Park Rose Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 1 of 20 sampled residents (Resident 14) reviewed for accuracy of assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 14 admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), and chronic pain. Resident 14 was able to make needs known. Resident 14 had a decrease in upper and lower extremity mobility. Observation and interview on 06/25/2025 at 11:42 AM showed Resident 14 in a wheelchair with a bent inward left hand. Resident 14 stated they were no longer receiving restorative services and staff was no longer assisting with putting on their hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure a care plan was reviewed and revised timely for 1 of 3 sampled residents (Resident 95) reviewed for accidents related to falls. Failure to timely revise/update Resident 95's care plan after a fall placed the resident at risk of subsequent falls, injuries, unmet needs, and a diminished quality of life Findings included . Review of the facility's policy and procedure titled, Incident Documentation and Investigation, revision dated 10/2022, showed an incident report was to be completed for falls, and Interventions implemented to prevent future events and address resident care needs. Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and hemiparesis (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 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 Resident 34 Resident 34 admitted to the facility on [DATE] with diagnoses that included aphasia (a language disorder that affects communication due to brain injury or stroke) chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) depression and dementia (a decline in mental ability that interferes with daily life). Resident 34's daily decision making was severely impaired. Review of Resident 34's EHR showed a provider's order dated 03/24/2022, for citalopram (an antidepressant medication) for major depressive disorder. The EHR also showed a provider's order, dated 02/20/2025, for Seroquel (an antipsychotic mediation) for dementia with behavioral disturbance. Observations on 06/25/2025 at 9:20 AM, 12:43 PM and 2:45 PM showed Resident 34 slept in bed. Observations on 06/27/2025 at 8:45 AM and 12:07 PM showed Resident 34 slept in bed. Observations on 06/30/2025 at 8:20 AM and 9:48 AM showed Resident 34 slept in bed. Review of Resident 34's EHR showed a provider's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to apply a brace/splint (a device used to immobilize and support a body part) and an offloading boot (a specialized orthopedic device designed to reduce wight bearing pressure on a specific area of the foot or ankle) per provider orders and comprehensive care plan for 1 of 4 sampled residents (Resident 95) reviewed for position/mobility. These failures placed Resident 95 at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and hemiparesis (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. Multiple observations on 06/25/2025 at 10:39 AM, 06/25/2025 at 2:42 PM, 06/26/2025 at 12:59 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide an environment conducive to healing of a pressure ulcer for 1 of 3 sampled residents (Resident 37) when reviewed for pressure ulcer. This failure placed residents at risk of difficulty healing, worsening pressure ulcers, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 37 readmitted to the facility on [DATE] with diagnoses to include chronic kidney disease, diabetes (too much sugar in the blood), and depression. The resident was able to make needs known. During an interview and observation on 06/24/2025 at 12:52 PM, Resident 37 stated they had a pressure ulcer (PU) on their heel which had started as a bruise. Observation showed Resident 37's feet touched the footboard of the bed, there was a gap between the mattress and the footboard, and there was a rolled-up blanket in the gap. Resident 37 stated their feet always touched the footboard, but the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 12 Review of the EHR showed Resident 12 admitted to the facility on [DATE] with diagnoses that included chronic pain, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 12 was able to make needs known. Observation on 06/24/2025 at 9:49 AM and 06/25/2025 at 2:28 PM showed Resident 12 sat in their wheelchair with oxygen being administered at two liters via nasal canula connected to an oxygen concentrator (medical device that provides supplemental oxygen). Review of Resident 12's provider's orders showed no order for oxygen. During an interview on 06/25/2025 at 12:34 PM, Staff D, RCM/LPN, reviewed the EHR and stated there was no provider's order and it must have been missed when Resident 12 returned from the hospital. During an interview on 07/02/2025 at 12:40 PM, Staff B, DNS, stated Resident 12 required a provider's order for oxygen use. Reference WAC 388-97-1060 (3)(j)(vi) Based on observation, interview and record review, the…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of insulin (injectable medication that regulates blood sugar) in 1 of 3 medication carts (300 hall/front cart) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and diminished quality of life. Findings included . Observation of the medication cart in the 300 hall/front cart on 06/30/2025 at 12:52 PM, with Staff Q, Licensed Practical Nurse (LPN), showed Lispro insulin with an open date of 05/15/2025, and Lantus insulin without an open date. Staff Q stated the insulins were to stay in the cart for 28 days and after that they were expired. During an interview on 06/30/2025 at 2:10 PM, Staff B, Director of Nursing Services, stated the insulin storage did not meet expectations. Reference WAC 399-97-1300(2) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide pharmaceutical services by transcribing orders with stop dates for medications that should be on-going for 1 of 5 sampled residents (Residents 1) reviewed for pharmacy services and the facility failed to consistently reconcile controlled medications correctly for 1 of 5 sampled residents (Resident 2) reviewed for medication storage. These failures placed residents at risk for inadequate and/or ineffective treatment of underlying medical conditions, risk for misappropriation/diversion of controlled medications, and other negative health outcomes. Findings included . <Pharmaceutical Services> Review of the policy titled 4.4 New Orders for Non-Controlled Substances, last revised on 01/01/2013, states 1. Facility should provide information regarding a new admission order to Pharmacy using a completed and reconciled physicians order sheet, telephone order sheet, or an electronically transmitted medication order. Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to follow physician orders and perform scheduled central line dressing changes for 2 of 10 sampled residents (Residents 1 and 2) reviewed for Peripherally Inserted Central Catheter (PICC) line (a long thin tube inserted through a vein in your arm and passed through to the larger veins near the heart) management. The failure placed residents at risk for infection, medical complications, and a decreased quality of life. Findings included . Review of a policy titled Central Vascular Access Device (CVAD) Dressing Change, revised January 15, 2004, documents under the title Guidance, Perform sterile dressing changes using Standard- ANTT: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label .1.2 At least weekly . Resident 1 Review of the electronic health record (EHR) documented Resident 1 re-admitted 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.

Based on observation, interview and record review, the facility failed to ensure 3 of 3 staff members (Staff B, C and D) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness) infections and failed to ensure 1 of 3 staff (Staff E) performed hand hygiene during care. This failure placed residents at risk of infection and contracting and spreading COVID 19. Findings included . A 06/24/2024 CDC update titled, Recommended routine infection prevention and control practices during the COVID-19 pandemic, showed when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. When a N95 respirator was used during the care of a resident with a COVID 19 infection, they should be removed and discarded after the resident care encounter. A 02/27/2024, CDC guidance titled, Clinical Safety: Hand Hygiene 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 interview and record review, the facility failed to inform the resident's representative in advance of physician visits and changes to the plan of care for 1 of 3 residents (Resident 1) reviewed for resident rights. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about care, lack of advocacy, and a diminished quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including heart disease, stroke and dementia. The Minimum Data Set Assessment, an assessment tool, dated 10/04/2024, showed the resident was severely cognitively impaired. Resident 1's care plan, revised on 01/24/2024, showed the resident had impaired cognitive function and staff were to anticipate and meet all needs resident is non-verbal. Resident 1's Power of Attorney for Health Care, dated 01/09/2018, showed the resident designated a power of attorney for healthcare (POA) to make health care decisions for them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents consistently received restorative care (movement of joints to maintain range of motion) to maintain or prevent declines in mobility for 2 of 3 residents (Residents 1 and 5) reviewed for range of motion (ROM)/mobility. This failure placed residents at risk for decreased mobility, pain and a diminished quality of life. Findings included . Resident 1 Resident 1 was admitted on [DATE] with diagnoses including stroke and dementia. The Minimum Data Set Assessment (MDS), an assessment tool, dated 10/04/2024, showed the resident was severely cognitively impaired, required substantial assistance for activities of daily living, had limitation in ROM on her upper extremities, lower extremities and participated in a restorative program. Resident 1's restorative care plan, initiated on 02/01/2024 and revised on 08/08/2024, showed the resident was on a restorative program to decrease risks of contractures. The care plan showed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to act on the consultant pharmacist's drug regimen review recommendations for 1 of 3 residents (Resident 1) reviewed for pharmacy services. This failure placed residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including heart disease, stroke and dementia. The Minimum Data Set Assessment, an assessment tool, dated 10/04/2024, showed the resident was severely cognitively impaired. Resident 1's Pharmacist Consultation Report, dated 05/14/2024, showed the pharmacist recommended a fasting lipid panel (lab that monitors levels of fats in blood) to evaluate the effectiveness and to assist in adjusting medication therapy. The report showed the medical provider accepted the recommendation from the pharmacist and wrote consent was needed from the POA (power of attorney). Resident 1's Pharmacist Consultation Report, dated 06/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to administer a medication in accordance with provider orders for 1 of 3 residents (Resident 1) reviewed for medications. This failure placed residents at risk for medical complications, adverse side effects and a diminished quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including stroke and dementia. The Minimum Data Set Assessment, an assessment tool, dated 10/04/2024, showed the resident was severely cognitively impaired and on a pain medication regimen. On 10/08/2024 at 12:36 PM, Collateral Contact 1, said they were concerned about Resident 1's pain patches and thought the nurses were not administering them correctly. Resident 1's physician order, dated 08/14/2024, showed an order for a Fentanyl (medication to treat severe pain) patch to be applied transdermal (application of a drug through the skin) every 72 hours for pain. Resident 1's physician order, dated 01/25/2024, showed an order for 2 nurses 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 observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse or neglect for 3 of 5 sampled residents (Residents 33, 101 and 87) reviewed for abuse. This failure prevented the facility from identifying the extent and nature of the occurrence of abuse/neglect in a timely manner and placed residents at risk for unidentified abuse and/or neglect, and a decreased quality of life. Findings included . Resident 33 Review of the electronic health record (EHR) showed Resident 33 admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure with a tracheostomy (an opening into the neck for breathing) and was dependent on staff for all activities of daily living (ADLs). The resident was usually able to make needs known. During an observation and interview on 09/13/2024 at 11:24 AM, Resident 33 laid in bed and was alert and responding to yes or no questions. The resident was able to answer questions regarding care and other yes or 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 observation, interview, and record review, the facility failed to provide consistent indwelling urinary catheter (a tube inserted into the bladder to provide urinary drainage) care and management for 3 of 3 sampled residents (Residents 7, 90, and 77) reviewed for urinary catheter. This failed practice placed the residents at increased risk of complications, catheter associated urinary tract infections, including the potential development of sepsis, and a decreased quality of life. Findings included . Review of the facility's policy titled Indwelling Urinary Catheters, revised 04/2018, showed residents with indwelling urinary catheters were to have interventions in place that included placing the drainage bags below the level of the resident's bladder, avoiding kinking of the drainage tubing, keeping the drainage tubing as straight as possible from the catheter to the drainage bag, and to secure the catheter with a catheter strap or tape. Resident 7 Review of the electronic health record (EHR) 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 observation, interview, and record review, the facility failed to provide routine dental care for 1 of 3 sampled residents (Resident 55) when reviewed for dental. This failure placed residents at risk of avoidable dental pain, difficulty eating, unintended weight loss, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 55 admitted to the facility on [DATE] with diagnoses of type two diabetes, dependence on renal dialysis (process of removing waste from the blood), and depression. Observation and interview on 09/12/2024 at 12:13 PM showed Resident 55 had multiple missing teeth and was not wearing a denture. Resident 55 stated they did not have a denture. Review of the admission minimum data set assessment, dated 01/10/2023, showed Resident 55 had obvious or likely cavity or broken natural teeth. Review of the care plan, dated 02/03/2023, showed Resident 55 had no care plan for missing teeth or use of a denture. Review of a dental consultation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to implement infection control and prevention measures to include transmission based precautions for 3 of 22 sampled residents (Residents 74, 324 and 14), during wound care for 1 of 4 residents (Resident 90) and catheter care for 1 of 3 residents (Resident 7). These failures placed residents at increased risk for healthcare associated infections, related complications and a decreased quality of life. Findings included . Resident 74 Review of Resident 74's electronic health record (EHR) showed the resident re-admitted on [DATE] with a diagnosis of respiratory failure with a tracheostomy (an opening into the neck for breathing), required mechanical ventilation (a machine that helps the resident breath) and had a feeding tube for nutrition (a tube that is inserted through the abdomen into the stomach for nutrition). The resident was receiving inhaled antibiotics for an multi drug resistant organism (MDRO, infection an infection with a bacterium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the mechanical lifts (used to help residents move from one surface to another) for 3 of 3 sampled halls (100, 300, and 400 Halls) when reviewed for safety. This failure placed residents at risk for falls, avoidable injury, and a diminished quality of life. Findings included . Review of a document titled Mechanical Lift Checklist, dated 01/2024, showed Swivel bar: Check bolts and sling hooks are they free from damage, bends, or deflections. Observation on 09/17/2024 showed the mechanical lifts on 100, 300, and 400 Halls had no safety clips attached to the sling hooks. During an interview on 09/17/2024 at 12:12 AM, Staff W, Maintenance Director, stated the facility ensured that mechanical lifts were safe to use by performing an audit of the lifts quarterly. Staff W stated the mechanical lifts should have safety clips attached to the sling hooks. Staff W inspected the mechanical lifts on 100, 300 and 400 Halls and stated there were no safety clips on any of the lifts and this did not meet expectation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 256) 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 256 admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, asthma and dependence on respirator. Resident 256 was able to make needs known. Review of Resident 256's EHR showed a hospitalization on 08/14/2024, and readmission to the facility on [DATE]. There was no documentation about transfer notice. During an interview on 09/17/2024 at 10:27 AM, Staff B, Director of Nursing Services, stated the expectation was that residents were provided with written documentation regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess 3 of 22 sample residents (Residents 95, 36 and 90) whose minimum data set (MDS, a required assessment tool) were reviewed. This failure placed the residents at risk of not receiving the care and services required to meet the residents' needs and inaccuracies in their care planning. Findings included . Resident 95 Resident 95 admitted to the facility on [DATE] with diagnoses of quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), anxiety, depression and had a psychotic disorder. The MDS showed the resident was able to make their needs known. Review of quarterly MDS dated [DATE] showed Resident 95 was marked with a diagnosis of dementia (non-Alzheimer's dementia). Review of Resident 96's electronic health record (EHR) on 09/17/2024 showed no diagnosis of dementia (non-Alzheimer's dementia) within the resident documented diagnoses listing. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure bathing/showers and personal hygiene were consistently provided according to the plan of care for 2 of 3 sample residents (Residents 33 and 87), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Resident 33 Review of the electronic health record (EHR) showed Resident 33 admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure with a tracheostomy (an opening into the neck for breathing) and was dependent on staff for all activities of daily living (ADLs). The resident was usually able to make needs known. During an interview on 09/12/2024 at 4:46 PM, Collateral Contact 1 stated Resident 33 preferred showers twice a week but they had not had a shower for a couple weeks. During an interview on 09/13/2024 at 11:58 AM, Resident 33 shook their head no when asked if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to monitor and implement interventions for bowel or diabetic care for 2 of 6 sample residents (Residents 38 and 156) reviewed for unnecessary medications and failed to ensure care and monitoring for edema (a condition caused by too much fluid trapped in the body's tissues) or activities of daily living (ADLs) were provided for 2 of 22 sample residents (Resident 156 and 87) when reviewed for showers and skin care. These failures placed the residents at risk for worsening condition, discomfort and a decreased quality of life. Findings included . Resident 38 Review of the electronic health record (EHR) showed Resident 38 was admitted to the facility on [DATE] with diagnoses of kidney and lung disease, diabetes, depression and anxiety. Resident 38 was able to make needs known and required assistance with ADLs. During an interview on 09/12/2024 at 11:40 AM, Resident 38 stated they had diarrhea for the last two weeks, and that they had an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pressure ulcer care consistent with professional standards of practice to prevent and treat pressure ulcers for 1 of 2 sampled residents (Resident 90) reviewed for pressure ulcers. This failure placed residents at risk for developing pressure ulcers, worsening pressure ulcers, increased pain, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 90 was admitted [DATE], had a tracheostomy (a tube for breathing that goes through an opening in the neck) and was dependent on staff for repositioning. Resident 90 was not able to make needs known. Review of the EHR showed Resident 90 had three pressure ulcers: one on the left lower leg, one on the sacrum (the bone at the base of the spine), and one on the left ear. The left lower leg pressure ulcer was identified on arrival, with an initial documentation of the wound, but with no follow up assessments documented in the EHR.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents were provided tracheostomy (an opening surgically created through the neck for breathing) care in accordance with professional standards of practice for 1 of 5 sampled residents (Resident 7) reviewed for respiratory care. This failure placed residents at risk for unmet care needs and potential negative outcomes. Findings included . Resident 7 Review of the EHR showed that Resident 7 was admitted on [DATE] with diagnoses that included brain damage, tracheostomy, and chronic respiratory failure. The Medicare 5 day minimum data set assessment (MDS), dated [DATE], showed Resident 7 was dependent on staff for all care, required oxygen, and required a ventilator (machine used to assist in breathing). Observation on 09/13/2024 at 11:56 AM showed two certified nursing assistants (CNA) entered Resident 7's room to provide care. The blue tubing connected to the ventilator was observed to have approximately six inches of yellow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 456 Resident 456 admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease (a breathing disease), and diabetes. The admission minimum data set (MDS, an assessment tool), dated 09/08/2024, showed Resident 456 was with moderate cognitive impairment. Observation on 09/12/2024 at 12:52 PM showed Resident 456 sitting in wheelchair in the room with a bruise on their forehead. Resident 456 described how they fell when trying to get in bed and hit their head. Review of the EHR showed Resident 456 had fallen on 09/05/2024 and was evaluated in the local emergency room. Continued review showed that Resident 456 was prescribed and administered quetiapine (an antipsychotic medication that affects the mind) in the evening time, with a black box warning that showed an increase in mortality in elderly patients with dementia. Additional review showed an AIMS test (a test that assesses the severity of involuntary movements) was not performed and ordered orthostatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in twenty-five opportunities during a medication administration for 1 of 5 sampled residents (Resident 77) 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 . Observation of medication administration on 09/16/2024 at 9:12 AM showed Staff V, Registered Nurse, prepared and administered the medications baclofen and tizanidine (medications for muscle spasms) via artificial tube to Resident 77. Review of a provider's orders for Resident 77 showed orders for baclofen and tizanidine with a specific time of administration to be administered at 8:00 AM. During an interview on 09/17/2024 at 10:23 AM, Staff B, Director of Nursing Services, stated the expectation was for nurses to follow orders including the correct time of administration and this did not meet expectations. Reference WAC…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 3 of 3 medication carts (400 front, 400 back, and 300 back) and 2 of 2 medication rooms (300 and 100 halls) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, and ineffective treatment, and diminished quality of life. Findings included . Observation of 300 hall medication room on 09/17/2024 at 9:20 AM with Staff P, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), showed the contents of the refrigerator to have an open vial of Tubersol solution (used in testing for tuberculosis) with no opened date. Observation of the 100 hall medication room on 09/17/2024 at 9:35 AM with Staff P, showed content of refrigerator to have an open vial of Tubersol solution without an open date. During an interview on 09/17/2024 at 9:40 AM, Staff P stated the Tubersol solution should be dated when opened as it would expire based on the opened date. Observation of the 400 front medication cart on 09/17/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide pneumococcal vaccines for 1 of 5 residents (Residents 97) reviewed for vaccinations. This failure placed the resident at a higher risk for contracting pneumococcal infections, related complications, and a decreased quality of life. Findings included . Resident 97 Review of the electronic health record (EHR) showed Resident 97 admitted to the facility on [DATE] with diagnosis of diabetes and surgical amputation of the legs. Review of the EHR showed Resident 97 consented to receiving the Pneumococcal Vaccine on 06/03/2024. Continued review on 09/17/2024 showed no documentation of Resident 97 receiving the pneumococcal vaccine. During an interview on 09/18/2024 at 10:19 AM, Staff H, Infection preventionist/Licensed Practical Nurse stated Resident 97 should have received the pneumococcal vaccine and that they did not have a process in place for screening residents and administering vaccines to residents who requested them. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure 1 of 6 residents (Resident 1) had Cardiopulmonary Resuscitation (CPR) directives clearly documented and available to inform staff of the resident/resident representative's wishes in the event CPR was needed. The failure to ensure the physician order was updated in the electronic health record (EHR) and the Physician Orders for Life Sustaining Treatment (POLST) form were available placed the resident at risk for not receiving care in accordance with their decision-making if their heart stopped beating or breathing stopped. Findings included . Facility policy, Cardiopulmonary Resuscitation (CPR), 05/2019, documented Regency Pacific Management, LLC and its affiliated communities shall be able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation, to resident requiring such care prior to the arrival of emergency medical personnel in accordance with the related physicians' orders and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures were not implemented for 1 of 8 sampled residents (Resident 1) reviewed for abuse. Resident 1 was assessed for bilateral shoulder subluxation (dislocation) with no investigation conducted to rule out abuse/neglect. This failure placed all residents at risk of abuse, and a diminished quality of life. Findings included . Review of the facility policy Abuse/Neglect/Misappropriation/Exploitation with an original date of 10/2017 and a revised date of 10/2022 states All alleged incidents of abuse, neglect, misappropriation of resident property and injuries of unknown source are thoroughly investigated in order to determine what occurred and make necessary changes to the provision of care and services to prevent reoccurrences. Resident 1 was admitted to the facility on [DATE] with diagnsis of anoxic brain damage, not elsewhere classified. The admission Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the hospital, reason why resident cannot be readmitted to the facility, and appeal contact information to the resident or responsible party for 1 of 8 sampled residents (Resident 3) reviewed for facility-initiated discharge. This failure placed residents at risk for diminished protection from being inappropriately discharged . Findings included . Review of the facility policy, Admission/Transfer/Discharge with an original date of 04/2018 and a revised date of 10/2022 states 3. Prior to a facility-initiated discharge or transfer; the facility must provide notice of transfer or discharge and reasons to the resident, resident representative, and State Long-Term Care Ombudsman. Copies of these notifications will be retained in the resident recordand 7. The facility must notify resident in writing when the facility determines that the resident cannot be readmitted to the facility, 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 implement post-op (post-operation) recommendations/orders and to coordinate visits with outside specialty providers, per the health care provider's orders in a timely manner for 1 of 8 sampled residents (Resident 2) reviewed for quality of care. This failure placed residents at risk for delayed healing, health complications, and a diminished quality of life. Finding included . Resident 2 was admitted to the facility on [DATE] with diagnosis of malignant neoplasm of larynx, unspecified with laryngectomy (throat cancer with removal of the voice box). The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 05/05/2024, documented Resident 2 required minimal assistance of 1-person for transfers, bed mobility, and dressing. Resident 2 was assessed as moderately cognitively impaired. <Recommendations/Orders> Record review of Resident 2's electronic health record (EHR) documented Resident 2 went to a follow up post-op laryngectomy…

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

Based on interview and record review, the facility failed to provide a written decision for a grievance when requested for 1 of 3 residents (Resident 1) reviewed for grievances. This failure placed residents at risk for unmet care needs and resolution of voiced concerns. Findings included . Review of the facility's policy titled, Grievance Procedure, revised 08/2023, showed the resident/representative, has the right to obtain a written decision regarding their grievance. On 04/23/2024 at 12:22 PM, Collateral Contact 1, said they had not received a response to the grievances they had submitted to the facility. Review of Resident 1's progress notes, dated 02/06/2024, showed Resident 1's representative had requested a copy of the outcomes of all grievances filed on behalf of Resident 1 and requested the facility included the latest grievances related to staff's neglect to wear personal protective equipment, delay of informing them of quarantine protocol, inaccurate information in the resident's medical record and the outcome of missing medication patches. The progress notes 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 services provided met professional standards of practice for 1 of 3 residents (Resident 1). Facility nurses' failure to follow physician orders and only sign for tasks that were completed, placed residents at risk for medication errors, unmet care needs and potential negative outcomes. Findings included . Resident 1 was admitted to the facility on [DATE] with a diagnosis of chronic pain. On 04/23/2024 at 12:22 PM, Collateral Contact 1, said they were concerned that Resident 1's medication was not being administered per the physician's order and specifically that medication patches were not applied as documented. Resident 1's physician orders showed the resident had an order, dated 06/23/2024, for a Lidoderm Patch (medication to relieve pain) to be applied to the lower back in the morning and removed per schedule for chronic pain. Review of the schedule in the physician order showed the patch was to be applied daily at 8:00 AM 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.

Based on observation, interview and record review, the facility failed to ensure infection control standards were followed related to use of required Personal Protective Equipment (PPE) with residents on Transmission Based Precautions (TBP) for 2 of 6 residents (Resident 2 and 6), cleaning resident equipment and performing hand hygiene between residents for 5 of 6 residents (Resident 2, 3 4, 5 and 7) reviewed for infection control. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility's policy titled, Transmission-Based Precautions, revised 03/2024, showed for residents placed on Enhanced Barrier Precautions (EBP), staff were required to wear gloves and gown during resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs and device care. Review of the facility's policy titled, Hand Hygiene, revised 10/2017, showed staff were to perform hand hygiene before and after direct resident contact and upon and after coming in…

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

Based on interview and record review, the facility failed to ensure a resident-to-resident allegation of abuse was reported to the State Agency within 24 hours and failed to log the incident in the facility's reporting log for 2 of 5 sampled residents (Residents 1 & 2) reviewed for abuse and neglect. This failure placed the residents at risk of incidents not being reported and at risk for abuse and neglect. Findings included . The policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised on October 2022 stated a. Mandated reporters include, but are not limited to State employees, law enforcement officers, facility employees, social workers, health care providers and facility operators. b. Individual mandated reporters must immediately report to the Abuse Hotline when there is reasonable cause to believe an incident is abuse, neglect or exploitation. c. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately . Review of progress note,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of neglect to the State Agency within 24 hours and to log the allegations in the facility's reporting log as required for 2 of 3 residents (Residents 1 and 13) when reviewed for abuse/neglect. The failure to report, log and timely investigate allegations of neglect placed residents at risk for ongoing unaddressed neglect, skin breakdown, psychosocial harm, decreased quality of life and other negative healthcare outcomes. Findings included . Resident 1 Resident 1 admitted to the facility on [DATE]. According to the 01/12/2023 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of quadriplegia (inability to move arms and legs), required extensive two-person assistance with bed mobility, was at risk for pressure injuries (PI) formation, but did not have any PIs. During an interview on 08/03/2023 at 10:47 AM, Resident 1 appeared frustrated and stated they had been a quadriplegic 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 complete thorough, timely investigations and timely assess and monitor incidents to rule out abuse or neglect for 4 of 4 residents (Residents 89, 77, 1 and 13) reviewed for Abuse and/or Neglect, and for incidents of falls for 1 of 3 residents (Resident 77) reviewed for Falls. These failures placed residents at risk for unidentified abuse and/or neglect, continued exposure to abuse and/or neglect, unmet needs, injuries, and a decrease quality of life. Findings included . Abuse/Neglect Resident 89 Review of the five-day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 89 readmitted to the facility on [DATE] and sometimes was able to make needs known. It further showed that Resident 89 had upper extremity (shoulder, elbow, wrist, hand) impairment on one side, lower extremity (hip, knee, ankle, foot) impairment on both sides, required physical assistance of one person for bed mobility, was totally dependent on one person 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 accurately document fluids consumed to ensure fluid restrictions (a diet witch limits the amount of daily fluid intake) was implemented per physician orders and/or to monitor, address nutritional needs for 3 of 4 residents (Residents 67, 89, and 94) when reviewed for Nutrition/Hydration and/or Feeding Tubes (a tube to provide liquid food and fluid to the body for nutrition and hydration). These failures placed the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Resident 67 Observation and interview on 08/04/2023 at 9:43 AM showed Resident 67 sitting on the side of the bed and a covered pitcher with 550 milliliters (ml) of water with a straw was within reach at the bedside. Resident 67 stated that the resident was told at the dialysis (treatment to filter wastes and water from the blood) clinic that they were to be on fluid restrictions; however, staff in the facility had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 22 Review of Resident 22's EHR showed that the resident was admitted to the facility on [DATE] with a diagnosis of major depressive disorder and was taking Duloxetine Hcl (an antidepressant medication) as prescribed by a physician. Review of Resident 22's EHR from January to July 2023 showed one Medication Management Review (MMR) was completed in July 2023. During an interview on 08/07/2023 at 1:15 PM, Staff C, ADNS, stated that an MMR should be completed every month. Additionally, Staff C stated Resident 22's lack of MMR did not meet their expectation. Reference WAC 388-97-1060(3)(k)(i) Resident 2 Review on 08/02/2023 at 4:22 PM of Resident 2's EHR showed a pharmacy review dated 04/21/2023. No other pharmacy reviews were found in the EHR. Review of the facility pharmacy review list showed Resident 2 had a pharmacy review on 06/20/2023 that had recommendations. During an interview on 08/03/2023 at 11:10 AM, Staff B, DNS, stated that they were unable to locate the pharmacy review for Resident 2 dated…

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

Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 3 of 5 residents (Residents 67, 2 and 6) reviewed for Unnecessary Medication Use. Failure to provide non-pharmacological interventions (approaches, therapies, or treatments that do not involve drugs) prior to giving as needed pain medications and/or to ensure physician ordered medication parameters were in place and/or followed, placed the residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Resident 67 Review of the electronic health record (EHR) on 08/01/2023 showed that Resident 67 had a physician order dated 02/03/2023 that showed to give Acetaminophen (used to treat pain) two tablets every four hours as needed for pain and to utilize non-pharmacological interventions for pain management. Review of the July 2023 Medication Administration Records (MAR) from 07/01/2023 - 07/31/2023 showed that Resident 67 received Acetaminophen on 07/15/2023 at 4:30 PM; however, it did not show…

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

Based on observation and interview, the facility failed to maintain a resident outside food program to ensure resident foods brought from outside the facility were stored according to food safety standards for 3 of 3 resident hallways (100, 300 and 400 Halls) when reviewed for Food Storage. Failure to provide residents with a safe place to store outside food placed residents at risk of consuming contaminated food products, foodborne illness, and a diminished quality of life. Findings included . During an interview on 07/31/2023 at 9:44 AM, Staff N, Dietary Manager (DM), stated that the facility's resident outside food refrigerator had broken a month prior, the facility did not currently have a dedicated refrigerator for resident outside food, and was unsure where residents were storing food brought in from outside the facility. Observation and interview on 07/31/2023 at 11:19 AM showed Resident 84 with a fast-food hamburger in its original wrapper placed on the resident's nightstand. Resident 84 stated that their mother brought them food and they would store the food on the…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to track and trend infections for 3 of 3 months (May, June, and July 2023) reviewed for infection control, to ensure appropriate transmission based precautions were implemented for 3 of 3 residents (Residents 3, 11, and 57) reviewed for transmission based precautions, and to perform wound care following professional standards of infection control for 1 of 2 residents (Resident 1) reviewed for wounds. These failures placed residents, visitors, and staff at an increased risk for infection, related complications, and a decreased quality of life. Findings included . Tracking and Trending Review of the facility policy titled Infection Report and Tracking, last reviewed 01/24/2023, showed that the infection preventionist would enter each new infection into the monthly infection log and map and maintain a separate log and map of any Multi Drug Resistant Organisms (MDRO, infections resistant to antibiotic therapies). Review of the infection control logs for May,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 2 of 2 residents (Residents 50 and 449) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Antibiotic Stewardship revised 04/2023 showed the facility would monitor/review response to/effectiveness of current antibiotic use and lab results when available to determine if the antibiotic was still indicated or adjustments should be made (Antibiotic time-out). The infection preventionist would monitor and document antibiotic use on a line listing to track and trend usage and monitor outcomes, and complete clinical reviews of documentation for residents with newly prescribed antibiotics to determine if criteria were met.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents had documented evidence in the medical record that education was provided regarding the benefits and potential side effects of the COVID-19 vaccine for 4 of 5 residents (Residents 73, 88, 454, and 9) reviewed for COVID-19 vaccinations. There was no documented evidence the resident/representative received education and accepted or refused the vaccine. These failures denied the resident/representative of the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease. Findings included . Review on 08/01/2023 at 3:45 PM of Resident 73's Electronic Health Record (EHR) showed an admission date of 04/06/2023. There was no documentation that the resident was administered the COVID-19 vaccine, that the facility provided education of the risks and benefits, or that the resident or their representative was offered and declined the COVID-19 vaccine. Review on 08/01/2023 at 3:45 PM of Resident 88's EHR showed an admission date of 05/05/2023. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided in a dignified manner which maintained and enhanced quality of life for 1 of 2 residents (Resident 1) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, disrespect, and decreased self-worth. Findings included . Resident 1 Resident 1 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of quadriplegia (inability to move arms and legs) and required one-person extensive assistance with meals. Observation and interview on 11/03/2023 at 11:53 AM showed Resident 1 laid in bed and stated that they should have been up a long time ago. The resident stated that they were completely independent with eating when they were up in their wheelchair, but because they were still in bed, they now had to be fed lunch by staff. Resident 1 stated in frustration I don't like it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party for one of two residents (Residents 23) reviewed for hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility and placed residents at risk for diminished protection from being inappropriately discharged . Findings included . Review of Minimum Data Set (MDS, a required assessment tool) tracker showed that Resident 23 was transferred from the facility to the hospital on [DATE], 05/02/2023, 06/10/2023, 06/19/2023 and 07/03/2023. Resident 23 readmitted after each stay with the most recent readmission date of 07/06/2023. Review of Resident 23's medical record on 08/04/2023 showed no documentation that a written notice of transfer/discharge was provided to Resident 23 and/or a responsible party for any of the transfers to the hospital. During an interview on 08/04/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written bed-hold notice at the time of transfer to the hospital for 1 of 2 residents (Residents 23) reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of Minimum Data Set (MDS, a required assessment tool) tracker showed that Resident 23 was transferred from the facility to the hospital on [DATE], 05/02/2023, 06/10/2023, 06/19/2023 and 07/03/2023. Resident 23 readmitted after each stay with the most recent readmission date of 07/06/2023. Review of Resident 23's medical record on 08/04/2023 showed no documentation that a bed hold was offered, or the bed hold notice had been provided to the resident or the resident's representative. Review of bed-hold forms on 08/04/2023 provided by Staff V, Admissions Coordinator, showed several incomplete forms that contained Resident 23's name, date of transfer, who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement individualized comprehensive care plans for 2 of 23 residents (Residents 67 and 1) whose care plans were reviewed. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs related to fluid restrictions and turning and repositioning placed residents at risk of unmet care needs and potential negative outcomes. Findings included . Resident 67 Observation and interview on 08/04/2023 at 9:43 AM showed Resident 67 sitting on the side of the bed and a covered pitcher with 550 milliliters (ml) of water with a straw was within reach at the bedside. Resident 67 stated that the resident was told at the dialysis (treatment to filter wastes and water from the blood) clinic that they were to be on fluid restrictions; however, staff in the facility had not explained the details and the resident was not sure how much water they could drink. Additionally, Resident 67 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, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 23 residents (Residents 94 and 1) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 94 During an interview on 08/01/2023 at 10:05 AM, Resident 94 stated that they were on a pureed diet (blended food with similar consistency of pudding) due to difficulty swallowing; however, their swallowing had improved, and the resident hoped to be on a regular diet soon. Observation and interview on 08/03/2023 showed that Resident 94 had feeding tube (a tube to provide liquid food and fluid to the body for nutrition and hydration) hooked to a feeding pump machine and was being administered liquid food and water via the pump. Resident 94 stated that they also were able to eat orally but usually not all of it, just what the resident felt like…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide care and services to maintain or improve hearing and communication abilities for 2 of 3 residents (Residents 92 and 1) reviewed for communication. These failures placed the residents at risk for unmet needs and a decreased quality of life. Findings included . Resident 92 Review of Resident 92's Electronic Health Record (EHR) showed the resident admitted on [DATE] with a diagnosis of quadriplegia (inability to use arms and legs). Resident had a care plan intervention to use communication sheets with pictures and words for communication and to ask simple yes/no questions and was alert and oriented. Observation and interview on 08/01/2023 at 9:08 AM, showed Resident 92 laid in bed attached to a tracheal ventilator (a machine attached to a tube in the neck for breathing). There was a dry erase board on the overbed table with key words such as Pain, Change, TV and an alphabet at the bottom. Resident was able to answer yes/no questions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grooming services for 3 of 5 residents (Residents 48, 92 and 11) when reviewed for Activities of Daily Living. This failure placed residents at risk of feelings of indignity, decreased social interaction, and a diminished quality of life. Findings included . Resident 48 Observations on 07/31/2023, 08/02/2023, 08/03/2023 and 08/04/2023 showed Resident 48 with long nails with two nails with jagged edges and brown debris under some nails. Review of Resident 48's 06/07/2023 Significant Change Minimum Data Set assessment (MDS) showed the resident required extensive assistance of one person for personal grooming. During an interview on 08/04/2023 at 9:31 AM, Staff L, Nursing Aid Certified (NAC), stated that NAC or shower aids would provide nail care to residents. Staff L further stated that Resident 48's nails were long with some jagged edges, and they needed to be cut. During an interview on 08/04/2023 at 9:58 AM, Staff E, Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe from falls and/or smoking accidents for 2 of 4 residents (Residents 22 and 86) reviewed for Accident Hazards. This failure placed residents at risk for fall related injury, smoking related injury and a diminished quality of life. Findings included . Resident 22 Observation on 07/31/2023 at 11:25 AM showed Resident 22 in their room sitting in a wheelchair. Further observation showed Resident 22 purposefully left the wheelchair and placed themselves on the floor. Observation showed Staff D, Licensed Practical Nurse/Patient Care Coordinator (LPN/PCC), came to the door, spoke to Resident 22, and left. Observation showed Staff M, Nursing Aid Certified (NAC), came to Resident 22's room, spoke with the resident, then left. Observation showed neither Staff D nor M asked if Resident 22 had fallen. Observation on 07/31/2023 at 11:33 AM showed Staff D, LPN/PCC, returned to the room, observed Resident 22, and left.…

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

Based on observation, interview and record review, the facility failed to ensure residents were provided care consistent with professional standards of practice for 1 of 2 residents (Resident 6) reviewed for respiratory care and services. The facility failed to ensure oxygen (O2) was ordered with a dosage, route, or parameters for titration (adjustments). This failure placed the residents at risk for respiratory complications, unmet care needs and a diminished quality of life. Findings included . Observation on 07/31/2023 at 10:14 AM showed Resident 6 laid in bed with oxygen tubing attached to the tracheostomy tube (a tube inserted into the front of the neck to create an airway) running at six liters per minute (LPM). Resident 6 appeared sleepy, and gray in color. Observation and interview on 08/02/2023 at 9:00 AM showed Resident 6 laid in bed with oxygen tubing attached to the tracheostomy tube running at eight liters per minute. Resident 6 appeared sleepy and gray in color. Resident 6 stated that the staff checked their oxygen saturations (O2 level in blood) all the time and it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring of orthostatic blood pressure (BP, blood pressure taken while laying, sitting, and standing) and adverse side effect monitoring related to the use of psychotropic (medications that affect the brain) medications occurred for 1 of 5 residents (Resident 22) reviewed for unnecessary medication use. This failure placed residents at risk for adverse side effects and medical complications. Findings included . Orthostatic BP Nursing considerations when using antipsychotic mediation requires baseline BP monitoring before starting therapy and monitor BP regularly. Watch for orthostatic hypotension. Reference: [NAME], [NAME] & [NAME] Nursing Drug Handbook (Page 1742). Review of the Resident 22's electronic health record (EHR) showed that the resident was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder and was taking Duloxetine Hcl (an antidepressant medication) as prescribed by a physician. Review of July 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the temperatures were within the proper range for 2 of 3 medication storage refrigerators (300 and 400 hall), that maintenance occurred due to excessive frost/ice build-up for 2 of 3 medication storage refrigerators (100 and 400 hall), and that germicidal/disinfectant cleaning materials were separately stored for 1 of 3 medication storage refrigerators (100 hall) when reviewed for medication storage. In addition, the facility failed to lock 1 of 3 treatment carts (300 hall) and 2 of 3 medication refrigerators (100 and 400 hall) when reviewed for narcotic medication storage. These failures placed residents and staff at potential risk for receiving expired, compromised, or ineffective medications with unknown potency. Findings included . A document titled, LTC Facility's Pharmacy Services and Procedures Manual dated [DATE] showed that the facility should ensure that all medication and biologicals, including items, were securely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 schedule a dental appointment for 1 of 1 resident (Resident 86) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a decreased quality of life. Findings included . Review of the admission Minimum Data Set (MDS, a required assessment tool) showed Resident 86 admitted to the facility on [DATE] from an acute hospital. During an interview and observation on 08/01/2023 at 9:56 AM, Resident 86 stated that they had mentioned their dental needs to the Resident Care Manager. Resident 86 denied having pain but stated having this lisp due to broken teeth bothers me. Review of Resident 86's Care Plan dated 03/08/2023 showed a focus care area of Dental Care relating to broken and missing teeth, halitosis [bad breath]. Further review showed an intervention of The resident will be free of infection, pain or bleeding in the oral cavity by review date. Coordinate arrangements for dental care,…

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

Based on observation and interview, the facility failed to maintain kitchen equipment in a safe operating condition for 1 of 2 freestanding refrigerators (Refrigerator 1) when reviewed for Kitchen. This failure placed staff at risk of injury, residents at risk of consuming contaminated food products, foodborne illness, and a diminished quality of life. Findings included . Observation on 07/31/2023 at 9:47 AM showed Refrigerator 1 in the kitchen with the top removed. Observation showed exposed machinery, an empty plastic tub, and an electric fan on top of Refrigerator 1. Further observation showed that Refrigerator 1 contained food products that were intended to be served to residents. Observation on 08/03/2023 at 11:01 AM showed Refrigerator 1 in the kitchen with the top removed, exposed machinery, an empty plastic tub, and an electric fan. Observation showed an Out of order sign taped to the door. During an interview on 08/03/2023 at 12:40 PM, Staff N, Dietary Manager, stated that staff reported maintenance issues to the maintenance director through an electronic system and Staff N…

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