Spokane Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to routinely inform and provide written information regarding the right to formulate an advance directive (legal document that oulined wishes for medical care if a person was unable to make decisions for themselves) for 4 of 19 sampled residents (Resident 3, 15, 69, and 263), reviewed for advanced directives. This failure placed residents at risk of not being able to exercise their rights, not having their wishes honored, and a diminished quality of life. Findings included . Review of the facility policy titled Advance Directives dated March 2023, showed residents would be provided with written information concerning the right to formulate an advanced directive if they chose to do so. If the resident was incapacitated and unable to receive information about their right to formulate an advanced directive, the information may be provided to the resident's legal representative. Upon admission, the Social Service Director or designee would inquire of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to routinely provide residents and/or their representatives oral and written information on how to apply for and use Medicare and/or Medicaid benefits for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. This failure placed residents and/or their representatives at risk of not being fully informed of their Medicare/Medicaid rights, unmet care needs, and a diminished quality of life. Findings included . <Resident 12> According to the 03/09/2025 admission assessment, Resident 12 admitted to the facility on [DATE] with diagnoses which included muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. Review of the March 2025 nursing progress notes showed no documentation the admission agreement that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare 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 routinely inform cognitively intact residents and/or their legal representatives, of items and services included in nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. Additionally, the facility failed to provide the required beneficiary notices for 2 of 3 sampled residents (Residents 19 and 85), reviewed for required notices and associated choices related to Medicare services ending. These failures placed residents at risk of not being fully informed of their rights and/or financial responsibilities, unmet care needs, and diminished quality of life. Findings included . Review of the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) form showed it provided information to Medicare beneficiaries so that they could decide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider for 3 of 4 sampled residents (Resident 16, 41, and 90), reviewed for hospitalization. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and diminished quality of life. Findings included . <Resident 41> According to the 02/10/2025 admission assessment, Resident 41 admitted to the facility on [DATE] with diagnoses including spinal cord compression (pressure on the spinal cord). Resident 41 was cognitively intact and able to clearly verbalize their needs. Review of the 03/19/2025 neurosurgeons (doctor that specialized in nerve, brain, and spinal cord surgery)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and provide written information regarding bed holds (the right to pay the facility to hold their room or bed while hospitalized or on therapeutic leave) upon admission for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission and upon transfer to the hospital for 4 of 4 sampled residents (Resident 19, 16, 41, and 90), review for hospitalizations. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized or on therapeutic leave. Findings included . An undated facility policy titled Bed Hold showed that the facility would inform the residents or their representatives in writing of the bed hold return policy at the time of admission. A second written notice was provided at the time of transfer, or in cases of emergency transfer, within 24 hours. The policy also showed the facility would document multiple attempts to reach the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan was developed that contained resident-specific goals and interventions which included the minimum healthcare information necessary to properly care for each resident immediately upon their admission for 4 of 6 sampled residents (Resident 313, 312, 33, and 263) reviewed for baseline care plans. Failure to develop a baseline care plan for Resident 313 related to hospice and nutrition, failiure to develop a baseline care plan for Resident 263 for nutrition, and failure to develop baseline care plans for both Residents 312 and 33 related to Multiple Sclerosis (MS), a disease where the immune system attacks the nerves which resulted in various symptoms such as fatigue, difficult coordination, muscle weakness, and vision changes, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 313> The 03/31/2025 admission assessment documented Resident 313 admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to repeatedly ensure care plans were developed that included resident specific goals and interventions related to their specific care needs for 3 of 60 sampled residents (Residents 264, 60, and 311), reviewed for care planning. Failure to develop care plans for Residents 264 for nail care, Resident 60 for shaving preferences, and for Resident 311 related to hospice placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 264> The 04/04/2025 quarterly assessment documented Resident 264 was admitted to the facility on [DATE] and had diagnoses which included stroke, traumatic brain injury, muscle weakness, and was dependent on nursing staff to complete activities of daily living for personal hygiene such as nail care. On 04/14/2025 at 1:56 PM, Resident 264 was observed lying in bed wearing a hospital gown. Resident 264's fingernails were observed to have dark brown matter underneath 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 ensure services provided consistently and routinely met professional standards of practice for 12 of 13 sampled residents (Resident 6, 262, 69, 16, 41, 83, 312, 63, 65, 311, 79, and 85), reviewed for skin conditions, constipation and accidents. Failure of staff to monitor wounds, follow and/or clarify physician orders when indicated, develop and implement an effective fall prevention policy and consistently monitor residents for injury after falls, placed residents at risk for a delay in treatment, injury, hospitalization, and a diminished quality of life. Findings included . The American Nurses Association (ANA) is a national professional organization that represents the interests of registered nurses in the United States and sets and promotes high standards of nursing practice to ensure quality and ethical care for patients. The ANA developed the document, Nursing: Scope and Standards of Practice, with its fourth edition released in…

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

Based on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 5 sampled staff (Staff K, L, and M), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and a diminished quality of life. Findings included . <Staff K > Review of Staff K's, Nursing Assistant, personnel file showed they were hired on 04/01/2023. No documentation of a performance evaluation was found. <Staff L> Review of Staff L's, Nursing Assistant, personnel file showed they were hired on 11/29/2023. No documentation of a performance evaluation was found. <Staff M> Review of Staff M'S, Nursing Assistant, personnel file showed they were hired on 12/06/2023. No documentation of a performance evaluation was found. In an interview on 04/23/2025 at 3:18 PM, Staff A, Administrator, acknowledged Staff K, L, and M did not have performance evaluations on file. Staff A stated they expected staff to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post nurse staffing information on a daily basis, as required for 4 of 4 months (January, February, March and April 2025), reviewed. This failure resulted in residents, families and visitors not being fully informed of the facility's current staffing levels and resident census information. Findings included . During an observation on 04/14/2025 at 10:19 AM, daily staffing information was not posted in a prominent place readily accessible to residents, families, and/or visitors. Similar observations were made at 1:15 PM, on 04/15/2025 at 8:28 AM, 9:50 AM, and 11:21 AM, on 04/16/2025 at 8:23 AM, 12:04 PM, 2:33 PM, on 04/17/2025 at 8:21 AM, on 04/18/2025 at 8:35 AM, 10:45 AM, and 3:17 PM, on 04/21/2025 at 4:17 AM and 7:45 AM. During observation and interview on 04/21/2025 at 8:21 AM, Staff N, Staffing Coordinator, stated nurse managers were to post the daily head count staffing information. Staff N walked the surveyor to Staff C, Assistant Director of Nursing's office. Staff N asked Staff C for 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 consistently ensure 2 of 3 sampled medication carts (Med Bridge unit carts 1 and 2) were free from expired medications, and medications were labeled and disposed of properly when unused. In addition, the facility failed to consistently ensure controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenic) were securely stored and monitored for loss or diversion as required for 1 of 2 sampled medication rooms (Med Bridge unit) reviewed for medication storage, and failed to ensure medications were stored securely for Resident 95 who was observed to have medicaiton in their room. Findings included . MEDICATION CARTS An observation of the Med Bridge Unit Cart 1 on 04/24/2025 at 9:09 AM showed opened insulins of Humalog Lispro dated 03/21/2025 and Novolin R dated 3/18/2025. Staff H, Licensed Practical Nurse (LPN), acknowledged the insulins were beyond the expiration date of 28 days and that they should have been discarded. An observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional assessments were completed accurately and timely for 4 out of 5 sampled residents (Residents 60, 88, 313, and 263), accurate and timely weights were obtained after a significant weight loss occurred (Resident 60), and the required nutritional supplements were available and/or provided (Residents 88 and 313). These failures placed the residents at risk for weight loss, unmet nutritional needs, and a diminished quality of life. Findings included . Review of a 05/25/2023 facility policy titled, Weight Assessment and Intervention showed, the facility strived to prevent, monitor and intervene for undesirable weight loss for the residents. The policy defined a significant weight change as, 5% [percent] in one month, 7.5% in 3 months, and 10% in 6 months, and anything above these percentages considered a severe weight change. The policy instructed the staff to weigh residents upon admission and if no weight concerns were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 8 of 9 sampled residents (Residents 262, 63, 89, 56, 3, 15, 47, and 16) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, potential weight loss, and a diminished quality of life. Findings included . <Resident 262> Review of a 04/03/2025 admission assessment showed Resident 262 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the resident was cognitively intact. In an interview on 04/14/2025 at 10:28 AM, Resident 262 stated, The food is not good. The cold food is lukewarm, and the hot food is cold. There is no variety, and the portion sizes are small. An observation and interview on 04/17/2025 at 11:38 AM showed, the staff delivered a lunch tray to Resident 262's room. Resident 262 stated of the meal, It's actually hot. First time I've had [the meal hot] in a week. You need to come more often. An observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety. Specifically, some foods were not labeled with the date opened or type of food item, labeled with a resident name (in the nourishment refrigerators) or discarded when expired. Additionally, the facility failed to maintain a clean kitchen environment, ensure dietary personnel wore appropriate hair coverings that fully covered their hair and performed hand hygiene when indicated. These failures placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the facility policy titled Food Brought by Family/Visitors dated February 2019 documented, perishable foods must be stored in the refrigerator. The policy instructed staff to label containers with the resident's name, and a use by date as appropriate. During the initial kitchen tour on 04/14/2025 at 9:02 AM with Staff GG, Kitchen Manager, the following 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 hand hygiene was followed during medication administration and wound care for Resident 89 and during the observation of the lunch meal service, failed to serve food in a sanitary manner for an unidentified resident, failed to ensure signage was placed to inform the staff of residents (Resident 6, 88, 89, 462 and 82) who required Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, germs that are resistant to many antibiotics]), failed to sanitize equipment between resident use, and failed to timely change and maintain infection control practices for a central line (a thin, flexible tube inserted into a large vein until the tip rested in a major vein near the heart) for Resident 89. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . ENHANCED BARRIER PRECAUTIONS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an established Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics (ABT) for newly admitted residents or those prescribed an ABT by community providers for 3 of 3 months (January, February, and March 2025) reviewed for infection control practices. This failure increased resident risk for multi-drug-resistant organisms (MDRO, germs that are resistant to many antibiotics) and had the potential for adverse outcomes with inappropriate and/or unnecessary use of ABT. Findings included . The 08/2023 facility policy titled Administrative Infection Control Processes documented the elements of the Infection Prevention and Control program included antibiotic stewardship. The staff used surveillance data to determine whether ABT usage patterns required change. The policy documented the facility used McGeer Criteria, a set of standardized definitions that helped identify potential infections and guided appropriate ABT use. A review of Monthly Infection Surveillance Logs for January, February, 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 repeatedly ensure residents' call lights were readily accessible for 2 of 4 sampled residents (Resident 21 and 65), reviewed for resident call systems. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and a diminished quality of life. Findings included . <Resident 21> The 03/29/2025 quarterly assessment documented Resident 21 had diagnoses that included muscle weakness and left below the knee amputation. Resident 21 was dependent on staff assistance to perform most activities of daily living (ADLs). Resident 21 had moderate cognitive impairment and was able to clearly verbalize their needs. The 01/09/2025 care plan documented Resident 21 was at risk for falls related to lower extremity weakness, impaired physical mobility, and a history of falls. Staff were instructed to anticipate Resident 21's needs, provide education and remind the resident to use their call light to request assistance with ADLs. On 04/14/2025 at 9:09 AM, Resident 21's room was observed. The right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was assessed for their ability to self-administer their medications safely for 1 of 5 sampled residents (Resident 22) reviewed for medication administration. This failure placed the resident at risk for adverse side effects or unintended health consequences if under- or over-medicated. Findings included . The 04/01/2025 significant change in condition assessment documented Resident 22 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affected movement), and acid reflux (stomach acid irritates the lining of the esophagus). Resident 22 had moderate cognitive impairments and was able to make their needs known. On 04/14/2025 at 1:33 PM, Resident 22 was observed in their room lying in bed. The resident had a bottle of Tums chewable tablets on their overbed table. Resident 22 stated they took the Tums whenever they needed them. Subsequent observations of the Tums chewable tablets on Resident 22's tray table were made on 04/15/2025 at 12:12 PM, 04/16/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure a clean, comfortable and homelike environment for 3 of 7 residents (Resident 56, 64, and 69) reviewed for environment. Specifically, Resident 56's call light button was dirty, Resident 64's wheelchair was not maintained in a clean manner, and Resident 69's sheets were not changed regularly. These failures placed the residents at risk of a diminished quality of life. Findings included . <Resident 56> According to a comprehensive assessment dated [DATE], Resident 56 had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes chronic respiratory symptoms) and depression. Resident 56 made their needs known and was able to eat independently after their food was set up by staff. On 04/14/2025 at 2:47 PM, Resident 56 was observed in their bed with an unkempt appearance. Their fingers were tightly contracted with limited movement other than their thumbs. Their fingernails were long with brown matter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 7 sampled residents (Resident 264, 79), reviewed for Pre-admission Screening and Resident Review (PASARR, an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was completed prior to admission, accurately, and if indicated, a referral for a PASARR Level II (a more in-depth screening assessment) had been made. Specifically both residents admitted to the faciity with an exempted hospital stay and should have been referred for a Level II evaluation after they remained in the facility for more than 30 days. This failure placed the residents at risk for unidentified care needs related to their mental health. Findings included . <Resident 264> The 04/04/2025 quarterly assessment documented Resident 264 admitted to the facility on [DATE] from the hospital and had diagnoses which included traumatic brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan revisions were completed and failed to ensure care plan conferences were held for 3 of 60 sampled residents (Resident 33, 38, and 85) reviewed for care planning. Failure to ensure Residents 33 and 85's care plans were revised to include interventions after the resident;s care needs had changed, and failure to conduct care plan conferences as required for Resident 38, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 33> The 02/03/2025 significant change assessment documented Resident 33 admitted to the facility on [DATE], was cognitively intact to make decisions regarding their care, had diagnoses which included medically complex conditions, and needed substantial assistance from nursing staff to reposition while in bed. In addition, the assessment documented Resident 33 had pressure ulcers (wounds caused from prolonged pressure, friction, and/or shearing to the skin), had…

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

Based on observation, interview and record review, the facility failed to ensure a resident's CPAP machine (a machine connected to a mask, that kept airways open while sleeping) was functional and failed to accurately document its use for 1 of 1 sampled resident (Resident 17) investigated for respiratory care. This failure placed the resident at risk of worsening health complications. Findings included . According to the 03/26/2025 admission assessment, Resident 17 had diagnoses which included heart failure (where the heart cannot pump enough blood for the body's needs), Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes chronic respiratory symptoms and airflow limitations) and obstructive sleep apnea (OSA, a condition where the airway becomes blocked during sleep, causing pauses in breathing). The resident was alert and able to make their needs known. A review of the medical record showed the following provider orders for use of their CPAP machine: 1) CPAP home setting, to be worn at bedtime every evening and night shift, started on 03/20/2025. 2) CPAP on at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 31) reviewed for prosthesis (an artificial limb designed to replace the function of an amputated or missing arm or leg) received the care and assistance required to be able to use the prosthesis. This failure placed the resident at risk for decreased mobility and balance, delayed discharge from the facility to the community, and a diminished quality of life. Findings included . An undated facility policy titled, Artificial Limb - Prosthesis showed, staff would assist the resident in caring for their prosthesis to encourage resident function and safety. The policy showed the use of the prosthesis would be addressed in the resident's plan of care. Care instructions included washing, rinsing, and drying the socket (the device that joins the residual limb [stump] to the prosthesis) every day, inspecting the prosthesis for loose or worn parts at least once each week, reporting the findings to the nurse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it obtained all treatment-related documentation from the dialysis center and the medical records showed the accurate dialysis access site and location of the dialysis center for 1 of 1 sampled resident (Resident 88) reviewed for dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys failed to do so). This failure placed the resident at risk for delayed treatment and post-dialysis complications. Findings included . Review of a 03/22/2025 admission assessment showed Resident 88 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the resident was cognitively intact and received dialysis services. Review of 03/16/2025 hospital transfer orders showed a dialysis access site to the left subclavian (a large blood vessel located beneath the collarbone used for central line [a flexible tube inserted into a large vein near the heart placement used to deliver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident food preferences were honored for 3 of 13 sampled residents (Residents 15, 63 and 89) reviewed for food preferences. This failure placed the residents at risk of unintended weight loss, less pleasure in dining and diminished quality of life. Findings included . <Resident 15> The 01/01/2025 quarterly assessment documented Resident 15 was cognitively intact and was able to make their needs known. On 04/16/2025 at 12:05 AM, Resident 15's meal was observed. They were served barbequed ribs and mashed potatoes. Resident 15 stated they were upset. They had ordered the shrimp scampi and filled out their menu twice. Resident 15 attempted to eat the ribs and stated they were going return their meal. On 04/17/2025 at 12:13 AM, Resident 15's meal included a chicken patty, green beans and mashed potatoes. Resident 15 stated they had ordered the alternate menu choice but their menu must have been lost. They stated they had filled out their menu twice and had given it to an aide. They were going to request a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 88 and 6) reviewed for infection control practices, received vaccinations for influenza and pneumonia as consented to. This failure placed the residents at risk of contracting pneumonia and influenza and potential complications associated with those illnesses. Findings included . Review of the 08/10/2023 facility policy titled Influenza Vaccine documented the facility offered residents an influenza vaccine within 5 working days of their admission to the facility between October 31st and March 31st (generally accepted as influenza season) each year. Review of the undated facility policy titled Pneumococcal Vaccine documented that before or upon admission, the staff assessed residents for eligibility to receive the pneumococcal vaccine series and, if indicated, offered the vaccine within 30 days of admission to the facility, unless previously received or medically contraindicated. <Resident 88> The 03/22/2025…

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

Based on observation, interview and record review, the facility failed to ensure equipment was maintained in a safe operational condition for 1 of 4 sampled residents (Resident 17) reviewed for environment. This failure placed the resident at risk of possible injury. Findings included . According to the 03/26/2025 admission assessment, Resident 17 was cognitively intact to make decisions regarding their care and able to make their needs known. On 04/15/2025 at 11:11 AM, Resident 17's call light/television (TV) cord was observed with various colored wire cords exposed near the control. The resident stated they told staff and asked if it could be replaced, but nothing had been done about it. Similar observations of the call light/TV cord with exposed wires were made on 04/17/2025 at 11:30 AM, 04/18/2025 at 1:45 PM, 04/21/2025 at 7:35 AM, and on 04/22/2025 at 9:22 AM. During an interview on 04/23/2025 at 9:26 AM, Staff G, Maintenance Director, stated if a call light was not working, there was usually a spare one in a drawer in the nurses station. For any non-urgent maintenance issues,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a sanitary, comfortable and homelike environment for 1 of 7 sampled residents (Resident 87) reviewed for environment. This failure placed the resident at risk of an unpleasant, uncomfortable living environment and a decreased quality of life. Findings included . The 03/24/2025 quarterly assessment documented Resident 87 had diagnoses including heart failure, high blood pressure and depression. Resident 87 was cognitively intact and able to make their needs known. In an observation on 04/14/2025 at 1:33 PM, upon entrance to shared room [ROOM NUMBER], there was a very strong foul odor that resembled sweat and urine. The odor became stronger as you passed Resident 87's side of the room. Resident 87 shared a room with Resident 22. The 04/01/2025 significant change in condition assessment documented Resident 22 had diagnoses including diabetes, high blood pressure and depression. Resident 22 had moderately cognitive impairments and was able to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and treatment for 3 of 3 sample residents (Residents 1, 2, and 3), who had surgically inserted devices to provide intravenous (IV) access. Specifically, the facility failed to show adequate monitoring of the IV site, document maintenance flushes, and change site dressings as required. These failures placed the residents at risk for medical complications associated with the use of IV devices. Findings included . Review of a 02/21/2024 Centers for Disease Control (CDC) article showed, a central line (CL) is a catheter (tube) placed in a large vein in the neck, chest or groin to give medication or fluids or to collect blood for medical tests. Central lines accessed a major vein close to the heart, could remain in place for weeks or months, and were much more likely to be a source of serious infection. Types of CL include a peripherally inserted central catheter (PICC, placed into a vein in the arm), a tunneled…

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

Based on observation and interview, the facility failed to ensure the staff secured topical (applied on the skin) medications for 1 of 4 units observed. This failure placed residents at risk for medication errors and accidental ingestion. Findings included . An observation on 04/04/2025 at 10:17 AM showed Staff C, Licensed Practical Nurse, walked out of a room in the back end of the Northwest Unit (Rooms 130 to 135) and head to the medication cart parked in the hall near those rooms. Observed about two rooms down from the medication cart and towards an exit door was a treatment cart. On top of the treatment cart were four food boats (disposable food packaging designed to hold a variety of foods), each identified with a forename. One boat had a medication cup with white powder inside, another had a medication cup with a white cream inside. Another boat had two medication cups, one with green cream and the other with white powder inside. Yet another boat had a medication cup with green cream inside. On 04/04/2025 at 10:18 AM, the above findings were shared with Staff C who was still…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written abuse policies and procedures related to monitoring for psychosocial harm after abuse and/or neglect allegations for 4 of 6 residents (Residents 7,8, 9 and 10). This failure placed residents at risk for unmet care needs related to possible psychosocial harm. Findings included . Review of the facility policy titled, Abuse revised 10/20/2022, showed the facility would maintain and implement policies and procedures to prohibit and prevent abuse that would include: in the event of an allegation or observation of abuse, the facility will immediately assess the resident . The policy further states that the resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. <Resident 7> Review of Resident 7's medical record showed they were admitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (ongoing lung disease caused by damage to the lungs) and heart failure (failure of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate records for 9 of 10 sampled residents (Residents 1, 2, 3, 4, 5, 6, 12, 13 and 14) whose medical records were reviewed. Failure to ensure completed consents for psychotropics (drugs that affect a person's mental state), signed nutrition documents, accurate documentation in progress notes, complete discharge paperwork, complete assessment and monitoring, accurate code status within a resident chart, and an accurate weight record, placed the residents at risk for unmet needs. Findings included . <Incomplete Psychotropic Consents> <Resident 2> Review of Resident 2's medical record showed an undated consent for Lexapro (a psychotropic) signed by Resident 2. The form showed no documentation who reviewed the form with the resident, and the areas to be addressed by staff with the resident were left blank. Similar findings were identified with a [DATE] consent for mirtazapine (a psychotropic). <Resident 3> Review of Resident 3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration for 2 of 7 sampled residents (Residents 1 and 2) whose medications were reviewed. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included . <Resident 1> Record review showed Resident 1 admitted to the facility on [DATE] with orders for the staff to administer sertraline, a psychotropic. Review of the December 2024 and January 2025 Medication Administration Records (MAR) showed the staff administered sertraline daily, starting 12/12/2024 through 01/16/2025. Review of a medication consent for sertraline showed the facility discussed the risks, benefits, purpose, and side effects of the medication with Resident 1's Power of Attorney for healthcare on 01/01/2025, 21 days after the resident's admission to the facility. <Resident 2> Review of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident representative of a significant weight loss experienced by 1 of 7 sampled residents (Resident 1) reviewed for nutrition. This failure placed the resident at risk for delayed decisions for treatment by the legal representative. <Resident 1> In an interview on 02/04/2025 at 12:06 PM, a Collateral Contact stated that on a visit with Resident 1, they observed the resident, looked terrible, skinny. In an interview on 02/05/2025 at 2:47 PM, another Collateral Contact stated that when they visited Resident 1, they were, not touching food when food was in front of [them]. Review of a 12/17/2024 comprehensive assessment showed Resident 1 admitted to the facility on [DATE], had severe cognitive impairment, and required assistance for eating. Record review also showed Resident 1 had a Power of Attorney (POA) for medical decision-making. Review of a 12/11/2024 hospital discharge summary showed Resident 1's weight at 178.9 pounds. Review of the…

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

Based on interview and record review, the facility failed to complete a thorough investigation into allegations of neglect, to include a skin assessment, for 1 of 5 residents (Resident 11) reviewed for abuse and/or neglect. Failure to complete a skin assessment placed the resident at risk for unmet care needs and diminished quality of life. Findings included . Review of a 01/10/2025 facility investigation noted that Resident 11 was found soaking wet, with brown urine rings soaked through [their] bedding and stool stuck to [their] bottom. The facility investigation noted that a skin check was completed and no skin issues noted. Record review on 02/06/2025 did not find a skin check for that date in Resident 11's medical record or in the facility investigation. A skin assessment was found for 01/08/2025 at 3:56 PM with no skin concerns in the groin region noted. On 01/12/2025 Resident 11 received assistance with a shower and no skin concerns were noted at that time. In an interview with Staff C, Director of Nursing, on 02/10/2025 at 10:32 AM, they stated that a skin check needed 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 observation, interview, and record review, the facility failed to ensure 5 of 12 dependent residents (Residents 1, 2, 3, 6, and 7), reviewed for activities of daily living (ADL's), received the appropriate number of showers per week. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 1> A facility assessment, dated 01/06/2025, showed Resident 1 was admitted on [DATE] with diagnoses which included a recent stroke with left sided weakness and colon perforation with a new ileostomy (surgical procedure where a diversion from the intestine to the outside of the abdomen is made to divert stool from the body). The Resident was not able to make their needs known and was dependent on staff for showers. Review of the Resident's shower record from 12/30/2024 to 01/21/2025 showed Resident 1 was scheduled for showers on Monday and Friday evenings. The record showed that the Resident received a shower on 12/31/2024 at 2:43 AM and on 01/13/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff obtained accurate and timely weights, to include weights on admission and/or ongoing weights per the medical provider order, for 6 of 12 sampled residents (Residents 1, 2, 3, 5, 6, and 7), reviewed for nutrition. Further findings included failure to provide required assistance with meals for 1 of 12 sampled residents (Resident 1). These failures placed the residents at risk for unrecognized, unplanned, weight loss and nutritional complications. Findings included . <Resident 1> A facility assessment, dated 01/06/2025, showed Resident 1 was admitted on [DATE] with diagnoses which included a recent stroke with left sided weakness, colon perforation with a new ileostomy (surgical procedure where a diversion from the intestine to the outside of the abdomen is made to divert stool from the body) and need for enteral nutrition (nutrition provide in liquid form through a tube inserted through the nose and then into the stomach). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care according to the medical provider orders for 2 of 12 sampled residents (Resident 1 and 3) reviewed for quality of care. Specifically, Resident 1 did not have their vital signs monitored per the medical provider orders and Resident 3 was on a fluid restriction but did not have evidence that the restriction was monitored. These failures placed residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 1> Resident 1's care plan dated 12/30/2024, showed they were admitted on [DATE] with diagnoses which included a recent stroke with left sided weakness, colon perforation with a new ileostomy (surgical procedure where a diversion from the intestine to the outside of the abdomen is made to divert stool from the body) and need for enteral nutrition (nutrition provide in liquid form through a tube inserted through the nose and then into the stomach). The same care plan had a focus for enteral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently implement infection control standards related to handling of contaminated laundry (laundry which has been soiled with blood/body fluids or other potentially infectious materials), for 5 of 13 residents. This failure placed residents at risk for exposure to an infectious disease. Findings included . During general facility observations on 11/13/2024 at 11:58 AM, Resident 1 was observed to have a collateral contact with them in their room. When both were asked how things were going at the facility the collateral contact displayed a white plastic bag with dirty laundry in it and stated that they had brought a bag from home to pick up Resident 1's dirty laundry. They stated that they thought the facility was washing Resident 1's laundry but had noticed on previous visits, Resident 1's room had been messy. They further stated that they had just collected dirty laundry from Resident 1's wheelchair and out of the bottom of their closet. They stated that one pair of sweatpants in the wheelchair had been wet, and 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 2 of 9 residents (Resident 7 and 8) reviewed for range of motion/mobility, received monitoring and consistent treatment for identified range of motion limitations. This failure placed the residents at risk for avoidable range of motion declines. Findings included . <Resident 7> Review of Resident 7's medical record showed they admitted to the facility on [DATE] with diagnosis of Parkinsonism (clinical syndrome characterized by tremor, rigidity and postural instability) and generalized muscle weakness. A quarterly assessment, dated November 8, 2024, showed the resident had no functional limitation in range of motion for their upper extremities, but had functional limitation for both of their lower extremities. Review of Resident 7's care plan, dated 11/10/2023, showed that they required total assistance from two staff for transfers using a mechanical lift (a hydraulic lift used to move residents who have a medical condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure physician ordered medications were available as ordered for 4 of 5 residents (Resident 1, 4, 5 and 6) and that medications were administered per the direction of the physician order for 2 of 5 (Resident 1 and 4) residents reviewed for quality of care. This failure placed residents at risk of not receiving necessary care and a diminished quality of life. Findings included . <Resident 1> Record review showed that Resident 1 re-admitted to the facility from the hospital on [DATE] with diagnosis including Enterocolitis due to Clostridium difficile (a bacteria that causes an infection of the bowel causing abdominal pain, nausea and diarrhea), Diabetes (a chronic disease that happens when the body cannot process sugar) and End Stage Renal Disease requiring dialysis (the kidneys have stopped working and a process for cleaning waste products from the blood (dialysis) is required to live). Review of the hospital Discharge summary dated [DATE] at 11:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 3 of 3 sampled resident (Residents 1,2 and 3), reviewed for dialysis. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . The facility policy, End Stage Renal Disease - Care of Resident, undated, stated that Agreements between this facility and the contracted ESRD (end stage renal disease) facility will include all aspects of how the resident's care will be managed including but not limited to: .the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration. The policy further states that the nursing facility staff will provide immediate monitoring and documentation of the status of the resident's condition and resident's access site(s)…

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

Based on interview and record review, the facility failed to protect the residents' right to be free from neglect for 2 of 5 residents (Resident 7 and 8). The failure to provide incontinence care to residents who were identified by nursing staff to have been incontinent, and required staff assistance for toileting and incontinence care, resulted in a possible diminished quality of life. Findings included . <Resident 7> Record review showed Resident 7 had admitted to the facility in April of 2024 with diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrolled movements) and dementia (a loss of thinking, remembering and reasoning skills). Review of Resident 7's care plan, dated 04/20/2024, showed that Resident 7 required assistance from one staff with toilet use and was incontinent. <Resident 8> Record review showed Resident 8 had admitted to the facility in April of 2024 with diagnoses of Parkinson's Disease, and a need for assistance with personal care. Review of Resident 8's care plan, dated 04/03/2024 and revised on 11/10/2023, showed that Resident 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the discharge summary was completed that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) for 3 of 3 sampled residents (Residents 2, 3 and 4) reviewed for discharge planning. This failure put residents at risk of complications and delayed treatment of medical conditions by not having the necessary information to ensure continuity of care when discharged to the community. Findings included . During an interview on 08/28/2024 at 10:25 PM, Staff C, Resident Care Manager, stated that the facility practice was to print out medication reconciliation paperwork prior to a resident discharging from the facility. The paperwork was then given to the nurse assigned to work with the resident on the day of their discharge. The assigned nurse would then go over the medications on the list with the resident, or their designee, to make sure they understood the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure several high risk medications, antidepressants (a medication used to treat low mood) and anticoagulants (a medication used to prevent blood clots), were consistently monitored for 3 of 5 sample resident (1,2 and 7) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical complications. Findings included . <Resident 1> Review of resident 1's medical record showed that they were admitted to the facility on [DATE] and at that time were taking an antidepressant (AD) medication one time daily. Review of their July and August 2024 Medication Administration Record (MAR) showed Resident 1 was being administered an AD medication in the morning daily. Neither the July nor the August MAR had a monitor for recording possible side effects of this medication. <Resident 2> Review of Resident 2's medical record showed that they were admitted to the facility on [DATE] and during their stay…

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

Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 1 of 3 sampled residents (1) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . Record review showed that on 08/04/2024 AT 3:30 PM an unidentified facility staff member notified Staff B, Director of Nursing that they had overheard Staff E yell at Resident 1. The facility was found to have not reported the incident to the required State Survey Agency until 08/05/2024 at 8:34 PM. In an interview at 1:02 PM on 08/29/2024, Staff A, Administrator, stated that the time frame for reporting abuse allegations to the required State agency is two hours and they were not sure why that had not happened in this case. They further stated that staff in the facility know that they are mandatory reporters and that they need to report abuse allegations promptly. Reference: (WAC) 388-97-0640 (5)(a)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to repeatedly prepare discharge summaries that include all the required components, complete a final summary of the resident's status upon discharge, complete a discharge plan of care with all the required components, and convey discharge information to the provider continuing care for 3 of 6 sampled residents (Resident 6, 7, and 8), reviewed for discharge planning. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Transfer or Discharge, Preparing a Resident for dated 10/2021, showed a post-discharge plan would be developed for each resident prior to their discharge or transfer and reviewed with the resident and/or their representative at least 24 hours prior to the resident's discharge or transfer. The policy instructed nursing or social service staff to obtain orders for discharge or transfer with recommended services and equipment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately transcribe and implement provider orders, routinely monitor and evaluate residents' conditions, consistently implement care interventions, routinely monitor, evaluate, and/or revise interventions as appropriate, and provide needed care and services for 3 of 8 sampled residents (Resident 2, 5, and 6), reviewed for quality of care. This failure placed residents at risk of medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Weight Assessment and Intervention dated 10/2021, showed residents would be weighed upon admission as ordered by the provider and recorded in the resident's medical record. Weights would be reviewed by designated dietary staff [based on frequency of weights] to follow individual weight trends over time. The policy further showed unplanned weight changes or impaired nutrition risks would be care planned with input from the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to repeatedly identify risks, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 2 sampled residents (Resident 1 and 2), reviewed for substance use disorder. In addition, the facility failed to accurately and routinely assess elopement risk for 4 of 6 sampled residents (Resident 1, 3, 4, and 11), reviewed for accidents and supervision. This failure placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life. Findings included . Review of the undated facility policy titled, Substance Use Disorder showed the admissions coordinator would notify the Director of Nursing (DNS) and Social Service department of a new admission referral with a substance use disorder with the risk for relapse. Social Services and the DNS would review the referral to determine if the facility was capable of providing adequate care and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify and implement interventions to prevent urinary tract infections (UTI) and restore continence to the extent possible for 2 of 8 sampled residents (Resident 9 and 10), reviewed for quality of care. This failure placed resulted in Resident 9 and Resident 10 experiencing recurrent UTIs, placed residents at risk of development of multidrug resistant organisms and diminished quality of life. Findings included . The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to UTI showed urinary tract includes the bladder [organ in pelvis that stores urine], urethra [tube which urine leaves the body] and kidneys [remove waste and extra water from the blood as urine]. UTIs are common infections that happen when bacteria, often form the skin or rectum, enter the urethra and infect the urinary tract any time you take antibiotic, they can cause side effects. Side effects can include rash, dizziness, nausea, diarrhea,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to repeatedly implement antibiotic protocols to ensure antibiotics were appropriately prescribed, and routinely implement a facility-wide system to monitor antibiotic use for 2 of 3 sampled residents (Resident 9 and 10), reviewed for infection control. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life. Findings included . Review of the facility undated policy titled, Infection Prevention and Control Program showed infection surveillance tools were used to recognize the occurrence of infections, record their number and frequency, detect outbreaks, and monitor adherence to infection prevention and control practices. The policy showed McGeer Constitutional Criteria (guidelines to assess antibiotic initiation appropriateness) was used to help recognize and mange infections. Culture reports, sensitivity date, and antibiotic usage was evaluated as part of antibiotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medications as ordered by the provider, monitor for potential side effects of missed medication doses and ensure freedom from significant medication errors for 2 of 7 sampled residents (Resident 1, and 2), reviewed for medication administration. This failure placed residents at risk of medical complications, adverse side effects, and diminished quality of life. Findings included . Review of the facility policy titled, Medication Administration General Guidelines dated 01/2023, showed medications would be administered per provider's written orders. The staff who administered a medication dose would immediately document the medication as given in the Medication Administration Record (MAR) and not report off-duty without first recording medications as administered. The policy instructed staff to enter an explanatory note into the medical record when a dose of a regularly scheduled medication was withheld, refused, or given at 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 interview and record review, the facility failed to ensure residents were free from physical and chemical restraints for 1 of 3 sampled residents (6) reviewed for restraints. This failure placed residents at risk for injury, limited freedom of movement and a decreased quality of life. Findings included . Review of Resident 6's medical record showed they admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (lungs are not able to properly oxygenate the blood or remove carbon dioxide), dementia (a general term for loss of memory, language, problem solving and other skills that interferes with everyday life) and hospice care (an outside agency who provides some care and resources when a person is close to death). Review of the facility's Physical Restraints policy, undated, states that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. The policy further states emergency use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently provide adequate hygiene for 1 of 3 residents (6) dependent on staff to complete activities of daily living. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . Review of Resident 6's medical record showed they admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (lungs are not able to properly oxygenate the blood or remove carbon dioxide) and hospice care (an outside agency who provides some care and resources when a person is close to death). According to Resident 6's care plan, dated 04/19/2024, Resident 6 required staff assistance to complete their oral care, was dependent on staff to use the toilet, and showered or received a bed bath two times a week. No focus or interventions for refusal of care was found. On 05/29/2024 at 11:11 AM an observation showed Resident 6 lying in bed covered with a blanket, on their right side, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently implement effective preventative measures for falls, for 1 of 3 sampled residents (5), reviewed for accidents. These failures placed residents at risk for repeat falls, injury, and diminished quality of life. Findings included . Review of Resident 5's medical record showed that they initially admitted to the facility on [DATE] after sustaining a hip fracture at home. At admit, they also had diagnosis of right sided weakness after a stroke. On 03/13/2024 Resident 5 sustained an arm fracture after falling in their room at the facility. On 05/01/2024 Resident 5 fell in their room again and fractured multiple ribs on their right side which resulted in decreased mobility and increased need for pain management. A fall assessment for Resident 5 dated 04/08/2024 showed they were high risk for falls and overestimated or forgot their own limits. Review of the facility accident and injury log for March 2024 through May 2024 showed that Resident 5 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to store controlled drugs in a locked storage compartment and only permit access to authorized personnel for 1 of 9 sampled residents (Resident 4), reviewed for controlled medication storage. This failure caused unauthorized individuals to have access to Resident 4's controlled medications. This failure constituted Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility immediately implemented and completed a plan of correction which was verified by surveyors. The plan of correction included a facility wide search for the missing controlled medication, an audit of all controlled medications in the facility to identify other potential concerns regarding inappropriate storage and/or tracking, education to licensed nurses on medication storage including controlled medication storage, tracking, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow transmission-based precautions to prevent the spread of a Multi-Drug Resistant Organisms (MDRO) for 1 of 3 sampled residents (Resident 3), reviewed for infection control. This failure placed residents at risk for transmission of a communicable MDRO diseases, and diminished quality of life. Findings included . Review of the facility policy titled, Transmission-Based Precautions dated 02/2022, showed transmission-based precautions would be implemented for residents who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission. The policy showed contact precautions may be implemented for residents known to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. For contact precautions, the policy instructed staff and visitors to wear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that residents or their representatives were given quarterly financial statements, as required, for 13 of 13 residents who had trust fund accounts. This failure did not allow residents with trust fund accounts to be fully informed of the facility's management of their money. Findings included . According to a list provided by the facility on 01/08/2024, there were 13 current residents who had active trust fund accounts. On 01/19/2024 at 2:15 PM, during a concurrent record review and interview, Staff F, Business Office Manager, initially pulled up the information on Residents 15, 41 and 35 on the computer. When asked how the residents got their quarterly financial statements, Staff F stated that they had not been doing that since they took the job in June of 2023. Staff F further stated they were unaware of the requirement to send quarterly statements out until the week prior. Staff F acknowledged that their current practice did not meet the requirement. A review of resident records showed that all 13 residents had…

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

Based on observation, interview and record review, the facility failed to identify an allegation as potential verbal abuse, ensure allegations of abuse and accidents that caused severe bodily injury were reported to the State Survey Agency as required for 5 of 7 sampled residents (1, 2, 65, 72, and 283), reviewed for abuse. This failure placed residents at risk for further abuse, injuries and decreased quality of life. Findings included . <Resident 65> A 10/10/2023 significant change assessment documented Resident 65 had diagnoses including a non-displaced femur (upper thigh bone) fracture. Resident 65 was cognitively intact and required moderate assistance of staff for ambulation and toileting. A care plan initiated on 08/09/2023 documented Resident 65 was at risk for falls related to gait and balance problems. Interventions included to be sure the resident's call light was in reach and to encourage the resident to use it for assistance as needed; the resident needed prompt response to all requests for assistance, physical therapy to evaluate and treat as ordered and as needed, 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 provide dialysis services (use of a machine to remove waste from the body when the kidneys do not function) according to accepted standards for 2 of 2 sampled residents (9, 429) reviewed. Specifically, the facility had no contract with the dialysis provider, a means of communicating with the dialysis center had not been established, the residents were not assessed for nutritional needs by the Registered Dietician (RD), and weights were not monitored. This failure placed the residents at risk for altered fluid balance, miscommunication regarding care, and poor outcomes. Findings included . A review of the facility undated policy titled End Stage Renal Disease (ESRD)-Care of Resident showed that residents with ESRD (kidneys did not function to remove waste from the body) would be cared for according to currently recognized standards. Agreements between the facility and the contracted ESRD facility would include all aspects of how the residents care would be managed including development of an integrated 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 observations, interview and record review, the facility failed to ensure that infection control processes were followed by staff during meal service, during medication administration, and during care of residents on Transmission Based Precautions (TBP) for COVID-19 (a viral illness that caused fever, fatigue, respiratory difficulty, and sometimes death) and Clostridium difficile (C-diff, a highly-infectious debilitating diarrheal illness). In addition, the facility failed to report a case of Influenza A to the appropriate state agencies, as required. These failures placed residents at risk of potential exposed to communicable diseases and diminished quality of life. Findings included . The 05/08/2023 updated Centers for Disease Control (CDC) Interim Infection Prevention and Control Practices during the COVID-19 Pandemic documented healthcare personnel (HCP) caring for residents with suspected or confirmed COVID-19 infection should use full personal protective equipment (PPE; gown, gloves, eye protection and a National Institute for Occupational Safety and Health [NIOSH]…

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

Based on observation, interview and record review, the facility failed to provide care that maintained a resident's dignity for 1 of 2 sampled residents (Resident73) reviewed. This failure placed the resident at risk for psychosocial harm and placed residents at risk for decreased quality of life. Findings included . A 12/11/2023 admission assessment documented Resident 73 had diagnoses including fracture of their left femur (thigh bone), and unspecified symptoms of cognitive (mental) function. The resident was severely cognitively impaired, rejected care at times, was dependent on staff for assistance with most activities of daily living (ADLs) and had an indwelling urinary catheter (a tube that was inserted into the bladder that drained urine). Resident 73's comprehensive care plan dated 12/12/2023 documented Resident 73 had a self-care deficit and was totally dependent on staff for assistance with dressing, and had an indwelling catheter related to having hip surgery. Staff were instructed to position the catheter and the urine collection bag below the level of the bladder and…

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

Based on interview and record review, the facility failed to thoroughly investigate potential allegations of abuse for 1 of 5 sampled residents (1), reviewed for abuse. Specifially, Resident 1 had a bruise on their forehead and the cause of the bruise was not investigated to rule out abuse. This failure placed residents at risk of further potential abuse and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, revised 10/2022, showed designated staff would immediately review and investigate all allegations of abuse then report investigation results to the administrator and other officials including the State Survey Agency within five working days of the incident. The policy further stated the resident's plan of care would be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified. <Resident 1> According to the 12/06/2023 quarterly assessment, Resident 1 had diagnoses of stroke with hemiplegia (paralysis that affects one side of the body) and dementia (loss of thinking, remembering, and reasoning that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 edema (swelling caused by fluid trapped in body tissues) care according to professional standards of practice for 2 of 2 sampled residents (62 and 37), reviewed for edema management. This failure placed residents at risk of complications due to excess fluid accumulation, unmet care needs, and diminished quality of life. Findings included . The website mayoclinic.org with regard to edema showed, wearing compression garments and raising the affected arm or leg higher than the heart helps compression garments keep pressure on the limbs to prevent fluid from building up . medicines that help the body get rid of too much fluid through urine can treat worse forms of edema. <Resident 62> According to the 12/19/2023 admission assessment, Resident 62 had diagnoses including septicemia (blood poisoning by bacteria, the most extreme response to an infection), lymphedema (chronic swelling caused by the lymph system not draining excess fluid)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently monitor a non-removable medical device for 1 of 2 sampled residents (2), and Resident 2 developed a pressure ulcer. This failure placed the residents at risk of unidentified pressure ulcers, unmet care needs, and diminished quality of life. Findings included . Review of the facility's undated policy titled, Pressure Injury Prevention and Management, showed staff would provide care consistent with professional standards of practice to ensure development of pressure injuries did not occur unless clinically unavoidable. Pressure ulcers were defined as localized damage to skin over a bony prominence or damage related to a medical device. A pressure ulcer was avoidable when one or more of the following was not completed: evaluation of the resident's clinical conditions and risk factors, implementation of interventions, monitoring or evaluation of interventions, or revision of interventions. According to the 04/13/2023 admission assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement toileting recommendations which contributed to a fall and continued incontinence for 1 of 2 sampled residents (70) reviewed for bowel and bladder incontinence. This failure placed the resident at risk for injuries from further falls and decreased dignity and quality of life. Findings included An admission assessment dated [DATE] showed Resident 70 had diagnoses including surgical care after removal of a non-cancerous brain tumor. Resident 70 was moderately impaired cognitively, was dependent on staff for toileting and transferring to the toilet, had a urinary catheter (a tube inserted in the bladder that allowed urine to drain) and was frequently incontinent of bowel. The 11/03/2023 comprehensive care plan had the following care areas developed for Resident 70: -Activities of daily living (ADLs) self-care deficit; two staff were required for transfers from bed, and for toileting the resident. -Risk for falls related to debility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify that a resident had separate and concurrent orders for the same medication, for 1 of 5 residents (19) reviewed for unnecessary medications. This failure put the resident at risk for receiving an incorrect amount of medication ordered by the physician, and possible ineffective response and increased side effects. Findings included . According to a comprehensive assessment dated [DATE], Resident 19 had moderately impaired cognition, but was understood and made their needs known. The document further showed that they had diagnosis which included diabetes. A review of the resident record showed the following current orders: 1) An order to apply antifungal cream (a medication to treat yeast infection) to redness in groin area until healed, every day and night shift, was started on 01/04/2023. This order was shown on the resident's January 2024 Treatment Administration Record (TAR) and scheduled for 6:15 AM and 10:15 PM. All slots were initialed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure psychotropic (medication that can reduce or relieve symptoms such as hearing or seeing something that is not there) medications were gradually reduced as required for 2 of 5 sampled residents (28, 11), reviewed. Additionally, the facility failed to ensure medications given on an as needed basis had a rationale for continued use, and an appropriate indication for its use. Also, target behaviors were not documented. These failures placed residents at risk of potential adverse side effects from psychotropic medications, unmet care needs, and diminished quality of life. Findings included . According to the 02/01/2023 quarterly assessment, Resident 28 was admitted to the facility on [DATE] with diagnoses including Pick's disease (less common form of dementia), anxiety, and depression. Resident 28 received routine antipsychotic, antianxiety, and antidepressant medications. According to the assessment no gradual dose reduction had been…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent for 3 of 11 sampled residents (41, 10, 72), observed during medication pass. Specifically, 3 errors were made during 31 medication administration opportunities, resulting in an error rate of 9.68 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication. Findings included . Review of the facility policy titled, Medication Administration General Guidelines, dated 01/2023, showed medications were to be administered as prescribed and within 60 minutes of the scheduled time. The policy instructed staff to verify the correct medication three times, when dispensing the medication out of the package, when the dose is being prepared, and before administering. Additionally, the policy instructed staff to notify the physician when two consecutive doses of a vital medication were withheld or refused, and an explanatory note entered into the medication administration record.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered as ordered for 3 of 12 sampled residents (9, 62, 84), reviewed for medication administration and monitoring. Spcifically, Residents 9, 62, and 84 did not receive medications when ordered and multiple doses were omitted, and Resident 9 was on an anti-coagulant (prevents blood clots from forming) that required monitoring, their blood level was high, and the medication was not held and levels rechecked as ordered. This failure placed residents at risk of possible bleeding, decline in their medical conditions and diminished quality of life. Findings included . Review of the facility policy titled, Medication Administration General Guidelines, dated 01/2023, showed medications were to be administered as prescribed. The policy instructed staff to verify the correct medication three times, when dispensing the medication out of the package, when the dose is being prepared, and before administering. Additionally, the policy…

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

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) remained free from verbal and physical abuse. This failure placed the resident at risk for psychosocial harm, as well as a diminished quality of life. Findings included . Record review showed Resident 1 was admitted to the facility for care after a planned surgery and was cognitively intact. The resident had been discharged from the facility prior to investigation of the incident. A facility investigation showed on 11/27/2023 Resident 1 reported to Staff C, Therapy Assistant, that Staff D, Nursing Assistant, told them to urinate in their brief when they asked for assistance to use the bathroom. When Staff D later returned and found that Resident 1 had urinated in their brief and on the bedding Staff D was verbally abusive and then physically pushed Resident 1 over in bed to change the sheets. Per the investigation Staff D worked for a staffing agency and was not allowed to return to the facility. The investigation report included a follow up interview with Resident 1, by 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 2 of 3 sampled residents (Resident 1 and 2) received appropriate services to maintain as much normal bladder function as possible. Failure to provide assistance with toileting placed the residents at risk for decline in urinary function, and diminished quality of life. Findings included: <Resident 1> According to an admission assessment dated [DATE], Resident 1 had diagnoses including aftercare for fusion of the spine and need for assistance with personal care. Per the same assessment the resident was cognitively intact, required extensive assistance with toileting, was frequently incontinent of urine, and did not have a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) in place. Review of Resident 1's care plan, dated 11/28/2023, showed the resident preferred to get up to use the toilet for bowel and bladder and wore a brief for accidental incontinence. Record review of a facility investigation, 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 interviews and record review the facility failed to ensure a safe discharge for one of three residents (Resident 1) reviewed for discharge planning. Failure to ensure the necessary durable medical equipment was available at discharge placed the resident at risk for medical complications, decreased quality of life and readmission to a hospital or nursing facility. Findings included . Record review showed Resident 1 admitted to the facility on [DATE] with diagnosis of a pressure ulcer (an open area in the skin caused by prolonged pressure on the area) on the sacral region (the triangle shaped bone at the base of the spine), and a skin infection in both legs. Resident 1's discharge assessment dated [DATE] showed that they were dependent on two staff for transfers and using the toilet and required a wheelchair for moving around. On 08/23/2023 at 10:30 AM Staff A, Therapy Director, stated that Resident 1 was non-ambulatory, had been for a long time and had used an electric wheelchair to move around. At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop comprehensive, person-centered care plans for 2 of 6 sample residents (42, 56), reviewed for care plans. Resident 42's care plan listed inaccurate diagnoses, was not updated after a wound had healed, and was missing goals and interventions related to limited range of motion (ROM) of their hands. Resident 56's care plan was missing goals and interventions related to having had a heart transplant, use of blood thinning medication, and diabetes. Failure to establish care plans that were individualized and accurately reflected current care needs, placed residents at risk for unmet care needs. Findings included . Resident 42 Resident 42 was admitted to the facility on [DATE] with diagnoses of bilateral amputations of both legs, peripheral vascular disease (a circulation disorder that can block blood flow to extremities), lung disease, and malnutrition. The resident's initial comprehensive assessment, dated 12/25/2021, showed that they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supplements were removed from the refrigerator and the dry storage room, in order to prevent the possible use of the supplements. This failure had the potential to affect 1 of 1 sample residents (43), who the facility identified as receiving the supplement via gastrostomy tube (a small flexible tube, inserted into the stomach to provide nutrition and medication). The facility further failed to ensure the hood vent was free of lint and grease. This had the potential to affect 91 of the 93 residents who consumed food from the kitchen. Findings included . Review of the facility's policy titled Hood and Duct Cleaning Log dated 05/01/2019 showed Grease filter cleaning: frequency: depending on condition. Minimum monthly; weekly if dust or grease is visible. Review of the facility's policy titled Labeling Food and Date Marking dated 11/2020, showed Refrigerators and storage areas are routinely checked for temperatures, labeling, and dating of food items with food being discarded when beyond the use-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 ensure personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 10 facility staff (L,P,Q,R,S,T,U,V,W,X), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19 (an acute respiratory illness caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Findings included . At the time of the survey, the county had a COVID-19 transmission rate classified as substantial. According to the 03/16/2022 CDC publication, How to use Your N95 Respirator, N95 masks (a special type of tight-fitting mask that filters particles) must form a seal to the face to work properly. The document showed the mask should be placed under the chin, with the nose piece bar at the top, with the top strap pulled over the head and placed near the crown,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review (to include facility policies and hospital records), and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotics for 3 of 3 sample residents (47, 4, 83) reviewed for urinary tract infections (UTIs), in a total sample of 19. These failures placed the residents at risk for potentially adverse outcomes. Findings included . Review of the facility policy titled Antibiotic Stewardship, dated 07/2021 showed, .According to the Centers for Disease Control and Prevention (CDC), 'Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management designed to make sure patients receive the right dose, of the right antibiotic, for the right amount of time; and only when truly necessary.' The over utilization of antibiotics has led 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 4 of 6 sample residents reviewed for pneumonia vaccinations (386, 82, 38, 28) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer the residents the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23), and if this vaccination was not available, to offer one dose of Prevnar 20 (PCV20). This failed practice had the potential to increase the risk for these residents to contract pneumonia. Findings included . Review of CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of five sample residents (9, 28, 56), reviewed for unnecessary medications, and/or their resident representative, were fully informed in writing of the potential risks associated with use of psychotropic medication (a medication which alters thought processes) and antidepressant medication (used to treat depression), prior to starting the medications, as required. This failure placed the residents at risk for adverse medication side effects, and failed to provide the residents and/or their representative at risk for not being able to make an informed decision about a medication. Findings included . Resident 9 According to Drugwatch.com, a Black Box Warning is the FDA's most stringent warning for drugs, to alert the public and health care providers to the most serious side effects, such as injury or death. Resident 9 was admitted to the facility on [DATE], with diagnoses of bipolar disorder (a mental disorder that causes extreme mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 5 sample residents (9, 56), reviewed for Pre-admission Screening and Resident Review (PASARR) [a form to evaluate residents for serious mental illness before going to a nursing facility], received a PASARR Level II screening (a more in-depth screening) for necessary services, as required. This failure placed the residents at risk for unidentified mental health needs. Findings included . Resident 9 Resident 9 was admitted to the facility on [DATE], with diagnoses of bipolar disorder (a mental disorder that causes extreme mood swings) and depression (a mental condition of persistent low mood.) An emergency department physician note from the hospital, dated 06/15/2021, showed that the resident had a diagnosis of bipolar 1 disorder and depression. A PASARR Level I (a form to evaluate residents for serious mental illness before going to a nursing facility), dated 06/17/2021, was completed by the hospital. This document did not have the bipolar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide grooming for one of four sample residents (337), reviewed for activities of daily living. This failure placed the resident at risk for not being groomed according to their preferences, and a diminished quality of life. Findings included . According to the admission assessment dated [DATE], Resident 337 was admitted with diagnoses which included dementia, and required supervised assistance from one staff to complete activities of daily living, such as grooming. The resident's 08/25/2022 care plan showed staff were to assist the resident with daily hygiene, grooming, dressing, oral care, and eating as needed. On 09/20/2022 12:49 PM, Resident 337 was observed to have long fingernails with a brown substance underneath them, facial hair on their cheeks, chin, and neck, and a mustache covering part of their lips. Similar observations of the resident with facial hair and the brown substance underneath their fingernails were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow-up on a medical provider's request to have a resident evaluated for a possible contracture (shortening of a muscle, causing the muscle to be resistant to stretching), for 1 of 3 sample residents (43), reviewed for range of motion. This failure placed the resident at risk for a decline in range of motion and unmet care needs. Findings included . Per the 09/14/2022 quarterly assessment, Resident 43 had diagnoses including stroke, and needed extensive assistance of two nursing staff to complete activities of daily living. In addition, the assessment showed the resident did not have any limitations or impairments in range of motion to their upper or lower extremities, and had not received restorative services (a program in which staff work with residents to maintain and/or improve their ability to participate in activities of daily living). A progress note dated 05/16/2022 by Staff F, Nurse Practitioner, documented the resident had 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.