Avamere At Pacific Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate the potential for abuse and/or neglect for 1 of 2 sampled residents (Resident 42) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 42 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and anxiety. Resident 42 was able to make needs known. Review of the February 2026 accident and incident log showed an entry dated 02/28/2026 for Resident 42 related to skin. The incident was logged as Small bruises occurring in places generally vulnerable to trauma. The action taken was no further action and was not reported to the State Agency according to the incident log. Review of a 02/28/2026 progress note showed Large bruise to right breast noted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received a transfer/discharge notice and/or offered a bed hold for 2 of 3 sampled residents (Residents 6 and 12) reviewed for discharge/hospitalization. This failure placed residents at risk of not understanding their reason for transfer, inability to return to their room, and a diminished quality of life. Findings included.Resident 6 Review of the electronic health record (EHR) showed Resident 6 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. During an interview on 04/23/2026 at 1:01 PM, Staff M, admission Director, stated the admission department would follow-up with the resident and/or representative after discharge to the hospital and offer a bed hold and fill out a nursing home transfer or discharge notice and send it to the ombudsman. Review of the nursing home transfer or discharge notice for Resident 6 showed that this notice was not given to Resident 6 or their representative; the area was left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive assessment was accurate for dental conditions or skin conditions for 2 of 17 sampled residents (Residents 35 and 3) reviewed for accuracy of the comprehensive assessment. These failures placed residents at risk of unidentified needs, risk of inadequate plan of care, and a diminished quality of life. Findings included.Resident 35 Review of the electronic health record (EHR) showed Resident 35 admitted to the facility on [DATE] with diagnoses to include spondylosis with myelopathy (compression of the bones in the spine), metabolic encephalopathy (brain dysfunction causing confusion and memory loss), and repeated falls. Resident 35 was able to make needs known. Observation on 04/20/2026 at 1:31 PM showed Resident 35 had damaged lower teeth and no upper teeth. Review of the 5-day minimum data set assessment (MDS), dated [DATE], showed Resident 35 was edentulous (lacked all teeth). During an interview on 04/23/2026 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 ensure resident care plans were comprehensively completed to include resident participation for 2 of 17 sampled residents (Residents 12 and 50) when reviewed for care plans. This failure placed residents at risk of not having their input considered in their plan of care, lack of treatments, a decline in clinical condition, and a diminished quality of life. Findings included.Resident 12 Review of the electronic health record (EHR) showed Resident 12 was re-admitted to the facility on [DATE] with diagnoses of urinary tract infection (UTI) with extended-spectrum B-lactamases (ESBL, enzymes produced by bacteria that are resistant to widely used anti-infective medications), diabetes (high blood sugar), and foot infection. Review of a provider orders dated 04/19/2026 showed Resident 12 was ordered antibiotics (anti-infective) medications for their ESBL and foot infection. Review of the care plan on 04/23/2025 showed Resident 12 did not have focus, goal and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assessed for hearing needs, obtained needed hearing devices, and hearing devices used were included in plans of care for 1 of 2 sampled residents (Resident 35) reviewed for communication/sensory. This failure placed the residents at risk of inability to hear, reduced ability to participate in activities, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 35 admitted to the facility on [DATE] with diagnoses to include spondylosis with myelopathy (compression of the bones in the spine), metabolic encephalopathy (brain dysfunction causing confusion and memory loss), and repeated falls. Resident 35 was able to make needs known. During an interview and observation on 04/20/2026 at 1:31 PM, Resident 35 stated they used hearing aids at home, and they had left them there before coming to the facility. Observation showed Resident 35 was able to hear questions 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 provide complete nail care to 1 of 3 sampled residents (Resident 1) reviewed for activities of daily living (ADL). This failure placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (too much sugar in the blood), polyneuropathy (nerve damage to multiple nerves) and vascular dementia (reduced or blocked blood flow to the brain, leading to cognitive decline and impaired daily functioning). Resident 1 required extensive staff assistance for ADLs. Observation on 04/20/2026 at 11:59 AM showed Resident 1 laid in bed with their feet in pressure relieving boots. Resident 1's toenails on both feet were long, curved and discolored. Review of the provider's orders showed an order for diabetic nail care (nail care performed by a medical professional) weekly on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement an individualized activity plan for 1 of 3 sampled residents (Residents 61) reviewed for activities. The failure to develop and implement an activity plan of care, that incorporated residents stated interests, hobbies and preferences, placed the residents at risk for boredom, isolation, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 61 admitted to the facility on [DATE] with diagnoses of stroke, vascular dementia (group of symptoms that affect cognition) and kidney failure. Resident 61 was non-verbal and unable to make needs known. Observations on 04/20/2026 at 9:45 AM, 04/21/2026 at 11:41 AM and 04/22/2026 at 1:46 PM showed Resident 61 laid in bed awake looking at the ceiling or the wall. There was a television in the room, but it was not observed on during any of the observations. Review of Resident 61's care plan (CP) showed the activity focus,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents on a fluid restriction were not provided too much fluid for 1 of 4 sampled residents (Resident 78) reviewed for nutrition. This failure placed residents at risk of fluid overload, a decreased clinical status, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 78 admitted to the facility on [DATE] with diagnoses to include acute hypoxemic respiratory failure (the lungs cannot adequately transfer oxygen to the blood), chronic systolic congestive heart failure (reduced ability for the heart to contract and pump blood effectively), and end-stage renal disease (kidney function has dropped to less than 10-15% of normal). Resident 78 was able to make needs known. Review of the care plan, initiated 01/12/2026, showed Resident 78 had a fluid restriction of 1800 milliliters (ml, unit of volume), with nursing providing 480 ml twice a day for 965 ml total and dietary providing 835 ml total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recommendations from mental health consultations were followed up on for 1 of 5 sampled residents (Resident 11) reviewed for unnecessary antipsychotic (mind altering) medications. This failure placed the residents at risk for increased side effects, increased behaviors and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include fracture of right arm, dementia (decline in cognitive function), diabetes (high blood sugar) and heart failure. Resident 11 was not able to communicate needs. Review of the significant change minimum data set assessment (MDS) dated [DATE] showed Resident 11 was receiving antipsychotic medication and had experienced a fall with injury. Review of a provider order dated 03/10/2026 showed Resident 11 was ordered Seroquel 25 mg (mind altering medication) twice a day for a diagnosis of vascular dementia without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were completed to address all aspects of care for 1 of 5 sampled residents (Resident 9) reviewed for dementia care. Failure to develop and implement care plans to address residents' dementia diagnoses and behaviors, placed the residents at risk for unmet care needs, avoidable decline, and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses of Alzheimer's Dementia (effects memory), chronic pain, and diabetes (too much sugar in the blood). Resident 9 was rarely/never understood, had a short-term memory problem, made poor decisions and required extensive assistance with activities of daily living. Review of the EHR showed Resident 9 had no Care Plan (CP) specifically for Focus, Goals or Interventions related to Alzheimer's Dementia. Review of the April 2026 MAR showed no behavior monitoring in place related to Alzheimer's Dementia.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had dental devices to improve resident ability to eat for 1 of 2 sampled residents (Resident 35) reviewed for dental. This failure placed the residents at risk of discomfort, reduced nutritional intake, unintended weight loss, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 35 admitted to the facility on [DATE] with diagnoses to include spondylosis with myelopathy (compression of the bones in the spine), metabolic encephalopathy (brain dysfunction causing confusion and memory loss), and repeated falls. Resident 35 was able to make needs known. Observation and interview on 04/20/2026 at 1:31 PM showed Resident 35 had damaged lower teeth and no upper teeth. Resident 35 stated they used an upper denture, but it was at their home. Review of the 5-day minimum data set assessment (MDS), dated [DATE], showed Resident 35 was edentulous (lacked all teeth). Review 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 ensure a wound was fully assessed on admission and weekly as ordered, was monitored, and changes reported as needed for 1 of 3 sampled residents (Resident 1) reviewed for wound care. This failure placed the resident at risk for pain, deterioration in condition, and diminished quality of life. Findings included .The facility's policy, Wound Management Guidelines, revised 03/31/2025, stated that on admission the admitting nurse or designee would complete a skin evaluation and document the patient's skin condition in the resident's clinical record. The policy also stated that actual pressure injuries, venous stasis ulcers, arterial ulcers, diabetic/neuropathic ulcers and open surgical wounds would have weekly documentation that included measurements and how the wound was progressing (improvement, worse, unchanged). Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, for skilled nursing care of a wound on their lower leg. The Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge plan that addressed all of the needs for a resident being discharged for 1 of 3 sample residents (Resident 1) reviewed for discharge process. This failure allowed a discharge plan to be implemented that did not address Resident 1's need for a CPAP (Continuous Positive Air Pressure device, a breathing therapy device that delivers air to a mask to ensure consistent breathing), and a shower chair and placed residents at risk of unsafe discharges. Findings included The facility policy, dated 09/2002, Discharge Planning Skilled Nursing Facility, noted that, when discharge from the facility was anticipated, Social Services staff would to interview the resident, responsible party, caregiver, and appropriate interdisciplinary team members to discern discharge needs such as equipment, supplies, etc. and then would arrange or assist in arranging for the services and make notifications of services arranged. The policy also noted that 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 Pre-admission Screening and Resident Review (PASARR, a mental health screening tool) assessments were accurately completed for 4 of 5 sampled residents (Residents 5, 28, 66 and 38) when reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . Review of a document titled, PASARR Policy, dated 07/2024, showed any potential admissions identified to have a positive Level I PASARR screen must be evaluated by the designated state authority, through the Level II PASARR process, and approved for admission prior to admitting to the nursing facility unless that individual meets criteria for an exempted hospital discharge. The Level II PASARR evaluations were required for all nursing facility residents identified to have indicators of serious mental illness/intellectual disability (SMI/ID) during the Level I screening or at any time during residency in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide food in an individualized manner when the therapeutic diet was not followed for 1 of 3 sampled residents (Resident 23) when reviewed for nutrition. This failure placed residents at risk of choking and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 23 admitted to the facility on [DATE] with diagnoses to include schizophrenia (a serious mental illness that affects a person's ability to think clearly, manage emotions, and interact with others), epilepsy (a brain condition that causes someone to have repeated seizures), and psychosis (trouble telling what's real from what is not). Resident 23 was able to make needs known. Observation of Resident 23's lunch meal ticket on 03/24/2025 at 12:48 PM showed to provide easy to chew foods and the plate had one large piece of unaltered fried chicken. The fried chicken did not appear to be easy to chew. Review of an aspiration…

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

Based on observation and interview, the facility failed to maintain sanitary food storage and preparation areas when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . Observation on 03/24/2025 at 9:23 AM showed the kitchen walk-in refrigerator contained a plastic bag with three energy water drinks and a coffee canned drink. Observation showed an extra-large fountain drink with straw in a different area of the refrigerator. During an interview on 03/24/2025 at 12:02 PM, Staff Y, Registered Dietician, stated the energy waters, coffee canned drink, and fountain drink were likely staff items and should not be stored in the facility walk-in refrigerator. Observation on 03/26/2025 at 11:30 AM showed Staff X, Dietary Services Manager, performed hand hygiene and turned off the water with bare hands. Observation on 03/26/2025 at 11:40 AM showed Staff V, Cook, performed hand hygiene and turned off the water with bare hands. Observation on 03/26/2025 at 12:05 PM showed a preparation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make needed repairs to maintain a homelike environment on 2 of 4 halls (Halls 100 and 400) and failed to use reusable utensils to maintain a homelike dining experience on 1 of 4 halls (Hall 300) when reviewed for environment. These failures place residents at risk for diminished mood, feelings of worthlessness, and a diminished quality of life. Findings included . Observations of the shared bathroom for rooms [ROOM NUMBERS] on 03/24/2025 at 9:50 AM, 03/25/2025 at 9:03 AM, and 03/27/2025 at 10:03 AM showed the lower part of both sides of the doorway frame and walls had gouges and peeled off paint. During an interview on 03/27/2025 at 10:03 AM, Staff J, Maintenance Director, stated the shared bathroom for rooms [ROOM NUMBERS] showed both sides of the corner wall doorway frame with gouges that needed to be repaired. Staff J stated staff were to put in a report into TELS (electronic system to put in a work order for items/issues to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer to the hospital, for 2 of 2 sampled residents (Residents 64 and 10) when reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 64 Review of the discharge assessment minimum data set (MDS, a required assessment tool), dated 03/23/2025, showed the resident was admitted on [DATE] and was transferred to a local hospital for short term care and with a return to the facility anticipated. Review of an interact document titled Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 03/23/2025, showed a licensed nurse (LN) had documented Resident 64 was transferred out of the facility at 10:30 AM. Review of Resident 64's electronic health record (EHR) on 03/24/2025 showed documentation LN had documented the transferred out of the facility 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 Resident 421 Resident 421 admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline in physical and functional abilities) and need for assistance with personal care. The admission minimum data set (MDS, an assessment tool), dated 03/25/2025, showed Resident 421 was usually able to make their needs known and understand others. Observation on 03/24/2025 showed Resident 421 laid in bed with their coat on with a strong smell of urine noted. Observation on 03/25/2025 at 2:29 PM showed Resident 421 stood in the doorway to their room with disheveled hair. The heels of their feet were not in their sneakers and the sneakers were not tied. Two different staff walked by Resident 421 without stopping to assist the resident. Observation on 3/27/2025 at 8:40 AM showed Resident 421 sat on the side of their bed eating breakfast. There was dark sediment noted under their fingernails. Review of the care plan dated 03/21/2025 showed Resident 421 required partial physical assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 4 Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses to include dementia (a loss of memory, language, problem-solving and other thinking abilities), depression, and psychosis (trouble telling what's real from what is not). Resident 4 was able to make needs known. Review of the EHR showed an MRR, dated 12/02/2024, with a recommendation to decrease some medications. Review showed the provider declined the recommendation on 01/17/2025. Review of the pharmacist medication review report for January 2025 showed Resident 4 had a recommendation for January. During an interview on 03/27/2025 at 10:29 AM, Staff H, LPN/RCM, stated the pharmacist would conduct a MRR monthly. Staff H stated these should be reviewed by the provider within 72 hours, but the facility had been struggling to do this. Staff H stated Resident 4 had a recommendation from 12/02/2024 which was not reviewed until 01/17/2025, and this did not meet expectation. During an interview on 03/27/2025 at 10:42 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 Resident 19 Review of the EHR showed Resident 19 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis or weakness) of left side, dementia and atrial fibrillation (an irregular and often very rapid heart rhythm). Resident 19 was able to make needs known. Review of the provider's order dated 04/03/2024 showed Resident 19 was prescribed Seroquel 60 milligram (mg) for behaviors related to dementia. Review of Resident 19's March 2025 MAR showed the Seroquel had been administered daily. Review of the MAR showed there was no side effect monitoring. During an interview on 03/27/2025 at 10:38 AM, Staff H, LPN/RCM, stated side effect monitoring for the antipsychotic medication should have been documented on the MAR upon the first administration. During an interview on 03/27/2025 at 11:58 AM, Staff C, Corporate Registered Nurse, stated the expectation was an order for side effect monitoring should have been implemented when the provider's order was entered. Reference WAC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage and labeling of medications in 2 of 4 medication carts (100 and 300 medication carts) and 1 of 2 medication rooms (100/200 medication room) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, and diminished quality of life. Findings included . Observation of medication room on 03/26/2025 at 1:58 PM with Staff E, Licensed Practical Nurse (LPN), showed the temperature log for March 2025 of the medication refrigerator to have missing documentation for 22 out of 26 opportunities. Review of the refrigerator showed storage of vaccinations, medication and emergency medication supply. During an interview on 03/26/2025 at 2:05 PM, Staff E, LPN, stated licensed nurses were to check the temperature of the refrigerator in the medication room and document twice a day. Observation of the 100 hall medication cart on 03/26/2025 at 1:50 PM with 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 proper fit and use of personal protective equipment (PPE, equipment worn to minimize exposure to infectious diseases/illnesses) as required for transmission-based precautions (TBP, precautions/PPE used with known or suspected infectious diseases/illnesses) for 3 nursing staff (Staff N, O, and P) in 3 of 4 halls (100, 200, and 300 halls) when reviewed for infection control. Also, the facility failed to complete the ongoing collection and analyzation of infection control data, which included the identification of organisms present in the facility for 3 of 3 months (December 2024, January 2025, and February 2025) when reviewed for infection control. These failures placed residents, visitors, and staff at risk for communicable diseases, infections and related complications. Findings included . <TBP> Review of the facility policy titled Categories of Transmission-Based Precautions revised 03/21/2024 showed Transmission-Based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and provide influenza and/or pneumococcal vaccines for 3 of 5 sampled residents (Residents 56, 37, and 48) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life. Findings included . Review of the facility policy titled Vaccination of Residents revised October 2019 showed, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated, Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations, If vaccines are refused, the refusal shall be documented in the resident's medical record., and If the resident receives a vaccine, at least the following information shall be documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to offer and provide Covid-19 vaccines for 2 of 5 sampled residents (Residents 28 and 37) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting Covid-19 infections, related complications, and a decreased quality of life. Findings included . Resident 28 Review of the electronic health record (EHR) showed Resident 28 admitted to the facility on [DATE] with a diagnosis of diabetes (too much sugar in the blood). The resident was able to make needs known. Review of the EHR showed the resident had consented to receive the Covid-19 vaccine on 10/31/2024. No documentation was found in the resident's EHR that Resident 28 was administered the Covid-19 vaccine. Resident 37 Review of the EHR showed Resident 37 admitted to the facility on [DATE] with diagnoses including hemiplegia (unable to move half of the body) and a brain bleed. The resident was able to make needs known. Review of the EHR on 03/24/2025 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.

Based on interview and record review, the facility failed to ensure oversight of certified nurse assistants (CNA) received 12 hours of in-service training per year as required and were provided mandatory dementia management training when reviewed for nurse competencies or their performance evaluations reviews. Failure to ensure CNAs completed required hours of training and competencies and conduct annual performance evaluation reviews placed residents at risk for potential negative outcomes and unmet care needs. Findings included . During an interview on 03/27/2025 at 11:49 AM, Staff CC, CNA, stated they had worked at the facility for the last three years and would be contacted on occasion via email as to what training they needed; however, they did not remember as to what training was still needed and further stated they did not remember getting any performance evaluations the last few years. During an interview and record review on 03/27/2025 at 11:53 AM, Staff Q, Registered Nurse/Infection Preventionist/Staff Development Coordinator, stated they or the facility's human resources…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have signed consent prior to administering mood altering medication for 1 of 5 sampled residents (Resident 66) when reviewed for unnecessary medications use. This failure placed the resident or their legal representatives at risk of receiving medication without knowledge to make informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 66 was admitted to the facility on [DATE] with diagnoses to include major depression, altered mental status, and dementia (brain function impairment with memory and judgment loss). Resident 66 was not able to communicate needs. Review of the medication administration record for the month of March 2025 showed an order dated 02/28/2025 for Divalproex (mood stabilizer medication) twice a day. Resident 66 was administered the medication 03/01/2025 through 03/26/2025 for violent behavior.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain an advanced directive (AD, a legal document that establishes a representative to make medical decisions when you and unable to) and/or perform periodic reviews of AD for 1 of 3 sampled residents (Resident 24) when reviewed for AD. This failure placed the resident at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 24 initially admitted to the facility on [DATE] with diagnoses that included depression and anxiety disorder. Resident 32 was able to make needs known. Review of the Comprehensive Plan of Care Review form, with an effective date of 05/02/2024, showed Resident 24 had no AD in place, did not wish to formulate an AD, and declined assistance with executing an AD. Review of Resident 24's Care Conference Information forms, dated 10/17/2024 and 12/19/2024, showed both forms were marked Yes, 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 conduct an assessment and signed consent for the use of low bed, bed next to the wall and tilt in space wheelchair for 1 of 2 sampled residents (Resident 38) when reviewed for use of physical restraints. This failure placed the resident at risk for injury, unmet needs, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 38 was admitted to the facility on [DATE] with diagnoses to include dementia (brain function impairment with memory and judgment loss), dislocation of internal left hip prosthesis (an artificial body part), and depression. Review of the admission minimum data set (MDS, an assessment tool), dated 12/24/2024, showed Resident 38 was a high fall risk and required assistance of staff for mobility. Resident 38 was not able to communicate their needs. Observation on 03/25/2025 at 1:40 PM, showed Resident 38 in their room sitting in tilt in space wheelchair with their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to transmit resident minimum data set (MDS, an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 19 sampled residents (Resident 53) when reviewed for MDS timeliness in transmission/submission. This failure to ensure MDS assessment and tracking records were completed and transmitted timely as required placed the resident at risk for unmet care needs and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 53 was admitted to the facility on [DATE] and discharged from the facility on 12/19/2024. Review of the MDS section in the EHR showed Resident 53 had Medicare-5 Day MDS dated [DATE] completed but not submitted to CMS, and a discharge MDS dated [DATE] was completed but not submitted to CMS. During an interview on 03/27/2025 at 3:13 PM, Staff JJ, Registered Nurse/MDS Nurse, stated the facility transmitted MDS once a week to CMS, and was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 minimum data set (MDS, a required assessment tool) accurately reflected a weight loss of 10 percent or more in six months for 1 of 3 sampled residents (Resident 24) when reviewed for nutrition. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 24 readmitted to the facility on [DATE] with diagnoses that included malnutrition (the body does not get the right amount or type of nutrients it needs to function properly), anxiety disorder, and depression. Resident 24 was able to make needs known. During an interview on 03/25/2025 at 9:17 AM, Resident 24 stated the food did not taste good and they thought they were losing weight because they did not eat enough. Review of Resident 24's EHR showed on 08/07/2024 the resident weighed 124.6 pounds (lbs.) and on 02/11/2025 the resident weighed 110.0 lbs., which was a 11.72 %…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 19 sampled residents (Residents 10 and 7) when reviewed for comprehensive care plans. Failure to care plan Resident 10's fall preventions and Resident 7's range of motion services placed residents at risk of avoidable injury, loss of movement, and a diminished quality of life. Findings included . Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses of hemiplegia (loss of movement on one side), diabetes (too much sugar in the blood), and deafness. Resident 10 was able to make needs known. Review of the facility's incident log from October 2024 to March 2025 showed Resident 10 had fallen on 10/08/2024, 12/01/2024, and 12/15/2024. Review of the incident reports for the falls on 10/08/2024, 12/01/2024, and 12/15/2024 showed new fall interventions to reduce reoccurrence of falls had been developed after each. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a resident's care plan was revised and accurately reflected the resident's care needs for 1 out of 19 sampled residents (Resident 24) 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 . Review of the electronic health records (EHR) showed Resident 24 readmitted to the facility on [DATE] with diagnoses to include anxiety disorder, depression, psychotic disorder (mental health condition that causes abnormal thinking and perceptions) and malnutrition (the body does not get the right amount or type of nutrients it needs to function properly). Resident 24 was able to make needs known. Review of the focused care plan initiated on 09/26/2024 showed Resident 24 was on an antipsychotic medication related to dementia (a group of thinking and social symptoms that interferes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 5 of 19 residents (Residents 5, 10, 24, 59, and 19) when reviewed for care and services. The facility failed to notify a provider (Resident 5), to follow provider parameters (Residents 10 and 19), to provide nonpharmacological interventions (Residents 10 and 24), to document alert charting (Resident 59), and to monitor for side effects (Resident 24). These failures placed residents at risk for unmet care needs, avoidable side effects, and a diminished quality of life. Findings included . According to the Lippincott Manual of Nursing Practice, Tenth Edition ([NAME], [NAME] & [NAME], 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. According to [NAME], Duell & [NAME], Clinical Nursing Skills, 6th Edition, page 4, Nurse Practice Act identified skills 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 Resident 425 Resident 425 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting right dominant side (weakness and paralysis of the right side of the body), and vascular dementia (a group of symptoms affecting memory and thinking). The end of Medicare Part A stay minimum data set (MDS, an assessment tool), dated 03/07/2025, showed Resident 425 was dependent on staff for all care. Review of the care plan dated 02/20/2025 showed Resident 425 was dependent on staff for activities, cognitive stimulation, and social interaction. Interventions included: Staff would provide social and one-on-one visits and activities to help meet Resident 425's activity goals. The care plan stated Resident 425's preferred activities were: Visits in room, music, television, movies, reading to them, and family visits. Observation on 03/25/2025 at 12:41 PM showed Resident 425 in bed. There was no radio or TV on. Observations were made at the following dates 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 Resident 425 Resident 425 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting right dominant side, and vascular dementia (a group of symptoms affecting memory and thinking). The end of Medicare Part A stay minimum data set (MDS, an assessment tool), dated 03/07/2025, showed Resident 425 was dependent on staff for all care. Observation on 03/24/2025 showed Resident 425 was lying in bed on their back. Resident 425 was laying diagonally in their bed with head on the right side of the bed and feet at the left side of their bed. Review of EHR on 03/25/2025 showed Resident 425 required two staff physical assistance to turn and reposition in bed. Review of the care plan, dated 02/19/2025, showed Resident 425 had potential for impairment to skin integrity due to poor skin turgor (elasticity of the skin). Review showed Resident 425 had severe cognitive (mental processes involved in gaining knowledge and comprehension) impairment. Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to increase range of motion or to prevent further decrease in range of motion for 1 of 3 sampled residents (Resident 7) when reviewed for contractures (a shortening of tissue which leads to rigidity of the joints) and mobility. This failure placed the resident at risk for worsening contractures, inability to complete activities of daily living, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 7 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone and posture), anxiety, depression, and contracture of muscles. Resident 7 was able to communicate needs. Observation and interview on 03/24/2025 at 3:08 PM showed Resident 7 laid in bed in their room with fingers to both hands with rigidity, curled inward towards palms with some fingers overlapping on top of other fingers. Resident 7 stated 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 a bathroom emergency call light (a system used to call for help) cord length was no higher than six inches from the floor in 1 of 4 hallways (400 hallway) when reviewed for accident hazards. This failure placed residents at risk for inability to reach the call light cord if they fell on the floor, delayed response in an emergency, and a diminished quality of life. Findings included . Observations on 03/24/2025 at 9:50 AM, 03/25/2025 at 9:03 AM, 03/25/2025 at 12:49 PM, and 03/27/2025 at 10:03 AM showed the shared bathroom for rooms [ROOM NUMBERS] had an emergency call cord that ended at the location of the handlebar attached to the wall to the left of the toilet (greater than six inches from the floor). During an interview on 03/25/2025 at 12:59 PM, Resident 28 in room [ROOM NUMBER] stated they did not use the bathroom at that time. During an interview and observation on 03/27/2025 at 9:51 AM, Resident 17 in room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently document weights per provider orders for 1 of 3 sampled residents (Resident 24) when reviewed for nutrition. This failure placed resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 24 readmitted to the facility on [DATE] with diagnoses that included malnutrition (the body does not get the right amount or type of nutrients it needs to function properly), anxiety disorder, and depression. Resident 32 was able to make needs known. During an interview on 03/25/2025 at 9:17 AM, Resident 24 stated the food did not taste good and they thought they were losing weight because they did not eat enough. Review of the provider order dated 12/02/2024 showed Resident 24 was ordered to have bi-weekly weights related to weight loss on day shift every two weeks on Monday. Review of Resident 24's EHR showed the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 3 sampled residents (Residents 28 and 10) when reviewed for dental. This failure placed the residents at risk for continued dental problems and a diminished quality of life. Findings included . Resident 28 Review of the electronic health record (EHR) showed Resident 28 readmitted to the facility on [DATE] with diagnoses that included malnutrition (the body does not get the right amount or type of nutrients it needs to function properly) and diabetes (high blood sugar levels). Resident 28 was usually able to make needs known. During an interview and observation on 03/24/2025 at 10:00 AM, Resident 28 stated they could not wear dentures because they did not fit right, and staff were aware. Resident 28 had no teeth and was not wearing dentures. Review of Resident 28's care plan, initiated on 01/15/2020, showed the resident had oral/dental health problems related to edentulous (no natural teeth), had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to maintain a homelike environment in resident areas for 3 of 4 halls (Halls 100, 200, and 400) when reviewed for environment. This failure placed residents at risk of decreased mood and a diminished quality of life. Findings included . Observation on 04/22/2024 showed the light fixture above the bathroom sink in rooms [ROOM NUMBERS] did not have a cover and the light bulbs were exposed. Observation on 04/26/2024 showed that the bathroom light fixtures in Rooms 110, 114 and 405 did not have a cover and the light bulbs were exposed. Observation on 04/22/2024 at 10:48 AM showed the wall in room [ROOM NUMBER] had deep gouges with flaking drywall which had accumulated on the ground. Observation on 04/22/2024 at 1:17 PM showed the corner near the bathroom of room [ROOM NUMBER] had damaged drywall which was covered by yellow and blue tape. Observation on 04/26/2024 showed that the deep gouges in room [ROOM NUMBER] and damaged drywall in room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 2 of 2 sampled residents (Residents 11 and 24) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, hydration, and other adverse outcomes. Findings included . Resident 11 Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed that Resident 11 readmitted to the facility on [DATE] and received their nutrition through a feeding tube. Review of Resident 11's provider order dated 04/01/2024 showed orders for enteral feeding four times a day of Fibersouce HN or equivalent 450…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assured timely acquiring, receiving, and administering of a prescribed medications) to meet the needs of 1 out of 4 sampled residents (Residents 55) reviewed for medication administration. The facility failed to consistently reconcile controlled medications in 3 of 3 medication carts (medication carts 200, 400, and 300) reviewed for medication storage. Failure to ensure timely receipt and administration of an ordered medication, placed Resident 55 at risk for medical complications and a poor quality of life, and failure to reconcile controlled medications placed residents at risk for misappropriation of their medications and the facility at risk for diversion of controlled medications. Findings included . <Pharmaceutical Services> Review of Resident 55's quarterly minimum data set assessment (MDS) dated [DATE] showed that Resident 55 readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to consistently monitor residents' behaviors and/or medication side effects for 3 of 5 sampled residents (Residents 5, 33 and 184) when reviewed for unnecessary medications. This failure placed residents at risk of not receiving adequate mental health supports, increased behaviors, increased psychotropic use, and a diminished quality of life. Findings included . Resident 5 Review showed that Resident 5 admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder) and psychotic disorder (thoughts and perceptions are disrupted). Review of Resident 5's April 2024 behavior monitoring record (BMR) showed orders to monitor the resident's behaviors and side effects of psychotropic medications. Review showed that four of 24 days were missing entries. During an interview on 04/25/2024 at 10:48 AM, Staff C, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated that the facility monitored resident behaviors and medication…

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

Based on observation, interview, and record review, the facility failed to consistently maintain the medication refrigerator temperature logs in 2 of 2 medication rooms (medication rooms 100/200 hall and 300/400 hall) reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included . Observation on 04/23/2024 at 11:30 AM with Staff H, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), of the 100/200 hall medication room refrigerator containing various liquid medications that included vaccines, showed April 2024 refrigerator temperature monitoring logs for AM and PM, from 04/01/2024 - 04/22/2024 with inconsistent documentation. The logs had either blanks or one temperature logged on 11 out of 22 dates. During an interview on 04/23/2024 at 11:30 AM, Staff H, RCM/LPN, stated the 100/200 hall medication room's April 2024 refrigerator temperature monitoring logs for AM and PM had blanks and one temperature logged at times and since there were vaccines stored in the refrigerator the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to maintain a call light system that allowed residents to call for help from the floor of the bathroom for 2 of 4 hallways (Halls 200 and 400) when reviewed for call light system. This failure placed residents at risk of not being able to call for assistance, delayed response to a fall, injury, and a diminished quality of life. Findings included . Observation on 04/22/2024 showed the call light string in the bathrooms of rooms [ROOM NUMBER] were short and could not be reached if laying on the floor. Observation on 04/26/2024 showed that the bathroom call light sting the bathrooms of rooms [ROOM NUMBER] were short and could not be reached if laying on the floor. Observation on 04/26/2024 showed the bathroom call light in room [ROOM NUMBER] was short and could not be reached if laying on the floor. During an interview on 04/26/2024 at 10:00 AM, Staff N, Maintenance Director, stated the facility performed call light audits to ensure they were accessible 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 have system and timely resolution of a grievance for 1 of 3 sampled residents (Resident 31) reviewed for grievances. Failure to ensure grievance/concerns were addressed and resolved timely had the potential to affect the resident's quality of life. Findings included . Resident 31 was admitted to the facility on [DATE] from an acute care hospital. Review of the annual comprehensive Minimum Data Set assessment, dated 10/09/2023, showed Resident 31 was admitted with diagnoses of anxiety, depression, post-traumatic stress disorder, renal insufficiency, and had intact cognitive functions. During an interview on 04/22/2024 at 11:48 AM, Resident 31 stated staff were not listening to their complaints. Resident 31 stated staff were not treating them well because their roommate had an iPad, and the volume was loud and was disturbing her. Resident 31 had reported their concern to staff, but the staff were not listening. Resident 31 stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess 2 of 22 residents (Residents 72 and 5) when reviewed for accuracy of assessments. This failure placed the residents at risk of not receiving the care and services required to meet the residents' needs and inaccuracies in their care planning. Findings included . Resident 72 Review of Resident 72's admission minimum data set (MDS, a required assessment tool), dated 03/18/2024, showed the resident was admitted on [DATE] with multiple diagnoses to include heart/lung disease, diabetes and for post-surgical care for partial amputation of both right and left foot. The MDS showed the resident was able to make their needs known. During an interview on 04/22/2024 at 11:43 AM, Resident 72 stated that they had diabetes but did not receive any insulin in the facility. Review of Resident 72's medication administration record (MAR) for March 2024 and April 2024 showed the resident did not have a provider's order for insulin and had not received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff were following provider's orders for medication administration for 1 of 5 sampled residents (Resident 18) reviewed for unnecessary medications. In addition, the facility failed provide a psychiatry referral per provider's recommendation for 1 of 2 sampled resident (Resident 184) when reviewed for behavioral health care needs. This failure placed the residents at potential risk of having adverse side effects, medication errors and unmet care services. Findings included . Resident 18 Resident 18 was admitted on [DATE] with diagnoses of diabetes, stroke, chronic kidney disease, anxiety, and depression. Review of the minimum data set (MDS, a required assessment tool), dated 03/18/2024, showed Resident 18 could make needs known. Review of Resident 18's provider's orders showed an order for hydralazine (used to treat high blood pressure) and to hold the medication if the systolic blood pressure was less than 120. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to consistently monitor and document bowel movements (BM) and implement the bowel program when needed for 2 of 3 residents (Residents 61 and 40) reviewed for bowel protocol. This failure placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . Review of a facility's policy titled, Avamere Living - Bowel Care Protocol, dated 10/2020, showed the policy of the facility was to monitor the bowel records of residents to assure that they attained a normal bowel pattern without complications. If the resident had not had a bowel movement for three consecutive days (must be medium or large), then staff were to administer the bowel protocol that the provider had ordered. Resident 61 Review of the admission minimum data set (MDS, a required assessment tool), dated 01/23/2024, showed the resident admitted on [DATE] with diagnoses to include lung disease, fracture of spine, opioid abuse (medication used 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 have a clear system in place to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per provider's orders for 1 of 2 sampled residents (Residents 24) reviewed for fluid restrictions. These failures placed the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the quarterly minimum data set assessment dated [DATE] showed that Resident 24 admitted to the facility on [DATE] with diagnoses to include malnutrition (a condition when the body does not get enough nutrients/poor nutrition), dysphagia (difficulty swallowing), had a feeding tube (a tube inserted through the skin and directly into the stomach or small intestine to provide liquid food), received dialysis (treatment to filter wastes and water from the blood) services, was provided a mechanically altered diet, and 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 freedom from unnecessary pain medication for 1 of 5 sampled residents (Residents 33) reviewed for unnecessary medication use. Failure to provide non-pharmacological interventions (approaches, therapies, or treatments that do not involve drugs) prior to giving as needed pain medications placed the resident at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 33 readmitted to the facility on [DATE] with diagnoses to include chronic pain syndrome (long standing persistent pain), anxiety disorder, and the resident was able to make needs known. Review of Resident 33's revision dated 01/03/2024 focused actual pain care plan showed an intervention was initiated on 04/28/2021 to attempt nonpharmacological intervention prior to administering pain medications such a reposition, redirection,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and treatment of an ileostomy (an opening in the body for the discharge of body wastes into a collection bag) was consistent to prevent skin breakdown for 1 of 1 sampled residents (Resident 1) reviewed for colostomy/ileostomy care. This failure placed the resident at risk for unmet care needs and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including Crohn's Disease (a type of inflammatory bowel disease that causes swelling of the tissues of the digestive tract), for which Resident 1 had had an ileostomy placed prior to admission to the facility. The Minimum Data Set, an assessment tool, dated 08/28/2023, documented Resident 1 had moderate cognitive impairment and required extensive staff assistance with activities of daily living. An 08/22/2023 11:21 AM admission Nursing Database documented Resident 1 had an ileostomy site, with no further measurements or…

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