Landmark Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice for 2 of 3 residents (Residents 33 and 27), reviewed for quality of care. This failure placed the residents at risk for unmet care needs and negative health outcomes. Findings included . <Resident 33> Review of the electronic medical record showed Resident 33 was admitted to the facility on [DATE] with diagnoses including a fracture to the right wrist, end stage renal disease (ESRD) with dialysis three times a week, diabetes, depression and heart disease. The comprehensive assessment dated [DATE] showed Resident 33 required moderate assistance of one to two caregivers for activities of daily living (ADLs) and was cognitively intact. During an observation and interview with Resident 33 on 06/10/2025 at 9:10 AM, showed them lying on their back in bed. A skin tear was noted on the top of their right…

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 3 of 6 sampled residents (Residents 19, 27, and 10) reviewed in a Restorative Nursing Program (RNP) for positioning, range of motion (ROM), and hand splinting, received consistent services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of consistently following documented care plans and providing services to identified residents. This failure of not following the restorative care plans on a consistent basis increased the residents at risk of being unable to maintain their current level of functioning. Findings included . A review of the 11/15/2023 Restorative Nursing Plan policy showed residents will receive restorative nursing care as needed to promote safety and independence. Restorative nursing care consists of nursing interventions .goals and objectives are 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.

Based on observation, interview, and record review, the facility failed to ensure that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder (develops in some people who have experienced a shocking, scary, or dangerous event) for 1of 2 residents (Resident 64) reviewed for mood and behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . During an observation and interview with Resident 64 on 06/10/2025 at 9:24 AM, showed them sitting in their wheelchair at the sink in their room combing their hair. A bandage was placed on the stump of Resident 64's lower left leg, which they stated was due for a dressing change that day. Resident 46 stated they were feeling depressed due to their recent amputation and still did not understand what had happened to cause the amputation. They stated the stump wound was not healing well,…

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 develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) care plan in collaboration with contracted hospice services, that identified the provider responsible for performing each or any specific services/functions for 2 of 3 sampled residents (Residents 21 and 43) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services. Findings included . Review of a policy titled Hospice, dated 03/2024, showed each resident's care plan would include both the most recent hospice car plan and the facility's care plan to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. <Resident 21> Review of the medical record showed the resident admitted to the facility with diagnoses including end stage renal disease (when your kidneys have permanently stopped working). The 05/16/2025 comprehensive assessment showed Resident 21's cognition…

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 funds were transferred to the Resident's Representative (RR) within 30 days of death, for 1 of 2 discharged residents (Resident 120) reviewed for conveyance of funds to the RR after death of Resident. This failure placed the RR at risk for loss of funds. Findings included . <Resident 120> Review of the medical record showed the resident was readmitted to the facility on [DATE] from the hospital on private pay hospice care. The resident passed away on 11/09/2024. The RR was asked to pay a full month of room and board at the facility which was $11,800.00. During an interview on 06/09/2025 at 11:35 AM, Staff GG, Business Office Manager, stated they had a conversation with the RR on 11/08/2024 and stated the money would be refunded the money that was not used for Resident 120's care. Review of the06/10/2025 Transaction Report for November 1, 2024, through June 30, 2025, showed the RR was owed a $11,800.00 refund. During an 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 develop a baseline care plan within 48 hours of admission that documented resident specific goals, physician orders, treatment plans and social services needs for 5 of 5 residents (Residents 1, 2, 3, 4 and 5) reviewed for baseline care plan. This failure place residents at risk of not receiving necessary care and services and continuity of care. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including paralytic syndrome (loss of muscle function/feeling), bleeding around the brain and chronic pain. The 01/15/2025 comprehensive assessment showed Resident 1 required maximal assistance of one to two staff for activities of daily living (ADLs) and was able to make their needs known. Review of Resident 1's admission nursing assessment dated [DATE], showed they had identified a sacral (relating to the sacrum [a triangular shaped bone at the base of the spine, forming the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to privacy, security, and confidentiality when a staff member relayed confidential information to a visiting family member for 1 of 1 resident (Resident 2) reviewed for personal privacy/confidentiality of records. This failed practice placed residents at risk for the loss of confidentiality and privacy and the right to have their preferences honored. Findings included . <Resident 2> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include an infection in their digestive system. The 06/21/2024 comprehensive assessment showed the resident's cognition was intact. During an interview on 08/23/2024 at 12:25 PM, the Resident's Representative (RR) stated Resident 2 discharged from the facility to the hospital on [DATE]. The RR stated Resident 2 had a urine infection that had gone into their blood stream and required hospitalization. The RR stated the infection had made…

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 residents received care and services according to standards of practice when they failed to timely implement their grievance process for 3 of 3 residents (Residents 3, 4, and 5) reviewed for grievances. This failed practice placed residents at risk for unmet care needs. Findings included . Review of a policy titled Grievances/Concerns dated 09/26/2022, showed the Grievance Officer (GO) was responsible for ensuring the grievance process was followed through with from beginning to completion. Once the grievance was resolved by the department manager assigned to the grievance and the resident was provided a follow-up, the department manager was to provide a written report of the findings to the Administrator and the GO within five working days. <Resident 3> Review of the resident's medical record showed the resident admitted with diagnoses to include a fracture of their left knee and muscle weakness. The 07/05/2024 comprehensive assessment showed the resident's cognition was intact. Review of a written grievance…

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 report suspected allegations of abuse and/or neglect to the State Agency for 1 of 1 resident (Resident 1) reviewed for abuse/neglect. This failed practice placed the residents at risk for unidentified and ongoing abuse and/or neglect. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include dementia (a group of diseases and conditions that affect your thinking, memory, reasoning, personality, mood and behavior), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of worry, nervousness, or unease). The 05/21/2024 comprehensive assessment showed Resident 1's cognition was severely impaired. During an interview on 08/23/2024 at 12:25 PM, a collateral contact (CC) discussed an allegation of abuse involving a resident, later identified to be Resident 1 and the alleged perpetrator (AP) Staff C, Occupational Therapist (OT, a specialist that performs a treatment that…

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

Based on observation, interview, and record review, the facility failed to conduct a thorough investigation into an allegation of abuse and did not protect the resident from further potential abuse when the Alleged Perpetrator (AP) was not removed for 1 of 1 resident (Resident1) reviewed for abuse. This failed practice placed residents at risk for unidentified abuse, unmet emotional needs, and the continued exposure to abuse and/or neglect. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include dementia (a group of diseases and conditions that affect your thinking, memory, reasoning, personality, mood and behavior). The 05/21/2024 comprehensive assessment showed the resident's cognition was severely impaired. During an interview on 08/23/2024 at 12:25 PM, the Collateral Contact (CC) reported an allegation to the facility involving Staff C, Occupational Therapist (OT, a specialist that performs a treatment that helps people improve their ability to perform daily tasks) and Resident 1, 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 document in the medical record any discussions regarding Advanced Directives (AD), including incorporation into the care planning process, for 2 of 3 residents (Residents 1 and 2) 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 Advance Directives, dated 10/29/2023, showed the facility would help residents, who did not have an AD in place, to establish one, and nursing staff would document the resident's decision to accept or decline assistance in the medical record. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of surgical after care for abscess and injury to urinary bladder, muscle weakness, and mild cognitive impairment. Review of the comprehensive assessment, dated 06/25/2024, showed Resident 1 required the assistance of one…

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 there were sufficient numbers of competent nursing staff to provide care and services for 14 of 14 residents (Residents 54, 10, 5, 28, 55, 25, 41, 20, 60, 59, 2, 3, 26, and 276) as evidenced by failures related to Resident Rights, Resident Mobility, Activities of Daily Living (ADLs), Quality of Care, Urinary Catheters, Pressure Injuries, Accident Prevention, Infection Control Practices, and Competent Staff. Additionally, reports in the facility grievance logbook, resident council meeting interviews, and staff interviews provided evidence of insufficient staff. 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-550 Resident Rights> The facility failed to provide an environment that enhanced and prompted a dignified lifestyle. <Resident 54> On 05/20/2024 at 9:30 AM Resident 54 stated they had not had a shower on Saturday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage [(NOMNC) a notice that indicates when your care is set to end from a skilled nursing facility] as required for 3 of 3 residents (Resident 280, 281, and 67) reviewed for beneficiary notification. Additionally, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] for 1 of 1 resident (Resident 67) reviewed for ABN requirements. These failures placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay. Findings included . Review of a policy titled, Issuing a Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice of Non-Coverage (ABN), dated 10/29/2023, showed a NOMNC would be issued two calendar days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive resident-centered care plans consistent with the residents identified care needs for 2 of 6 residents (Resident's 4, and 60) reviewed for accuracy of care plans. This failure placed residents at risk for not receiving appropriate goods and services consistent with their identified care needs. Findings included . <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including heart failure, obstructive sleep apnea (a sleep disorder that keeps you from breathing normally while you sleep), diabetes (a group of diseases that result in too much sugar in the blood), and end stage renal disease (the last stage of kidney disease where the kidneys can no longer support the body's needs). The 05/03/2024 comprehensive assessment showed Resident 4 required supervision/minimal assistance of one staff member for dressing and oral hygiene and was dependent 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 observation, interview, and record review the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 5 of 11 residents (Residents 5, 28, 54, 55, and 10) reviewed for activities of daily living (ADLs). The failure to receive adequate showering and grooming care according to the residents' care plan placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment. Findings included . Review of a facility policy titled, Activities of Daily Living (ADLs), dated 06/2023, showed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. In addition, the policy showed residents that were unable to carry out ADLs independently would receive the necessary services to maintain good nutrition, grooming, personal care, and oral hygiene. <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility on [DATE] 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 observation, interview, and record review, the facility failed to ensure 2 of 4 residents (Resident's 7 and 26), reviewed for unnecessary medications, had adequate monitoring and assessment for the use of psychotropic medications (medications that alter brain activity of mental functioning and behavior). The facility did not ensure as needed psychotropic medications had stop dates as required or consistently perform assessments for abnormal voluntary movement (AIMS) testing with the use of antipsychotic medications [a class psychotropic medication that has a high risk for serious adverse side effects (ASE)]. Additionally, the facility failed to conduct quarterly Interdisciplinary Team [(IDT) a group of healthcare professionals that bring together knowledge from different health care disciplines to help people receive the care they need] reviews to ensure the psychotropic medications were appropriate or if a gradual dose reduction (GDR) could be attempted. These failures placed residents at risk 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 enhanced barrier precautions [(EBPs) an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities] were implemented for 7 of 7 Residents (2, 3, 20, 26, 41, 60, and 276) reviewed for infection control practices. The failure to identify, provide appropriate signage, and educate residents and staff on the need for EBPs placed all residents at risk for exposure, transmission of MDRO's, and serious medical complications. Findings included . According to the Centers for Medicare and Medicaid Services document titled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, showed EBPs were used along with standard precautions and expanded the use of PPE to donning (put on) of gown and gloves during high-contact resident care activities that provided opportunities for transmission of Centers for Disease Control 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 maintain resident care equipment in a fully functional manner, for 3 of 3 mechanical lifts (Lift's 1, 2, and 3) reviewed for safety. This failure placed residents who were dependent for transfers at risk for injuries and potential harm. Findings included . <Lift 1> Observation on 05/17/2024 at 10:15 AM showed Lift 1 stored outside of the South Hall Dining Room. On the arm of the lift was a red emergency manual safety feature for lowering the mechanical lift arm in the event it malfunctioned. The emergency feature was loose, stripped and was no longer working. The motor box located at the base of the lift was broken with wires hanging down. It was also noted that the remote control did not match the make and model of the lift. <Lift 2> During an observation on 05/17/2024 at 10:30 AM showed Lift 2 stored on the South hall outside of room [ROOM NUMBER]. Lift 2 was observed to have the same red emergency feature for the manual lowering 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 provide care in a manner that promoted resident respect and dignity for 3 of 3 residents (Residents 54, 10, and 5) reviewed for dignity. The failure to shower residents on a regular basis placed the residents at risk for distress, embarrassment, and an undignified existence. Findings included . Review of the facility admission agreement titled, Welcome to Landmark Care and Rehabilitation, dated 07/12/2021, showed the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. <Resident 54> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include Polymyalgia Rheumatica (an inflammatory disease causing inflammation, muscle pain, and stiffness around the shoulders and hips), osteoarthritis (a type of arthritis that occurs when tissue at the ends of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice to the resident and their representative of the facility's intention and justification for the discharge of 4 of 4 residents (Resident 50, 4, Unidentified Resident 1, and Unidentified Resident 2) reviewed for facility-initiated discharges. Additionally, the facility failed to send a legible copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes). This failed practice disallowed the resident and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharge. This failure also placed the resident at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 1 of 2 residents (Resident 50) reviewed for hospital transfers. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital. Findings included . Review of the policy titled, Bed Hold Policy Notification 2024, updated 01/11/2024, showed residents were able to retain their bed when they were discharged to the hospital or on a therapeutic leave. The resident and/or their representative must sign and return the Bed Hold Policy Notification 2024 form to the business within 24 hours of receipt of the form if they chose to retain their bed. <Resident 50> Review of the medical record showed Resident 50 was admitted to the facility on [DATE], readmission on [DATE], with diagnoses…

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 accuracy and completion of a Preadmission Screening and Resident Review (PASARR) for 2 of 7 residents (Residents 10 and 36) reviewed for PASARR Level 1. This failed practice placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . <Resident 10> Review of the medical record showed Resident 10 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event], and heart failure. The 05/24/2024 comprehensive assessment showed Resident 10 required substantial/maximal assistance of one staff member for activities of daily living; dependent on one to two staff members for toileting,…

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 provide to the resident and/or resident representative, a baseline care plan within 48 hours of admission that documented resident specific initial goals, physician orders, and treatment plans for 2 of 2 newly admitted residents (Residents 20 and 59) reviewed for baseline careplans. This failure placed the residents at risk of not receiving continuity of care and resident centered care needs. Findings included . Per the F-655 Federal requirement effective date 11/28/2017: The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. <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 ensure the ongoing review, coordination of care conferences, and revisions to care plans were implemented for 4 of 4 residents (Resident 28, 35, 54 and 55) reviewed for care planning. This failure placed the residents at risk for unmet care needs and decreased quality of life. Findings including . <Resident 28> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory), anxiety (a feeling of worry, nervousness, or unease), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The comprehensive assessment dated [DATE] showed Resident 28 required maximal assistance for activities of daily living (ADLs) and had moderate cognitive impairment. Review of Resident 28's medical record showed the last quarterly care conference held was dated 04/20/2023, and showed the resident, their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide goods and services that met professional standards of care for 1 of 1 resident (Resident 41) reviewed for quality of care. Resident 41 had referrals for follow up with specialized physicians (a group of physicians who focus on specific illnesses or diseases) related to their complicated medical condition. The facility failed to follow through with the referrals which placed the resident at risk for a decline in their health status. Findings included . <Resident 41> Review of Resident 41's medical record showed they were admitted to the facility on [DATE] with diagnoses including Paget's disease (a disease that disrupts the replacement of old bone tissue with new bone tissue), Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and a Stage 4 sacral pressure injury (a deep wound at the tail bone that involves muscle, tendon and exposed bone). The resident had an additional…

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 on 5/14/2024, 0505/15/2024, Based on observation, interview, and record review, the facility failed to provide services to prevent a potential reduction in range of motion for 2 of 2 residents (Residents 55 and 25) reviewed for range of motion and/or use of splints. This failure placed the residents at risk for decreased mobility and loss of independence. Findings included . <Resident 55> Review of Resident 55's medical records showed they were admitted to the facility on [DATE] with diagnoses including left side hemiplegia (the loss of the ability to move in part of the body), muscle weakness, and a need or assistance with personal care. Review of Resident 55's comprehensive assessment dated [DATE], showed the resident had moderate cognitive impairment. During a concurrent observation and interview on 05/14/2024 at 11:31 AM, Resident 55 had a brace on their left hand, the resident stated that they wore the brace daily. Review of the resident's care plan dated 04/22/2024, showed no updates to the care plan…

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 staff supervision during dining for 2 of 2 residents (Residents 20 and 59), and to provide a safe, functional environment for 5 of 5 shower rooms (South Hall shower room [ROOM NUMBER], shower room [ROOM NUMBER], North Hall shower room [ROOM NUMBER], shower room [ROOM NUMBER], and shower room [ROOM NUMBER]) reviewed for accidents. These failures placed the residents at risk of choking episodes, aspiration (when food or liquid enters the airways or lungs), access to toxic (a substance that can be poisonous or cause adverse health effects) chemicals, and dissatisfaction with their shower experiences. Findings included . <Dining Supervision> <Resident 20> Review of the medical record showed Resident 20 was admitted to the facility on [DATE] with diagnoses including pneumonia (a lung infection), dysphagia (difficulty swallowing), pleural effusion, (a buildup of fluid between the tissues that line the lungs and the chest), 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 adequate justification for the placement of a urinary catheter (a flexible tube inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) for 1 of 1 resident (Resident 54) reviewed for placement of a urinary catheter. Additionally, the facility failed to ensure the appropriate care and use of a urinary catheter for 1 of 1 resident (Resident 3) by positioning the catheter drainage bag below the level of the bladder to prevent infection during a transfer with the mechanical lift. This failure placed the residents at risk for urinary tract infections (UTIs) and serious medical complications. Findings included . Review of the Centers for Disease Control and Prevention Guidelines titled, Prevention of Catheter-Associated Urinary Tract Infections 2009, dated 06/06/2019, showed the Proper Techniques for Urinary Catheter Maintenance, included the catheter drainage bag must be kept below 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 provide respiratory care consistent with accepted standards of practice for 1 of 1 resident (Resident 2) reviewed for respiratory care and treatment. This deficient practice placed the resident at an increased risk of respiratory and tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe.) status complications, including infection and injury. Findings included . Review of an undated facility policy titled, Laryngectomy/Tracheostomy Stoma Care stated the purpose of this procedure is to guide Laryngectomy/Tracheostomy care and the cleaning of reusable cannulas, which did not apply to Resident 2. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including a total laryngectomy in 2016 (removal of the larynx, the part of the throat containing the vocal cords), tracheostomy care with a permanent laryngectomy stoma (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis services were consistent with professional standards of practice for 1 of 1 resident (Resident 4) reviewed for dialysis services. The failure to monitor Resident 4's condition before and after dialysis treatments, complete a comprehensive care plan, adhere to a fluid restriction, provide ongoing communication, and collaboration with the dialysis facility, ensure a current written agreement was in effect between the facility and the dialysis facility, and ensure policies and procedures were developed and implemented placed the resident at risk for complications and adverse medical conditions. Findings included . <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes (a group of diseases that result in too much sugar in the blood), and end stage renal disease (the last stage of kidney disease where the kidneys can no longer support the body'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 residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing, monitoring, or treating past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event] for 1 of 2 residents (Resident 10) reviewed for mood and behavior. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of an undated policy titled, Trauma Informed Care Purpose, showed the trauma informed assessment would identify a history of trauma or interpersonal violence, when possible. <Resident 10> Review of the medical record showed Resident 10 was admitted to the facility on [DATE] with a diagnosis of PTSD. The 05/24/2024 comprehensive assessment showed Resident 10 required substantial/maximal assistance of one staff member 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 licensed nurses had the specific competencies and skill sets, which included documented demonstration, necessary to safely and efficiently perform care for residents' needs in the area of Peripherally Inserted Central Catheter [(PICC) - a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term administration of antibiotics, medications, nutrition, and blood draws] line for 2 of 2 nursing staff (Staff Q and R) reviewed for staff competencies. This failure placed residents at risk for adverse outcomes related to PICC lines and unmet care needs. Findings included . Review of the [NAME] Manual of Nursing Practice, 11th edition, Unit 1, Chapter 6, titled, Intravenous[(IV) a needle inserted directly into a vein to deliver liquids to the blood stream) Therapy; Standards of Care Guidelines, dated 2024, showed the resident should be monitored frequently for signs of infiltration (the accidental leakage of IV…

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 mental and psychosocial health needs were identified and met for 1 of 1 resident (Resident 10) reviewed for behavioral health. Failure to identify and utilize person-centered interventions placed the resident at risk for unmet care needs. Findings included . <Resident 10> Review of the medical record showed Resident 10 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event] and depression. The 05/24/2024 comprehensive assessment showed Resident 10 required substantial/maximal assistance of one staff member for activities of daily living; dependent on one to two staff members for toileting, showering, and dressing. The assessment also showed the resident was cognitively intact. Additional review of the comprehensive assessment showed Resident 10 expressed little interest/pleasure…

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's physician order of heparin (a substance that slows the formation of blood clots) was not implemented as observed during the medication administration observation, resulting in a significant medication error for 1 of 3 residents (Resident 276) was free from significant medication errors. This failure placed the resident at risk for adverse complications from the significant medication error and an unmet care needs. Findings including . Review of the policy titled, Administering Medications, dated June 2023, showed that all medications would be passed according to physician orders and medication guidelines. The licensed nurse were to follow general guidelines for safe and accurate medication administration. Review of the Nursing 2023 Drug Handbook, 43rd edition, page 29, showed heparin had the following adverse reactions; commonly caused bleeding and could cause hypersensitivity or hemorrhage. Contraindicated in patients…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or their resident representatives (RR) provided an informed consent (the process in which a health care staff educates a resident and/or their RR about the risks, benefits, and alternatives treatment of a given procedure, intervention, or medication therapy and obtains the resident consent), in advance of implementing psychotropic (a type of drug [like antidepressants, anti-anxiety, and antipsychotics] that affects brain activities associated with mental processes and behaviors) medications for 2 of 3 residents (Residents 3 and 4) reviewed for psychotropic medications. This failure placed the resident and/or their RR at risk of not being fully informed, a lack of knowledge regarding the risks/benefits of psychotropic medications and prevented them from exercising their right to participate in treatment options. Finding included . Review of the facility's policy titled, Antipsychotic and Psychotropic Medication Use, dated…

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 an effective Quality Assurance Performance Improvement (QAPI) program that identified or corrected deficiencies related to the facility's skin program that did not meet professional standards for pressure injury care for 3 of 3 residents (Resident's 1, 2 and 8) reviewed for pressure injuries. This failure resulted in an emergent situation and placed other residents at risk to receive poor quality of care. Findings included . Refer to CFR 483.2 (b)(1) F 686 Treatment/Services to Prevent/Heal Pressure Ulcers During an interview on 03/12/2024 at 10:20 AM, Staff A, Administrator stated their QAPI process had not identified or corrected the deficient practice related to management and treatment of pressure injuries that resulted in resident harm. Reference WAC 388-97-1760(1)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure they did not employ staff with negative disqualifying crimes for 1 of 5 staff sampled, (Staff E) with a negative disqualifying finding on a background check for work with vulnerable adults. This failure placed residents at risk for possible abuse. Findings included . Record review of [NAME] Administrative Code (WAC) 388-97-1820 (1) showed (1) The nursing home must not employ directly or by contract, or accept as a volunteer or student, any individual: (a) Who has a criminal conviction or pending charge for a crime, which is automatically disqualifying under chapter 388-113 WAC; (b) Who has one or more of the following disqualifying negative actions. Record review of current Staff E's, Nursing Assistant (NA), personnel file showed they were hired on 03/27/2023 and had a background check dated 03/23/2023 which disqualified them from working with vulnerable adults. Review of the Residential Care Services (RCS) Character, Competence, and Suitability…

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 timely identify and initiate medical treatment for 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) present on admission for 1 of 3 residents (Resident 2) 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 . Review of The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed Pressure Ulcer Stages as follows: - Stage 2 pressure ulcer is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Fat and deeper tissues are not visible. These injuries commonly result from pressure and an adverse microclimate such as moisture associated skin damage (MASD, a term used to describe skin…

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 identify 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) present on admission, consistently document, and provide an off-loading mattress for 1 of 3 residents (Resident 3) reviewed for pressure ulcers. These failures placed residents at potential risk for development and/or worsening of pressure ulcers. Findings included . Review of The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed Pressure Ulcer Stages as follows: - Stage 2 pressure ulcer is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Fat and deeper tissues are not visible. These injuries commonly result from pressure and an adverse microclimate such as moisture associated skin damage (MASD, a term used to describe skin…

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 the trust funds and a final accounting of the trust funds for two of two residents (12 and 15) reviewed for final accounting of the trust funds, were returned within thirty days of discharge. This failure placed the residents and /or their representatives at increased risk for financial loss. Findings included . Review of the facility policy titled [Corporation] Trust Policy revised on [DATE], showed that all trust balances must be refunded to the resident within 14 days of discharge and 30 days of death. Resident 12. Review of the medical record showed that the resident was admitted to the facility on [DATE]. Diagnosis including high blood pressure, Atrial fibrillation ( an irregular, often rapid heart rate). The most recent quarterly assessment, dated [DATE], showed the resident was cognitively intact and required extensive assistance of two staff members for activities of daily living (ADLs), except for eating. The [DATE]…

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 thoroughly investigate neglect for one of two residents (38) reviewed for abuse and/or neglect. This failure prevented the facility from identifying the extent and nature of the occurrence and placed the resident at risk for unidentified neglect. Findings included . Record review of the facility's 09/12/2022 policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, showed the facility would identify and assess all possible incidents of abuse .Investigate and report any allegations of abuse within timeframes as required by federal requirements .Protect residents during abuse investigations. The policy further showed .Signs of Actual Physical Neglect .Improper use or administration of medication Resident 38. Review of the resident's admission record showed the resident admitted to the facility on [DATE] with diagnoses to include a chronic lung disease, respiratory failure, and anxiety (the sense of uneasiness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pre-Admissions Screening and Resident Review (PASARR) assessment was accurately completed upon or prior to admission to the facility or updated during a change in condition for three of six residents (8,16, and 21) reviewed for PASARR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health (MH) and/or developmentally disability (DD) care needs. Findings included . Resident 8. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), Post Traumatic Stress Disorder (PTSD, a mental health condition that's triggered by a terrifying event by either experiencing it or witnessing it), depression (a mood disorder that causes a persistent feeling of sadness and loss 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 provide care and services to maintain effective communication, hearing, and vision methods to carry out the activities of daily living for one of three residents (8), reviewed for communication and sensory. This failed practice put the resident at risk for unmet care needs, decreased independence, and a decreased quality of life. Findings included . Resident 8. Review of the resident's admission record showed the resident admitted to the facility on [DATE] with diagnoses to include legally blind, unsteady on their feet, and the need for assistance with personal care. The comprehensive assessment, dated 02/03/02023, showed the resident had moderate cognitive impairment, adequate hearing with the use of hearing aids, and highly impaired vision. The assessment further showed the resident required one person assistance for moving from location to location in their wheelchair (w/c) while in their room. A concurrent observation and 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 observation, interview, and record review the facility failed to ensure two of two residents (55 and 17) reviewed for accidents, were free from hot liquid spills. The residents were served hot beverages without placing lids on the cups which resulted in spills and put them at risk for burns. Additionally, Resident 55 did not have their skin assessed after the incident which placed them at further risk for unidentified injury and pain. Findings included . Resident 55. Review of the resident's electronic medical record showed the resident had diagnoses including dementia, cognitive communication disorder and muscle weakness. The most recent assessment, dated 03/23/2023, showed the resident had severe cognitive impairment and required assistance from staff for eating and other activities of daily living (ADLs). Review of the care plan, dated 12/29/2022, did not identify any risks related to serving the resident a hot beverage. Additionally, there was no assessment to identify if the resident was safe to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for one of two residents (8) reviewed for trauma-informed care. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . Resident 8. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include lung disease, and Post Traumatic Stress Disorder (PTSD, a mental health condition that's triggered by a terrifying event by either experiencing it or witnessing it). The comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition. Review of the resident's Trauma Screening assessment, dated 10/20/2022, showed the resident suffered from trauma while the served in military service. The resident stated they were in a war zone and would be…

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

Based on interview and record review the facility failed to ensure staff followed Washington State law for the disposition (the process of destroying unused medications) of Controlled Substance/Schedule Drugs (categories of drugs regulated by the U.S. government and classified based on their potential for abuse, potential to cause dependence and their accepted medical use) for two of three medication carts (North Cart 2 and South Cart 1) reviewed for destruction of controlled medications, by not having the controlled medications destroyed by two of the following individuals: A licensed pharmacist, the director of nursing or a registered nurse designee, and a registered nurse employee of the facility. Findings Included . Review of the facility's policy titled, Disposal of Medications and Medication-Related Supplies, revised January 2018, showed direction for the facility staff to destroy controlled medications ot in the presence of [two licensed nurses] and the disposal was documented on the accountability record/book. Review of the Individual Patient's Narcotics Record Book 5, 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 a medication error rate was less than 5 percent (%). During the medication administration observation task. Staff L, Medication Assistant Certified-Endorsed (MAC-E) made two medication errors, an error rate of 6.45%. This failure placed residents at risk for not receiving medications according to the physician orders and a diminished quality of life. Findings included . Review of facility policy titled Preparation and General Guidelines-Medication Administration, revised December 2019, showed that crushing tablets may require a physician's order. Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. Such as long-acting or enteric-coated dosage forms should not be crushed . Review of the Nursing 2023 Drug Handbook, Showed that before crushing a drug, always check with the pharmacist and established references, such as the Institute for Safe Medical Practices (ISMP's) list…

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 serve meals that were at an appetizing temperature and palatable for 3 of 7 residents (4, 25, and 10) reviewed for meal satisfaction. Failure to serve food at the proper temperature, placed all residents at risk for decreased nutritional intake and food borne illness. Findings included . Resident 4. Review of the resident's medical record showed the resident had diagnoses including atrial fibrillation (a disorder in the hearts normal rhythm) and muscle weakness. Review of the most recent comprehensive assessment, dated 01/18/2023, showed the resident was cognitively intact and required extensive assistance for activities of daily living, except ate independently after it was set up. During an observation and interview on 04/05/2023 at 12:49 PM, Resident 4 was in bed with their lunch tray on the over bed table. The resident stated, I did not like the lunch, so I decided to ask for something else. The resident's lunch consisted of a bowl 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.