Bridge Crest Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately assess oral care status and communication needs for 1 of 20 residents (Resident 6) reviewed for accuracy of assessments. This failure placed residents at risk of having unmet needs, ineffective communication and a diminished quality of life. Findings included .Resident 6 was admitted to the facility on [DATE] after a hospitalization. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/23/2025, indicated Resident 6 was alert and oriented and had no oral care devices or concerns; and indicated no hearing impairment or devices.In an interview on 12/08/2025 at 3:18 PM, Resident 6 indicated he had an upper partial denture plate that needed repair. Resident 6 said he had natural lower teeth.In an interview on 12/11/2025 at 10:02 AM, Staff H, Registered Nurse/MDS Nurse, said she did not think Resident 6 had teeth. Staff H said she does a face-to-face interview with the residents during their assessment. Staff H said she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident care plans were reviewed, revised, and accurately reflected residents' care needs for 1 of 20 residents (Resident 30) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life.Findings included .Resident 30 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 11/10/2025, documented Resident 30 was alert and oriented. Review of Resident 30's physician's order, dated 09/17/2025, documented Resident 30 was using a BiPAP [Bilevel Positive Airway Pressure, Non-invasive ventilation used for breathing support]. Review of Resident 30's comprehensive care plan, initiated 09/17/2025, showed no care plan was developed to address Resident 30's BiPap. During an interview on 12/12/2025 at 12:22 PM, Staff R, Resident Care Manage/Registered Nurse, said residents can bring their own medical equipment, which was assessed 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 resident centered activities incorporating the resident's preferences for 3 of 3 sampled resident (Resident 7, 14 & 62) reviewed for activities. This failure placed residents at risk of unmet needs and a decreased quality of life.Findings included.Record review of facility's policy, titled, Activity Programs, revised June 2018, documented, .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.Record review of facility's activities calendars from September 2024 through December 2025 did not show any resident bus outings.Resident 7Resident 7 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/14/2025, documented Resident 7 was alert and oriented.In an interview on 12/08/2025 at 11:35 AM, when asked about activities she enjoyed, Resident 7 stated, there is a bus, and they don't use it. Would be nice to just get out. Resident 7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a Bed Rail/Bed Enabler and Device Consent and Evaluation for 1 of 4 sampled residents (Resident 1) reviewed for accidents. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.Findings included. Record review of the facility's policy, titled, Physical Restraints and Enablers/Devices, date revised July 2023, documented, .a. Devices may include but are not limited to the following: i. Bed rails (quarter, 1/2, 3/4 full) .5. The resident and/or resident representative is provided risks/benefits of restraint use or enabler/device use, and consent obtained prior to implementation of the device.6. The care plan is updated for the device use with the goal for the least restrictive measures. The Kardex is updated to identify restraint or enabler use and identifies other interventions put into place addressing the medical symptoms, environmental, safety, and psychosocial concerns. Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure routine pain medication was acquired timely for 1 of 6 residents (Resident 53) reviewed for pain management. This failure placed residents at risk for increased pain and diminished quality of life. Findings included .Resident 53 was admitted to the facility on [DATE] with diagnosis including chronic pain. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/12/2025, documented Resident 53 was alert and oriented and was almost constantly in pain which occasionally interfered with her day-to-day activities.Record review of Resident 53's physician order, dated 10/02/2025, showed Buprenorphine Transdermal Patch [pain medication] Weekly 20 MCG/HR [micrograms/hour] (Buprenorphine) Apply 1 patch transdermally in the evening every Thu [Thursday] for chronic pain and remove per schedule.Record review of Resident 53's electronic medication administration record (EMAR) did not show Buprenorphine transdermal patch was administered on Thursday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as directed by the physician's orders for 2 of 5 residents (Resident 4 & 32) reviewed for unnecessary medications. This failure placed residents at risk for increased side effects and a diminished quality of life.Findings included. Resident 4 Resident 4 was admitted to the facility on [DATE], with multiple diagnoses to include Type 2 Diabetes Mellitus with Hyperglycemia (condition where the body either doesn't make enough insulin or can't use insulin properly). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 09/19/2025, showed Resident 4 was alert and oriented. Record Review of Resident 4's physician order, dated 11/13/2025, showed Insulin Glargine Subcutaneous Solution 100 UNIT/ML [milliliter] (Insulin Glargine) Inject 17 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) HOLD FOR BG< [blood glucose less than] 100. Record review of Resident 4's December 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 secure medications in 1 of 4 sampled medication carts (Number Two medication cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication and a diminished quality of life. Findings included .In an observation and interview on 12/10/2025 at 2:43 PM, the Number Two medication cart was observed in the Expressions dining room unlocked. No nursing and/or facility staff were observed within view of the medication cart. The drawers of the unlocked medication cart were able to be opened, with access to multiple bottles of medicine and residents' prescription medications. A resident was observed sitting alone in the dining room six feet away from the unlocked medication cart. A visitor was observed to walk into the Expressions dining room while cart was unlocked, and no staff were present. After 1 minute, Staff D, Licensed Practical Nurse, and Staff E, Registered Nurse (RN), entered the Expressions dining room. When asked what their practice was for locking a medication cart when 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 their abuse policy and procedure by not ensuring a background check was completed prior to the hire date for 1 out of 5 staff [Staff F] reviewed for background checks. In addition, the facility did not ensure reference checks were conducted prior to the hire date for 5 of 5 staff [Staff D, E, F, G, and H] reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included. Review of the facility's policy titled, Abuse Prohibition Policy and Procedures, reviewed April 2021, showed,4. Conduct employee background checks and not knowingly or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing assistants were screened through the nurse aide registry [OBRA] prior to providing care to the residents for 2 of 2 staff [Staff E and H] reviewed for staff qualifications. This failure placed residents at risk for receiving care from unqualified staff. Findings included.Staff E, Nursing assistant certified, was hired on 08/06/2025. Staff H, Nursing assistant certified was hired on 10/06/2016.Record review of Staff E and H's personnel files did not include documentation from the nurse aide registry.On 09/04/2024 at 2:35 PM, Staff C, Human Resource Director, said he had not been able to locate OBRA checks for the 2 nursing assistants reviewed, however he has them now and going forward nursing assistants will have OBRA checks completed at least 72 hours prior to being hired and not less than every 2 years thereafter. Reference WAC 388-97-1660 [3][c]

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of discharge for 1 of 4 residents (Resident 1) reviewed for transfer and discharge requirements. This failure placed residents at risk of uninformed discharge plans, psychological distress, and decreased quality of life. Finding included. Record review of a facility policy and procedure titled, Notice of Transfer or Discharge, dated 04/2020 showed, POLICY:It is the policy of this center to provide written notice of transfer/discharge in accordance with state and federal regulations. Notice of transfer/discharge shall be made 30-days prior to transfer/discharge unless the health and/or safety of the resident or resident's residing in this center are endangered. Additionally, a procedure showed,PROCEDURE:1. The facilities interdisciplinary team validate transfers and discharges occur in a manner that maintains or improves the resident's physical, mental and psychosocial well-being.2. Transfers and discharges may occur for any 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 acquire, administer, and accurately document a medication for 1 of 4 residents (Resident 1) reviewed for pharmacy services and drug regime. Failure to ensure the medication was received and administered placed Resident 1 at risk for delayed treatment, medical complications, and decreased quality of life Findings included.Record review of the facility's policy, titled, Section 3.2 Medication Ordering and Receiving from Pharmacy Provider-Ordering and Receiving Non-Controlled Medications, revised on 01/2023, showed section 2. Receiving medications from the pharmacy:a.A licensed nurse or appropriate personnel as required by law:Receives medication delivered to the nursing care center from the pharmacy and documents delivery on the medication delivery receipt/manifest.Verifies medication received with the prescriber orders.Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.Resident 1 was admitted to the…

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

Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 3 of 30 days. This failure placed residents at risk for not receiving needed care and supervision. Findings included . The Aging and Long-Term Support Administration (ALTSA) Staffing Pattern, and the facility's Daily Nurse Staffing Forms, dated 09/07/2024 through 10/07/2024, showed the facility did not have an RN on duty for all the three shifts (day, evening & night) on 09/29/2024, 10/05/2024 and 10/06/2024. On 10/11/2024 at 9:37 AM, Staff T, Staffing Coordinator, said they don't always have 24 hours of RN coverage but they are currently recruiting. At 10:18 PM, Staff B, Director of Nursing Services and Registered Nurse, said they have been attempting to recruit RNs, were using online hiring services and would be working on submitting an exception for staffing. Reference WAC 388-97-1080 (3) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a licensed pharmacist completed a monthly Medication Regimen Review (MRR) for 4 of 5 sampled residents (28, 41, 12, & 26) reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, adverse side effects, and receiving medications without required pharmacist oversight. Findings included . 1) Resident 28 was admitted to the facility on [DATE]. The Medicare - 5 day Minimum Data Set (MDS) assessment, dated 08/23/2024, documented Resident 28 was alert and oriented, and was receiving medications including an antipsychotic (medication used to treat symptoms of various mental disorders), an antidepressant (medication used to treat depression), a hypnotic (medication used to reduce anxiety or to induce sleep), an anticoagulant (medication that prevents or treats blood clots), a diuretic (medication to helps get rid of excess fluid), and an opioid (medication to help with pain relief). 2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 2 of 5 sampled residents (41 & 3) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life. Findings included . 1) Resident 41 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 08/21/2024, documented Resident 41 was alert and oriented, had diagnoses including schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and was taking antipsychotic (a class of medications used to treat symptoms of various mental disorders) and antianxiety (medications that help reduce the symptoms 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 provide and/or have procedures in place to assist with completing advance directives (ADs), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 2 of 11 sampled residents (3 & 9) reviewed for ADs. This failure place residents at risk for losing their right to have healthcare preferences and decisions honored and a diminished quality of life. Findings included . The facility's policy entitled, Advanced Directives, dated 08/01/2018, indicated, During the admission process, if it is determined that the resident does not have an advance directive and wishes to formulate one, assistance will be provided, using state specific advance directive forms. This will be documented in the medical chart along with a copy of the advance directive. 1) Resident 3 was admitted to the facility on [DATE]. The admission 5 Day Minimum Data Set (MDS) assessment, dated 09/15/2024, showed Resident 3 was moderately cognitively impaired. Resident 3's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 1 of 1 sampled resident (258) reviewed for privacy and confidentiality. These failures placed residents at risk for loss of confidential medical information and a diminished quality of life. Finding included . On 10/08/2024 at 9:22 AM, Staff S, Podiatrist, went into room [ROOM NUMBER], the room of Resident 258. At 9:34 AM, Staff S was observed providing care to Resident 258's toes nails. On Staff S's cart, in the hallway, were multiple papers. The top paper was facing up, and on it was a Podiatric Progress Note showing medical information for Resident 258. At 9:36 AM, Staff R, Registered Nurse, was observed coming out of a room from across the hallway. Staff R said resident information should not be visible to people in the hallway. When asked what she would do with visible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents were free from restraints for 1 of 3 sample residents (38) reviewed for physical restraints. This failure placed residents at risk for injury and a decrease quality of life. Findings included . Resident 38 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/30/2024, indicated Resident 38 was severely cognitively impaired. The fall risk interventions, dated 07/26/2024, indicated bed against wall, and fall mat [mattress] on side of the bed that is not against the wall to prevent/decrease chance of injury. No consent for the bed against the wall was found in the electronic health records. On 10/07/2024 at 10:36 AM, Resident 38 was observed lying on the bed on his back. The bed was against the wall, low to the floor and had a floor mat. At 2:51 PM, Collateral Contact 1 said the bed was against the wall and the mat was on the floor because Resident 38 tried to get out of bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a written Bed Hold Notice was provided at the time of transfer to the hospital to the resident or resident representative for 1 of 2 sampled residents (7) reviewed for notice of bed hold. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while at the hospital. Findings included . Review of the facility's Bed Hold Policy and Procedure documented, The resident and/or resident representative will be informed of this policy in writing upon admission, transfer or leave of absence. If unable to provide at the time of transfer or leave of absence, the policy will be provided within 24 hours. Resident 7 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/23/2024, documented the resident was moderately cognitive impaired. Resident 7's electronic health records (EHR) documented an emergent transfer to an acute care hospital on [DATE]. The EHR showed Resident 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to develop a care plan addressing an urinary catheter (a tube inserted into the bladder that drains urine into a bag outside the body) for 1 of 2 sampled residents (28) reviewed for comprehensive care plan. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . The facility's undated policy entitled, In-dwelling Urinary Catheter, documented .The Preliminary and In Room Care Plans (for [a healthcare software platform] Comprehensive Care Plan and [NAME] [a paper or electronic system that contains a summary of a patient's care]) will be developed for indwelling urinary catheter. Resident 28 was admitted to the facility on [DATE] and re-admitted on [DATE]. The Medicare - 5 day Minimum Data Set assessment, dated 08/23/2024, documented Resident 28 was alert and oriented and had an indwelling catheter. Review of Resident 28's Electronic Health Record comprehensive care plan did not show…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the physician's orders in the Electronic Health Record (EHR) were updated to accurately reflect the resident's wishes for Cardiopulmonary Resuscitation (CPR) status as directed by the Physician Orders for Life Sustaining Treatment (POLST) form for 1 of 1 sampled resident (13) reviewed for CPR. This failure placed residents at risk for not receiving care in accordance with the resident's and/or resident's representative decision-making if their heart stopped beating or breathing stopped. Findings included . Resident 13 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, dated [DATE], documented Resident 13 was alert and oriented. Review of Resident 13's Advance Directive POLST care plan, revised [DATE], documented, Advanced Directive POLST in place . [Resident 13] states that the orders on the POLST reflect their advance directive wishes . Review of Resident 13's POLST, dated [DATE], signed by Resident 13 and 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 perform ongoing neurological assessments (assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) for residents after an unwitnessed fall for 1 of 3 sampled residents (38), and failed to ensure bowel interventions were initiated for 4 of 6 sampled residents (10, 11, 28 & 41) reviewed for quality of care. These failures placed residents at risk of having unidentified injuries, a delay in treatment, at risk for worsening conditions, health complications and a diminished quality of life. Findings included . <Neurological Assessments> Resident 38 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/30/2024, indicated Resident 38 was severely cognitively impaired. The electronic health record (EHR) showed Resident 38 had unwitnessed falls on 08/24/2024, 09/05/2024, 09/14/2024, 09/25/2024 and 09/28/2024. No neurological assessments were located with the fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) physician orders for 1 of 2 sampled residents (28) reviewed for urinary catheter. This failure placed residents at risk for infection, unmet care needs, and a diminished quality of life. Findings included . The facility's undated policy entitled, In-dwelling Urinary Catheter, documented .orders will be reviewed to include medical justification for the catheter use, catheter size, and frequency of catheter, bag and tubing changes and catheter irrigations if appropriate . Resident 28 was admitted to the facility on [DATE] and re-admitted [DATE]. The Medicare - 5 day Minimum Data Set assessment, dated 08/23/2024, documented Resident 28 was alert and oriented and had an indwelling catheter. Review of Resident 28's Electronic Health Record did not have a physician's order for an indwelling foley catheter. On 10/07/2024 at 3:01 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify and address weight loss for 1 of 7 sampled residents (3) reviewed for nutrition. This failure placed residents at risk for inadequate nutrition and diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 09/15/2024, showed Resident 3 was alert and oriented. Resident 3's nutrition care plan, initiated 09/18/2024, showed Resident 3 Will maintain adequate nutritional status as evidenced by stable weight. Care plan interventions included Obtain weights as ordered, report significant changes to physician and RP [Responsible Party]. Residents 3's electronic health record (EHR) showed the following weights: On 09/27/2024 at 12:05 PM 163.5 Lbs Wheelchair On 09/28/2024 at 1:51 PM 145.0 Lbs Chair Scale On 09/29/2024 at 7:13 AM 144.2 Lbs Standing On 09/30/2024 at 9:21 AM 159.2 Lbs Wheelchair On 10/03/2024 at 12:27 PM 149.0 Lbs Wheelchair On 10/10/2024 at 9:48…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing hours were accurately posted daily for 4 of 30 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census. Findings included . The nurse staff postings, dated 09/07/2024 through 10/07/2024, were reviewed. On 10/07/24 at 10:27 AM, the nurse staff posting displayed Friday, 10/04/2024, with a census 67. On 10/08/2024 at 8:07 AM, the nurse staff posting displayed Friday, 10/04/2024, with a census of 67. On 10/11/2024 at 9:37 AM, Staff T, Staffing Coordinator, said the overnight charge nurse were supposed to change the postings over the weekend. At 10:18 AM, Staff B, Director of Nursing Services and Registered Nurse, said the night shift nurse was supposed to change the posting. No Associated WAC .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure targeted behaviors (desired responses to prescribed drugs) were monitored for 1 of 3 sampled residents (3) and failed to complete an AIMS (Abnormal Involuntary Movement Scale) Test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications) for 2 of 5 sampled residents (3 & 41) reviewed for unnecessary psychotropic medications. These failures placed residents at risk of receiving unnecessary medications, experience adverse side effects and a diminished quality of life. Findings included . <Targeted Behaviors> Resident 3 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 09/15/2024, documented Resident 3 was alert and oriented, and had diagnoses including dementia and depression. A review of Resident 3's Electric Health Record (EHR) did not show a record of targeted behaviors being monitored. On 10/11/24 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, interview and record review, the facility failed to ensure medication refrigerators were monitored for appropriate temperatures on 2 of 2 sampled units (West Hall & TCU (Transitional Care Unit)) reviewed for medication storage. This failure placed the residents at risk of receiving unsafe or ineffective medication. Findings included . On 10/09/2024 at 3:26 PM, the medication refrigerator in [NAME] Hall medication room was observed with Staff H, Registered Nurse (RN). Medications were stored in the [NAME] Hall medication refrigerator. A review of the temperature log on the refrigerator door showed temperature readings were not documented on 10/03/2024, 10/04/2024 and 10/05/2024. On 10/10/2024 at 1:42 PM, the medication refrigerator in the TCU medication room was observed with Staff K, Licensed Practical Nurse. Medications were stored in the refrigerator. A temperature monitoring log was not located in the medication room or on the medication refrigerator in the TCU medication room. Staff K said night shift was supposed to check the refrigerator temperatures.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing medical device care and wound care for 3 of 3 sampled residents (13, 28 & 107) and the facility failed to ensure staff properly donned (putting on) and doffed (removing) personal protective equipment (PPE) for 1 of 1 staff (S) reviewed for infection prevention and control. These failures placed residents, staff, and visitors at risk for contracting infectious diseases, developing infections and a decreased quality of life. Findings included . <Enhanced Barrier Precautions (EBP)> Record review of the Centers for Medicare and Medicaid Services (CMS) Memorandum (Ref: QSO-24-08-NH), dated 03/20/2024, with the subject of: Enhanced Barrier Precautions in Nursing Homes explains that: --EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offered, educated and provided the risks and benefits of Pneumococcal, Influenza and COVID-19 vaccines for 1 of 5 sampled residents (15) reviewed for immunizations. This failure placed residents at risk for developing Pneumonia, Influenza and/or COVID-19, with potential negative outcomes. Findings included . Facility's Influenza and Pneumococcal Immunizations policy, revised 02/02/2022 documented: 1. a. Residents: The center reviews risks and benefits of the vaccine with residents/Resident Representatives via the Vaccine Informed Consent. 2. The resident, resident's representative, or employee can refuse the Immunizations. Vaccine declinations and reason for declination are recorded in the resident medical record. Resident 15 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/31/2024, documented the resident was alert and oriented. Review of Resident 15's electronic health record (EHR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to conduct routine inspections of beds and/or bed rails throughout the facility to identify loose bed rails or areas of possible entrapment due to gaps between the mattress and side rail for 1 of 3 sampled residents (106) reviewed resident beds. This failure placed residents at risk of entrapment and injury. Findings included . Resident 106 was admitted to the facility on [DATE]. The resident's Electronic Health Record showed Resident 106 was alert and oriented. On 10/07/2024 at 2:36 PM, Resident 106 said the bed rail made her feel safe but was concerned about of it being loose. On 10/11/2024 at 9:06 AM, Resident 106's bed rail was observed to be loose. The rail had about six to eight inches of movement. At 9:10 AM, after observing Resident 106's bed and bed rail, Staff L, Resident Care Manager and Licensed Practical Nurse, said it was loose. At 10:18 AM, Staff B, Director of Nursing Services and Registered Nurse, said if there was an issue with a bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 4 of 8 sampled residents (1, 2, 3 & 4) reviewed for ADLs for dependent residents. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 01/27/2024, documented the resident required partial/moderate assistance with bathing; and supervision and touch assistance with ADLs including personal hygiene and tub/shower transfer. Resident 1's care plan, dated 01/20/2023, documented Resident 1 was scheduled for two showers a week with one person extensive assistance. On 03/11/2024 at 1:27 PM, Resident 1 said she had not received a bath or shower in the last couple weeks and had not received more than a couple since she had been admitted to the facility. Resident 1 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure resident rooms were maintained in good condition for 6 of 11 sampled rooms (108, 112, 113, 115, 117 & 119) reviewed for homelike environment. This failure placed residents at risk of not having rooms maintained with a comfortable interior and a decreased quality of life. Findings included . On 11/06/2023 at 3:10 PM, room [ROOM NUMBER] was observed with a basketball size deep scrape, through several layers, in the drywall. The area was located at a resident's face level on the wall that the bed was against. The scrape was visible from the hallway. On 11/13/2023 at 11:35 AM, Staff E, Nursing Assistant Registered, said the scraped area in room [ROOM NUMBER] had been there since March 2023 and was from the resident scratching. Staff E said they let maintenance know through the Point of Care system. Staff E said she did not know if anyone had asked to get it fixed. At 11:37 AM, after looking at the scraped area in room [ROOM NUMBER], Staff T,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations in the facility were comprehensively investigated for 4 of 4 sampled residents (42, 153, 12 & 44) reviewed for investigation of alleged abuse/neglect. This failure placed residents at risk of inadequate interventions, abuse, and a diminished quality of life. Findings included . 1) Resident 42 was admitted to the facility on [DATE]. Resident 42's admission Minimum Data Set (MDS), an assessment tool, dated 10/10/2023, documented the resident was cognitively intact. The State Agency received an incident, dated 10/30/2023, showing the facility reported Resident 42 alleged medications were not administered correctly. A facility investigation, dated 10/30/2023, did not show documentation of witness statements from Resident 42 or witness statements from the staff working with Resident 42 on the day the allegation was made. The investigation indicated a sample of residents were asked questions related to the investigation, but no witness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adhere to proper transmission-based precautions for 4 of 4 sampled residents (6, 24, 41 & 45) reviewed for infection control and prevention. This failure placed residents at risk of contracting a multi-drug resistant organism and a diminished quality of life. Findings included . The Centers for Disease Control and Prevention defines contact precautions as use of personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (applying) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. On 11/13/2023 at 10:48 AM, Staff M, Infection Preventionist/Licensed Practical Nurse, said there were 4 residents on contact precautions, two for Methicillin-resistant Staphylococcus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 1 of 1 sampled residents (32) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . Resident 32 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 09/28/2023, documented the resident was cognitively intact. Resident 32's electronic medical record documented two transfers to an acute care hospital on [DATE] and 10/07/2023. Resident 32's electronic medical record did not show documentation of a written notice of transfer for the 10/03/2023 and 10/07/2023 transfers out of the facility. At 11/08/2023 at 11:18 AM, Staff I, Residential Care Manager and Registered Nurse, said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan addressing placing a bed against the wall was developed for 1 of 2 sampled residents (1) reviewed for comprehensive care plans including restraints. This failure placed residents at risk for abuse, entrapment, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility 01/08/1999 with diagnoses including non-traumatic brain dysfunction, Alzheimer's Disease and dementia. The quarterly Minimum Data Set, an assessment tool, dated 09/30/2023, showed Resident 1 was severely cognitively impaired and was dependent on staff for activities of daily living. A Provider order, dated 06/27/2019, showed one side of bed to wall per resident preference. Review of Resident 1's care plan did not include having the bed against the walls. On 11/06/2023 at 3:10 PM, Resident 1 was observed in bed, with the bed against the wall in the corner of the room. The left and footboard sides of the bed were against walls. Resident 1 was not interviewable. On 11/07/2023 at 9:04 AM, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure hospice services were being managed when not discontinuing the order and care plan when removed from hospice services and when not acting on a new recommendation to re-start hospice services for 1 of 1 sampled residents (1) reviewed for quality of care related to hospice services. This failure placed residents at risk of not getting the services needed and unmet care needs and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction (injury to the brain), Alzheimer's disease (cognitive disease impacting memory) and dementia. The quarterly Minimum Data Set, an assessment tool, dated 09/30/2023, showed Resident 1 was severely cognitively impaired and was dependent on staff for activities of daily living. An active provider order, dated 10/27/2022, showed Resident 1 was on hospice services with a local hospice service for a diagnosis of Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to thoroughly evaluate the resident population in order to develop a facility assessment to meet each resident's care and service needs and accurately reflect the resources the facility determined were necessary for day-to-day and emergency operations including a ventilator assisted resident dependent on life sustaining equipment and trained respiratory service staff for 1 of 1 sampled residents (10) reviewed for facility assessment regarding respiratory services. This failure placed residents at risk for unmet care needs, possible death and a diminished quality of life. Findings included . Resident 10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy (a group of muscle diseases which cause progressive muscle weakness. This can affect the muscles required for breathing and movement) and quadriplegia (unable to move the body from neck area down). The quarterly Minimum Data Set, an assessment tool, dated 08/19/2023, 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.