Crescent Health Care

Based on interview and record review the facility failed to have a system in place to promptly resolve grievances that were voiced in Resident Council (a formal meeting for facility residents to communicate preferences and concerns) for 1 of 4 residents (Resident 9) who expressed concerns about broken medical equipment that had been reported during the meeting and not resolved. Additionally, 4 of 4 residents (Residents 13, 4, 6 and 33) who regularly attended Resident Council were unaware of how to file a grievance (a formal complaint by a resident or resident representative [RR]) or who the facility Grievance Officer was. These failures placed residents at risk for overall dissatisfaction with their lives and unresolved concerns. Findings included . Record review of a facility policy titled Resident Grievance updated 09/2023 showed a grievance was defined as a complaint or concern that a resident had about care, services, or any other problem that may arise during their stay. The Grievance Officer is the Social Services Director. The Director of Nursing or the Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR, a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment accurately reflected residents' mental health conditions for 2 of 5 residents (Resident 16 and 8) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 16> Review of the resident's medical records showed they admitted on [DATE] with diagnoses to include a stroke (when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). The 10/23/2024 comprehensive assessment showed Resident 16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for 3 of 4 residents (Residents 12, 27, and 38) reviewed for trauma informed care. The facility failed to identify triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding history of Post-Traumatic Stress Disorder (PTSD, a mental health that is triggered by a terrifying event) and interventions. This failure placed the residents at risk for unidentified triggers and re-traumatization. Findings included . <Resident 12> Review of the medical record showed Resident 12 was re-admitted to the facility with diagnoses to include end stage kidney disease with kidney dialysis (process of cleaning waste from the blood artificially), heart disease and failure, left above the knee amputation, and amputation of their penis due to gangrene (death of tissue due…

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 routine and repair maintenance services for a safe and sanitary environment in 1 of 1 kitchen. This failure placed residents at risk for infection by not having cleanable and maintained surfaces. Findings included . <Floor under the Oven/ Oven top dust> An observation on 12/02/2024 at 9:20 AM, showed the kitchen floor under the oven's right leg support, had an uncleanable, broken, and missing area of rubberized concrete which measured 6 inches by 4 inches. During an observation on 12/02/2024 at 9:23 AM, showed the top of the oven had several stainless steel appliances and inserts used for the steam table that were piled on top of the dusty oven. <Leaky Faucets> An observation on 12/02/2024 at 9:30 AM, showed the clean sink area had a leaking water faucet. Additional observations on 12/05/2024 at 11:10 AM and 12/15/2024 at 11:15 AM, showed the water leak had increased to the second faucet. During an interview with Staff FF, Dietary Manager, stated they had previously reported the issue a week before to Staff I,…

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 care that maintained a resident's dignity for 1 of 2 sampled residents (Resident 12) reviewed for dignity. This failure placed the resident not able to maintain their bowel continence (using the commode) status and only received one shower a week. These failures caused embarrassment for bowel incontinent accidents and lack of shower/cleanliness before going to appointments and family visits. This placed the resident at risk for decreased quality of life. Findings included . <Resident 12> Review of the medical record showed Resident 12 was re-admitted to the facility on [DATE] with a fracture of the right lower leg and no weight bearing to the right leg. Diagnoses include end stage kidney disease with kidney dialysis (process of cleaning waste from the blood artificially), heart disease and failure, left above the knee amputation, diabetes (disease that occurs when your blood sugar is too high), gangrene (death of tissue due 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 observation, interview, and record review, the facility failed to comprehensively assess and monitor the need of physical restraints (posey (a brand of roll bolsters, an alternative to bed side rails to help protect alert patients from rolling out of the bed) for 2 of 4 residents (Residents 30 and 39) reviewed for physical restraints. In addition, the facility failed to obtain consents in the language the resident was able to read/understand, to document ongoing re-evaluation for the need of the restraint, and to ensure a least restrictive intervention were attempted prior to the use of the restraint. This failed practice placed residents at risk for a diminished quality of life, freedom of movement in their bed, and skin breakdown. Findings included . <Resident 30> Review of the resident's medical record showed they admitted with diagnoses to include a mood disorder (a group of mental conditions that affect a person's general emotional state) and heart failure. The 10/22/2024 comprehensive assessment…

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 significant change assessment had been completed for 2 of 4 residents (Resident 9 and 30) reviewed for hospice and end of life care. This failed practice placed the residents at risk for unmet care needs due to their imminent decline and/or improvement in health. Findings included . Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual (helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan), dated October 2024, showed it was a Centers for Medicare & Medicaid Services (CMS, a federal agency that administers health programs for seniors and people with disabilities) requirement to complete a significant change assessment (SCA) every time the hospice benefit had been selected and was also required if the resident came off of the hospice benefit. Additionally, the RAI manual showed a SCA should be completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level I form (a screening tool used to determine if a resident requires further evaluation for serious mental illness or intellectual disability), was updated when the resident was newly diagnosed with mental health concerns for 1 of 5 residents (Resident 7) reviewed for PASARR accuracy. This failed practice placed the resident at risk for health and/or emotional decline related to the lack of a professional evaluation to determine if further mental health interventions were required. Findings included . <Resident 7> Review of the resident's medical records showed the resident admitted on [DATE] with diagnoses to include depression (a mood disorder that causes persistent feelings of sadness and loss of interest) and blindness. Review of Resident 7's July 2024 Medication Administration Record (MAR), showed an order on 07/17/2024 for Ativan (a brand of medication used to treat anxiety [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 observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected resident care needs for 2 of 5 sampled residents (Residents 38 and 39) whose CPs were reviewed for accuracy. These failures placed residents at risk for unmet care needs and psychosocial interventions to maintain current preferences. Findings included . <Resident 38> Review of the medical record showed the resident had been at the facility for over one year with diagnoses to include dementia (cognitive impairment) with behaviors, history of hip fractures with falls and anxiety. The 11/15/2024 comprehensive assessment showed the resident was cognitively impaired but able to determine their needs and express them clearly. Resident 38 used a wheelchair for mobility. The 11/15/2024 quarterly assessment showed the resident did not demonstrate any mood to resistive behaviors. Additionally, the quarterly assessment showed no impairment of vision or hearing.…

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 the necessary care and services to ensure Restorative Aide (RA) Nursing programs were consistently provided for 3 of 5 residents (Resident's 21, 39, and 9) reviewed for activities of daily living (ADLs, basic tasks people perform regularly to care for themselves). This failure placed residents at risk for avoidable decline in function and a diminished ability to reach their highest practicable level of well being. Findings included . Record review of a facility policy titled Rehabilitation Nursing Care revised 10/21 showed; The facility Rehabilitative Nursing Program was designed to assist each resident to achieve and maintain an optimal level of self care and independence. Through the resident care plan the goals of rehabilitation are reinforced. <Resident 21> Review of the residents medical record showed they were admitted to the facility with diagnoses including, dementia (a disease that effects brain function such as memory 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 provide meaningful and engaging activities for 1 of 3 residents (Resident 38), that do not participate in activities. Resident 38 did not participate in activities designed for someone who could not see well and had difficulty hearing which was relevant to their mental state. This placed the resident at risk of decreased interactions with people, a decreased meaning to their life, and a decreased mental well-being. Findings included . <Resident 38> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include cataracts (opacity of the lens of the eyes), dementia (cognitive impairment), and multiple falls with fracture. The 11/15/2024 quarterly assessment showed for Preferences for Daily and Routine activities showed reading books and newspaper was not important to the resident. Resident 38 could make their needs known and used a wheelchair to wheel themselves around the facility. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice regarding ongoing skin assessments for 2 of 5 residents (Residents 37 and 8) reviewed for skin impairment. Additionally, the facility failed to follow physicians' orders to obtain specialized services timely for 2 of 5 Residents (Resident 9 and 20) reviewed for Range of motion (ROM). The facility's failure to provide the care and services required related to non-pressure skin issues and specialized services placed residents at risk for unidentified and/or avoidable decline, delay in treatment, pain/discomfort, and unmet care needs. Findings included . Review of the 01/2021 Urostomy Care procedure showed the purposes were to promote cleanliness and to protect the peristomal skin (skin around the stoma) where the urostomy (surgically constructed opening in the bladder/urinary tract allowing urine to flow through an opening outside the body) is…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's bathroom had safe and functional Durable Medical Equipment (DME, medically necessary equipment used by people with a medical condition, disability, or injury) for 1 of 3 sampled residents (Resident 9) reviewed for accident hazards. This failure placed the resident at risk for falls, injuries, and decreased independence. Findings included . <Resident 9> Review of the resident's medical record showed the resident admitted with diagnoses to include lower back pain and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The 09/11/2024 comprehensive assessment showed Resident 9's cognition was moderately impaired and they had not experienced any falls since admission. An observation and concurrent interview on 12/03/2024 at 9:53 AM, showed Resident 9 sitting in their wheelchair, self-propelling in their room. Observation of Resident 9's bathroom, showed a toilet seat riser (a portable toilet seat that provides…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 7 and 16) reviewed for unnecessary medications. The facility failed to consistently develop, monitor, and implement individualized targeted behaviors and ensure as needed (PRN) psychotropic medications were limited to 14-days or had a documented rationale for the extended use. Additionally, the facility failed to consistently obtain informed consent for the use of psychotropic medications. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, and a decreased independence for making their own informed decisions. Findings included . <Resident 7> Review of the resident's medical records showed they admitted on [DATE] with diagnoses to include depression (a mood disorder that causes persistent feelings of sadness and…

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

Based on observation, interview and record review the facility failed to provide access of an interpreter for 1 of 1 resident (Resident 1) reviewed for communication. This failure resulted in miscommunications between the resident, family and facility staff placing Resident 1 at risk for frustration and unmet care needs. Findings included . The undated facility policy Crescent Health Care Auxiliary Aids and Services for Persons with Disabilities showed for persons who are deaf or hard of hearing and who use sign language as their primary means of communication, the social services staff will provide white boards and pens for effective communication with residents. Persons who are deaf may request family members or friend as interpreters however, family members or friends will not be used as interpreters unless specifically requested by that individual and after and offer of an interpreter at no charge to the resident. <Resident 1> Review of the medical record showed the resident had diagnoses including deafness (complete hearing loss), heart disease, diabetes (when blood sugar is…

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 a change in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure caused delay in treatment when they complained of abdominal pain. These failures placed Resident 1 at risk for unmanaged pain. Findings included . <Resident 1> Review of the medical record showed Resident 1with diagnoses including deaf-nonspeaking, urinary retention with urinary catheter, chronic Urinary Tract Infections (UTI), pain in right hip and knee, heart failure and kidney failure. The resident was alert and oriented used sign language, writing on a white board with an erasable marker for communication. Review of the comprehensive assessment dated [DATE] showed Resident 1 had a urinary catheter and required oxygen. The resident required assistance of one staff member with Activities of Daily Living. <Urinary Catheter> During an interview on 09/05/2024 at 9:10 AM, Resident 1 stated on 08/25/2024 Staff F, Nursing Assistant…

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 provide a cleanable and sanitary environment for 3 of 10 resident rooms (rooms [ROOM NUMBER]) the tiles were worn with cracks between the tiles that were not cleanable. There was a black sticky substance between the tiles on the flooring. This failure placed staff and residents at an increased risk for infectious diseases and non-functional resident environment related to uncleanable flooring surfaces. Findings included . <room [ROOM NUMBER]> During an observation on 09/05/2024 at 10:20 AM, the flooring in room [ROOM NUMBER] located on the right side of the resident's bed showed a five feet (ft-unit of measure) by four ft area of white tile that was discolored to a blackish-brown color. There were several areas of black sticky substance between the square floor tiles. The under flooring was showing through the seams of the tiles. There were multiple indentations in the flooring that were uncleanable. During an interview on 09/05/2024 at 10:30 AM, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free of abuse when Staff D, Licensed Practical Nurse (LPN) utilized verbal abuse and intimidation during cares for 3 of 4 residents (Resident 1, 2, and 3) reviewed for abuse. This deficient practice placed residents at risk for unrecognized emotional harm, mental anguish, and the potential for additional abuse. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of bacterial pneumonia (an infection in the lungs caused by bacteria), chronic respiratory failure (a condition in which the blood does not have enough oxygen), anxiety (feelings of fear or uneasiness), and supplemental oxygen dependence (delivery of concentrated oxygen from a device to aide breathing). Review of the comprehensive assessment, dated 12/04/2023, showed Resident 1 was cognitively intact and required the assistance of one person for dressing, transfers, personal hygiene,…

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 report an allegation of abuse to the State Agency for 1 of 4 residents (Resident 1) reviewed for abuse and neglect. This deficient practice placed residents at risk for unidentified and potential ongoing abuse and/or neglect. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), a nursing home employee (or other mandated reporter) is required to make a report if they had reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of bacterial pneumonia (an infection in the lungs caused by bacteria), chronic respiratory failure (a condition in which the blood does not have enough…

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 document in the medical record any discussions regarding Advanced Directives (AD), including incorporation into the care planning process, for 4 of 5 residents (Residents 12, 28, 50 and 46) reviewed for AD. This failure placed the residents at risk of losing their right to have their preferences/decisions followed regarding end-of-life care. Findings included . Review of the facility policy titled Resident Self Determination Policies, dated 05/2006, showed at the time of admission, the facility will provide information concerning (i) an adult individual's right to make decisions concerning medical care, including the right to accept or refuse medical treatment or surgical treatment and the right to give advance directives; (ii) the facility's policy relating to implementation of these rights. Additionally, the facility would document in each resident's medical record whether or not the resident had executed an AD. Review of State Operations Manual,…

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 conveyance of funds in a resident trust fund account occurred within 30 days following their death, for 1 of 1 resident (Resident 69), reviewed for conveyance of resident funds. This failure placed the state department at risk for loss of funds and interest accumulated. Findings included . Review of the facility's undated policy titled, Conveyance of Funds Upon a Resident's Death/Discharge, showed within 30 days of the death of the resident, the facility would return the deceased resident's personal funds .if the resident was on Medicaid, the funds would be returned to the Office of Financial recovery. <Resident 69> Review of Resident 69's medical record showed they were admitted to the facility on [DATE] and passed away on [DATE]. The resident had $11.02 personal funds remaining in their facility held trust account. Review of Resident 69's trust fund account showed the balance of $11.02 had not been returned to the Office of Financial…

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 privacy was provided during toileting for 2 of 3 residents (Resident 45 and 50) reviewed for personal privacy. This failure placed the residents at risk for embarrassment and a lack of dignified care. Findings included . <Resident 45> Review of the medical record showed Resident 45 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and a history of falls. The comprehensive assessment dated [DATE] showed the resident required supervision of one staff member for transfers and toileting. The assessment also showed the resident was cognitively intact. During an interview on 10/24/2023 at 9:52 AM, Resident 45 stated they did not have privacy when using the restroom and were unable to independently shut the door to the restroom when they used the toilet. Resident 45 further stated there was an incident of a resident that wandered in their room while getting dressed a week ago. Resident 45 stated that it…

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 protect the resident's right to be free from neglect when staff failed to provide a wheelchair in good working condition for 1 of 1 resident (Resident 50) reviewed for neglect. This failed practice put Resident 50 at risk for further accidents secondary to the facility not acting to repair the brakes on the resident's wheelchair that were not working. Findings included . Review of a facility policy titled, Abuse and Neglect - Clinical Protocol, dated 01/2020, showed the definition of neglect was failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further review showed the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. <Resident 50> Review of the medical record showed Resident 50 was admitted to the facility on [DATE] with diagnoses including surgical amputation (loss or removal of a body part)…

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 an allegation of neglect was reported to the State Agency as required for 1 of 1 resident (Resident 50) reviewed for neglect. Failure to report allegations of neglect placed residents at risk for additional neglect. Findings included . Review of the facility policy titled Abuse and Neglect - Clinical Protocol, dated 01/2020, showed the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 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 50> Review of the medical record showed Resident 50 was admitted to the facility on [DATE] with diagnoses including…

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 written bed hold information prior to transfers to an acute care hospital for 2 of 4 residents (Resident 42 and 9) reviewed for hospital discharge. This failure placed the residents at risk for lack of knowledge of the right to hold their bed while in the hospital. Findings included . <Resident 42> Review of Resident 42's medical record showed they were admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other brain functions). Review of the most recent comprehensive assessment dated [DATE] showed the resident was cognitively impaired and required extensive assistance from staff for activities of daily living (daily activities such as mobility. dressing, personal hygiene and grooming). Review of Resident 42's progress notes showed they were sent to the hospital on [DATE] and returned to the facility on [DATE] with a diagnosis of urinary tract infection and sepsis (an infection 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 develop a base line care plan within 48 hours of admission to include resident specific initial goals and treatment plans for 1 of 3 newly admitted residents (Resident 28) reviewed for base line care plan. This failure placed the resident at risk for a lack of continuity of care and unmet care needs. Findings included . <Resident 28> Review of Resident 28's medical record showed the resident was admitted to the facility on [DATE] with diagnoses that included, left leg fractures, Parkinson's (a progressive disease that damages nerves) and anxiety. The most recent comprehensive assessment dated [DATE] showed the resident was cognitively impaired and required extensive assistance from two staff for bed mobility, transfers, personal hygiene and grooming. Review of Resident 28's initial care plan dated 08/19/2023 showed that it did not have the required components for a 48 hour baseline care plan which included, medications, dietary orders, and goals 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 adequate pain control for 1 of 3 residents (Resident 48) reviewed for pain. This failure resulted in Resident 48 experiencing severe pain during an indwelling catheter (a hollow tube inserted into the bladder through the penis to drain urine) exchange (procedure to replace previous indwelling catheter with a new one). This failure to recognize and implement pain interventions to minimize pain for Resident 48 caused inadequate pain control and a diminished quality of life when their pain was unrelieved during the indwelling catheter exchange. Findings included . <Resident 48> Review of the medical record showed Resident 48 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD [a lung disease that causes difficult breathing]), urinary retention (inability to pass urine) with an indwelling catheter, and palliative care (specialized care for serious illnesses). 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 observation, interview and record review the facility failed to ensure that 1 of 4 residents (Resident 28), reviewed for unnecessary medications, had an adequate indication for use of a psychotropic medication (a class of medication that affects brain activity of mental functioning and behavior) based on clinical rationale. Additionally, the facility failed to provide sufficient monitoring for adverse side effects (ASE, unwanted, undesirable effects that are possibly related to medication) with the use of an antipsychotic medication (a class of psychotropic medication with a high risk for ASE). This failure placed Resident 28 at risk for a deterioration in their mental and physical health status. Findings included . Record review of an Alzheimer's Society August 2021 article titled Antipsychotics and other drug approaches in dementia care showed .the decision to use an antipsychoic drug for dementia care should be taken very seriously, benefits may impact the person's health and quality of life…

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. Two medication errors were identified for 2 of 11 residents (Residents 50 and 37) observed during 25 medication administration opportunities, that resulted in an error rate of 8%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . Review of the Instructions for use an insulin pen, by the U.S. Food and Drug Administration, (USFDA) dated 11/2018, showed to keep the needle in the skin for at least 10 seconds, and keep the push button pressed all the way in until the needle has been pulled out of the skin. This process is to ensure the full dosage was provided. In addition, the Instructions for use stated to prime the insulin pen before each injection. Priming is meant to remove air from the needle and cartridge that may collect 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.

Based on observations, interviews, and record review the facility failed to ensure one of one medication storage room (South Hall), one of one medication storage refrigerator, and one of three medication carts (North Hall) were 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 facility policy titled, Storage of Medications, revised 09/2022, showed the facility shall not use discontinued or outdated medications and all medications should be returned to the dispensing pharmacy or destroyed. During an observation on 10/26/2023 at 12:46 PM, the following expired medications were found : < Intravenous ([IV] medications administered into a vein) medication cart located in medication storage room> Two vials of Lidocaine 1% (numbing medication). Expired 07/2023 Two syringes of Heparin 500 units (used to prevent blood clots). Expired 08/2021 and 04/2022 One syringe of Heparin 50 units Expired 06/2023 One intravenous (IV) bag 500…

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 designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk of contracting communicable diseases. Findings included . Record review of the facility's undated policy titled, Infection Prevention and Control Program, showed that .at least one Health Care Provider (HCP) would be assigned and trained as the Infection Preventionist to provide on-site management of the Infection Prevention and Control Program. During an interview on 10/03/2023 at 12:30 PM, Staff A, Administrator, stated that they did not currently have an IP and that Staff B, Director of Nurses (DON), was taking on that role. Staff A further stated Staff B had not received the certified IP training. During an interview on 10/03/2023 at 2:05 PM, Staff B, stated that there was no one certified for the IP position, and they were…

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

Based on interview and record review, the facility failed to implement their Respiratory Protection Program (RPP) to ensure resident and staff safety by not completing annual respiratory mask fit testing (a test conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) for 16 of 78 staff reviewed for annual fit testing and annual respiratory training. This failed practice put all residents at risk for developing communicable diseases and infections. Findings included . Record review of the February 2022 guidance from the Washington State Department of Health titled, Respiratory Protection Program for Long-Term Care Facilities, showed the program included a medical evaluation to determine whether it was safe for employees to use respirators, completion of respirator training before the first use of a respirator, and respirator fit testing initially and annually thereafter. Review of the facility's undated RPP policy, showed employees were required to receive respirator mask fit testing to ensure proper size and fit, and training…

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.