Sullivan Park Care Center

Based on observation, interview, and record review the facility failed to make reasonable efforts to accommodate a resident's visual impairment needs for 1 of 4 sampled resident (Resident 46), reviewed for personal property. This failure placed residents at risk of eye strain, potentially avoidable accidents, and diminished quality of life. Findings included . According to the 02/17/2025 quarterly assessment, Resident 46 had diagnoses including cataracts (the natural clear eye lens becomes cloudy making it difficult to see). The assessment further showed Resident 46 had impaired vision and had no corrective lenses. Resident 46 was cognitively intact and able to clearly verbalize their needs. Review of the 10/19/2021 vision care plan showed Resident 46's vision was within normal limits with use of their glasses and instructed staff to arrange eye appointments as needed, monitor for signs and/or symptoms of eye problems and to ensure Resident 46's glasses were clean, in good repair, and easily available for use. Review of a 01/22/2025 vison exam progress notes showed Resident 46 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure advanced directive documents were completed accurately and the correct information was entered into the medical record for 3 of 3 sampled residents (Residents 102, 91 and 63), reviewed for advanced directives. Specifically, Resident 102 had conflicting information regarding what interventions staff were to take during a code situation (an emergency where one would die if cardio-pulmonary rescusitation, CPR, was not started) and Resident 91 had severe cognitive impairement and signed their own advanced directive documents. These failures created potential for confusion during medical emergencies and for resident decision makers to be uninformed of a resident's care. Findings included Review of the facility policy titled, Advanced Directives reviewed [DATE], defined advanced directives as written instruction, such as a living will or durable power of attorney (POA) for healthcare, recognized under law, related to the provision of healthcare when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a clean, comfortable, safe and homelike environment for 1 of 2 sampled residents (Resident 20), reviewed for environment. Specifically, Resident 20's walls in their room were in disrepair and chemicals were not properly secured in a storage room. These failures placed all residents at risk for potentially avoidable injuries and a diminished quality of life. Findings included . During an observation and interview on 02/24/2025 at 10:31 AM, Resident 20 was sitting in their wheelchair in their room. Resident 20's room had multiple patches of drywall on the wall next to their bed and the wall at the foot of their bed. The wall to the right as you entered the room had black scrapes and gauges out of the wall. The wall to the left as you entered the room had a hole near the floor. The bathroom was painted a tan color, a paper towel dispenser in the room had been raised and the area was blue from the previous paint job. 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 consistently supervise and/or monitor cognitively impaired residents' behaviors to prevent verbal and/or physical resident-to-resident altercations to the extent possible for 2 of 10 sampled residents (Resident 89 and 63), reviewed for abuse. This failure placed residents at risk of potential abuse, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, documented the facility would develop and implement policies to prevent and identify abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. Staff would be provided orientation and training on abuse prevention, incident identification and reporting. The policy further showed all potential allegations of abuse, neglect, mistreatment, or misappropriation of resident property would 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 identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (Resident 110 and 104), reviewed for hospitalizations. This failure placed residents at risk for a disruptive, ineffective transition from the facility to the hospital setting and unmet care needs. Findings included . Review of the facility policy titled, Notice of Transfer or Discharge dated April 2020, showed when a resident transferred to the hospital, staff documented the transfer in the medical record and appropriate information was communicated to the receiving hospital. The policy showed the minimum information communicated to the hospital included the contact information of the provider responsible for the care of the resident, resident representative information, including contact information, Advanced Directive information, special instructions or precautions for ongoing care, Comprehensive Care Plan goals, a copy 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 ensure the completion of a required Pre-admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition) prior to admission for 2 of 5 sampled residents (Resident 6 and 102), reviewed for PASRR. Additionally, the facility failed to ensure Resident 52's PASRR Level 2 recommendations were implemented. These failures placed the residents at risk for unmet mental health care needs. Findings included . Review of the facility policy titled PASRR Process dated March 2019, showed that if a Level 2 PASRR was indicated the facility Social Worker would ensure the resident was evaluated within a timely period. <Resident 6> Review of a 02/17/2025 assessment showed Resident 6 admitted to the facility on [DATE] with medically complex conditions and assessed 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 interview and record review, the facility failed to ensure Preadmission Screening and Resident Review Level I (PASRR, determines if an individual had or was suspected of having a serious mental illness [SMI], intellectual or developmental disability or related condition) were accurately completed for 3 of 5 sampled residents (Residents 6, 411, and 63 ) reviewed for PASRR. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . Review of the facility policy titled, PASRR Process dated March 2019, showed the facility ensured that upon a resident's admission to the facility, a PASRR Level I was included in the admission paperwork. If there was no PASRR Level I, the Medical Records Director or designee contacted the hospital to obtain it. Review of the Washington State Department of Social and Health Services Level I PASRR form showed the facility was responsible for ensuring the form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a baseline care plan within 48 hours of admission that documented resident specific goals and treatment plans for 2 of 3 residents (Resident 6 and 411), reviewed for new admissions. This failure placed residents at risk for unmet care needs, possible medical complications, and diminished quality of life. Findings included . <Resident 6> Review of an admission assessment showed Resident 6 admitted to the facility on [DATE]. The medical record showed the resident was treated with medications for heart failure, high blood pressure, and atrial fibrillation (an irregular and often very rapid heart rhythm). Additionally, the resident was diagnosed as legally blind. Review of the resident's baseline care plan showed no goals or interventions to address the provider orders for the management of the cardiovascular diagnoses or the vision impairment. <Resident 411> Review of the medical record showed Resident 411 admitted to the facility on [DATE]. 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 develop the care plans and implement interventions for 3 of 24 sampled residents (Resident 78, 62, and 41), reviewed for care planning. This failure placed the residents at risk for inadequate care, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled Quarterly MDS [Minimum Data Set, an assessment]/Care Plan Review dated June 2017 showed, the facility reviewed a resident's care plan, no less frequently than quarterly to ensure the care plan reflected the resident's current needs. <Resident 78> Review of a 12/16/2024 admission assessment showed Resident 78 admitted to the facility on [DATE] with medically complex conditions. The assessment further showed Resident 78 had difficulty hearing and used a hearing aid or other hearing appliance. During an observation on 02/24/2025 at 9:50 AM, Resident 78 was in bed with a hearing aid (HA) to the right ear. An observation on 02/25/2025 at 10:19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the care plans in response to changing goals, needs of the residents or in response to current interventions for 2 of 33 sampled residents (Residents 44 and 35) reviewed. Specifically, Resident 44 fell and broke their hip, and had continued falls and the care plan was not updated. Additionally, Resident 35 was newly diagnosed with Addison's disease (when the adrenal glands are damaged and do not produce enough hormones to regulate blood pressure, water and salt balance, and respond to stress), and disease related interventions were not added to the residents care plan. These failures put the residents at risk for unmet care needs and unintended health consequences. Findings included . <Resident 44> A review of the 12/18/2024 significant change assessment documented Resident 44 had diagnoses that included dementia with behavioral disturbances and right femur (upper thigh bone) fracture. Resident 44 was severely cognitively impaired, behaviors had worsened since their last assessment, and they had fallen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 requiring assistance with their activities of daily living (ADLs), were provided timely assistance according to their needs and preference for 2 of XXX sampled residents (Residents 52 and 41) reviewed for ADLs. Specifically, Resident 52 was not provided showers per their preference and Resident 41 was not shaved when indicated. This failure put residents at risk for decreased quality of life. Findings included . <Resident 52> The 12/26/2024 admission assessment documented Resident 52 had diagnoses that included empyema (pockets of infection that build up in the space between the lung and the chest wall) and fractured ribs. The resident was cognitively intact and required substantial assistance of 1 to 2 staff for showering. The 12/28/24 care plan revised on 01/30/2025 documented Resident 52 was at risk for skin breakdown related to incontinence. Staff were instructed to keep the skin clean and dry, and minimize exposure to moisture from incontinence, wounds, and perspiration. Nursing…

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

Based on observation, interview and record review the facility failed to implement the bowel management protocol when indicated for 2 of 3 sampled residents (Resident 18 and 71), reviewed for constipation. In addition, the facility failed to identify changes in a resident's skin condition timely for 1 of 2 sampled residents, (Resident 15), reviewed for skin conditions. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Bowel Protocol, revised Febuary 2019, documented nursing staff was to review a resident's bowel monitor every shift. The policy instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for three days. The policy documented nursing staff was to administer Milk of Magnesia (MOM) on day three and a laxative suppository was to be administered the next shift if there were no results from MOM. If the resident exceeded four days without a BM, the Licensed Nurse performed an abdominal assessment and notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who admitted without pressure injuries did not develop pressure injuries and residents with pressure injuries did not worsen. Specifically, the facility failed to communicate interventions to the staff including settings of specialty mattresses, the correct use of positioning devices, and to address the identification of refusals of care for 3 of 5 residents (Residents 101, 1, and 105), reviewed for pressure injury. These failures placed residents at risk for pressure injury development, wound infections and/or complications, and diminished quality of life. Findings included . Review of the facility policy titled, Skin at Risk/Skin Breakdown revised September 2020, showed residents who entered the facility without pressure injuries would not develop pressure injuries unless the clinical condition demonstrated it was unavoidable and a resident with pressure injuries would receive the necessary treatment and services to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure smoking materials were secured as care planned for 1 of 3 sampled residents (Resident 18), reviewed for smoking. In Addition, the facility failed to assessed and monitored for the safe use of an electrical heating appliance for 1 of 5 sampled residents (Resident 78), reviewed for accident hazards. These failures placed residents at risk for potentially avoidable accident and placed the facility at risk of fire. Findings included . <Electrical Appliances> Review of a 12/16/2024 admission assessment showed Resident 78 admitted to the facility on [DATE] with medically complex conditions. The assessment further showed Resident 78's cognition as intact and had both vision and hearing impairment. Resident 78 required assistance from the staff to complete Activities of Daily Living. An observation on 02/25/2025 at 10:19 AM showed Resident 78 in bed, head slightly up, and a heating pad to their right side. When asked about its use, Resident…

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

Based on observation, interview and record review, the facility failed to ensure a resident's peripherally inserted central catheter (PICC, also known as a central line, a catheter placed in a large vein in the arm that extended to a large vein in the heart, used if long term antibiotic therapy was required or if antiobiotics were damaging to smaller veins) was maintained according to standards for 1 of 1 sampled residents (Resident 52) reviewed. This failure placed the resident at risk for complications related to their PICC including blood stream infections, blood clots, or inflammation of the vein. Findings included . The 2011 Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated October 2017, retrieved at https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infection/index.html documented the following recommendations: replace transparent dressings used on central venous catheters at least every 7 days or if it becomes loosened, damp, or visibly soiled, and promptly remove any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (Residents 35, 74) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . Review of the facility policy titled, Respiratory Treatment, dated 06/22/2022, documented the external filter of an oxygen concentrator provided no protection to the resident from respiratory illness, per manufacturers. The filter kept debris from the concentrator compressor only and provided no respiratory protection to the resident. Oxygen cannulas/mask and tubing were to be changed as needed if soiled or damaged and the concentrator filters were to be cleaned weekly. <Resident 74> Per the 12/18/2024 quarterly assessment, Resident 74 had diagnoses which included chronic obstructive lung disease (COPD, a group of lung diseases that make it difficult to breathe), respiratory failure and needed oxygen due to those conditions. Review of the physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and respond to each resident's individualized needs for 10 of 12 sampled staff (Staff I, S, N, BB, HH, JJ, LL, RR, SS, and UU), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed January 2025, showed the facility's average daily census was 120. The facility admitted more acutely ill residents with multiple co-morbidities (two or more medical conditions) and was able to provide care for residents who required total parental nutrition (TPN, liquid nutrition provided into the bloodstream), respiratory care, intravenous (IV) medications, and wound care. Staff completed routine competency checks to ensure staff could provide care to the facility population to include infection prevention 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 observations, interview and record review, the facility failed to ensure that controlled medications were tracked, and controlled medications for discharged residents were discarded, in 1 of 2 medication rooms (North Hall) inspected. This failure placed the facility at risk for drug diversion. Findings included . On [DATE] at 8:40 AM, the North Hall medication room was inspected with Staff F, Licensed Practical Nurse/ Resident Care Manager (LPN/RCM.) In the locked narcotic box in the refrigerator, the following medications were found for two residents: Resident 999 1) an unopened, full sealed bottle of liquid Morphine (a narcotic pain medication) that was filled on [DATE]. 2) an unopened, full sealed bottle of liquid Lorazepam (a controlled anti-anxiety medication) that was filled on [DATE]. 3) a medication card contained 10 Dronabinol 5 milligram (mg) capsules (used to treat nausea and stimulate appetite) was filled on [DATE] and had expired on [DATE]. Resident 998 4) an unopened, full sealed bottle 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 interview and record review, the facility failed to identify and monitor target behaviors for the use of psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior and are typically used to treat mental health conditions) medications for 2 of 5 sampled residents (Resident 6 and 411), reviewed for unnecessary medications. This failure placed residents at risk for potential adverse consequences related to the use of the medications. Findings included . <Resident 6> A 10/2022 facility policy titled Psychoactive Medications showed, the facility reviewed the use of psychoactive drugs and behaviors associated with the use of the drugs quarterly. The facility evaluated the number of targeted behaviors or symptoms, the effectiveness of the medication, potential side effects, and supporting diagnoses for the use of psychoactive medications. Review of a 02/17/2025 admission assessment showed Resident 6 admitted to the facility 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, interview, and record review, the facility failed to ensure medications were administered according to the provider's order for 2 of 7 sampled residents (Residents 95 and 102) reviewed for medication administration. Specifically, multiple doses of a medication that treated Resident 95's lupus (the body's immune system attacks it's own healthy tissues causing pain and swelling) were omitted. Additionally, medication to control Resident 102's heart rate was not held when hold parameters were met. This failure placed the residents at risk for unintended health consequences from omitted doses, and medication side effects when medications were not held as ordered. Findings included . <Resident 95> A review of the 02/14/2025 quarterly assessment documented Resident 95 had diagnoses that included lupus and drug-induced suppression of the immune system. Resident 95 was cognitively intact and frequently had pain that interfered with therapy and day-to-day activities. The 11/19/2024 care plan documented Resident 95 was at risk for pain and discomfort. Staff were…

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

Based on observation, interview, and record review, the facility failed to ensure dietary staff had the required qualifications (current Washington State Food Worker Cards) for 1 of 14 dietary staff (Staff Z), whose records were reviewed. This failed practice had the potential risk for unsafe food handling practices and placed residents at risk for developing foodborne illness. Findings included . On 02/28/2025, a copy of dietary staff's current Washington State Food Worker cards were requested. Review of dietary cards on 02/28/2025 at 3:25 PM showed no documentation Staff Z, Dietary Manager/Registered Dietician, had a Food Workers Card, as required. Staff Z acknowledged they did not have a Washington State Food Worker card. In a follow-up interview on 03/06/2025 at 10:53 AM, Staff Z confirmed they were required to obtain the Washington State Food Worker card. Staff Z further stated it was important because it showed proof of competency and knowledge of dietary operations. Reference WAC 388-97-1160. .

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 5 sampled residents (Resident 104) whose discharge records reviewed. Specifically, Resident 104 was sent to the local hospital for urgent treatment and the medical record did not include events leading to the resident's decline and need for transfer. This failure created a risk for incomplete sharing of vital information with care givers across levels of care and lack of evidence of care provided. Findings included . A review of the 01/30/2025 five-day assessment documented Resident 104 had diagnoses that included stroke and difficult swallowing. Resident 104 required substantial staff assistance for their activities of daily living and was able to make decisions regarding their care. On 03/03/2025 at 9:07 AM, it was observed that Resident 104 was not present in their room and the nursing unit. When asked, Staff Y, Nursing Assistant, stated they heard Resident 104 had been vomiting blood and was sent to the hospital, but they were unsure.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff were educated regarding the risks and benefits of and provided the COVID (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccine if desired, and failed to ensure minimum documentation was maintained regarding staff COVID vaccination status for 1 of 1 sampled staff (Staff P) reviewed. This failure placed staff and residents at risk of exposure to and illness from COVID-19. Findings included . The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages 19 years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age [AGE]-64 years, or adults age [AGE] or older who were unvaccinated for COVID-19, were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 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 interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 2 of 45sampled residents (Resident 1 and 3), reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . <Resident 1> Per the admission assessment dated [DATE] Resident 1 admitted to the facility for therapy services after a fracture (arm). The assessment documented the resident required extensive staff assistance to perform ADLs. Review of the 11/06/2024 care plan showed Resident 1 was to work with therapies to meet goals of improvement in their functional abilities. Review of a physical therapy discharge summary, signed 12/06/2024, showed Resident 1 met one out of three short-term goals and zero out of three long-term goals. Per the summary the resident was referred to the Restorative Nursing Program (RNP; nursing interventions that promote 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 interview, and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications. Findings included . <Resident 1> Review of the 11/15/2024 care plan showed Resident 1 had a diagnosis of schizoaffective disorder, bipolar type (((a mental disorder characterized by symptoms of both schizophrenia (hallucinations, delusions, disorganized thinking) and a mood disorder (bouts of mania and depression))). In a telephone interview on 01/08/2025 at 11:09 AM with Staff C, Physican Assistant, they stated that they were the provider in the facility who worked with residents who used medications for psychological diagnoses requiring medication managment. They further stated that they had worked with Resident 1 since shortly after they admitted . Staff C stated 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.

Based on interview and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 8) and their representatives and medical provider, reviewed for notification of changes, received timely notification of an incident. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life. Findings included . Review of a 09/19/2024 facility investigation report showed Resident 8 was found in Resident 1's bed at 9:40 PM the previous evening. Per the report, Resident 8 was fully dressed but Resident 1 was undressed and both residents had diagnoses of dementia (group of symptoms affecting memory, thinking, and social abilities). Resident 8 was interviewed in their primary language the next morning and reported that Resident 1 brought them into Resident 1's room, encouraged them into bed, attempted to remove their clothes, and laid down next to them in bed. The report showed Resident 8's representatives and the medical provider were notified of the incident but did not include the date and time of…

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

Based on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse, for 1 of 6 sampled residents (Resident 8), reviewed for abuse. The failure to provide timely follow-up medical care and to preserve potential evidence placed the resident at risk of unidentified abuse. Findings included . Review of a 09/19/2024 facility investigation report showed Resident 8 was found in Resident 1's bed at 9:40 PM the previous evening. Per the report, Resident 8 was fully dressed but Resident 1 was undressed and both residents had diagnoses of dementia (group of symptoms affecting memory, thinking, and social abilities). Resident 1 was unable to give a statement about the incident due to their cognitive deficits. Resident 8 was not interviewed until the following morning. Resident 8 was interviewed in their primary language and denied sexual assault but was transferred to the hospital for additional examination due to the potential for sexual assault. In an interview on 10/01/2024 at 2:36 PM a representative for Resident 8 stated 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 provide a written transfer/discharge notice to the resident, their representative, and the State Long-Term Care Ombudsman for 1 of 5 sampled residents (Resident 10), reviewed for discharge. This failure placed the resident at risk of not having the opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Notice of Transfer or Discharge, adopted on 08/01/2024, showed the facility would notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in a written notice using the Resident Notice of Transfer or Discharge. In the case of an emergency transfer, the written notice would be issued as soon as practical. Additionally, the facility would send a copy of the notice to the State Long-Term Care Ombudsman. Review of the 09/12/2024 admission assessment showed Resident 10 had cognitive impairments and physical behaviors that impacted their care one-to-three-days of the assessment period. Review of 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 observation, interview, and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 8 and 12), reviewed for meal intake, received assistance setting up their meals and continued supervision and cueing while eating. This failure placed the residents at risk of decreased dietary intake, potential weight loss, and decreased quality of life. Additionally, the facility failed to ensure 3 of 3 sampled residents (Resident 8, 1, and 5), reviewed for bathing, received the assistance they required with baths and/or showers. This failure placed the residents at risk for skin breakdown, discomfort, and diminished quality of life. Findings included <Resident 8> Review of the admission assessment dated [DATE] showed Resident 8 had impairments to upper and lower extremities and was dependent on staff for activities of daily living (ADLs) such as eating, transferring and bathing. Per the assessment, the resident did not refuse care. Review of the care plan dated 08/09/2024 showed staff were 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 ensure sufficient nursing staff were available to respond to call lights timely and to meet the care needs of 6 of 13 sampled residents (Residents 13, 8, 3, 4, 5, and 12), reviewed for sufficient nursing staff. This failure resulted in feelings of frustration and vulnerability, diminished quality of life and unmet care needs of the residents. Findings included . <Resident 13> Observation on 08/16/2024 at 12:25 PM showed Resident 13 was sitting in their wheelchair in the doorway of their room with the call light activated. The resident was looking up and down the hallway and muttering to themself. At 12:56 PM the resident's call light was still activated and the resident wheeled themself to the nurse's medication cart and asked when staff would be available to assist them into bed to use the bedpan. The resident stated they had been waiting more than 45 minutes and were beginning to become nauseous due to their gastrointestinal (GI) symptoms. Staff G, Licensed Practical Nurse (LPN), told Resident 13 that 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 observation, interview, and record review, the facility failed to ensure significant medications were given as ordered for 3 of 3 sampled residents (Resident 3, 4, 5), reviewed for medication administration. This failure placed the residents at risk for worsening of their medical conditions and unintended consequences. Findings included . <Resident 3> Per the 07/27/2024 hospital transition of care orders Resident 3 had the following medication orders: -an oral antibiotic, cephalexin 500 mg (milligrams), four times daily for seven days for a skin infection to their left lower leg -requip (medication to treat restless legs and neurological disorders) 3mg at bedtime -amitriptyline (tricyclic antidepressant) 25mg at bedtime -gabapentin 300mg three times daily (drug that affects chemicals and nerves involved in seizures and pain) Review of Resident 3's July 2024 Medication Administration Record (MAR) showed no administration of any medications. Review of the July 2024 progress notes showed Resident 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personal privacy for 2 of 2 sampled residents (Resident 5 and 8), reviewed for dignity. Failure to ensure the residents' personal privacy placed them at risk for lack of dignity and a diminished quality of life. Findings included . <Resident 8> In an interview on 08/15/2024 at 1:17 PM, Collateral Contact (CC) 1 stated when visitors came in to see Resident 8 they found the resident obviously soaked in urine on two separate occasions. Observation on 08/16/2024 at 12:42 PM showed Resident 8 was in bed covered with a blanket. Staff O, Physical Therapist, came into the resident's room and invited the resident to go to the therapy gym for a therapy session. Staff O pulled back the blankets which revealed Resident 8 was lying in a large puddle of fluid that was clearly visible on the front and back of their shirt and pants. A strong odor of urine was present. Staff O stated the resident needed assistance from nursing staff then went out into the hallway and immediately returned with a non-mechanical lift for…

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

Based on interview and record review, the facility failed to ensure allegations of potential misappropriation were reported immediately to administration and the State Agency as required, for 1 of 3 sampled residents (Resident 4) reviewed for abuse. This failure placed residents at risk for possible misappropriation. Findings included . Review of Resident 4's July 2024 progress notes showed an entry on 07/07/2024 by Staff H, Licensed Practical Nurse, which documented an allegation that Staff I, Registered Nurse, had misappropriated oxycodone (narcotic pain medication) from an unknown resident and administered it to Resident 4, due to lack of availability of Resident 4's medication from the pharmacy. The note showed Resident 4's pain was discussed with Staff B, Director of Nursing, but did not document whether Staff B was notified of the allegation of misappropriation. Review of the facility's Incident Log for July 2024 did not show any entries related to Resident 4 and/or any entries of misappropriation for any resident. In an interview on 09/04/2024 at 11:45 AM, Staff B, Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary wound care supplies were available and staff were knowledgeable in their use for 1 of 14 sampled residents (Resident 4), reviewed for quality of care. This failure placed residents at risk of not receiving necessary care and a diminished quality of life. Findings included . Review of the hospital Discharge summary dated [DATE] showed Resident 4 had multiple abdominal surgeries and discharged with two surgical drains (to remove fluid from a wound) to the abdomen. The resident was to discharge to a skilled nursing facility as they were not safe to return home. Per the 07/07/2024 skilled nursing facility transfer orders Resident 4 was to have negative pressure wound therapy (wound vacuum) to their abdominal incision continuously. Review of the July 2024 progress notes showed Resident 4 admitted to the facility on [DATE] with a specialty dressing intended for use with a wound vacuum but did not have a wound vacuum machine. Per the notes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (Resident 8), reviewed for accident hazards and staff supervision, were safely transferred with via the assistance devices and staff supervision level they were assessed to need. This placed the resident at risk for injury, decreased sense of safety and a diminished quality of life. Findings included . Review of the 08/13/2024 admission assessment showed Resident 8 had a diagnosis of hemiplegia (one sided paralysis or weakness) and was dependent upon staff for transfers. Review of the care plan initiated 08/06/2024 showed staff were to transfer Resident 8 via a total body mechanical lift and assistance of two staff. The care plan included that the resident had weak legs. In an interview on 08/15/2024 at 1:17 PM, Collateral Contact (CC) 1 stated an unidentified staff member transferred Resident 8 from their wheelchair into their bed with a mechanical sit-to-stand lift and no additional staff assistance. CC1 stated the resident had not been strapped into the lift properly 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.

Based on observation, interview, and record review, the facility failed to provide meals with assistive devices in the correct position for use for 1 of 3 sampled residents (Resident 8), reviewed for meal service. This failure placed the resident at risk for decreased meal intake, loss of dignity, and a diminished quality of life. Findings included . Review of the 08/13/20204 admission assessment showed Resident 8 had an impairment in mobility to their upper extremity and were dependent upon staff for eating assistance. Review of Resident 8's care plan for nutrition and activities of daily living (ADLs), initiated 08/06/2024, showed a goal of no further avoidable decline in ADLs and an intervention of staff to provide supervision and cues when the resident ate. There was no instruction to staff on how to maintain/encourage independence with eating for Resident 8 and/or assistive devices the resident utilized with their meals. In an interview on 08/08/2024 at 11:04 AM Collateral Contact (CC) 1 stated Resident 8 was not receiving adequate assistance with eating and was not provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a system was in place in which residents' records were complete and accurate for 1 of 11 sampled residents (Resident 4) reviewed for accurate and complete medical records. The facility failed to ensure the medical record included medications administered for pain control immediately prior to a transfer to a hospital for pain control. Failure to maintain complete and accurate medical records placed the resident at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of Resident 4's Medication Administration Record (MAR) for July 2024 showed no medications were administered to the resident on 07/07/2024. An order for oxycodone 5 mg (milligrams) one to two tablets every four hours as needed for pain was present on the MAR, but not administrations were documented. There was no order for acetaminophen on the MAR. Review of the July 2024 progress notes showed a note which documented Staff I, Registered Nurse, administered a pill in a cup to Resident 4 on 07/07/2024…

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 observation, interview, and record review, the facility failed to ensure that one randomly observed staff (Staff L) wore personal protective equipment (PPE) in accordance with Centers for Disease Control (CDC) guidelines for prevention of spread of COVID-19 (a disease with a wide range of symptoms ranging from mild symptoms to severe illness caused by the SARS-CoV-2 virus). This failure placed residents (facility census 108) and staff at risk for spread of a contagious disease. Findings included . Review of the CDC guidelines titled, Infection Control Guidance: SARS-CoV-2, updated 06/24/2024, showed staff working on a unit or area of a facility experiencing a SARS-CoV-2 outbreak should use source control (face mask or respirator to cover a person's mouth and nose to prevent spread of respiratory secretions). Additionally, staff who entered the room of a resident with suspected or confirmed SARS-CoV-2 infection should use a N95 respirator (instead of source control), gown, gloves and eye protection. Review of a document titled, COVID, dated 08/08/2024, provided by Staff F,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care planned interventions for 1 of 4 sampled residents (Resident 1) reviewed for care planning. This failure left the resident at risk for unmet needs, falls and fall related injuries. Findings included . Review of the fall prevention care plan revised 01/25/2024 showed staff were to keep Resident 1's call light was in reach, provide a Paddle-style call light for ease of use, and place a fall mat at the bedside when the resident was in bed. Observation on 02/16/2024 at 2:51 PM showed Resident 1 was in bed with a standard call light, a bedside table with personal items next to the bed, and no fall mat. A similar observation was made on 02/29/2024 at 2:37 PM. The care planned interventions of the specialty paddle-style call light and fall mat at bedside were not observed on either date. In an interview on 02/29/2024 at 2:41 PM Staff G, Nursing Assistant, stated they were responsible for Resident 1's care that day but did not know whether their care planned interventions to prevent falls were in place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three staff members (Staff F and G), reviewed for competency, were evaluated by the facility for competency with skills and techniques upon hire. This failure placed residents at risk to receive substandard care. Findings included . Review of Staff F's employee file showed Staff F, Nursing Assistant, was hired on 07/17/2023 and had no documentation showing their competency with skills and techniques were assessed. Review of Staff G's employee file showed Staff G, Nursing Assistant, was hired on 09/20/2023 and had no documentation showing their competency with skills and techniques were assessed prior to 01/22/2024. The employee file showed Staff G was assessed for skill competency related to resident transfers only on 01/22/2024 (after an incident involving Staff G improperly transferring a resident; see F-689 Free of Accident Hazards/Supervision for more information). In an interview on 02/29/2024 at 2:41 PM Staff G stated they got training if they asked for it and were oriented to the facility 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 ensure a medication error rate of less than 5 percent for 2 of 4 sampled residents (62,35) during 4 medication passes observed. Specifically, 3 errors were made during 27 medication administration opportunities, resulting in an error rate of 11.11 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication. Findings included . <Resident 62> During an observation on 12/18/2023 at 6:12 AM, Staff J, Registered Nurse, prepared medications for Resident 62. The medications included a Bisacodyl suppository (a medication used to treat constipation) to be administered every morning. Staff J decided not to administer the suppository related to the resident had a bowel movement. The resident also had an order to check placement of their peg tube (a tube that is placed inside the stomach wall to provide a means of feeding when oral intake is not possible). Staff J did not check placement of the tube per physician order. In an interview…

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

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. Additionally, temperatures were not monitored consistently for refrigerators containing vaccines, narcotic books did not contain two verifying signatures that the count was correct, and insulin was expired and undated when opened. The facility further failed to ensure narcotics were locked in a permanently affixed narcotic container in 2 of 2 medication storage room refrigerators. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . According to the Centers for Disease Control (CDC), vaccines should be stored between 36-46 degrees Fahrenheit (F) and failure to do so reduced or destroyed their potency, resulting in inadequate or no immune response in the recipient. During observation of the north…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 service safety. Specifically, perishable foods were not labeled with the opened on or discard date, expired foods were not discarded, refrigerator temperatures were not monitored, hand hygiene was not performed with glove changes, and facial hair was not covered in the food preparation area. These failures placed residents at risk for consuming contaminated foods and food-borne illness. Findings included . On 12/11/2023 at 9:05 AM, during a tour of the kitchen with Staff Y, Food Service Manager, the following observations were made: In the dry storage area, the following items were opened and partially used, but were not labeled with an opened on or use by date. 1) Cream Soup base 2) [NAME] style cooking wine, 1 gallon 3) Light molasses, 1 gallon 4) Worchestershire sauce, 1 gallon 5) [NAME] cooking wine, 1 gallon 6) Vegetable oil, 1 gallon 7) White cooking wine, 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a system for identifying, investigating and reporting infectious diseases for 1 of 5 sampled residents (82) reviewed for tuberculosis (TB) screening (a bacterial infectious disease spread through contact with or breathing in particles coughed into the air) and failed to ensure hand hygiene was completed when indicated during observations of three medication passes, one dressing change, and two meals in the South unit dining room. This failure placed residents at risk for spread of infectious illnesses and decreased quality of life. Findings included . The Centers for Disease Control and Prevention (CDC) Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis (TB) in Healthcare Settings, 2005 retrieved 01/02/2024 from http://www.cdc.gov/tb/topic/infectioncontrol/TBhealthCareSettings.htm documented primary tuberculosis (TB) risk to others was the undiagnosed or unsuspected patient with infectious TB. A high index…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preserve a resident's dignity for 1 of 2 sampled residents (10) reviewed. Failure to ensure signage regarding Resident 10's personal care was not hung in public view placed Resident 10 at risk for embarassment and decreased quality of life. Findings included . According to a quarterly assessment completed on 11/09/2023, Resident 10 was severely cognitively impaired and required total assistance with personal hygiene. Review of the Physicians Order dated 05/17/2023 instructed nursing staff to monitor redness on Resident 10's left buttock. During an observation on 12/11/2023 at 9:11 AM, a sign hung to the right of Resident 10's bed documented to apply Calazyme (a skin protectant that repels moisture) to the resident's buttocks for bed sores. The sign was highlighted in a bright yellow color, decorated with hearts, and included Resident 10's name at the bottom. The sign was in view of Resident 10's roommate or any visitors that came into the room. During subsequent observations on 12/13/2023 at 9:10 AM, 12/13/2023 at 10:43 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop care planned goals and interventions for 3 of 27 sampled residents (82, 53 and 81) reviewed and failed to ensure the care plan was implemented by staff for 1 of 27 sampled residents (81) reviewed for care planning. Specifically, Resident 82 was dependent on dialysis (a way of removing waste from the body when kidneys no longer function). Residents 53 and 80 had post-traumatic stress disorder (PTSD, condition triggered when one expierienced or witnessed shocking or terrifying events). These residents had no goals or interventions developed related to these diagnoses. Also, Resident 81 had a history of falling and their call bell was not left within their reach as care-planned. These failures left residents at risk for unmet needs, and at risk for fall related injuries. Findings included <Resident 82> An 11/27/2023 admission assessment documented Resident 82 had diagnoses including end-stage renal (kidney) failure dependent on dialysis. The resident was cognitively intact and was dependent on staff 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, interview, and record review, the facility failed to ensure the care plan was reviewed and revised for 1 of 27 sampled residents (62) reviewed for care planning. Specifically, Resident 62's care plan did not reflect that they were not to have their nutrition by mouth. This failures placed the resident at risk for adverse events related to receiving the wrong therapies. Findings included . <Resident 62> According to a 10/11/2023 quarterly assessment, Resident 62 was admitted to the facility with a diagnosis of Cerebrovascular Accident (stroke) and dysphagia (swallowing difficulty). The assessment showed Resident 62 had moderately impaired cognitive skills. Review of the nursing progress notes from 10/12/2023 through 10/20/2023 documented the resident was admitted to the hospital and upon readmission to the facility, was not to have any food/fluids by mouth. According to the October 2023 Medication Administration Record (MAR), Resident 62 was to receive nothing by mouth, and medication was to be administered through a gastrostomy tube, (G-Tube, a tube that was…

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

Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled residents (16) reviewed for activities, received an ongoing program of activities that met their interests. This failure placed the resident at risk for boredom and diminished quality of life. Findings included Per the 09/30/2023 quarterly assessment, Resident 16 was cognitively intact and had diagnoses which included macular degeneration (an eye disease that caused vision loss). The assessment showed it was very important to the resident to be involved in activities that included: books, newspapers, and magazines to read. Review of Resident 16's care plan, showed they were dependent for meeting emotional, intellectual, physical, and social needs related to their disease process and staff would offer opportunities to engage in planned group/social activities as well as material to self-engage. The goal for Resident 16 was to participate in activities of choice one to three times weekly. The interventions were to provide the resident with books on tape, assist with tapes, and to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that residents environment remained free of accident hazards, and that 1 of 5 sampled residents (29), reviewed for accidents/hazards, received adequate supervision to prevent accidents. Specifically, hazardous chemicals and materials were not secured on 5 of 5 halls where residents could access them, treatment and medication carts were left unlocked and unsupervised. In addition, Resident 29 had unsecured cigarettes and a lighter in a pouch on their wheelchair. These failures placed the residents at a potential risk of harm related to avoidable incidents. Findings included . <200 Hall Shower Room> On 12/11/2023 at 10:49 AM, a gallon container labeled ZEPS (a cleaning product) was observed in the unlocked 200 Hall shower room. An unnamed Nursing Assistant (NA) stated that the shower door was usually locked. A similar observation on 12/12/2023 at 11:30 AM, showed the door to the shower room remained unlocked. There were no residents…

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

Based on observation, interview and record review, the facility failed to ensure residents that had significant weight loss were reassessed by the Registered Dietician (RD) timely for 2 of 6 sampled residents (10, 62) reviewed for nutrition. This failure placed residents at risk for further undesired weight loss, and a decline in their health. Findings included . <Resident 10> According to a quarterly assessment completed on 11/09/2023, Resident 10 had diagnoses including dysphagia (swallowing difficulty), stroke and anxiety. Resident 10 was severely cognitively impaired and required substantial assistance of one for eating and had significant weight loss not on a prescribed weight loss regimen. A review of the resident weights showed the following weights for Resident 10: -6/4/2023 140 pounds (lbs.), -09/03/2023 142 lbs., -11/08/2023 121 lbs., -12/12/2023 124 lbs., a -12.68% loss in 3 months and -11.43% loss in 6 months. The 12/06/2023 Nutritional Risk assessment showed Resident 10 had significant weight loss, they ate 0-25% of their meals and occasionally consumed nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standards of care for 1 of 2 residents (62) reviewed for tube feedings. Specifically Resident 62 experienced vomiting and failure of staff to check gastric residual volumes (GRV - fluid/contents that remain undisgested in the stomach) prior to tube feeding administration. This failure placed the resident at risk for weight loss, continued vomiting, medical complications, and decreased quality of life. Findings included . Review of the comprehensive care plan dated 05/11/2022, showed Resident 62 had dysphagia (difficulty swallowing), and received 100% of their nutrition and hydration through use of a tube feeding. Review of the medical record showed there were no orders that directed staff to check for GRV prior to the initiation of tube feeding, what an acceptable GRV was for Resident 62, or when to notify the physician when the GRV exceeded the acceptable range. During an interview on 12/20/2023 at 10:43 AM, Staff L, Resident Care Manager, stated there should have been an order to check for GRV as this was…

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

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (16, 40) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . <Resident 16> Per the 09/30/2023 quarterly assessment, Resident 16 had diagnoses which included heart failure (when the heart muscle doesn't pump blood as well as it should), circulation problems, lung disease, and needed oxygen due to those conditions. Review of the physician orders showed on 03/03/2020, the resident had been prescribed oxygen to be used continuously, due to the heart and lung conditions listed above. The 04/02/2020 respiratory care plan showed no direction for cleaning oxygen filters on the oxygen concentrator, a machine that delivers oxygen to the resident. On 12/11/2023 at 9:14 AM, Resident 16 was observed wearing oxygen while lying in bed. An inspection of the oxygen concentrator in the resident's room showed the concentrator was unclean with thick…

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

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered for 1 of 6 sampled residents (53) reviewed for medication administration. This failure placed Resident 53 at risk for worsening depression and adverse health consequences when they missed doses of their medications. Findings included . <Resident 53> A review of the 11/29/2023 quarterly assessment documented Resident 53 had diagnoses including general anxiety disorder, post-traumatic stress disorder (PTSD, trauma from experienced stressful or terrifying events), and high cholesterol and was cognitively intact. On 12/13/2023 at 9:52 AM, Resident 53 was observed to keep their door closed. Upon entrance, Resident 53 was observed sitting on their bed organizing personal bank items. Resident 53 rocked back and forth during conversation. Resident 53 stated they went to a friend's house and stayed until midnight most nights because they did not sleep well. Resident 53 stated that usually upon return to the facility, their nighttime medications were brought in for them to take.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 92 residents. Specifically, the Registered Dietician (RD) did not have a license to practice in Washington State. This failure placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain. Findings included . A review of staff credentials showed that Staff R, Registered Dietician (RD), had successfully completed requirements for dietetic registration through the Academy of Nutrition and Dietetics Commission on Dietetic Registration, with a certificate valid through 08/31/2024. A copy of Staff R's license to practice in Washington State was also requested and none was provided. A search of the Washington State Department of Health Provider Credential database could not confirm that Staff R had a Dietician Certification (license) necessary for practice in Washington State. During an interview on 12/19/2023 at 1:07 PM, Staff A, Administrator, stated they requested 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 consistently monitor and/or accurately document condition changes for 2 of 3 sampled residents (Resident 2 and 3). These failures placed residents at risk of potential medical complications, unmet care needs and diminished quality of life. Findings included . <Resident 2> Review of Resident 2's medical record showed they admitted on [DATE] with diagnoses of heart failure (the inability of the heart to beat effectively resulting in fluid buildup in the body), edema (swelling), chronic kidney disease (kidneys are not able to filter toxins and fluids as they normally would) and chronic obstructive pulmonary disease [COPD] (treatable disease characterized by progressive breathlessness and cough). The record also showed the resident was a full code (indicating they would like all life saving measures performed in case of a medical emergency). Review of Resident 2's July 2023 Medication Administration Record (MAR) showed an order to complete a Heart 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 interview and record review the facility failed to consistently monitor tolerance to dialysis (procedure to remove fluid and waste from the body when the kidneys stop working properly) treatments for 1 of 2 sampled residents (Resident 1), reviewed for dialysis care. In addition, the facility failed to communicate and collaborate care with the dialysis center. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Dialysis-Provision of Care by Outside Providers, revised 02/2019, showed communication would exist between the dialysis center and the facility with an interchange of information necessary for the care of the resident. Review of the facility policy titled, Hemodialysis Care, revised 11/2023, showed residents who require hemodialysis were provided ongoing assessment and monitoring for complications of their condition before and after treatments. The policy further stated the licensed nurse was to complete the Dialysis Center Communication Form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transcribe providers orders accurately and/or ensure residents routinely received their medications as ordered by the provider for 2 of 3 sampled residents (Resident 1 and 2), reviewed for significant medication errors. These failures placed residents at risk of potential adverse side effects, unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Medication and Treatment Orders, revised 06/2019, showed medication and treatment orders would be entered into the electronic medical record completely and accurately exactly as ordered. The policy further showed orders would be reviewed for completeness and accuracy during the first week a resident was admitted . Standards of nursing care indicate medication should be administered as ordered by the prescribing provider. <Resident 1> According to the 05/26/2023 admission assessment, Resident 1 admitted to the facility with diagnoses of diabetes, heart failure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of personal property and funds for 3 of 4 sampled residents (Residents 2, 4, and 7), reviewed for misappropriation. This failure placed residents at risk for missing property, missing funds, and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed misappropriation definitions included the deliberate use of a resident's resources for personal profit or gain, and borrowing or spending resident funds. Exploitation was defined as taking advantage of a resident for personal gain. <Resident 2> Review of the admission assessment dated [DATE] showed Resident 2 admitted to the facility on e week prior to the assessment date (08/15/20023) with diagnoses of stroke and dementia. The assessment showed the resident had weakness to one side of their body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 measures to prevent the spread of communicable disease during a COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness]) outbreak on 2 of 2 affected units (200 & 300 halls). This failure placed residents at risk of contracting a communicable disease. Findings included . Per the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/2023, respirators or well fitting face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing should be worn by those working on a unit or area of the facility experiencing a COVID-19 or other outbreak of respiratory infection until no new cases of infection have been identified for 14 days. Additionally, the facility should perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one staff member (Staff G) timely reported allegations of staff misappropriation of resident property, as required. This failure placed residents at risk of misappropriation and exploitation. Findings included . Review of the facility policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed any staff member observing staff to resident exploitation or misappropriation of resident property would immediately remove the resident from the situation and report to administrative personnel. If the allegation included misappropriation of resident property, the incident would be reported to local law enforcement and the State Survey Agency within 24 hours. Review of the care plan revised 06/24/2023 showed Resident 7 was at risk of altered mental status due to delirium, opioid use, and Parkinson's with a psychotic disorder with delusions. In an interview on 10/12/2023 at 3:31 PM, Staff G, Nursing Assistant, stated they started working at…

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

Based on interview and record review, the facility failed to thoroughly investigate 1 of 3 (Resident 2) allegations of misappropriation of resident property. This failure placed residents at risk of unidentified misappropriation and diminished quality of life. Findings included . Review of a facility investigation dated 09/13/2023 showed a representative for Resident 2 reported the resident was missing a medical alert necklace, which had been removed from the resident by Staff C, Social Services, while the resident was at the facility. The investigation included a typed summary by Staff B, Director of Nursing, which documented both Staff C and Staff D, Social Services, were interviewed, as well as unidentified nurses and nursing assistants, who worked on the same hall the resident resided on, as well as a list of residents. Neither the staff member nor the resident statements, including date and time of the interviews or specific statements made, were included. Additionally, the interviewed parties did not include Staff F, Transport Staff, the first person to see the resident during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 sample residents (Resident 1), reviewed for skin conditions, received appropriate monitoring and nursing care related to skin care. This failure placed the resident at risk for unidentified wounds, unmet care needs, and a decreased quality of life. Findings included . Review of the facility policy titled, Skin at Risk/Skin Breakdown, revised September 2020, showed a licensed nurse was to examine a resident's entire body within 8 hours of admission, to determine if skin impairment was present. Additionally, a full body skin evaluation was to be completed and documented weekly by the licensed nurse. Per the admission assessment dated [DATE], Resident 1 admitted to the facility from a hospital one week prior and required limited to extensive assistance of 1-2 staff for dressing, toileting, hygiene and bathing. The assessment also showed the resident had no behaviors of rejecting care. Review of the July 2023 Treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 4 of 4 sample residents (36, 16, 44, 83), reviewed for hospitalization, were given a written copy of a bed-hold notice prior to or within 24-hours of an emergency transfer to the hospital, as required. This failure created the potential for residents and/or their responsible parties to not have the information needed to safeguard their return to the facility. Findings included . Review of the facility policy titled Bed Hold (revised March 2019) read, Policy. The resident and or resident representative will be informed of this policy in writing upon admission, transfer or leave of absence. If unable to provide at the time of transfer or leave of absence, the policy will be provided within 24 hours. Review of the record showed Resident 36 was admitted to the facility on [DATE] with diagnoses including heart disease, diabetes, bipolar disorder (a serious mental illness characterized by extreme mood swings), and a psychotic disorder with delusions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 9 sample residents (8, 36, 43, 68, 74), who were dependent on staff for care, received appropriate care and services related to hair removal and bathing. Failure to provide necessary care and services to dependent residents placed them at risk for embarrassment and a diminished quality of life. Findings included . According to the 05/04/2022 quarterly assessment, Resident 8 had diagnoses which included muscle weakness, history of a stroke, and a cognitive communication deficit. Additionally, the assessment showed the resident required extensive, one person physical assistance with personal hygiene. Per the resident's care plan dated 03/09/2022, staff were directed to provide physical assistance with bathing and personal hygiene, which included shaving. During an observation on 06/14/2022 at 10:23 AM, Resident 8 was sitting in a common area of the facility in a wheelchair. The resident had very long nostril hair, protruding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fully investigate a mechanical lift failure involving 1 sample resident (10); to ensure the smoking area on the rehabilitation unit was equipped with a fire extinguisher; to ensure cigarette butts were disposed of in the appropriate containers.; and maintain fall interventions and ensure wheelchair armrests were in good condition for 1 sample resident (83). These failures placed the residents at risk for accidents and injuries (including burns). Findings included . Mechanical Lifts Review of the Resident 10's record showed they were admitted to the facility on [DATE], with diagnoses including morbid obesity. Review of the resident's significant change in condition assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident 10 was cognitively intact. The assessment also showed the resident had experienced one fall with minor injury since the last assessment. Review of 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 observation, interview, and record review, the facility failed to maintain the cleanliness of the oxygen concentrator filter (a type of medical device used for delivering oxygen to individuals), change nasal canula tubing (flexible tubing placed in the nose to administer oxygen), label the nasal cannula tubing, and cover nasal canula tubing when not in use according to the facility protocol, for 4 of 5 sample residents (36, 38, 34, 14), who required respiratory care. This failure placed the residents at increased risk for infection and unmet care needs. Findings included . The facility respiratory treatment policy, dated 03/31/2022, showed that oxygen concentrator filters were to be cleaned weekly. The task was documented on the treatment record and when oxygen was not in use, the nasal cannula and tubing were to be stored in a plastic or mesh bag. Review of Resident 36's record showed an admission date of 05/12/2022, with diagnosis including mild asthma and heart disease. Further review of the 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 observation, record review, and interview, the facility failed to ensure menus and recipes were followed to ensure nutritional adequacy for 5 of 5 sample residents (439, 53, 68, 15, 64), observed in the 100-hall dining room. This failure had the potential to affect residents who received food from the kitchen, causing decreased quality of life and health complications to include weight loss. Findings included . Review of the facility's policy titled Portion Size Adjustment, reviewed 05/2019, showed The standard menu lists regular size portions to be served unless otherwise indicated. Review of the facility's policy titled Menus, reviewed 02/2019, showed The menus serviced will meet the nutritional needs of the residents in accordance with established national guidelines .If there are changes to the menus, the changes must be written on all posted menus (production and resident) prior to services. Review of the facility's menu for breakfast on 06/16/2022 showed waffles, breakfast meat of choice, seasonal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food served to the residents was palatable and at proper temperature for 13 of 13 sample residents (439, 85, 49, 8, 74, 29, 52, 11, 27, 34, 69, 15, 64) interviewed related to the food quality. This failure placed the residents at decreased quality of life and potential weight loss. Findings included . Interview with the Staff B, Director of Nursing, on 06/16/2022 at 3:09 PM showed the facility did not have any policies related to food palatability. During an interview on 06/14/2022 at 9:43 AM, Resident 439 stated the meals were terrible, stating the menu was repetitive and there was not enough food. During an interview on 06/14/2022 at 10:02 AM, Resident 85 stated the food was inedible the day before. Resident 85 stated the ice cream was melted, and they consistently ran out of snacks. During an interview on 06/14/2022 at 10:47 AM, Resident 49 stated the food did not look good or taste good. During an interview on 06/14/2022 at 11:06 AM, Resident 8 stated the food was not good. During an interview on…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one facility kitchens. This failure had the potential to affect all residents that received food from the kitchen. Findings included . Review of the facility's policy titled Discard Date, reviewed 02/2019, showed Leftover food that is to be reused will be wrapped, covered with plastic wrap or placed in a suitable NSF [National Sanitation Foundation] approved plastic container and stored in the appropriate manner. Review of the facility's policy titled Bare Hand Contact, reviewed 02/2019, showed It is the policy of our facility to NOT allow bare hand and arm contact with all food. In an interview with Staff B, Director of Nursing, on 06/16/2022 at 3:09 PM, showed the facility did not have any policies related to box storage in the refrigerator/freezer walk-ins. During an observation on 06/14/2022 at 8:44 AM, the walk-in refrigerator had one plate of salad, uncovered; one metal pan with cooked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a Quality Assessment and Performance Improvement (QAPI) program that identified quality deficiencies and developed, implemented, and maintained corrective actions that ensured ongoing compliance with federal regulations. These failures placed residents at risk for not receiving care and services for optimal resident outcomes. Findings included Per documentation provided by the facility on 06/14/2022, the facility had a census of 99 residents. On 06/17/2022 at 10:30 AM, an interview was completed with Staff A, Administrator, and Staff B, Director of Nursing, regarding the facility's QAPI program. Staff A stated the facility had a QAPI committee, and meetings were held at least quarterly with the required members. The following deficiencies were identified by the survey team during the Long Term Care Survey Process, and were not identified by the facility, until brought to their attention by the survey team: Notice of Bed-Hold Policy Before/Upon Transfer See F625 for additional information. When Staff A was asked if…

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

Based on interview and record review, the facility failed to accommodate 1 of 2 sample residents (11), reviewed for choices, related to when they could get out of bed to smoke. This failure placed the resident at risk of decreased quality of life. Findings included . Resident 11 was admitted to the facility in March 2021, with a diagnosis of paraplegia (paralysis of the legs). The most recent comprehensive assessment, dated 03/12/2022, showed that the resident was cognitively intact and able to make their needs known. Resident 11 required staff assistance to get into their wheelchair, but were independent with mobility once in their chair. A 03/19/2022 Smoking Safety Evaluation showed that the resident was safe to smoke independently. A review of the record showed that the resident had fallen on 05/10/2022. A further review of the fall report investigation from the same date showed a recommendation for two people to assist with transfers to and from the wheelchair, and the resident's care plan was updated with that information. During an interview on 06/14/2022 at 3:30 PM, 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 record review and interview, the facility failed to ensure an allegation of misappropriation of property was thoroughly investigated for 1 of 1 sample residents (22), reviewed for abuse, out of a total sample of 42 residents. This failure placed the resident at risk for additional incidents of misappropriation. Findings included . Review of the facility's Abuse policy, revised February 2019, read, Policy- It is the policy of this center to: . 4) investigate allegations of abuse . 6) Protect our residents from abuse. Procedure to include Prevention, Investigation, and Protection . 6. Facility shall utilize Incident/ Accident Investigation policy and procedure to investigate concerns and incidents. The investigations will include but not limited to the following: a. All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and or/financial exploitation or misappropriation of resident property must be thoroughly investigated . b. A thorough investigation is completed through a systematic collection and review of evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to provide required transfer notices for 2 of 4 sample residents (36, 83), reviewed for hospitalization. The facility failed to provide the resident and/or their representative a written notice at the time the resident was transferred to the hospital, and failed to send a copy of the notice to the Ombudsman (a person who investigates complaints and/or concerns related to care and services in a nursing home), as required. Findings included . Per record review, Resident 36 was admitted to the facility in May 2022 with diagnoses including heart disease, diabetes, bipolar disorder (a serious mental illness characterized by extreme mood swings), and a psychotic disorder with delusions (a mental illness in which the person has an unshakable belief in something untrue). Review of a 02/08/2022 progress note showed the resident was sent to the hospital with increased blood pressure, diaphoresis (profuse sweating), and chest pain. Further review of the 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.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of a comprehensive assessment (an assessment tool used to identify a resident's care needs), for 1 of 3 sample residents (4), reviewed for assessments. Failure to accurately assess the resident related to hearing loss, placed the resident at risk for feelings of isolation, and unmet care needs. Findings included . Per the 06/05/2022 annual assessment, Resident 4 had diagnoses which included respiratory failure, and loss of vision. The assessment further showed the resident required extensive physical assistance with most activities of daily living. Under the communication and sensory evaluation of the same assessment, the resident was assessed as having adequate hearing, with no use of hearing aids. During an observation and interview on 06/14/2022 at 9:18 AM, hearing aids were in a box on Resident #4's beside table. The resident stated the hearing aids didn't work and needed repaired. A review of the care plan dated 02/25/2021, showed there was no care plan in place related 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 observation, interview, and record review, the facility failed to provide and follow a comprehensive activity plan, that met specific resident interests and needs, and to promote well-being, for 3 of 7 sample residents (71, 12, 83), reviewed for activities. This failure placed the residents at risk of a diminished quality of life and unmet needs. Findings included . Per record review, Resident 71 was admitted to the facility on [DATE] with diagnoses of dementia (a condition that makes it hard to remember, think clearly and make decisions), anxiety, and depression. The most recent comprehensive assessment, dated 05/06/2022, showed that Resident 71 had moderately impaired cognition, but was able to understand and be understood. The resident had impaired vision and used a walker or wheelchair with assistance. The document further showed that music, pets/animals, keeping up with the news, going outside when the weather was good, and religious services were all very important to the resident. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to ensure a central intravenous (IV) catheter - a thin flexible tube inserted into a vein, which is then guided into a large vein above the right side of the heart - had dressing changes as ordered by the physician for 1 of 5 sample residents (340), reviewed during medication administration. This failure placed the resident at risk for infection at the insertion site. Findings included . Review of the facility's undated IV Catheter Insertion and Care Policy showed . Central and Midline Dressing Changes: Central and Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings . Review of the undated admission Record, showed Resident 340 was admitted to the facility on [DATE], with diagnoses including chronic osteomyelitis (bone infection). An admission assessment had not yet been completed, but per interview,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 sample residents (43), reviewed for positioning and range of motion, received services to prevent a further decrease in range of motion for a hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to rigidity of joints), through use of a hand brace. This failure placed the resident at increased risk for a worsening contracture, potential decrease in range of motion, and skin integrity issues. Findings included . Per the quarterly assessment dated [DATE], Resident 43 had diagnoses which included cerebral palsy (cerebral palsy is a group of disorders that affect a person's ability to move and maintain balance and posture). Additionally, the assessment showed the resident had right sided upper body mobility limitations. During an observation on 06/14/2022 at 10:57 AM, Resident 43 was seated in a wheelchair in their room. The resident's right hand and wrist were curled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 acceptable parameters of nutritional status, such as usual body weight, or to monitor weight consistently, for 2 of 6 sample residents (439, 10), reviewed for nutritional status. This failure resulted in significant weight loss for Resident 439, and placed Resident 10 at risk for nutritional compromise and weight loss. Findings included . Review of the facility's policy titled Weight Monitoring and Documentation, revised 03/2019, showed, It is the policy of this facility to monitor nutrition parameters, including weights. In an interview with Staff B, Director of Nursing, on 06/16/2022 at 3:09 PM, showed the facility did not have any other policies related to nutritional status. Per record review, Resident 439 was admitted to the facility on [DATE] with diagnoses of right hip fracture, macular degeneration (vision loss), vascular dementia without behavioral disturbance, and dysphagia (difficulty swallowing). Review of the assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent aspiration for 1 of 2 sample residents (83), reviewed for tube feeding. This failure placed the resident at risk for medical complications and a decline in condition. Findings included . Review of the facility's policy Gastrostomy Feeding Tube, undated, showed the resident's head of bed should be elevated a minimum of 30-45 degrees during administration of enteral feeding (providing nutrition through a tube into the stomach), and for at least 30 minutes following administration. Should the resident be required to be in the supine position for any reason during a tube feeding, the tube feeding shall be stopped and then restarted once the procedure is completed. If the resident's clinical condition warrants supine or a position less than 30-45 degrees in elevation, this will be indicated on the resident's care plan . Review of the facility's policy Enteral Feeding Tubes, undated, showed 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 ensure appropriate behavior monitoring for 2 of 5 sample residents (9, 10), reviewed for unnecessary use of psychotropic medication drugs that affect behavior, mood, thoughts, or perception. This failure placed the residents at risk for receiving unnecessary and/or ineffective medications. Findings included . Review of the facility's Psychoactive Medication Policy, revised in 05/2022, showed the resident's medication regimen should be free from unnecessary drugs and help to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. The policy also stated newly admitted residents and residents started on psychoactive medication would be placed on alert charting for monitoring behaviors and a behavior management plan would be initiated. Review of the Resident 10's admission record, dated 09/20/2017, showed the resident admitted with diagnoses including insomnia, anxiety, and major depression. Review of a 03/08/2022 significant change assessment showed Resident 10 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, in a timely manner, there was a functioning call light in resident rooms occupied by 1 of 5 residents (4), reviewed for call light use. This failure placed the resident at risk for unmet care needs, and the inability to call for assistance. Findings included . Per the annual assessment dated [DATE], Resident 4 had diagnoses which included respiratory failure, and loss of vision. The assessment further showed the resident required extensive physical assistance with most activities of daily living. During an observation and interview on 06/14/2022 at 9:18 AM, Resident 4 reported that the call light in their room would not work unless the call light in the bathroom was turned completely off. The resident stated the problem had been reported to maintenance. On 06/14/2022 at 9:30 AM, the survey team tested the call lights in all sample resident rooms. All other call lights were in working order. In an interview on 06/14/2022 at 11:00…

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