Orchard Park Health Care & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue Notification of Medicare (federal health insurance program for people age [AGE] or older) Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 2 of 3 sampled residents (Residents 27 and161) reviewed for beneficiary notices. This failure placed the residents and/or their representatives at risk of not being fully informed and losing their right to an appeals process. Findings included . Resident 27Review of the electronic health record (EHR) showed Resident 27 was admitted to the facility on [DATE] and discharged on 04/27/2026 to an adult family home. Review of records showed Resident 27 was not provided with a NOMNC form prior to discharge. Resident 161Review of the EHR showed Resident 161 was admitted to the facility on [DATE] and was discharged on 12/02/2025 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe environment to ensure reasonable care and protection of resident's personal property from loss or theft for 1 of 3 sampled residents (Resident 2) reviewed for environment. Failure to ensure a cell phone was protected and/or replaced when reported missing placed a resident at risk for lack of ability to easily communicate with others outside of the facility, loneliness, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed that Resident 2 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar) and high blood pressure and was able to make needs known. During an interview on 05/18/2026 at 10:26 AM, Resident 2 stated their cell phone went missing and staff were aware; however, it had not been found or replaced. Review of Resident 2's Inventory of Personal Effects, form dated 04/17/2026 showed Resident 2 had a cell phone with charger and black bag listed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from chemical restraints for 1 of 6 sampled residents (Resident 65) reviewed for behavioral-emotional and unnecessary medications. The failure to evaluate and document a clinical rational for use of a psychotropic medication and ensure adequate indications for the use of the medications placed residents at risk for decline in activities of daily living, potential adverse consequences, and diminished quality of life. Findings included. Review of the electronic health record (EHR) showed Resident 65 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, diabetes (high blood sugar), dementia (decline in mental ability, memory and reasoning) and acute pyelonephritis (bacterial infection of kidneys). Resident 65 was not able to communicate their needs. Observation on 05/20/2026 at 10:03 AM and 1:25 PM to 2:20 PM showed Resident 65 sitting in wheelchair by the nurse's station with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely complete the admission minimum data set assessment (MDS) within 14 days of admission for 1 of 24 sampled residents (Resident 114) reviewed for MDS. This failure placed the residents at risk for unmet care needs, inaccurate medical record data, and poor clinical outcomes. Findings included.Resident 114Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnosis of kidney failure and bladder infection. The resident was able to make needs known. Review of the EHR on 05/19/2026 at 10:20 AM showed the admission comprehensive MDS assessment was still in process 29 days after admission with multiple sections unanswered. During an interview on 05/20/2026 at 10:42 AM, Staff J, Minimum Data Set/Registered Nurse (MDS/RN), stated Resident 114 should have had the admission MDS assessment completed within 14 days of admission but did not. During an interview on 05/20/2026 at 11:01 AM, Staff B, Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an assessment for a significant change in condition for 1 of 23 sampled residents (Resident 123) whose assessments were reviewed. Failure to identify Resident 123's need for a significant change assessment related to decline in health and who received hospice services (supportive care for people in the final phase of a terminal illness, focusing on comfort and quality of life) placed the resident at risk for unidentified and/or unmet needs. Findings included.Review of the electronic health record (EHR) showed Resident 123 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a brain malfunction caused by an underlying chemical imbalance or disease in the body) and dysphagia (difficulty swallowing). Resident 123 was able to make needs known and sometimes able to understand others. Review of the provider order dated 01/02/2026 showed Resident 123 was admitted to Hospice on 12/26/2025 related to a terminal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 minimum data set assessments (MDS) were completed accurately for 2 of 23 sampled residents (Residents 8 and 85) reviewed for resident assessments. Failure to accurately complete MDS assessments placed residents at risk for a delay in identification of care needs and diminished quality of life. Findings included .Resident 8 Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include cancer of breast and bone, anemia (too few healthy red blood cells) and diabetes (high blood sugar). Resident 8 was able to communicate needs. During an interview on 05/18/2026 at 1:55 PM, Resident 8 stated they needed new glasses, they were nearsighted and were unable to read what was on TV. Resident 8 stated they had a pair of glasses at home. Review of the admission MDS, dated [DATE], showed Resident 8 had adequate vision and did not use corrective lenses. During an interview on 05/21/2026 at 10:31…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessments were accurately completed for 3 of 8 sampled residents (Residents 13, 14, and 150) reviewed for PASRR and unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included .Resident 13Review of the electronic health record (EHR) showed Resident 13 admitted to the facility on [DATE] with diagnoses that included paranoid personality disorder (mental health condition characterized by a long-term pattern of distrust and suspicion of others without sufficient reason), delusional disorders (having one or more false beliefs based on an incorrect interpretation of reality), dementia, and heart failure. Resident 13 was able to make needs known. Review of Resident 13's EHR showed a Level I PASRR was completed on 11/29/2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 formulate baseline care plans within 48 hours of admitting to the facility for 1 of 23 sampled residents (Resident 159) reviewed for position and mobility. This failure placed residents at risk of delays in services, avoidable pain, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 159 was admitted to the facility on [DATE] with diagnoses to include traumatic subdural hemorrhage (brain injury), fractures of T5-6 vertebra (broken bones in mid back), and respiratory failure. Resident 159 was not able to communicate needs. Observation on 05/18/2026 at 1:48 PM showed Resident 159 in bed with head of the bed (HOB) elevated and their body slouching down. Observation on 05/20/2026 at 9:57 AM showed Resident 159 in bed with HOB elevated and their feet touching the lower bed frame. Review of care plan dated 05/10/2026 showed Resident 159 had no instructions or directions on how to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were accurate and reflected resident care needs for 2 of 23 sampled residents (Residents 103 and 2) reviewed for care plans. Failure to ensure Resident 103's fluid restriction and Resident 2's hard of hearing status were included in their plans of care placed residents at risk of fluid overload, avoidable discomfort, unmet needs, and a diminished quality of life. Findings included.Resident 103 Review of the electronic health record (EHR) showed Resident 103 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), amputation of leg, and end stage renal disease (last stages of kidney failure). Resident 103 was able to communicate needs. During an interview on 05/18/2026 at 10:34 AM, Resident 103 stated they were on fluid restrictions. Review of the providers orders showed Resident 103 had an order for Fluid restriction, 1500 mL (milliliters) Dietary=900ml and nursing=600ml/day dated 05/05/2026.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to monitor actual pressure injuries or prevent new pressure injuries for 1 of 3 sampled residents (Resident 1) reviewed for pressure injuries. This failure placed the residents at risk for new or worsening pressure injuries and a decreased quality of life. Findings included.Review of the facility policy and procedure titled Skin Integrity Management dated 05/26/2021 showed the facility would identify residents' skin integrity status and need for prevention intervention and the facility would perform wound observations and measurements upon initial identification of altered skin integrity, weekly and as needed. The facility would develop a comprehensive plan of care to include pressure ulcer prevention and determine the need for offloading and repositioning. Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of encephalopathy (inflammation 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 ensure falls were investigated and future falls prevented and smoking assessments and interventions were in place for 1 of 6 sampled residents (Residents 85) and failed to protect residents from eloping (exiting the facility without the required supervision) and anti-elopement devices were in place for 1 of 6 sampled residents (Resident 14) reviewed for accidents. These failures placed residents at risk of significant injury and a decreased quality of life. Findings included.Resident 85 Review of the electronic health record (EHR) showed that Resident 85 admitted to the facility on [DATE] with diagnoses to include respiratory failure, generalized muscle weakness, and dysphagia (difficulty swallowing). Resident 85 was able to make needs known. <Fall> During an interview on 05/18/2026 at 1:27 PM, Resident 85 stated they had rolled over and fell out of their bed last night because they were too close to the edge of their bed but did not get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fluid restrictions were implemented for 2 of 4 sampled residents (Residents 103 and 2) reviewed for nutrition. This failure placed residents at risk of fluid overload, avoidable discomfort, and a diminished quality of life. Findings included.Resident 103 Review of the electronic health record (EHR) showed Resident 103 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), amputation of leg, and end stage renal disease (last stage of kidney failure). Resident 103 was able to communicate needs. During an interview on 05/18/2026 at 10:34 AM, Resident 103 stated they were on fluid restrictions. Review of the providers orders showed Resident 103 had an order for Fluid restriction, 1500 mL (milliliters) Dietary=900ml and nursing=600ml/day dated 05/05/2026. Review of May 2026 medication administration record (MAR) showed Resident 103 had order Water restriction 1500ml for Nursing only. AM- 600 ml PM- 600 ml Night…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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/documented in accordance with provider's orders for 2 of 3 sampled residents (Residents 9 and 4) reviewed for tube feeding. These failures placed the residents at risk for inadequate nutrition and 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 that included hemiplegia and hemiparesis (weakness/paralysis) affecting right dominant side, dysphagia (difficulty swallowing) and aphasia (a neurological disorder that impairs a person's ability to speak, write, and understand both spoken and written language). Resident 9 was assessed to require nutrition through a feeding tube (device that is inserted into the stomach through the abdomen to supply nutrition). Review of Resident 9's dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a contract with the dialysis (a process of filtering the toxins out of the blood) facility regarding dialysis care and services for 2 of 3 sampled residents (Residents 103 and 2) reviewed for dialysis. This failure placed residents at risk of avoidable complications, unmet care needs, and diminished quality of life. Findings included.Resident 103Review of the electronic health record (EHR) showed Resident 103 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), amputation of leg, end stage renal disease (final stage of kidney disease) and was dependent on dialysis. Resident 103 was able to communicate needs. Resident 2Review of the EHR showed that Resident 2 was admitted to the facility on [DATE] with diagnoses to include diabetes and was dependent on renal dialysis. Resident 2 and was able to make needs known. Review of facility contracts showed no active agreement and contract with the dialysis center…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address the psychosocial needs for 1 of 6 sampled residents (Residents 128) reviewed for abuse. This failure placed the residents at risk of unmet psychosocial needs and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 128 admitted to the facility on [DATE] with diagnoses that included tremors (neurological condition that includes shaking or trembling movements in one or more parts of the body) and heart failure. Resident 128 was able to make needs known. Review of Resident 128's Care Plan dated 07/24/2025 showed a focus area that included: Resident is at risk for or is experiencing adjustment issues related to loss of social support network as a result of moving into the center. Interventions showed, Review for impact on social involvement and provide assistance, as needed, to increase social involvement, monitor medical conditions that may contribute to social isolation, 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 provide nonpharmacological interventions (NPI, nonmedicated methods to reduce pain, e.g. massage, heat, repositioning) prior to providing as needed (PRN) pain medications for 1 of 5 sampled residents (Resident 16) reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 16 admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental health condition that causes extreme shifts between depression and mania) and dementia (a decline in mental ability that interferes with daily life). Resident 16 was able to make needs known. Review of provider's orders showed Resident 16 had an order for oxycodone (a narcotic pain medication) PRN. Review showed an order for Document Non-Pharmacological Interventions(s) A. Heat B. Repositioning C. Relaxation breathing D. Food/Fluid E. Massage F.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide prompt dental care services and ensure a care plan reflected current dental status for 1 of 3 sampled residents (Residents 85) reviewed for dental. This failure placed the residents at risk for continued dental problems, unmet needs, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed that Resident 85 admitted to the facility on [DATE] with diagnoses to include respiratory failure, generalized muscle weakness, and dysphagia (difficulty swallowing). Resident 85 was able to make needs known. During an interview on 05/18/2026 at 12:53 PM, Resident 85 stated they had no dentures and would not mind getting dentures. Resident 85 stated they did not remember staff ever asking them if they wanted dentures, but, if they had, they would have told them Yes. Review of the admission minimum data set assessment (MDS) dated [DATE] showed Resident 85 had no natural teeth or tooth fragments. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received necessary care and services for 1 of 3 residents (Resident 2) reviewed for quality of care when Resident 2 experienced a delay in care and developed a skin rash. This failure placed residents at risk of unmet care needs, discomfort, and decreased quality of life.Findings included Resident 2 was admitted to the facility on [DATE] with multiple diagnoses for medical management, nursing care and rehabilitative services. The resident was alert and aware and was their own decision maker. The Nursing Evaluation Documentation, dated 03/19/2026 at 9:24 PM, documented Resident 2 was continent of bowel and bladder. The skin assessment section documented the resident had swelling to the scrotum, and did not document the presence of a rash. On 03/25/2026, a provider note documented, under the physical exam section, that Resident 2 had scrotal edema and a diffuse rash. The provider wrote for zinc oxide to apply to groin and genitals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free from significant medication errors for 1 of 3 residents (Resident 1) reviewed for a significant medication error. This failure placed Resident 1 at risk of medical complications and unintended adverse reactions, and placed other residents at risk for medication errors and unmet needs, when they were discharged with medications that were prescribed to two other residents of the facility, along with their own medications. Findings included .Resident 1 was readmitted to the facility on [DATE] with multiple diagnoses, including history of a stroke with one-sided paralysis and weakness. Resident 1 was alert and oriented and was their own decision-maker. Resident 1 was discharged to their home on [DATE]. Discharge Plan Documentation dated 12/17/2025 showed Resident 1's prescribed medications at discharge included furosemide 20 mg (a diuretic or water pill), one tablet to be taken two times a day, and Warfarin, an anticoagulant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the State Survey Agency within 24 hours an unwitnessed fall, and failed to log the incident in the facility's reporting log, for 2 of 3 sample residents (Resident 1 and Resident 2) reviewed for falls. This failure placed residents at risk of incidents not being reported and placed residents at risk for abuse and neglect. Findings include . <Resident 1> Resident 1 was admitted to the facility on [DATE] for nursing care and rehabilitation after a fall that required surgery to their hip and femur (thigh bone). Resident 1 was alert and oriented, was their own decision maker and able to make their needs known. On 02/20/2026 at 10:20 AM, Resident 1 said a couple of days before, they had tried to get into their chair and fallen onto the floor around 9:00 PM at night. Resident 1 said when they fell, they hit their hip and it hurt. Resident 1 said they could not reach their call light so they crawled to the door to yell for help. A 02/19/2026 8:19 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a restorative nursing program was initiated for 1 of 1 residents (Resident 1) reviewed for range of motion (ROM) and mobility. This failure placed the resident at risk for decreased ROM, worsening contractures (a tightening/shortening or muscles, tendons, or ligaments causing a rigid, abnormal, and typically fixed positioning of joints), decreased independence, and a diminished quality of life. The facility had corrected the above deficiency prior to the complaint survey, and it is constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.Findings included. Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 12/05/2025, showed that Resident 1 admitted to the facility on [DATE] with diagnoses to include stroke, aphasia (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 develop and/or implement an individualized comprehensive care plan, for 1 of 3 sampled residents (Resident 1) reviewed for Pressure Injuries (PI's- localized skin and underlying tissue damage from prolonged pressure). This failure placed residents at risk of developing PI's, pain, and a decreased quality of life. Findings included. The facility's Skin Integrity Management - General Policy Guidelines, dated 05/26/2025, directs facility staff to Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated, review care plans and revise as indicated. Facility staff is directed to implement PI prevention for identified risk factors, determine the resident's need for offloading devices, turning and repositioning, implement special wound care treatments/techniques, and support surface for a resident's bed. In addition, facility staff are to review care plans and revise as indicated. Resident 1admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services to promote pressure injury (PI- localized skin and underlying tissue damage from prolonged pressure) prevention and healing, for 1 of 3 residents (Resident 1) reviewed for PIs. This failure placed residents at risk of developing new or worsening PIs, pain, infection and loss of limb Findings included.The National Pressure Injury Advisory Panel (NPIAP) PI definitions and stages included:A PI is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open injury and may be painful. The injury occurs as a result of intense pressure, prolonged pressure or pressure in combination with shear (a mechanical force that damages skin that occurs when skin stays put while underlying tissues slide in the opposite direction). The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rehabilitative services were provided as determined by physician order for 1 of 3 residents (Resident 1) reviewed for rehabilitation services. This failure placed residents at risk for delayed progress towards goals, unmet care needs, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses for rehabilitative services and administration of intravenous (IV) antibiotics. The Minimum Data Set, an assessment tool, dated 07/07/2025, showed Resident 1 had mild cognitive impairment and was able to make their needs known, and required assistance with activities daily living. On 08/14/2025 at 4:10 PM, a Collateral Contact (CC-1) said that concerns about Resident 1's care at the facility were discussed during a Care Conference meeting on 07/15/2025. CC-1 said Resident 1 had been there since 07/03/2025 and had not started physical therapy (PT). CC-1 said the physical therapy staff came…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe environment when the fire alarm panel malfunctioned, and fire watch was not performed as directed. The failure to perform fire watch, in the absence of a functioning fire alarm system, would likely cause a delayed response if a fire were to occur, which placed residents at risk for smoke inhalation, burns, displacement from their homes, and death.Findings included .Review of the facility August 2018 Emergency Procedure - Fire Watch policy showed Fire Watch procedures would be initiated if the fire alarm system failed. The purpose of a Fire Watch is to serve as a plan of action should the fire alarm system fail to work properly to provide continuous facility-wide fire detection and alarm capabilities. Fire watch tours occur at one half hour intervals, 24 hours a day, and consist of a periodic walking tour of the entire facility by one or more assigned and trained staff. The fire watch staff monitors the facility through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and treatment of an ileostomy (an opening in the body for the discharge of body wastes into a collection bag) was consistent to protect skin integrity for 1 of 3 sampled residents (Resident 1) reviewed for colostomy/ileostomy care. This failure placed the resident at risk for skin breakdown, discomfort, and diminished quality of life.Findings included . Review of the facility's policy titled, Skin Integrity Management, effective 05/26/2021, stated the purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The policy provided staff were to perform skin inspection on admission/re-admission and weekly, and to document on the Treatment Administration Record (TAR) or in the electronic health record.Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including short-gut syndrome, a condition in which the body cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly and timely investigate falls and/or injuries and implement interventions to prevent repeat falls for 4 of 6 sampled residents (Resident 14, 110, 21 and 29) reviewed for abuse / neglect. These failures placed the residents at risk for repeated falls, avoidable injuries and diminished quality of life. Findings included . Resident 14 Review of the electronic health record (EHR) showed, Resident 14 was admitted to the facility on [DATE] with diagnoses to include dementia (impaired memory and judgment), chronic obstructive pulmonary disease (COPD, a condition which blocks airflow that makes it difficult to breath), hypotension (low blood pressure), and anemia (a low red blood cell count). Resident 14 was not able to communicate needs. Review of the EHR showed Resident 14 had falls on the following dates: 02/05/2025, 02/13/2025, 03/18/2025, 03/31/2025, 04/02/2025, 04/29/2025, 05/24/2025, and 05/26/2025. Review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure an accurate assessments for 2 of 4 sampled residents (Resident 15 and 40) reviewed for dental conditions, 1 of 4 sampled residents (Resident 67) reviewed for respiratory care and 1 of 1 sampled residents (Resident 14) reviewed for restraints. These failures placed the residents at risk of unmet care needs and diminished quality of life. Findings included . Resident 15 Review of the electronic health record (EHR) showed Resident 15 admitted on [DATE] with multiple diagnoses to include quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso [trunk of the body]), malnutrition, muscle weakness, and depression. Resident 15 was able to make needs known and required substantial assistance with activities of daily living (ADLs). During an observation and interview on 06/08/2025 at 11:31 AM, Resident 15 laid in bed, the resident's oral cavity showed multiple lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for oxygen (O2) therapy for 2 of 4 sampled residents (Residents 65 and 97) reviewed for respiratory care. This failure placed the residents at risk for unmet needs and potential negative outcomes. Findings included . Resident 65 Review of the electronic health record (EHR) showed Resident 65 readmitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), and asthma (a condition where the airways in the lungs get inflamed/swollen and narrowed, making it hard to breathe). Resident 65 was able to make needs known. Observation on 06/08/2025 at 11:41 AM, showed Resident 65 with oxygen (O2) being administered at five liters via nasal canula (NC, a flexible tube used to deliver extra O2 through the nose) connected to an O2 concentrator (medical device that provides supplemental…

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

Based on observation, interview and record review, the facility failed to store medication requiring refrigeration in the medication refrigerator and to discard expired equipment and/or supplies in 1 of 2 medication rooms (East medication room) when reviewed for medication storage and labeling. These failures placed residents at potential risk for receiving medications contaminated by food items and/or for receiving compromised or ineffective supplies that had expired. Findings included . Observation on 06/11/2025 at 1:14 PM, with Staff L, Licensed Practical Nurse (LPN) at the East medication storage room showed the following: <Resident's food refrigerator> *Located in the bottom drawer of the refrigerator was a large plastic bag labeled with Resident 90's name that was filled with an intravenous (IV, a way of giving a drug or other substance through a needle or tube/catheter inserted into a vein) solution of liquid nutrition along with two vials of infuvite (multivitamin supplement), and an infusion kit (collection of devices used to administer fluids and medications via an IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food services which met resident preferences for 5 of 8 sampled residents (Residents 91, 21, 89, 16, and 80) when reviewed for food. This failure placed residents at risk of decreased mood, feelings of hunger, avoidable weight loss, and a diminished quality of life. Findings included . Resident 91 During an interview on 06/08/2025 at 10:48 AM, Resident 91 stated they filled out a menu at the beginning of the week with their preferences, but it was not honored. During an interview on 06/10/2025 at 2:01 PM, Resident 91 stated the previous night they had not received their ordered cheeseburger. Resident 91 stated they went to the kitchen and the dietary manager prepared a cheeseburger for them. Resident 21 During an interview on 06/09/2025 at 12:58 AM, Resident 21 stated they ordered a hamburger, juice, and tea for lunch, but they did not receive it. Resident 21 stated their food preferences were frequently ignored. Resident 89 Review of the facility's grievance log showed Resident 89 had filed 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 report an infectious disease outbreak to the local health department (LHD) as required for 1 of 1 Covid-19 outbreak (Resident 377 and 20) when reviewed for infection control. The facility failed to implement infection control practices for surveillance of current infections for 2 of 3 months (03/2025 and 04/2025) when reviewed for infection control. The facility failed to complete timely ordered labs for a possible infection for Resident 378. These failures placed the residents at risk for communicable diseases, clinical complications and a decreased quality of life. Findings included . <Covid-19 Outbreak> Review of the facility policy titled reportable diseases revised 09/2022 showed, When a resident(s) presents with a suspected or confirmed infection, illness or condition that is reportable, the administrator (or designee) notifies the local health department (LHD) within the required timeframe. Resident 377 Review of the electronic health record…

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

Based on interview and record review, the facility failed to ensure each staff member received training related to resident abuse, dementia management and had continuing competencies for certified nurse aides on a yearly basis for 2 of 5 staff members (Staff S and T), reviewed for training. These failures placed residents at risk for potential abuse, lack of dementia care and a diminished quality of life. Findings included . Review of training records on 06/12/2025 showed the training record for Staff S, Certified Nurse Assistant (CNA) was blank. Review of the training records on 06/12/2025 showed for the training record for Staff T, CNA, had one in-service training completed on 08/25/2023. During an interview on 06/12/2025 at 2:24 PM, Staff A, Administrator, stated Staff S and Staff T did not have training. Staff A stated their expectation was for staff to have their education and competencies completed before they work with residents, and the records for Staff S and Staff T did not meet their expectations. Reference WAC 388-97-1680(2)(a-c) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 1 of 2 sampled residents (Resident 40) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed, Resident 40 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone, or posture), urinary tract infection and muscle weakness. Resident 40 was able to communicate needs. During an observation on 06/08/2025 at 12:28 PM, Resident 40 was sitting in their wheelchair in their room. Resident 40 stated they could not set their own shower time, per the facility schedule, it was provided only two times a week at specific times that were not followed. During an interview on 06/11/2025 at 9:07 AM, Staff P, Residential Care Manger /…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess for adverse side effects (ASE) related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents (Resident 107) when reviewed for unnecessary medication use. Failure to conduct/obtain an initial/baseline abnormal involuntary movement (AIM) assessment for the use of an antipsychotic medication (a psychoactive medication that affects a person's mental status) and identify potential involuntary movement placed Resident 107 at risk of unidentified presence and severity of AIM ASE, medical complications, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 107 readmitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability that interferes with daily life) with psychotic disturbance (a mental state where individuals experience a significant disconnect from reality), and a cognitive (mental process in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 14 Review of the EHR showed Resident 14 was admitted to the facility on [DATE] with diagnoses to include dementia (impaired memory and judgment), chronic obstructive pulmonary disease (COPD, a condition which blocks airflow that makes it difficult to breath), hypotension (low blood pressure), and depression. Resident 14 was unable to make their needs known. Review of a provider order, dated 01/21/2025, showed an antidepressant was prescribed. Review of June 2025 medication administration record showed Resident 14 was administered an antidepressant medication three times a day and a second antidepressant medication for appetite stimulation. Review of a Level I PASARR, dated 01/21/2025, showed Resident 14 had indications for serious mental illness. No Level II referral was completed. During an interview on 06/10/2025 at 1:44 PM, Staff E, SW, stated they performed audits to correct PASARR's after admission to the facility; however, Resident 14's PASARR was missed. Staff E stated the lack of Level II…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to develop and/or implement individualized comprehensive care plans related to oxygen therapy and oral/dental status for 3 of 23 sampled residents (Residents 67, 40, and 90) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs placed residents at risk of unmet care needs and potential negative outcomes. Findings included . Resident 67 Review of the electronic health record (EHR) showed Resident 67 readmitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD, a long-term disease that makes it hard to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms of COPD). Resident 67 was able to make needs known. Observations on 06/08/2025 at 11:03 AM, 06/09/2025 at 1:13 PM, and on 06/10/2025 at 8:56 AM, showed Resident 67 laid in bed with the head of the bed elevated and received oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 23 residents (Residents 44, 14, and 90) when reviewed for quality of care. The facility failed to follow provider ordered boots (used to protect the heel and alleviate pressure) to heels every shift (Resident 44), to follow provider parameters (Resident 14), and to obtain orders to care for a central line/central venous catheter (CVC, flexible tube inserted into a large vein used to deliver fluids/nutrition (Resident 90). These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . According to the Lippincott Manual of Nursing Practice, Tenth Edition ([NAME], [NAME] & [NAME], 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. According to [NAME], Duell & [NAME], Clinical Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop and implement an individualized activity plan for 1 of 1 sampled resident (Resident 97) reviewed for activities. This failure placed the resident at risk for boredom, isolation, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 97 admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Observations on 06/09/2025 at 1:09 PM, 06/10/2025 at 12:27 PM and 06/12/2025 at 11:49 AM, showed Resident 97 in their wheelchair sitting next to the nurse's station. Review of the EHR showed no activities assessment was completed upon admission and the care plan did not have a activities focus area. During an interview on 06/12/2025 at 11:46 AM, Staff J, Recreation Director (RD), stated no recreation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide the necessary care and services for the treatment of non-pressure skin injuries for 2 of 3 sampled residents (Residents 44 and 65) when reviewed for non-pressure skin conditions. Additionally, the facility failed to develop a collaborative comprehensive care plan involving Hospice (specialized care for people who are nearing the end of their life) service for 1 of 2 sampled residents (Resident 67) when reviewed for Hospice and end of life. These failures placed the residents at risk for unmet care needs, poor clinical outcomes, and diminished quality of life. Findings included . Resident 44 Review of the electronic health record (EHR) showed Resident 44 readmitted to the facility on [DATE] with diagnoses that included diabetes (high blood sugar levels), stiff joints, muscle weakness, and heart failure. Resident 44 was able to make needs known. Review of Resident 44's June 2025 treatment administration record (TAR) 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 assist residents obtain new glasses for 1 of 2 sampled residents (Resident 63) when reviewed for communication/sensory. This failure placed the resident at risk of being unable to participate in activities, social isolation, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 63 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), obesity, and chronic pain. Resident 63 was able to make needs known. During an interview on 06/08/2025 at 9:45 AM, Resident 63 stated their glasses were four years old and they needed new glasses. Resident 63 stated they were seen by an eye doctor, but there was no follow-up. Review of the annual minimum data set assessment, dated 06/03/2025, showed Resident 63's vision was adequate with glasses. During an interview on 06/11/2025 at 3:38 PM, Staff L, Licensed Practical Nurse, stated residents who had vision needs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide routine dental care for 1 of 4 sampled residents (Resident 40) reviewed for dental care. This failure placed the residents at risk for difficulty eating, dental pain, unintended weight loss and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 40 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone, or posture), urinary tract infection and muscle weakness. Resident 40 was able to make needs known. Observation on 06/08/2025 at 12:28 PM showed Resident 40 sat in their wheelchair in their room. Resident 40 had many broken and discolored upper front teeth. Resident 40 stated they had many dental issues. Review of Resident 40's EHR showed no dental consultation, plan or treatment. During an interview on 06/11/2025 at 2:39 PM, Resident 40 stated staff told them they were unable to see the dentist in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide assistance and follow up on an appointment for dental care services for 2 of 4 sampled residents (Residents 15 and 90) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and diminished quality of life. Findings included . Review of the quarterly minimum data set (MDS, a required assessment), dated 05/14/2025, showed Resident 15 admitted on [DATE] with multiple diagnoses to include quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso [trunk of the body]), malnutrition, muscle weakness, and depression. Resident 15 was able to make needs known and required substantial assistance with activities of daily living (ADLs). Observation and interview on 06/08/2025 at 11:31 AM showed Resident 15 laid in bed, the resident's oral cavity showed multiple lower teeth missing with their remaining teeth deeply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary activities of daily living care and services for 2 of 3 sample residents (Residents 1 and 2) reviewed for bathing. The failure to bathe residents as per their bathing care plans placed residents at risk for hygiene issues and for diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS), an assessment tool, dated 04/16/2025, they had no cognitive impairment. Resident 1 needed substantial/maximal assistance with bathing and they were dependent on staff for tub/shower transfers. On 04/23/2025 at 1:05 PM, Resident 1 said their shower/bath days were supposed to be Wednesdays and Saturdays but they usually only get a bed bath. Resident 1 said they had recently gone two weeks without a bath or shower. Resident 1 said they never got a shower or bed bath on Saturdays because the shower aide worked Monday through Friday and the other staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify, report, and investigate allegations of neglect for 2 of 5 residents (Residents 1 and 4) reviewed for abuse and neglect. This failure placed the residents at risk for ongoing neglect, unmet needs, unmanaged pain, and a decreased quality of life. Findings included . Resident 1 Review of the electronic medical record (EMR) showed that Resident 1 admitted to the facility on [DATE] after a leg amputation (surgical procedure to remove the leg), and had complications with healing, leading to rehospitalization in April 2024, with additional surgeries on the amputation site. Resident 1 had other diagnoses including fibromyalgia (a long-term condition that involves widespread body pain and tiredness), depression and anxiety. The EMR showed that Resident 1 was alert, oriented, and able to make their needs known. Review of the physician orders showed that Resident 1 had an active order for oxycodone (a prescription pain medication) to be given every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage pain, in accordance with professional standards, and failed to administer ordered pain medications in a timely manner for 2 of 2 sampled residents (Residents 1 and 4) reviewed for pain management. This failure placed the residents at risk for unmanaged and increased levels of pain, interrupted sleep, decreased ability to participate in daily activities, and a diminished quality of life. Findings included . Resident 1 Review of the electronic medical record (EMR) showed that Resident 1 admitted to the facility on [DATE] after a leg amputation (surgical procedure to remove the leg), and had complications with healing, leading to rehospitalization in April, 2024, with additional surgeries on the amputation site. Resident 1 had other diagnoses including fibromyalgia (a long-term condition that involves widespread body pain and tiredness), depression and anxiety. The EMR showed that Resident 1 was alert, oriented, and able to make…

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

Based on interview and record review, the facility failed to have a written transfer agreement with at least one area hospital approved for participation in Medicare/Medicaid programs. This failure placed residents at risk for delayed transfers and timely admissions to the hospital when medically appropriate. Findings included . Review of facility documentation on 09/09/2024 related to written transfer agreements showed no documentation of a transfer agreement with a local hospital and/or documented attempts to establish a transfer agreement. During an interview on 09/09/2024 at 2:36 PM, Staff A, Administrator, stated they were unable to provide any documentation related to hospital transfer agreements. Reference WAC 388-97-1620 (6)(a) .

Based on interview and record review, the facility failed to employ a qualified social worker when reviewed for qualifications of social worker. This failure placed residents at risk of not having access to medically related social services, inability to coordinate care, and a diminished quality of life. Findings included . Review of the facility's daily census report provided on 08/22/2024 at 10:13 AM showed that the facility had 145 available beds. During an interview on 09/09/2024 at 9:30 AM, Staff C, Director of Social Services, stated they did not hold a bachelor's degree. Staff C stated they were aware of the requirement for a facility with greater than 120 beds to employ a qualified social worker, the facility had over 120 beds, and the facility did not employ a qualified social worker. During an interview on 09/09/2024 at 9:43 AM, Staff A, Administrator, stated they were aware of the requirement for a facility with greater than 120 beds to employ a qualified social worker, the facility had 147 beds, and the facility did not employ a qualified social worker. Staff A stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to maintain a safe homelike environment for 2 of 4 halls (East B and [NAME] B) reviewed for environment. This failure placed residents at risk for lack of privacy, unsanitary conditions and diminished quality of life. Findings included . <Resident Blinds> Multiple observations between 08/23/2024 and 08/27/2024 between 8:00 AM and 4:00 PM showed the following resident rooms with broken or missing blind slats on the [NAME] B Hall. Rooms 61, 63, 65, 67, 69, 46, 55 and 50. Multiple observations between 08/23/2024 and 08/27/2024 between 8:00 AM and 4:00 PM showed the following resident rooms with broken or missing blind slats on the East B Hall. Rooms 19, 28, 31, 33, 34 and 37. During an interview on 08/23/2024 at 9:44 AM, Resident 29 stated they had complained about the missing blinds slats weeks ago since the window faced a parking lot. Resident 29 stated a family member put a large piece of dark reflective material on the window where the blinds 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 62 Review of the EHR showed Resident 62 was admitted on [DATE] with diagnoses that included anxiety and depression. Review of the quarterly MDS assessment, dated 08/08/2024, showed Resident 62 was cognitively intact and able to make needs known. <Investigation One> During an interview on 08/22/2024 at 10:07 AM, Resident 62 alleged that they had been verbally assaulted by a staff member, had requested the staff leave their room twice, and that during the alleged incident the staff member had gotten spit in Resident 62's eye. Review of the incident investigation report showed a statement dated 08/19/2024 by the alleged perpetrator that they confronted Resident 62 in their room and 3 witnesses were present. Two of the staff witness statements did not include any statement on the alleged incident itself, only the events surrounding it. The third witness statement reported they heard the alleged perpetrator talking to Resident 62, no details were provided on where the witness was when they heard 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 Resident 67 Review of the EHR showed that Resident 67 was admitted on [DATE] with diagnoses that included protein-calorie malnutrition (not enough protein and calories being consumed, weakening the body), anorexia (fear of gaining weight leading to poor nutrition), and gastroesophageal reflux disease (the backflow of stomach acid or bile). Review of the annual MDS assessment, dated 05/16/2024, showed Resident 67 was cognitively intact and able to make needs known. Resident 67 smoked cigarettes daily. <Dental> Further review of the annual MDS showed that Resident 67 did not have any dental issues or dental care areas selected. Review on 08/24/2024 of Resident 67's care plan, initiated on 06/01/2022, showed Resident 67 was at risk for dental care problems. Review of the document titled, Oral Health Evaluation dated 09/19/2023, showed Resident 67 had 1-3 decayed or broken teeth. Review of an uploaded communication to the provider, dated 02/19/2024, stated Resident 67 was having trouble chewing related to missing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed for four of five residents (Resident 83, 60, 93 and 20) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . Review of a document titled, Preadmission Screening Resident Review (PASRR), dated 02/01/2023 showed all facility residents were to be screened for mental illness and mental retardation prior to admission. In addition, the facility's PASRR designee was responsible to access and ensure updates to the PASRR was done. Resident 83 Review of Resident 83's electronic health record (EHR) showed the resident re-admitted on [DATE] with diagnoses to included heart and lung disease, anxiety, depression and bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The resident was able to make needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident care plans were reviewed, revised to ensure needed interventions were in place, and accurately reflected residents' care needs and/or failed to provide care conferences in a timely manner for 5 out of 25 sampled residents (Resident 10, 78, 68, 25 and 62) reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . Resident 10 Resident 10 readmitted to the facility on [DATE] with a diagnosis of paraplegia (the inability to voluntarily move the lower parts of the body/hips, legs, and feet) and was able to make needs known. Review of Resident 10's minimum data set assessment (MDS) dated [DATE] showed that the resident had traumatic spinal cord dysfunction (damage to the spinal cord that blocks communication between the brain and the body), Hammer Toe(s) (a foot condition in which the toe has an abnormal bend in the middle joint) on both feet, contracture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure the necessary interventions were in place to prevent further skin condition issues for one of 3 sampled residents (Resident 35) when reviewed for skin care. Additionally, the facility failed to ensure wound care and ADLs (activities of daily living) were enacted for 2 of 3 sampled residents (458 and 68) when reviewed for hospice care. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 3 of 5 sampled residents (Resident 93, 358 and 25) reviewed for bowel protocol. Furthermore, the facility lacked timely clinical interventions for 1 of 2 sampled residents (Resident 108) when reviewed for hospitalization. These failures placed the residents at risk for unmet needs, worsening condition, discomfort, and a decreased quality of life. Findings included . <Skin Conditions> Resident 35 Review of the quarterly minimum data set assessment (MDS) dated [DATE], showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to maintain a safe dialysis program for 2 of 2 sampled residents (Residents 308 and 60) when reviewed for dialysis. Failure to accurately document, care plan, and communicate with the dialysis provider placed residents at risk of not receiving dialysis care as ordered and a diminished quality of life. Findings included . Resident 308 Resident 308 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (a condition where the kidneys are damaged and lose their ability to function normally) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Resident 308 was able to make needs known. Review of provider's orders showed Resident 308 received dialysis on Tuesday, Thursday, and Saturday with a 3:00 PM pick-up time. Review of Resident 308's care plan, dated 08/09/2024, showed the resident received dialysis on Tuesday, Thursday, and Saturday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 83 Review of Resident 83's EHR showed the resident re-admitted on [DATE] with diagnoses to include heart and lung disease, anxiety, depression and bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The MDS further showed that the resident was able to make needs known. During an observation and interview on 08/22/2024 at 10:01 AM, Resident 83 sat on the side of their bed. Resident 83 stated they took pain medication related to back issues. Review of Resident 83's focus care plan dated 10/16/2023 showed the resident exhibited or was at risk for alterations in comfort related to chronic pain, lumbar (relating to the lower part of the back) fracture. Interventions included to medicate the resident as ordered for pain, monitor effectiveness and side effects. Additionally, staff were to assist the resident to a position of comfort, utilize pillows and appropriate positioning devices and to offer /encourage food and fluid of choice. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure monitoring of potential adverse side effects (ASE) related to the use of psychoactive (used for the treatment of certain mental health conditions) medications for 2 of 5 sampled residents (Resident's 460, and 25) and ensure an appropriate diagnosis was in place prior to the administration of an antipsychotic medication for 1 of 5 sampled residents (Resident 460) reviewed for unnecessary medication use. These failures placed the residents at risk for adverse side effects and medical complications and unmet needs. Findings included . Review of a document titled, Psychotropic Medication Use, July 2022, showed residents will not receive medications that were not clinically indicated to treat a specific condition. Additionally, psychotropic medication management included indications for use, adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. Furthermore,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the posted menu for 1 of 1 tray line observation (Lunch) when reviewed for kitchen. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life. Findings included . During an interview on 08/22/2024 at 1:41 PM, Resident 62 stated half the items on the menu were not received. Review of the facility menu for lunch on 08/26/2024 showed one cup of macaroni with ham would be served at lunch. Observation and interview on 08/26/2024 at 11:42 AM showed staff serving a single scoop of macaroni with ham using a scoop with a grey handle. Review of the wall posted Scoop Guide showed a grey spoon was one half cup. During an interview on 08/26/2024 at 11:55 AM, Staff R, Dietary Manager, stated the grey scoop was a half a cup and the server should be providing two scoops. Review of the resident council minutes, dated 06/17/2024, showed a section for Food and Nutrition which showed 1 of 14 residents had a concern of the menu not…

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

Based on observation, interview, and record review, the facility failed to provide palatable food served at appetizing temperatures for 6 of 22 sampled residents (Residents 68, 7, 93, 20, 10, 62) and failed to resolve resident council grievances regarding unpalatable food for 3 of 3 months (June, July, and August 2024) when reviewed for palatable food. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life. Findings included . During an interview on 08/22/2024 at 10:16 AM, Resident 68 stated the food was usually cold. During an interview on 08/22/2024 at 11:13 AM, Resident 7 stated the facility food was bland and often arrived cold. Resident 7 stated they had their daughter bring them food because they did not like the facility's food. During an interview on 08/22/2024 at 11:46 AM, Resident 93 stated the facility food was always cold and they frequently did not receive lunch until 3:00 PM. During an interview on 08/22/2024 at 1:02 PM, Resident 20 stated they did not like the smell, taste or…

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

Based on observation, interview, and record review, the facility failed to prepare and store food safely for 1 of 2 kitchen observations and failed to monitor resident food refrigerators for 2 of 2 sampled refrigerators (East and West). These failures placed residents at risk of consuming tainted food, foodborne illness, discomfort, and a diminished quality of life. Findings included . Observation on 08/26/2024 showed two cans of food (butterscotch pudding and cut sweet potato) were stored on the canned food shelf and had dents in the cans stored in dry storage. Observation and interview on 08/26/2024 at 12:34 PM showed the tray line ran out of spinach. Observation showed staff took a white bag, placed it in a microwave in a container of water, and began to microwave it. Staff R stated the bag contained new spinach. Observation on 08/26/2024 at 12:47 PM and 1:01 PM showed Staff S, Dietary Aid, performed hand hygiene and turned the water off with their bare hands. Review on 08/28/2024 showed the East Hall resident refrigerator had a temperature log showing an acceptable range of 36…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . During an interview on 08/28/2024 at 4:23 PM, when asked if they had reviewed the [NAME] report (a report with previously cited deficiencies) to identify any repeat deficiencies that needed to be addressed, Staff A, Administrator, stated, Yes, but they had only been in the facility since July 2024 so was unable to speak to last year's survey. When asked if they thought the QAPI process was effective, Staff A stated, Not currently, 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 observations, interviews and record reviews the facility failed to implement transmission-based precautions for 5 of 22 residents (Residents 6, 458, 358, 466 and 93) also the facility failed to ensure staff followed current infection control guidelines for cleaning and disinfecting of the washing machines during use. These failures placed the residents at an increased risk for infections and a decreased quality of life. Findings included . Review of the facility document titled Enhanced Standard/Barrier Precautions undated, showed enhanced standard/barrier precautions referred to the use of a gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a multi drug resistant organism (MDRO) as well as those at an increased risk of MDRO acquisition (e.g., residents with wounds or indwelling devices). <Enhanced Barrier Precautions> Resident 6 Review of resident 6's electronic health record (EHR) showed the resident admitted on [DATE] with 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 have an antianxiety (a psychotropic medication that affect s a person's mental state) medication informed consent signed and in place prior to the resident receiving the medication for 1 of 5 sampled residents (Residents 60) reviewed for unnecessary medication use. Failure to obtain informed consents as required, placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication for the resident. Findings included . Review of a document titled, Psychotropic Medication Use, dated July 2022, showed residents, families and/or the representatives were to be involved in the medication management process. Psychotropic medication management included: indications for use, doses (including duplicate therapy), duration, adequate monitoring for efficacy and adverse consequences and preventing, identifying and responding to adverse consequences. Residents and/or representatives have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident privacy was honored when providing topical medications for 2 of 4 sampled residents (Resident 62, and Resident 465) reviewed for medication administration, and failed to ensure a private location for personal phone calls and personal conversation for 1 of 2 sampled residents (Resident 25) reviewed for dignity. These failures placed residents at risk of not having personal space honored, feelings of institutionalization and a diminished quality of life Findings included . Resident 25 Review of the Electronic Health Record (EHR) showed Resident 25 was admitted to the facility on [DATE] with multiple diagnoses to include retention of urine, depression and heart failure. Resident 25 was able to make needs known. During an interview and observation on 08/22/2024 at 11:59 AM, Resident 25 stated there was no privacy in this room, roommate was yelling even when I am on the phone. Resident 25 stated that staff were laughing about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Review of the policy titled Grievance/Concern, dated 08/25/2021, showed that the facility would investigate the grievance, and that the person who filed the grievance should be notified of the status or resolution of the grievance within 72 hours. Resident 67 Review of the electronic health record (EHR) showed Resident 67 was admitted on [DATE]. Review of the MDS, dated [DATE], showed Resident 67 was cognitively intact and able to make needs known. During an interview on 08/23/2024 at 8:58 AM, Resident 67 stated they had a pair of black pants that went missing about 5 months ago and they filed a grievance that was still unresolved. Review of the facility's grievance log on 02/28/2024, showed Resident 67 had a missing clothes grievance with no resolution. During an interview on 08/27/2024 at 8:43 AM, Staff C, Social Services Director, stated they have 72 hours to resolve a grievance, that Resident 67's grievance was still unresolved by the laundry department, and that this did not meet expectations. 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 provide written notification of the reason for transfer to the hospital to resident or responsible party for 1 of 2 sampled residents, (Resident 358) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged . Findings included . Review of the electronic health record (EHR) showed Resident 358 admitted to the facility on [DATE] with a diagnosis that included multiple sclerosis (a chronic autoimmune disease that damages the protective covering of nerve cells in the brain, spinal cord, and optic nerve), heart failure and diabetes. Resident 358 was able to make needs known. Review of Resident 358s EHR showed a hospitalization on 07/27/2024, and readmission to the facility on [DATE]. There was no documentation about transfer notice. During an interview on 08/28/2024 at 8:20 AM, Staff D, Resident Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 2 sampled residents, (Resident 358) reviewed for hospitalization. This failure placed the resident at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 358 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a chronic autoimmune disease that damages the protective covering of nerve cells in the brain, spinal cord, and optic nerve), heart failure and diabetes and was able to make needs known. Review of Resident 358's EHR showed a hospitalization on 07/27/2024, and readmission to the facility on [DATE]. There was no documentation about bed hold notice. During an interview on 08/28/2024 at 8:20 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN) stated that there was no bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 22 sampled residents (Resident 460 and 68) reviewed for new admissions. Failure to ensure initial care plans were addressed for dementia and hospice care placed the residents at risk for unmet needs and a diminished quality of life. Findings included . <Dementia> Resident 460 Review of the Medicare 5-day minimum data set assessment (MDS) on 08/23/2024 showed Resident 460 admitted to the facility 08/17/2024 with multiple diagnoses to include heart disease, diabetes, Alzheimer's (a brain disorder that gradually destroys memory and thinking skills), and dementia. The electronic health record (EHR) showed the residents cognitive skills for decision making were moderately impaired. Review of the provider orders dated 08/17/2024 showed several orders for the treatment of dementia to include monitoring episodes of agitation due to dementia with behaviors every shift and to document non-drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation in a manner that meets professional standards of quality for 1 of 22 sampled residents (Resident 67) reviewed. This failure placed residents at risk for decreased quality of care, biases towards residents, and a diminished quality of life. Findings included . The American Nurse Journal published an article on 08/07/2023 titled, Proper documentation protects patients and your license by [NAME], which stated documentation should be clinical and objective. Review of the electronic health record showed that Resident 67 was admitted on [DATE] with diagnoses of reduced mobility, chronic obstructive pulmonary disease (chronic lung disease making it difficult to breath), cognitive communication deficit (a problem with one or more communication abilities), chronic pain, anxiety and was able to make needs known. Review of a progress note dated 08/15/2024 showed Staff F, Registered Nurse (RN) described Resident 67 as annoying me. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 sampled residents (Residents 458 and 358) when reviewed for pressure injuries. These failures placed the residents at risk for decreased comfort, infection, poor clinical outcomes and a decreased quality of life. Findings included . Resident 458 Review of the electronic health record (EHR) showed Resident 458 admitted to the facility on [DATE] with diagnoses to include congestive heart failure and was a high risk for pressure injuries. The resident was able to make needs known. During an interview on 08/22/2024 at 10:57 AM, Resident 458 stated they had wounds on their tailbone and their ischium (sitting bone). The one on the sitting bone was very painful. Review of physician's orders showed an order for staff to cleanse…

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

Based on observation and interview, the facility failed to ensure resident spaces were free from accident hazards by not locking facility shower rooms where shaving supplies were stored for 3 of 4 sampled shower rooms (East A Hall, East B Hall and [NAME] C Hall) when reviewed for accidents. This failure placed residents at risk for accessing shaving supplies, increased injury risk, and a diminished quality of life. Findings included . Observations on 08/27/2024 and 08/28/2024 showed the East A Hall shower room was unsecured. Observation of the interior showed a plastic storage bin with shaving supplies and nail clippers. Observations on 08/22/2024 and 08/28/2024 showed the East B Hall shower room was unsecured and the door had signage to inform staff to keep the room locked. Observation of the interior showed a cabinet with a lock, which was unsecured, which contained two electric shavers and a razor. Observation on 08/26/2024 and 08/27/2024 showed the [NAME] C Hall shower room was unsecured and the door had signage to inform staff to keep the room locked. Observation 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 have a clear system in place to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders and/or to monitor and address nutritional needs for 3 of 4 sampled residents (Residents 60, 92, and 67) reviewed for nutrition and/or dialysis (the process of removing excess water, waste, and toxins from the blood). These failures placed the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . <Fluid Restriction> Resident 60 Review of the electronic health record (EHR) showed that Resident 60 was readmitted to the facility on [DATE] with diagnoses that included heart failure, dementia (a group of thinking and social symptoms that interfere with daily functioning) and kidney failure. The resident was able to make needs known. Review of Resident 60's quarterly minimum data set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 6 sampled residents (Residents 60 and 78) reviewed for respiratory care. Failure to obtain and/or follow physician orders for oxygen (O2) therapy, care plan, ensure O2 tubing was appropriately maintained, regularly changed, and O2 concentrators (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 unmet needs and potential negative outcomes. Findings included . Resident 60 Review of the electronic health record (EHR) showed that Resident 60 was readmitted to the facility on [DATE] with diagnoses that included heart failure, anxiety disorder, and kidney failure. The resident was able to make needs known. Review of Resident 60's quarterly minimum data set assessment (MDS) dated [DATE] showed that the resident received 02 therapy. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to act on the consultant pharmacist's Medication Regimen Review (MRR) recommendations for 2 of 5 sampled residents (Resident 83 and 460) reviewed for unnecessary medication use. Failure to act on the pharmacist's recommendations placed the residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Resident 83 Review of Resident 83's electronic health record (EHR) showed the resident re-admitted on [DATE] with diagnoses to included heart and lung disease, anxiety, depression and bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The resident was able to make needs known. Review of the document titled, Consultant Report a pharmacist's medication regiment review, dated 06/01/2024 and 06/30/2024, showed that the pharmacist had noted Resident 83 had a recent fall and showed that they were prescribed multiple medications…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made out of twenty seven opportunities during medication administration for 1 of 5 sampled residents (Resident 465) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life. Findings included . During a medication administration observation on 08/26/2024 at 9:38 AM, Staff BB, Licensed Practical Nurse (LPN), prepared and administered seven medications including simethicone (medicine for flatulence) and diphenhyd-lidocaine-nystatin suspension (medication that treats fungal infection in mouth) to Resident 465. Review on 08/26/2024 at 10:00 AM of the providers orders for Resident 465, showed an order for simethicone and diphenhyd-lidocaine-nystatin suspension with specific times to be administered at 8:00AM. During an interview on 08/26/2024 at 11:50 AM, Staff B, Director of Nursing Services, stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide dental services to ensure residents could eat and drink for 1 of 4 sampled residents (Resident 308) reviewed for dental. This failure placed residents at risk of discomfort while eating, diminished nutritional intake, and a diminished quality of life. Findings included . Resident 308 admitted to the facility on [DATE] with diagnoses to include pneumonia and chronic pain. Resident 308 was able to make needs known and was a Medicare participant. During an interview and observation on 08/22/2024 at 1:42 PM, Resident 308 stated they had no natural teeth, they used dentures, the dentures were at their home, and they had difficulty eating because they did not have their dentures. Observation showed Resident 308 had no natural teeth. Review of a minimum data set assessment, dated 08/15/2024, showed Resident 308 had no natural teeth or had fragments of teeth. Review of the care plan, dated 08/09/2024, showed Resident 308 had 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 assist residents with obtaining routine dental care for 1 of 4 sampled residents (Resident 67) reviewed for dental care. This failure placed residents at increased risk of pain, nutritional concerns, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed that Resident 67 was admitted on [DATE] with diagnoses that included protein-calorie malnutrition (not enough protein and calories being consumed, weakening the body), and gastroesophageal reflux disease (the backflow of stomach acid). Review of the annual minimum data set assessment (MDS), dated [DATE], showed Resident 67 was able to make needs known. Resident 67 smoked cigarettes daily. Review of Resident 67's care plan, initiated on 06/01/2022, showed the resident was at risk for dental care problems, with instructions to obtain a dental consult and/or referral as needed/ordered. Resident 67 had previously been seen by Sound Dental Care in 2023,…

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

Based on observation, interview, and record review, the facility failed to honor resident food preferences for 4 of 22 sampled residents (Residents 62, 67, 87, and 8) when reviewed for food preferences. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life. Findings included . During an interview on 08/22/2024 at 1:41 PM, Resident 62 stated fresh fruit was not available daily, and half the items on the menu were not received. During an interview on 08/23/2024 at 8:52 AM, Resident 67 stated the alternative meals were grilled cheese and hamburger. Resident 67 stated they were tired of the alternatives, so there were no real alternatives. Resident 67 stated they requested fresh fruit but only occasionally received them. Observation on 08/27/2024 at 1:38 PM showed Resident 67's menu tray card had a preference for chocolate protein shakes, but the resident was provided with strawberry. During an interview on 08/27/2024 at 1:04 PM, Staff T, Certified Nursing Assistant, stated they had just…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 or obtain the required specialized rehabilitative services for 1 of 2 sampled residents (Resident 67) reviewed for rehabilitation. This failure placed the residents at a risk for decreased activities of daily living (ADL), decreased range of motion, preventable pain, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 67 was admitted on [DATE] with multiple diagnoses that included difficulty in walking, reduced mobility, dependence on a wheelchair, monoplegia of upper limb following a cerebral infarction affecting the right dominant side (paralysis of one limb caused by a stroke), osteoarthritis (joint pain and stiffness), and chronic obstructive pulmonary disease (chronic lung disease making it difficult to breath). The annual minimum data set assessment (MDS), dated [DATE], showed Resident 67 was able to make needs know, had constant pain, and was not receiving occupational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided met professional standards of practice for anti-hypertensive medication administration for 3 of 4 sampled residents (Residents 2, 3, and 6). These failures placed residents at risk of medical complications, and diminished quality of care. Findings included . <Resident 2> Review of the June 2024 Medication Administration Record (MAR) showed a 05/18/2024 Physician's Order (PO) for an Ace Inhibitor (a class of blood pressure medications to treat high blood pressure), to be administered one time a day, and to hold (Do not give) if their systolic blood pressure (SBP - the top number of a blood pressure reading) was less than 100 AND apical pulse (AP - the heart rate measured at the apex/pointed end of the heart) was less than 50, AND notify MD (Medical Doctor/Provider). Further review of the June 2024 MAR showed on 06/15/2024 at 9:00 AM, Resident 2's SBP was 91 and AP was 69. The medication was documented as held. Review of the 06/15/2024 9:42 AM progress note showed Staff D, Licensed Practical Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for 4 of 5 sampled residents (Residents 1, 2, 3 and 4) reviewed for skin and non pressure wound management. This failure placed residents at risk for unidentified wounds, wound decline, infection, and diminished quality of life. Findings included . <Resident 1> According to the 05/21/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 1 was discharged to acute care 05/21/2024 with no pressure ulcers. According to the 05/15/2024 5-day MDS, Resident 1 was assessed at risk, but had no pressure ulcers, no open lesions, and no Moisture Associated Skin Damage (MASD). Review of the 05/09/2024 Resident is at risk for skin breakdown Care Plan (CP) instructed nursing staff to perform preventative skin care (apply barrier cream) observe skin for signs/symptoms of skin breakdown, and conduct weekly skin assessments.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 5 sampled residents (Residents 1, 2, 3 and 5) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure of the facility to ensure physician orders with a supporting diagnosis, routine catheter care and monitoring was provided, placed the residents at risk for infections, skin breakdown, and diminished quality of care. Findings included . Review of the facility policy titles, Urinary Catheter (UC), dated 11/15/2021 showed the purpose of the policy was to ensure there was a valid medical justification for use, that the catheter was discontinued as soon as clinically warranted, and to decrease difficulties associated with urinary catheter use. <Resident 1> Review of the discharge Minimum Data Set (MDS - an assessment tool) dated 05/21/2024 showed that Resident 1 was admitted to the facility 05/09/2024 and had 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 initiate, document, investigate and/or resolve grievances for 3 of 4 sampled residents (Residents 2, 3 and 5) reviewed for grievances and missing property. This failure placed residents at risk for loss of clothing and property, having their complaints and concerns go un-addressed, feelings of unimportance, and a diminished quality of life. Findings included . RESIDENT 2 Review of the electronic health record (EHR) showed Resident 2 was admitted on [DATE] and discharged on 04/30/2024. During interview on 05/24/2024 at 10:24 AM, Collateral Contact 1 (CC1, Resident 2's family member) stated while Resident 2 was in the facility, several items of clothing had gone missing. CC1 stated they had spoken with facility staff, and had given them a list of missing clothing, and had left messages asking to speak with the Director of Nursing (DNS) in order to attempt to address the missing items, but never got a call back. CC1 stated they never had any follow-up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 routinely provide dependent residents bathing assistance for 2 of 5 sampled residents (Residents 1 and 5) reviewed for activities of daily living. This failure placed residents at risk for poor hygiene, infection, a negative impact on mental health and dignity, and a decreased quality of life. Findings included . RESIDENT 1 Review of the electronic health record (EHR) showed Resident 1 was admitted on [DATE] and discharged on 04/20/2024. Review of the care plan, dated 04/09/2024, showed Resident 1 was dependent on staff for bathing. Review of facility bathing records (electronic and paper) showed Resident 1 was offered a shower, and declined it, on 04/12/2024. No other documentation of bathing, or offering bathing, was seen. RESIDENT 5 Review of the EHR showed Resident 5 was admitted on [DATE]. Review of the care plan, dated 04/30/2024, showed Resident 5 was dependent on staff for bathing. During interview on 06/05/2024 at 10:12 AM, Resident 5 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.

Based on observation and interview, the facility failed to provide a readily available and adequate supply of bath linens (washcloths, towels) on four of four occupied wings of the facility (Wings A, B, C and D) reviewed for Safe/Clean/Comfortable/Homelike Environment. This failure placed residents at risk for longer wait times for care, inadequate hygiene, infection, diminished dignity, and a diminished quality of life. Findings included . Observations on 05/20/2024 between 11:29 AM and 1:12 PM showed no washcloths on the A Wing linen cart or in the A Wing linen closet; no washcloths on the B Wing linen cart (there was no linen closet located on B Wing); no washcloths on the C Wing linen cart or in the C Wing linen closet; and no washcloths on the D Wing linen cart (there was no linen closet located on D Wing). During interview on 05/20/2024 at 11:15 AM, Staff B, anonymous, stated for several months, washcloths, bath towels and bed linens had been consistently hard to find in the facility, and that the problem had not been improving. Staff B stated they had reported the problem to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to follow their process for nurses to document findings of weekly skin assessments, for three of three residents (Residents 2, 3 and 4) reviewed for pressure ulcer prevention. This failure placed residents at risk for undocumented skin impairments, lack of treatment, and inability for care staff to determine changes in skin condition, due to insufficient documentation. Findings included . During interview on 04/02/2024 at 2:07 PM, Staff A, Nurse Manager, stated that nurses (Licensed Practical Nurses [LPNs] or Registered Nurses [RNs]) performed weekly skin assessments on each resident, and that the findings of the assessments were to be documented in a body check assessment found in the Assessment tab of the residents' electronic medical records. Staff A, Nurse Manager, further stated that if there were no issues identfied during the skin assessment, that would be documented within the assessment, and if there were skin impairments indentified, 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 notify the medical provider and family/resident representative of newly identified injuries for one of three residents (Resident 4) reviewed for notification of changes. This failure placed the resident at risk for lack of medical provider oversight and treatment, related to the injuries, and lack of family involvement in care plan decisions. Findings included . Review of the facility electronic medical record, on 03/19/2024, showed that Resident 4 admitted to the facility on [DATE]. Resident 4 had a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and had family listed as emergency contacts, and had a durable power of attorney (DPOA, someone designated to make decisions if one becomes sick or injured and is unable to make decisions for themselves). Review of a document titled, Body Check .x - V 2, dated 02/22/2024, showed that Resident 4 was identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate injuries of unknown origin, to identify root cause and rule out potential abuse and/or neglect, for one of three residents (Resident 4) reviewed for investigations. This failure placed the resident at risk for continued injuries and unidentified abuse and neglect. Findings included . Review of the facility electronic medical record, on 03/19/2024, showed that Resident 4 admitted to the facility on [DATE] and had a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). In addition, the medical record showed that Resident 4 had family listed as emergency contacts, and had a durable power of attorney (DPOA, someone designated to make decisions if one becomes sick or injured and is unable to make decisions for themselves). Review of the Minimum Data Set (MDS, a required assessment tool), dated 02/12/2024, showed that Resident 4 was severely cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide bathing, according to the care plans, or resident preferences, for three of five residents who required assistance with bathing (Residents 2, 4 and 10), reviewed for activities of daily living. This failure placed the residents at risk for poor hygiene, skin impairments/rashes, infection, poor self-esteem, and a diminished quality of life. Findings included . RESIDENT 2 Review of the Minimum Data Set (MDS, a required assessment tool), dated 12/05/2023, showed that Resident 2 admitted to the facility on [DATE] with diagnoses including debility (weakness), and required total assistance for showering/bathing. The MDS further showed that Resident 2 was alert, oriented, and able to make needs known, and that it was very important for them to be able to choose the type of bathing they received. During observation and interview on 01/29/2024 at 1:03 PM, Resident 2's hair appeared oily, near the scalp, and did not appear to have 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.

Based on observation and interview, the facility failed maintain a safe homelike environment for 2 of 2 residents' bathrooms (Residents 85 and 68) reviewed for environment. The facility's failure to repair loose and broken toilets placed residents at risk for injury and decreased independence. Findings included . During an interview and observation on 10/22/2023 at 5:49 PM, Resident 68 stated that the toilet was not attached to the floor and spun around when sat on. Observation showed the toilet spun around when touched. During an interview and observation on 10/24/2023 at 1:46 PM, Resident 85 stated that they were the only one who used the toilet, but it had been broken for a long time and it spun around when sat on. During an interview on 10/24/2023 at 11:12 AM, Resident 68 stated that the toilet was still loose and spun and that a maintenance person had been in twice before to look at it weeks ago but nothing had been fixed. Resident 68 stated that the toilet leaked when flushed and they were worried about who would use it when they left. During an interview on 10/25/2023 at…

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

Based on interview and record review, the facility failed to thoroughly investigate incidents to rule out neglect for 1 of 2 residents (Resident 34) reviewed for Abuse/Neglect. This failure placed the resident at risk of lacking planned fall interventions, repeated falls, avoidable injury, and a diminished quality of life. Findings included . Review of Resident 34's progress notes on 10/24/2023 showed that the resident had fallen on 10/12/2023, 10/17/2023, 10/19/2023, and 10/23/2023. Review of an investigative report for Resident 34's 10/12/2023 fall showed that the root cause was impulsive behavior and implemented new fall prevention interventions of environmental cues to remind to call for help and continued physical therapy. Further review showed abuse/neglect was ruled out but did not include information whether Resident 34 was wearing non-skid socks. Review of an investigative report for Resident 34's 10/17/2023 fall showed that the root cause was not identified and implemented new fall prevention interventions of measuring blood pressure when laying, sitting, and standing for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 95 Observation and interview on 10/22/2023 at 11:25 AM showed Resident 95 in bed in a hospital gown, their hair appeared dirty and tangled, and the resident was brushing at their hair saying please excuse my appearance. During an interview on 10/27/2023 at 12:25 PM, Resident 95 stated that they thought they had received one shower in the last month but couldn't remember and would love to have a shower. Review of Resident 95's MDS assessment dated [DATE] showed that choosing between bathing/ shower/bed bath was very important. Review of Resident 95's care plan showed they preferred a tub bath in the evenings. Review of Resident 95's Electronic Health Record (EHR) on 10/27/2023 showed no documented showers/baths during the month of October. The last documented shower showed a date of 09/29/2023. During an interview on 10/26/2023, Staff B, DNS stated that Resident 95 should have received a minimum one shower/bath a week but had not and this did not meet their expectations. Reference WAC 388-97 1060 (2)(c)…

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

Based on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure placed residents at risk of unmet needs, decreased range of motion and mobility and a diminished quality of life. Findings included . Resident Statements During an interview on 10/22/2023 at 5:18 PM Resident 56 stated that, The facility is short of help, and I am sympathetic. During an interview on 10/22/2023 at 6:28 PM Resident 12 stated that, I have been here for 9 years. There used to be four Certified Nursing Aides (CNAs) on this hall, now we have one and it takes 5-10 minutes for my call light to be answered. The Staff are really good, but they are stretched too thin. During an interview on 10/22/2023 at 6:00 PM, Resident 108 stated that in the evening, I would have to wait up to an hour, often. The workers are great, but they don't have enough. They are getting people to bed and picking up trays and passing meds,…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate was less than 5 percent (%). During observation of 26 opportunities for error, 3 of 3 Licensed Nurses (Staff G, P and EE) made three errors; an error rate of 11.54%. This failure placed residents at risk for not receiving medication timely and according to the physician orders. Findings included . ERROR 1 In medication administration observation on 10/24/2023 at 11:30 AM, Staff P, Licensed Practical Nurse (LPN) administered gabapentin (a medication for nerve pain) to Resident 73, outside of the ordered timeframe of 7:00 AM to 10:00 AM. In interview on 10/24/2023 at 12:30 PM, Staff P, LPN, stated that acceptable times to administer medications, outside of the ordered time, was one hour before to one hour after the ordered administration time. Staff P, LPN, stated that Resident 73 received their gabapentin outside of this timeframe. ERROR 2 In medication administration observation on 10/26/2023 at 9:07 AM, Staff EE, LPN, administered two Senokot (a medication used to treat…

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

Based on observation and interview, the facility failed to ensure professional standards were met during medication administration for 2 of 3 residents (Residents 62 and 73) reviewed during Medication Administration. Two staff (Staff G and P) left medications sitting at the residents' bedsides and did not ensure that the medications were taken by the residents prior to leaving their rooms. This failure placed residents at risk for not receiving their medications as ordered, untreated medical conditions, and a decreased quality of life. Findings included . Resident 73 Observation on 10/24/2023 at 11:30 AM, showed Staff P, Licensed Practical Nurse (LPN), mixed Miralax (a medication used to treat constipation) powder in 4 ounces (oz) of water, placed it on Resident 73's bedside table, administered other ordered medications, and then left Resident 73's room with the cup of Miralax mixture, untouched, still sitting on Resident 73's bedside table. Staff P, LPN, then documented the medication as being administered. During an interview on 10/24/2023 at 12:30 PM, Staff P, LPN, stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer bowel medications in accordance with Physician's orders (POs) for 2 of 5 residents (Residents 34 and 75) and implement dressing changes per Physicians Orders for 1 of 6 residents (Resident 81). These failures placed residents at risk for pain/discomfort related to constipation, poor wound healing/infections related to wound care, and diminished quality of life. Findings included . Resident 75 Review of Resident 75's Electronic Health Record (EHR) showed the resident had an order for Lactulose Oral Solution (a laxative) to be given daily as needed if the resident had no bowel movement (BM) in 48 hours, and an order for Dulcolax Suppository (a laxative) daily as needed for constipation. Review of Resident 75's EHR showed the resident had no documented bowel movement between 10/2/2023 through 10/5/2023, between 10/7/2023 through 10/10/2023, and between 10/21/2023 through 10/24/2023. Review of Resident 75's Medication Administration Record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for one of two residents (Resident 65), reviewed for limited range of motion (ROM). This failure placed the residents at risk for decreased ROM, increased pain, and diminished quality of life. Findings included . Review of Resident 65's Minimum Data Set (MDS, a required assessment tool) dated 09/07/2023, showed Resident 65 re-admitted on [DATE] with multiple health conditions including difficulty walking, history of falls, muscle wasting and history of traumatic fracture. Review of a document titled, Therapy to Restorative Communication Form, Resident was referred to restorative for a walking program on 09/29/2023. During an interview on 10/23/2023 at 11:20 AM Resident 65 stated I would like to get out of bed more and maybe do some exercises Multiple observations on 10/24/2023 at 8:05 AM, 10/25/2023 at…

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

Resident 75 Review of Resident 75's EHR showed an order for oxycodone (a narcotic pain medication) every 8 hours as needed for pain with a start date of 09/22/2023. Review showed this pain medication was given 3 to 4 times a day for the past 24 days. Further review showed no documentation that non-pharmacological interventions were attempted prior to administering as needed oxycodone for the last 24 days. During an interview on 10/25/2023 at 9:03 AM, Staff P, Licensed Practical Nurse (LPN), stated that they were aware that non-pharmacological interventions for pain should be attempted before offering narcotic pain medications but Resident 75 just wants their pain meds. Staff P stated that Resident 75 had no physicians' orders to attempt non-pharmacological interventions for pain. During an interview on 10/26/2023 at 9:52 AM, Staff B, Director of Nursing Services, stated that it was their expectation that residents who had pain were offered non-pharmacological interventions prior to administering a narcotic pain medication and that they should be documented in the EHR but were not…

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

Based on observation, interview and record review, the facility failed to report an outbreak of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) to the State Agency for two of two residents (Residents 1 and 2) reviewed for infection control. This failure placed residents, staff, and visitors at increased risk of contracting illness due to the facility's lack of regulatory oversight. Findings included . Observation on 08/24/2023 at 11:30 AM showed signs posted at the facility entrance indicating that the facility was experiencing an outbreak of COVID-19. Review of the facility state reporting log dated, 06/05/2023 - 08/24/2023, showed no entry that logged a COVID-19 outbreak. Review of the facility infection control line listing, dated 08/21/2023, showed that Residents 1 and 2 tested positive for COVID-19 on 08/20/2023. In interview on 08/24/2023 at 11:48 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated that the facility had 18 residents who had tested positive for COVID-19 since 08/20/2023. Staff A and B stated that they did not call 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.