Salmon Creek Post Acute & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a written transfer/discharge notice was provided to the resident or the resident representative in a language and manner they understood for 1 of 1 residents (Resident 115) reviewed for hospitalization. This failure placed the resident at risk for not knowing the reason for their transfer or have the opportunity to make decisions about their transfer/discharge rights.Findings included .Record Review of the facility's undated Bed Hold Policy, documented, .Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: .The details of the transfer (per the notice of transfer).Record review of Resident 115's admission Minimum Data Set (MDS, an assessment tool), dated 12/05/2025, documented Resident 115 was admitted on [DATE] and had moderate cognitive impairment.Record review of Resident 115's Nursing Note, dated 12/03/2025, stated, .At 0002 [12:02 am], the patient's granddaughter,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 2 of 2 sampled residents (Residents 39 and 22) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Dialysis Resident 39 was admitted to the facility on [DATE] with multiple diagnosis to include acute kidney failure (the sudden loss of the kidneys' ability to filter waste and balance fluids in your body) and chronic kidney disease, stage 4 (severe kidney damage). The Quarterly MDS, dated [DATE], showed Resident 7 was cognitively intact, had acute kidney failure, and was not on dialysis (a life sustaining medical treatment that filters waste products and excess fluid from your body when your kidneys fail). Record review of Resident 39's physician orders, dated 07/01/2025, showed Resident 39 was ordered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (Resident 116) reviewed for comfort care (medical focus shifts from curing an illness to providing relief from pain and symptoms).This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included.Resident 116 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set, an assessment tool, dated 11/18/2025, documented Resident 116 was moderately cognitively impaired. Record review of Resident 116's Portable Orders for Life-Sustaining Treatment, dated 11/11/2025, documented Resident 116 was on comfort care. Record review of Resident 116's care plan, dated 12/11/2025, showed a care plan for comfort care was developed a month after Resident 116 was placed on comfort care.In an interview on 01/08/2026 at 12:50 PM, Staff B, Director of Nursing/Registered Nurse, said it was the expectation that Resident 116's care plan was updated when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with grooming for 1 of 4 residents (Resident 80) reviewed for activities of daily living. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included.Resident 80 was admitted to the facility on [DATE] with diagnosis including unspecified visual field defects. The Annual Minimum Data Set (MDS), an assessment tool, dated 10/13/2025, documented Resident 80 was alert and oriented. Record review of Resident 80's electronic health record, showed resident was scheduled for and received showers on Tuesday, Friday and Sunday. In an interview on 01/06/2026 at 12:45 PM, Resident 80 said the facility staff did not help him shave his facial hair. Resident 80 was observed with unkempt facial hair during the interview. Resident 80 said he was unable to shave himself and needed assistance from staff. In an observation on 01/08/2026 at 1:59 PM, Resident 80 was observed with unkempt facial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 1 of 8 sampled residents (Resident 74) reviewed for quality of care and failed to perform ordered weights for 1 of 5 residents (Resident 13) reviewed for weights. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.Findings included . Resident 74 was admitted to the facility on [DATE]. The Modification of Quarterly Minimum Data Set (MDS, assessment tool), dated 12/16/2025, documented the resident was alert and oriented. Review of Resident 74's Electronic Health Record (EHR) order, dated 06/04/2025, documented, Polyethylene Glycol Powder [laxative]. Give 17 grams by mouth as needed for Constipation. Dissolve in 8oz [ounce] fluid and drink daily as needed. Review of Resident 74's EHR order, dated 06/29/2025, documented, Bisacodyl [laxative] Rectal Suppository 10 MG [milligrams]. Insert 1 suppository rectally every 24 hours as needed for constipation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for oxygen use for 1 of 2 sampled residents (Resident 83) reviewed for respiratory care. This failure placed residents at risk for worsening health complications, unmet care needs, and a diminished quality of life.Findings Included. Record review of the facility's policy titled, Oxygen Administration, undated, documented .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident 83 was admitted to the facility on [DATE], discharged return anticipated on 12/19/2025, and re-admitted on [DATE] on hospice. The admission Minimum Data Set, (an assessment tool) dated 11/11/2025, showed Resident 83 was cognitively intact and was on oxygen therapy. In an observation on 01/06/2026 at 10:52 AM, Resident 83 was observed lying in bed with oxygen on per nasal cannula (NC) running at 3 liters per minute (lpm). In an observation on…

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

Based on interview and record review, the facility failed to ensure resident census and nursing hours were accurately posted and/or updated daily for 30 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 resident census information.Findings included.Record review of facility's policy titled, Posting Nursing Staffing Information Policy dated 10/06/2022, documented, I. The facility will post the following information daily, at the beginning of each shift. The posting shall include:. d. The information should reflect staff absence on each shift due to call-outs and illness.e. Resident Census.Record review of the daily nursing staffing information postings, from 12/07/2025 to 01/06/2026 did not show resident census posted daily.In an interview on 01/09/2026 at 11:05 AM, Staff H, Staffing, reviewed the Daily Nursing Staffing Information postings from 12/07/2025 to 01/06/2026 and said they did not include resident census on them. Staff H said the nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 3 sampled resident rooms (room [ROOM NUMBER]) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.Findings included. Record review of the facility's policy titled, Transmission-Based Precautions [TBP, extra infection control measures used in healthcare settings for people with known or suspected infections that spread easily], dated 02/01/2022, documented: .Contact Precautions [infection control measures used to prevent the spread of infections that are transmitted through direct contact with an infected person or their environment]. 2. Personal Protective Equipment (PPE)A. Glovesa. Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or the resident'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 provide activities of daily living (ADL's) for resident's dependent on staff assistance related to bathing for two of three sampled residents (Resident 1 & 2) reviewed for ADLs. This failure placed residents at risk for unmet needs, poor hygiene, and a diminished quality of life.Findings included.Review of the facility's undated Shower/Tub Bath policy showed, At a minimum, the resident will be offered at least 2 full baths or showers per week. Resident 1Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease (permanent kidney failure), weakness, and reduced mobility. Review of Resident 1's 5-day Minimum Data Set (MDS) assessment, dated 11/20/2025, showed Resident 1 had moderate cognitive impairment and was dependent upon staff for bathing assistance.During an interview on 11/25/2025 at 1:50PM, Resident 1 said they frequently were not assisted with bathing because they were at their regularly scheduled dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 2 of 5 sampled residents (Residents 2 &4) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition, and a diminished quality of life.Findings included.Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, showed, Medications are administered in accordance with written orders of the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record, comprehensive records of physicians' orders and the medications and treatments administered to a resident] immediately following the medication being given.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including metastatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescriptions provided on discharge accurately reflected the residents reconciled medication list in the discharge summary for 1 of 5 sample residents (Resident 3) reviewed. This facility failure placed residents at risk for adverse medication side effects, changes in health conditions, and a diminished quality of life.Findings included.Review of the facility policy titled, Discharge Planning, dated 10/01/2021, documented, When the facility anticipates discharge, the facility will prepare discharge summary that includes, but is not limited to, the following: .Reconciliation of all pre-discharge medications with the resident's post-discharge medications.Resident 3 admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (a serious condition that results from the rapid death of muscle tissue). Review of Resident 3's admission Minimum Data Set (MDS) assessment, dated 11/28/2025, showed Resident 3 had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from medication and/ or treatment errors when medications and or treatments were not administered in accordance with provider orders for 1 of 3 sampled residents (Resident 1) reviewed for medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life. Findings included .Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, noted, Medications are administered in accordance with written orders of the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given.Resident 1 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus II [a chronic condition characterized by high blood sugar] and Peripheral Vascular Disease [a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to inform the physician about a significant change in the residents' physical condition for 1 of 3 residents (Resident 1) reviewed for notice of changes. This failure placed residents at risk of adverse medical conditions and a diminished quality of life.Findings included.Review of the facility policy, Change in a Resident's Condition, undated, noted, The nurse will notify the resident's Attending Physician / practitioner or physician on call when there has been. significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, and acute pancreatitis (inflammation of the pancreas). The Minimum Data Set (MDS) assessment, dated 04/27/2025, showed Resident 1 was cognitively intact.Record review of Resident 1's vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bathing assistance for 1 of 3 (Resident 1) residents reviewed for Activities of Daily Living care. This failure placed residents at risk of adverse medical conditions and a diminished quality of life. Findings included .Review of the facility policy, Shower/Tub Bath, undated, noted, At a minimum, residents will be offered at least 2 full baths or showers per week.Documentation- if the resident refused the shower/tub bath, the reason(s) why and the intervention taken.Reporting-notify the licensed nurse if the resident refuses the shower/tub bath.Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle weakness, and acute pancreatitis (inflammation of the pancreas). The Minimum Data Set (MDS) assessment, dated 04/27/2025, showed Resident 1 was cognitively intact.Record review of Resident 1's Progress Note, dated 05/06/2025, showed Staff D, Registered Nurse/previous Director of Nursing Services,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and accurately document a residents wound for 1 of 3 residents (Resident 1) sampled for wound care. This failure placed residents at risk of adverse medical conditions and a diminished quality of life.Findings included.Review of the facility policy, Pressure Injury Prevention and Management, dated 10/19/2022, noted, Identification.Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. The facility will maintain effective and accurate data collection on the development of pressure ulcer/injuries to ensure that systems and processes are maintained to prevent development of unavoidable pressure ulcer /injuries, and that care and treatment is provided to promote healing of pressure ulcer/injury.Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle weakness, and acute pancreatitis (inflammation of the pancreas). The Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 was free from significant medication errors when medications were not administered in accordance with provider orders for 1 of 3 sampled residents (Resident 1) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.Findings included .Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated 01/2023, noted, Medications are administered in accordance with written orders of the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given.Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, chronic obstructive pulmonary disease [lung disease that make it difficult to breath], acute pancreatitis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents received information about the risk and benefits and failed to obtain the resident's informed consent prior to the administration of psychotropic medications for 2 of 6 sampled residents (32 & 78) reviewed for right to be informed and make treatment decisions. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with psychotropic medications and a diminished quality of life. Findings included . 1) Resident 32 was admitted to the facility on [DATE] with diagnoses including depression. The admission Minimum Data Set (MDS) assessment, dated 09/17/2024, indicated Resident 32 was alert and oriented. Resident 32 received a physician order for Wellbutrin, an antidepressant, dated 10/24/2024. The October Medication Administration Record (MAR) showed Wellbutrin was administered on 10/25/2024, before an informed consent 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.

Based on observations, interviews, and record review the facility failed to accurately assess significant weight loss for 1 of 1 sampled resident (71) reviewed for assessment accuracy. This failure placed residents at risk for nutritional and functional decline in overall health status and a diminished quality of life. Findings included . The facility provided policy entitled, Weight Management Guideline, created 05/25/2023, indicated weight change of 10% is significant, greater than 10% is severe. All scheduled weights will be obtained prior to meetings . Identification of weight loss to determine accurate weight with supporting documentation to prevent, monitor, or intervene with undesirable weight. Resident 71 was admitted to facility on 05/16/2024 with diagnoses including severe malnutrition and Diabetes Mellitus. The Significant Change Minimum Data Set (MDS) assessment, dated 09/24/2024, indicated Resident 71 was moderately cognitively impaired. Resident 71's alteration in nutritional status care plan, dated 05/26/2024, documented the goal was to maintain stable weights within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II were followed for 1 of 1 sampled resident (23) reviewed for PASARR. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of care. Findings included . Resident 23 was admitted to facility on 11/09/2022 with a diagnoses including Alzheimer dementia and Major depression. The Quarterly Minimum Data Set assessment, dated 10/04/2024, indicated Resident 23's cognition was not assessed. Resident 23's PASARR 1, dated 06/03/2024, indicated the need for a level II assessment by a licensed mental health professional or mental health agency for individual services. PASARR level II recommendations were not found in Resident 23's medical record. On 10/24/2024 at 9:05 AM, when asked about the PASARR Level 1, dated 06/03/2024 for Resident 23, and if a Level 2 evaluation had occurred, Staff A, Administrator, said it likely was not done. At 3:15 PM, Staff A said the facility had a fax…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a baseline care plan was not developed to address falls and communication for 2 of 8 sampled residents (66 & 82) reviewed for baseline care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Fall Risk > Resident 66 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/05/2024, documented Resident 66 was severely cognitively impaired, and had diagnoses including Cognitive Communication Deficit and Cerebrovascular Accident (a condition when blood flow to a section in the brain is suddenly cut off). Resident 66's progress note, dated 09/29/2024, noted, Resident had a fall (unwitnessed) and was found on floor next to the bed . Resident 66's electronic health record (EHR) showed a care plan initiated on 10/02/2024, and noted, The resident is at risk for fall r/t [related to] stroke. The resident has had an actual fall with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure ongoing neurological assessments (assess the nervous system and identify any abnormalities that affect function and activities of daily living) were performed after an unwitnessed fall for 1 of 2 sampled residents (66); failed to ensure daily weights were obtained for 2 of 9 sampled residents (75 & 288) reviewed for weight management; failed to ensure the bowel protocol was initiated for 2 of 7 sampled residents (24 & 73) and failed to ensure dental services were obtained for 1 of 1 sampled resident (53) reviewed for quality of care related to neurological assessments, weight management, bowel management, and dental services. These failures placed residents at risk for worsening conditions, health complications and diminished quality of life. Findings included . <Neurological Assessments> Resident 66 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/05/2024, documented Resident 66 was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 5 sampled residents (62, 240, 241 & 339) reviewed for infection prevention and control. These failures placed residents, staff, and visitors at risk for contracting infectious diseases and a decreased quality of life. Findings included . Record review of the facility's policy entitled, Enhanced Barrier Precautions Policy, dated 03/28/2024, showed the requirement for facility staff were to use gown and gloves during high contact resident care activities for residents with certain Centers for Disease Control (CDC) targeted infections and for residents with wounds or indwelling medical devices. 1) Resident 62 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 10/03/2024, documented Resident 62 was alert and oriented and had an indwelling urinary catheter. On 10/21/2024 at 12:26 PM, Resident 62…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to notify a resident's family and/or representative of a positive COVID-19 (Coronavirus - a contagious disease) results for 1 of 5 sampled residents (75) reviewed for infection prevention and control. This failure placed residents and/or resident's representative at risk of not being knowledgeable to make decisions about their care in relation to the facility's COVID-19 management plan and a diminished quality of care. Findings included . The facility's policy, entitled Reporting to: Residents, Representatives, and Families During COVID-19 Pandemic, dated 05/15/2020, documented, The facility will inform residents, resident representatives, and families by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Resident 75 was admitted to the facility on [DATE]. The admission 5-Day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed with specific information for that resident for 6 of 6 sampled residents (1, 2, 3, 4, 5, and 6) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE] with diagnosis including Congestive Heart Failure, Hypothyroid, Hyperlipidemia (HLD - high cholesterol). The admission Minimum Data Set (MDS) assessment, dated 07/19/2024, showed Resident 1 had moderate cognitive impairment and utilized a walker to assist with ambulation. Review of Resident 1's Care Plan, initiated 07/14/2024, showed the following segments were incomplete and/or not individualized: --Focus: The resident has an ADL [activities of daily living] self-care performance deficit AEB [as evidenced by] Intervention: physical assist as needed with Intervention: provide supervision and cueing as needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 4 of 6 sampled residents (Residents 1, 2, 5, & 6) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition and a diminished quality of life. Findings included . Review of the facility policy Medication Error Reporting, undated, noted, Medication error/variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional . 1) Resident 1 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Hypothyroid, Hyperlipidemia (HLD - high cholesterol). The admission Minimum Data Set (MDS) Assessment, dated 07/19/2024, showed Resident 1 had moderate cognitive impairment and utilized 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 ensure fall mats (a cushioned surface used for the purpose of reducing injuries from falls) were in place on either side of the resident's bed, as directed in the comprehensive care plan, for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk of a fall with injury and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including weakness and reduced mobility. Resident 1's quarterly Minimum Data Set assessment, dated 04/05/2024, indicated the resident was dependent for bathing needs and required maximum assistance to roll right and left. Resident 1's care plan, initiated 11/18/2020, showed Resident 1 was, At risk for falls due to history of falls, impaired balance/poor coordination, potential medication side effects, unsteady gait and cognitive deficits. An intervention, initiated 12/04/2020, showed, Staff to place fall mats on either…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents were free from medication errors when medication orders for bedside administration were not followed for 1 of 7 sampled residents (1) reviewed for medication errors. This failure placed residents at risk for a decline in medical condition and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (changes on how the brain functions), acute respiratory failure, and chronic kidney disease. The admission Minimum Data Set, an assessment tool, dated 02/16/2024, documented the resident had moderate cognitive impairment. A provider order for Resident 1, dated 02/12/2024 at 2:26 PM, documented, [Okay] for bedside administration of budesonide-formoterol inhaler [used to control and prevent wheezing and shortness of breath]. [Okay] for bedside administration of albuterol sulfate nebulizer solution [used to treat lung problems]. A Provider Communication Note,…

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

Based on observation, interview, and record review, the facility failed to ensure medication refrigerator temperature logs were consistently maintained in 2 of 2 sampled medication rooms (1st Floor and 2nd Floor) reviewed for medication storage. This failure placed residents at risk for receiving compromised or ineffective medications with unknown potency. Findings included . 1) On 12/08/2023 at 8:51 AM, the first-floor medication room was observed with Staff B, Director of Nursing Services and Registered Nurse. The medication refrigerator temperature log, dated October 2023, documented, Twice daily refrigerator temperatures recommended. The October 2023 temperature log was completed 17 times out of the 62 opportunities, a 27% completion rate. The temperature log, dated November 2023, documented the temperature log was completed 22 times out of the 60 opportunities, a 35% completion rate. The temperature log, dated December 2023, documented the temperature log was completed 6 times out of the 14 opportunities, a 42% completion rate. At 8:51 AM, Staff B said the temperature logs 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 ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 2 of 5 sampled residents (29 & 21) reviewed for right to be informed and make treatment decisions related to 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 psychotropic medications and a diminished quality of life. Findings included . 1) Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 10/10/2023, documented Resident 29 was cognitively intact and had diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A physician's order, dated 02/13/2023, documented Resident 29 was prescribed sertraline (a psychotropic medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing advanced directives (ADs) for 3 of 16 sampled residents (38, 54, and 278) reviewed for ADs. This failure placed residents at risk for losing their right to have their health care preferences and/or have their decisions honored. Findings included . The facility's Advanced Directives Policy, revised 03/31/2023, defined an Advanced Directive as a written instruction, such as a living will or a durable power of attorney for healthcare, recognized under State law, relating to the provision of health care when the individual is incapacitated. Under Specific Procedures/Guidance: 7) Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 8) If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. 8b) Nursing staff will document in…

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

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 transfer to the resident and/or the resident's representative describing the reason for transfer for 2 of 5 sampled residents (10 & 33) reviewed for transfer notification requirement. This failure placed residents at risk of not being informed of their condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 10 was admitted to the facility on [DATE]. The admissions Minimum Data Set (MDS), an assessment tool, dated 09/05/2023, showed the resident was moderately cognitively impaired. A progress note, dated 11/12/2023 at 9:30 AM, documented pt. [patient] sent to hospital for deterioration of symptoms . called 911 for patient to transfer to hospital, N-95 mask placed on pt for transport. Report given to ambulance staff and paper work [sic] for hospital. Resident 10's Electronic Health Record (EHR) did not show she was provided a written notice of the transfer. 2) Resident 33 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 4 of 5 sampled residents (10, 40, 13 & 33) reviewed for bed hold notifications. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 10 was admitted to the facility on [DATE]. The admissions Minimum Data Set (MDS), an assessment tool, dated 09/05/2023, showed the resident was moderately cognitively impaired. The electronic health records (EHR) documented Resident 10 transferred to an acute hospital on [DATE]. No documentation was noted that contact was made to the resident or resident's family regarding a Bed-Hold. 2) Resident 33 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired. Resident 10's EHR documented he was transferred to an acute hospital 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 implement a care plan related to nephrostomy tube (a tube that drains urine from the kidney to an external bag) for 1 of 3 sampled residents (13) reviewed for comprehensive care plans. catheter care. This failure placed residents at risk of unmet care needs, delayed care, and a decreased quality of life. Findings included . Resident 13 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 10/24/2023, documented the resident was moderately cognitively impaired. A physician's order, dated 10/12/2023, documented, New nephrostomy to gravity. Flush tube with 10cc [cubic centimeters] NS [Normal Saline] daily. A physician's order, dated 10/24/2023, documented, Keep abdominal binder in place to reduce risk of dislodging the nephrostomy tube. Resident 13's comprehensive care plan did not show documentation the care plan addressed the nephrostomy tube. On 12/08/2023 at 10:23 AM, an observation of the nephrostomy tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to initiate bowel interventions for 2 of 2 sampled residents (10 & 268) and failed to perform ongoing neurological assessments (assesses the nervous system and identifies abnormalities affecting function and activities of daily living) for a resident after an unwitnessed falls for 2 of 5 sampled residents (21 & 26) reviewed for quality care related to bowel management and neurological assessments. These failures placed residents at risk for interventions not be intimated, discomfort, health complications and a diminished qualify of life. Finding included . <Bowel Management> 1) Resident 10 was admitted to the facility on [DATE]. The admissions Minimum Data Set (MDS), an assessment tool, dated 09/05/2023, showed the resident was moderately cognitively impaired. The facility census showed Resident 10 was admitted to an acute hospital on [DATE] and returned to the facility on [DATE]. The Bowel Movement (BM) task sheet documented Resident 10 did not have 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 ensure resident weights were monitored per physician orders for 1 of 5 sampled residents (13) reviewed for nutrition. This failure placed residents at risk of malnutrition, delayed wound-healing, and a decreased quality of life. Findings included . Resident 13 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/24/2023, documented the resident was moderately cognitively impaired and did not reject evaluation and/or care (marked behavior not exhibited) during the assessment period. The MDS documented the resident was transferred out of the facility from 08/22/2023 to 08/29/2023, from 09/14/2023 to 10/05/2023, and from 10/12/2023 to 10/20/2023. A nutritional risk care plan, initiated 08/23/2016 and revised 03/31/2023, documented the interventions, Review weights and notify physician and responsible party of significant weight change. Resident 13's weight record documented a weight of 143.6 pounds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistent and ongoing communication and collaboration with the dialysis facility regarding dialysis treatment and care for 1 of 2 sampled residents (26) reviewed for dialysis. This failure placed residents at risk of unidentified medical complications and a diminished quality of life. Finding included . The Hill Valley Healthcare Hemodialysis Access Care policy (the policy used by the facility), undated, showed, The facility is committed to following current CMS (Centers for Medicare/Medicaid Services), state guidelines, and clinical standards of practice in providing care for residents with End Stage Renal Dialysis receiving hemodialysis at an outpatient dialysis facility. Resident 26 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD) and was receiving Hemodialysis. The admissions Minimum Data Set, an assessment tool, dated 11/12/2023, showed the resident was moderately cognitively impaired. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 7 of 10 sampled residents (1, 2, 3, 4, 5, 6 & 7) 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 09/04/2023, documented the resident required 1-person extensive assistance with ADLs including 1-person total dependence with bathing. The facility shower schedule, undated, documented Resident 1 was scheduled for 2 showers a week. The bath report documented Resident 1 received 3 of 8 bath or shower opportunities from 08/16/2023 to 09/15/2023. On 09/20/2023 at 1:51 PM, Resident 1 said she has been in the facility over three weeks and has only received one shower during the first few days she was in the facility.…

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