Washington Odd Fellows Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop/implement components of their infection prevention and control precautions regarding, A) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols, identification of areas at risk and procedures for when control measures (actions or steps taken), adopted to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water, were not met for 1 of 1 water management program (WMP) reviewed for infection control, and B) Nursing Staff hand hygiene and glove change for 1 of 3 residents (Resident 3) reviewed for infection control. The failure to implement the infection control components placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's policy titled, Legionella Management Program, dated 06/03/2025, showed 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.

Based on observation and interview, the facility failed to provide a clean sanitary environment for 1 of 1 Kitchen floor area that had an uncleanable surface. This failed practice of an uncleanable surface could potentially placed staff and residents at risk of illness. Finding included . During an interview and concurrent observation on 08/04/2025 at 9:25 AM, Staff O, Dietary Supervisor, observed in the thresh hold entryway to the dry goods food storage room, the flooring had cracked, damaged and missing linoleum. Staff O stated the floor had been that way for some time and difficult to clean. An observation on 08/04/2025 at 9:35 AM, the tilt skillet/stove (commercial cooking equipment used to prepare large batches of food for grilling and braising), which stood three feet above some broken tiled floor. The tile floor, under the tilt skillet showed a four-foot by three-foot area of broken/loose tile with missing and loose grout (mortar poured between cervices to consolidate and seal areas) in between several individual tiles. The tiles were wet due to the steam produced from the…

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

Based on observation, interview and record review, the facility failed to ensure infection control interventions intended to prevent the spread of communicable disease during a COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak were consistently implemented for the use of: personal protective equipment (PPE) during COVID-19 testing for 3 of 3 staff (Staff G, J, and K); National Institute for Occupational Safety and Health (NIOSH) approved respiratory protective device (N95) fitted masks (a respirator mask used to achieve a very close facial fit and very efficient filtration of airborne particles) for 5 of 5 staff (Staff B, D, F, H, and I) when entering a COVID-19 positive resident room; and face shields for 4 of 4 staff (Staff F, G, H, and I), reviewed for infection control practices. Additionally, 2 of 2 staff (Staff J and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received dignified care and services related to the lack of 1) timely assistance with toileting needs for 1 of 2 residents (Resident 10) reviewed for embarrassment after an incontinent episode; 2) serving meals at the same time at their dining table for 4 of 22 residents (Residents 10, 11, 33, and 36) reviewed for dining; and 3) providing dignity and respect during the admission process for 2 of 2 residents (Residents 217 and 208) reviewed for admissions. These failures placed the residents at risk for not attaining their highest practicable level of well-being. Findings included . Review of the policy titled, Resident Rights, dated 03/14/2024, showed the resident had the right to a dignified existence, self-determination, and the right to be treated with respect and dignity. <Toileting Assistance> <Resident 10> Review of Resident 10's medical record showed they were admitted to the facility with a diagnosis of dementia…

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 issue a Notice of Medicare Non-Coverage [(NOMNC) a notice that indicates when your care is set to end from a skilled nursing facility] as required for 1 of 3 residents (Resident 215) reviewed for beneficiary notification. Additionally, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] for 3 of 3 residents (Residents 215, 50, and 52) reviewed for SNF ABN requirements. These failures placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay. Findings included . Review of a policy titled, Advance Beneficiary Notices, dated 09/14/2023, showed the facility would inform Medicare beneficiaries of their potential liability for payment upon admission or during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review [(PASARR) - a federally required form that is used to help ensure individuals receive appropriate mental health services after admission to a skilled nursing facility] was completed correctly for 4 of 6 residents (Residents 6, 11, 210 and 23) reviewed for PASARR accuracy. This failure placed the residents at risk for not receiving appropriate mental health services. Findings included . <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with mental health diagnoses including, major depression and delusional disorder (a disorder that causes altered beliefs which are not reality). Review of the most recent comprehensive assessment dated [DATE] showed the resident was able to make their needs known and had mild cognitive impairment. Additional review showed Resident 6 had experienced mental health symptoms during the assessment period, including feelings…

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 medically related social services (SS) that met the needs of residents in the areas of Notice of Medicare Non-Coverage (NOMNC- a required notice to Medicare beneficiaries to inform them when their Medicare covered services were ending, and of their right to appeal) for 1 of 3 residents (Resident 215). The facility failed to provide Advanced Beneficiary Notices (ABN- a notice to Medicare beneficiaries informing them of the cost of continued Medicare covered services and services that may not be covered) for 3 of 3 residents (Residents 50, 52 and 215). In the area of Pre-admission Screening and Resident Review (PASARR, a required assessment prior to admission to a nursing facility to ensure mental illnesses are identified so appropriate treatments and resources are available) for 4 of 6 residents (Residents 6, 11, 210 and 43). Additionally, in the area of discharge planning for 2 of 3 residents (Residents 208 and 38). These identified failures…

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

Based on observation, interview, and record review the facility failed to maintain cleanliness of the kitchen environment to ensure food was stored, prepared and served under sanitary conditions for 1 of 1 kitchen and I of 3 ice machines reviewed for food safety. These failures placed residents at risk for potential food borne illness. Findings included . During an observation and concurrent interview on 07/15/2024 at 8:56 AM, Staff Z, Dietary Manager, opened the janitors closet in the kitchen that contained a mop and bucket filled with chemicals (cleaning and disinfectants) were stored. Staff Z switched on the ventilation fan in the closet and showed the ventilation fan was not operational as it did not ventilate (no exhaust suction from the fan when a paper towel was placed against the vent) the room that had a chemical odor. Staff Z stated they were not aware the ventilation fan was not functioning properly. During an observation on 07/15/2024 at 9:15 AM, showed there were two mounted portable air conditioners (AC) on the upper wall with dirt (dark grime) and the AC vents located…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse/neglect was reported to the State Agency in the required 24-hour time frame, for 1 of 1 resident (Resident 28) reviewed for abuse/neglect. Resident 28 was found with significant bruising to their left hand and forearm. Failure to report abuse/neglect in a timely manner placed the resident at risk for additional abuse. Findings included . Review of the Nursing Home Guidelines, The Purple Book, sixth edition, Chapter 1 Facility Reporting Requirements, dated October 2015, showed the facility was required to report substantial injuries of unknown source within 24 hours. <Resident 28> Review of the Resident's 28 medical record showed the resident was admitted with diagnoses including dementia (disease which causes loss of memory, skills and functions), heart disease and depression. The 04/29/2024 comprehensive assessment showed the resident was dependent on one to two staff members for activities of daily living (ADLs) and mobility. The assessment also showed Resident 28 had difficulty recalling…

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, interviews and record review, the facility failed to thoroughly investigate an allegation of abuse which resulted in a significant bruise of unknown origin for 1 of 1 resident (Resident 28) reviewed for abuse. This failure placed residents at risk for unidentified abuse, neglect, and unmet care needs. Findings included . Review of the policy titled, Abuse, Neglect and Exploitation, dated 09/05/2023, showed an immediate investigation was warranted when suspicion of abuse or reports of abuse occurred. The written procedures would include identifying and interviewing all involved persons, alleged victim, alleged perpetrator, witnesses, and others who might have had knowledge of the allegation. The policy also showed the facility would provide a complete thorough documentation of the investigation. <Resident 28> Review of the Resident 28's medical record showed the resident was admitted with diagnoses including dementia (disease which causes loss of memory, skills and functions), heart disease and rheumatica polymyalgia (inflammatory disease that causes muscle pain…

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 to the resident and their representative of the facility's intention and justification for the discharge of 2 of 2 residents (Residents 39 and 55) reviewed for facility-initiated discharges. Additionally, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes). This failed practice disallowed the resident and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharge. This failure also placed the residents at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. Findings included . Review of a policy titled, Transfer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed-hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 2 residents (Residents 39 and 55) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed-hold while in the hospital. Findings included . Review of a policy titled, Transfer and Discharge (including AMA [against medical advice]), dated 02/05/2024, showed the facility would provide a notice of bed-hold policy to the resident and/or their representative upon transfer to the hospital. <Resident 39> Review of the medical record showed Resident 39 was re-admitted to the facility on [DATE] with diagnoses including clostridium difficile [(C-diff) a bacterium that causes an infection of the colon], kidney failure, and gastrointestinal hemorrhage (internal bleeding from 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 develop and implement an effective discharge planning process that addressed the resident's goals and needs and involved the resident and/or their representative and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 3 residents (Resident 208 and 38) reviewed for discharge planning process. The failure to develop and implement a plan consistent with the resident's needs and expressed discharge goals, placed the residents at risk for decreased self-worth and dissatisfaction with their living situation. Findings included . <Resident 208> Review of the medical record showed Resident 208 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a series of brain dysfunction caused by illness), high blood pressure, and depression. Resident 208 was able to make their needs known. Record review of the Discharge Planning Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 of 2 residents (Residents 11 and 10) reviewed for dependence with activities of daily living received care and services to meet their elimination needs. Residents 11 and 10 had specific care directives for toileting programs and did not receive timely assistance as required. This failure placed the residents at risk for incontinence unmet care care needs. Findings included . <Resident 11> Review of Resident 11's medical record showed the resident was admitted with diagnoses including dementia (a brain disease that causes memory loss with poor judgement) and type 2 diabetes (a chronic disease which results in a build up of too much sugar in the blood). Review of the most recent comprehensive assessment dated [DATE] showed the resident had severe cognitive impairment and was on a timed toileting program (a specific program to provide scheduled times to provide assistance to help remain continent of bowel and bladder). Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services and assistive devices to maintain vision abilities for 1 of 1 resident (Resident 23) reviewed for vision. The failure to provide vision care and assistive devices placed the resident at risk for worsening vision. Findings included . <Resident 23> Review of Resident 23's medical record showed they were admitted to the facility on [DATE] with diagnoses including stroke and depression. The 06/14/2024 comprehensive assessment showed Resident 23 was dependent on two staff members for activities of daily living (ADLs) and had moderately impaired vision and cognition. During and observation and interview on 07/15/2024 at 10:42 AM, Resident 23 was lying in their bed with the lights off and curtains closed. Resident 23 stated they used to wear glasses and their eyes hurt and would like to see an eye doctor. During an interview on 07/17/2024 at 9:46 AM, Resident 23 stated they were unsure why they could not have any eyeglasses.…

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 who were trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 1 resident (Resident 23) reviewed for mood and behavior. This failed practice placed residents at risk for unidentified triggers, re-traumatization and unmet care needs. Findings included . <Resident 23> Review of the medical record showed Resident 23 was admitted to the facility on [DATE] with diagnoses including stroke, depression, psychoactive substance abuse (an intense focus or addition to use mind-altering chemical substance such as alcohol, tobacco and/or illicit drugs that alters mood, perceptions, consciousness and cognition), and severe dementia with mood disturbance (a progressive disease that causes memory loss, confusion, sadness, anxiety, and delusions). The 6/14/2024 admission assessment showed Resident 23 was dependent on two staff members for activities…

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 Staff AA, Licensed Practice Nurse (LPN), had the specific competencies and skill sets, which included documented demonstration, necessary to safely and efficiently perform care for residents' needs for intravenous [(IV) a soft, flexible tube placed inside a vein, usually in the hand or arm] medication administration for 1 of 2 residents (Resident 208) through a Peripherally Inserted Central Catheter [(PICC) - a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term administration of antibiotics, medications, nutrition, and blood draws] line. This failure placed residents at risk for adverse outcomes related to medication administration and unmet care needs. Findings included . Review of the policy, Medication Administration, dated 02/14/2024, showed medications were administered by licensed nurses, who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. <Resident 208> Review of the medical…

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 2 of 2 medication storage rooms (East Hall and [NAME] Hall) was free from expired medications. This failed practice placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications. Findings included . Review of the policy titled, Medication Administration, dated 02/14/2024, showed staff were to identify medication expiration dates and notify the nurse manager. During a concurrent observation and interview on 07/18/2024 at 9:29 AM, the [NAME] Hall medication storage room refrigerator contained four COVID-19 [an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise (a general feeling of discomfort/uneasiness), headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death] vaccinations that had expired on 04/07/2024. Staff N,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of records, the facility failed to thoroughly investigate an allegation of potential neglect and unwitnessed falls which resulted in substantial injuries to 3 of 3 residents (Residents 2, 3, and 4) reviewed for incidents and accidents. Failure to conduct thorough investigations to identify a root cause placed residents at risk for unidentified neglect, lack of corrective action and/or recurrent falls with injury. Findings included . Review of the facility policy, titled Use of Gait Belt, undated, showed gait belts were to be utilized for all residents that could not independently ambulate or transfer for the purpose of safety. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses which included stroke with right sided weakness, aphasia (language disorder that affected ability to communicate) and osteoporosis (bone disease resulting in a decrease in bone strength which could increase the risk of fractures).…

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 had the ability to exercise self-determination related to aspects of life in the facility that were significant to the resident, including the frequency of bathing for 2 of 4 residents (Resident 5 and 6) reviewed for choices. The failure to allow residents to choose how often to bathe placed the residents at risk for hygiene concerns, decreased self-worth and powerlessness. Findings included . Review of the facility's undated policy titled, Resident Rights, showed the resident had the right to a dignified existence and self-determination .the right to make choices about aspects of their life that were significant to the resident including schedules for care. <Resident 5> Review of Resident 5's medical record showed they were admitted to the facility on [DATE] with diagnoses including stroke, depression, and anxiety. The 02/19/2024 comprehensive assessment showed Resident 5 was dependent on one to two staff for bathing and had an intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure an allegation of neglect was reported to the State Agency as required for 1 of 3 residents (Resident 2) reviewed for neglect. Failure to report allegations of neglect placed residents at risk for further neglect. Findings included . Review of the Nursing Home Guidelines titled, The Purple Book, dated October 2015, showed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility and to other officials in accordance with State law .including to the State survey and certification agency. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses which included stroke with right sided weakness, aphasia (language disorder that affected ability to communicate) and osteoporosis (bone disease resulting in a decrease in bone strength which could increase the risk of fractures). Review of Resident 2'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 follow and/or clarify physician orders for 1 of 4 residents (Resident 1) reviewed for services provided met professional standards of practice. This failure placed the resident at risk for negative health outcomes and unmet care needs. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection that caused pain, redness and swelling) and heart failure. The medical record also showed Resident 1 had an intact cognition. Review of Resident 1's hospital discharge orders dated 04/10/2024, showed the resident had a medication order change to increase furosemide (medication to help the body lose fluid) from 40 milligrams (mg-unit of measure) to 80 mg every morning and an additional 40 mg at 1:00 PM for seven days. During an interview on 04/16/2024 at 5:35 PM, Resident 1 stated they went to the hospital on [DATE] for shortness of…

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

Based on interviews and record review, the facility failed to have the State Reporting Log (method used by facilities to report incidents of possible abuse, neglect, abandonment, mistreatment, injuries of unknown source, evacuation, disasters/major outbreaks, unexpected death/suicide, personal and/or financial exploitation, or misappropriation of resident property in nursing homes) accessible to State investigators upon their request. This failed practice placed all residents at risk for unidentified abuse and neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015, showed the facility must maintain a state Reporting Log. The log must be retained in the facility and readily accessible at all times to state licensing and certification staff, and others according to their authority. On 03/05/2024 at 10:05 AM the state investigator informed Staff A, Director of Nursing, the need to visualize the facility Reporting Log as part of conducting their investigation. On 03/05/2024 at 12:54 PM Staff A stated Staff B, Assistant Director 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 make a comprehensive assessment of each resident's functional capacity for 4 of 4 residents (Residents 269, 271, 219, and 220) reviewed for comprehensive assessments and timing. This failure placed the residents at risk of not having comprehensive care, not having appropriate services provided, and placed the residents at risk of their needs and preferences not being identified and care-planned for implementation. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023 (F636) 483.20 Resident Assessment, showed the facility must conduct initially and periodically a comprehensive, accurate standardized reproducible assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by the Center of Medicare and Medicaid Services (CMS). The RAI consists of three basic components: the Minimum Data Set (MDS) version 3.0, the Care Area…

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 baseline care plan within 48 hours of admission that documented resident specific initial goals and treatment plans for 3 of 3 newly admitted residents (Residents 269, 271, and 219) to ensure continuity of care upon admission. The failure to develop baseline care-plans that meet all the requirements placed the residents at risk of unmet care needs, a delay in care and services and a diminished quality of life. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023 (F655) §483.21 Baseline Care Plans, showed they are required to address, at a minimum, the following: Initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations, if applicable. The facility must provide the resident and their representative with a written summary of the baseline care plan and be in a language and conveyed in a manner the resident and or their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP), in a timely manner, to address anticoagulant (a high-risk, blood thinning medication) and psychotropic (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) medication use for 3 of 7 residents (Resident 169, 219, and 220) reviewed for care planning. This failure placed residents at risk for unrecognized adverse side effects (ASE), unmet psychosocial well-being and care needs, and a decreased quality of life. Findings included . Review of the facility's 02/24/2023 policy, titled Care Plans, Comprehensive Person-Centered showed the CP should be developed within seven days of the completed comprehensive assessment, and no more than 21 days after admission. The policy further showed the CP should identify services that were to be maintained to achieve the highest, practicable physical, mental, and psychosocial well-being. <Resident 169>…

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 ensure care plans (CP) were reviewed and revised to identify the changing needs for 3 of 7 residents (Residents 63, 21, and 34) reviewed for care plans. Areas of change were identified as psychotropic medication (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) use, hospice services, and discharge planning. This failed practice put residents at risk for unidentified/unmet care needs, and a decreased quality of life. Findings included . <Resident 63> Review of Resident 63's electronic health record (EHR) showed the resident admitted to the facility on [DATE] with diagnoses that did not include Insomnia (a sleep disorder). Review of the comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition and no diagnosis of Insomnia had been identified. Review of the resident's September 2023 Electronic Medication Administration Record (EMAR) showed an order that began on 07/26/2023…

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

Based on observation, interview and record review, the facility failed to post the location of the survey results and failed to ensure survey results were accessible to residents for 5 of 7 residents (Resident 48, 24, 22, 55, and 52) who attended resident council meeting on 09/11/2023. This failure prevented residents, family members and visitors from exercising their right to review and access past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility. Findings included . An observation on 09/08/2023 at 11:11AM around the facility showed no signs directing residents, staff, and/or visitors to the location of the survey results and plan of corrections. During an observation on 09/08/2023 at 11:13 AM, a blue binder labeled Survey Book was located in between other white binders, next to the computers behind the east hall nurse's station. The binder contained information on previous surveys, complaint results, and plan of corrections. During the resident council meeting on 09/11/2023 at 10:00 AM, Residents 48, 24, 22 and 55…

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 or have processes in place to assist with the development of Advanced Directives (AD) for 3 of 6 residents (Residents 60, 22, and 219) reviewed for Advanced Directives. This failure placed the residents at risk for not having the opportunity to make their healthcare preferences and/or decisions known. Findings included . Record review of the facility's admission packet did not show information for residents and/or their representatives on how to formulate an AD. <Resident 60> Review of Resident 60's electronic health record (EHR) showed the resident was admitted to the facility on [DATE] with a diagnosis of a stroke and left sided weakness. The most recent assessment dated [DATE] showed the resident had no cognitive impairment and required extensive assistance for transfers, bedmobility and personal hygiene. Continued review of Resident 60's EHR showed that the resident did not have an AD formulated. Additionally, there was no documented…

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 comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a residents freedom of movement) by applying bolsters under the mattress elevating the bed to prevent the resident from getting out of bed, for 1 of 1 resident (Resident 26) reviewed for physical restraints. Additionally, the facility did not obtain a consent or identify the need for the restraint to ensure the least restrictive intervention was utilized. This failure placed the resident at risk for injuries and a diminished quality of life. Findings included . <Resident 26> Review of Resident 26's electronic health record (EHR) showed they had a diagnosis of dementia (an ongoing disease which causes a decline in mental functioning). The most recent comprehensive assessment dated [DATE] showed the resident was cognitively impaired and required extensive assistance from staff for transfers and bed mobility. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change in status assessment for 2 of 2 residents (Residents 21 and 30) reviewed for comprehensive assessments. Failure to complete significant change of status care assessments placed the residents at risk for not receiving the care and services they required. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023 (F637) §483.20 (b) (2) (ii) Significant change in Status Assessment, (SCSA) shows a SCSA Minimum Data Set (MDS) is required within 14 days after a facility determines or should have determined that there was a significant change in a resident's physical or mental condition. (a significant change means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 6), reviewed for pressure injuries, received necessary care and services consistent with professional standards of practice to prevent a pressure injury from developing or worsening. The facility did not follow Resident 6's care plan interventions for positioning which placed the resident at risk to develop new pressure injuries or delay healing and worsening of their current pressure injuries. Findings included . The National Pressure Injury Advisory Panel (PAP-an organization that sets professional standards for prevention and healing of pressure injuries) defines pressure injuries as injuries to the skin caused by unrelieved pressure to the area . with four stages of pressure injuries to include . *Stage I: The skin is red or discolored, but is still intact *Stage II: Partial thickness loss, the top layer of the skin is open creating a shallow sore *Stage III: Full thickness skin loss, skin is broken and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately supervise and initiate interventions for an exit seeking resident for 1 of 1 resident (Resident 49) reviewed for accidents. The failure to identify preventative measures resulted in the resident getting outside of the building and placed the resident at risk for re-elopement, accidents/hazards, and a decreased quality of life. Findings included . Review of the facility's 03/24/2023 policy, titled Elopements and Wandering Residents showed the facility monitored and managed residents at risk by identifying and assessing the risks, evaluating and analyzing the risks and hazards and then implementing/monitoring interventions to reduce hazards and risks, and modifying the interventions as needed. The policy further showed the elopement definition to be .when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so . Review of the State Operations Manual (SOM), Appendix PP, last revised 02/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 2 residents (Resident 22 and 63) reviewed for respiratory care and treatment, received appropriate oxygen services consistent with professional standards of practice. Failure of the facility to ensure oxygen delivery was provided according to physician orders, monitored respiratory status, and maintained oxygen equipment, placed residents at risk of unmet needs, discomfort, and secondary medical complications. Findings included . Review of the facility's 03/24/2023 policy, titled Oxygen Concentrators and Canisters showed as follows; concentrator maintenance was provided by the vendor; oxygen start-up was managed by the admitting nurse, Assistant Director of Nursing (ADON), or designee at the time of admission in conjunction with provider orders . The policy further showed that humidification may be used if ordered by the physician. <Resident 22> Review of Resident 22's electronic health record (EHR) showed the 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 observation, interview, and record review, the facility failed to monitor for adverse side effects (ASEs), initiate interventions, or identify adequate indications of use for anticoagulant (a high-risk, blood thinning medication) medications for 2 of 3 residents (Resident 63 and 64) reviewed for anticoagulants. Residents 63 and 64 did not have monitoring, or interventions. Resident 63 did not have an adequate indication of use. This failed practice caused the potential for residents to receive unnecessary medications, experience unidentified symptoms and risks, and a decreased quality of life. Findings included . Review of the facility policy, titled High Risk Medications-Anticoagulants, dated 02/24/2023 showed the resident's plan of care should alert staff to monitor for risks and adverse side effects and include interventions as follows; Bleeding and hemorrhage; decreased blood pressure or blood work; blood clots; limit blood draws and injections if possible and make them aware of the need to apply…

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 adequate monitoring and follow up with residents receiving psychoactive medications (medications that alter brain function related to perception, mood and behavior) for 3 of 5 residents (Resident 26, 22 and 49) reviewed for unnecessary medications. The facility failed to provide adequate monitoring for adverse side effects (ASE's) for changes in psychoactive medications for Resident 26. Additionally, the facility failed to have physician documented rationale for antianxiety medications used beyond 14 days for Resident 22 and 49. These failures put the residents at risk for adverse outcomes related to the use of psychoactive medications. Findings included . Review of the facility policy titled Psychoactive Medication and Antipsychotic Medication dated 02/24/2023 showed . The Director of Nurses will hold a weekly Psychotropic meeting . The team will monitor: a. Proper charting and documentation is in the resident's medical record. b.…

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 establish an effective communication process to ensure hospice services were delivered for 1 of 1 resident (Resident 220) reviewed for hospice services. This failure placed the resident at risk for diminished end of life care, hospice management and overall quality of care. Findings included . Review of the facility's policy Coordination of Hospice Services dated 06/06/2023 showed when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility Hospice agreement titled Hospice Services Facility Agreement, dated 06/06/2023, showed If hospice care is furnished in the facility through an agreement, the facility will ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility and 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.