Parkside Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions [RC] are not inappropriately placed in nursing homes for long-term care) Level I form was completed after a 30-day exempt hospital discharge (EHD-an expected stay to be less than 30 days at a nursing home) for 2 of 5 residents (Residents 1 and 10) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement, and/or not receiving necessary services for mental health needs.Findings included. Review of policy titled, PASRR Requirements, dated 04/2023, showed the facility would review all PASRR's for accuracy and would immediately complete a new PASRR Level I form and notify the PASRR evaluators. Additionally, when a resident was admitted on an EHD, the facility would notify the PASRR evaluators prior 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 ensure the nature/terms of entering into a binding arbitration agreement (an alternative means of settling disputes without a jury by trial) were explained to residents in a form and manner in which they could understand for 1 of 4 residents (Resident 64) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding concerning the legal contract that had been signed/entered into and being fully informed regarding the resident's choice in the event of a dispute with the facility.Findings included.Review of the medical record showed they were admitted to the facility on [DATE] with diagnosis including a right foot/ankle bone infection, Multiple Sclerosis (MS, a chronic disease where an individual's own immune system attacks the protective covering of the brain and spinal cord nerve fibers which can lead to communication issues between the brain and the rest of the body). The 03/11/2026 admission assessment showed 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 interview and record review, the facility failed to implement, maintain, and enforce an effective compliance/ethics program that utilized monitoring/auditing systems designed to be effective in preventing/detecting criminal, civil, and administrative violations of the Social Security Act S 1819 (Title 42 United States Code 1395i-3, a set of laws that identifies the requirements for and assuring the quality of care in skilled nursing facilities) to promote residents quality of care for 2 of 2 staff (Staff A and Staff W) reviewed for compliance and ethics. This failure placed residents at an increased risk of negative outcomes related to care and services provided by the facility.Findings included .Review of the facility's policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, revised August 2025, showed residents had the right to be free from abuse/neglect, and facility staff were prohibited from using verbal/mental abuse. Verbal/mental abuse included threatening 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.

Based on observation and interview the facility failed to provide a safe, functional and sanitary (relating to the conditions that affect hygiene and health) Laundry room environment for 1 of 2 washing machines (WM1) and 1 of 1 drainage system (DS1), reviewed for environmental conditions. This failure placed residents and staff at an increased risk of cross-contamination (the harmful spread of diseases).Findings included.Observations of the Laundry room on 03/18/2026 at 5:11 PM showed: The facility had two washing machines and WM1 had a one foot (ft, a unit of measure) by one ft puddle of water underneath the back end of WM1, on the concrete floor, which was in the process of drying. The water was coming from a pipe supplying water to WM1 and was slowly dripping down the back left side of WM1's metal plate, which was wet to the touch. The water had been dripping down to the bottom of the washing machine and then to the ground. The ground beneath the washing machine had a white soap-like substance that had formed a white dried up two ft by three ft ring, which extended underneath…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a comprehensive person-centered care plan was followed related to transfer guidelines for 1 of 3 residents (Resident 1) reviewed for implementation of the care plan. This failure placed the resident at risk for injury and unmet care needs. Findings included. Resident 1 Review of the resident's medical record showed they were admitted with diagnoses that included multiple sclerosis (a chronic condition that damages the nervous system causing muscle weakness), epilepsy (a brain disorder which results in seizures) and osteoporosis (a disease that weakens bones). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required total staff assistance to perform activities of daily living (basic tasks such as eating, grooming, mobility, transfers and personal hygiene) related to their chronic weakness. Review of Resident 1's care plan dated 09/25/2025 showed they were unable to bear weight or stand and had…

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

Based on observation, interview and record review, the facility failed to ensure proper sanitization and food handling practices in accordance with standards of practice for 1 of 1 kitchen reviewed for food safety. The failure to maintain a clean/sanitary kitchen and complete Hand Hygiene (HH, washing or sanitizing hands) as required, placed residents at risk for foodborne illnesses. Findings included . Review of the policy titled, Food Safety Requirements, revised 01/2024, showed food safety practices would be followed throughout the entire food handling process. All equipment used for food handling would be cleaned, sanitized and handlined to prevent contamination. Clean dishes would be kept separate from dirty dishes. The policy also showed staff were to follow safe hygienic practices to prevent contamination of foods by washing hands and change gloves appropriately. Review of the policy titled, Handwashing Guidelines for Dietary Employees, revised 03/2023, showed employees were to perform handwashing to prevent the spread of bacteria that may cause foodborne illness. 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.

Based on interview and record review the facility failed to ensure that direct care staffing information was electronically submitted to the Centers for Medicare and Medicaid Services (CMS) for 1 of 3 quartersof 2024 reviewed for Payroll Based Journal (PBJ a mandatory report for staffing based on payroll data submission). This failure caused CMS to have inaccuraterelated to Nursing home staffing levels and the potential impact on care and services provided by direct care staff. Findings included . Record review of the Certification and Survey Provider Enhanced Report (CASPER) showed the facility had failed to report PBJ data for the 4th Quarter July 1, 2024 to September 30, 2024. During an interview on 02/07/2025 at 3:50 PM, Staff A, Administrator, stated they were unaware that the PBJ data had not been submitted as required and would look into it. Reference WAC 388-97-109(1)(2)(3)

Based on interview and record review the facility failed to ensure management staff only attended Resident Council meetings (a group at the facility comprised of and ran by residents) with a specific invitation to attend. This failure resulted in 2 of 4 residents (Resident's 11 and 35) expressed discomfort with voicing their concerns in the presence of management staff during their Resident Council meeting. This failure placed residents who attended Resident Council meetings at risk for discomfort and fear of reprisal (an act of retaliation) if bringing up issues that concerned them. Findings included . On 02/05/2025 at 9:30 AM a Resident Council meeting was held with surveyors per the long-term care survey process for nursing homes. Four facility residents participated in the meeting (Residents 20, 35, 23 and 11) and there were no staff present at the meeting. During a concurrent interview on 02/05/2025 at 9:36 AM, Resident 11 stated they felt uncomfortable speaking up in their usual Resident Council meetings because Staff A, Administrator, and Staff K, Resident Care Manager always…

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

Based on observation, interview, and record review, the facility failed to accurately assess 2 of 5 residents (Residents 1 and 26), reviewed for Minimum Data Set (MDS, a standardized assessment tool used in long-term care facilities that assesses functional, medical, psychosocial, and cognitive status) accuracy. The failure to ensure accurate assessments regarding end-of-life care to guide the development of the comprehensive care plan placed the residents at risk for unmet care needs. Findings included . <Resident 1> Review of the resident's medical record showed they admitted with diagnoses of spastic quadriplegic cerebral palsy (a severe form of cerebral palsy where all four limbs (arms and legs) are effected by excessive muscle stiffness), dementia (a group of symptoms affecting memory, thinking and social abilities), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and post-traumatic stress disorder (PTSD - a mental health condition that can develop after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 ' Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission and updated when new SMIs were identified and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 4 of 9 residents (Residents 12, 42, 14 and 48) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings Included . Review of the facility's undated policy titled Coordination with PASRR [newly titled PASARR] Program, showed all applicants to the facility would have a Level I PASAAR for SMI, ID/DD,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 interviews and record review the facility failed to ensure staff followed accepted standards of clinical practice for 6 of 7 residents (Residents 16, 26, and 34) reviewed for end of life care( EOL, six months or less to live) and 3 of 6 residents (Resident's 12, 35 and 48) reviewed for Post Traumatic Stresss Disorder (PTSD, a mental health condition where someone continues to experience intense negative feelings and memories from a tramatic life event). All six residents were identified based on information provided on the Matrix (a form provided to the facility to be completed at the beginning of a Standard Re-Certification Survey to identify resident care categories) form. Residents 16, 26, and 34's medical records did not have supporting documentation to support the resident required EOL care nor were there diagnoses given by a physician. Additionally, Resident's 12 and 35 had no supporting documentation for the new diagnosis of PTSD and Resident 48 had no physician order or supporting documentaion…

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

Based on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions for hand hygiene and glove change for 2 of 3 residents (Residents 14 and 48) reviewed during wound care treatment, and utilizing appropriate Personal Protective Equipment (PPE, clothing and equipment that is worn and used to provide protection against hazardous substances or environments) and the sanitation of blood glucose testing (a blood test that measures the level of sugar in your blood) equipment for 2 of 2 Licensed Nurses (Staff BB and Staff CC) reviewed for medication administration. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . <Medication Administration> An observation of a medication pass on 02/06/2025 at 2:46 PM, showed Staff BB, Licensed Practical Nurse (LPN), administered blood glucose testing to Resident 46. Staff BB placed their supplies on a clean barrier, applied gloves, cleansed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 17) reviewed for resident rights, was treated with respect and dignity. The facility developed the resident's care plan with inaccurate information which labeled the resident in a negative manner. The inaccurate information had the potential to create an environment that did not promote Resident 17's quality of life. Additionally, the facility did not identify appropriate interventions based on Resident 17's individualized care needs to ensure their right to a dignified existence. Findings included . <Resident 17> Review of Resident 17's medical record showed they were admitted to the facility with diagnoses which included, deafness (inability to hear), diabetes (a condition in which the body has trouble processing blood sugar), end stage renal disease (the kidneys no longer work) with dialysis (a procedure that removes excess fluid and waste from the body when the kidneys no longer work) and Post Traumatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fully inform the Resident Representative (RR) of benefits, options and treatment alternatives to receive hospice services (a program that gives special care to people who are near the end of life offering physical, emotional, social, and spiritual support for residents and their family) when a resident experienced a significant change in medical condition and placed on end-of life care (medical and supportive services provided for individuals nearing the end of their life due to a terminal illness or advanced age) for 1 of 6 residents (Resident 1) reviewed for resident rights. This failure prevented the resident and their representative from making an informed decision regarding their treatment alternatives. Findings included . Review of the policy titled, Providing End of Life Care, revised 10/23/2024, showed the facility would provide the needed care and services to end of life care residents in accordance with the resident ' s preferences, goals and professional standards of practice. In addition, the end-of-life 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, interview, and record review the facility failed to ensure the physical environment accommodated the individualized needs of 2 of 2 residents (Residents 32 and 12) reviewed for accommodation of needs. The failure to make needed adjustments to the resident's living space, placed the residents at risk for frustration, lack of desired independence, and injury. Findings included . <Resident 32> Review of the resident's medical record showed they admitted with diagnoses including Parkinson's Disease (a movement disorder of the nervous system that worsens over time). The 11/08/2024 comprehensive assessment showed Resident 32's cognition was intact and was very important for them to choose what clothes to wear and to care for their personal belongings. The assessment also showed Resident 32 used a wheelchair (w/c) and a walker and required staff supervision for personal hygiene and mobility. An observation on 02/03/2025 at 9:48 AM, showed Resident 32 was independently self-propelling their w/c into their room. Resident 32's bed was the furthest away from the entry way…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pooled resident funds had separate accounting with separate statements maintained showing deposits and withdrawals for 3 of 5 resident ' s (Resident 12, 40 and 43) reviewed for personal funds. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust. Findings included . Review of the facility policy titled Resident Personal Funds, dated 12/11/2024, showed the facility deposits the resident's personal funds of more than $50 in an interest-bearing account (or accounts) separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be separate accounting for each resident's share.) <Resident 12> Review of the residents medical record showed they admitted with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that cause persistent airflow obstruction and breathing problems). The 12/02/2024 comprehensive assessment 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 ensure a warm and comfortable, homelike environment for 6 of 12 residents (Residents 35, 42, 16, 13, 31, and 41) reviewed for heat and adaptive equipment maintenance. This failure placed residents at risk for unmet care needs, discomfort, and a non-homelike environment. Findings included . <Equipment> <Resident 35> Review of the resident 's medical records showed they admitted to the facility with diagnoses to include diabetes and chronic pain. The 11/22/2024 comprehensive assessment showed Resident 35 's cognition was intact and required staff supervision/touching assistance for personal hygiene. An observation on 02/02/2025 at 10:23 AM, showed Resident 35 sitting up in their wheelchair (w/c) at their bedside. Resident 35 ' s bed had padded mobility rails (used to prevent injury from unpredictable movements) to the sides of their bed. The outer pad material of the rails had missing areas that exposed the inner white mesh like material…

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

Based on observation, interview, and record review, the facility failed to complete care conferences for 1 of 3 residents (Resident 1) reviewed for resident/resident representative participation in care conferences. The failure to complete care conferences and allow resident participation in planning their care placed residents at risk for unmet care needs. Findings included . Review of the facility policy titled Interdisciplinary Care Conference Policy, dated 05/2023, showed the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goal of their residents) would hold a face-to-face care conference 72 hours after admission, 14 days after admission, quarterly (every three months), and with any significant changes in condition. <Resident 1> Review of the resident's medical record showed they admitted with diagnoses of spastic quadriplegic cerebral palsy (a severe form of cerebral palsy where all four limbs (arms and legs) are affected by excessive muscle stiffness) and dementia (a group of symptoms affecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative therapy services (a personalized training program to help people maintain or regain their ability to do every day tasks, like walking, dressing, and eating) were consistently implemented to prevent avoidable reduction of range of motion (ROM, how far you can move a joint in any direction) for 1 of 4 residents (Resident 35), reviewed for restorative therapy and limited ROM. This failure placed the resident at risk for loss of ROM, deconditioning, and loss of independence. Findings included . <Resident 35> Review of the resident ' s medical record showed they admitted to the facility with diagnoses to include diabetes (elevated sugar in the blood) and low back pain. The 11/22/2024 comprehensive assessment showed Resident 35 had intact cognition, could eat independently, and required supervision/touching assistance of one staff member for bed mobility, transfers, and toileting. The assessment additionally showed the resident received no specialized therapy or restorative programs. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis (the kidneys no longer function and require a mechanical process to remove waste and excess fluids from the blood stream) services met professional standards of care for 1 of 2 residents (Resident 17), reviewed for dialysis. The facility did not have an effective or coordinated process for communication between the facility and the offsite dialysis center for continuity of care. This failure placed residents receiving dialysis at risk for complications and unmet care needs. Findings included . Review of a policy titled Care Planning and Special Needs Dialysis dated April 2024 showed, The care plan will reflect coordination between the facility and the dialysis provider. Document, monitor pre/post dialysis weights and vital signs. Nursing staff will provide a report to the dialysis provider regarding the resident's condition each dialysis treatment. If no report is recieved upon return from dialysis, nursing staff will call provder to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 17) received cultural, competent, trauma informed care in accordance with professional standards, reviewed for trauma care. The facility failed to implement identified care plan interventions related to Resident 17's Post Traumatic Stress Disorder (PTSD, a mental health condition that develops after an extremely traumatic event). This failure placed Resident 17 at risk for re-experiencing past trauma. Findings included . <Resident 17> Review of the resident's record showed they were admitted to the facility with diagnoses which included, deafness, PTSD, diabetes (elevate blood sugar levels) and end stage kidney disease (the kidneys are no longer functioning) with dialysis (a process in which removes waste and excess fluid from the blood). Review of the comprehensive assessment dated [DATE] showed the Resident 17 was cognitively intact. Further review showed the resident experienced feeling down and had…

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

Based on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 12 and 42) reviewed for unnecessary medications. The facility failed to consistently develop, monitor, and document specific person-centered targeted behaviors, interventions, and adverse side effects of medication. Additionally, they failed to assess for abnormal involuntary movements with the Assessment Involuntary Movement Scale (AIMS, a scale that assesses the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia [abnormal and uncontrollable movements caused by antipsychotic medications] prior to starting a psychotropic medication and periodically thereafter). The deficient practice placed residents at an increased risk for experiencing medication-related adverse side effects, receiving medications they no longer needed, and increased behaviors due to inadequate dosing of medication. Findings included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 medications and wound supplies were discarded when expired and labeled correctly for 1 of 1 medication storage rooms and 1 of 1 treatment storage rooms. This failure placed residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications and treatments. Findings included . Review of the facility's 12/2023 policy, titled Medication Storage showed, all medication rooms were routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels and would be destroyed. <Medication storage room> An observation on [DATE] at 3:55 Accompanied by Staff S, Registered Nurse, the medication room showed: Two - glucagon (an emergency medication used to treat severe low blood sugar) injection pens 1 milligram (mg-unit of measure) each that expired on 01/2025. One- 16 - ounce (oz-unit of measure) bottle of lactulose (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 interview and record review, the facility failed to implement key components of their immunization program regarding the pneumococcal vaccine (a vaccine that protects against pneumococcal infections that can lead pneumonia and blood infections) by not ensuring residents were thoroughly screened for the pneumococcal vaccination status on admission and were administered the pneumococcal vaccines as required per current Center for Disease Control and Prevention (CDC) and Advisory Committee on Immunization practices guidance for 2 of 5 residents (Residents 2 and 21) reviewed for immunizations. This failure placed residents at risk of exposure to contagious diseases and an increased the risk for respiratory complications. Findings included . Review of the 05/01/2017 policy, titled Influenza and Pneumococcal Immunizations, showed upon admission residents would be given information regarding the immunizations risks and benefits, obtain history of previous immunizations, and obtain consent from the resident or the Resident Representative if an immunization needed to be given.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment for 2 of 2 storage rooms reviewed for environment. This failure placed residents at risk of injury and potential illness from unsanitary equipment storage. Findings included . Review of the facility policy titled, Resident Environmental Quality, revised 05/2023, showed the facility would maintain and provide a safe and sanitary environment by utilizing preventive maintenance schedules for the building and equipment to maintain a safe environment. <Storage Room> An observation on 02/02/2025 at 10:48 AM, showed the labeled storage room door ajar and unlocked. Inside the storage room was a wall to the left with an electrical panel, multiple electrical wires exposed. The floor had three-foot-tall computer network equipment system with an open computer laptop on top of the system. On the floor was two large spools of wire, a white board leaned up against the wall, and an easel. The back wall directly behind the computer network system had painted open wood shelving. The shelving had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility Administration failed to effectively, efficiently, and in accordance with acceptable standards of practice, manage its resources to ensure continued services were secured for the facility. This failure placed the residents at risk for disruptions in care and services. Findings included . Review of a job description titled, Administrator, undated and unsigned, showed the Administrator was responsible for directing the overall operation of the facility in accordance with current state and federal regulations. Additionally, the Administrator was responsible for leading budget development with department heads, and in conjunction with the Business Office Manager, leads weekly or bi-monthly budget compliance meetings to ensure financial goals were met. The Administrator was responsible for reviewing and interpreting monthly financial statements and provides that information to the governing board. The Administrator was responsible for establishing a culture of…

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

Based on interview and record review, the facility failed to review and update the Facility Assessment [(FA) - an evaluation that determines the resources required to meet each resident's care and services needs] with substantial modifications for vendor services, did not include input from a member of the governing body, medical director, and residents and/or their representatives when developing the FA, and was inaccurate regarding the provision of compliance and ethics training. These failures placed the residents at risk of unidentified and/or unmet care and services. Findings included . Record review of the FA dated 08/01/2024, showed the FA would demonstrate a good faith effort by the facility to evaluate necessary resources for resident care during daily operations and emergencies. The FA included care and services related to the types of disease conditions, physical and behavioral health needs, and any other pertinent conditions consistent with resident assessments. The FA included necessary resources, but not limited to, providing staff training and education, policies 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 interview and record review, the facility failed to have an effective Quality Assurance/Performance Improvement (QAPI) Committee that self-identified deficient practices which led to a pattern of widespread deficiency systems issues within the facility related to the Administration, Governing Body, compliance and ethics, Facility Assessment and financial instability. The failure to utilize the facility's QAPI procedures to sustain compliance with regulations for the facility, placed residents at risk for unsafe conditions, a delay in necessary care and services, and a diminished quality of life. Findings included . Review of a policy titled Quality Assurance and Performance Improvement (QAPI), revised 10/19/2023, showed The QAPI plan would have a process to identify and correct quality deficiencies, including analyzing causes of a systemic deficiency; develop and implement corrective action plans; commitment for quality assessment, improvement and accountability by the Governing Body; and a process to ensure care and services meet accepted quality standards. Refer to Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 design, implement, maintain, and enforce a compliance and ethics program aimed at preventing and identifying criminal, civil, and administrative violations of the Social Security Act § 1819 (a set of laws that identifies the requirements for and assuring the quality of care in skilled nursing facilities), and promoting quality of care. This failure placed the residents at risk of negative outcomes related to care and services provided by the facility. Findings included . Review of the undated policy titled, Process for Handling the Compliance Hotline, showed the facility had a Compliance Hotline for reporting concerns to the Chief Compliance Officer or designee (may be a third-party vendor) for compliance and ethics related to facility business practices and policies. Review of the undated policy titled, Compliance and Ethics Reporting, showed the facility implemented and publicized a reporting system for anyone to report violations that ensures the integrity of the reported concern. The policy also showed there was 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 return the balance of funds to the Office of Financial Recovery [(OFR) responsible for the recovery of financial, medical, social services, and food assistance overpayments from the Department of Social and Health Services clients] for 4 of 4 residents (Residents 1, 2, 3 and 4) reviewed for conveyance of personal funds. This failure placed the state department of risk for loss of funds and interest accumulated. Findings included . Review of a policy titled, Resident Personal Funds, revised 06/12/2024, showed upon discharge, eviction, or death of a resident that had personal funds held by the facility in a trust account, would convey those funds within 30 days to the resident, or in case of death, the individual or probate district administering the resident's estate, in accordance with state law. <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] and expired on 08/20/2024. Resident 1's trust account…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 behavioral health services for 1 of 3 residents (Resident 5) reviewed for behavioral health services. The failure to provide behavioral health services placed Resident 5 and other residents at risk for not receiving necessary services to meet their mental health needs. Findings included . Review of the policy titled, Behavioral Health Services, revised 12/01/2022, showed the facility would ensure the residents received necessary behavioral health services. <Resident 5> Record review of Resident 5's medical record showed they had diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity level, and concentration), anxiety, depression and history of substance abuse. The 10/08/2024 comprehensive assessment showed the resident had a moderate cognitive impairment and was able to make their needs known. The assessment also showed Resident 5 felt depressed, hopeless, and felt bad about themselves nearly every day during the assessment period. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to effectively implement infection control interventions intended to mitigate and contain infestations of bed bugs (small insects that feed on blood) for 4 of 6 Sampled residents (Residents 1, 2, 3, and 4) reviewed for infection control and communicable disease outbreaks. This deficient practice placed all residents at risk for the spread and development of a bed bug infestation with the potential for impaired skin integrity and physical discomfort. Findings included . Review of the facility's incident log showed two incidents of bed bugs identified on 03/31/2024. Review of the facility's investigations, dated 04/02/2024, showed the bed bug infestation was identified in room [ROOM NUMBER] affecting Resident 1 and Resident 2. The investigation summary showed Resident 1 and Resident 2 were moved into an isolation room, all clothing and linen were washed and dried twice with high heat, and other personal belongings were placed in plastic bags…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ sufficient and qualified staff that were adequately trained and supervised to prepare/provide and safely carry out the functions of meal preparation (food temperatures, portion sizes, and recipes) and kitchen sanitation practices (dishwasher maintenance and sanitizing buckets) for 5 of 6 kitchen staff (Staff R, S, Q, T, and U), reviewed for food service. These failures placed the residents at risk for improperly prepared meals, less than palatable meals, and risk for food borne illnesses. Findings included . <Food temperatures> Review of the State Operations Manual, Appendix PP, last revised 02/03/2023 (F812) §483.60(i)(1)-(2), showed final cooking temperatures as the following: • Poultry and stuffed foods - 165 degrees Fahrenheit (F, unit of measurement); • Ground meat, ground fish, and eggs - at least 155 degrees F; • Fish and other non-ground meats - 145 degrees F; • Fresh, frozen, or canned fruits and vegetables should be cooked to a hot holding temperature of 135 degrees F to prevent the growth 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 provide meals that were flavorful, palatable, attractive, and served at an appetizing temperature for 12 of 12 residents (Residents 4, 249, 11, 15, 5, 43, 16, 20, 2, 21, 22, and 32) reviewed for food. This failure placed the residents at risk for a diminished dining experience, dissatisfaction with meals, and a less than adequate nutritional intake leading to weight loss. Findings included . <Resident 4> Review of the medical record showed Resident 4 was admitted the facility on 12/11/2023. The 12/14/2023 comprehensive assessment showed that Resident 4 had an intact cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception). During an interview on 01/10/2024 at 1:44 PM, Resident 4 stated the food was horrible. They stated some days the facility runs out of food .they run out of everything all of the time. Resident 4 stated the meals were not balanced,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the kitchen followed proper sanitation and food handling practices for 1 of 1 kitchen reviewed for food safety. The failure to handle and prepare food in a sanitary manner, obtain and record food temperatures, refrigerator and freezer temperatures, and dishwasher water temperatures, test and record sanitation solution levels, and monitor and follow a cleaning schedule for the kitchen placed all residents at risk for food borne illness. Findings included . <Food Handling and Preparation> An observation on 01/07/2024 at 10:56 AM, showed Staff R, Cook, wearing a glove on their left hand and placed a slice of white bread on the unsanitized stainless-steel countertop They proceeded to spread egg salad on the bread with their non-gloved hand and placed a slice of bread on top of the egg salad with their non-gloved hand. Staff R removed their left-hand glove and obtained a box of plastic wrap from a shelf, then wrapped the sandwich in the plastic wrap. Staff R did not perform hand hygiene at any time during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 support the resident right to voice concerns nor have timely follow up regarding grievances for 8 of 8 residents (Resident 13, 21, 32, 37, 38, 39, 41 and 42) reviewed for grievances. This failure placed the residents at risk for unmet dietary needs, care needs and resolution of voiced concerns. Findings included . A review of the facility's 03/14/2023 policy titled, Resident and Family Grievances showed that it was the right for each resident and family member to voice grievances and there will be prompt efforts to resolve those complaints/grievances. A review of the facility's June 2023 policy Resident Council Meetings showed the activities staff were to be a liaison between the food and resident council and the facility. <Grievances> Review of six months of Resident council meeting minutes showed grievances related to food and missing clothing. On June 8, 2023, Residents 37 and 38 they would like a variety of salad dressings for their salads. The food complaints were passed on the Dietary Manager (DM). • On July 6, 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 consistently offer substantial nutritional snacks in the evening for 5 of 5 residents (Residents 4, 21, 22, 32, and 200) reviewed for evening snacks. This failure placed the residents at risk for hunger and unmet nutritional needs. Findings included . Review of an undated facility provided document titled, Meal Delivery Times, showed meals were served at 7:30 AM, 11:30 AM, and 4:30 PM (15 hours between the evening meal and breakfast meal). Record review of the facility provided documents titled Eve Shift Assignments, dated 12/01/2023 through 01/08/2024, showed the nursing assistants (NA) were assigned to passing the nutrition and/or snack cart on 23 of 39 evening shifts. <Resident 4> Review of the electronic medical record showed Resident 4 was admitted to the facility on [DATE]. The 12/14/2023 comprehensive assessment showed Resident 4 had an intact cognition (a term for the mental processes that take place in the brain, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 infection control practices for 1 of 1 resident (Resident 18) were implemented related to hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment) and 2 of 2 staff (Staff DD and EE) observed for infection control during meal tray delivery. These failures placed the residents at an increased risk for exposure to cross-contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's undated policy titled, Hand Hygiene, showed that all staff were to perform proper hand hygiene to prevent the spread of infections to other personal, residents and visitors. When performing hand washing, facility staff were to .apply soap or Alcohol Based Hand rub, rub hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers . Additionally, facility staff were to perform hand hygiene…

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

Based on observation and interview the facility failed maintain safe operating conditions for washing machine used for laundry of residents' personal care items and kitchen laundry for 1 of 3 washing machines (Washer 1) reviewed for laundry equipment. This failure placed the residents at risk for ineffective cleaning of laundry and cross contamination of infectious diseases. Findings included . <Laundry> During an observation and interview on 01/09/2024 at 1:30 PM, Staff O, Laundry Aide, stated that the rust located within the top loader stand-alone washer had been there for months. The washer had been used for residents' personal laundry and laundering of kitchen cloths. Washer 1 was observed with significant rust when opened the top loader. Under the lid on left side of the lid was a five inch by five inches by five-inch triangular shaped area that had significant dark rust color with rust flakes along where the bleach was poured in the reservoir. The rust discoloration was in the barrel of the washer where clothing was also placed for washing. Additionally, observations 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 ensure residents were treated with dignity and respect for 2 of 2 residents (Resident 11 and 15) reviewed for care and services. This failure placed the residents at risk for embarrassment and low self-esteem. Findings included . Review of a facility policy titled, Resident Rights, revised May 2023, showed the resident had the right to be treated with respect and dignity, and to make choices about aspects of their life that were significant to them. <Resident 11> Review of the medical record showed Resident 11 was admitted to the facility on [DATE] with diagnoses including cancer, depression, and anxiety. The 12/28/2023 comprehensive assessment showed the resident required partial to substantial assistance of one to two staff members with their activities of daily living (ADL), including showering and personal care. The assessment also showed the resident had an intact cognition. A concurrent observation and interview on 01/07/2024 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 ensure residents, or their representatives, were provided with quarterly personal fund statements for 1 of 2 residents (Resident 37) reviewed for trust accounts. This failure placed the residents at risk of not having an accurate accounting of their personal funds held in trust accounts by the facility and financial exploitation. Findings included . <Resident 37> Review of Resident 37's medical record showed they were admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), weakness, and depression. The 11/04/2023 comprehensive assessment showed the resident had a severely impaired cognition. During an interview on 01/07/2024 at 1:53 PM, Resident 37's representative (RR) stated the facility held money in a trust account for Resident 37 for small purchases such as a haircut. The RR stated they did not know how much money was 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.

Based on interview and record review, the facility failed to ensure an active surety bond (a written agreement wherein the facility and their insurance company agree to compensate the resident for any loss of resident funds that the facility holds, safeguards, manages, and accounts for) covered an amount greater than or equal to the value of resident funds deposited in the facility's resident trust account. This failure placed 31 of 48 residents, who had trust accounts with the facility, at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . Review of the facility's Trial Balance report, dated 01/10/2024, showed 31 residents had trust accounts with the facility. The total balance of the facility resident trust accounts was $8,564.64. During an interview on 01/10/2024, Staff I, Business Office Manager, stated the Administrator had requested a copy of the surety bond in October of 2023 but had not received it yet. Staff I did not know the amount of the surety bond. During an interview on 01/12/2024 at 8:05 AM, Staff A,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had a safe, homelike environment for 9 of 12 residents (Residents 29, 7, 37, 6, 11, 22, 32, 28, and 25) reviewed for homelike environment. This failure placed the residents at risk for compromised dignity and a less than homelike living environment. Findings included . Review of the facility policy titled, Resident Rights, revised May 2023, showed the residents have the right to a safe, clean, comfortable, and homelike environment. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] with diagnoses including dementia (impaired memory loss, thinking ability, judgement, and forgetfulness, that impairs daily functioning), depression, and heart failure. The 10/31/2023 comprehensive assessment showed Resident 29 required set up/supervision assistance of one staff member for activities of daily living (ADLs). The assessment also showed the resident had a moderately impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the plan of care for 1 of 1 resident (Resident 5), reviewed for activities of daily living (ADLs). The failure to follow the plan of care intervention for transfers placed the resident at risk for injury. Findings included . Record review of an in-service training provided to staff, dated 10/03/2023, showed that transfers should be done after reviewing the [NAME] (a quick reference guide for nursing staff directives to care for the resident per the plan of care). The training showed that a Hoyer lift (a mechanical lift that allows a person to be lifted with minimum of physical effort) transfer were to be conducted by two people. Further review of the training showed that Staff M, Nursing Assistant (NA) and Staff L, NA, did not sign the in-service training sheet. Record review of the plan of care, dated 12/05/2018, showed that Resident 5 was a two person assist for transfers with the use of a Hoyer lift. Review of the medical record 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 ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 1 resident (Resident 18) reviewed for mood and behavior. The facility failed to assess and monitor, a resident with a traumatic history and diagnosis of post-traumatic stress disorder (PTSD, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) for potential triggers that may cause re-traumatization. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . <Resident 18> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including PTSD. The 10/14/2023 comprehensive assessment showed the resident had a severely impaired cognition and were unable to make their needs known. Review of the trauma informed care assessment, 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 interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 1 of 5 residents (Residents 20) reviewed for unnecessary medications. The facility failed to monitor individualized targeted behaviors, ensure as needed (PRN) psychotropic medications were limited to 14-days or had a documented rationale for the extended use of the PRN psychotropic, nor consistently attempted non-pharmacological interventions (alternative treatment of a resident's symptoms that do not involve medications and directed toward understanding, preventing and relieving a resident's distress or loss of abilities) prior to psychotropic medication administration. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Finding included . Review of the facility's policy titled, Use of Psychotropic Medication, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide prompt routine dental services for 1 of 2 resident (Resident 16) reviewed for dental services. The failure to address Resident 16's concerns around dental care needs and placed Resident 16 at increased risk for dental impairment/nutritional needs. Findings included . <Resident 16> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnosis of insulin dependent diabetes (your body does not make enough insulin or cannot use it well as it should), end stage kidney disease with dialysis (a procedure that removes waste products and excess fluid from the blood when a resident's kidneys stopped working properly and multiple other medical diagnoses. The 12/07/2023 resident assessment showed the resident had no missing teeth or dental issues. The resident was alert and able to make needs known. During an interview on 01/07/2024 at 10:29 AM, the resident stated their back teeth needed to be looked 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 observation and interview, the facility failed to ensure the proper disposal of trash for 1 of 1 dumpster (Dumpster 1) reviewed for outdoor refuse storage. The failure to ensure Dumpster 1 was covered with a lid placed the facility at risk of attracting bugs, rodents, and an unsanitary environment. Findings included . Review of an undated facility policy titled, Disposal of Garbage and Refuse, showed refuse containers and dumpsters kept outside the facility would be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters would be kept covered when not being loaded. An observation on 01/07/2024 at 8:25 AM, showed dumpster 1 located outside, behind the facility. The lid to one side of the dumpster was open and trash bags were visible. An observation on 01/08/2024 at 1:23 PM, showed the same dumpster with one lid open and exposed trash bags. An observation on 01/12/2024 at 7:49 AM, showed dumpster 1 with both lids open. During an interview on 01/12/2024 at 8:24 AM, Staff Y, Dietary Manager, stated the dumpster needed to remain closed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 44> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including fusion of the lower spine bones, UTI, and kidney stones. Review of the resident's comprehensive assessment, dated 12/24/2023, showed the resident had a moderately impaired cognition, was able to make their needs known to nursing staff, and required substantial to maximal assistance of one to two staff members for toileting hygiene (actions performed daily tasks like perineal care [cleaning of the private areas of the body], and management of an indwelling urinary catheter [IUC, a tube that drains urine from the bladder] or adjustment of clothes after going to the bathroom). Additionally, the comprehensive assessment showed the resident had an IUC and had been receiving antibiotics. Review of Resident 44's Physician's orders for Antibiotics from 08/16/2023 through 01/11/2024 showed: • From 08/18/2023 through 08/25/2023 and 11/15/2023 through 11/20/2023 Ciprofloxacin (a type 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.