Birch Creek Post Acute & Rehabilitation

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 4 of 21 sampled residents (Residents 1, 9, 10, and 26) when reviewed for comprehensive care plans. Failure to develop care plans that accurately reflected resident care needs related to oxygen therapy, wound/skin impairment, use of an indwelling catheter (a thin flexible tube that is inserted through the urethra/tube like structure into the bladder to continuously drain urine), and antidepressant medication use placed residents at risk of unmet care needs and potential negative outcomes. Findings included.Resident 1 Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include heart failure, respiratory conditions due to unspecified external agent (a lung disease or breathing problem triggered by something inhaled or exposed to from the environment), and cerebral infarction (stroke, blood flow to part of the brain is blocked preventing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 1, 9, and 67) reviewed for respiratory care. Failure to obtain and/or follow provider orders for oxygen (O2) therapy, ensure O2 tubing was appropriately maintained, regularly changed and dated, and O2 concentrator (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for avoidable respiratory disease, unmet needs, and potential negative outcomes. Findings included.Resident 1Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include heart failure, respiratory conditions due to unspecified external agent (a lung disease or breathing problem triggered by something inhaled or exposed to from the environment), and cerebral infarction (stroke, blood flow to part…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 periodically review and provide assistance with advanced directives (legal documents that appoints a trusted person to make healthcare decisions on your behalf if you become unable to communicate or incapacitated) for 2 of 3 sampled residents (Residents 5 and 4) when reviewed for advanced directives. This failure placed residents at risk of not having a healthcare decisionmaker, inability to control care received when incapacitated, and a diminished quality of life. Findings included.Resident 5Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known. Review of a Multidisciplinary Care Conference form, dated 07/23/2025, showed Resident 5's advanced directive was reviewed and assistance offered. Review of a progress note, dated…

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

Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) were provided timely and/or completed as required for 2 of 3 sampled residents (Residents 18 and 54) when reviewed for Beneficiary Notification. Failure to provide SNF ABN notification at least two calendar days before the Medicare coverage ended placed the residents and/or the residents' representative at risk of not having adequate information to make financial decisions related to a continued stay in the facility. Findings included. Resident 18Review of a Notice of Medicare Non-Coverage (NOMNC), dated 10/23/2025, showed the facility informed Resident 93 and/or representative that skilled nursing services would end on 10/27/2025. Review of Resident 18's SNF ABN dated 03/09/2025 showed, Beginning on 10/28/2026 you may have to pay out of pocket for this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make needed repairs to maintain a homelike environment for 1 of 4 halls (200 hall) when reviewed for environment. This failure placed residents at risk of decreased mood and a diminished quality of life. Findings included.Observation and interview on 03/08/2026 at 1:07 PM showed room [ROOM NUMBER]'s bathroom with a gouge in the floor at the entry way and two large scrapes and gouges, black scrapes, and chipped paint on the wall to the right of the sink. Resident 11 stated they were surprised the gouge in the floor did not interfere with entering or leaving the bathroom when using their wheelchair. Observation of room [ROOM NUMBER] on 03/08/2026 at 1:13 PM showed Resident 31's closet was missing a door exposing all items in the closet. During an interview on 03/13/2026 at 9:14 AM, Resident 31 stated they were not aware that their closet door was missing. Observation of room [ROOM NUMBER] on 03/08/2026 at 1:18 PM showed both closets were missing doors…

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

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 assessment (MDS) accurately reflected the status for 3 of 21 sampled residents (Residents 9, 6, and 40) when reviewed for accuracy of assessments. Failure to accurately reflect Resident 9's skin/wound status, Resident 6's mental health screening status, and Resident 40's medication use status placed the residents at risk for unmet care, inaccurate medical record data, and a diminished quality of life. Findings included.Resident 9 Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses of diabetes (too much sugar in the blood), dementia (a decline in mental abilities, severe enough to interfere with daily life), and chronic obstructive pulmonary disease (restricted airflow making it difficult to breathe). Resident 9 was usually able to make needs known. Review of the February 2026 and March 2026 treatment administration records showed Resident 9 was being treated for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care conferences occurred timely for 1 of 3 sampled residents (Resident 32) when reviewed to care conferences and accurately reflected a resident's eating status for 1 of 3 sampled residents (Resident 87) when reviewed for tube feeding. This failure placed the residents at risk of not providing input into the plan of care, impaired nutritional status, and a diminished quality of life. Findings included. During an interview on 03/11/2026 at 11:01 AM, Staff J, Social Services Director (SSD), stated residents were able to provide input into their plan of care through care conferences. Staff J stated care conferences should occur on admission and with the minimum data set (MDS) assessment schedule (quarterly and with change of condition). Resident 32 Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses to include chronic lymphocytic leukemia (a slow-growing cancer of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services that met professional standards of practice for 2 of 22 sampled residents (Residents 2 and 26) when reviewed quality of care. Failure to provide wound care for Resident 2 and failure to follow provider orders for parameters when administering blood pressure medications for Resident 26 placed the residents at risk for complications, poor clinical outcomes, and a decreased quality of life. Findings included .Resident 2 Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses of head/face and neck cancer. The resident was able to make needs known. Observation and interview on 03/09/2026 at 11:15 AM showed Resident 2 was pointing at bandages on their left wrist and right hand and stated that the bandages were bothering them. The bandages were undated and had hard dried drainage on them and were soiled. Review of the EHR showed orders to monitor left hand, cleans…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment conductive to healing of a pressure ulcer and failed to have documentation describing the progress of the pressure ulcer for 1 of 3 sampled residents (Resident 111) when reviewed for pressure ulcer. This failure placed residents at risk for worsening pressure ulcers and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 111 was admitted to the facility on [DATE] with diagnoses to include hospice (end of life care), senile degeneration of brain (progressive break down of nerve cells), diabetes (high blood sugar) and kidney failure. Resident 111 was not able to communicate needs. Review of the admission minimum data set (MDS) a required assessment dated [DATE], showed Resident 111 was admitted to the facility with one sacral (large triangular bone at the base of the spine) stage two pressure ulcers (loss of partial thickness of the skin related to pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect a resident from continued accident risk when it failed to thoroughly investigate an accident for 1 of 4 sampled residents (Resident 5) when reviewed for accident hazards. This failure placed the resident at risk of continued risk of accident, avoidable injury, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known. During an interview and observation on 03/08/2026 at 10:46 AM, Resident 5 stated a staff member had been transferring them from the bed to a wheelchair and the resident's leg had been scratched on the wheelchair. Observation showed Resident 5's leg was bandaged from ankle to knee. Review of the Accident and Incident Log showed an incident for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fluid restrictions (limits the amount of fluids a person can consume through food/drink) for 1 of 1 sampled resident (Resident 26) when reviewed for nutrition. This failure placed the resident at risk for fluid overload, medical complications, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 26 was admitted to the facility on [DATE] with diagnoses to include heart failure, end stage renal disease (kidney failure), and dependence on renal dialysis (life sustaining treatment that filters waste and excess fluid from the blood). Resident 26 was able to communicate their needs. Observation on 03/08/2026 at 10:10 AM showed Resident 26 sitting in their chair with a small water bottle on top of the overbed table. Resident 26 stated they were on a fluid restriction because of their health condition. Review of a provider's order, dated 02/18/2026, showed Resident 26 was on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with providers orders and professional standards of practice for 1 of 3 sampled residents (Resident 87) when reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food product) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and adverse outcomes. Findings included.Review of the electronic health record (EHR) showed Resident 87 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (blockage of blood flow to the brain causing cell death), gastrostomy (feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition and medication), anxiety, 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 provide pain management that was consistent with professional standards for 2 of 3 sampled residents (Residents 2 and 26) when reviewed for pain management. Failure to assess and monitor Resident 2's pain and provide nonpharmacological interventions for Resident 26 placed the residents at risk for uncontrolled pain and a decreased quality of life. Findings included .Resident 2 Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses of head/face and neck cancer. The resident was able to make needs known. Observation and interview on 03/09/2026 at 11:15 AM, showed Resident 2 laid in bed with bandages to their right ear. Resident 2 pointed to the bandages and stated, It hurts all the time. Review of the initial nursing assessment showed Resident 2 reported pain at a 8 on a scale of 0 to 10 on 11/22/2025. No other pain assessments were found in the EHR. No orders or documentation 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 promptly provide denture care when requested for 1 of 3 sampled residents (Resident 13) when reviewed for dental. This failure placed residents at risk for unmet dental needs, inability to eat, avoidable weight loss, 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 to include anxiety disorder, dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion), and schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness, causing individuals to lose touch with reality). Resident 13 was able to make needs known. During an interview on 03/08/2026 at 12:25 PM, Resident 13 stated their dentures had been left in their rental when they moved into the facility and there was no way for them to retrieve them. Review of a Preventative Report from an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 3 (Resident 1 & 2) residents who experienced dementia-related behaviors received care and services to mitigate adverse behaviors. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered care plan prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing.Findings included . Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression.Review of the facility Behavioral Assessment, Intervention and Monitoring Policy dated 10/01/2021, the interdisciplinary team would…

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

Based on observation, interview and record review, the facility failed to implement their abuse prohibition policy for 1 of 3 residents (Resident 5) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 5's injury of unknown origin. The failure to initiate incident reports, conduct a thorough investigation to identify root cause(s) and all contributing factors placed the residents at risk for unidentified abuse or neglect, unidentified corrective actions, risk for injury, and unmet care needs. Findings included .Review of the facility Abuse policy dated 10/20/2022 showed the facility was committed to developing and operationalizing policies and procedures for the prevention, identification, investigation and reporting of abuse, neglect, and mistreatment.Review of the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines 'The Purple Book', dated October 2015, showed Chapter 2, titled The Investigation Process, listed substantial injuries of unknown source as incidents that must be thoroughly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate monitoring and supervision and implement preventative measures to prevent unsafe feeding for one (Resident 1) of three residents reviewed for accidents. Failure to identify known risks, implement individualized, resident-centered interventions, including adequate supervision, communicating interventions to all relevant staff, provide training as needed to reduce those risks and ensure interventions were put into action, placed the resident at risk of being force fed, choked, developing aspiration pneumonia, and psychosocial harm.Findings included.Review of clinical census showed Resident 1 resided in the facility from [DATE] until 05/15/2025. Review of a facility incident investigation showed that on 05/11/2025, at approximately 1:30 PM, staff witnessed an apparent altercation involving Resident 1 and their son during a routine visit. Resident 1 was refusing to take their prescribed medications and had been resisting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system in place that ensured fluid intake/output was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated for 5 of 5 residents (Resident 2, 3, 4, 5 & 6) reviewed for dehydration and fluid restriction (a diet which limits the amount of daily fluid intake). These failures placed residents at risk for fluid and electrolyte imbalances, dehydration, fluid overload, and rehospitalization.Findings included .Review of the facility's Resident Hydration and Prevention of Dehydration Policy and Procedure, dated 10/01/2021, showed nursing staff would monitor residents for signs and symptoms of dehydration during daily care, intake and output monitoring would be initiated and incorporated into the care plan, medications that may exacerbate dehydration (e.g., diuretics) would be reviewed and held if medically necessary, laboratory tests would be ordered to assess hydration status, and nursing would monitor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely report an allegation of potential abuse for 1 of 3 Residents (Resident 1) reviewed for abuse. Failure of the facility to ensure 4 of 4 staff (Staff D, E, F, and G) timely reported alleged abuse, placed residents at risk of abuse, psychological distress, and diminished quality of life.Findings included .Review of a facility policy titled Abuse, dated 10/01/2021, showed staff were encouraged to identify, correct, and intervene in situations in which abuse and neglect was likely to occur. Immediately following, ensuring the resident's safety, staff were to report an allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. Each mandated reporter should report immediately, but no later than 24 hours if the events of the suspicion did not result in serious bodily injury.<Resident 1>Resident 1, a long-term resident, was admitted to the facility on [DATE] with a medically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate an allegation of potential abuse and implement interventions to prevent further suspected abuse for 1 of 3 Residents (Resident 1) reviewed for abuse. These failures placed the residents at risk of abuse, psychological distress, and diminished quality of life.Findings included .Review of a facility policy titled Abuse Investigation and Reporting, dated 10/21/2021, showed all reports of resident abuse, neglect and exploitation would be thoroughly investigated by facility management. Further review of the policy showed the facility would ensure that any further potential abuse, neglect, or exploitation would be prevented. Review of a facility policy titled Abuse, dated 10/01/2021, showed in the event of an allegation or observation of abuse, the facility would protect the resident and other residents from further abuse. Review of a facility policy titled Abuse Prevention Program, dated 10/01/2021, showed the facility would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store and prepare food in manner which prevents food illness when reviewed for kitchen. This failure placed residents at risk for foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . Observation on 03/10/2025 at 9:09 AM showed the kitchen refrigerator contained a large undated ham. Observation showed diced turkey, diced ham, and opened hotdogs labeled 3/2025. Observation showed shredded cheese labeled 02/25/2025. Observation showed the kitchen freezer had food boxes stored on the floor. During an interview on 03/10/2025 at 9:46 AM, Staff BB, Dietary Manager, stated the boxes stored on the freezer floor were not to be stored there. Staff BB stated food being stored should have an open date when it was stored and good for seven days if removed from the original packaging. Observation on 03/11/2025 at 11:47 AM showed headphones and a cell phone charger placed in the corner of the kitchen on a counter containing peanut butter, food bags, and condiments. Observation on 03/11/2025 showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 advanced directives (AD) and/or perform periodic reviews to determine if residents had an AD, and if not, determine whether the residents wished to formulate an AD for 3 of 4 sampled residents (Residents 22, 43, and 77) when reviewed for AD. This failure denied the residents the opportunity to direct their health care in the event they were to become unable to make decisions or communicate their health care preferences. Findings included . Resident 22 Review of the electronic health record (EHR) showed Resident 22 initially admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar levels), depression, and was able to make needs known. Review of a progress note, dated 03/14/2024, showed social service staff provided AD paperwork to Resident 22's family member. Review of the EHR showed an attempt to schedule a care conference on 02/18/2025; however, there was no documented follow-up related to the AD. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents with mental health disorders were screened for the need of additional mental health support for 5 of 9 sampled residents (Residents 77, 95, 103, 22, and 26) when reviewed for Preadmission Screening and Resident Review (PASARR, a mental health screening tool). This failure placed residents at risk of lacking needed mental health support, avoidable adverse behaviors, and diminished quality of life. Findings included . Resident 77 Review of the electronic health record (EHR) showed Resident 77 was admitted to the facility on [DATE] with diagnoses to include dementia (impairment of brain function that causes loss of memory and thinking) with psychosis (mental disorder characterized by a disconnection from reality), anxiety, and insomnia (inability to sleep). Resident 77 was not able to communicate needs. Review of the current provider's orders, on 03/12/2025, showed Resident 77 was prescribed medications to treat their psychosis, anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 3 of 21 sampled residents (Residents 30, 103 and 215) when reviewed for care plans. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life. Findings included . Resident 30 Review of the electronic health records (EHR) showed Resident 30 admitted to the facility on [DATE] with diagnoses including cancer of the colon (lower intestines), dementia (problems with memory), and diabetes (too much sugar in the blood). The resident was unable to make needs known. During an interview on 03/12/2025 at 9:01 AM, Collateral Contact Z stated Resident 30 did not eat on their own and staff took the tray out without assisting them. Review of the baseline care plan, dated 11/16/2024, did not show care areas for activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 77 Review of the EHR showed Resident 77 was admitted to the facility on [DATE] with diagnoses to include dementia (impairment of brain function that causes loss of memory and thinking) with psychosis (mental disorder characterized by a disconnection from reality), anxiety, and insomnia (inability to sleep). Resident 77 was not able to communicate needs. Review of the significant change MDS dated [DATE] showed Resident 77 was dependent on staff to provide activities of daily leaving (ADL) care. Observations from 03/10/2025 to 03/14/2025 showed Resident 77 in bed with closed eyes. During an interview on 03/12/2025 at 9:15 AM, Resident 59, who was a roommate of Resident 77, stated Resident 77 has been in the bed for three months. Review of the care plan, dated 11/09/2024, showed Resident 77 had a focus area for rehabilitation with interventions dependent for transfers with mechanical lift. There were no instructions or directions for staff to describe what other support Resident 77 needed for activities 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 Resident 77 Review of the EHR showed Resident 77 was admitted to the facility on [DATE] with diagnoses to include dementia with psychosis (mental disorder characterized by a disconnection from reality), anxiety and insomnia (inability to sleep). Resident 77 was not able to communicate needs. Review of the EHR showed Resident 77 was placed on isolation on 12/20/2024 for testing positive for COVID-19. Review of the care plan dated 12/20/2024 showed Resident 77 to continue to need isolation for COVID-19. Observations on 03/12/2025 at 9:15 AM showed Resident 77's room to have no signs for isolation. During an interview on 03/13/2025 at 10:45 AM, Staff L, LPN/UM, stated Resident 77's care plan was developed by the infection preventionist nurse and was not updated when the isolation stopped. During an interview on 03/13/2025 at 12:35 PM, Staff B, DNS, stated Resident 77's care plan did not meet expectation. Reference WAC 388-97-1020(2)(c)(d) Resident 30 Review of the EHR showed Resident 30 admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure a safe environment was maintained related to medications at bedside and falls for 3 of 6 sampled residents (Residents 45, 5 and 22) when reviewed for accidents. Failure to ensure fall interventions were in place for Residents 22 and 5 and to assess and care plan self-medication administration for Resident 45 and placed residents at risk for avoidable injuries and a diminished quality of life. <FALLS> Review of facility document titled, Fall Protocols, undated, showed in the event of an actual fall the facility would implement a resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. If the falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Resident 22 Resident 22 admitted to the facility on [DATE] with diagnoses that included diabetes (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 implement an effective antibiotic stewardship program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 residents (Residents 418, 419 and 420) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Antibiotic Stewardship Program, undated, showed antibiotic therapy should be based on the following guidelines: (if the infective pathogen is not known) or prophylactic therapy (given to prevent development of an infection) the therapy is prescribed using a narrow spectrum antimicrobial over the shortest duration possible to achieve therapeutic effectiveness, and if the infective agent is known - according to the microbiology results and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure and document that each resident was informed about the benefits and risks of and had the opportunity to receive the influenza and pneumococcal vaccines unless medically contraindicated, refused or was already immunized for 4 of 5 sampled residents (Resident 87, 27, 92 and 78) when reviewed for immunizations. These failures placed the residents at an increased risk of viral infections, lack of knowledge to make an informed decision, and poor clinical outcomes. Findings included . Resident 87 Review of the electronic health record (EHR) showed Resident 87 was admitted on [DATE] with diagnoses of acute respiratory failure, asthma and diabetes. The resident was able to make needs known. Review of the EHR on 03/13/2025 showed no documentation that the resident received education on the risks and benefits of the pneumococcal vaccine and was offered, provided, refused or already received the vaccine. Resident 27 Review of the EHR showed Resident 27…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and document that each resident was informed about the benefits and risks of and had the opportunity to receive Covid-19 vaccine unless medically contraindicated, refused or was already immunized for 3 of 5 sampled residents (Residents 87, 27, and 92) when reviewed for immunizations. This failure placed the residents at an increased risk of Covid-19 infections, lack of knowledge to make an informed decisions and poor clinical outcomes. Findings included . Resident 87 Review of the electronic health record (EHR) showed Resident 87 was admitted on [DATE] with diagnoses of acute respiratory failure, asthma and diabetes (too much sugar in the blood). The resident was able to make needs known. Review of the EHR on 03/13/2025 showed no documentation that the resident received education on the risks and benefits of the Covid-19 vaccine and was offered, provided, refused or already received the vaccine. Resident 27 Review of the EHR showed Resident 27…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 psychotropic medication (medications that affect a person's mental state) consents completed prior to receiving medications for 1 of 5 sampled residents (Resident 26) reviewed for unnecessary medication use. This failure placed the resident or their legal representatives at risk for lack of knowledge to make an 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 26 readmitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 01/04/2025, showed Resident 26 had diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), anxiety disorder, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 26's March 2025 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to honor resident shower preferences for 1 of 3 sampled residents (Resident 216) reviewed for choices. This failure placed the resident at risk for infection, medical complications, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 216 was re-admitted to the facility on [DATE] with diagnoses to include bipolar disorder (disorder associated with mood swings ranging from depressive low to manic highs), heart failure, spinal stenosis (spaces inside the bones of the spine get too small and causes pressure on the nerves) and morbid obesity (disorder that involves having too much body fat). Resident 216 was able to communicate needs. Review of the care plan, initiated 03/01/2025, did not showed instructions or preferences for showers. During an interview on 03/10/2025 at 10:30 AM, Resident 216 stated they did not get a choice about their shower. Resident 216 stated when staff ask to shower them,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to provide a homelike environment in resident rooms for 2 of 4 hallways (200 and 100 halls) when review for environment. This failure placed residents at risk of decreased mood and a diminished quality of life. Findings included . 200 Hall Observations on 03/10/2025, 03/11/2025, and 03/14/2025 showed the wall behind Resident 65's head of their bed board with torn wallpaper and deep gouges with a small amount of flaking drywall accumulated on the floor. During an interview on 03/10/2025 at 12:53 PM, Resident 65 stated the wall had been in disrepair since they arrived in the room about three weeks ago and staff were aware. 100 Hall Observations of room [ROOM NUMBER] on 03/10/2025, 03/11/2025, and 03/12/2025 showed the wall behind the head of bed A had torn wallpaper and deep gouges. Observations of room [ROOM NUMBER] on 03/10/2025, 03/11/2025, and 03/12/2025 showed the wall behind the head of bed had torn wallpaper and deep gouges. During an interview on…

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

Based on observation, interview, and record review, the facility failed to complete criminal background check prior to hire for 1 of 5 staff (Staff F) when reviewed for abuse and neglect prevention. This failure placed the residents at risk for abuse and neglect. Findings included . Review of a policy titled, Background Screening Investigations, dated 03/27/2024, showed employees cannot work in positions that involve direct contact with patients until the criminal background check was completed. During an interview and observation on 03/10/2025 at 10:34 AM, Resident 216 stated one nursing assistant was rude and pushed hard on their hip and caused them to scream. As Resident 216 was describing this, the door to the room opened and Staff F, Certified Nursing Assistant (CNA), came in and then left the room. Resident 216 stated that was the rude aide. Observation during day shift on 03/10/2025 and 03/11/2025 showed Staff F was working on the same hallway as Resident 216's room. Review of the employee file on 03/12/2025 showed Staff F, CNA, was hired on 09/05/2024. There was 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 identify and report an allegation of abuse for 1 of 2 sampled residents (Resident 216) when reviewed for abuse. This failure placed the resident at risk of further abuse, psychological distress, and diminished quality of life. Finings included . Review of the electronic health record (EHR) showed Resident 216 was re-admitted to the facility on [DATE] with diagnoses to include bipolar disorder (disorder associated with mood swings ranging from depressive low to manic highs), heart failure, spinal stenosis (spaces inside the bones of the spine get too small and causes pressure on the nerves) and morbid obesity (disorder that involves having too much body fat). Resident 216 was able to communicate needs. During an interview on 03/10/2025 at 10:34 AM, Resident 216 stated the night before last there was a certified nursing assistant who was rude to them and during care pushed hard on their hip and made them scream. Resident 216 stated they reported 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 follow provider's order for 1 of 5 sampled residents (Resident 215) reviewed for professional standard of care and services. This failure placed the resident at risk for avoidable pain, medical complications, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 215 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (kidney failure), spinal stenosis in cervical region (spinal canal in the neck area narrows and compresses the spinal cord and nerves), diabetes (high blood sugar) and urine retention. Resident 215 was able to make needs known. Observation on 03/10/2025 at 10:16AM showed Resident 215 in their room with a cervical (neck) collar device on the nightstand. Observations from 03/10/2025 to 03/14/2025 showed Resident 215 without neck collar. During an interview on 03/12/2025 at 9:28 AM, Resident 215 stated they have not used the neck…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 30 Review of the EHR showed Resident 30 admitted to the facility on [DATE] with diagnoses including cancer of the colon (lower intestines), dementia, and diabetes. The resident was unable to make needs known. During an interview on 03/12/2025 at 9:01 AM, Collateral Contact Z (CCZ), stated Resident 30 did not eat on their own and staff took the tray out without assisting them. CCZ stated staff did not get Resident 30 up out of bed during the day. During an interview and observation on 03/12/2025 at 9:01 AM, CCZ stated Resident 30 needed assistance with meals and to get up out of bed. Resident 30 was observed lying in bed while CCZ assisted them with the morning meal. Observations on 03/12/2025 at 11:08 AM, 1:18 PM, and 3:31 PM showed Resident 30 laid in bed with an absorbent pad under them. Their position was unchanged. Review of Resident 30's care plan initiated 11/16/2024 showed the resident required assistance with eating meals, to get out of bed for meals, and to assist the resident to turn 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 64 Review of the EHR showed Resident 64 admitted to the facility on [DATE] with diagnoses that included disorder of muscle, lymphedema (tissue swelling caused by accumulation of fluid), and difficulty walking. Review of the admission MDS dated [DATE] showed Resident 64 was assessed to have lower extremity impairment of both sides. During an interview on 03/12/2025 at 1:52 PM, Resident 64 stated Staff never do what they're supposed to do here. I'm supposed to get my legs wrapped daily and it doesn't get done. Observations on 03/12/2025 at 9:51 AM and 03/13/2025 at 11:03 AM showed Resident 64's legs were not wrapped. Review of Resident 64's provider's order dated 02/28/2025 showed staff were to apply ACE wraps (elastic bandages) to bilateral extremities one time a day for edema and remove at night per schedule. Review of the March 2025 MAR showed the ACE wraps had not been applied on any days during the month. During an interview on 03/13/2025 at 11:23 AM, Staff T, LPN, stated Resident 64's legs 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 Resident 88 Review of the EHR showed Resident 88 admitted to the facility on [DATE] with diagnoses of cognitive communication deficit (when someone has trouble with one or more cognitive processes involved in communication) and diabetes (when the body cannot process sugar effectively). The resident was able to make needs known. Observation and interview on 03/11/2025 at 9:36 AM showed Resident 88 laid in bed. The resident had their left hand resting on their chest with the fingers curled and the skin appeared dry and flakey. Resident 88 attempted to move their fingers on the left hand but was unable and stated I can't open my hand. Review of a therapy discharge note showed Resident 88 was discharged from physical and occupational therapy on 3/10/2025 and showed Restorative Program Established / Trained = Not Indicated at This Time and Functional Maintenance Program Established/Trained = Not Indicated at This Time. During an interview on 03/12/2025 at 9:55 AM, Staff N, Director of Rehabilitation (DOR), 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 Resident 82 Review of the EHR showed Resident 82 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease) and congestive heart failure (CHF, when the heart does not pump enough causing fluid buildup). The resident was able to make needs known. Observation on 03/10/2025 at 9:38 AM showed Resident 82 laid in bed. There was a full water pitcher on the overbed table. Observation and interview on 03/11/2025 at 10:22 AM showed Resident 82 laid in bed. There was a full water pitcher, a half empty bottle of soda on the overbed table, and a half drank bottle of water on the bedside table. Resident 82 stated they were aware they were on a fluid restriction and they do not drink the fluids on the meal trays. Review of the EHR showed a provider's order for fluid restriction of 2000 ml per day, for nursing to provide 560 ml per day and dietary to provide 1440 ml per day. Review of the March 2025 medication administration record (MAR) showed Resident 82 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 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 1 of 2 sampled residents (Resident 36) when reviewed for enteral nutrition. The facility failed to ensure the amount of enteral formula (liquid food products) Resident 36 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 . Review of the electronic health record (EHR) showed Resident 36 admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar levels), chronic obstructive pulmonary disease (COPD, blocks airflow making it difficult to breathe), had a feeding tube (a flexible tube used to deliver nutrition and fluids directly into the stomach or small intestine), 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 82 Review of the EHR showed Resident 82 admitted to the facility on [DATE] with diagnoses of COPD and CHF. The resident was able to make needs known. Review of the EHR showed a provider order with a start date of 01/31/2025 for oxygen to be provided at three L per minute through a nasal canula every shift for COPD. Observations on 03/10/2025 at 9:51 AM, 03/11/2025 at 1:16 PM, and 03/12/2025 at 10:50 AM showed oxygen being delivered at two L per minute through a nasal canula. During an interview on 03/13/2025 at 9:39 AM, Staff P, LPN, stated they should check each shift if O2 was set correctly, and Resident 82 should be receiving three L per minute. During an interview on 03/13/2025 at 11:18 AM, Staff B, DNS, stated Resident 82 should have been checked once a shift for oxygen needs and they should be receiving the ordered amount. Reference WAC 388-97 -1060 (3)(j)(vi) Resident 5 Review of the EHR showed Resident 5 readmitted to the facility on [DATE] with diagnoses that included diabetes, chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 non-pharmacological interventions (health interventions/approaches used instead of medication) for 2 of 11 sampled residents (Residents 26 and 88) when reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk for receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 26 Review of the electronic health record (EHR) showed Resident 26 readmitted to the facility on [DATE] with diagnoses to include anxiety disorder, high blood pressure, and chronic obstructive pulmonary disease (COPD, blocks airflow making it difficult to breathe). Resident 26 was able to make needs known. Review of the March 2025 medication administration records (MAR) from 03/01/2025 - 03/12/2025 showed an order with a start date of 05/27/2023 for Hydrocodone-Acetaminophen every six hours as needed for moderate to severe pain. Resident 26 was provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to monitor behaviors related to psychotropic medication (a medication that affects behavior, mood, thoughts and/or perception) use, and/or conduct a psychotropic medication gradual dose reduction for 2 of 5 sampled residents (Residents 22 and 77) reviewed for unnecessary medications. These failures placed residents at risk for adverse side effects, unknown behaviors, medical complications, and diminished quality of life. Findings included . Resident 22 Review of the electronic health record (EHR) showed Resident 22 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar levels), depression, and was able to make needs known. Review of the provider order dated 01/06/2025 showed Resident 22 was prescribed Duloxetine HCI (an antidepressant medication) once a day for depression. Review of the medication administration records (MAR) dated March 2025 from 03/01/2025 - 03/12/2025 showed Resident 22 was provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a skin condition was accurately assessed, treated and monitored for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for unmet care needs, discomfort, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic osteomyelitis (infection of the bone), high blood pressure, and for rehabilitation and skilled nursing care of wounds including a diabetic foot ulcer. The Minimum Data Set (an assessment tool), dated 09/11/2024, documented Resident 1 was alert and oriented and required assistance with activities of daily living. Review of Resident 1's electronic health record included a Weekly Skin Observation, dated 09/25/2024 at 2:53 PM, that documented, under Other Skin Concerns, pustule/boil on left butt cheek, open wound on right foot, blanchable redness on sacrum, rash/dermatitis in groin area. 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.

Based on interview and record review, the facility failed to ensure that direct care staffing information was accurate and submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 annual quarters (Quarter 4- October 1, 2023, through December 31, 2023) reviewed for Payroll-Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of staffing level data collected by CMS and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) PBJ Data Report showed the facility reported data for Quarter 4, 2023 (October 1, 2023, through December 31, 2023), at a level lower than required by mandated staffing levels. In an interview on 10/28/2024 at 4:10 PM, Staff A, Administrator, acknowledged the data submitted for Quarter 4, 2023 was not accurate or timely and additional hours were submitted to State Agency for recalculation of total direct care staffing hours. Staff A stated after recalculation, 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 necessary care and services to prevent the occurrance of an avoidable pressure ulcer/pressure injury (PU/PI) for 1 of 3 sampled Residents (Resident 1) reviewed for PU/PI. The failure to implement physician ordered (PO) weekly skin observations and adequately evaluate, document, and monitor a newly identified PU/PI placed residents at risk for worsening skin conditions, unmet care needs, and dimished quality of care/quality of life. Findings included Review of the facility's Pressure Injury Prevention and Management policy, revised 05/22/2023, showed the licensed nurses would conduct weekly skin observations and the findings would be documented in the residents medical record. Observations of newly identified PU/PI would be reported to the physician for evaluation/treatment and referred to the designated wound nurse. The evaluation of the PU/PI would include description of the PU/PI including staging of the wound. 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 observations, interviews and record reviews, the facility failed to ensure physician orders were clarified and treatment was provided according to physician orders for 3 of 5 sampled residents (Residents 1, 4 & 7) reviewed for wound care. This failure placed residents at risk for delayed healing or deterioration of wounds and a diminished quality of life. Findings included . < Resident 4 > Resident 4 was admitted [DATE] with diagnoses including diabetes and spinal stenosis (condition of spine that can put pressure on the bowel and bladder). The Minimum Data Set (MDS), an assessment, dated 06/09/2024, showed Resident 4 was always incontinent. MASD (Moisture Associated Skin Damage) Care Plan, dated 12/27/2022, documented licensed nurses were responsible to carry out physician orders for treatment of the MASD. Physicians Order, dated 03/8/2024, documented Resident 4 was to have Moisture Associated Skin Damage (MASD) at the sacrococcygeal region (portion of spine between lower back and tailbone), cleansed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, report to administrator and investigate an allegation of neglect for 1 of 3 sampled residents (Resident 1) reviewed for abuse and neglect. Failure to report alleged abuse and neglect placed the residents at risk for unidentified abuse, mistreatment, and a diminished quality of life. Findings included . Facility policy, Abuse Investigation and Reporting, dated 10/01/2001, documented all reports of abuse or neglect would be reported and thoroughly nvestigatigated by facility management. Resident 1 was admitted to the facility on [DATE] with multiple diagnoses to include a sacral pressure injury (bedsore on tailbone) and osteomyelitis (bone infection) of the sacrococcygeal region (portion of spine between lower back and tailbone). During an interview on 6/12/2024 at 11:34 AM, Collateral Contact 1 (CC 1) stated that on 2/10/2024, Resident 1 was found in bed with urine-soaked briefs and bedsheets. CC-1 indicated concern that Resident 1 had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interviews and record review, facility failed to provide care and treatment according to professional standards to prevent development or deterioration of pressure injuries for 2 of 5 residents (Residents 1 & 2) reviewed for pressure injury prevention when it did not develop, revise and implement individualized care planned interventions for incontinence care, positioning and behaviors. This failure placed residents at risk for new or worsening pressure injuries and a diminished quality of life. Findings included . The 2019 National Pressure Injury Advisory Panel (NPIAP) guidance, Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide, documented wounds should be protected from contamination by urine by cleansing the skin promptly after each episode of incontinence. Facility Policy, Pressure Injury Prevention and Management, dated 10/01/2021, documented that a resident-centered (individualized) care plan would be developed and implemented by the interdisciplinary team…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 22 Resident 22 admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD, a long-term lung disease). Observation on 05/20/2024 at 10:22 AM showed Resident 22 laid in bed with long facial hair and their hair appeared oily. During an interview on 05/20/2024 at 2:30 PM, Collateral Contact 1 stated Resident 22 had not been getting enough showers or being shaven. During an interview on 05/22/2024 at 8:54 AM, Staff F, CNA, stated they had assisted Resident 22 with bathing and that the resident wanted to be shaved but would rather a male caregiver do it. During an interview on 05/22/2024 at 8:50 AM, Staff G, CNA/Bath Aid, stated residents should receive at least two showers/bed baths a week and they should be shaved if needed at that time. Review of Resident 22's shower/bathing documentation showed the resident had received four bed baths in the prior 30 days and no showers. During an interview on 05/22/2024 at 10:49 AM, Staff B, Director of Nursing Services, stated it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy per provider orders and/or ensure oxygen tubing was dated and regularly changed for 2 of 2 sampled residents (Residents 41 and 22) reviewed for respiratory care. These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . Resident 41 Resident 41 admitted to the facility on [DATE] with multiple diagnoses to include chronic obstructive pulmonary disease (COPD, causes restricted airflow and breathing problems) and cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) in part of the lung (organ to help one breath) or bronchus (passageway into the lungs). Observations on 05/20/2024, 05/21/2024, and 05/22/2024 showed Resident 41 had an oxygen machine with a prefilled humidifier container (used to humidify the oxygen) at the bedside set to deliver four liters per minute of oxygen to the resident through an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to act on and/or consistently follow the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for 3 of 5 sampled residents (Resident 20, 22, and 11) reviewed for unnecessary medication use. These failures placed the residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Resident 20 Resident 20 admitted to the facility on [DATE] with diagnoses to include coronary artery disease (damage or disease in the heart's major blood vessels) and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of Resident 20's pharmacist recommendation dated 01/25/2024 showed a recommendation that if indicated and congruent with goals of therapy, consider starting Eliquis (blood thinner) medication after obtaining a weight and if weight was greater than 60 kilograms (kg) start 5 milligrams (mg)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 7 sampled residents (Residents 20, 22, and 154) when reviewed for unnecessary medications and/or anticoagulant (blood thinner) medication use. The facility failed to monitor Resident 20's blood pressure (BP) and heart rate/pulse and follow parameters prior to giving medications; failed to ensure Residents 20 and 22 were provided non-pharmacological (NPI, non-medication) interventions prior to the use of as needed (PRN) pain medications; and monitor Resident 154's blood thinner medication side effects. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 20 Resident 20 admitted to the facility on [DATE] with diagnoses to include coronary artery disease (damage or disease in the heart's major blood vessels), high blood pressure (the pressure of circulating blood against the walls of…

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

Based on observation, interview, and record review, the facility failed to provide dental services for 2 of 3 sampled residents (Resident 33 and 204) reviewed for dental services. This failure placed the resident at risk of difficulty eating, unmet needs and a diminished quality of life. Findings included . Resident 33 Observation and interview on 05/20/2024 at 10:12 AM showed Resident 33 had a small plastic denture cup on a bedside table that contained one upper denture. Resident 33 stated that they could not wear it because they were too loose and they needed denture adhesive to secure them better but was not provided any during their stay at the facility. Review of Resident 33's focus care plan dated 11/06/2023 showed the resident had oral/dental health problems related to poor repair and the resident had full top dentures. Interventions included for staff to monitor, document and report, when necessary, any signs or symptoms of oral dental problems that needed attention. Staff were required to provide mouth care as per activities of daily living (ADLs) personal hygiene.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapeutic diets for 3 of 5 sampled residents (Residents 153, 79, and 92) when reviewed for kitchen. This failure placed residents at risk of choking, increased blood pressure, avoidable injury, and a diminished quality of life. Findings included . Resident 153 Review of Resident 153's electronic health record (EHR) showed they admitted on [DATE], had a diagnosis of dysphagia (problems with using the mouth, lips and tongue to control food or liquid) and had a diet order for soft and bite sized food. Observation and interview on 05/22/2024 at 11:48 AM showed Staff Q, Certified Nursing Aid (CNA), served a whole hamburger to Resident 153. Staff Q stated Resident 153 was served a whole hamburger, Resident 153's tray card showed to serve soft and bite sized foods, and that a whole hamburger was soft and bite sized. Resident 92 Review of Resident 92's EHR showed they admitted on [DATE], had a diagnosis of dysphagia and had a diet…

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

Based on observation, interview, and record review the facility failed to ensure an effective infection prevention and control program was in place to prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 4 of 4 months (January, February, March, and April 2024) when reviewed for infection control. The facility failed to ensure the laundry/linen storage room had defined separation between dirty/contaminated waste and clean linen. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, cross-contamination, and a decreased quality of life. Findings included . <Tracking and Trending> Review of the facility policy titled Infection Control Program, revised 10/24/2022, showed the infection preventionist was responsible for gathering and interpreting surveillance data. The data collection and recording included identification of the pathogens (a microorganism that…

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

Based on interview and record review, the facility failed to resolve grievances brought forward by the resident council (RC) for 2 of 3 months (March and April 2024) when reviewed for resident council. This failure placed the residents at risk of not having group grievances resolved, reduced capacity to provide input to the facility, and a diminished quality of life. Findings included . During an interview on 05/22/2024 at 10:20 AM, the RC stated Staff P, Director of Activities, recorded the RC grievances at each meeting, but the RC did not receive a response back. The RC stated that occasionally a department head would come to RC to respond to a grievance, but this was not routine. Review of RC minutes, dated March 2024, showed grievances related to medical equipment stored on hallways, healthy options in the vending machine, staff use of walkie talkies, meat on no meat days, staff attending RC, and meals not served at scheduled times. Review of the grievance log, dated March 2024, showed one grievance generated from the RC, which was related to meals not served at scheduled times.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to report to the administrator and investigate an allegation of abuse for 1 of 2 sampled residents (Resident 19) reviewed for abuse and neglect. Failure to report alleged abuse and neglect placed the residents at risk for unidentified abuse, mistreatment, and a diminished quality of life. Findings included . Resident 19 was admitted to the facility on [DATE] with multiple diagnoses to include high blood pressure, right lower leg fracture, depression, and asthma. Resident 19 was cognitively intact. During an interview on 05/20/2024 at 10:27 AM, Resident 19 stated a couple of days ago a woman came into their room and threw ice water on them. Resident 19 stated they reported it to facility staff. Review of a progress note, dated 05/18/2024, showed Resident 19 was banging on the wall and the resident from the next room came to Resident 19's room. Review showed that there was a verbal altercation between Resident 19 and this resident. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 1 of 21 sampled residents (Resident 154) reviewed for monitoring. Failure to ensure clinical symptoms for congestive heart failure were monitored and addressed and failure to monitor for adverse side effects of an anticoagulant (AG, blood thinning medication) placed the resident at risk for decreased comfort, poor clinical outcomes, and a diminished quality of life. Findings included . Review of Resident 154's electronic health record (EHR) showed the resident admitted on [DATE] with a diagnoses of congestive heart failure and kidney disease and was receiving an AG medication daily to prevent blood clots. Review of the admission orders, dated 05/13/2024, showed to notify the primary clinician for new onset or worsening lower extremity edema (leg swelling), nighttime dyspnea (difficulty breathing), and to monitor for bleeding. Observation and interview on 05/20/2024 at 11:23 AM…

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

Based on observation, interview, and record review, the facility failed to ensure hearing aids were implemented and/or provided the necessary auditory (hearing) services in a timely manner for 1 of 3 sampled residents (Resident 33) reviewed for communication/sensory. This failure placed the resident at risk for diminished independence with activities of daily living, unmet needs, and a diminished quality of life. Findings included . Resident 33 was admitted to the facility in October 2023. The minimum data set (MDS), a required assessment tool, dated 05/17/2024, showed the resident had moderate difficulty hearing. Review of Resident 33's inventory list showed the resident had hearing aids documented within their possession upon admission in October 2023. Observation and interview on 05/20/2024 at 10:12 AM showed Resident 33 laid in bed without hearing devices in place. When speaking towards Resident 33, the resident responded by yelling, What? What? loudly while leaning forward and angling their ear toward the communication. Resident 33 stated they had hearing aids but did not know…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation on an unwitnessed fall for 1 of 3 residents (Resident 1) reviewed for accidents and/or incidents. This failure placed all residents at risk for inadequate interventions, recurrent falls, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation after hospitalization for a fall at home. Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 11/23/2023 showed that Resident 1 admitted to the facility with multiple diagnoses, had impaired cognition, and required staff assistance with activities of daily living. Review of a Fall assessment dated [DATE] at 3:47 PM documented Resident 1 was at high risk for falling. The facility's Fall Management Guideline, dated 05/10/2023, documented facility staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try…

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