Spokane Veterans Home

Based on observation, interview and record review, the facility failed to ensure meals were served at palatable temperatures for 1 of 6 sampled residents (Resident 12) reviewed and 1 of 1 meal test trays sampled.This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake. Findings inculded . According to the Washington State Food Handlers Guide Website, the Washington State Department of Health Safety and Licensing Division recommended that all potentially hazardous foods be held at a temperature of 41°F or below in commercial refrigerators and freezers. This included meats, fish, poultry, eggs, dairy products, cooked vegetables, cooked rice and pasta, cut melons, and other perishable items. All frozen foods were to be stored at 0°F or below. Hot food items were to be held at a temperature of 140°F or above. The 03/10/2025 quarterly assessment documented Resident 12 had diagnoses that included obesity, high blood pressure and diabetes. The assessment further documented the resident was cognitively intact and was able to make their…

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

Based on interview and record review, the facility failed to ensure that consents for psychotropic medications (drugs that affected behavior, mood, thoughts or perception) were completed accurately for 1 of 5 residents (Resident 43) reviewed for unnecessary medications. Specifically, some consents were not documented as late entries, and two consents were not completed before the medication was resumed. Failure to ensure clinical records were accurate placed residents at risk of not having their needs met. Findings included . A quarterly assessment, dated 01/20/2025, documented Resident 43 had diagnoses of Parkinsons Disease (an illness that affected the part of the brain that controlled movement), depression and anxiety. The assessment further showed that they were alert and made their needs known. Resident 43's Medication Administration Record for March 2025, showed they were taking the following psychotropic medications, that required documented consents: 1) Quetiapine (a medication that treated symptoms such as delusions, hallucinations or paranoia) daily in the evening 2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed during meal service to include performing hand hygiene (HH) when indicated. In addition, staff did not follow Enhanced Barrier Precautions (EBP) when indicated for 1 of 3 sampled residents (Resident 91), reviewed for infection control. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . Review of the facility policy titled, Hand Washing/Hand Hygiene revised March 2024, showed hand hygiene was the primary means of preventing the spread of infections. The policy further showed staff should perform hand hygiene before and after direct contact with residents, after contact with a resident's intact skin, after contact with objects in the immediate vicinity of a resident, before and after assisting a resident with a meal. Review of the facility policy titled, Enhanced Barrier Precautions revised March 2024,…

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

Based on interview and record review, the facility failed to provide timely follow-up for resident representative reported concerns (grievances) for 1 of 3 sampled residents (Resident 1), reviewed for grievances. This failure placed the resident at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the policy titled, Washington State Veterans Home Grievances, effective 08/01/2024, showed that residents had a right to make formal or informal concerns or grievances orally or in writing, and the facility would make efforts to provide a reasonable timeframe the resident or representative could expect a completed review of the grievance. Once the investigation was completed the facility would respond back to the resident or representative with any findings and steps the facility would take to resolve the concern, and the resident or representative's response to the investigation would be recorded on the grievance form. In an interview on 10/22/2024 at 1:11 PM a representative for Resident 1 stated they had several concerns with 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 implement standards of care to prevent elopement (leaving a facility without notice or supervision) for 1 of 3 sampled residents (Resident 2), reviewed for accidents/supervision. This failure placed the resident at risk of injury, becoming lost, and/or exposure to the elements. Findings included . Review of the facility policy titled, WanderGuards, effective 02/06/2019, showed WanderGuards would be placed on residents identified to have a history of wandering and exit seeking. WanderGuards would be tested routinely to ensure they were working and all doors with WanderGuard monitors were to be checked monthly by maintenance to ensure they were working properly. The policy did not list any direction to staff on how to respond when a WanderGuard alarm sounded, and/or additional actions to take when an alarm sounded but no residents were found at the door/area of alarm. Review of the 08/26/2024 quarterly assessment showed Resident 2 had a diagnosis of dementia, was severely cognitively impaired, and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative of a significant change in condition for 1 of 3 sampled residents (Resident 4), reviewed for quality of care. This failure placed the resident at risk of receipt of inadequate care and diminished quality of life. Findings included . Review of the June 2024 progress notes showed on the evening of 06/20/2024, Resident 4 was transferred to the hospital due to a fracture to their foot. There was no documentation showing Resident 4's representative was notified of the transfer. Additional review showed the resident returned to their former residence (instead of the facility) after their hospitalization on 06/21/2024, where the resident was found by their representative with injuries from falls that occurred while the resident was alone. In an interview on 06/27/2024 at 4:48 PM a representative for Resident 4 stated they were not notified of the resident's transfer to the hospital and were surprised to find the resident…

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

Based on interview and record review, the facility failed to follow up with a physician's order to advance a catheter, and obtain an order to increase the oxygen rate, for 1 of 3 sampled residents (1) reviewed for neglect. This failure placed the resident at risk for potential deterioration in their medical condition and unmet care needs. Findings included . According to the 03/16/2022 admission assessment, Resident 1 had diagnoses which included benign prostatic hyperplasia (prostate gland enlargement that can cause difficulty with urination), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and was able to make their needs known. The assessment also documented the resident required supplemental oxygen. A progress note dated 08/01/2022, by the urology clinic, documented Resident 1's urinary catheter was positioned in their prostate and was not placed fully into the bladder. The clinic called the facility and instructed Staff B, Registered Nurse, to advance the catheter into the bladder. A progress note 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.

Based on observation, interview and record review, the facility failed to ensure catheter care was provided in a dignified manner for 1 of 1 sampled residents (31), reviewed for use and care of a urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine). This failure placed the resident at risk for diminished quality of life. Findings included . Per review of the 01/19/2024 annual assessment, Resident 31 had diagnoses which included neurogenic bladder, (a condition in which one lacked bladder control due to a brain, spinal cord, or nerve problem), and utilized a urinary catheter. On 03/06/2024 at 12:54 PM, Resident 31 was observed with the urine collection bag of their catheter attached to the bed, not covered by a privacy bag. Staff J, Nursing Assistant emptied the urine into a container and the procedure was visualized from the doorway of Resident 31's room. Additional observations of the collection bag without a privacy bag were observed on 03/06/2024 at 12:54 PM, 03/07/2024 at 9:22 AM, 03/08/2024 at 8:50 AM, 03/11/2024 at 9:00 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 interview and record review, the facility failed to complete a discharge summary that included a recapitulation/synopsis of the resident's stay as required, for 1 of 1 sampled residents (94), reviewed for community discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included . Per the admission assessment dated [DATE], Resident 94 had diagnoses which included urinary retention and aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed), had moderate cognitive impairments, and needed moderate to substantial assistance to complete activities of daily living. A record review showed Resident 94 was admitted to the facility for physical and occupational therapy, following deconditioning related to the above diagnoses. The resident discharged to home on [DATE]. A review of the discharge packet showed the resident was discharged with a referral to a wound care provider and included the list of prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that residents with fluid balance concerns were monitored for 1 of 3 sampled residents (89) reviewed for fluid restrictions. This failure placed residents at risk for adverse health events and decreased quality of life. Findings included The facility provided policy Encouraging and Restriciting Fluids revised in 10/2010 documented guidelines which included to record fluid intake in milliliters (mls) as instructed by the physician. When placed on restricted fluids, remove the water pitcher and cup from the resident's room. If the resident refuses to have the pitcher removed, notify the supervisor and provider to discuss the risk and benefits of continuing versus discontinuing the restriction to honor the resident's preference. A review of the record documented Resident 89 had diagnoses including cirrhosis of the liver (scarring caused by many years of damage to the liver from various sources), ascites (fluid in the abdomen caused by cirrhosis) and general edema (too much fluid trapped in the body'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 observation, interview and record review, the facility failed to ensure the Registered Dietician (RD) had completed comprehensive nutritional assessments as required for 2 of 4 sampled residents (4, 83) reviewed for nutrition.This failure placed the residents at risk for unplanned weight loss and decreased quality of life. Findings included . <Resident 4> The 01/15/2024 quarterly assessment showed Resident 4 was able to make decisions regarding their care, was independent for eating, and had diagnoses which included depression, diabetes and stroke. On 03/08/2024 at 2:29 PM, Resident 4 was observed lying in bed watching television. When asked about the food, the resident stated lunch was good, and the food was all right. Review of the nutritional care plan last revised 08/24/2022 showed Resident 4 was identified as being at nutritional risk and instructed nursing staff to adhere to the resident's food preferences. In addition, the interventions stated the RD and dietary manager would update preferences…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received their scheduled medications on the mornings they had dialysis for 1 of 7 sampled residents (15) reviewed for medication administration. This failure put residents at risk for worsening of their chronic health conditions or unintended adverse events. Findings included . A quarterly assessment dated [DATE] documented Resident 15 had diagnoses including end-stage renal disease (ESRD) dependent on dialysis (a means of removing waste from the body when the kidneys no longer function) and atrial fibrillation (AFIB, irregular heartbeat) and Parkinson's disease (nerve cell damage in the brain that affects movement). The resident was cognitively intact and able to participate in their care. Resident 15 had the following provider orders: -06/24/2023 Multivitamin, one tablet daily for supplement -09/14/2023 Apixaban 5 milligrams (mg) twice daily for anticoagulant (prevents blood clots from forming) -09/14/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenics) stored in the medication refrigerators were secured in a permanently affixed container for 2 of 2 medication rooms reviewed for medication storage. This failure placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . On 03/13/2024 at 3:32 PM, in the second floor medication room, the medication refrigerator was inspected with Staff O, Registered Nurse (RN). The door of the refrigerator had a padlock and contained numerous medications that required refrigeration. The controlled medications (Ativan, an anti-anxiety medication and Marinol, an anti-nausea medication) were in an open plastic basket on a shelf in the refrigerator. On 03/14/2024 at 10:24 AM, the medication refrigerator in the first floor medication room was inspected with Staff P, RN. The door of the fridge had a padlock and contained numerous medications that required…

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

Based on observation, interview and record review, the facility failed to ensure dietary staff had the required qualifications (current Food Worker Cards) for two of nine sampled dietary staff (L, M). This failure had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards on 3/13/2024 at 2:00pm showed no Washington State Food Workers card for Staff L, Food Service Worker, and a Washington State Food Workers card for Staff M, Food Service Worker that had expired on 3/7/2024. On 3/13/2024 at 3:00pm Staff K, Dietary Manager, provided a copy of a Washington State Food Workers card for Staff L with an effective date of 3/13/2024. When asked, Staff K stated Staff L had been working with an expired food handler's card and had just renewed it. In an interview on 03/14/2024 at 12:52 PM, Staff K stated they did not have a process for ensuring food handler cards were renewed prior to the expiration date but were working on getting a process into place. They stated a process for…

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

Based on observation and interview, the facility failed to ensure food was prepared and served in a sanitary manner during 2 of 2 meal preparations observed. One staff member with a beard was not wearing a beard covering. This failure caused potential risk of contamination of food and exposure of all residents to food borne illness. Findings included . During an observation on 03/06/2024 at 10:49 AM, Staff Q, Cook, was preparing food for lunch service. They were noted to have a beard and were not wearing a beard covering. During an observation on 03/13/2024 at 10:59 AM, Staff Q was serving food for the lunch meal. They were noted to have a beard and were not wearing a beard covering. In an interview on 03/13/2024 at 11:32 AM, Staff Q was asked why they were not wearing a beard covering and they stated in the 5 years they had worked at the facility it had never been an issue and they usually kept their beard shorter. They also stated they didn't know if there were beard covers available. During an observation on 03/13/2024 at 11:35 AM Staff Q put a beard cover on over their beard and…

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

Based on observation and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 2 dining rooms, during wound care for 1 of 2 sampled residents (31) reviewed for wounds and during personal care for 1 of 1 sampled residents (36). These failures placed the residents at risk for infections and decreased quality of life. Findings included . <Dining Room> During a lunch observation of the second-floor dining room on 03/06/2024 at 11:59 AM, Staff T, Nursing Assistant, donned gloves, then pushed a resident up to the table and no hand hygiene was performed. Staff T then removed lids from their food items, left the dining room wearing the same pair of gloves, grabbed a straw and placed it into their drink, then removed gloves and performed hand hygiene. During the same lunch observation at 12:03 PM, Staff T donned gloves and assisted a resident with cutting up their meat. The resident's table mate attempted to grab their milk and put their hands on top of the container where fluids are consumed. Staff T did not remove the milk 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 and interview, the facility failed to ensure equipment to allow residents to call for staff assistance was provided for 1 of 19 sampled residents (44) reviewed for resident call systems. This failure placed residents at risk of having unmet care needs, accidents, and a diminished quality of life. Findings included . Per the quarterly assessment dated [DATE], Resident 44 had diagnoses which included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), dementia, and falls. Resident 44 had moderate cognitive impairments, and needed partial to substantial assistance to complete activities of daily living. Review of Resident 44's care plan dated 06/08/2022, documented resident was at risk for falling. Staff were to ensure call light was within reach and to encourage the resident to use it as needed. During an observation on 03/06/2024 at 2:59 PM, Resident 31's call light was under their bed, not within their reach. Subsequent…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 7 sample residents (Resident 4), reviewed for abuse, were treated with dignity and respect by all facility staff. This failure placed the resident at risk for feeling disrespected and having a decreased quality of life. Findings included . Review of a facility investigation report dated 12/11/2023 showed a verbal altercation occurred between Staff D, Nursing Assistant, Resident 4, and the resident's representative in the dining room on 12/08/2023. Per the report, Staff D was monitoring residents in the dining room and was providing verbal direction to Resident 4 and their representative regarding infection control procedures, which upset the resident, who then began yelling at Staff D. Per Staff D's written statement, Staff D became upset and also began yelling at Resident 4. Included in the investigation report were statements from staff and residents who witnessed the interaction which documented Staff D was yelling that they were in charge of the dining room while pointing their finger 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 ensure 1 of 3 sample residents (Resident 1), reviewed for medication administration, received medications appropriately, in accordance with a valid physician's order. This failure resulted in a significant medication error which placed the resident at risk for discomfort and a diminished quality of life. Findings included . Review of a facility investigation dated 12/07/2023 showed Resident 1 went to an appointment with an external provider in November 2023, and reported to facility on 12/05/2023 that their provider had changed one of their medication orders during their previous visit, which the resident was not yet receiving. Per the investigation, the provider had sent the new order directly to the pharmacy and had not notified the facility of the order change. Review of the November 2023 and December 2023 Medication Administration Records (MAR) showed Resident 1 received 2 tablets of Suboxone (medication that treats opioid addiction) 2-0.5 milligram (mg) every eight hours, from 11/10/2023 to 12/05/2023. Further review…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (Resident 3), reviewed for abuse, were treated with dignity and respect by all facility staff. This failure placed the resident at risk for feeling disrespected, and having a decreased quality of life. Findings included . Review of a facility investigation report dated 09/02/2023 showed a verbal altercation occured between Staff D, Nursing Assistant, and Resident 3 in the resident's room that day. Per the report, Staff D was providing care to the resident and the resident was berating and cussing at the staff member, and the staff member in return cussed at the resident before leaving the room. Staff D immediately reported the incident to Staff C, Registered Nurse, who had the staff member leave the building for the duration of the investigation. The resident was monitored after the incident and stated they felt safe in the facility. On 09/12/2023 at 12:46 PM Resident 3 was observed sitting up in their wheelchair in the hallway outside their room laughing and joking with nearby…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise a resident to prevent elopement (leaving a facility without notice or supervision) for 1 of 3 sampled residents (Resident 4), reviewed for accidents/supervision. This failure placed the resident at risk of injury, becoming lost, and/or exposure to the elements. Findings included . Review of the 05/15/2023 annual assessment showed Resident 4 had diagnoses of stroke (medical event where blood supply to the brain is interrupted or reduced) and aphasia (communication disorder resulting from damage to the brain), could not make themselves verbally understood, and was moderately cognitively impaired. Per the assessment the resident was independent with locomotion with the use of a wheelchair and had no wandering behaviors. Per Resident 4's elopement care plan, initiated 12/06/2022, they were only to be outside in the outdoor common areas when staff were aware they were outside, as the resident had refused a Wanderguard alarm (a device that alarms when in close proximity to a sensor placed on exit doors)…

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

Based on interview and record review, the facility failed to ensure incidents of potential abuse/neglect were reported to the State Survey Agency within the required two-hour time frame for 5 of 6 sampled resident (37, 13, 49, 73, 47), reviewed for abuse. Failure to report allegations of abuse placed the residents at risk for further abuse. Findings included Residents 37 and 13 Review of a grievance form dated 11/16/2022 at 10:45 AM showed during a Resident Council meeting, Resident 37 stated staff needed trained to not argue with residents who had dementia. The grievance documented a follow-up interview was done with Resident 37 on 11/22/2022 by Staff C, Social Services, and during the interview, the resident expressed concern that a nursing assistant (NA) had yelled at Resident 13, Resident 37's roommate. Review of the facility investigation dated 11/23/2022, showed Resident 37 had alleged neglect to Resident 13 during the follow-up interview with Staff C, and included the dated, written statement that Resident 37 had provided at the time of the interview. The statement showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure investigations related to allegations of abuse/neglect were initiated, thorough, and completed timely for six of six sample residents (30, 73, 47, 49, 37, 13), reviewed for abuse. These failures placed the residents at risk for repeated incidents and potential abuse. Findings included Residents 13 and 37 Per the 09/07/2022 admission assessment, Resident 13 had diagnoses of dementia and Parkinson's disease, a progressive nerve disorder that caused unintended or uncontrolled movements. In addition, the assessment showed the resident needed extensive assistance of two staff to complete activities of daily living (ADLS), such as dressing and toileting. Per the 10/06/2022 admission assessment, Resident 37 was cognitively intact and able to make decisions regarding their care. On 11/28/2022 at 10:08 AM, Resident 37 was observed in their room sitting in their wheelchair. Resident 13 was lying in bed watching television. When asked if the staff treated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy monthly medication reviews were done for 4 of 5 sampled residents (53, 30, 47, 43), reviewed for unnecessary medications. This failure placed the residents at risk for experiencing adverse medication side effects and unmet care needs. Findings included . The 10/10/2022 quarterly assessment for Resident 53 showed diagnoses which included diabetes, anxiety, and depression. In addition, the assessment showed the resident received insulin injections, antianxiety medication, and antidepressant medication daily. Review of the April 2022 through November 2022 pharmacy monthly medication reviews showed no reviews had been completed for April 2022, July 2022, and October 2022. Per the 08/29/2022 quarterly assessment, Resident 30 had diagnoses which included anxiety, depression and schizophrenia (a serious mental illness that affects a person's ability to think, feel and behave). The assessment further showed the resident received an antipsychotic (to treat schizophrenia), antidepressant, and antianxiety medication…

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

Based on interview and record review, the facility failed to assess the facility water system and implement measures to prevent the growth of Legionella (a bacteria that grows in water and causes lung infections) and other waterborne pathogens that were based on nationally accepted standards for 81 residents at risk for waterborne illnesses. This failure placed residents at risk for illness and decreased quality of life. Findings included . The 06/24/2021 Centers for Disease Control and Prevention (CDC) Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings Guide to Implementing Industry Standards showed that healthcare facilities where people with chronic medical problems or weakened immune systems were housed were at increased risk for Legionella. A water management program included key steps: -establishing a water management program team -describing the building water systems using text and flow diagrams -identifying areas where Legionella could grow and spread -decide where control measures should be applied and how to monitor -establish ways to…

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

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 1 sampled residents (45), reviewed for environment. Specifically, the bedrail padding and fall mat were dirty, unsanitary, and in poor condition. This failure placed Resident 45 at risk for possible injury, illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included . Resident 45 had diagnoses including Huntington's disease (a terminal condition that causes parts of the brain to stop working properly over time, often causing uncontrolled body movements), and dementia. A 10/31/2022 assessment showed Resident 45 was moderately cognitively impaired, required extensive assistance for activities of daily living, coughed frequently, and lost food and fluids from their mouth when they ate or drank. The 02/27/2019 comprehensive care plan showed the resident was dependent on staff for meeting their emotional, physical and social needs, had significant uncontrolled body movements, was risk for skin tears and falls, and…

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

Based on interview and record review, the facility failed to ensure that two of six sampled residents (49, 73), investigated for abuse were free from abuse, and protected from further abuse after staff were notified of the allegations. This failure resulted in a second allegation from a different resident about the same staff member, when that staff member was not removed from resident care. Additionally, those residents were not monitored for emotional harm following the allegations of abuse. These failures placed the residents at risk of unrecognized emotional harm and potential additional abuse. Findings included . Resident 49 According to a 08/01/2022 comprehensive assessment Resident 49 had severe visual impairment and no hearing loss. The document also showed that they were alert, oriented, and had no cognitive impairment. A progress note, dated 11/04/2022 at 3:05 PM, showed that on 10/31/2022, Staff L, Nursing Assistant (NA), reported that the resident requested to use the phone. (The note did not identify who this was reported to). Per the note Staff G, NA, had loudly said…

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

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the hospital transfer of one sampled resident (21), reviewed for hospitalization, as required. This failure disallowed the resident additional advocacy per 42 CFR 483.15(c)(4)(ii)(D) from the State Long-Term Care Ombudsman. Findings included . A 07/18/2022 comprehensive assessment showed that Resident 21 was cognitively intact, had frequent urinary tract infections, and required a urinary catheter (a tube inserted in the bladder to continuously drain urine into a bag.) A progress note on 09/01/2022 at 1:53 PM, showed that the resident's condition had deteriorated, and they were transferred to the hospital by ambulance. During an interview on 12/01/2022 at 3:54 PM, Staff A, Administrator, stated that they did not have a notification to the ombudsman's office for Resident 21. They had not realized that the requirement was for all discharges or transfers, not just facility-initiated discharges. Per Staff A, they thought they were following the required process, and…

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

Based on observation, interview, and record review, the facility failed to ensure falls were thoroughly investigated, and/or fall prevention interventions specific to resident needs were identified and consistently implemented, for one of two sampled residents (30), reviewed for accidents. Failure to comprehensively evaluate possible root causes, and revise and implement interventions to meet the resident's needs, placed the resident at risk for continued falls. Findings included . Review of the 08/29/2022 quarterly assessment showed Resident 30 had diagnoses to include coronary artery disease (damage or disease in the heart's major blood vessels), high blood pressure, anxiety, depression, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder), and atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow). Per the 08/23/2022 fall risk 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 interview and record review, the facility failed to monitor and notify the physician of the absence of urinary output, for one sampled resident (21), reviewed for hospitalization. This failure placed all residents at risk for lack of monitoring. Findings included . A 07/18/2022 comprehensive assessment showed that Resident 21 was cognitively intact, had frequent urinary tract infections (UTI's), and required a urinary catheter (a tube inserted in the bladder to continuously drain urine into a bag). A 09/01/2022 progress note, written that day at 1:53 PM, showed that the resident reported having felt unwell for several days. The note further showed that resident had no urinary output since the previous morning, according to the nursing assistant. The assigned nurse noted that the resident was sluggish, shaking more than usual and their abdoment was swollen and hard. The staff nurse flushed the urinary catheter (to determine if it was blocked), and the resident yelled out in pain. Staff E, Resident Care…

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

Based on observation, interview, and record review, the facility failed to ensure that continuous positive airway pressure (CPAP, a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) respiratory equipment was cleaned and maintained according to professional standards for 1 of 4 sampled residents (1), reviewed for respiratory care. This failure placed Resident 1 and other residents that required CPAP therapy at risk for lung infections and deterioration of their health. Findings included . Resident 1's record showed they had diagnoses including obstructive sleep apnea (a decrease in airflow and upper airway collapse while breathing when asleep). A 09/19/2022 assessment showed the resident was cognitively intact, had increased shortness of breath when lying flat, and required oxygen therapy. The 03/14/2022 provider orders showed the resident was to use a CPAP machine (continuous positive airway pressure, a respiratory therapy that pumps air into the lungs to treat sleep apnea) per preprogrammed settings with 4 liters of supplemental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety by assessing the risk for entrapment, reviewing risks and benefits of bed rails (side rails), and obtaining informed consent prior to the use of them for one of two sampled residents (30), reviewed for accidents. These failures placed the residents at risk for injury and diminished quality of life. Findings included . The facility policy titled, Bed Safety dated December 2007, showed that staff shall obtain consent for the use of side rails from the resident or the resident's legal representative, prior to their use. On the policy it was handwritten by Staff B, Director of Nursing, that an assistive device assessment was needed, which included safety questions and interventions. Review of the Assistive Device Assessment form did not include the possibility of entrapment related to side rails. Review of the 08/29/2022 quarterly assesment showed that Resident 30 admitted in May 2020 with multiple mental health diagnoses, and had no restraints or bed rails. During 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.

Based on observation and record review, the licensed nursing staff failed to recognize significant changes in 1 of 1 sampled residents (11), reviewed for a change in condition. This placed the resident at risk for unmet care needs and a diminished quality of life. Findings included: Per the Minimum Data Set (MDS) assessment - a mandated process for clinical assessment of all residents in nursing homes - a significant change must be completed when two areas of decline are noted. A progress note dated 11/10/2022 at 12:39 PM showed that Resident 11 had significant weight loss related to their nutritional intake. Additionally, they added that the resident was making end-of-life statements to staff. On 06/04/2022, the resident's weight was 194 pounds, and on 12/07/2022 their weight was 174 pounds. This was a 10.31% loss in 6 months. According to the MDS parameters, this was considered to be a significant weight loss. A progress note dated 11/15/2022 at 11:40 AM showed that resident was not interested in doing things, and just wanted to sleep unbothered. The note also showed that resident…

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

Based on interview and record review, the facility failed to complete performance reviews at least once every 12 months, and provide in-service education based on the outcome of the reviews , as required, for one of five sampled staff (G), whose records were reviewed. This failure placed residents at risk for receiving care from inadequately trained staff. Findings included . During an interview on 12/08/2022 at 1:15 PM, Staff E, Resident Care Manager (RCM), stated that they were new to the role of RCM. They further explained they were in the process of doing Staff G's performance evaluation when the allegations of abuse came up. They were advised to put the evaluation on hold, as they were not sure what Staff G's role would be moving forward. Staff E stated that performance evaluations should be done yearly. They reported that they did not have the evaluations in their office, but they would find it for Staff G and provide the most recent copy. On 12/08/2022 at 2:12 PM, Staff E provided a copy of a performance evaluation done that same day for 2021 to 2022, and the next most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 behavioral health services related to depression, for one of five sampled residents (11), reviewed for behavioral and emotional health. This failure placed the resident at risk for worsening mental health, and a decreased quality of life. Findings included . Per the quarterly assessment dated [DATE], Resident 11 had diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), diabetes (an inability of the body to produce insulin), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). The assessment also showed the resident had mild depression. Social Services Assessments dated 05/04/2022 and 07/22/2022 showed that the resident has diagnoses of depression and anxiety. The 07/21/2022 history and physical assessment showed the resident had depression which was chronic in nature, but also had a situational component when 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 assess if a resident's change of condition was the result of a progression of a medical condition or a side effect of the prescribed psychotropic medications, (medication that can affect the mind, emotions, and behaviors), for one of five sampled residents (43), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medication, unmet care needs, and a decreased quality of life. Findings included . Per the 10/10/2022 significant change assessment, Resident 43 had diagnoses which included dementia, a traumatic brain injury, and Huntington's disease, a hereditary condition where nerve cells in the brain break down causing movement, thinking and psychiatric disorders. In addition, the assessment showed the resident received psychotropic medication daily. Further review of the significant change assessment showed the assessment was completed due to changes in the following care areas: cognition, communication, activities of daily living, and antipsychotic…

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