN's), were responsible to document the resident's weight in the Electronic Medical Record (EMR). Residents were to be weighed within…

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 enhanced barrier precautions were implemented during cares and a dressing change for 2 of 4 residents on Enhanced Barrier Precautions (Resident 35 & 61); failed to ensure hand hygiene was completed when indicated during 1 of 3 medication administration observations, and failed to ensure a comprehensive Water Management Plan was developed as required. These failures placed staff and residents at risk for spread of bacterial illnesses, exposure to splashes of body fluids, and illness related to water borne bacteria. Findings included . The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to hand hygiene showed, Hand hygiene means handwashing with water and soap or antiseptic hand rub (alcohol-based foam or gel hand sanitizer) . gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning [applying] gloves and touching the patient or the patient's surroundings recommendations for hand hygiene in healthcare…

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 routinely inform cognitively intact residents and/or the legal representatives of cognitively impaired residents of the facility rules, resident rights and responsibilities including notice of Medicaid rights for 10 of 14 sampled residents (Residents 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270), reviewed for resident rights. This failure placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life. Findings included . <Resident 27> Review of the 09/12/2024 admission assessment showed Resident 27 admitted to the facility on [DATE]. Resident 27 was not comatose (unresponsive), was cognitively intact, and able to clearly verbalize their needs. Review of Resident 27's medical record as of 12/11/2024, 90 days after their admission, showed no documentation an admission agreement that included information on basic charges, all resident rights including the right to leave and/or refuse treatment,…

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 routinely provide written information including the facility policy on advanced directives (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so), review and thoroughly explained information on the right to formulate advanced directives with cognitively intact residents and/or the resident's legal representative when indicated upon admission, as required for 6 of 12 sampled residents (Residents 68, 28, 271, 44, 20, and 218), reviewed for advanced directives. This failure placed residents and/or their legal representatives at risk of losing their right to have their healthcare preferences and/or decisions honored. Findings included . Review of the facility policy titled, Advanced Directives revised [DATE], showed residents had the right to refuse…

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 and implement an effective admission policy with all the required components, failed to not require a third-party guarantee of payment to the facility as a condition of admission, and failed to routinely review and complete admission paperwork with cognitively intact residents and/or the resident's legal representative when indicated upon admission, as required for 10 of 14 sampled residents (Resident 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270), reviewed for admission. This failure placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, admission Policy revised September 2024, showed the facility offered 24 hours a day, seven days a week admissions based on resident needs and center ability to meet the identified needs. The policy further showed the facility would utilize a 24 hours a day, seven day a week admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to review and provide written information regarding bed holds (the right to pay the facility to hold their room/bed while hospitalized or on therapeutic leave) including the facility's policy to cognitively intact resident and/or the legal representatives of cognitively impaired residents upon admission for 8 of 14 sampled residents (Resident 27, 28, 42, 44, 68, 268, 270, and 271), reviewed for admission. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized or on a therapeutic leave. Findings included . Review of the facility policy titled, Bed Hold: Notification of Bed Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave) implemented September 2022, showed the resident and/or the resident representative would be provided written notice of the bed hold policy at time of admission. The policy further showed the facility required a written notice be provided to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to address subtherapeutic (less than therapeutic) blood values for a resident on a blood thinner, routinely implement the bowel protocol when indicated, and administer medications as ordered for 3 of 6 sampled residents (Residents 268, 27, and 29), reviewed unnecessary medications. This failure placed residents at risk of potentially avoidable accidents, medical complications, and diminished quality of life. Findings included . Review of the facility policy titled, Coumadin [blood thinner] and Other Anticoagulant [blood thinner] Medication revised January 2024, showed blood test monitoring would occur for resident who received Coumadin, per provider orders. The policy instructed staff to enter blood test orders into the resident's medical record, complete laboratory requisition paperwork, and implement an anticoagulant care plan to monitor for signs and/or symptoms of bleeding. Review of the facility policy titled, Management of Constipation…

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 dialysis (a mechanical way of removing waste from the body when the kidneys no longer function) care was delivered comprehensively for 4 of 7 sampled residents (Residents 30, 32, 35, and 63) reviewed for dialysis care. Specifically, individualized care plans were not developed, medications were omitted on days residents attended dialysis treatments, and fluid intake was not monitored for those on fluid restrictions, and one resident had blood drawn from an extremity that had a non-functioning fistula (a surgical connection of a vein and artery, usually in one arm used to conduct dialysis, also referred to as a graft) that was the potential cause of a large hematoma. This failure placed the residents at risk for deterioration of their chronic health conditions and unmet care needs. See also F655-Baseline care plan, and F760-Significant Medication Errors Findings included . <Resident 30> A review of the 09/24/2024 admission assessment documented Resident 30 had diagnoses that included end-stage renal…

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 nursing assistant and licensed nurses competencies/skill sets or performance evaluations were completed yearly as required for 6 out of 10 sampled employees reviewed for sufficient and competent nurse staffing. This failure had the potential to place the residents at risk for unmet care needs and impact the quality of care provided. Findings included . In an interview on 12/13/2024 at 11:02 AM, Staff M, Nursing Assistant, stated the facility used to do evaluations and skills fairs, but they hadn't been done in about two years. Review of employee files found no documentation of staff competencies/skill sets or yearly performance evaluations for the following: - Staff C, Resident Care Manager, hired 10/09/2023 - Staff M, hired 10/19/2018 - Staff R, Nursing Assistant, hired 02/04/2020 - Staff U, Licensed Practical Nurse, hired 12/14/2012 - Staff X, Nursing Assistant, hired 12/18/2019 - Staff Y, Registered Nurse, hired 03/18/2015 In an interview on 12/17/2024 at 11:36 AM, Staff B, Director of Nursing, stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure significant medications were given as ordered for 4 of 7 sampled residents (Residents 30, 35, 63 and 221) reviewed for dialysis care. This failure put the residents at risk for sub-therapeutic levels of their medications and unintended health consequences. Findings included . <Resident 30> A review of the 09/24/2024 admission assessment documented Resident 30 had diagnoses that included end-stage renal disease (ESRD, kidney failure) dependent on dialysis and cirrhosis of the liver (damage to the liver that caused scarring and failure). The resident 30 was cognitively intact. Resident 30 had provider orders that included the following: -Renal dialysis 3 times weekly on Monday, Wednesday and Friday -Gabapentin twice daily for nerve pain -Sevelamer (controls blood levels of phosphate in those with kidney disease) three times a day with meals -acetaminophen three times daily for hip pain A review of the December 2024 medication…

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

Based on observation, interview, and record review, the facility administration failed to effectively use its resources to maintain facility compliance with Federal regulatory requirements for 6 of 12 sampled residents (Resident 20, 28, 44, 68, 218, and 271) reviewed for Advance Directives, 10 of 14 sampled residents (Resident 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270) reviewed for admission and resident rights, and 8 of 14 sampled residents (Resident 27, 28, 42, 44, 68, 268, 270, and 271) reviewed for bed hold notification. Failure to ensure the facility's admission Agreement which included information on advance directives, resident rights, and the facility's bed hold notification/policy was completed upon admission and/or timely placed the residents at risk of not being informed of their rights, unmet care needs, and diminished quality of life. Findings included . Please see the following F tags for additional information: F572 483.10(g)(1)(16) - Notice of Rights and Rules The Administration failed to inform residents and/or representatives of the facility rules and their…

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

Based on observation, interview and record review, the facility failed to ensure residents that required urinary catheters (a tube inserted in the bladder that drained urine) had the drainage collection bags maintained in a dignified manner for 1 of 2 sampled residents (Resident 61) reviewed for resident rights. This failure placed the residents at risk for loss of dignity and decreased quality of life. Findings included . The undated Bowel and Bladder Program: Indwelling Urinary Catheters policy did not have guidance regarding dignity concerns that may have arisen related to the use of urinary catheters. A review of the record documented Resident 61 had diagnoses including prostate cancer that had spread to the brain, and urinary retention. The 10/11/2024 significant change assessment documented the resident had a urinary catheter and required maximum assistance of staff for toileting. The 08/18/2024 comprehensive care plan documented Resident 61 had altered urinary elimination related to an indwelling catheter. Staff were instructed to change the catheter if it leaked or 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 ensure informed consents, information that explained the potential risks associated with the use of psychotropic medications, were obtained prior to administration of psychotropic medications (medications that affected how the brain worked and caused changes in mood, feelings or behavior) for 2 of 6 sampled residents (Residents 20 and 60) reviewed for resident rights. This failure did not allow residents to be fully informed or to participate in their treatment. Findings included . <Resident 60> The 11/12/2024 quarterly assessment documented Resident #60 had diagnoses which included depression, a mental health condition characterized by a persistent feeling of sadness that lasted over an extended period. In addition, the assessment documented the resident had received psychotropic medication. Review of the Order Summary Report from 01/01/2024 through 12/06/2024 documented on 10/18/2024, a psychotropic medication, Paroxetine, had been prescribed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the interdisciplinary team (IDT) assessed and determined a resident was clinically appropriate to self-administer medications safely or store medications at the bedside and care plan accordingly for 1 of 14 sampled residents (Resident 68), reviewed for resident rights. This failure placed residents at risk of access to unsecured medications, medication errors, and diminished quality of life. Findings included . Review of the facility policy titled, Self-Medication Program and Evaluation revised September 2024, showed a resident who requested to self-administer medication would be assessed for their ability to safely self-administer medications. The policy instructed staff to complete a self-medication evaluation that would be analyzed by the IDT. The policy further showed staff would determine a safe and secure location for bedside medication storage, progress notes would be made showing the resident was self-administering…

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 sink faucets were safe and functional in resident rooms for 2 of 5 residents (Residents 38 and 23) reviewed for environment. Failure to have a working faucet for Resident 38, and failure to repair a loose faucet for Resident 23 placed the residents at risk for unmet care needs and diminished quality of life. Findings included . <Resident 38> The 09/13/2024 quarterly assessment documented Resident 38 was able to make decisions regarding their care and was independent to complete activities of daily living (ADLS) for oral hygiene and personal hygiene, such as washing their face, with the assistance from nursing staff to set up the supplies needed. On 12/04/2024 at 2:39 PM, Resident 38 was observed in their room lying in bed watching television. When asked if they received the assistance they needed to complete ADLS, Resident 38 stated it was hard to do because the water to the sink had been turned off for a few weeks due to a leak that caused water to run into the room next to theirs. An observation 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 mail delivery was provided consistently, including Saturdays, for 4 of 8 sampled residents (Residents 13, 29, 44, 50) reviewed for resident rights. This failure placed residents at risk of not having their rights honored to receive and send communication through the mail, and a diminished quality of life. Findings included . Review of the facility's 08/2022 Resident Rights/Resident [NAME] of Rights policy showed residents were informed of their right to have privacy in written communication which included the right to send and promptly receive mail. In an interview on 12/06/2024 at 12:08 PM, Resident 13 stated they didn't get mail on the weekends because there was nobody there to hand the mail out to the residents. Per Resident 13, Staff O, Life Enrichment Assistant, received the mail when it was delivered, then handed it out to the residents, but on the weekends, there was nobody working to give the mail to Staff O. During a group interview on 12/06/2024 at 1:22 PM with members of the Resident Council, the group…

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 residents with newly evident mental conditions were referred for a Preadmission Screening and Resident Review (PASRR, an evaluation that ensured residents received the appropriate behavioral health services), and were referred for behavioral health services once recommended for 3 of 11 sampled residents (Residents 35, 54 and 60) reviewed. Specifically, Residents 35 and 60 were diagnosed with depression and started on psychotropic medication therapy (medications that altered mood, behavior and brain function) and a PASRR level I screening and referral for level II was not completed, and Resident 54 had PASRR level II recommendations for behavioral health services and the recommendations were not implemented timely. Findings included . The 04/26/2023 PASRR Requirements facility policy documented the center strives to ensure that PASRR documentation is correct at the time of admission. The facility was to immediately complete a new level I…

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 residents with histories of mental disorders were screened appropriately for a need for specialized behavioral health services prior to admission as required for 2 of 11 sampled residents (Residents 20 and 61) reviewed. This failure placed residents at risk for unmet behavioral health needs and potential decline in their psycho-social well-being. Findings included . A State of [NAME] Department of Social and Health Services Dear Nursing Facility Administrator letter dated June 6, 2024, provided clarification to the Pre-admission Screening and Resident Review (PASRR) process. The initial screening, referred to as a PASRR Level I, was to be completed prior to the nursing facility admission with the purpose of identifying individuals who have or may have serious mental illness or intellectual disability. Those that had been identified with any of the qualifying criteria required a PASRR Level II referral prior to admission. The Level II evaluation…

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 baseline care plan goals and interventions related to dialysis (a mechanical way of removing waste from the body when the kidneys no longer function) needs were developed in the required timeframe for 2 of 7 sampled residents (Residents 63 and 220) reviewed for dialysis care. This failure put the residents at risk for unmet complex dialysis care needs and potential undesired health complications. Findings included . <Resident 63> A review of the record documented Resident 63 was admitted to the facility on [DATE] and had diagnoses including end-stage renal disease (ESRD, lack of kidney function) and was dependent on dialysis. The 10/29/2024 nursing admission Evaluation documented Resident 63 was not incontinent of urine, had no urinary catheter, and did not receive dialysis. There was no mention what type of dialysis access the resident had or where it was located on the resident. The 10/31/2024 Provider History and Physical…

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 discharge summary with all the required components including a recapitulation of the resident's stay, the resident's status at time of discharge, a medication reconciliation, or a discharge plan of care, as required for 1 of 2 sampled residents (Resident 66), reviewed for discharge. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life. Findings included . Review of the 09/05/2024 admission assessment showed Resident 66 admitted to the facility on [DATE]. Review of the 09/06/2024 discharge assessment showed Resident 66 discharged the facility on 09/06/2024. Review of September 2024 nursing progress notes showed no progress notes had been documented for Resident 66. In a telephone interview on 12/16/2024 at 11:45 AM, Resident 66 stated they left the facility against medical advice (AMA) because they were unhappy with their room. Resident 66 further stated they signed an AMA form prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to evaluate and assess a resident for substance use disorder, thoroughly assess for safe smoking abilities, and monitor a resident after they sustained a fall for 3 of 5 sampled residents (Resident 68, 20, and 23), reviewed for accident hazards and supervision. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Management of Residents with Substance Use Disorder revised December 2024, defined a substance use disorder (SUD) as recurrent use of alcohol and/or drugs that cause significant impairment. Residents would be assessed upon admission for SUD and/or history of SUD using the social service admission and discharge evaluation. The policy further showed residents with a SUD would have increased monitoring and have care planned interventions. Review of the facility policy titled, Smoking- [NAME] Center Smoking…

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

Based on observation, interview and record review, the facility failed to ensure a resident with symptoms of a urinary tract infection (UTI) had interventions implemented timely for 1 of 2 sampled residents (Resident 218) reviewed for UTIs. This failure placed the resident at risk of worsening infection, deterioration of their health and decreased quality of life. Findings included . A review of the record documented Resident 218 had diagnoses that included left below the knee amputation related to gangrene (death of tissue due to lack of blood flow). The 11/27/2024 admission assessment documented Resident 218 was cognitively intact, was occasionally incontinent of urine, required supervision assistance for toileting, and used a wheelchair independently for mobility. The 11/20/2024 care plan had no goals or interventions developed related to the resident's elimination patterns. On 12/01/2024, a provider order was given to send a urine sample for a urinalysis with culture and sensitivity (UA C&S, laboratory examination of urine to detect various substances or the presence of bacteria…

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 physician orders for nutrition were transcribed completely for one of two sampled residents (60) reviewed for tube feeding (a medical device used to deliver nutrients through a tube directly inserted into the stomach). Failure to ensure previous physician orders for tube feeding formula and water flushes were discontinued when new orders were obtained, placed the resident at risk for adverse medical and nutritional complications. Findings included . <Resident 60> The 11/12/2024 quarterly assessment documented Resident 60 had diagnoses which included stroke and received more than 51 percent of their calories and water through a feeding tube. On 12/05/2024 at 9:11 AM, Resident 60 was observed sleeping in their bed. A tube feeding formula bag and water bag were hanging on the intravenous pole (IV pole: a medical device that holds bags that delivered fluids to a resident). Both bags were labeled with the date the bag was hung, and the type of formula and fluid in the bag. Observation of the tube feeding…

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 have a system in place that identified residents that were survivors of trauma in order to eliminate or mitigate triggers (a stimulus that causes an adverse emotional response for one with a history of trauma) for 1 of 2 sampled residents (Resident 20) reviewed. This failure put the resident at risk for re-traumatization and for decline in their psycho-social well being. Findings included . A review of the record documented Resident 20 had diagnoses that included hemiplegia (paralysis on one side of the body) after a stroke, depression, and failure to thrive. The [DATE] admission assessment documented Resident 20 had memory problems, required moderate assistance for most of their activities of daily living (ADLs), and took an antipsychotic medication (medications that changed brain function, mood and behavior). A hospital history and physical documented Resident 20 was seen for profound weakness and left leg pain and swelling. The note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received the appropriate services to address their mental health needs timely for 1 of 2 sampled residents (Resident 54) reviewed. This failure put the resident at risk of having unmet behavioral health needs and a deterioration of their psychosocial well being. Findings included . A review of the record documented Resident 54 was admitted on [DATE] and had diagnoses that included stimulant induced psychotic disorder. The 03/2024 PASRR Level II evaluation completed prior to the resident's admission to the facility documented Resident 54 met criteria for nursing home level of care and required behavioral health services once admitted . The 03/27/2024 Social Services admission Evaluation documented Resident 54's stay was expected to be short term stay; the question regarding mood and behavior, PASRR, and involvement of psychiatric services were blank. The 03/25/2024 care plan documented Resident 54 demonstrated verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently complete monthly medication regimen reviews and follow-up on recommendations timely, as required for 3 of 6 sampled residents (Resident 27, 29, and 60), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, potential diminished quality of life. Findings included . Review of the facility policy titled, Medication Monitoring Medication Regimen Review and Reporting dated January 2024, showed a medication regimen review (MRR) included a review of a resident's medical record performed by the consultant pharmacist in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The policy further showed the pharmacist would submit a report with recommendations to the facility nurses, physicians, and the care planning team within 48 hours of MRR completion. Recommendations would be acted upon within 30 calendar days. The provider…

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

Based on observation, interview and record review, the facility failed to ensure expired medications were removed from inventory in 1 of 2 medication storage rooms (South Hall) and 1 of 2 medication carts (South Hall), observed for medication storage. In addition, one bottle of a liquid oral narcotic was not monitored for loss or diversion as required. This failure placed residents at risk of receiving less than the optimum dose of their medications, placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion. Findings included . Review of the facility undated policy titled, Controlled Drugs showed controlled drugs would be logged into a controlled substance record book by a licensed nurse. The policy further showed all controlled drugs were to be counted at each change of shift by one off going and one oncoming licensed nurse and documented on the shift verification of controlled substance sheet. On 12/12/2024 at 8:39 AM, an observation of the medication room on the South unit…

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

Based on interview and record review, the facility failed to ensure dietary staff had the proper qualifications. Specifically, the failure to ensure the dietary manager had the proper certification placed all residents at risk for nutritional deficits, unmet nutritional needs, and diminished quality of life. Findings included . During an interview on 12/12/2024 at 2:22 PM, Staff Z, Regional Registered Dietician, stated they were at the facility part-time, typically two days per week. During a phone interview on 12/17/2024 at 11:45 AM, Staff Q, Dietary Manager, stated that they had been in their current position for almost three years. Staff Q further stated that they did not have their dietary manager certification, but had been approved to take the class. A review of dietary staff records showed that Staff Q had a current food handler card, but no other documents were provided. During an interview on 12/17/2024 at 2:24 PM, Staff A, Administrator, stated that Staff Q had been at the facility for about three years. Staff A acknowledged that since the dietician was not full-time at…

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

Based on observation, interview, and record review the facility failed to provide residents with their preferred beverages upon request for 2 of 3 sampled residents (Resident 27 and 68), reviewed for choices. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Food Preferences revised August 2023, showed the facility would gather information upon admission to inform the food and nutrition services department of an individual's food preference, allergies, intolerances, cultural preferences, and diet history. The policy instructed staff to use the food preference interview form to gather information including beverage preferences. <Resident 27> Review of the 09/12/2024 admission assessment showed Resident 27 had diagnoses including malnutrition, was cognitively intact and able to clearly verbalize their needs. The assessment further showed it was very important for Resident 27 to have snack available between meals. Review of the 09/09/2024 food preference record showed 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.

Based on interview and record review, the facility failed to maintain accurate medical records for 1 of 5 residents (Resident 23), reviewed for unnecessary medications. Resident 23 had two medication allergies listed, that were not accurate and were not corrected in their medical record when staff determined that they were not true allergies. This failure placed the resident at risk of unmet care needs. Findings included . According to a quarterly assessment, dated 09/12/2024, Resident 23 had diagnoses of cancer, dementia and heart failure and was on Hospice (end-of-life) services. The assessment further documented the resident was alert, made their needs known. Residents electronic medical record (EMR) documented resident allergies in a number of areas, including the resident profile, the allergy tab, the Medication Administration Record (MAR) and care plan. A review of Resident 23's EMR, listed Acetaminophen (Tylenol/APAP), Baclofen (a muscle relaxant) and Morphine (a narcotic pain medication) as allergies and were documented on all those areas of their chart. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to explain the 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 1 of 4 sampled residents (Resident 272), reviewed for arbitration agreement. 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 06/13/2024 admission assessment showed Resident 272 admitted to the facility on [DATE]. The assessment further showed Resident 272's preferred language was Mandarin, and they would like an interpreter to communicate with healthcare staff. Resident 272 had severe cognitive impairment. Review of the voluntary arbitration agreement showed the agreement was written in English and signed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently communicate and coordinate care with the hospice provider, for 1 of 4 residents (Resident 23) reviewed for hospice (end-of-life) services. In addition, the facility failed to designate an interdisciplinary team member, in writing, to coordinate care and communication with the hospice agency, as required. These failures placed the residents at risk for unmet care needs. Findings included . A review of the facility policy titled Hospice - Admission, Discharge, Care, and Treatment, revised on 12/30/2022, did not name a facility staff member designated to coordinate care between the facility and the hospice agency. A review of a facility agreement, dated 03/19/2018, showed the agreement was between the hospice provider and the facility under their previous name ([NAME] Hills Health & Rehabilitation Center) and a former administrator. The document did not include a facility staff member designated to coordinate care between 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 thoroughly investigate allegations of abuse and/or neglect for 2 of 6 residents (Residents 1 and 5), reviewed for abuse and/or neglect. This failure placed residents at risk for abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility policy: Prevention and Reporting: Resident mistreatment, Neglect, Abuse .Misappropriation of Resident Property, dated 08/2022, showed there was to be an investigation of all allegations of abuse and/or neglect to include resident interview, resident observation, staff interviews and other resident interviews. The investigation was to include a summary to rule out abuse and neglect. <Resident 1> Review of a facility assessment, dated 09/22/2024, showed Resident 1 had diagnoses of chronic pain and depression. The resident was alert and oriented and was able to make their needs known. Resident 1 was independent with most Activities of Daily Living (ADL's). Review of a facility grievance by Resident 1, dated 09/16/2024, showed the resident documented…

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

Based on interview and record review, the facility failed to ensure there was a Registered Nurse (RN) on duty at least eight hours a day, seven days a week. This failure had the potential to impact all residents present in the building. Findings included . Review of the staffing pattern from 10/01/2024 through 10/31/2024 showed no RN coverage for 18 full days. 11/01/2024 through 11/15/2024 showed no RN coverage for 10 full days. During an interview on 11/15/2024 at 1:20 PM, Staff C, Staffing Coordinator, confirmed the facility did not have RN coverage seven days a week. The facility had a RN that worked 16 hour shifts every Saturday and Sunday and until 11/01/2024 had a RN that worked one day during the week. Staff C stated the facility used agency staff but normally they would send Licensed Practical Nurses (LPN). On 11/15/2024 at 3:10 PM, Staff D, Administrator, confirmed the facility did not have the required RN coverage. Staff D stated they were in the process of hiring RN's. Reference: WAC 388-97-1080(3)(a)

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 sample residents (Resident 1), reviewed for abuse, remained free from mental abuse when Resident 2 made sexually inappropriate comments towards Resident 1. Failure to implement adequate interventions and supervision for Resident 2, placed all residents at risk for psychosocial harm and potential mental abuse. Findings included . Review of a facility assessment, dated 09/22/2024, showed Resident 1 had diagnoses of chronic pain and depression. The resident was alert and oriented and was able to make their needs known. Resident 1 was independent with most Activities of Daily Living (ADL's). Review of a facility grievance by Resident 1, dated 09/16/2024, showed the resident documented inappropriate sexual comments had been ongoing from Resident 2. Resident 1 wrote Resident 2 had told Resident 1 he would like to perform lewd, sexual acts on Resident 1. The resident requested one of them be moved to another room. When Social Services followed up, Resident 1 explained how uncomfortable it made them…

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 follow physician orders, as intended, for 1 of 3 sample residents (Resident 4), reviewed for medication administration. Resident 4 had an order to receive Carvedilol (a heart medication) one tablet twice a day. On 07/11/2024, the medication was changed to once a day with no order to make the change. This failure placed the resident at risk for adverse side effects and diminished quality of life. Findings included . According to the facility assessment, dated 10/03/2024, Resident 4 had diagnoses to include heart disease. Resident 4 was able to make their needs known. During an interview on 10/24/2024 at 1:26 PM, Resident 4 stated they were supposed to take a cardiac medication twice a day. Resident 4 went to a cardiology appointment on 09/30/2024 and it was discovered the resident had only been getting the medication once a day since July 2024. Review of the Medication Administration Record (MAR) for July 2024 showed the resident took one tablet of Carvedilol twice a day since admission, 06/26/2024. On 07/11/2024, the order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dry food and refrigerated food were stored in sanitary conditions. This failure placed residents at risk for food borne illness. Findings included . The kitchen was entered on 09/11/2024 at 9:05 AM. Towels were observed on the floor, outside of the walk in refrigerator, soaked with water. The walk in refrigerator door was open and water covered the floor with food debris floating in the water. The dry storage room was next to the refrigerator. There was about an inch of standing water on the floor. The canned goods had water pooled on the top, the labels were coming off, and the card board boxes they were on were saturated with water. There were pipes on the wall between the refrigerator and the dry storage room. Water was dripping from the pipes and being collected into a bucket. At 9:10 AM Staff G, Maintenance Director, stated the leak in the walk in refrigerator and dry storage had been going on for a month or so. Staff G said they brought it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a quiet, comfortable, homelike environment for the residents in 4 out of 4 Hallways (Southwest, Southeast, Northwest, and Northeast) during construction. This failure placed all residents at risk for fatigue, unwanted noise, and a non-homelike environment. Findings included . <Southwest hall> During an Observation on 9/11/2024 at 8:45 AM Construction workers were observed using an air compressor and automatic nail gun to hang wood trim above residents doors. The noise was very loud with the air compressor running and when the nails were being placed. Residents were in the rooms where the construction was occurring. The hose of the nail gun was across the hallway, a resident in a wheel chair was in the hall and wanted to go through, the hose was moved by the worker. During an interview on 09/11/2024 at 8:57 AM, Resident 3 was in their room on the Southwest hall in a wheel chair. The resident stated the noise was loud and but said there 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 observation, interview, and record review, the facility failed to ensure 2 of 2 medication storage rooms (North and South medication rooms) stored medications at proper temperatures. This failures placed residents at risk of receiving compromised medications and biologicals. Findings included . <South medication room> On 09/11/2024 at 9:35 am, Staff A, Licensed Practical Nurse (LPN), unlocked and entered the South medication room with the surveyor. There was a thermometer on the wall of the room that showed the maximum temperature it reached was 80 degrees Fahrenheit (F). The current reading showed slightly above 80 degrees. Staff A said the medication room got hot and the only thing that could be done was put a fan in the room and prop open the door, as long as staff were at the nurses station. When asked if a log was kept, Staff A stated they didn't log temperatures in the room. At 11:22 AM Staff L, Resident Care Manager (RCM), stated the temperatures were logged in the medication room. Staff L…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure there were functioning call lights in 10 resident rooms out of 13 rooms observed (room [ROOM NUMBER], 30, 34, 37, 38, 39, 62, 79, 81, and 85). The facility was undergoing construction which had caused the call lights to not function correctly. This failure placed the residents at risk for unmet care needs, and the inability to call for assistance. Findings included . In an interview on 09/11/2024 at 9:18 AM, Staff G, Maintenance Director, stated the call lights went out all the time. Staff G said the system was very old, needed to be replaced, and was always going out. On 09/11/2024 at 9:29 AM, Resident 4, in room [ROOM NUMBER], had a bell at their bedside. The resident was asked about the bell and stated they had it when the call light went out. It had happened on several occasions, the last time it hadn't worked since. The resident had a call light box on the wall, the light on the box was red but the light wasn't on outside their door in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices had dressing changes completed weekly, in accordance with professional standards of practice, for 2 of 2 residents (Residents 1 and 2), reviewed for IV therapy. In addition, the facility failed to follow orders to measure the circumference of the resident's arm, measure the length of the Peripherally Inserted Central Catheter (PICC a long, thin tube that is inserted through a vein and passed through to the larger veins near the heart), and ensure normal saline flushes (a solution pushed through the catheter to help prevent blockage) were completed. These failures placed residents at risk for loss of vascular access, infection, and other complications. Findings included . <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include cellulitis (a bacterial infection that affects the skin's deeper layers) and an infection of the blood. The resident had a PICC (thin, flexible…

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

Based on observation and interview, the facility failed to ensure proper personal protection equipment (PPE's) was used during a COVID outbreak, in accordance with Centers for Disease Control (CDC) guidelines, by 1 of 4 staff (Staff E), when reviewing infection control practices. This failure placed residents and the staff at risk for contracting COVID-19, a respiratory disease caused by a virus. Findings included . At the beginning of the complaint investigation on 09/11/2024, Staff D, Administrator, stated there was 12 residents that were in isolation for COVID-19. The residents were spread through out the facility on different units. According to the April 2024 Washington State Department of Health COVID-19 preparedness and outbreak control checklist for long term care showed staff were required to wear N95 respirators, gowns, gloves, and eye protection and be donned, prior to entering a COVID-19 room. On 09/24/2024 at 9:35 AM, Staff E, Housekeeper, was observed exiting a room in isolation. The staff member had a gown on with gloves. The staff was wearing a surgical mask, pulled…

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 1, 2, 5, and 6), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 03/12/2024, showed Resident 1 had diagnoses which included a stroke. The resident was alert and able to make their needs known. Resident 1 required moderate assistance with showers. According to Resident 1's care plan, dated 03/07/2024, Resident 1 preferred 2 showers a week, in the mornings. A review of the resident's shower records from 03/05/2024 through 03/30/2024 showed Resident 1 refused a shower on 03/07/2024 and received a shower 6 days later on 03/13/2024. The resident refused a shower on 03/20/2024 and the next shower the resident received was 03/26/2024, 13 days from their previous shower. <Resident 2> Review of a facility assessment, dated 02/19/2024, showed Resident 2 had diagnoses to include heart and kidney disease. Resident 2 was able…

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 implement bowel management protocol when indicated for 4 of 4 residents (Resident 1, 2, 3, and 4) reviewed for constipation. This failure placed residents at risk for medical complications and unmet care needs. Findings included . Review of the facility policy titled, Management of Constipation, revised on 11/2023, showed residents Bowel Movements (BM's) were to be monitored through the electronic charting system. When a resident was identified with no/small BM's documented for 64 hours, the Licensed Nurse (LN) would assess the resident and determine if the bowel protocol would be initiated. The policy showed staff were to administer Milk of Magnesia (MOM) after eight shifts of no BM, a laxative suppository was to be administered if no results from the MOM, and an enema was to be administered if no results from the suppository. <Resident 1> Review of a facility assessment, dated 03/12/2024, showed Resident 1 had diagnoses which included cancer and malnourishment. Resident 1 was able to make their needs known and required…

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 thoroughly investigate allegations of abuse and/or neglect for 3 of 4 sampled residents (Resident 1, 2, and 3), reviewed for abuse and/or neglect. This failure placed residents at risk for continued abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility policy: Prevention and Reporting: Resident mistreatment, Neglect, Abuse .Misappropriation of Resident Property, dated 08/2022, showed there was to be an investigation of all allegations of abuse and/or neglect to include resident interview, resident observation, staff interviews and other resident interviews. The investigation was to include a summary to rule out abuse and neglect. <Resident 1> According to the facility assessment, dated 02/02/2024, Resident 1 had diagnoses to include a fracture and anxiety. The resident was able to make their needs known. During an interview on 02/27/2024 at 11:11 AM, Resident 1 was sitting on the side of their bed. The resident stated they had concerns about Staff A, Resident Care…

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

Based on observation, interview, and record review, the facility failed to thoroughly assess and evaluate changes in condition for 1 of 3 sampled residents (Resident 4), reviewed for change in condition. Resident 4 had been observed with seizure-like activity on 01/16/24 by a Collateral Contact (CC). CC reported the incident to a staff member and asked the provider be contacted. Staff G and Staff K, Nursing Assistants (CNA's) and Staff I, Hospitality Aide (HA), had observed Resident #4 with abnormal involuntary movements which had been reported to nursing staff. There was no documentation found to show Resident 4's change in condition and no documentation to show the provider had been notified. This failure constituted a Past Non-Compliance (the facility was not in compliance at the time the situations occurred; however, there was sufficient evidence that the facility corrected the non-compliance after they were identified). The facility imposed a plan of correction which included staff education, measures to prevent recurrence, and monitors to ensure solutions were sustained.…

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 administer medications according to professional standards of practice and provider orders for 7 of 9 sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7), reviewed for medication administration. This failure placed residents at risk of adverse side effects, potential complications from medical conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Medication Administration, revised 12/2022, showed the licensed nurse would check the following to administer medication: right medication, right dose, right dosage form, right route, right resident, and right time. The policy instructed staff to read the Medication Administration Record (MAR) for the ordered medication, dose, dose form, route, time, and document medication administration into the MAR as soon as medications are given. The website nih.gov -which NIH refers to National Institute of Health showed, nurses have traditionally followed the '5 rights' 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 thoroughly investigate allegations of abuse and/or neglect for 1 of 3 residents (Residents 1), reviewed for abuse and/or neglect. This failure placed residents at risk for abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility policy: Prevention and Reporting: Resident mistreatment, Neglect, Abuse .Misappropriation of Resident Property, dated 08/2022, showed there was to be an investigation of all allegations of abuse and/or neglect to include resident interview, resident observation, staff interviews and other resident interviews. The investigation was to include a summary to rule out abuse and neglect. According to the facility assessment, dated 08/10/2023, Resident 1 had diagnoses to include Diabetes and lung disease. Resident 1 required extensive assistance for most Activities of Daily living (ADL's). Resident 1 was able to make their needs known. During an interview on 11/30/2023 at 12:23 PM, Resident 1 stated at times, they waited an hour or more for their call light to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and document wound characteristics (size, depth, and tissue appearance) from 06/20/2023 to 07/06/2023 on a vascular ulcer (wounds that develop because of poor circulation) for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure related skin wounds. Failure to thoroughly assess and document the wound appearance, to determine the effectiveness of treatment, and if the wounds got better or worse, placed the resident at risk for unmet care needs and potential worsening of the wounds. Findings included . According to the 08/10/2023 assessment, Resident 1 was admitted with diagnoses to include Diabetes and a disorder that involves the narrowing of peripheral blood vessels. Resident 1 was able to make their needs known. During an interview on 11/30/2023 at 12:23 PM, Resident 1, stated they had a wound on their leg that had not been properly treated by the facility until a wound care team evaluated it. Resident 1 stated it took several…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff possessed appropriate competencies and skills to administer medications to residents in 2 of 4 hallways (Southwest and Southeast). This failure placed residents at risk for adverse medication outcomes and potential medication errors. Findings included . Per the Washington State Department of Health website: https://doh.wa.gov/licenses-permits-and-certificates/professions-new-renew-or-update/pharmacy-professions/who-can-prescribe-and-administer-prescriptions-[NAME]-state, a Certified Nursing Assistant (CNA) may administer medications in community-based care settings or in-home care settings under nurse delegation. The document showed a CNA may administer medications in a nursing home with a medication assistant endorsement. During an interview on 11/20/2023 at 12:23 PM, a former resident stated they had been given medications from nursing assistants numerous times when Staff B, Resident Care Manager, worked on the medication cart. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident property for 4 of 5 residents (Residents 1, 2, 3, and 4), reviewed for personal property. This failure placed residents at risk for misappropriation of personal property and a diminished quality of life. Findings included . Review of the facility policy: Prevention and Reporting: Resident mistreatment, Neglect, Abuse .Misappropriation of Resident Property, dated 08/2022, showed there was to be an investigation of all allegations of misappropriations of resident property to include resident interview, resident observation, staff interviews and other resident interviews. The investigation was to include a summary to rule out abuse and neglect. <Resident 1> According to the facility assessment, dated 07/11/2023, Resident 1 required extensive assistance with most activities of daily living. The resident was able to make their needs known. During an interview on 09/07/2023 at…

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

Based on interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 5 and 6) were free from potential sexual abuse. The facility failed to immediately investigate the allegations of sexual abuse and immediately suspend the accused staff member, Staff C, Nursing Assistant, to protect residents. This failure placed all residents at risk for potential sexual abuse. Findings included . The facility policy Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, dated 08/2022, showed when allegations met the definition of abuse were received, the facility would report all alleged violations immediately, thoroughly investigate all alleged violations, and prevent further abuse while the investigation was in progress. Under protection the facility was to provide for immediate safety of the resident upon identification of potential abuse, neglect, mistreatment. The identified employee would be immediately suspended pending outcome of the investigation. <Resident 5> According to the facility assessment, dated 07/20/2023, Resident 5 had diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide thorough assessments and evaluate for changes in condition, for 1 of 3 residents (Resident 7), reviewed for change in condition. Failure to monitor a sudden increase in weight, thoroughly evaluate respiratory status, and consistently monitor for edema (swelling caused by too much fluid in the tissues) placed the resident at risk for worsening symptoms and a potential delay in treatment. Findings included . Review of the facility assessment, dated 06/10/2023, showed Resident 7 was admitted with congestive heart failure (a weakened heart that causes fluid build up in feet, arms, and lungs) and lung disease. Resident 7 required supervision or was independent with most activities of daily living. The resident was able to make their needs known. Review of Resident 7's Treatment Administration Record (TAR) for August and September 2023 showed the resident had a monitor in place to check edema in the lower legs. The entries from August showed three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide residents with drinks per their request or preferences for 5 of 11 sampled residents (Resident 14, 16, 18, 40, and 53), reviewed for food and nutrtion. This failure placed residents at risk of dehydration, unmet care need, and diminished quality of life. Findings included . Review of the facility policy titled, Food Preferences dated 03/2023, showed that a food preference interview form would be completed upon admission, reassessment and as needed. The policy further stated that the food preference information would be used to assure residents needs and desires for food were met. Review of the weekly menus for July and August 2023 showed that water was the only fluid offered during the lunch meal. <Resident 14> The 07/18/2023 quarterly assessment showed Resident 14 had severe cognitive impairment, but was able to make needs known to staff, and had diagnoses which included malnutrition and adult failure to thrive. On 07/24/2023 at…

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

Based on interview and record review, the facility failed to identify misappropriation of resident money as potential abuse, and failed to report to the State Survey Agency as required, for 2 of 3 sample residents (Residents 16 and 273), reviewed for abuse. This failure placed residents at risk for additional abuse and diminished quality of life. Findings included . The undated facility policy, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Injuries of Unknown Sources, and Misappropriation of Resident Property defined misappropriation of resident property as deliberate misplacement, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further showed that when a report that met the criteria of abuse, neglect, or misappropriation of resident property was received the facility should ensure the alleged violations were reported immediately to the appropriate entities, including the State Survey Agency. The policy defined immediately to mean as soon as possible but not to exceed 24 hours after discovery.…

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 bathing/showers for 3 of 5 sampled residents (Residents 16, 40 and 57), reviewed for activities of daily living (ADL). This failure placed the residents at risk for a diminished quality of life and unmet care needs. Findings included . The facility policy titled, Personal Needs revised 12/20/2022, showed that a resident's care plan would address an individual resident's needs and ADL support would be provided according to the care plan. <Resident 16> The 07/10/2023 quarterly assessment showed Resident 16 had no cognitive impairment, made decisions regarding care, and needed extensive assistance from one staff to complete activities of daily living such as bathing. In an interview on 07/24/2023 at 2:41 PM, Resident 16 stated they were scheduled to be bathed three times a week and it was not being done consistently due to the bath aide being pulled to work the floor. The resident further stated they had a medical appointment today and smelled bad because of not getting bathed prior to the…

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

Based on observation, interview, and record review the facility failed to maintain a system for accurate reconciliation of controlled drugs in 2 of 2 sampled medication rooms (South Hall and North Hall), reviewed for medication storage. This failure placed residents at risk for misappropriation of their controlled medications and placed the facility at increased risk for controlled substance drug diversion. Findings included . The undated facility procedure titled, Controlled Drugs- Storage and Accountability of Controlled Drugs showed that controlled drugs needed to be logged into a controlled substance record book by a licensed nurse. The procedure further stated each entry needed to be signed by a licensed nurse. The undated facility procedure titled, Controlled Drugs- Ongoing inventory of Controlled Drugs at Each Shift showed that all controlled substances need to be counted at each change of shift by one off-going and one oncoming licensed nurse. The procedure further stated that on-going and off-going licensed staff also had to verify and document the emergency kit supply 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 provide a dignified dining experience for 4 of 16 sampled residents (Residents 2, 20, 22, and 123), observed during lunch. This failure placed residents at risk for a decreased quality of life. Findings included . A review of records revealed the following: A 05/07/2023 quarterly assessment showed Resident 2 had diagnoses including cancer, was cognitively intact and was able to eat independently. A 05/07/2023 quarterly assessment showed Resident 20 had diagnoses including dementia and malnutrition, was cognitively intact, and required set-up assistance (help opening lids, dressings, or condiments or cutting up meats) for eating. A 07/11/2023 annual assessment showed Resident 22 had diagnoses including dementia and stroke, was moderately cognitively impaired, and required set-up assistance for eating. A 07/20/2023 quarterly assessment showed Resident 123 had diagnoses including malnutrition, was moderately cognitively impaired, and required supervision and set-up assistance for eating. On 07/25/2023, three…

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, investigate and resolve a grievance of missing clothing timely for 1 of 4 sampled residents (Resident 39), reviewed for personal property. Failure to identify and follow up on grievances promptly placed residents at risk for diminished quality of life. Findings include . Review of the facility policy titled, Grievances revised on 01/27/2023, showed that an employee who received a grievance from a resident and/or their representative should assist in filling out a grievance form as needed and immediately provide the completed grievance report to the grievance officer or their designee. The policy further showed the facility would attempt to resolve a grievance within five business days of receipt and follow up with the resident and/or their representative to ascertain satisfaction with the resolution. According to the 07/09/2023 quarterly assessment, Resident 39 was able to make their needs known, and required extensive assistance of one to two staff to perform most activities of daily living. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed prior to admission as required for 3 of 5 sampled residents (Residents 21, 47 and 60), reviewed. This failure placed residents at risk for unmet behavioral healthcare needs and diniminshed quality of life. Findings included . The facility policy titled, PASRR Requirements dated 04/26/2023, showed the facility strived to ensure PASRR documentation was correct at time of admission. <Resident 47> According to the 02/14/2023 admission assessment, Resident 47 was admitted to the facility on [DATE] with diagnoses including depression, dementia and had severe cognitive impairment. Review of Resident 47's record showed the PASRR was completed by Staff B, Social Service Director, 10 days after admission on [DATE]. <Resident 21> According to the 04/20/2023 admission assessment, Resident 21 was admitted to the facility on [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 interview and record review, the facility failed to follow-up timely on a doctor's referral for 1 of 2 sampled residents (Resident 18), reviewed for vision and dental needs. This failure placed the resident at risk for diminished quality of life and unmet care needs. Findings included . The 07/03/2023 quarterly assessment showed Resident 18 was able to make decisions regarding care, had vision impairments and wore glasses. On 07/31/2023 at 5:04 AM, Resident 18 was observed lying in bed watching Westerns on the television. A pair of glasses were lying on the over the bed tray table. When asked about the glasses, the resident pointed to the glasses, stated the glasses did not work well, they did not like to wear them, and they needed an eye examination. Review of the 04/06/2023 vision care plan showed the resident needed larger print materials for reading related to a history of cataracts, (a condition that caused blurred vision due to the lens of the eyes becoming progressively cloudy), diabetes, and glaucoma, (an eye disease that caused damage to the optic nerve, increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 sampled residents (Resident 1), reviewed for decreased range of motion. This failure placed residents at risk of worsening contractures (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement), pain, and diminished quality of life. Findings included . According to the 06/07/2023 admission assessment, Resident 1 was admitted on [DATE] with diagnoses including hip fracture, paraplegia (paralysis that affects legs but not arms), and traumatic brain injury (sudden trauma causes damage to brain and affects how it works). In addition, Resident 1 received services from occupational therapy for one day on 06/01/2023. Review of 05/31/2023 nursing admission assessment completed by Staff F, showed listed impairment on both sides of upper extremity (shoulder, elbow, wrist, and hand) under range of motion. Resident 1 was…

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

Based on observation, interview and record review, the facility failed to provide follow-up specialty care for 1 of 1 sampled residents (Resident 32) reviewed for bladder incontinence (inability to control urination.) This failure placed the resident at risk for further decline in their bladder function, frustration, and placed residents at risk for unmet needs. Findings included . A review of the record showed Resident 32 had diagnoses including stroke and overactive bladder. A quarterly assessment completed on 05/10/2023 showed Resident 32 was cognitively intact, was frequently incontinent of urine, and required limited assistance of one staff for toileting. The 07/24/2019 comprehensive care plan showed Resident 32 required extensive assistance at times for toileting, was able to call for assistance when needed, had urge incontinence (a sudden strong urge to urinate then unable to delay going to the toilet) related to muscle weakness, and used incontinence briefs. A urologist (a medical provider that specializes in diagnosing and treating diseases of the urinary system) progress…

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 follow provider orders for weight monitoring and maintenance of feeding tube equipment for 1 of 1 sampled residents (Resident 39), reviewed for tube feeding. This failure placed residents at risk of unidentified weight fluctuations, potential infections, and diminished quality of life. Findings included . According to the 07/09/2023 quarterly assessment, Resident 39 had diagnoses of anemia (body produces lower than normal amount of healthy red blood cells), diabetes (body doesn't make enough insulin or cannot use it as well as it should), dysphasia (swallowing difficulties) and moderate malnutrition (body is deprived of vitamins, minerals and other nutrients needed to maintain healthy tissue and organ function). Review of the Order Summary Report showed the following orders: - 03/31/2023 replace tube feeding syringe and tubing every 24 hours and as needed for tube feeding maintenance. - 04/01/2023 obtain weekly weights. Review of the 04/03/2023 nutritional care plan instructed staff to monitor weights as…

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 clean and maintain respiratory care equipment consistent with professional standards for 2 of 6 sampled residents (Residents 4 and 32), reviewed. This failure placed the residents at risk for contact with contaminated care equipment and potential respiratory infections. Findings included . <Resident 4> According to the 04/23/2023 annual assessment, Resident 4 had diagnoses that included obstructive sleep apnea (weakened muscles that cause narrowing or collapse of the airway during sleep resulting in fragmented sleep). Resident 4 was cognitively intact and used BIPAP/CPAP (bilevel positive airway pressure/constant positive airway pressure; machines that supply pressure to the airway via a mask to keep the airway open when sleeping.) The 05/03/2023 care plan showed the resident used CPAP related to sleep apnea. Staff were to apply CPAP per order, monitor and report signs and symptoms of respiratory distress, place on aerosol-generating procedure (AGP) precautions as needed (precautions using masks and other…

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 a resident for risk of entrapment, obtain informed consent and care plan for the use of bed rails for 1 of 2 sampled residents (Resident 44), reviewed for restraints. This failure placed residents at risk of entrapment, injury, and diminished quality of life. Findings included . The facility policy titled, Safety Device- Least Restrictive revised on 04/07/2023, showed that the facility required completion of a safety device data collection assessment and information evaluation when a resident showed an identified need for a safety device, or a safety device was in use. The policy further stated that risks versus benefits would be reviewed with the residents and/or their representative, provider order would be obtained, and a care plan would be initiated. According to the 06/13/2023 admission assessment, Resident 44 admitted to the facility on [DATE]. Resident 44 required extensive assistance of two staff for bed mobility. Resident…

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

Based on interview and record review the facility failed to ensure adequate weight monitoring for diuretic (medication that helps rid the body of water) medication use was completed per provider orders and care plan for 1 of 6 sampled residents (Resident 26), reviewed for unnecessary medications. This failure placed the resident at risk of dehydration, muscle weakness, and cardiac arrhythmias (problem with rate or rhythm of one's heartbeat). Findings included . According to the 06/24/2023 quarterly assessment, Resident 26 had diagnoses of fluid overload (condition where there was too much fluid volume in the body), heart failure (heart cannot pump enough blood to meet the body's needs for blood or oxygen), and respiratory failure (serious condition that makes it difficult to breathe on one's own because the lungs cannot get enough oxygen into the lungs). Review of Resident 26's record showed a provider order initiated on 04/01/2023 to obtain weekly weights and instructed nursing staff to notify the doctor of a weight gain of five pounds or more to monitor heart failure. Provider…

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 blood pressure medication (hydralazine) was administered according to the ordered parameters for 1 of 5 sampled residents (Resident 59) whose medication regimens were reviewed. Additionally, the facility failed to obtain an order and assess Resident 59 for the ability to safely keep at their bedside and self-administer an albuterol (medication to open the airway when short of breath) rescue inhaler. This failure placed the resident at risk for adverse cardiovascular events, insufficient monitoring of medication effects, and placed the resident at risk for adverse events related to medication errors. Findings included . According to a review of the record, Resident 59 was admitted on [DATE]. A quarterly assessment completed on 07/21/2023 showed Resident 59 had diagnoses including high blood pressure, chronic obstructive respiratory disease (COPD, increased mucus and inflammation in the lungs that causes difficult breathing) and…

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

Based on observation and interview, the facility failed to store resident foods as required in 2 of 2 nursing unit kitchenettes. This failure placed residents at risk for foodborn illness and decreased quality of life. Findings included . On 08/02/2023 at 11:10 AM, the North Unit kitchenette was observed. There were two refrigerators in the room. The first refrigerator contained many half sandwiches that had been prepared by the facility kitchen: -7 peanut butter and jelly sandwiches were dated 07/28/2023. -1 peanut butter and jelly and 4 meat and cheese sandwiches were dated 07/29/2023. -1 meat and cheese and 3 peanut butter and jelly sandwiches were dated 07/30/2023. -1 meat and cheese sandwich was dated 07/31/2023. - 6 meat and cheese and 5 peanut butter and jelly sandwiches were dated 08/01/2023. None of the sandwiches included a use by date. An open half pint carton of milk was in the refrigerator door. The milk was not dated when opened. The second larger refrigerator contain resident foods brought in from outside sources. -A Styrofoam carton of chow main for was dated…

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 fit testing (a test done to ensure an N95 mask formed a tight seal) was completed for 3 of 13 staff (E, H, and Q) reviewed for fit testing. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by the SARS-CoV-2 virus. According to the 09/03/2021 Center for Disease Control publication, Fit Testing, Fit testing should be done at least annually to ensure the respirator (N95) continued to fit properly. In addition, a new fit test should be performed if a new brand, model, or size of respirator was used, and when there were changes to weight or facial/dental alterations, as all of these factors can change how the respirator forms a seal. On 07/24/2023 at 8:40 AM, a sign at the reception desk in the lobby of the facility stated there was active COVID-19 in the building. When asked, Staff N, Director of Nursing, stated there was one resident who had tested positive for COVID-19, and staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident was offered an influenza and/or pneumococcal immunization as required for 2 of 6 sample residents (62, 65) reviewed for immunizations. This failure prevented the residents from making decisions about their care, and placed the residents at risk for illness, and possible health complications. Findings included . The Center for Disease Control (CDC) has different guidelines for the schedule of pneumococcal vaccinations depending on age, medical conditions, and previous vaccination history. Per 02/17/2022 guidelines: Anyone ages 19-[AGE] years of age with certain underlying medical conditions, other risk factors, or those who have not previously received a pneumococcal conjugate vaccine, or who have an unknown vaccination history; 1 dose PCV15 or 1 dose of PCV20 should be given. If PCV15 is used, a dose of PPSV23 should be given at least one year later. For those who are 65 years or older who have not received a pneumococcal conjugate…

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.