Alaska Gardens Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received needed dental care for 1 of 3 sampled residents (Resident 112) reviewed for dental. This failure placed the residents at risk of dental pain, decreased nutritional intake, unintended weight loss, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 112 admitted to the facility on [DATE] with diagnoses to include leg fracture, dementia (a decline in mental ability severe enough to interfere with daily life), and hearing loss in both ears. Observation on 05/03/2026 at 1:43 PM showed Resident 112 had missing lower teeth. Review of the admission minimum data set assessment (MDS), dated [DATE], showed Resident 112 had obvious or likely cavities or broken natural teeth. Review of the care plan, dated 02/24/2026, showed Resident 112 had oral/dental health problems related to likely cavities/broken teeth with an intervention to coordinate dental care and provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately document the amount of food eaten for 1 of 3 sampled residents (Resident 13) reviewed for nutrition. This failure placed residents at risk of inaccurate assessments, lack of timely interventions, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 13 admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (too much sugar in the blood), dysphagia (difficulty swallowing), and protein-calorie malnutrition (lack of nutrients in the body). The quarterly minimum data set (MDS, an assessment tool), dated 02/12/2026, showed Resident 13 was moderately cognitively impaired. Observation on 05/05/2026 at 12:09 PM showed a meal tray was delivered to Resident 13 in their room. Observation showed the meal tray was set up on a bedside table next to Resident 13's bed. Observation showed Resident 13 was eating slowly. Observation showed Resident 13 ate less than 25%…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light system was functioning for 1 of 3 call light panels (500 hall) when reviewed for call lights. This failure placed residents at risk of inability to receive timely assistance, possible neglect, and a diminished quality of life. Findings included.Observation on 05/03/2026 at 11:04 AM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/04/2026 at 1:13 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/07/2026 at 12:37 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/07/2026 at 1:17 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] continued to be lit, but the call light above room [ROOM NUMBER] was not lit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 staff (Staff N & O) reviewed had the appropriate knowledge, competencies, and skill sets to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air), to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments, individual plans of care, and facility policy. Failure of the nursing staff to demonstrate a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics needed to successfully perform work roles or occupational functions resulted in deficiencies related to the competency of nursing staff and placed residents at risk for unmet care needs including not receiving CPR if/when needed, a diminished quality of life, and adverse outcomes including death.Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 8 out of state licensed nurses (Staff C) reviewed had a multistate license authorizing practice in the state the facility was located. This failure placed residents at risk of receiving care from an unlicensed and unqualified individual.Findings included . On [DATE] Resident 1 experienced a change in condition, and coded. CPR (Cardiopulmonary Resuscitation) was started, 911 notified, medics continued CPR and pronounced Resident 1 deceased . The assigned nurse, Staff C, Registered Nurse (RN),was suspended pending investigation. On [DATE] at 6:55 PM, Staff A, Administrator documented the facility investigation substantiated that Staff C did not meet the standard of care when responding to a reported change in condition. Staff C was terminated and license reported. Record review showed Staff C, was hired [DATE], and had a California State RN license with an expiration date of [DATE]. Review of the license verification report showed Staff C 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 provide ensure care and services were provided in a manner that maintained and promoted dignity and respect for 8 of 9 current residents (Residents 3, 4, 5, 6, 7, 10, 12 and 13) interviewed. Failure of the facility to respond to resident's requests in a timely, respectful and professional manner, placed residents at risk for diminished self-worth, frustration, and a decreased quality of life. Findings included . <Resident 3>During an interview on 07/16/2025 at 10:98 AM, Resident 3 shared an interaction with Staff D, Nursing Assistant Certified (NAC) that occurred during care. Resident 3 stated that Staff D was incredibly negative, talking under their breath the entire time and when the resident said sorry to inconvenience you, Staff D said, would you like another aide? , Resident 3 said that would be lovely, and right in the place Staff D stood and screamed down the hall for another aide and left Resident 3 entirely exposed and stomped out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 convey the refunds of 2 of 3 residents (Resident 8 & 14) to the resident or to the individual or jurisdiction administering the resident's estate, or the Office of Financial Recovery within thirty days of the discharge, transfer or death. This failure placed resident family and/or representatives at risk for financial hardship.Findings included . Review of the facility admission Agreement last updated [DATE], showed the center would issue any refunds to the Resident Group or, in the even of the Resident's death, to the Resident's estate, or applicable state agency within the time required by law. <Resident 8>Resident 8 discharged from the facility on [DATE]. On [DATE] at 8:40 AM Collateral Contact 1 stated the facility overbilled Resident 8 and were withholding payment, stating the funds were already spent, but were unable to articulate if the funds were spent on the resident while they were a resident in the facility. During an interview on [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 4 of 7 sampled residents (Residents 85, 32, 38 and 68) when reviewed for abuse/neglect. These failures placed the residents at risk of continued abuse/neglect, diminished quality of life and unmet needs. Review of a facility policy titled, Abuse Neglect and Misappropriation of Resident Property Prohibition, dated March 2025, showed each resident had the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center implements policies and processes so that residents were not subject to abuse by staff, other residents, volunteers, consultants, facility members, and others who may have unsupervised access to residents. These policies addressed screening,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication storage refrigerators (ASSISI and Long-Term Care), were secured when reviewed for controlled substance storage for lorazepam (a scheduled IV controlled substance medication used in the treatment of anxiety). In addition, the facility failed to ensure 2 of 3 medication carts (ASSISI and Long-Term 2) had medications dated once opened for an insulin pen (a prefilled insulin injector used to deliver as set number of units) and multiple eye medications. These failures had the potential for adverse side effects, ineffective dosage and a decreased quality of life. Findings included . Review of a policy titled, Medication Storage/Storage of Medication, dated 01/2023, showed the facility's medications and biologicals were to be stored properly, follow manufacturers or provider pharmacy recommendations, and to maintain their integrity to support safe effective drug administration. In addition, insulin products should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop a baseline care plan, with goals and interventions to communicate resident care needs to staff for 1 of 19 sampled residents (Resident 5) reviewed for care planning. This failure had the potential to place residents at risk for unmet care needs, negative outcomes, and a diminished quality of life. Findings included . Resident 5 Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes (high blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and was able to make needs known. During an interview on 05/19/2025, Resident 5 stated their eyeglasses were at home and wanted them at the facility. Review of the admission Minimum Data Set assessment, dated 05/02/2025, section B1000 Vision, showed Resident 5 was assessed to have impaired vision. Section B1200 Corrective Lenses showed No. Review of Resident 5's care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's care needs and/or care conferences occurred timely for 3 out of 21 sampled residents (Resident 48, 51 and 53) when reviewed for care planning and revision of care plans. This failure placed the resident at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life. Findings included . Resident 48 Review of the electronic health records (EHR) showed Resident 48 admitted to the facility on [DATE] with diagnoses to include pulmonary fibrosis (a condition characterized by scarring and thickening of tissue around the air sacs in the lungs), chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, resulting in low oxygen levels in the blood over an extended period of time), anxiety disorder, depression, and bipolar disorder (a mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents' ability to communicate was maintained for 1 of 3 sampled resident (Resident 33) when reviewed for communication. This failure placed the resident at risk of inability to communicate needs, social isolation, feelings of worthlessness, and diminished quality of life. Findings included . Review of the electronic health record showed Resident 33 admitted to the facility on [DATE] with diagnoses to include aphasia (a language disorder caused by damage to the brain's language centers, resulting in difficulties with speaking, understanding, reading, or writing) and adult failure to thrive. Resident 33 was able to communicate needs. Observation on 05/19/2025 at 10:15 AM showed Resident 33 laid in bed with a sign on the wall showing to use the whiteboard to communicate. Observation showed no whiteboard in the room. Observations on 05/20/2025 at 1:04 PM and 05/22/2025 at 9:38 AM showed Resident 33 laid in bed with no whiteboard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to ensure that residents were shaved and/or dressed in clean clothing for 2 of 3 sampled residents (Residents 30 and 15) when reviewed for dependent activities of daily living (ADLs) care. These failures placed the residents at risk of unmet needs, poor self-esteem, and a diminished quality of life. Findings included . Resident 30 Review of the electronic health record (EHR) showed Resident 30 readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain disease that alters brain function or structure), diabetes (high blood sugar), depression, and muscle weakness. Resident 30 was able to make needs known. Observations on 05/19/2025 at 11:44 AM, 05/20/2025 at 9:42 AM, 05/22/2025 at 7:07 AM, and on 05/23/2025 at 9:40 AM showed Resident 30 with long facial hair around the chin area. During an interview on 05/20/2025 at 9:42 AM, Resident 30 stated they did not always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for 2 of 4 sampled residents (Residents 53 and 148) reviewed for nutrition. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . Resident 53 Review of the electronic health records (EHR) showed Resident 53 readmitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), renal failure (kidneys lose the ability to remove waste and balance fluids), and was depended on dialysis (a treatment that filters blood when the kidneys are unable to do so, removing waste and excess fluid). Resident 53 was able to make needs known. During an interview on 05/19/2025 at 10:12 AM, Resident 53 stated they could not drink a lot of water because they were on fluid restriction and thought they could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt dental care and services and obtain post dental visit documentation for 1 of 4 sampled residents (Residents 30) when reviewed for dental. These failures placed the resident at risk for continued dental problems, unmet needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 30 readmitted to the facility on [DATE] with diagnoses that included diabetes (high blood sugar), depression, and muscle weakness. Resident 30 was able to make needs known. Observation and interview on 05/19/2025 at 1:15 PM, showed Resident 30 with broken and missing upper and lower teeth. Resident 30 stated they had seen a dentist, and the plan was to be seen again but did not know when that would happen. Resident 30 stated they had occasional oral pain and wanted their teeth to be taken care of. Review of the significant change in status minimum data set (MDS, an assessment tool) 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 provide prompt dental services for 1 of 4 sampled residents (Residents 53) when reviewed for dental. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included . Review of the electronic health records (EHR) showed Resident 53 readmitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood) and renal failure (kidneys lose the ability to remove waste and balance fluids). Resident 53 was able to make needs known. Observation and interview on 05/19/2025 at 10:09 AM showed Resident 53 with missing upper and lower teeth. Resident 53 stated they would like to see a dentist to have teeth removed to be able to get dentures or partial dentures and staff were aware. Resident 53 stated they could not remember the last time they saw a dentist. Review of Resident 53's focused care plan for at risk for decline in oral/dental health due to broken teeth,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to maintain equipment so that they could be disinfected for 1 of 5 sampled halls (400 Hall) when reviewed for environment. This failure placed residents at risks of exposure to unsanitary surfaces, avoidable illness, and a diminished quality of life. Findings included . room [ROOM NUMBER] Observation and interview on 05/19/2025 at 10:51 AM showed Resident 62 in a wheelchair which had tearing to the left-hand armrest. Observation showed the vinyl had worn away from the armrest and exposed the underlying foam padding which was not a cleanable surface. Resident 62 stated the armrest had been damaged for a while. Observation on 05/23/2025 at 1:27 PM showed the wheelchair armrest continued to be damaged with exposed padding. room [ROOM NUMBER] Observation on 05/19/2025 at 2:10 PM showed approximately 25 shoelaces tied to the handrail next to the toilet in room [ROOM NUMBER]. The shoelaces were stained with brown material and were not a cleanable surface…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure baseline care plans (CP) were developed/implemented and provided in written summary to the resident/responsible party, in a language they understood, within 48 hours of admission for 5 of 5 sample residents (Residents 1, 2, 8, 19, & 13) reviewed for baseline CPs. The failure to ensure completion of the baseline or comprehensive CP timely after admission, that addressed the resident's immediate health/safety needs and provided the instructions necessary to properly provide effective, person-centered care that met professional standards of quality placed the residents at risk for unidentified and/or unmet care needs, rehospitalization, adverse events, substandard quality of care, and diminished quality of life. Findings included . POLICY Review of the facility's Baseline Care Plans policy, revised [DATE], showed the facility would develop a baseline CP (or comprehensive CP) to meet the immediate health and safety needs for each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 [it] was administered in a manner that used resources effectively and efficiently to attain or maintain the residents highest practical physical, mental, and psychosocial well-being, and the facility maintained substantial compliance with state and federal regulations. The failure to ensure adequate clinical administrative oversight in the absence of both the Director of Nursing (DNS) and Regional [NAME] President of Clinicals and implement an effective Quality Assurance Process Improvement (QAPI) program placed residents at risk for adverse events, substandard quality of care, rehospitalization, and diminished quality of care/quality of life. Findings included . During a review of the facility's historical surveys showed the facility continued out of compliance after they received citations on 01/22/2025 for F684 Quality of Care and F760 Significant Medication Errors. Before the facility achieved compliance, an abbreviated Complaint Investigation (CI) initiated on 01/15/2025 resulted in a citation on 01/31/2025 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 have an effective Quality Assurance/Performance Improvement (QAPI) Committee that self-identified deficient practices, and/or implemented corrective action for identified deficiencies. The failure to utilize the facility's QAPI procedures to sustain compliance with regulations for the facility, placed residents at risk for adverse events, unsafe conditions, delay in necessary care and services, and a diminished quality of care/quality of life. Findings included . Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, revised March 2020, showed that quality of care deficiencies was identified through feedback and data, and would undergo appropriate corrective action. Corrective actions were monitored against established goals and benchmarks by the QAPI committee. 1. Refer to Code of Federal Regulations (CFR): §483.45(f)(2) F760 Residents are Free of Significant Med Errors: During an interview on 03/04/2025 at 2:11 PM, when asked if the facility had any active Performance Improvement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 incidents, accidents, and alleged violations were thoroughly investigated for 3 of 3 sample residents (Residents 1, 8, & 38) reviewed for investigations. These failures placed residents at risk for abuse, neglect, adverse events, significant injuries, rehospitalizations, and diminished quality of care/quality of life. Findings included . POLICY Review of the facility's Abuse and Neglect Policy and Procedure revised 03/10/2017 showed all resident events would be thoroughly investigated to determine if abuse had occurred. The thorough investigation would conclude with the answers to the who, what when, where, how, and why the incident happened. Each phase of a thorough investigation would include two stages: data collection (who, when, where) including written, signed and dated witness statements collected as soon as possible after the event with as much detail as possible. Other documents included in a thorough investigation (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure care and services provided met professional standards of practice for 8 of 12 sample residents reviewed for professional standards. The failure to: hold anti-hypertensive blood pressure (bp) medications when vital signs were outside ordered parameters (Residents 2, 38, & 40), ensure labs specimens were collected and results reported to the physician timely (Residents 22, 8, 1, & 26), and ensure residents were consistently monitored (and documented) regarding alert charting (events and changes of condition) and daily skilled nursing documentation (for residents who were admitted under their skilled Medicare A benefit) (Residents 8, 2, 14, & 38) was timely, thorough, and complete with the required relevant information to show they continued to require skilled nursing care. These failures placed residents at risk for adverse events, rehospitalization, diminished quality of care/quality of life. Findings included . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide care and services in accordance with professional standards of practice and quality care to meet their physical, mental, and psychosocial needs for 5 of 6 residents (Residents 38, 2, 13, 5, & 10) reviewed. The failure to conduct weekly skin checks, follow physician orders for dressing changes, and monitor residents with wounds (Residents 38, 2, 13, & 5) and failure to develop/implement heart failure/respiratory care plans that aligned with professional standards, follow physician ordered heart failure care interventions, and provide consistent monitoring of their chronic/acute/change of conditions (Residents 2 & 10) placed the residents at risk for adverse events, rehospitalizations, worsening skin conditions, infections, pain, and diminished quality of care/quality of life. Findings included . Review of the facility's Skin Integrity policy, revised January 2025, showed the facility had a systematic monitoring process for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure 12 of 12 sampled residents (Residents 26, 2, 22, 13, 10, 38, 14, 8, 17, 34, 23, & 15) were free from significant medication errors. The failure to: conduct a thorough medication reconciliation on admission, verify allergies prior to administration, clarify duplicate or questionable orders, correctly transcribe orders into the electronic Medication Administration Record (MAR), administer medications timely in accordance with professional standards of practice, and report/investigate all identified medication errors placed residents at risk for adverse events, rehospitalization, poorly managed health conditions, and diminished quality of care/quality of life. Findings included . Review of the facility's Adverse Consequences and Medication Errors policy, revised April 2014, showed the Interdisciplinary Team (IDT) would evaluate medication usage to prevent and detect adverse consequences and medication-related problems like adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were educated on all required topics specified on their Facility Assessment for 4 of 4 sampled staff (Staff Q, R, S & T) reviewed for annual education and training. Failure to ensure staff received required trainings placed residents at risk for unmet care needs, inadequate quality of care, and diminished quality of life. Findings included . Review of the facility assessment, dated 02/27/2025, showed the following trainings were provided to staff annually: -Resident Rights and Facility Responsibilities - ensured staff members were educated on the rights of the resident and the facility's responsibility to provide proper quality care. -Change of Condition - ensured staff were educated on how to identify a resident's change of condition including: including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. -Person-Centered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 4 Certified Nursing Assistants (CNAs) (Staff Q, R, S, & T) were provided mandatory Quality Assurance and Performance Improvement (QAPI) training. Failure to ensure staff received the required QAPI training, which included how to communicate concerns, problems, or opportunities for improvement placed residents at risk for unmet care needs, unsafe environment, and diminished quality of care/quality of life. Findings included . In an interview on 03/04/2025 at 12:15 PM, Staff R, CNA, stated they did not know what the QAPI committee was or what QAPI meant. Staff R stated if they had concerns they told their nurse. In an interview and record review on 03/04/2025 at 1:21 PM, Staff P, Staff Development Coordinator reviewed the facility's training records and stated Staff Q did not have QAPI training. During the interview Staff P was not able to provide a carriculum for QAPI training, but did say the facility trained staff on Stop and Watch, directing staff that if they see something to report it and put a note in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident's responsible party of orders for a new medication for 1 of 3 sample residents (Resident 2) reviewed for notification of changes. This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and being knowledgeable about medications the resident was taking. Findings included . Review of the quarterly minimum data set (MDS, a required assessment tool), dated 01/13/2025, showed Resident 2 admitted on [DATE] and had diagnoses to include communication deficit, genetic-related intellectual disability, and need for assistance with personal care. The MDS further showed that Resident 2 was moderately cognitively impaired (had problems with their ability to think, learn, remember, use judgement, and make decisions). Review of an untitled document, from the King County Superior Court Clerk, dated August 29, 2022, showed Resident 2 had a court appointed guardian and conservator (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 document a measurable and descriptive baseline, and routinely monitor the progression of healing or worsening, of a skin impairment for 1 of 3 sample residents (Resident 4) reviewed for skin impairments. This failure placed the resident at risk for undetected worsening of the skin impairment, delay in treatment, complications in healing, and a decreased quality of life. Findings included . Review of the facility electronic medical record (EMR) showed that Resident 4 admitted on [DATE] with a diagnosis of a hematoma (a collection of blood that forms outside of a blood vessel in an organ, tissue or body space), to their left lower leg. Review of a facility evaluation titled, Clinical admission V-22, dated 12/03/2024, showed that Resident 4 had a skin issue described as a large hematoma, present on admission, to their left lateral calf (outer side of calf). There were no documented measurements or additional details describing the hematoma. 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 interview and record review, the facility failed to ensure administration of a prescribed respiratory medication (a medication used to treat breathing problems) for 1 of 1 sample resident (Resident 8) reviewed for medication errors. This failure placed residents at risk for medical complications and a decreased quality of life. Findings included . Review of the Quarterly Minimum Data Set (MDS, a required assessment tool), dated 11/19/2024, showed Resident 8 admitted on [DATE], and had diagnoses to include chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and respiratory failure. Review of a physician's order, dated 08/24/2022, showed Resident 8 was to receive Trelegy (an inhaled medication) one time per day for the diagnosis of COPD. Review of the medication administration records (MARs), dated December 2024 and January 2025, showed that Trelegy was not administered to Resident 8, as ordered, on 12/26/2024, 12/28/2024,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative of a change in medication orders for two of four residents (Residents 1 and 2) reviewed for notification of changes. This failure prevented the residents' representatives from being included in the plan of care and having the ability to provide input and make decisions on the resident's behalf. Findings included . Resident 1 Resident 1 admitted to the facility on [DATE]. Review of the Significant Change Minimum Data Set (MDS, an assessment tool), dated 07/29/2024, showed Resident 1 began receiving hospice (end-of-life) support and services on 07/24/2024. The MDS showed Resident 1 had a diagnosis of Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions) and was severely cognitively impaired. Review of the medical record showed that Resident 1 had a Durable Power of Attorney (DPOA, a legal document that allows someone to make decisions for another person), dated…

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

Based on interview and record review, the facility failed to follow up on concerns of the resident council related to resident care for 3 of 4 resident council meeting minutes reviewed. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the resident council minutes dated 11/29/2023, showed concerns voiced by members regarding lack of bathing, long call light wait times by named staff, and missing items Review of the resident council minutes dated 12/27/2023, showed concerns voiced by members to include menu concerns, dietary preferences being followed, lack of staff on the night shift, and staff speaking native language while providing care. Review of the resident council minutes dated 01/31/2024, showed concerns voiced by members to include staff on electronic devices at nurses' station, not getting medication timely, staff not attentive to resident needs, and staff speaking in native language while providing care. Review of the grievance log dated 10/2023 through 03/2024 showed no grievances that corresponded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respond timely to abuse/neglect allegations and thoroughly investigate and/or follow up on identified interventions for incidents of falls and abuse/neglect allegations for 3 of 3 sampled residents (Residents 12, 64, and 157) reviewed for abuse/neglect and 2 of 3 sampled residents (Resident 7 and 70) reviewed for accident/falls. These failures placed residents at risk for ongoing abuse/neglect, continued falls, unmet needs, and a decreased quality of life. Findings included . Resident 12 admitted to the facility on [DATE] with diagnoses to include central cord syndrome (a cervical spinal cord injury), diabetes and dysphagia (a swallowing disorder). Resident 12 was vision impaired and able to make needs known. Review of an incident report (IR) dated 03/06/2024 showed Resident 12 reported a staff member told them to stop using their call light and to grin and bear it when the resident asked for the time. Resident 12 reported that they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess residents for mental health supports through the Preadmission Screening and Resident Review (PASRR, a tool to refer residents for further mental health supports) for 3 of 3 sampled residents (Residents 83, 64 and 23) reviewed for PASRR. This failure placed residents at risk of not receiving needed mental health supports, avoidable behaviors, and a diminished quality of life. Findings included . 1) Resident 83 admitted to the facility on [DATE] with diagnoses including psychosis (a disconnection from reality) and depression. Review of Resident 83's PASRR, dated 02/09/2024, showed no mental health diagnoses. 2) Resident 64 admitted to the facility on [DATE] with diagnoses of anxiety and depression. Review of Resident 64's PASRR, dated 01/02/2024, showed no mental health diagnoses. 3) Resident 23 admitted to the facility on [DATE] with diagnoses of anxiety and depression. Review of Resident 23's PASRR, dated 01/12/2024, showed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quarterly care conferences/care plan review which included the resident and/or their representative in a timely manner for 4 of 26 sampled residents (Residents 15, 51, 73, and 80) reviewed for care planning. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 15 admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (a disease which effects the brain and spinal cord). Review of the electronic health record (EHR) showed the last documented care conference was completed on 01/23/2023. 2) Resident 51 admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Review of the EHR showed the last documented care conference was completed on 11/16/2023. 3) Resident 73 admitted to the facility on [DATE] with a diagnosis of Guillain-Barre syndrome (rapid-onset muscle weakness caused by the immune system damaging the nerves). Review of the EHR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to follow recommendations made by the wound care provider for 1 of 2 sample residents (Resident 91) reviewed for non-pressure skin injury and failed to follow the care plan/provider orders for positioning for 1 of 4 sampled residents (Resident 159) reviewed for positioning. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life. Findings included . <Non-pressure Skin Injury> Resident 91 admitted to the facility on [DATE] with a diagnosis of diabetic foot ulcer. Review of a treatment order dated 02/23/2024 showed to cleanse the right foot wound and apply iodosorb (a paste decreases bacteria) to the wound and cover it with a non-stick dressing three times a week. Review of a wound care provider note dated 03/08/2024 showed a recommendation to change the order from iodosorb to collagen (a powder or sheet applied to a wound to boost healing ability). During an interview on 03/13/2024 at 8:31 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 sampled residents (Residents 7, 357, 1, 159, and 161) reviewed for unnecessary medications and/or pain management. The facility failed to ensure Residents 7 and 357 were provided non-pharmacological interventions (NPI, non-medication) prior to the use of as needed (PRN) pain medications, monitor Resident 1's blood pressure and heart rate, implement pain medication parameters for Residents 159, and monitor Resident 161's blood thinner side effects. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . <NPI> Resident 7 readmitted to the facility on [DATE] with diagnoses to include cancer and anxiety disorder, received pain medications, and was able to make needs known. Review of 02/01/2024 - 02/12/2024 medication administration record (MAR) showed an order dated 06/28/2023 for oxycodone HCI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report a staff to resident abuse allegation of a verbal threat of physical harm to law enforcement for 1 of 3 sampled residents (Resident 157) reviewed for abuse. This failure placed residents at risk of staff having lack of ability to recognize required reportable abuse to the police, potential unrecognized abuse or neglect, and recurrence of incidents. Findings included . According to the Nursing Home Guidelines, also known as the Purple Book, sixth edition, dated October 2015, reporting requirements included that staff to resident abuse, neglect, mistreatment, sexual or physical abuse/assault were to be reported to the Department of Social and Health Services (DSHS) state hotline, the police, and logged on the DSHS reporting log within five days. Review of the facility's policy titled, Abuse and Neglect Policy and Procedure, dated 10/29/2017 showed, Each employee is a Mandated Reporter and has the duty as an individual to report any actual/known,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess a resident's bowel elimination for 1 of 26 sampled residents (Residents 95) when reviewed for accuracy of assessments. This failure placed the resident at risk for unidentified and/or unmet care needs. Findings included . Review of Resident 95's quarterly Minimum Data Set assessment (MDS) dated [DATE] showed that the resident readmitted to the facility on [DATE] and was able to make needs known. Section H showed Resident 95 had an ostomy (a surgical created opening from an area inside the body to the outside). During an interview on 03/12/2024 at 12:37 PM, Resident 95 stated they did not have an ostomy. During an interview on 03/12/2024 at 1:31 PM, Staff P, Minimum Data Set/Registered Nurse, stated Resident 95 has never had an ostomy and the quarterly MDS dated [DATE] was inaccurate. Staff P stated the MDS needed to be modified. During an interview on 03/13/2024, Staff C, [NAME] President of Clinical Operations, stated Resident 95's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure staff contacted the Level II Evaluator for a Preadmission Screening and Resident Review (PASRR) Level II assessment for 1 of 5 sampled residents (Resident 80) reviewed for PASRR. This failure placed the resident at risk of health and/or emotional decline related to a lack of professional evaluation to determine if further mental health interventions were required. Findings included . Resident 80 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (manic highs and depressive lows), obsessive compulsive disorder, major depressive disorder, and anxiety disorder. Review of Resident 80's level one PASRR dated 11/06/2023 completed by facility staff showed a referral for a level II evaluation was required. No level II evaluation was found in the resident's medical record. During an interview on 03/14/2024 at 11:05 AM, Staff H, Social Services Director, stated Resident 80's level II PASRR should have been sent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure that residents were free from accident hazards for 2 of 3 sampled residents (Residents 73 and 60) reviewed for accident hazards. The facility failed to remove an inappropriate transfer device (Resident 73) and assess and monitor for risk of smoking (Resident 60). These failures placed residents at risk of avoidable injury and a diminished quality of life. Findings included . <Transfer Device> Resident 73 admitted to the facility on [DATE] and was diagnosed with unsteadiness on feet and muscle weakness. Observation on 03/11/2024 at 11:53 AM showed Resident 73 with a floor-to-ceiling transfer pole. Review of the providers orders showed no order for a transfer pole. Review of a 11/27/2022 initiated care plan showed no intervention for the use of a transfer pole. Review showed that Resident 73 required two-person assistance with a sling lift to get out of bed. Review of a 08/22/2023 device assessment for a transfer pole showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure accurate monitoring and documentation for fluid restrictions and completion of daily weights for 1 of 3 sampled residents (Resident 1) reviewed for hydration. This failure placed Resident 1 at risk for medical complications and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure (when the heart cannot pump blood well enough causing a buildup of fluid in the lungs or limbs). <Fluid Restriction> Observation on 03/11/2024 at 12:21 PM showed Resident 1 laid in bed and had dry cracked lips. There was an empty water pitcher on the bedside table. Review of a provider order dated 02/21/2024 for a fluid restriction of 2000 milliliters (ML) every 24 hours. The order listed 666 ml on day shift, 666 ml on evening shift, and 666 ml on night shift. The order did not specify the amount to be provided on meal trays. Review of a diet order, 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 . Resident 357 admitted to the facility on [DATE] with diagnoses to include fracture of the right tibia (shinbone), alcoholic polyneuropathy (nerve damage from alcohol use), muscle weakness, and was able to make needs known. Review of the provider order dated 03/06/2024 showed Resident 357 was prescribed duloxetine (an anti-depressant medication) 60 milligram (mg) for depression. Review of the March 2024 MAR showed the duloxetine had been administered since 03/07/2024; however, behavior monitoring had not been implemented until 03/12/2024. During an interview on 03/14/2024 at 11:12 AM, Staff F, RN/UM, stated behavior monitoring for the antidepressant medication should have been documented on the MAR upon the first administration. During an interview on 03/14/2024 at 1:40 PM, Staff C, [NAME] President of Clinical Operations, stated an order for behavior monitoring should have been implemented on 03/07/2024 when the provider order was entered for Resident 357 related to the anti-depressant medication. Reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 routine dental services for 2 of 2 sampled residents (Residents 73 and 51) when reviewed for dental. This failure placed residents at risk of avoidable dental pain, difficulty eating, unintentional weight loss, and a diminished quality of life. Findings included . Resident 73 admitted to the facility on [DATE] and was diagnosed with unsteadiness on feet and muscle weakness. During an interview on 03/11/2024 at 1:29 PM, Resident 73 stated their teeth were breaking down, had asked to see a dentist, and had been waiting for dental assistance. Review of the 11/27/2022 initiated care plan showed Resident 73 was at risk of broken teeth and obvious or likely cavity with an intervention to, Refer to Facility dentist, Facility dental hygienist as needed. Review of a 03/06/2024 progress note showed that Resident 73's poor teeth were observed by facility staff. During an interview on 03/14/2024 at 8:49 AM, Staff H, Social Services Director (SSD), stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement pressure ulcer care and prevention measures for 1 of 3 sampled residents (Resident 1) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life. Findings included . The facility Policy and Procedure Manual for Long-Term Care on Skin and Wound Management, dated 2001, Revised July 2017, documented a Stage I Pressure Injury appeared as intact skin with a localized area of non-blanchable redness. The policy described a Deep Tissue Pressure Injury as persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue. The policy indicated that type of injury resulted from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The facility policy indicated the size and location of any red or tender areas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pressure ulcers were identified, documented and monitored to provide needed interventions for one of three sampled residents (Resident 1) reviewed for pressure ulcers. This failure placed the resident at risk for unmet needs, medical decline, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including quadriplegia (loss of functional movement of four limbs) for skilled nursing care. The Minimum Data Set, an assessment tool, dated 05/18/2023, documented the resident was alert and oriented and totally dependent upon staff for activities of daily living. A 05/11/2023 4:25 PM Admission/readmission Nursing Evaluation, Section 9, Pressure Ulcers, documented Resident 1 did not have pressure ulcer(s) on admission to the facility. A 05/11/2023 4:28 PM Braden Scale for Predicting Pressure Sore Risk documented Resident 1 was determined to have been at high risk for development…

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