Agility Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for 2 of 5 sampled residents (Residents 27 and 50) reviewed for accidents. Failure to provide a properly fitting wheelchair for Resident 27 and failure to implement interventions after a fall for Resident 50 placed the residents at risk for accidents or injuries and a decreased quality of life. Findings included .Resident 27 Review of the electronic health record (EHR) showed Resident 27 re-admitted to the facility on [DATE] with diagnoses to include cancer, peripheral vascular disease (slow circulation problem where blood vessels restrict blood flow to parts of the body), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Resident 27 was sometimes able to make needs known. Observations on 06/03/2026 at 11:06 AM, 06/04/2026 at 2:11 PM, and 06/08/2026 at 9:17 AM showed Resident 27 in a slightly tilted back wheelchair with feet extended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nine errors were made in thirty-one opportunities during a medication administration for 1 of 6 sampled residents (Resident 96) 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 .Review of the provider's orders for June 2026 showed Resident 96 was prescribed nine oral medications with a specific time of administration to be given at 8:00 AM. Observation of medication administration on 06/08/2026 at 9:36 AM showed Staff J, Licensed Practical Nurse (LPN), prepared and administered these nine oral medications to Resident 96 (one hour and 36 minutes late). During an interview on 06/08/2026 at 10:13 AM, Staff J, LPN, stated the nurses had up to two hours to administer medications after the ordered time. During an interview on 06/08/2026 at 10:17 AM, Staff B, Director of Nursing Services, stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse prohibition policy for 2 of 2 residents (Residents 2 & 3) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 2's unexpected death and failed to conduct through investigations to identify the root cause(s) and contributing factors related to Resident 2 & 3's falls. Failure to conduct a thorough investigation placed residents at risk for further injuries, potential abuse/neglect, and other negative health outcomes.Findings included .Review of the facility Abuse, Neglect and Exploitation Policy revised 05/01/2025, showed Neglect means the failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. According to the policy the facility would investigate suspicion and/or reports of abuse, neglect, identifying and interviewing all involved persons,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 4 of 5 residents (Resident 2, 7, 8 & 9) reviewed for respiratory services. This failure placed the residents at risk for respiratory complications, unmet needs and diminished quality of life.Findings included .Review of the facility Oxygen Administration policy revised 07/03/2024 showed oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. According to the policy Oxygen would be administered under orders of a physician, staff shall change oxygen tubing and mask/cannula weekly and as needed, change humidifier bottle when empty, weekly or per facility policy, or as recommended by the manufacturer. Oxygen delivery by Nasal Cannula (NC) requires humidification at flow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically-related social services were provided for 1 of 4 residents (Resident 2) reviewed for respiratory services. The failure to involve facility social workers for residents demonstrating behaviors of rejection of care placed residents at risk for unmet health needs and other negative health outcomes.Findings included .RESIDENT 2Review of Minimum Data Sets (MDS - an assessment tool), dated 07/31/2025, 08/14/2025 and 09/03/2025 showed Resident 2 was cognitively intact and did not reject care that was necessary to achieve the resident's goals for health and well-being.Review of a 07/07/2025 8:41 PM Nurse's Note showed Resident 2 continued removing oxygen tubing on and off, kept bed in flat position, when encouraged to have head of bed up to ease breathing, became upset. Resident 2 was resistant to care, declined shower offered, encouraged to have shower, kept refusing.Review of a 07/08/2025 11:39 AM note written by Staff D, Resident Care Manager, showed Resident 2 was non compliant with diet, aware of risks 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 follow up on concerns of the resident council related to resident care for 3 of 4 resident council meetings minutes (November and December 2024, and January 2025) when reviewed. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . During an interview on 04/09/2025 at 8:37 AM, Resident 14 stated management did not follow up with concerns discussed during the resident council meetings. Review of the resident council minutes, dated 11/25/2024, showed concerns voiced by members regarding evening shift staff chatting at the nurse's station and not promptly responding to call lights. Review of the resident council minutes, dated 12/30/2024, showed concerns voiced by members regarding night shift staff on their cell phones and long call light wait times. Review of the resident council minutes, dated 01/27/2025, showed concerns voiced by members to include night shift staff on their cell phones and continued long call wait times. Review of the grievance log dates 11/2024…

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 observation, interview, and record review, the facility failed to ensure a provider's order for blood pressure parameters were consistently followed for 1 of 5 sampled residents (Resident 81) and initiated non-pharmacological interventions (NPI) prior to the administration of as needed (PRN) pain medication for 3 of 5 sampled residents (Residents 100, 79, and 18) when reviewed for unnecessary medications. These failures placed residents at risk for receiving unnecessary medications, a diminished quality of life, and unmet needs. Findings included . Review of a facility document titled, Medication Ordering and Receiving From Pharmacy Provider, Medication with Boxed Warning, dated 01/2025, showed all licensed nurses (LNs) must be familiar with medications used by residents that carry a boxed warning relevant to the resident. In addition, nursing staff shall refer to boxed warning monitoring guidelines and appropriate references for specific health risk and signs and symptoms for monitoring. Nursing…

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

Based on observation, interview, and record review, the facility failed to ensure food items were dated and meals/beverages were served at the appropriate temperatures when reviewed for kitchen services. These failures placed residents at risk for foodborne illnesses and diminished quality life. Findings included . Observation during the brief initial tour on 04/07/2025 at 9:12 AM showed multiple flavored syrups and large containers of seasonings to include Parsley, Paprika, Taco, Ground Pepper, Thyme, Ginger, [NAME] undated. Observation of tray line on 04/10/2025 between 11:17 AM and 11:39 AM showed Staff O, Cook, put all entrees and side items for the lunch meal on the steam table. Observation on 04/10/2025 at 11:42 AM, showed Staff O preparing resident plates. There were no observations of temperatures taken prior to service. Review of the lunch meal temperature log on 04/10/2025 at 12:00 PM showed temperatures for all items to include cold beverages. During an interview on 04/11/2025 at 11:16 AM, Staff E, Dietary Manager, stated Staff O admitted to not taking the temperatures of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) informed consent accurately completed prior to administering the medication for 1 of 5 sampled residents (Resident 100) when reviewed for unnecessary medication use. This failure placed the resident and/or their legal representative at risk for lack of knowledge to make an informed decision regarding the use of the medication, inaccurate data in the medical record, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 100 readmitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, a required assessment tool) dated 03/03/2025 showed Resident 100 had diagnoses of depression and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 100's provider order dated 03/28/2025 showed the resident was prescribed olanzapine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain an advanced directive (AD, a legal document that establishes a representative to make medical decisions when you are unable to) and/or perform periodic reviews of AD for 1 of 3 sampled residents (Resident 16) when reviewed for AD. This failure placed the resident at risk of not having an established decision-maker, lack of ability to direct care, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 16 initially admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes (too much sugar in the blood). Resident 16 was able to make needs known. Review showed no AD was in place for Resident 16. During an interview on 04/08/2025 at 1:20 PM, Resident 16 stated they thought they had an AD, and the facility had the paperwork. Review of Resident 16's care plan conference/welcome meeting form dated 09/27/2024 showed Resident 16 had an AD, In place. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to identify and report an allegation of abuse for 2 of 2 sampled residents (Residents 82 and 169) when reviewed for abuse. This failure placed the residents at risk of further abuse, psychological distress, and diminished quality of life. Findings included . Review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation, dated 03/04/2025, showed the facility would identify the different types of abuse, investigate immediately when suspicions of abuse occurred, make efforts to ensure all residents were protected from physical and psychological harm as well as additional abuse during the investigation, and report all allegations to the administrator, state agency, and others as needed. Resident 82 Review of the electronic health record (EHR) showed Resident 82 was admitted to the facility on [DATE] with diagnoses to include fracture of right humerus (long bone of upper arm), type two diabetes (high blood sugar),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an incident to rule out abuse for 1 of 2 sampled residents (Resident 82) when reviewed for abuse. This failure to conduct and document a thorough investigation and clearly identify the root cause and contributing factors, and follow-through with new interventions, placed the residents at risk for further abuse, psychological distress and diminished quality of life. Findings included . Review of the facility's policy and procedure titled Abuse, Neglect and Exploitation, dated 03/04/2025, showed the facility would identify and interview all involved persons, including the alleged victim, alleged perpetrator, and witnesses. It showed the investigation would focus on determining if abuse had occurred, the extent and cause, and provide complete and thorough documentation. Review of the electronic health record (EHR) showed Resident 82 was admitted to the facility on [DATE] with diagnoses to include fracture of right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 100 Review of the EHR showed Resident 100 readmitted to the facility on [DATE] with diagnoses of depression, diabetes (too much sugar in the blood), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Resident 100 was able to make needs known. Review of a care plan initiated 12/03/2024 showed Resident 100 was at risk for falls and had five falls in the month of February 2025. Interventions included a CALL DON'T FALL sign placed in line of sight to remind Resident 100 to use the call light for any transfers, toileting, or any other assistance and - Bed in lowest position when unattended. Observations on 04/07/2025 at 2:30 PM, 04/08/2025 at 1:31 PM and 04/09/2025 at 10:04 AM showed no CALL DON'T FALL sign posted in Resident 100's room. Observation and interview on 04/09/2025 at 10:04 AM showed Resident 100 laid on the bed in the highest position with their pants halfway on. Resident 100 stated the CNA was assisting with dressing but left the room to go and get…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) was properly monitored to ensure it was functioning for 1 of 2 sampled residents (Resident 26) reviewed for urinary catheters. This failure placed the resident at risk for further complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Indwelling Catheter Use, dated 04/2023, showed if an indwelling catheter was in use, the facility provided appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that included but were not limited to ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. Resident 26 Review of the quarterly minimum data set (MDS, an assessment tool) 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 ensure respiratory services were provided according to professional standards of practice for 1of 2 sampled residents (Resident 26) when reviewed for respiratory care. Failure to ensure oxygen delivery was provided according to the provider's order placed the resident at risk for discomfort, a potential negative outcome, and unmet needs. Findings included . Review of a facility's policy titled, Oxygen Use, dated 06/2023, showed oxygen was to be administered under the orders of the attending provider. Review of the quarterly minimum data set (MDS, an assessment tool) dated 01/24/2025 showed Resident 26 admitted to the facility on [DATE] with multiple diagnoses to include heart and kidney disease, neurogenic bladder (a lack of bladder control due to a brain, spinal cord or nerve problem), urinary tract infection and respiratory failure. In addition, the MDS showed Resident 26 was able to make their needs known, required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide dental services for 1 of 4 sampled residents (Resident 56) when reviewed for dental services. This failure placed the resident at risk for dental problems, nutritional compromise, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 56 admitted to the facility on [DATE] with diagnoses of chronic kidney disease (damage of the kidney's which effects functioning) and diabetes (too much sugar in the blood). Resident 56 was able to make needs known. Observation on 04/07/2025 at 9:30 AM showed Resident 56 had broken and missing bottom teeth. Resident 56 stated they had been waiting to see the dental hygienist. Review of an oral exam document dated 06/14/2024 showed a recommendation for dental hygiene cleaning. Review of the EHR showed no documentation of follow up on the recommendation. During an interview on 04/10/2025 at 10:34 AM, Staff D, Social Services Director (SSD), stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 82 Review of the EHR showed Resident 82 was admitted to the facility on [DATE] with diagnoses to include fracture of right humerus (long bone of upper arm), type two diabetes (high blood sugar), insomnia (inability to sleep), and chronic pain syndrome. Resident 82 was able to communicate needs. During an interview on 04/07/2025 at 10:33 AM, Resident 82 stated they did not have an upper denture, and their lower denture did not fit them. Resident 82 stated they had not seen the dentist and were not aware of plans to see them. Review of a dental consult dated 01/23/2025 showed Resident 82 was not in the room and the resident was not seen. A second dental consult dated 04/08/2025 showed Resident 82 was in the shower and the resident was not seen. During an interview on 04/09/2025 at 12:56 PM, Staff D, Social Service Director, stated Resident 82 missing the dentist appointment two times did not meet expectations. Reference WAC 388-97- 1060(3)(j)(vii) 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 serve food at proper temperatures and palatable taste when reviewed for kitchen services. These failures placed residents at risk for decreased nutritional intake, foodborne illness, and decreased quality of life. Findings included . During an interview on 04/07/2025 at 2:54 PM, Resident 30 stated the French fries and vegetables were served cold. During an interview on 04/07/2025 at 10:37 AM, Resident 100 stated the food Tastes bad and is served lukewarm. During an interview on 04/08/2025 at 9:03 AM, Resident 88 stated the food was horrible. Observation on 04/10/2025 at 11:42 AM showed Staff O, Cook, preparing resident plates. There were no observations of temperatures taken prior to service. Observation on 04/10/2025 at 12:59 PM showed a lunch test tray was received and reviewed. The test tray revealed a piece of country fried steak which was overcooked on the bottom. The mashed potatoes lacked palpability and flavor. Review of the Resident Council Minutes, dated 11/25/2024, showed dietary concerns related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess 2 of 22 sampled residents (Residents 2 and 68) when reviewed for comprehensive assessment. This failure placed residents at risk of unidentified care needs, lack of care planning, lack of needed services, and a diminished quality of life. Findings included . Resident 2 Review of Resident 2's annual minimum data set (MDS), an assessment tool, dated 03/17/2024, showed the resident did not have a pre-admission screening and resident review (PASRR) level two and did not have dental issues. Review of Resident 2's electronic health record showed a PASRR level two was completed on 05/19/2023. During an interview on 05/06/2024 at 10:00 AM, Resident 2 stated they had lost their denture since October of 2023. Review of a progress note, dated 10/10/2023, showed Resident 2 had reported they lost their denture. Review of a denture consultation, dated 01/24/2024, showed a referral for x-ray and extraction of a tooth, and recommendation for new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident refrigerators in sanitary conditions for 1 of 1 resident refrigerator when reviewed for kitchen. This failure placed residents at risk of consuming contaminated foods, foodborne illness, and a diminished quality of life. Findings included . Observation on 05/07/2024 at 12:38 PM of the resident refrigerator's freezer showed a severely freezer burnt hotdog in a plastic container without a date label and a box of yogurt sticks with a best by date of November 2023. Review of the refrigerator section showed a brown paper bag dated 04/26/2024 with artichoke dip and antipasto salad with sell through dates of 04/29/2024, an original cardboard pizza box with a date of 04/26/2024 with dried, curled slices of pizza, a small cake without name or date, a plastic bag with a hamburger wrapped in paper with no name or date, and a bag with cut fruit with a sell through date of 04/22/2024. During an interview on 05/07/2024 at 12:52 PM, Staff M, Dietary Supervisor, stated the resident refrigerator did not meet expectation 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 provide and accurately complete in writing the required forms of their potential liability for payment, related to Medicare services ending, for 1 of 3 sampled residents (Resident 14) reviewed for coverage notification. Failure to ensure Resident 14 was provided the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable), diminished their ability to make informed financial and care decisions related to their continued stay. Findings included . Resident 14 admitted to the facility on [DATE] with diagnoses that included pneumonia (lung infection) and weakness and was able to make needs known. Review of Resident 14's electronic health record (EHR) showed Resident 14 was their own responsible party (manages,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed upon or prior to admission for 1 of 5 sampled residents (Resident 76) reviewed for unnecessary medications. This failure placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet one's mental health care needs. Findings included . Resident 76 was admitted to the facility on [DATE] with diagnoses that included depression and adjustment disorder with anxiety (emotional or behavioral problems that occur after a stressful life event). Review of the quarterly minimum data set (MDS), an assessment tool, dated 03/13/2024, showed Resident 76 was able to make their needs known. Review of the PASRR assessment, dated 11/17/2022, completed by the hospital prior to Resident 76's admission on [DATE], showed no serious mental illness indicators documented on the form. This form showed, No Level II evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 25 sampled residents (Residents 214 and 39) reviewed for quality of care. The facility failed to ensure Resident 214's peripherally inserted midline catheter (PICC, a long flexible catheter [tube] placed into a vein in the upper arm and into a large vein) and Resident 39's provider order for a referral to urology (a provider that specialized in diagnosing and treating diseases of the urinary organs) was obtained. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life. Findings included . According to the Lippincott Manual of Nursing Practice, Tenth Edition ([NAME], [NAME] & [NAME], 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. According to [NAME], Duell & [NAME], Clinical Nursing Skills,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation, and record review, the facility failed to ensure transfer pole and bed mobility bar (safety devices used for residents to assist in transfers and/or positioning) provider orders were obtained, assessments were completed, and care plan was updated for 1 of 3 sampled residents (Resident 11) reviewed for accident hazards. This failure placed residents at risk of improper transfer pole and bed mobility bar use, decreased freedom of movement, and a decreased quality of life. Findings included . Resident 11 admitted to the facility on [DATE], with a recent readmission on [DATE], with multiple diagnoses to include hemiplegia unspecified affecting left nondominant side (paralysis of left side of body). Multiple observations on 05/06/2024, 05/07/2024, 05/08/2024, and 05/09/2024 showed a transfer pole next to Resident 11's left side of the bed and a bed mobility bar to the right side of the bed. There were no observed markings on the floor or the wall to indicate the appropriate position…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 1 sampled resident (Resident 15) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes. Findings included . Resident 15 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia (paralysis of one side of the body), and dysphagia (difficulty swallowing). Review of the admission minimum data set (MDS), an assessment tool, dated 04/21/2023, showed Resident 15 had malnutrition and received their nutrition through a feeding tube. 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.

Based on interview and record review, the facility failed to provide timely dental assistance to residents for 2 of 3 sampled residents (Residents 2 and 53) when reviewed for dental services. This failure placed residents at risk of dental pain, difficulty eating, avoidable weight loss, and a diminished quality of life. Findings included . Resident 2 During an interview on 05/06/2024 at 10:00 AM, Resident 2 stated they had been missing their denture since October of 2023. Review of a progress note, dated 10/10/2023, showed Resident 2 had reported a missing denture. Review of a denture consultation, dated 01/24/2024, showed referral for x-ray and extraction of a tooth, and recommendation for new lower partial denture. During an interview on 05/09/2024 at 12:22 PM, Staff L, License Practical Nurse Supervisor, stated Resident 2 had been referred for an extraction and new dentures on 01/24/2024, but this had not occurred. Resident 53 During an interview on 05/07/2024 at 8:25 AM, Resident 53 stated they had four teeth. Review of Resident 53's care plan, initiated 12/25/2023, showed 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 interview and record review, the facility failed to ensure 4 of 5 residents (Residents 1,2,3 and 4) reviewed for Covid-19 vaccinations had received Covid-19 Vaccines after consent was obtained. This failure placed residents at risk for adverse health effects of a communicable disease, unmet needs and a decreased quality of life. Findings included . Review of Resident 1's electronic health record (EHR) on 11/16/2023, showed the facility staff reviewed education with risks and benefits and consent was obtained for Covid-19 vaccine on 09/22/2023. There was no documentation that the covid-19 vaccine was administered, located in resident 1's EHR. Review of Resident 2's EHR on 11/16/2023, showed the facility staff reviewed education with risks and benefits and consent was obtained for Covid-19 vaccine on 10/05/2023. There was no documentation that the covid-19 vaccine was administered, located in resident 2's EHR. Review of Resident 3's EHR on 11/16/2023, showed the facility staff reviewed education with risks and benefits and consent was obtained for Covid-19 vaccine 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 reimburse the outstanding balance, for a private pay stay, for one of two residents (Resident 1) reviewed for personal funds. This failure prevented the designated recipients from having timely access to funds owed to them. Findings included . Review of the electronic medical record showed that Resident 1 was admitted to the facility 04/22/2022 through 04/22/2023. Review of the census record section of the electronic medical record, showed that Resident 1's payor status became Private Pay on 05/13/2022, and remained as such until discharge on [DATE]. During email correspondence interview, on 08/29/2023 at 8:54 PM, Collateral Contact 1 stated that there was an outstanding balance of $2776.62 for room and board that was owed to the family. This balance was for the remaining days in April 2023 (22nd - 30th) that had been pre-paid for the month, but were not used due to Resident 1's discharge on [DATE]. Collateral Contact 1 stated that upon several…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of neglect to the State Agency for one of one of four residents (Resident 3) reviewed for abuse and neglect. This failure placed the resident at risk for potential continued abuse, neglect or mistreatment due to lack of regulatory oversight and investigation into the allegations. Findings included . Review of the Quarterly Minimum Data Set (MDS, a required assessment tool) dated 08/25/2023 showed that Resident 3 admitted on [DATE] with diagnoses to include history of a stroke with weakness on one side of the body, and general weakness. Further review of the MDS showed that Resident 3 was alert and oriented, was able to make needs known, required extensive assistance of 1-2 people for turning/repositioning in bed, transfers and mobility, and was able to eat and drink independently. During interview and observation on 08/18/2023 at 2:45 PM, Resident 3 stated that they had recently been served soup for either the lunch or…

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