Regency Wenatchee Rehabiliation & Nursing Center

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control [(CDC) a public agency that protects the public's health and well-being] guidance for temperature monitoring of vaccines in 1 of 1 medication storage refrigerators (Refrigerator 1) reviewed for medication storage. This failure placed the residents at risk of receiving compromised or ineffective vaccines and negative outcomes. Findings included . Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. Review of a policy titled Storage and Expiration Dating of Medications and Biologicals, revised 08/01/2024, showed the facility would ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were offered the pneumococcal immunizations (a vaccine that protects against pneumococcal infections that can lead to serious lung infections) nor documentation of the resident refusal or acceptance of the vaccine along with education on the risk/benefits of the vaccine for 1 of 5 residents (Resident 29) residents reviewed for pneumococcal immunizations. This failure placed the resident at an increased risk for a contagious disease without the opportunity to make an informed decision in the refusal or acceptance of the pneumococcal vaccine. Findings included . Review of the facility policy titled, Resident Immunizations, revised 2022, showed the facility would offer the pneumococcal vaccine to residents with the facility, and have a consent completed, education and the pneumococcal vaccine administered unless medically contraindicated (something that is not advised as the course of treatment). Additionally, the policy showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the resident environment was free from accident hazards, due to the placement of a 1500-[NAME] oil filled indoor electric space heater in 1 of 1 resident room (room [ROOM NUMBER]), reviewed for accident hazards. This failure placed the residents at risk for avoidable accidents and/or injury. Findings included . An observation on 12/10/2024 at 3:50 PM, in room [ROOM NUMBER], showed an oil filled indoor electric space heater was on the right side of the sink, turned on medium heat, was hot to touch. When the Department Investigator placed their hand near the electric space heater, they had to quickly remove their hand (after less than two seconds) due to the hot temperature felt on palm of their hand. During an interview on 12/10/2024 at 5:10 PM, Staff B, Maintenance Director, stated they had placed the space heater in room [ROOM NUMBER] when the thermostat in the room stopped working on 12/03/2024. Staff B stated they were not aware if there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address required documentation for Advanced Directives [(ADs) a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity] including incorporating ADs into the care planning process for 3 of 5 residents (Residents 6, 15, and 16) reviewed for ADs. These failures placed the residents at risk of losing their right to have their preferences and/or decisions followed regarding their end-of-life care. Findings included . Review of the policy titled, Advanced Directives/POLST (a portable physician order form that describes the residents care direction regarding end of life treatment), revised date 05/2019, showed the Social Services Director (SSD), would offer assistance in developing an AD if the resident wanted to formulate one and the ADs would be reviewed periodically. <Resident 6> Review of the resident's medical record showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement two components of their abuse policy when they did not verify licensure for 1 of 2 staff (Staff AA) for screening and did not provide abuse training for 5 of 8 staff (Staff O, T, U, V, and R) reviewed for abuse and neglect. This failure placed the residents at risk for unrecognized abuse, and unmet care needs. Findings included . Review of the policy titled, Abuse/Neglect/Misappropriation/Exploitation, dated 10/2022, showed the facility would; screen employees by verifying their licensure, and train employees at orientation, annually, and as needed. <Licensure> Review of employee files showed Staff AA, Nursing Assistant Registered (NAR), was hired on [DATE] as a student in a Nursing Assistant (NA) training class at a nearby training center. Staff AA graduated the training class and worked as a NAR for the facility starting on 12/052023. Staff AA obtained NAR licensure on [DATE], which expired on [DATE] (on their annual birthdate) and failed…

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 interdisciplinary team [(IDT) a group of healthcare providers from different fields who work together for the best outcome for residents] care conferences were completed for 2 of 2 residents (Residents 18 and 6) reviewed for comprehensive care planning. Additionally, the facility failed to ensure the IDT care conference meetings included the required team members for 2 of 2 residents (Residents 14 and 25) reviewed for comprehensive care planning. These failures disallowed the resident and/or their representative the involvement in planning resident care and placed the residents at risk for unmet care needs. Findings included . <Care Conferences> <Resident 18> Review of the medical record showed Resident 18 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), kidney…

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 restorative therapy services including the consistent use of braces/splints were implemented for 4 of 4 residents (Resident 6, 16, 17, and 23), reviewed for restorative therapy and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Review of a document titled, Restorative Program, dated 04/2018, showed: The goal of the Restorative Program was to promote and maintain functioning. Identify residents need for a restorative program at the time of admission/readmission/identified concerns. Restorative program to include but not limited to ROM, applying, and removing splint or braces, and walking with/without assisted devices. Daily documentation…

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 appropriate administration and documentation of enteral feedings (delivery of nutrition directly to your stomach or small intestine through a tube) and fluid intake via gastrostomy tube [(g-tube) a device inserted into the stomach through the abdomen that provides nutrition when you are unable to eat on your own] feedings for 1 of 2 residents (Resident 16) reviewed for enteral feeding. This failed practice put Resident 16 at risk for dehydration, fluid overload, and weight loss/gain. Findings included . <Resident 16> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include difficulty swallowing which resulted in nutritional support provided via a g-tube, malnutrition (lack of sufficient nutrients in the body) and absent of speech. The comprehensive assessment, dated 12/31/2023, showed Resident 16's cognition was moderately impaired and received greater than 51 percent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Eight medication errors were identified for 3 of 11 residents (Residents 9, 5 and 13) observed during 28 medication administration opportunities, that resulted in an error rate of 28.57%. Errors in medication administration placed the residents at risk for side effects and/or reduced or increased medication effectiveness due to improper administration. Findings included . Review of the Instructions for use of an insulin pen, by the U.S. Food and Drug Administration, (USFDA), dated 10/2022, showed the instructions for use stated to prime (to remove air from the needle and cartridge that may collect during administration) the insulin pen before each injection. This step was important to ensure the insulin pen worked correctly and the proper dose of medication was administered. Review of a document titled, Medication Administration Schedule, showed the following: • AM- Meds to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clinically appropriate self-administration of medications assessment was completed by the interdisciplinary team [(IDT) a group of healthcare providers from different fields who work together for the best outcome for residents] for 1 of 1 resident (Resident 14) reviewed for safe self-administration of medications. Failure to complete a self-administration assessment placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications. Findings included . <Resident 14> Review of the medical record showed Resident 14 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning). The 03/19/2024 comprehensive assessment, showed Resident 14 was dependent on one to two staff members…

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 a comfortable, appropriate length bed for 1 of 1 resident (Resident 33) reviewed for accommodations. This failed practice placed the resident at risk for discomfort and skin issues. Findings included . <Resident 33> Review of the resident's medical record showed Resident 33 admitted to the facility on [DATE] with diagnoses to include degeneration (decline or deterioration) of their lower spine, and left foot drop (difficulty lifting the top part of the foot). The comprehensive assessment, dated 03/02/2024, showed the resident's cognition was intact, required one staff member supervision for transferring, and was independent with bed mobility. An observation on 03/26/2024 at 9:22 AM, showed Resident 33 lying in bed, both feet pushed up against the foot board of the bed. Resident 33's area on the bottom of their left foot, underneath their toes, was red, and appeared soft and wrinkly. Resident 33 lowered the head of the bed 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 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] as required for 1 of 5 residents (Resident 149) reviewed for beneficiary notification. Resident 149 was not issued the required ABN when they remained in the facility after their Medicare Part A skilled nursing and rehabilitation services (nursing services such as intravenous fluids or medications or therapy services) ended. This failure placed the resident at risk for the inability to make informed financial and care decisions related to their continued stay. Findings included . <Resident 149> Review of the medical record showed Resident 149 was admitted to the facility on [DATE] with diagnoses including an infection of the left lower leg and venous insufficiency (improper functioning of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a quiet, comfortable, and homelike environment for 4 of 10 resident rooms (Rooms 7, 5, 4, and 3) and 2 of 2 residents (Residents 25 and 33) reviewed for homelike environment. Observations showed resident rooms needed physical repairs, storage of nutritional supplies in cardboard boxes, and noisy beds. This failure placed residents at risk for unmet care needs, discomfort, and a non-homelike environment. Findings included . <Physical Repairs> <room [ROOM NUMBER]> An observation on 03/25/2024 at 8:56 AM, showed the wall to the left side of the sink had an area greater than 24 inches by four inches with scraped paint and missing pieces of drywall (a wall panel made of calcium). Additionally, the entrance to the room showed an area greater than 36 inches by four inches of scraped and missing paint and drywall. <room [ROOM NUMBER]> An observation on 03/25/2024 at 10:08 AM, showed an area on the wall, to the right of the sink that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that prompt efforts were made to resolve a grievance involving a missing hearing aide for 1 of 1 resident (Resident 23) reviewed for grievances. The failure to promptly attempt to resolve a grievance disallowed the resident their right to a timely grievance resolution and placed the resident at risk for hearing difficulties and financial concerns. Findings included . Record review of a policy titled, Grievance Procedure, dated 08/2023, showed: • Grievances are resolved immediately, when possible, by the individual receiving the grievance; • The individual receiving the grievance will fill out a grievance form. <Resident 23> Review of the medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). The comprehensive assessment dated [DATE], showed the…

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

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/or resident's representative (RR) of the facility policy for bed hold at the time of transfer to the hospital for 1 of 2 residents (Resident 9) reviewed for hospitalization. This failure placed the resident and/or resident's representative at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Record review of a policy titled, Bed Hold/Notice of Transfer/Discharge, dated 10/2018, showed: • The facility would offer the option of a bed hold to residents and/or RRs that were out of the facility at the hospital or on social leave, and provide them information on the appeal process if denied readmission to the facility; • Residents and/or RRs would be provided the bed hold notice at the time of transfer. <Resident 9> Review of the medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease (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 Pre-Admissions Screening and Resident Review [(PASARR) a federal required assessment to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Assesses for serious mental illness and intellectual disability, ensures most appropriate setting for their needs, and receive services they need in those settings) assessment was accurately completed upon or prior to admission to the facility for 1 of 6 residents (Resident 33) reviewed for PASARR. This failure placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or developmentally disability care needs. Findings included . Review of a policy titled, Pre-admission Screening and Resident Review (PASARR), dated 11/2016, showed the facility would request a PASARR prior to admission and it was the Social Service department's responsibility to review the document and ensure it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was provided assistance with meals for 1 of 1 resident (Resident 6) reviewed for dining. This failure placed the resident at risk for weight loss and an undignified dining experience. Findings included . <Resident 6> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to their right hand, arm, shoulder, and leg and Parkinson's disease (a chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement). The comprehensive assessment dated [DATE], showed the resident's cognition was intact and required one staff assistance with set-up or cleanup with meals. During an interview on 03/25/2024 at 1:25 PM, the Resident's Representative (RR)…

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 follow physician orders for bowel and pain management for 1 of 2 residents (Resident 25) reviewed for constipation and pain. This failure placed the resident at risk for unmet care needs and negative health outcomes. Findings included . <Resident 25> Review of the resident's medical health record showed the resident admitted to the facility on [DATE] with diagnoses to include constipation, a right hip fracture (a partial or complete break in the continuity of any bone in the body), and a right displaced collar bone fracture. The comprehensive assessment, dated 03/10/2024, showed Resident 25's cognition was intact and was dependent on two staff assistance for bed mobility, transfers, and toileting. The assessment further showed the resident received an opioid (a class of pain medication) and had constipation. During an interview on 03/26/2024 at 11:50 AM, Resident 25 stated they had issues with constipation and was not sure what they…

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 that pre/post dialysis (a process that uses a machine to filter waste and fluids from the blood when the kidneys no longer function) communication forms and vital signs (reflect essential body functions, including your heart beat, breathing rate, temperature, and blood pressure) were completed for 1 of 1 resident (Resident 17) reviewed for dialysis services. This failure placed the residents at risk for unidentified complications. Findings included . Record review of a policy titled Dialysis, dated 11/2015, showed: • Send the dialysis communication form to the dialysis center on treatment days; • Licensed nurse to complete the pre & post dialysis assessments with each dialysis visit, to include vital signs; • Licensed Nurse will review dialysis communication form post dialysis; • Completed dialysis communication forms will be scanned into the resident's medical record; • The licensed nurse will contact the dialysis center if 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 observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care, related to assessing for trauma and identifying triggers for residents with a history of the loss of a loved one for 1 of 2 residents (Resident 33) reviewed for mood and behavior. This failed practice put residents at risk for re-traumatization, unidentified triggers, and a decline in their psychosocial well-being. Findings included . Review of a policy titled, Trauma Informed Care, dated 10/2022, showed residents would be screened on admission, triggers and trauma history would be identified, a care plan would be developed, and services provided if needed. The policy further showed the care plan would be routinely reviewed. <Resident 33> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and insomnia (trouble sleeping). 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 interview and record review, the facility failed to serve a nourishing snack at bedtime for 3 of 4 residents (Residents 1, 4, and 17) reviewed for bedtime snacks. This failure placed the residents at risk for hunger, weight loss, and unmet nutritional needs. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including liver and kidney disease. The 03/07/2024 comprehensive assessment showed Resident 1 required moderate to maximum assistance of one staff member for activities of daily living (ADLs) and set up assistance of one staff member for eating. The assessment also showed the resident had a moderately impaired cognition. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture) and type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar…

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

Based on observation and interview, the facility failed to ensure the proper disposal of trash for 1 of 1 dumpster reviewed for outdoor refuse storage. Failure to ensure the dumpster was covered placed the facility at risk of attracting bugs, rodents, and an unsanitary environment. An observation on 03/26/2024 at 11:17 AM, showed the dumpster located in a walled off area of the parking lot, with two gates enclosing the front side of the wall and one opened gate on the side. There was one dumpster located inside the enclosure that had both lids open; visible trash included trash bags that were not secured to keep trash contained, and a mattress. An observation on 03/27/2024 at 8:15 AM, showed the dumpster in the same area, with additional bags of trash added from the previous observation, and both dumpster lids open. An observation on 03/28/2024 at 11:32 AM, showed the dumpster with one lid open. During an interview on 03/28/2024 at 11:45 AM, Staff D, Maintenance Director, stated they were responsible for the dumpster and surrounding area. Staff D stated they did not know the lids…

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.