Garden Village

Based on observation, interview, and record review, the facility failed to consistently implement interventions for 1 of 2 residents (Resident 9) reviewed for nutrition. This failure placed the resident at risk for continued significant weight loss and the loss of nutritional satisfaction. Findings included.Resident 9 Review of Resident 9's medical records showed they admitted with diagnoses to include dementia (a loss of thinking, remembering, and reasoning skills), malnutrition (inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting) and most recently, neck and tonsil cancer (06/06/2025, a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body). The 06/10/2025 comprehensive assessment showed Resident 9's cognition was moderately impaired, was independent for eating, complained of difficulty or pain with swallowing, and had no issues with weight loss. Additional review of Resident 9's medical records showed the resident had received weekly chemotherapy (a drug…

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 1 of 5 residents (Resident 9) were free of unnecessary drugs due to lack of monitoring and care planning of high-risk cancer (a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body) medication. This failed practice placed the resident at risk of adverse side effects and unmet care/personal needs.Findings included.Review of Lippincott Nursing Procedures 8th edition, dated 2019, titled Chemotherapeutic [a drug that kills cancer cells] Drug Administration, Special considerations, showed for 48 hours after receiving a chemotherapy drug, the resident's feces and urine would be contaminated and required special handling for washing clothes and linens and feces and urine, and hand washing would be completed often. The guidelines showed healthcare workers who were pregnant, were trying to become pregnant, or breast-feeding should not be exposed to chemotherapy drugs. The guidelines showed adverse side effects (ASE) were unique to the medication being administered…

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 maintain an effective pest control program ensuring that flies (an insect that can develop/breed in various environments, rapidly reproduce and known for spreading diseases) were not entering/gathering in hallways and resident rooms for 1 of 4 Hallways (Hall 3 [H3, 300's rooms]) reviewed for environment. This failure placed the resident at risk of infection, infestation (the state of being overrun by pests) and unmet care needs. Findings included .Review of the facility's policy titled, Physical Environment Safe, Functional, Sanitary Environment, dated July 2018, showed the facility would maintain an effective pest control program (measures to eliminate and contain common household pest like roaches, ants and flies) to control pests and rodents.Resident 12 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including kidney complications, history of a stroke with dysarthria (speech disorder that occurs…

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 that direct care staffing information, including information for agency and contract staff, was electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for 1 of 3 quarters (3rd quarter of 2024), reviewed for Payroll Based Journal (PBJ, mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility failed to report data for the period of July 1, 2024, through September 30, 2024, as required. During an interview on 04/16/2025 at 1:42 PM, Staff C, Business Office Manager, stated that they were responsible for reporting the PBJ data in 2024. The 3rd quarter report was the last one they transmitted, and now corporate accounting were responsible. During a telephone interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and resident representative for 1 of 4 residents (Resident 2) reviewed for falls. This failure placed the resident at risk for a delay in medical treatment and of not having a resident representative involved in health care decision making. Findings included . Record review of the facility's policy titled, Notification of Changes of Condition, dated 07/2018, showed that the facility would inform the resident representative and the resident's physician changes in condition or accidents resulting in injury. Record review of the facility's policy titled, Accident Hazards Supervision Devices, dated 07/2018, showed that when a resident experienced a fall, the facility would assess for injuries, provide necessary treatment, address risk factors and revise the resident's care plan as needed. <Resident 2> Record review showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (stroke,…

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 the comprehensive care plan was revised for 1 of 3 residents (Resident 1) reviewed for care plan revisions after a significant change. This failure placed the residents at risk for injury and unmet care needs. Findings included . Review of a policy titled, Comprehensive Care Plans, dated 11/2017, showed the care plan was comprehensive, person-centered, and would drive the type of care and services a resident would receive. The care plan would describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences, and how the facility would assist in meeting those needs. The Minimum Data Set [(MDS) a federally mandated assessment tool that helps nursing homes evaluate the health and functional capabilities of their residents] would be used to assess the resident's clinical condition, cognitive and functional status, and use of services in developing the comprehensive care plan. The care planning process…

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 there were sufficient numbers of nursing staff to provide care and services for 17 of 17 residents (Residents 293, 245, 79, 2, 11, 1,19, 49, 71, 5, 83, 18, 51, 84, 3, 244 and 54). These failures placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health. Findings included . < F 636 Resident Comprehensive Assessments and Timing> The facility failed to ensure resident admission Minimum Data Sets (MDS, a required assessment and care planning tool) were completed within the required timeframes. <Resident 293> Record review of Resident 293's medical record showed an admission MDS had an admission Assessment Reference Date (ARD, refers to the specific endpoint for the observation [or look-back] periods in the MDS assessment process) of 09/29/2024. Review of the MDS completion date showed it was not completed until 10/22/2024 (27 days after the admission and 13 days late). <Resident 245> Record review of Resident 245's medical record showed 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.

Based on observation, interview, and record review the facility failed to identify and properly discard foods after the expiration date for 1 of 1 dry food storage rooms and 1 of 1 walk in refrigerators reviewed for kitchen and food safety. This failure placed the residents at risk for food borne illness (fever, chills, stomach cramps, diarrhea, nausea, and vomiting caused by the ingestion of contaminated food and/or beverages). Findings included . Review of the facility's 07/2018 policy titled Food and Nutrition Services, Food Safety showed dry foods will be rotated and refrigerated foods will be labeled, dated and discarded on the expiration date. An observation on the initial kitchen tour with Staff R, Dietary Manager, on 10/15/2024 at 8:20 AM, showed the refrigerator and dry storage room contained the following expired foods: -Two-pound bag organic greens, unopened, expired on 10/07/2024 -Three-pound box of Spring mix salad blend, unopened/unsealed, expired on 10/03/2024 -Two-pound bag Greens Fresh Onions, unopened, expired on 10/13/2024 -Two boxes of green mountain coffee…

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 their representative of the discharge for 5 of 5 residents (Residents 5, 54, 67, 18, and 51) reviewed for hospitalization. This failure placed the residents at risk for unmet discharge needs. Findings included . <Resident 5> Review of the medical record showed the resident was admitted to the facility with diagnoses to include left breast cellulitis (a bacterial skin infection that causes swelling, pain, warmth and redness) and a skin infection to their pannus (excess skin and fat hanging down from the abdomen). The 08/07/2024 comprehensive assessment showed Resident 5's cognition was intact. Review of nursing progress notes showed the resident was sent to the hospital on [DATE] due to increased redness, pain, and swelling to their breasts. Resident 5 readmitted back to the facility on [DATE]. Review of Resident 5's discharge documents showed no notice of transfer had been given to the resident or 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 <Resident 67> Review of Resident 67's medical record showed they admitted to the facility with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), and liver cirrhosis (severe scarring of the liver). The 06/30/24 comprehensive assessment showed Resident 67 was independent for activities of daily living and had severe impaired cognition. Record review showed Resident 67 had a change of condition on 10/03/2024 and was transported to the hospital emergency department followed by a six day stay at the hospital. Record review showed no bed hold information communicated to the resident or their representative at the time of the transfer to the hospital on [DATE]. During an interview on10/24/2024 at 11:40 AM, Staff J stated they recalled sending Resident 67 to the hospital on [DATE]; however, they did not provide the bed hold notice to the resident or…

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 complete quarterly Minimum Data Set (MDS, a required assessment and care planning tool) assessments within the regulatory timeframes for 6 of 6 residents (Residents 2, 11, 1, 19, 49 and 71) reviewed for timeliness of assessments. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . Review of the 10/2023 Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's) showed the quarterly Assessment Reference Date (ARD, refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process) should be completed no later than 92 calendar days from the previous quarterly MDS. <Resident 2> Record review of Resident 2's medical record showed Resident 2's quarterly MDS with an ARD of 09/06/2024 and showed it was completed on 10/11/2024 (35 days late). <Resident 11> Record review of Resident 11'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 provide the necessary care and services to ensure that dependent residents received assistance with dressing, personal hygiene, and shower/bathing for 4 of 5 residents (Resident 5, 83, 18, and 51). This failure placed the residents at increased risk for skin breakdown and unmet care needs. Findings included . <Resident 5> Review of the medical record showed the resident admitted with diagnoses to include diabetes (a chronic condition the occurs when the body has high levels of sugar in the blood) and kidney failure. The 08/09/2024 comprehensive assessment showed Resident 5's cognition was intact and required substantial to maximum assistance for hygiene and bathing. During an interview on 10/15/2024 at 10:40 AM, Resident 5 stated they were frustrated because they would like to have a shower more than twice a week but would like to at least get the two a week they were scheduled for. Resident 5 stated their shower days were on Wednesdays…

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 serve meals that were at a safe temperature and appetizing for 2 of 5 residents (Residents 3 and 1) reviewed for food quality. This failed practice placed the residents at risk for decreased nutritional intake and food borne illness. Findings included . Review of the undated policy titled, Record of Food Temperatures, showed that food was to be served in such a manner that temperatures were safe and acceptable to residents. The hot foods would be held at a minimum of 135 degrees Fahrenheit (F- a unit of measure) and cold foods would be held at a maximum of 41 degrees F. Further review showed that no food will be served that does not meet the food code standard temperatures. <Resident Council> During a resident council meeting on 10/16/2024 at 10:02 AM Residents 51, 71, 8, 7 and 28 were in attendance 3 of the 5 residents reported the following concerns: Resident 51 stated they had not had a hot meal in years., Resident 71 stated the food was cold and the breakfast was the worst and always cold. Resident 8 stated the food 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 staff compliance with current infection control guidelines and standards of practice by staff not following the guidance for a sign that was posted on the transmission based precaution (TBP) rooms for donning (putting on) personal protective equipment (PPE); and not adhering to fit testing (to ensure a proper fit) guidelines for an N-95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for 3 of 5 staff (Staff AA, T, and K). During a COVID- 19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of illness)…

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 resident, Resident Representative (RR), or payee were notified when their personal funds account reached a balance that was below $200 of the Social Security Income (SSI, a monthly Social Security benefit for people with low incomes, limited resources and who are blind, disabled or 65 or older) resource limit of $2000, for 1 of 5 residents (Resident 64) reviewed for personal funds. This failed practice placed the resident at risk of losing their Medicaid (a federal system of health insurance for those requiring financial assistance) or SSI eligibility. Findings included . Review of a policy titled Heritage Grove Trust Procedures dated 10/29/2024, showed the facility must inform the resident or the Resident's Representative (RR) when their trust balance was within $200.00 of the social security limit of $2000.00 and a copy of notification would be put in the resident's financial file. The policy also showed the Social Services Director (SSD) would be notified. <Resident 64> Review of the resident's 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 interview and record review, the facility failed to ensure a Resident's Representative (RR) was fully informed of a change of condition for 2 of 4 residents (Resident 68 and 79) reviewed for nutrition. The facility failed to inform the RR of severe weight loss. This failure denied the RR the right to be involved and make decisions regarding the care and treatment of the resident. Findings included . <Resident 68> Record review showed the resident was admitted to the facility with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and failure to thrive (a progressive functional deterioration of a physical and cognitive nature). Review of the 08/23/2024 quarterly Minimum Data Set (MDS, a required assessment and care planning tool) showed that the resident had a weight of 149 pounds (lbs, a unit of weight measurement), had no weight loss,…

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 personal privacy for 1 of 4 residents (Resident 245) observed for incontinent care and 1 of 1 resident (Resident 293) observed after a fall. This failure placed the residents at risk for loss of the right to personal privacy. Findings included Record review of the facility's policy titled, Privacy and Confidentiality, dated 07/2018, showed that each resident had the right to privacy during personal care. Record review of the facility's policy titled, Respect and Dignity, dated 09/20/2022, showed that the residents had the right to be treated with respect and dignity. <Resident 245> Record review showed Resident 245 was admitted on [DATE] with diagnoses to include stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), depression, and pain. Review of the incomplete comprehensive admission assessment showed that on 10/04/2024 the resident had…

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

Based on interviews and record review the facility failed to report an incident involving a missing resident in a timely manner to local law enforcement (LLE) and the State Agency (SA) as required for 1 of 5 residents (Resident 143) reviewed for missing persons. This failure disallowed an opportunity for LLE to assist in the search of Resident 143 and placed the residents at risk for harm related to unrecognized and uninvestigated abuse and/or neglect. Findings included . A review of the Nursing Home Guidelines or The Purple Book, dated October 2015 showed that facilities were required to report a missing resident to Law Enforcement and the State Agency Hotline in a timely manner. <Resident 143> Review of the medical record showed the resident was admitted to the facility with diagnoses including stroke (occurs when blood flow to the brain is cut off, which can damage and kill brain cells), frontal lobe deficit (causes personality changes, difficulty concentrating or planning, impulsivity), and psychoactive substance abuse (the use of illegal/legal drugs or alcohol for purposes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse, for one of five sampled residents (Resident 4), reviewed for abuse. The failure to complete a thorough investigation placed the resident at risk for potential abuse and other negative health outcomes. Findings included . Review of the facility policy dated 11/2017, titled, Freedom from Abuse, Neglect and Exploitation showed when the facility had identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The policy discussed the need for taking steps to prevent further potential abuse, report the allegation to appropriate authorities within required timeframes, and conduct a thorough investigation of the allegation. <Resident 4> Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses to include dementia (a loss of mental ability severe enough to interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident admission Minimum Data Sets (MDS, a required assessment and care planning tool) were completed within the required timeframes for 2 of 3 residents (Residents 293 and 245) reviewed for admission assessments. Failure to complete admission within the required timeframes placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's) showed the admission Assessment Reference Date (ARD, refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process) should be completed no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). <Resident 293> Record review showed Resident 293 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, bipolar disorder (a mood disorder…

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 significant change assessment had been completed for 1 of 2 residents (Resident 79) reviewed for hospice and end of life care. This failed practice placed the resident at risk for unmet care needs due to their imminent decline in health. Findings included . Review of the Resident Assessment Instrument Manual (RAI, a manual directing staff on how to accurately assess the status of residents), dated 10/2023, showed a significant change assessment was required when a resident was placed on hospice for a terminal prognosis, with a life expectancy of six months or less. <Resident 79> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), delusions (fixed, false conviction in something that is not real or shared by other people), and hallucinations (an experience in which you see, hear, feel, or smell something that does not exist). The 07/15/2024…

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/or implement comprehensive resident centered care plans for 2 of 3 residents (Residents 73 and 18) reviewed for care planning in the areas of accident prevention and edema (extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease). This failed practice put residents at risk for unmet care needs. Findings included . <Accident Prevention> <Resident 73> Record review showed Resident 73 was admitted with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and depression. Review of the 08/14/2024 comprehensive assessment showed the resident had severe cognitive impairment and was independent with meals. Record review of a 11/06/2023 nursing admission assessment showed Resident 73 was identified at a safety risk when drinking hot beverages and required lids on their coffee cups. Record review of Resident 73's care…

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 prevent the development of a pressure ulcer (PU, localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer and may be painful) for 1 of 3 residents (Resident 293) reviewed for pressure ulcers. This failure placed the resident at risk for worsening of the wound, increased discomfort and a diminished quality of life. Findings included . Record review of the facility's policy titled, Skin Integrity, dated 08/2018, showed that the facility would provide care, consistent with professional standards of practice, to prevent pressure ulcers, promote healing and prevent new ulcers from developing. Pressure ulcers would be staged according to professional standards of practice. Review of The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed Pressure Ulcer Stages as follows: • Stage 1- Intact skin with a localized area of non- blanchable erythema…

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 care and services were provided for 1 of 2 residents (Resident 51), reviewed for restorative nursing 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 a decrease in mobility, developing/worsening of contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and unmet care needs. Findings included . Review of a policy titled, Restorative Nursing programs, revised 06/2018, showed the goal of the Restorative Program was to assist residents in obtaining and maintaining their highest practicable functional levels, prevent unnecessary declines, and provide an active and healthy living environment. <Resident 51> Review of the medical record showed Resident 51 was admitted to the facility on [DATE] with diagnoses to include quadriplegia (complete…

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 consistently monitor or implement interventions per Registered Dietician (RD) recommendations for 2 of 4 residents (Residents 79 and 83) reviewed for nutrition. This failure placed the residents at risk for continued significant weight loss and the loss of nutritional satisfaction. Findings included . <Resident 79> Review of the resident's medical record showed they were admitted with diagnoses of schizoaffective disorder (a mental health disorder with symptoms of delusions [fixed, false conviction in something that is not real or shared by other people] and hallucinations [an experience in which you see, hear, feel, or smell something that does not exist]) and malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). Review of the 07/15/2024 comprehensive assessment showed Resident 79's cognition was severely impaired and required set-up assistance for eating. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis services met professional standards of care for 1 of 1 resident (Resident 193) reviewed for dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream). This failure placed residents receiving dialysis at risk for unmet care needs and medical complications. Findings included . The facility's policy titled Quality of Care Dialysis, dated 05/2019, showed the facility would provide residents who require dialysis care and services consistent with professional standards of practice. The facility and the dialysis center would collaborate to assure that the resident's needs related to dialysis treatments were being met. There would be ongoing communication and collaboration between the nursing home and dialysis staff for the development and implementation of the dialysis care plan. <Resident 193> Review of Resident 193's medical record showed the resident was admitted to 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 ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and discarded when expired on one of two medication carts (Halls 1 and 2) and one of two medication rooms (Main Nurse's station), reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medication. Findings included . <Main Nurse's Station> A concurrent observation and interview on 10/22/2024 at 3:46 PM, showed as follows: • two glucagon (a medication that controls sugar in the blood) shots that expired on 08/20/2024 and 06/05/2024, and one unlabeled glucagon shot. • 50 Needles Size 18 gauge (refers to the thickness of the needle and the size of the hole that the medication passes through) expired 08/31/2024. • Resident 16's Valproic Acid (a brand of medication used for seizures) one full bottle, and one opened bottle with 200 milliliters (ml, a unit of measure) that expired on 06/22/2024 Medication refrigerator: • 12 hemorrhoidal suppositories (a medication used…

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 each resident's medical record was complete and accurately documented their Physician Orders for Self-Sustaining Treatment (POLST, a form that communicates a person's wishes for health care treatments during a medical emergency) for 2 of 3 residents (Resident 67, 73) reviewed for advanced directives. This failure put residents at risk for staff not knowing if they want cardiopulmonary resuscitation, (CPR, an emergency, lifesaving procedure) or do not resuscitate, (DNR, an order that a person had decided not to have CPR if their breathing and heart stopped.) Findings included . Record review of the facility's policy titled, Resident Records - Identifiable Information, 07/2018, showed that the facility would maintain a complete and accurate medical record in accordance with accepted professional standards and practices. <Resident 67> Medical record review showed Resident 67 was admitted with diagnoses to include chronic obstructive pulmonary…

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 a resident's right to be free from verbal and physical abuse for 1 of 6 residents (Resident 1) reviewed for abuse. This failure placed the resident at risk for further abuse, injury, and diminished quality of life. Findings included . Record review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 09/20/2023, showed that the facility will provide protections for the health, welfare, and rights of each resident by prohibition and prevention of abuse. <Resident 1> Review of the medical record showed Resident 1 was admitted on [DATE] with diagnosis including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and depression. Review of the 03/01/2024 comprehensive assessment showed that the resident had severe cognitive impairment and required extensive assistance from staff…

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 complete and accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quarter (3rd Quarter, 2023), reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure had the potential to impact resident care and services for all residents. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility reported 27,934 direct care hours for the period of July 2023, August 2023, and September 2023. Review of the facility's daily staffing assignments for July 2023, August 2023, and September 2023 and employee payroll data validated that the additional 115.71 direct care hours had not been included in the original PBJ submission for the third quarter in 2023. During an interview on 03/19/2024 at 10:40 AM, Staff B, Business Office Manager (BOM), stated that they were able to determine that 115.71…

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 effective interventions to protect a resident from physical abuse for 1 of 6 residents (Resident 2) reviewed for resident-to-resident incidents. This failed practice placed all residents in the secured unit of the facility at risk for abuse and/or further abuse, and unmet psychosocial needs. Findings included . <Resident 1> Review of Resident 1's medical record showed the resident admitted to the secured unit of the facility on 09/14/2023 with diagnoses to include Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions), and has difficulty speaking, The comprehensive assessment dated [DATE], showed Resident 1's decision making skills were moderately impaired, they had verbal behavior symptoms that were directed towards others that did not impact themselves or others. The assessment further 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 interview and record review, the facility failed to develop and implement a process to ensure culturally competent, trauma-informed care related to assessing for a history of traumatic life events or post-traumatic stress disorder (PTSD, a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and identifying triggers in accordance with professional standards of practice for 1 of 3 residents (Residents 1) reviewed for trauma informed care. This failure placed the residents at risk for unidentified triggers, re-traumatization, and unmet care needs. Findings included . <Resident 1> Review of Resident 1's medical record, showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (A group of symptoms that affects memory, thinking and interferes with daily life), depression, and anxiety (a group of mental health conditions that cause…

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 store, prepare, distribute, and serve food in accordance with professional standards for food services regarding, 1) Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) and dry goods that did not have the proper labels and dates for food safety tracking for 1 of 1 kitchen reviewed, 2) Staff implementation of standard hygienic practices with not wearing hair nets or performing proper hand washing/glove changing during food preparation for 1 of 1 meal tray serve out, and 3) sanitation of food preparation areas that were not adequately disinfected to prevent cross contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses and diminished quality of life. Findings included . Review of the Washington State Retail Food Code [PHONE NUMBER]6(1)(2)(a,b)(3)(4), dated March 1, 2022 showed ready-to-eat…

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 implementation of infection prevention and control precautions in the following areas : 1) COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of that or smell, and in severe cases difficulty breathing that could result in severe impairment or death) testing of residents, for three 3 of 6 residents (Resident 89, 11, and 13) reviewed for COVID-19 testing; 2) fit testing of N95 (a National Institute for Occupational Safety and Health [NIOSH] approved respirator that has straps around the back of the head to create a tight seal that filters varying levels of particles in the air) respiratory masks for 62 of 147 staff reviewed for N95 mask fit testing; and 3) hand hygiene during COVID-19 testing and meal service for residents. These failures placed the residents at an increased risk for exposure to cross…

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 observations and interview, the facility failed to ensure a clean, comfortable living environment for 8 of 8 sampled residents (Resident 23, 78, 83, 68, 34, 86, 60 and 67), including 2 of 2 resident rooms and 2 of 3 hallways reviewed for homelike environment. The failure to 1) ensure the ambient temperature in the secure unit was safe and comfortable, 2) replaced or repaired window trim, and 3) ensure the facility was free from worn carpet and urine odors, placed the residents at risk for injury, compromised dignity, and a decreased quality of life. Findings included . <Ambient air temperature> <Resident 23> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including heart failure and dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning). The 07/03/2023 comprehensive assessment showed the resident required extensive assistance of two staff members for ADLs. The assessment also showed the resident had…

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

Based on interview and record review, the facility failed to address concerns that were voiced during resident council meetings, for 6 of 6 months (Febuary 2023 through July 2023) of resident council minutes reviewed. Additionally, Resident 1's representative stated they had not had any response from the facility concerning a greivance for Resident 1. Failure to timely address and implement interventions to address identified concerns, resulted in the Resident Council process being ineffective in improving resident quality of life. Findings included . Review of facility's undated 'Resident Council Meeting' policy showed the liaison (Activity Staff) shall be responsible for providing assistance with facilitating successful group meetings .and act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Additionally, a Resident Representative for (Resident 1) did not recieve a follow up response for a greivance filed on 08/10/2023. This failure placed the residents,…

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 abuse prohibition policies and procedures related to 1) screening for 3 of 10 staff (Staff I, J, and K) for background checks, 2) providing thorough and complete training at orientation and before the new staff member had contact with residents for 10 of 15 staff (Staff G, F, Z, BB, EE, KK, LL, MM, NN and TT ), and 3) prevention and protection after a resident to resident altercation for 1 of 6 residents (Resident 89), when the lack of monitoring and implementation of appropriate interventions lead to an alleged perpetrator having access to the victim. These failures placed all residents at risk for potential and/or further abuse, neglect, misappropriation of property, and exploitation. Findings included . Review of the facility policies titled Policy and Procedures of Investigating and Reporting Abuse and Allegations of Abuse, dated 03/2014, Abuse/Neglect - Reporting/Response, dated 07/13/2011, and Abuse/Neglect - Identification,…

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

Based on interview and record review, the facility failed to ensure nursing staff had documented competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares), and skill sets including the demonstration of competency in skills to provide care and services for each resident in accordance with professional standards and individualized resident care needs for 14 of 15 nursing staff (Staff G, F, H, Q, V, Z, BB, EE, KK, LL, MM, NN, TT, and DDD) reviewed for staff competencies. This deficient practice placed all residents at risk of unmet care needs and a diminished quality of life. Findings included . Review of facility's assessment tool dated 04/28/2023 showed the facility evaluated their resident population care needs and identified that staffing training with education and competencies were a necessary requirement in providing the level and type of support/care needed for their residents. Additionally, the facility assessment showed that urinary catheters (a tube that drains urine 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 serve meals that were at a safe temperature and appetizing for 7 of 10 residents (Residents 9, 21, 36, 40, 44, 64 and 68) reviewed for food quality. This failed practice placed all residents at risk for decreased nutritional intake and food borne illness. Findings included . Review of the facility policy and procedure titled, Food Temps, Dated 11/20/2017, showed that food is to be served in such a manner to be attractive and temperatures are safe and acceptable to residents. The policy further stated that they are to deliver food carts to their proper destination immediately. And that Hot foods will be held at a minimum of 140 degrees Fahrenheit (F) and Cold foods will be held at a maximum of 41 degrees Fahrenheit (F). During a resident council meeting on 08/24/2023 at 10:18 AM the following concerns were voiced during the meeting: Resident 21 stated that all they did was wait for meals. Breakfast was not until 9:00 AM. They further stated the food was cold sometimes, I tell them they don't do anything…

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 implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing services to residents and annually, related to: 1) mandatory effective communications for 7 of 15 staff (Staff Z, BB, KK, LL, MM, NN, and TT), 2) activities that constitute abuse/neglect, procedures for reporting incidents of abuse/neglect and dementia management regarding abuse prevention for 10 of 15 staff (Staff F, G, Z, BB, EE, KK, LL, MM, NN, TT) and, 3) mandatory Quality Assurance and Performance Improvement (QAPI), for 10 of 15 staff (Staff F, G, Z, BB, EE, KK, LL, MM, NN, TT) reviewed for training requirements. This failure placed residents at increased risk for unidentified abuse/neglect, and inadequate care from unqualified staff. Findings included . Review of facility's assessment tool, dated 04/28/2023, showed the facility evaluated the resident care needs and identified staff training requirements necessary to provide the level and type of support/care needed for 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.

Based on interview and record review, the facility failed to provide documented evidence of the required annual 12-hours of in-service training for 5 of 10 staff (Staff Q, Z, KK, LL, and NN), reviewed for Nursing Assistance (NA) continuing competencies training. This deficient practice placed the residents at risk of being cared for by inadequately trained staff, and unmet care needs. Findings included . <Staff Q> Review of the staff personnel records showed Staff Q, NA, was hired on 08/23/2022. Review of the facility's training records showed Staff Q did not completed the required 12 hours of trainings and/or in-services within the last year. <Staff Z> Review of the staff personnel records showed Staff Z, NA was hired on 12/23/2019. Review of the facility's training records showed Staff Z did not completed the required 12 hours of trainings and/or in-services within the last year. <Staff KK> Review of the staff personnel records showed Staff KK, NA was hired on 12/08/2020. Review of the facility's training records showed Staff KK did not completed the required 12 hours of trainings…

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 a dignified dining experience while staff were conversating with each other and not engaged with the residents during mealtime and referred to the residents as feeders for 8 of 8 residents (Residents 3, 19, 80, 41, 43, 79, 36 and 84), reviewed for dining. This failure placed residents at risk to feel diminished and embarrassed. Findings included . Review of Centers for Medicare and Medicaid Services (CMS) guidance §483.10(a)-(b)(1)&(2) in Appendix PP, last revised on 02/03/2023 . for treating residents with dignity and respect while dining, showed staff were to avoid conversing with each other while providing assistance with meals. Staff were to address residents with their name or pronoun of choice and avoid the use of labels such as feeders. Staff were also to refrain from practices that were demeaning to residents. <Resident 3> Review of the resident's 06/09/2023 comprehensive assessment showed they required extensive assistance with one-person physical assistance while eating. The assessment also…

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 properly fitted mobility equipment for 1 of 2 residents (Resident 80), reviewed for accommodation of needs for comfort and positioning. This failure placed the resident at risk diminished comfort and dignity. Findings included . <Resident 80> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including encephalopathy (a brain disease that can cause difficulty in thinking, muscle twitching, weakness, and impulsive behavior) and cachexia (extreme weight loss and muscle loss). The 06/12/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff for activities of daily living (ADLs) and required a wheelchair for mobility. The assessment also showed the resident had a severe impaired cognition. Review of the 05/18/2023 physician orders, showed the resident may have a tilt-in-space wheelchair for comfort. Review of the 03/08/2023 Physical Therapy…

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 physical and verbal abuse by another resident and prevent actual and potential further abuse for 1 of 6 residents (Resident 89), reviewed for allegations of abuse. The facility allowed the alleged perpetrator to continue to share a room with the alleged victim after an incident of abuse. This failure placed the resident at risk for further abuse and a diminished quality of life. Findings included . Review of the facility's Abuse policy revised date 12/02/2014, showed that abuse was any action that caused injury, intimidation, or punishment to a person including physical, verbal, emotional or mental abuse. <Resident 62> Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including respiratory failure, depression, and agitation. The 08/23/2023 comprehensive assessment showed the resident required limited assistance of one to two staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding multiple non-pressure skin wounds that were not consistently assessed, monitored, and/or had wound care treatment completed for 1 of 3 residents (Resident 244) reviewed for non-pressure related skin issues. These failures placed residents at an increased risk for unmet care needs, untreated skin impairments, and a diminished quality of life. Findings included . Review of the facility's policy titled, Skin Assessment, unknown date, showed that a full body skin assessment would be conducted by a licensed nurse .upon admission/re-admission, daily for three days, and weekly thereafter . and that the assessment was one approach to skin injury prevention and management. Additionally, the documentation of the skin assessment would include the type of wound, observation of skin conditions, description of the wound (measurements, color, type…

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 received necessary treatment and services, consistent with professional standards of practice for 1 of 3 residents (Resident 64), reviewed for pressure ulcers. The failure to thoroughly assess, consistently monitor, and/or ensure consistent and timely provision of ordered skin care and treatments placed residents at risk for deterioration in skin condition and decreased quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) November 2016, Pressure Ulcer Definition and Stages: A Pressure Ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The pressure ulcer can present as intact skin or an open ulcer and may be painful. This occurs as result of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction). A Stage 2 Pressure Ulcer:…

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 residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 1 resident (Resident 244), reviewed for urinary catheter care. This placed the residents at risk of developing medical complications, secondary to an infection in the bladder. Findings included . Review of the facility's policy titled, Care & emptying of catheter and bag, dated 05/19/2011, showed that during the catheter care process, staff were to perform perineal care (cleaning of the private area, including genitals and rectal areas of the body), then proceed to clean the location where the urethral meatus and the IUC tube meet, cleaning down the tube, away from the residents…

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 pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections like pneumonia and blood infections) were administered to 5 of 9 residents (Resident 82, 62, 245, 86, and 64) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease, and a decreased quality of life. Findings included . Review of the facility policy titled, Influenza and Pneumococcal Vaccines, revised on 06/09/2023, showed pneumococcal vaccines would be made available for residents. All residents would receive information related to the risks and benefits of the immunization. The resident record would reflect the provision of education and the administration or refusal of the immunization. The consent or declination would be documented in the resident's medical record. <Resident 82> Review of the medical record showed the resident was admitted…

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.