Lacey Post Acute & Rehabilitation

Inspectors wroteBased on interviews and record review, the facility failed to hold enteral feedings (Method of delivering liquid nutrition directly into the stomach), for 1 of 3 (Resident 2) residents reviewed for enteral feeding. This failure placed residents at risk of receiving unnecessary enteral feedings and the potential for a diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that residents were dressed in personal clothing for 1 of 4 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for an undignified appearance and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident census and nursing hours were accurately posted and/or updated daily for 7 of 18 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and resident census information.

Inspectors wroteBased on interviews and record review, the facility failed to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1of 4 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk of injuries related to falls and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate care and services and complete assessments for 1 of 2 residents (Resident 2) reviewed for dialysis (a procedure that acts as an artificial kidney, filtering waste products, toxins, and excess fluid from the blood). This failure placed residents at risk for compromised health outcomes and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents were treated with dignity and respect for 2 of 4 (Resident 2 and Resident 3) sampled residents reviewed for quality of care. This failure placed residents at risk for negative outcomes to mental and psychosocial well-being and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents were free from unnecessary drugs for 1 of 4 (Resident 1) sampled residents reviewed for unnecessary medications. This failure caused Resident 1 to be given psychotropic medication without prior consent. This failure placed residents at risk for increased side effects and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement appropriate infection control practices when handling medication for 1of 3 (Resident 2) sampled residents reviewed for infection control and prevention. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a safe discharge plan was in place for 1 of 3 (Resident 1) sampled residents reviewed for admission/discharge/transfer. This failure placed residents at risk for an unsafe discharge to the community, and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents received pain medication timely for 2 of 4 [Residents 1 and 2] reviewed for Quality of care. This failure caused Resident 1 and Resident 2 to experience ongoing pain and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented on 1 of 4 (Resident 2) residents reviewed for infection control. This failure placed the facility at risk of exposing staff and other residents to multidrug-resistant organisms (MDROs) and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 3 of 4 sampled residents (44, 32, & 83) reviewed for smoking, position/mobility, and anticoagulants (often called a blood thinner, a medication that inhibits blood clotting). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wrote4) Resident 220 was admitted to the facility on [DATE]. The admission note, dated 05/22/2025 at 3:08 PM, showed Resident 220 was alert and oriented. Resident 220's admission care plan dated 05/29/2025 documented: SKIN IMPAIRMENT UPON ADMISSION/readmission - The resident has an area of impaired skin integrity. Left hip abrasion Left vascular wound to toes Left lower extremity vascular wound Left heel diabetic foot ulcer (DFU) stage 3 Right heel DFU unstageable Left lateral DFU unstageable. Resident 220's physician orders, dated 05/29/205, documented: Left hip abrasion clean with normal saline, pat dry, apply medihoney [wound treatment], and skin prep [skin protectant]. Cover with foam dressing. Change every other day until resolved. On 06/03/2025 at 11:43 AM, Resident 220 was observed sitting in his wheelchair with therapeutic cushion in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 1 of 5 sampled residents (56) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were conveyed to the resident's representative and/or to the state office of financial recovery (OFR) within 30 days of death or discharge for 1 of 1 discharged resident (311) reviewed for Trust Funds. This failure placed residents and/or their representatives at risk for delayed reconciliation of resident trust funds.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) for 1 of 7 sampled residents (83) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an evaluation assessment, consent, and/or physician's order for 2 of 2 sampled residents (56 & 86) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected mental health diagnoses for 2 of 6 sampled residents (409 & 410) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings Included . Review of facility policy, entitled Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy, documented, 1) Prior to an individual's admission, The Social Worker, Admissions Coordinator, or designee will review the completed screening forms via e-PAS and obtain a copy for placement in the electronic medical record . 1) Resident 409 was admitted to the facility on [DATE] with diagnoses including depression and anxiety. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to document completion and/or refusal of weights for 1 of 3 residents (223) reviewed for nutrition. This failure placed residents at risk for unplanned weight loss and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs, biologicals, and medical equipment were dated upon opening and discarded once expired for one of two medications rooms (2nd floor) and one of two treatment carts (1st floor) reviewed for medication and equipment storage. This failure placed the residents at risk for receiving compromised or ineffective medication and receiving treatment with outdated equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure transfer training was provided to family resulting in an unsafe discharge for 1 of 3 sample residents (1) reviewed for discharge process. This failure placed residents at risk for an unsafe discharge into the community and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that advance directives were implemented on admission for 1 of 7 (1) residents reviewed for advance directives. This failure placed residents at risk for not having advanced directives honored and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to establish a wound plan of care for 1 of 4 sampled residents (Resident 1) reviewed for comprehensive care plans. This failure placed residents at risk of unmet care needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) for 1 of 11 sampled residents (157) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 1 of 3 sampled residents (42) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk for not having adequate information to make financial decisions related to the residents' stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 1 of 1 sampled resident (105) reviewed for bed hold notification. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's condition at the time of assessment for 1 of 27 sampled residents (75) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II for 1 of 7 sampled residents (14) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission and Resident Review (PASARR) assessment was completed correctly for 2 of 9 sampled residents (38 & 100) reviewed for PASARR. This failure placed residents at risk for not receiving the necessary mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was updated to reflect changing needs for 1 of 27 sampled residents (67) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure toilet assistance was provided consistently, in accordance with the resident's preferences and current abilities for 1 of 6 sampled residents (67) reviewed for activities of daily living (ADLs) for dependent residents. This failure placed residents at risk for embarrassment, poor hygiene, potential falls, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary care and services were provided to maintain residents' abilities in range of motion and activities of daily living, and provide preventative range of motion (ROM) services for 4 of 5 sampled residents (64, 82,15 & 67) reviewed ROM services. This failure placed residents at risk for an avoidable decline and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility administered Tuberculin (TB) Solution to a resident allergic to the TB solution for 1 of 5 sampled residents (100) reviewed for Tuberculin testing. This failure placed residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on interview and observation, the facility failed to ensure medication was secured in 1 of 4 medication carts (100 hall medication cart) reviewed for medication administration. This failure placed resident at risk for medications being accessible to unauthorized staff and residents.

Inspectors wroteBased on interview and observation, the facility failed to ensure patient care equipment was maintained in safe operating condition for 1 of 1 suction machines (2nd Floor Crash Cart Suction Machine) reviewed for equipment in safe operating condition. This failure placed residents at risk for not having their care needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure consents for wanderguards, a device used for residents at-risk of elopement, were in place for 2 of 3 sampled residents (Residents 1 & 2) reviewed for informed consents regarding wanderguards. This failure placed residents and resident representatives at risk of inadequate knowledge of wanderguard use, decreased freedom of movement, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure wanderguard, a device used for residents at-risk of elopement, assessments were completed and in place for 3 of 3 sampled residents (Residents 1, 2 & 3) reviewed for accident hazards related to wanderguards. This failure placed residents at risk of improper wanderguard use, decreased freedom of movement, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were administered oxygen according to the provider orders for 1 of 3 sample residents (1) reviewed for respiratory care. This failure resulted in harm to Resident 1 when their oxygen was not maintained at the ordered rate and the resident experienced hypoxia (low oxygen blood levels) and requried hospitalization. This failure placed residents at risk for shortness of breath, unmet care needs and a decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were able to give an informed consent before psychotropic medications (mind altering) administration for 2 of 5 sampled residents (34 & 79) reviewed for right to be informed and make decisions about treatment. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure dependent residents were provided scheduled bathing/showering opportunities for 1 of 3 sampled residents (Resident 34) reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure compression socks were applied per physician orders and failed to obtain resident weights per physician orders for 2 of 5 sampled residents (82 & 33) reviewed for quality of care related to following physician orders. This failure placed residents at risk of poor circulation, weight loss, unmet care needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify weight loss for 1 of 4 sampled residents (Resident 34) reviewed for nutrition. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and target behaviors for 1 of 5 sampled residents (Resident 34) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 1 of 2 sampled medication rooms (1st floor) reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications with unknown potency.